DM Basics

First module

Healthy FBG and Random

FSBG <100

Random <140

A1c <5.7%

Prediabetes FBG and Random

FSBG 100-125

Random 140-199

A1c 5.7-6.4%

Pancreas working 50%

Diabetes FBG and Random

FBG 126+

Random 200+

A1c 6.5% or above

Pancreas working 20%

Can Pre-DM and DM go backwards?

Pre-DM can be reversed back to “healthy” but DM cannot reverse to PreDM (even tho BG can appear “healthy” they will always have DM dx) Pancreas damage will always be.

Target Glucose coefficient of variation (CV)

Spread of glucose values. Goal </=36%

Time in Range goals

TAR >250 <5%

TAR >180 <25%

TIR 70-180 >70%

TBR <70 <4%

TBR <54 <1%

Percent active 70% of the time in 14 days (at least 10/14 days)

Glycemic Goals for non-pregnant Diabetes

A1c <7%

Fasting BG 80-130 mg/dL

PP BG <180 mg/dL

A1c Test to Diagnose & Eval

Measures glycation of RBCs over 2-3 months

Weighted mean (50% preceding month)

Each 1% ~ 29mg/dL

Accuracy: affected by some anemias, hemoglobinopathies- Use Fructosamine or glucose monitoring if needed

A measurement of glucose in fasting and PP states

A1c and eAG

eAG = 28.7 x A1c-46.7 ~29 pts per 1%

e.g. A1c 7% = eAG 154 (123-185) mg/dL

Type 1 age and percent of DM

T1DM accounts for 5-10% of all DM

Most commonly expressed at age 10-14 years

Insulin sensitive. Requires 0.5-1.0 units/kg/day

Healthy pH level for blood

Healthy pH lvl is 7.35-7.45 (slightly alkaline)

If drops below 7.35 = acidosis

If rises above 7.45 (alkalosis)

Normal Anion Gap (AGAP)

Normal ~5-15 mmol/L

Anion Gap = Sodium - (Chloride + Bicarbonate)

Or sometimes as (Sodium + Potassium) - (Chloride + Bicarbonate)

The anion gap is a calculation used to evaluate the balance of electrolytes in your blood and is primarily helpful in diagnosing metabolic acidosis.

DKA INCREASES anion Gap (due to bicarb being used to neutralize ketone acids in the blood and maintain pH, as bicarb is lost, anion gap will increase).

Type I Positive Antibodies

GAD - Glutamic acid decarboxylase (primary)

IA2 - Islet antigen 2

ZnT8 - Zinc transporter 8

(Can also check c-peptide lvls to determine endogenous insulin production)

Younger ppl develop quickly while older people take longer

**Misdiagnosis is common and occurs in 40% of adults with new T1DM!

Pharmacologic interventions to delay T1 (in stage 2)

Teplizumab (CD3-monoclonal antibody)

14-day infusion can delay the onset of symptomatic T1DM (stage 3) by an additional 2 years.

An option in selected individuals aged >/=8 years w/ stage 2 T1DM

Very high cost $193,000. Manufacture w/ financial assistance

Criteria for Screening for T1DM

Screen those at risk for presymptomatic T1DM by testing autoantibodies (GAD, Islet antigen 2, or ZnT8)

Also test antibodies for those with T1 phenotypic risk (younger age, wt loss, ketoacidosis, etc)

Criteria for Screening for T2DM

Test all adults starting age 35 for preDM and DM using FBG, A1c, or OGTT

Perform risk-based screening if BMI >25 or >23 if Asian Americans 10+ years with 1 or more risk factors:

• Hx CVD, 1st degree relative w/ DM, High risk ethnicity, Physical inactivity, HDL <35 or TG >150, HTN or normal BP but on HTN meds, or other condition associated w/ insulin resistance (PCOS, Acanthosis Nigricans, Steatosis, Obesity)

If results are normal, repeat test at a min of 3-year intervals or more frequently based on risk

Test yearly if A1c >5.7% or impaired FBG or hx of GDM (test at least every 1-3 years)

Closely monitor high-risk groups- ppl w/ HIV, exposure of high-risk medicines, evidence of periodontal disease, hx of pancreatitis.

The Noxious Nine - Pathophysiology T2DM

Pancreas- decreased insulin B-cell secretion

Pancreas- increased glucagon alpha-cell secretion

Adrenal Gland- Hypercortisolism

Kidney- Increase renal glucose reabsorption

GI- Decreased incretin effect of gut hormones

Fat cells- Increased lipolysis

Muscle cells- Decreased muscle glucose uptake

Liver- Increased hepatic glucose production

Nervous System- Neurotransmission dysfunction

Type 3c DM (Pancreatogenic)

Includes both structural and functional loss of insulin secretion in the context of exocrine pancreatic dysfunction

About 5-10% of DM, often misdiagnosed as T2DM

The diverse set of etiologies includes:

1. Pancreatitis

2. Trauma or pancreatectomy

3. Neoplasia

4. Cystic Fibrosis (CF)

5. Hemochromatosis

6. Fibrocalculous pancreatopathy

7. Rare genetic disorders, and idiopathic

Screening at First Prenatal Visit prior to 15 weeks

Screen for undiagnosed Type 2 at the first prenatal visit using standard risk factors.

Before 15 weeks of gestation, test individuals with risk factors: (FYI 1st trimester is 12-13 weeks long)

• overweight or obesity, (or BMI >23 for Asian am), 1st-degree relative w/ DM, CVD hx, HTN, HDL < 35, PCOS, Physical inactivity), etc.)

Use standard diagnostic testing and criteria for diagnosing DM. (Diagnostic criteria for identifying undiagnosed diabetes in early pregnancy are the same as those used in nonpregnant individuals) Pre-DM / DM dx criteria.

Those found to have diabetes at their initial prenatal visit treated as “Diabetes in Pregnancy”

**a diagnosis made in the first trimester is not classified as Gestational Diabetes Mellitus (GDM) — it is considered pre-existing (overt) diabetes (most commonly undiagnosed Type 2).

Those with an A1C 5.9–6.4% or fasting BG of 110–125 mg/dL are at higher risk of adverse pregnancy and neonatal outcomes (preeclampisa) and are at high risk of a later gestational diabetes mellitus (GDM) diagnosis.

If normal, recheck at 24-28 weeks

Diagnosis and Screening of GDM at 24-28 weeks gestation- ONE STEP

at 24-28 weeks gestation for those WITHOUT known DM, IADPSG “One Step” test:

One Step: 75 g OGTT at fasting, 1 hour, and at 2 hours. (Fasting of at least 8 hours)

If ANY of the following values are exceeded, it is a GDM diagnosis:

Fasting >/= 92 mg/dL

1 hr >/= 180 mg/dL

2 hrs >/= 153 mg/dL

Screening for GDM at 24-28 weeks gestation - Two Step

Step 1: 50g glucose load (non fasting) w/ plasma BG test at 1 hr. If BG >130-140, go to step 2

Step 2: 100g OGTT (fasting) DM diagnosis if at least 2 of 4 BG measured after OGTT meet or exceed:

Fasting: 95

1 hr: 180

2 hr: 155

3 hr: 140

Screening GDM for DM postpartum

To see if GDM → DM

4-12 weeks postpartum

75-g OGTT.

Lifelong screening q 3 years