Diabetes Mellitus

Clinical Description

The diagnosis of diabetes is based on 2 abnormal blood sugar measurements (FBS > 7 mmol/L (126 mg/dl) or RBS >11.1mmol/L (200 mg/dl) or HbA1C >6.5%) in an asymptomatic patient or 1 abnormal measurement if the patient has symptoms of hyperglycinemia.

Forms of diabetes:

• Type 1 diabetes (can be early onset or late onset)
• Type 2 diabetes (usually late onset but can be early onset (MODY - mature onset diabetes of the young)
• Gestational diabetes
• Secondary diabetes (related to medication use (e.g. steroids), endocrine or pancreatic disease etc.)

Causes:

• Autoimmune disorder (Type 1 diabetes)
• Idiopathic (Type 1 diabetes)
• Genetic factors causing a defect in the action or secretion of insulin (Type 2 diabetes)
• Environmental factors e.g., excessive calorie intake and lack of physical activity (Type 2 diabetes)
• Pregnancy (Gestational diabetes)
• Secondary diabetes: Medication e.g., corticosteroid use or abuse,
• Pancreatic disease or pancreatectomy, Endocrine disorders e.g., Cushing’s syndrome, acromegaly etc.

Signs and Symptoms

• Polyuria, Polydipsia, Burning sensation/pins and needles (feet), Blurred vision, Foot ulcers, Family history of diabetes (type 2 diabetes),
• Obesity (some type 2 diabetes patients)
• Erectile dysfunction in men
• Recurrent skin boils
• Recurrent vulvovaginal candidiasis in women
• Big baby (gestational diabetes)

Complications of diabetes

• Retinopathy and nephropathy, Hypertension, Myocardial infarction, heart failure, Stroke, Diabetic foot, peripheral neuropathy, erectile dysfunction, Peripheral vascular disease, Recurrent infections: skin, UTI, candidiasis, Pregnancy and Birth complications

Investigations

• Random or fasting blood sugar, HBA1c, FBC, urea, creatinine, and electrolytes, urine dipstick: assess glucosuria, ketonuria, proteinuria, fasting lipogram, fundoscopy:

screening for diabetes retinopathy, HIV test

Treatment

Treatment objectives

• Establish treatment aims: some patients require strict glycaemic control with near normal glucose values targeted, for others symptom control and avoiding severe side effects of treatment may be the maximum achievable.
• Check BP regularly and aim for BP <130/80 mmHg
• Advise to stop smoking
• Educate about foot care and screen annually for foot problems (neuropathy or peripheral vascular disease)
• Screen annually for decrease in visual acuities, look for cataracts
• Educate on appropriate dietary measures and manageable exercises according to individual patient

Non-pharmacological

• Measures mentioned above

Pharmacological

• Give Aspirin 75mg (to 81mg) daily to hypertensive diabetics aged over 50
• If a diabetic is admitted unconscious always consider the possibility of hypoglycaemia- administer 100ml 20% or 50ml 50% Dextrose/Glucose IV even if a blood glucose measurement is not available.

Do not rush to refer the unconscious Diabetic mellitus patient before you consider managing hypoglycemia. Hypoglycaemia is more likely to cause sudden death than hyperglycaemia.