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1. Description of diabetes
2. Classification base on
etiopathogenesis
of the disease
3. Diagnostic criteria
4. Testing for diabetes
Diabetes Mellitus
A group of metabolic diseases
Characterized by hyperglycemia
Resulting from defects in insulin secretion ,
insulin action, or both
A. Clinical Classification
1. Diabetes Mellitus
IDDM
NIDDM Obese
Non-obese
Secondary Diabetes
MRDM
2. Gestational Diabetes
3. Impaired Glucose Tolerance
ETIOLOGIC CLASSIFIACTION
I.
II. Type 2
Predominantly insulin resistance + relative insulin
deficiency
Predominantly secretory defect + insulin resistance
III. Other specific types
IV. Gestasional diabetes mellitus
Type 1 + Type 2 = 70 95% of diabetes
The Expert Committee,1997
IDDM
Type 1a (autoimmune)
LADA (late stage)
Type 1b (idiopathic)
DM linked to acute or chronic
pancreatic diseases Cancer,
pancreatitis etc)
MODY 3
DM associated with
endocrinopathies (Cushing,
acromegaly)
Gestasional diabetes
Mitochondriopathy
Flatbush diabetes
NIDDM
Type 2 associated with metabolic
syndrome
Type 2 without insulin resistance
LADA (early phase)
DM linked to acute or chronic
pancreatic diseases Cancer,
pancreatitis etc)
MODY (including MODY3)
DM associated with
endocrinopathies (Cushing,
acromegaly)
Gestasional diabetes
Mitochondriopathy
Flatbush diabetes
Controversies in Classification
=
Controversies in Management
Type 1 diabetes = Insulin dependent DM
(Dependency on insulin for life)
Type 2 diabetes = Non Insulin Dependent DM
= Not requiring insulin ??
Clinical Features
Age at onset
Onset
Weight
Spontaneous ketosis
Chronic complication
Epidemiology
Prevalence
Sex
Insulin (C-petide) level
Genetics
Concordance in twins
HLA asoociation
Pathology
Islet cell mass
Insulitis at onset
Immunology
Associated with other endocrinopathy
Anti-islet ell immunity
Humoral
Cell mediatedl
Type 1
Type 2
Usually < 30
Acute
Non obese
Common
(++)
Usually > 40
Insidious
Obese
Rare
(++)
0,5%
Male prepdominancece
/ (-)
2%
Female predominance
/N/
40%
(+) (DR3/DR4)
70 90%
(-)
Severely reduced
Present
Moderately reduced
?
Frequent
Frequent
60 80% at onset
35 50% at onset
5 20%
< 5%
Type 1 Diabetes
(-cell destruction leading to
absolut deficiency)
GAD65 antibodies
ICA antibodies
IAA antibodies
IA2 and IA-2
Abnormal -cell function test
Tolerance reestablished
T-cell tests (+)
T-cell tests ()
Clinical onset
5-10%
Type 2 Diabetes
Insulin resistance
?
vs
-cell dysfunction
Post-prandial glucose
Fasting glucose
Relative to normal
(%)
Insulin resistance
250
200
150
100
50 At risk for Beta-cell dysfunction
Insulin level
diabetes
0
30
0
5
10 15 20 25
-10 -5
Years
R.M. Bergenstal, International Diabetes Center
Insulin Resistance
Normal -cells
Abnormal -cells
Compensatory
Hyperinsulinemia
Inadequate Insulin
Response
Isulin Resistance
Syndrome
Type 2 Diabetes
Hypertension
Dyslipidemia Obesity
CVD
Retinopathy
Neuropathy
Nephropaty
Genetic
Insulin resistance
Obesity (Genetic ?)
Inactivity
Hyperglycemia
Hyperinsulinemia
Drugs
Secondary and
facilitative
Environmental
F
A
M
I
L
Y
S
T
U
D
Y
F
E
N
O
T
Y
P
E
VS
G
E
N
O
T
Y
P
E
DISORDERS OF GLYCAEMIA
Etiologic types and Stages
Hyperglycemia
Stages Normoglycemia
Types
Type 1
Type 2
Other
types
Gestational
diabetes
Normal glucose
regulation
Diabetes Mellitus
IGT or
Insulin requiring
IFG
No
For control
Insulin requirement
+++
For survival
+++++
Hyperglycemia
Hypertension
Atherogenic
dyslipidemia
Insulin resistance
+
Hyperinsulinaemia
Abdominal obesity
Impaired
fibrinolysis
Pro-inflammatory
profile
CASE
Female 56 y.o, diagnosed as NIDDM 7
years ago, BMI 22 kg/m2, addhere to diet,
routine exercise, Tx. Glibenclamide 15
mg/day + metformin 1500 kg, Blood
sugar : fasting 230 mg ; 2 h pp 324 mg%
Past medical history : good controlled
with 2 mg glibenclamide but gradually
needs higher dose and finally needs
combined oral hypoglycemic drugs
7. -adrenergic agonist
8. Thiazides
9. Dilantin
10. -interferon
11. Others
ENDOCRINOPATHIES
Acromegaly
Cushings syndrome
Glucagonoma
Pheochromocytoma
Hyperthyroidism
Somatostatinoma
Aldosteronoma
Others
INFECTIONS
Congenital rubella
Cytomegalo virus
Others
UNCOMMON FORMS
OF IMMUNE-MEDIATED DIABETES
Stiff-man syndrome
Anti-insulin receptor anribodies
Others
Downs syndrome
Klinefelters syndrome
Tuners syndrome
Wolframs syndrome
Friedereichs ataxia
Huntungtons chorea
Laurence-Moon-Biedl syndrome
Myotonic dystrophya
Porphyria
Prader-Willy syndrome
Others
The Expert Committee,1997
DIAGNOSTIC CRITERIA
Slama, 2003
DM
ADA, 2004
GESTATIONAL DIABETES
140 mg/dl
-
105
190
165
145
mg/dl
mg/dl
mg/dl
mg/dl
mmol/l
95
180
155
140
5.3
10.0
8.6
7.8
95
180
155
5.3
10.0
8.6
Thank You
For Your Attention !!
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