Internal medicine 
29-10-2013
lec. # 6

How to diagnose diabetes ?
Diabetes is increasing the sugar in the blood and normally it has a different variation depends on the time of measurements for example at fasting state (fasting for 8 hours at least )  it should be less than 100 for the normal person  , if more than 125 the patient has diabetes and between 100 and 125 we call it a gray zone , pre diabetic or impaired fasting stage or impaired fasting blood sugar  .
Blood sugar after eating (after 2 hours from eating) we call if postprandial reading and for the normal person it should be less than 140 but if the patient has diabetes it will be 200 or more and if its between 140-200 we will call it impaired glucose tolerance ..
So if the fasting state reading was 127 we don't call him a diabetic patient from this reading only  we have to take at least 2 readings from the patient to say he is a diabetic patient or not , they could be postprandial reading or fasting reading or both  and this is the first way to diagnose the diabetes .
 - the second way to diagnose the diabetes take  any random blood sugar reading ,  if its more than 200 with classic symptoms of hyperglycemia like poly urea , poly depsia and poly phagia (eating a lot) .
If the randomly reading is 250 and the patient has poly urea and drinking a lot of water or any other symptoms (even though there is only a one reading with symptoms)  we called him diabetic  patient .
- the third way we measure HbA1c which gave the average of the blood sugar for 3 months.
Hb in the blood cells determine if the patient has anemia or not.
Sugar glucose normally interact with proteins ( Hb) and it called glycated Hb and its normally up to 5.6 % ( if its 6.4% the patient has diabetes ).
-for 3 months because RBC half life is around 90 days so we measure the sugar in the blood during 3 months then we take an average ; for example if its 6 that's mean its 160 mg , if its  7 that's mean its 170 mg and so on  (not for memorization these numbers) . if its more than 6.4 the patient has diabetes .
** So to diagnose the diabetes we must have 2 readings of high blood sugar ( any 2 combination of readings from HbA1C , fasting blood sugar  or postprandial blood sugar ) except in randomly readings (only one reading is enough with the classical symptoms).
patient might have a symptoms for the diabetes like :  polyuria, polydepsia, polypjagia ,sweats ,fatigue , blurred vision and weight change ( weight loss first) .

** Most hormone control sugar in the blood is insulin and it secrets from beta cells of pancreas , its function to maintain good blood sugar and facilitate the entry of the sugar from the blood to the cells , so if the patient has a deficiency in the insulin (no enough insulin) there will not be enough insulin in the cells.
Insulin resistance :
 insulin in order to work it needs to binds to its receptors , if there is a problems in the receptors there will be a problems with the insulin function too in this case we might have enough insulin and more than normal  and we might have Hyper-insulinia to compensate and over come  the resistance and the patient here not diabetic but if the resistance > hyper-insulinia , the patients will have a diabetes .
Types of diabetes : 
Type 1 : 
Patient characterized by absolute insulin deficiency because beta cells destructed by auto immune disease and usually it happens in young patient 
They have to be treated with insulin
Before they discover insulin ( before 1921) the patients were died  because they didn't receive insulin .
 Type 2 :
 The patients have an insulin  resistance  and they treated it by oral hypoglycemia and they can take insulin .
Now moving on to talking about the less common types of diabetes:
The third type of diabetes is termed Gestational Diabetes.
There is a different set of criteria that is used to diagnose this form that we need not worry about; however, what is used LEGALLY to treat it is the introduction of insulin. We do not use any form of hypoglycemic agents.
The fourth type is named Secondary Diabetes. As the name implies this form of hyperglycemia would be related to some other identifiable factor such as Cushing’s syndrome that could be due to either hyper secretion of endogenous cortisol or exogenous steroid therapy. Pancreatic surgery and acromegaly being other causes among a variety of other metabolic  conditions.

ALL forms of diabetes-even those that are mild- should be treated mainly to avoid complications.
Complications due to uncontrolled diabetes are classified into Acute and Chronic.
Acute complications include:  **Diabetic Ketoacidosis (Related to DM type 1 mainly) ç A condition of severe dehydration and is an absolute emergency.
**Hyperosmolar NonKetotic State (associated with DM 2 mainly) also characterized by severe dehydration presenting with high concentration of glucose in urine (the patient usually comes with Blood Sugar levels of 700-1000 mg/dl) resulting in osmotic diuresis with up to 10 L urine output/day.
  
Chronic complications include those that are Microvascular and those that are Macrovascular.
Microvascular complications affect small vessels and include but are not limited to:
1.	Retinopathy.
2.	Neuropathy
3.	Nephropathy
The presenting signs associated with neuropathy vary depending on the nerves affected but usually appear as parasthesia in the lower limbs. Sometimes the nerves affected are those innervating the GIT and the patient presents with diarrhea, nausea and vomiting, or even  constipation.
Neuropathy may also manifest in the form of neurogenic bladder/ urine retention and even in the form of erectile dysfunction in affected males. 
Nephropathy usually is associated with proteinuria alongside deterioration of kidney function.
Macrovascular complications are mainly related to the process of atherosclerosis. Atherosclerosis is a well-known predisposing factor to myocardial infarctions (mainly), strokes and other IHDs. In fact the most common cause of death among patients with DM2 is IHD mainly in the form of MI; whereas, the most common cause of death in patients with DM1 is infections (this has been determined mainly from statistical analyses). Infections and diabetes have a very close relationship mainly due to decreased immunity.

 NB:   The economic burden designated for the treatment and prevention of DM by the US government is 100,000 Million or 100 Billion $.

Treatment of Diabetes

Treatment to avoid complications for both types DM1 and 2 should involve lifestyle modifications.
DM1 (accounting for ≤ 10 % of DM cases) è** Lifestyle modifications (patients are mainly of the young generation and this approach often imposes patient’s compliance problems). Those modifications would involve a diet of healthy food and exercise.
**Pharmacological intervention mainly depends on administration of insulin as in the case of gestational diabetes.
DM2 (accounting for ≥ 90%) è **lifestyle modifications  & **combined drug therapy. The most commonly used group of hypoglycemic drugs are referred to as Sulfonylureas which potentiate the secretory function of the pancreas to generate more insulin. Other groups of drugs work on minimizing insulin resistance.
DM is particularly important from a dental viewpoint as patients with DM present to the dental clinic with various oral and dental manifestations including gingivitis, lowered OH, delayed healing (important mainly from a surgical perspective) and even bleeding problems.

Good luck 
done by : 
Mais B. Abu Ghosh
Farah AlKaraki