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INSULIN SECRETION BY
CELLS
3.
Action of Insulin
The action of insulin on target cells begins when
the
hormone binds to its receptor in the cell
membrane.
The insulin receptor is a tetramer composed of
two subunits and two subunits.
The subunits lie in the extracellular domain, and
the subunits span the cell membrane.
A disulfide bond connects the two subunits, and
each subunit is connected to a subunit by a
disulfide bond.
The subunits have intrinsic tyrosine kinase
activity.
Diabetes Mellitus
Clinical diabetes mellitus is a
syndrome of disordered
metabolism with inappropriate
hyperglycemia due to an
absolute or relative deficiency of
insulin. There may also be a
defect in insulin action (insulin
resistance).
Classification
Diabetes is classified into 4 main groups
based on known pathological and etiologic
mechanisms:
1) Type 1
2) type 2
3) other specific types
4) gestational diabetes
Type 1 a- 95%
Most patients with type 1 diabetes at diagnosis have
circulating antibodies against cell proteins:
Islet cell antibodies (ICA)
Insulin autoantibodies (IAA)
Antibodies to glutamic acid decarboxylase 65 (GAD),
Tyrosine phosphatase IA2 (ICA512)
Zinc transporter 8 (ZnT8)
These antibodies can often be detected well before the
onset of frank hyperglycemia, even decades earlier,
providing evidence that the autoimmune process may be
prolonged.
After diagnosis, autoantibody levels often decline with
increasing duration of the disease.
Genetics of Type 1
Diabetes
Family members of patients with type1
diabetes have an increased lifetime risk of
developing type 1 diabetes.
The offspring of a mother with type 1
diabetes have a risk of 3%, whereas the risk is
6% for children of affected fathers.
The risk in siblings of affected individuals is
related to the number of human leukocyte
antigen (HLA) haplotypes , that the sibling
shares.
Type 2 DM is characterized
by:
1) Impaired insulin secretion
2) Insulin resistance
3) Excessive hepatic glucose
production
4) Abnormal fat metabolismDyslipidemia
This is related to :
Access of food
with high caloric
content and
decreased physical
activity !!!
Obesity classes
BMI = kilograms
meters 2
BMI
1.8 m2
Classification
< 18.5
18.524.9
25.029.9
30.034.9
35.039.9
40.0
underweight
normal weight
overweight
class I obesity
class II obesity
class III obesity (total obesity)
Maturity-onset diabetes of
the young (MODY)
Autosomal Dominant Genetic Defects of
Pancreatic Cells.
This subgroup of monogenic disorders is
characterized by the onset of diabetes in late
childhood or before the age of 25 years as a
result of a partial defect in glucose-induced insulin
release and accounts for up to 5% of diabetes in
North American and European populations.
A strong family history of early-onset diabetes
occurring in one parent and in one-half of the
parent's offspring suggests autosomal dominant
transmission
Other causes of DM
DM can result from pancreatic exocrin diseas,
When the majority of pancreatic islets are
destroyed.
Cystic fibrosis-related DM is an important
consideration in that patient population.
Hormones that antagonize insulin action can also
lead to DM. Thus, DM is often a
feature of endocrinopathies such as acromegaly
and Cushing's disease.
Viral infections have been implicated in pancreatic
islet destruction but are an extremely rare cause of
DM. A form of acute onset of type 1 diabetes
termed fulminant diabetes has been noted in
Japan and may be related to viral infection of islets.
Gestational Diabetes
Mellitus
Glucose intolerance developing
during pregnancy is classified as
gestational diabetes mellitus
(GDM) .
Insulin resistance is related to metabolic changes of
late pregnancy and the increased insulin
requirements may lead to IGT or diabetes.
GDM occurs in -7% (range 1 - 14%) of pregnancies
in the United States.
Most women revert to normal glucose tolerance
postpartum but have a substantial risk (35-60%)
of developing DM in the next 10-20 years.
diabetes
diagnosed at the initial
prenatal visit should be
classified as ,,overt" diabetes
rather than GDM.
recommend that
Eruptive xanthomata
Eruptive xanthomata
Acanthosis nigricans
in type 1 DM)
4) HBA1C (Glycated Hemoglobin)
5) Lipoproteins
Lipoproteins in Diabetes
Levels of circulating lipoproteins are dependent
on normal levels and action of insulin, just as is
the plasma glucose.
In type 1 diabetes, moderately deficient
control of hyperglycemia is associated with only
a slight elevation of low-density lipoprotein
(LDL) cholesterol and serum triglycerides and
little if any changes in HDL cholesterol.
Once the hyperglycemia is corrected,
lipoprotein levels are generally normal.
and
Exersise
Biguanides-Metformin
Representative of this class of agents reduces
hepatic glucose production and improves
peripheral glucose utilization slightly. Metformin
activates AMP-dependent protein kinase and
enters cells through organic cation transporters.
Metformin reduces fasting plasma glucose (FPG) ,
improves the lipid profile and promotes modest
weight loss.
