英文教学课件 糖尿病

nullDiabetes MellitusDiabetes MellitusZhao-xiaojuanIntroduction Introduction Diabetes mellitus is a heterogeneous group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.IntroductionIntroductionThe chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. SymptomsSymptomsPolyuria Polydipsia (thirst) Weight loss Weakness Polyphagia Blurred vision Recurrent infection Impairment of growthCriteria for diagnosis of diabetes (WHO1999)Criteria for diagnosis of diabetes (WHO1999) Symptoms of diabetes + Casual plasma glucose ≥ 1.1mmol/l(200mg/dl) Or FPG ≥ 7.0mmol/l (126mg/dl) Or 2-hPG ≥ 11.1mmol/l Diagnostic Criteria WHO1999Diagnostic Criteria WHO1999IGT -FPG<7mmol/L -2-h PG≥7.8mmol/L and <11.1mmol/L IFG -FPG≥6.1mmol/L and <7.0mmol/L Laboratory FindingsLaboratory FindingsUrinary glucose Urinary ketone Blood glucose (FPG and 2-hPG) HbA1c and FA(fructosamine) OGTT Insulin / CP releasing test Classification (1)Classification (1)Type 1 diabetes β-cell destruction, usually leading to absolute deficiency Immune-mediated diabetes Idiopathic diabetes Type 2 diabetes Ranging from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistanceClassification (2)Classification (2)Other specific types of diabetes Due to other causes, e.g.,genetic defects in insulin action, diseases of the exocrine pancreas, drug or chemical induced Gestational diabetes mellitus(GDM) diagnosed during pregnancy Etiologic classification of diabetes mellitus(1)Etiologic classification of diabetes mellitus(1)I.Type 1diabetes (  -cell destruction, usually leading to absolute insulin deficiency ) A. immune mediated B. Idiopathic II.Type 2diabetes ( may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance ) III.Other specific types A. genetic defects of  -cell function 1. Chromosome 12, HNF-1 (MODY3) 2. Chromosome 7, glucokinase (MODY2) 3. Chromosome 20, HNF-4 (MODY1) 4. Mitochondrial DNA 5. Others B. Genetic defects in insulin action 1. Type A insulin resistance 2. Leprechaunism 3. Rabson- Mendenhall syndrome 4. Lipoatrophic disease 5. Others C. Diseases of the exocrine pancreas 1. Pancreatitis 2. Trauma / pancreatectomy 3. Neoplasia 4. Cystic fibrosis 5. Hemochromatosis 6. Fibrocalculous pancreatopathy 7. OthersEtiologic classification of diabetes mellitus(2)Etiologic classification of diabetes mellitus(2) D. Endocrinopathies 1. Acromegaly 2. Cushing’s syndrome 3. Glucagonoma 4. Pheochromocytoma 5. Hyperthyroidism 6. Somatostatinoma 7. Aldosteronoma 8. Others E. Drud- or chemical-induced 1. Vacor 2. Pentamidine 3. Nicotinic acid 4. Glucocorticoid 5. Thyroid hormone 6. Diazoxide 7. -adrenergic agonists 8. Thiazides 9. Dilantin 10. -Interferon 11. Others F. Infections 1. Congenital rubella 2. Cytomegalovirus 3. Others Etiologic classification of diabetes mellitus(3)Etiologic classification of diabetes mellitus(3) G. Uncommon forms of immune- mediated diabetes 1. “Stiff-man” syndrome 2. Anti-insulin receptor antibodies 3. Others H. Other genetic syndromes sometimes associated with diabetes 1. Down’s syndrome 2. Klinefelter’s syndrome 3. Turner’s syndrome 4. Wolfram’s syndrome 5. Friedreich’s ataxia 6. Huntington’s chorea 7. Laurence-moon-Biedl syndrome 8. Myotonic dystrophy 9. Porphyria 10. Prader-Willi syndrome 11. Others IV. Gestational diabetes mellitus ( GDM ) Patients with any form of diabetes may require insulin treatment at some stage of their disease. Such use of insulin dose not, of itself, classify the patient.Type 1 DMType 1 DMGenerally <30 years Rapid onset Moderate to severe symptoms Significant weight loss Lean Ketonuria or keto-acidosis Low fasting or post-prandial C-peptide Immune markers(anti-GAD,ICA,IA-2)Type 2 DMType 2 DMGenerally ＞40 years Slowly onset Not severe symptoms Obese Ketoacidosis seldom occur Nonketotic hyperosmolar syndrome Normal or elevated C-peptide levels Genetic predispositionPathophysiological model for development of obesity and T2DMPathophysiological model for development of obesity and T2DMBeta-cell defectIntra-uterin growth retardationInsulin Resistance genesObesity genesInsulin Resistance + Intraabdominal obesityIGTT2DMWestern lifestyleGlucose toxicityMetabolic Insulin Resistance (FFA)080402060YearnullDisorder of glycemia: etiological types clinical stages StagesTypesNormoglycemia Hyperglycemia Diabetes mellitusType 1 Type 2 Other specific types Gestational diabetesNormal glucose toleranceIGT and/or IFGNot insulin requiringInsulin requiring for controlInsulin requiring for survivalAcute,life-threatening consequences Acute,life-threatening consequences Hyperglycemia with ketoacidosis Nonketotic hyperosmolar syndromeMicrovascular complicationsMicrovascular complicationsRetinopathy Nephropathy Peripheral neuropathy Autonomic neuropathyMacrovascular complicationsMacrovascular complicationsAtherosclerotic cardiovascular disease Peripheral vascular disease cerebrovascular diseaseOthersOthersHypertension Abnormalities of lipoprotein metabolism Periodontal disease Potential chronic complications of elevated HbA1cPotential chronic complications of elevated HbA1cgoodpoorcontrolRISKMicroalbuminuria Mild Retinopathy Mild NeuropathyAlbuminuria Macular Edema Proliferative Retinopathy Peridontal Disease Impotence Gastroparesis DepressionFoot Ulcers Angina Heart Attack Coronary Bypass Surgery Stroke Blindness Amputation Dialysis Kidney TransplantThe Aims of TreatmentThe Aims of TreatmentRelief of hyperglycemic symptoms Correction of hyperglycemia, ketonuria and hyperlipidemia Establishment and maintenance of a desirable body weight, and in children normal growth and development Avoidance of acute metabolic disturbance Prevent or delay the onset of the long-term complicationsTargets for controlTargets for controlManagementManagementEssentials of management Monitoring of glucose levels Food planning Physical activity Treatment of hyperglycemia2.Monitoring of Glucose Levels2.Monitoring of Glucose LevelsBlood glucose levels - before each meal - at bedtime Urine glucose testing Urine ketone tests (should be performed during illness or when blood glucose is 20mmol/L ) 3.Food Planning3.Food PlanningWeight control. 50-60%of the total dietary energy should come from complex carbohydrates. 20-25% form fats and oils. 15-20% from protein. Restrict alcohol intake. Restrict salt intake to below 7g/d. 4.Physical Activity4.Physical ActivityPhysical activity play an important role in the management of diabetes particularly in T2DM. Physical activity improves insulin sensitivity, thus improving glycemic control, and may help with weight reduction Do sparingly avoid sedentary activities Do regularly participate in leisure activities and recreational sports Do every day adopt healthy lifestyle habits5.Drug Treatment5.Drug TreatmentIf the patient is very symptomatic or has a very high blood glucose level, diet and lifestyle changes are unlikely to achieve target values. In this instance, pharmacological therapy should be started without delay.TreatmentTreatmentSulphonylureas Biguanides -Glucosidase inhibitors Thiazolidinediones Glinides Insulin Combination therapy1.Sulphonylureas1.SulphonylureasChlorpropamide Tolbutamide Glibenclamide Glipizide Gliclazide Gliguidone Glimepiride2.Biguanides2.BiguanidesMetformin Phenformin Buformin 3.-Glucosidase inhibitors3.-Glucosidase inhibitorsAcarbose Voglibose Miglitol4.Thiazolidinediones4.ThiazolidinedionesRosiglitazone Pioglitazone Ciglitazone 5.Glinides5.GlinidesNateglinide repaglinide6.Insulin6.InsulinInsulin is the most efficacious pharmacologic treatment for patients with diabetes6.Insulin6.InsulinIndication Preparation Therapy Adverse reactionManagement Algorithm for Overweight and Obese T2DMManagement Algorithm for Overweight and Obese T2DMDiet Exercise and weight control Failure Add biguanide, TZD or -glucosidase inhibitorsFailure Failure Combine two of these or add sulphonylurea or glinideAdd insulin or change to insulinCheck adherance at each stepManagement Algorithm for Non-Obese T2DMManagement Algorithm for Non-Obese T2DMFailure FailureFailureAdd sulphonylurea, biguanide, -glucosidase inhibitors or glinideCombine sulphonylurea or glinide with biguande and/or -glucosidase inhibitors and/or add TZDAdd insulin or change to insulinCheck adherance at each step