1) It May have fewer gastrointestinal side
effects: diarrhea,anorexia,nausea,metallic taste
2) Vitamin B l2 1evels are -30% lower during
metformin
treatment.
Thiazolidinediones
Thiazolidinediones are insulin sensitizers exerting
their antidiabetic effects through the activation of
PPAR-y (peroxisome proliferator-activated receptor
y). They reduce insulin resistance.
Troglitazone, the first drug in this class to go into
widespread clinical use, was withdrawn from clinical
use because of drug-associated fatal liver failure.
Two other drugs in the same class are available for
clinical use: Rosiglitazone and Pioglitazone.
Circulatinginsulin levels decrease with use of the
thiazolidinediones indicating a reduction in
insulin resistance.
Alpha-Glucosidase Inhibitors
Acarbose and Miglitol
Drugs of this family are competitive inhibitors of
intestinal brush border -glucosidases. -Glucosidase
inhibitors reduce postprandial hyperglycemia by
reducing glucose absorption. These drugs must be
taken just before each meal. The major side
effect(diarrhea,flatulence,abdominal distention) are
related to increased delivery of oligosaccharides to the
large bowel. When acarbose is given alone, there is no
risk of hypoglycemia. However, if combined with insulin
or sulfonylureas, it may increase risk of hypoglycemia
from these agents. This class of agents is not as potent
as other oral agents in lowering the HbA1c.
Sodium-Glucose Co-Transporter 2
Inhibitors (SGLT2)
These agents lower the blood glucose by selectively inhibiting this
co-transporter which is expressed almost exclusively in the
proximal convoluted tubule in the kidney.
Insulin Therapy
Insulin is indicated for individuals with type 1
diabetes as well as for those with type 2 diabetes
whose hyperglycemia does not respond to diet
therapy and other diabetes drugs.
Human insulin is now produced by recombinant
DNA techniques (biosynthetic human insulin).
Insulins in Europe and United States are available
only in a concentration of 100 U/mL (U100). For use
in rare cases of severe insulin resistance in which
large quantities of insulin are required, a U 500 (500
U/mL) regular human insulin is available from Eli Lilly.
Summary of Bioavailability
Characteristics of the Injectable Insulins
Premixed Insulins
(Insulin combinations )
And
2)Those arising from Neuroglycopenia
(insufficient glucose for normal central
nervous system function)
If these autonomic symptoms are ignored and
the glucose levels fall further (to around 50
mg/dL), then neuroglycopenic symptoms
appear, including irritability, confusion,
Hypoglycemic Unawareness
1) Autonomic neuropathy
2)Gastroparesis
3)Renal failure
Treatment of Hypoglacemia
To treat insulin-induced hypoglycemia, the
diabetic patient should carry glucose tablets
or juice at all times. For most episodes,
ingestion of 15 g of carbohydrate is sufficient
to reverse the hypoglycemia. The patient
should be instructed to check the blood
glucose in 15 minutes and treat again if the
glucose level is still low. A parenteral glucagon
emergency kit (1 mg) should be provided to
every patient with diabetes who is on insulin
therapy. Family or friends should be instructed
how to inject it subcutaneously or
intramuscularly into the buttock, arm or thigh
Glucagon is contraindicated in
sulfonylureainduced hypoglycemia
where it paradoxically causes insulin
release.
People with diabetes on hypoglycemic
drug therapy should also wear a
MedicAlert bracelet or necklace or carry
a card in his or her wallet.
Diabetic Ketoacidosis
This acute complication of diabetes mellitus may be the
first manifestation of previously undiagnosed type 1
diabetes or may result from increased insulin
requirements in type 1 diabetes patients during the
course of infection, trauma, myocardial infarction, or
surgery.
Patients with type 2 diabetes may also develop
ketoacidosis under severe stress such as sepsis, trauma,
or major surgery.
hyperglycemia
should be assessed for clinical stability, including
mentation and hydration.
Laboratory Findings
Typically, the patient with moderately severe diabetic ketoacidosis
has :
Plasma glucose of 350 to 900 mg/dL (19.4-50 mmol/L),
Serum ketones are
positive at a dilution of 1:8 or greater
(serum or plasma assays for -hydroxybutyrate are
preffered because they more accurately reflect the true ketone
body level)
Hyperkalemia of 5 to 8 mEq/L
Slight hyponatremia of approximately 130 mEq/L
Hyperphosphatemia of 6 to 7 mg/dL
And
an elevated blood urea nitrogen and creatinine. Acidosis may
be severe (pH ranging from 6.9 to 7.2 with a Bicarbonate
concentration ranging from 5 to 15 mEq/L); pCO2 is low (15-20
mm Hg) secondary to hyperventilation
18
The effective serum osmolality in humans
is generally between 280 and 300
mOsm/kg.
Central nervous depression or coma
occurs when the effective serum osmolality
Treatment
Transition to Subcutaneous
Insulin Regimen
Once the diabetic ketoacidosis is controlled and the
patient is awake and able to eat, subcutaneous
insulin therapy can be initiated. Initially, the patient
may still have significant tissue insulin resistance
and may require a total daily insulin dose of 0.6 to
0.7 U/kg. Half of the total daily dose can be given
as a long-acting basal insulin and the other half as
short-acting insulin premeals. The patient should
get injection of the basal insulin and a dose of the
rapid-acting insulin analog with the first meal and
the insulin infusion discontinued an hour later.
Pathogenesis
A partial or relative insulin deficiency may
initiate the syndrome by reducing glucose
utilization by muscle, fat, and liver, while
promoting hyperglucagonemia and
increasing hepatic glucose output. The
result is hyperglycemia that leads to
glycosuria and osmotic diuresis with
obligatory water loss. The presence of
even small amounts of insulin is believed
to prevent the development of ketosis by
inhibiting lipolysis in the adipose stores.
Laboratory Findings
Severe hyperglycemia is present, with blood
glucose values ranging from 800 to as high as 2400
mg/dL (44.4-133.2 mmol/L). In mild cases, where
dehydration is less severe, dilutional hyponatremia as
well as urinary sodium losses may reduce serum
sodium to about 120 to 125 mEq/Lthis protects,
to some extent, against extreme hyperosmolality.
Once dehydration progresses further, however, serum
sodium can exceed 140 mEq/L, producing serum
osmolalities of 330 to 440 mOsm/kg (normal, 280
to 295 mOsm/kg; Ketosis is usually absent or mild;
however, a small degree of ketonuria may be present
if the patient has not been eating because of illness.
Treatment
There are some differences in fluid,
insulin, and electrolyte replacement
in this disorder, as compared with
diabetic ketoacidosis.
However, in common with the
treatment of ketoacidotic patients,
careful monitoring of the patient's
clinical and laboratory response to
therapy is essential.
Lactic Acidosis
When severely ill diabetic patients present with
profound acidosis and an anion gap over 15 mEq/L but
relatively low or undetectable levels of keto acids in
plasma, the presence of excessive plasma lactate (>5
mmol/L) should be considered, especially if other
causes of acidosis such as uremia are not present.
Lactic acid is the end product of the anaerobic
metabolism of glucose.
Type A lactic acidosis is associated with tissue hypoxia
from hypovolemia or endotoxic shock and need not be
associated with hyperglycemia. Type B lactic acidosis is
defined as that which occurs in the absence of clinical
evidence for tissue hypoxia and is associated with
diabetes per se or with biguanide therapy.
type 1.
Ophthalmologic Complications
Diabetic Retinopathy
Two main categories of diabetic retinopathy exist:
Nonproliferative (background) retinopathy represents
the earliest stage of retinal involvement by diabetes and is
characterized by such changes as microaneurysms, dot
hemorrhages, exudates, and retinal edema.
Proliferative retinopathy involves the growth of new
capillaries and fibrous tissue within the retina and into the
vitreous chamber.
Proliferative retinopathy is a leading cause of
blindness,particularly because it increases the risk of
retinal detachment.
Diabetic macular edema can occur at any stage !
Treatment
The most effective therapy for diabetic
retinopathy is prevention.
Regular,comprehensive eye examinations
are essential for all individuals with DM
.Most diabetic eye disease can be
successfully treated if detected early.
Individuals with known retinopathy may
be treated with laser
photocoagulation.
of
Renal Complications
Diabetic Nephropathy
About 4000 cases of end-stage renal disease due to
diabetic nephropathy occur annually among diabetic
patients in the United States. This represents about
one-third of all patients being treated for renalfailure.
Diabetic nephropathy is initially manifested by
proteinuria; subsequently, as kidney function
declines, urea and creatinine accumulate in the
blood.
Subsequent renal failure can be predicted by
persistent urinary albumin excretion rates
exceeding 30 g/min
Microalbuminuria - defined as
in a 24-h collection urine
30-299 mg/d
mg/24 h
urine
The American Diabetes Association (ADA)
recently suggested to change these terms to
persistent albuminuria.
Because some individuals with type 1 or type
2 DM have a decline in GFR in the absence
of albuminuria annual measurement of
the serum Creatinine to estimate GFR
should also be performed.
Treatment
The optimal therapy for diabetic nephropathy is
prevention by control of glycemia .
Interventions effective in slowing progression
of albuminuria include:
1 ) improved glycemic control
2) strict blood pressure control
3) administration of a n ACE inhibitor or ARB.
Cardiovascular Complications
Heart Disease
Microangiopathy occurs in the heart and may
explain the existence of congestive
cardiomyopathies found in diabetic patients
without demonstrable coronary artery disease. But
much more commonly, however, heart failure in
patients with diabetes is a consequence of
coronary atherosclerosis. Myocardial infarction
is three to five times more common in diabetic
patients than in age-matched controls and is the
leading cause of death in patients with type 2
diabetes.