diabetes mellitus mcmaster mini-med school march 17, 2004 dr. william harper assistant professor of...
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Diabetes mellitusDiabetes mellitus
McMaster Mini-Med School
March 17, 2004
Dr. William HarperAssistant Professor of Medicine, McMaster University.
Endocrinologist, Hamilton General Hospital
www.drharper.ca
Diabetes MellitusDiabetes Mellitus
Type 1, IDDM, Juvenile-onset
Type 2, NIDDM, Adult-onset
The pancreas!
Type 1 v.s. Type 2 DiabetesType 1 v.s. Type 2 Diabetes
Type 1 DM
(< 10%)
Type 2 DM
(> 90%)
Age of onset < 40 > 40
DKA Yes No
Weight Usually lean 80% overweight
Cause Autoimmune or unknown
No autoimmune markers
Pathophysiology of T1DMPathophysiology of T1DM
antibodiesattack islets!
Pathophysiology of T2DMPathophysiology of T2DM
Blood glucose
diet
Hepatic glucose output INSULIN
PeripheralTissueUptake
+
_
Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Normal Impaired glucosetolerance
Type 2 diabetes
Time
Insulinresistance
Insulinproduction
Glucoselevel
-celldysfunction
Rising DM Prevalence (Rising DM Prevalence (DiagnosedDiagnosed))
0
50
100
150
200
250
300
N (
mill
ion
s)
1995 2000 2025
Developed WorldDeveloping World
Whole World
5.9 6.2 7.6
3.3 3.54.9
4.04.2
5.4
(Decimal Numbers = Percent of the population affected)
Why is the prevalence of Type 2 Why is the prevalence of Type 2 Diabetes mellitus increasing?Diabetes mellitus increasing?
The answer is magically ridiculous…The answer is magically ridiculous…
Summary: Public Health ImpactSummary: Public Health Impact DM Prevalence - 1/14; 1/8 of age 40-75; 1/5 of 75+
- 1/3 unaware that they have DM- increasing throughout world
IGT - age 40-49: 12%- age 50-59: 14%- age 60-74: 21%
DM Risk in IGT: - from epi studies: 4 – 6%/year DM Impact (USA) - $130B/yr (much of it CVD)
Macrovascular Microvascular
Stroke
Heart disease and hypertension
2-4 X increased risk
Foot problems
Diabetic eye disease(retinopathy and cataracts)
Renal disease
Peripheral Neuropathy
Peripheral vascular disease
Diabetes: ComplicationsDiabetes: Complications
Meltzer et al. CMAJ 1998;20(Suppl 8):S1-S29.
Complications
Erectile Dysfunction
Disease Burden of Diabetes MellitusDisease Burden of Diabetes Mellitus
• Leading cause of blindness (12.5% of cases)• Leading cause of ESRD (42% of cases)• 50% of all non-traumatic amputations• 2.5x increase risk of stroke• 2-4x increase in cardiovascular mortality• DM responsible for 25% of cardiac surgeries• Mortality in DM: 70% due to Cardiovascular
disease
Haffner et al, NEJM, 339(4):229-34, 1998.Haffner et al, NEJM, 339(4):229-34, 1998.
Is there any reason to be hopeful?Is there any reason to be hopeful?
Is there any reason to be hopeful?Is there any reason to be hopeful?
YES!YES!
Evans et al.Evans et al.
BMJ 324: 939-942 April 2002 Cross-sectional study
DM 1155 patients MI 1347 patients
Cohort study DM 3477 patients MI 7414 patients
Insulin Glargine (Lantus)Insulin Glargine (Lantus)
Insulin Glargine (Lantus)Insulin Glargine (Lantus)
InsulinInsulin
Type Starts Peaks Duration
Humalog
NovoRapid
5-10 min 0.5-1hrs 3.5 hrs
Regular 30 min 2-4 hrs 6-8 hrs
NPH
Lente
1-2 hrs 6-10 hrs 16-24 hrs
Ultralente 4-6 hrs 8-24 hrs 24-36 hrs
Glargine 1.5h None Up to 24 hrs
GLUCOSE ABSORPTION
GLUCOSE PRODUCTION
Metformin Thiazolidinediones
MUSCLE
PERIPHERAL GLUCOSE UPTAKE Thiazolidinediones Metformin
PANCREAS
INSULIN SECRETION Sulfonylureas: Glyburide, Gliclazide, Glimepiride Non-SU Secretagogues: Repaglinide, Nateglinide
ADIPOSE TISSUELIVER
Alpha-glucosidase inhibitors
INTESTINE
Sites of Action of Currently Sites of Action of Currently Available Therapeutic OptionsAvailable Therapeutic Options
Control Zucker Rats ROSIG Zucker Rats
12 weeks
16 weeks
Thiazolidinedione Thiazolidinedione ββ-cell preservation: -cell preservation: Animal studiesAnimal studies
UKPDS 33, Lancet 352:837-53, 1998.
STENO-2, NEJM, 348:383-93, 2003.
DCCT, NEJM 329:977-86, 1993.
Heart Protection StudyHeart Protection Study
BP Trials in DM patientsBP Trials in DM patients
UKPDS atenolol = captopril at
reducing outcomes
(UKPDS 39) Benefit to reducing SBP <
120 (UKPDS 36, post-hoc subgroup analysis)
Currently SBP target < 120 being assessed in BP arm of the ACCORD Study
BP Trials in DM patientsBP Trials in DM patients
UKPDS: atenolol = captopril in events HOT: felodipine, CV events with DBP < 80 ALLHAT
Chlorthalidone > lisinopril or amlodipine (less CHF) Chlorthalidone BS/diagnosis of DM
LIFE (DM substudy) 1195 patients with DM/HTN/LVH Losartan > atenolol in CV death/MI/CVA despite equivalent
BP lowering effects
HOPE: not a BP trial per se
Effect of ACE InhibitionEffect of ACE Inhibitionin Diabetesin Diabetes
HOPE StudyHOPE Study
Relative Risk Reduction of Ramipril vs. Placebo in Subjects with Diabetes
22% Myocardial infarction p = 0.01
33% Stroke p = 0.0074
37% Cardiovascular death p = 0.0001
24% Overt nephropathy p = 0.027
17% Revascularization p = 0.031
20% Heart failure p = 0.019
Complications
DM NephropathyDM Nephropathy
Microalbuminuria: 30-300 mg/d (20-200 ug/min)Macroalbuminuria: > 300 mg/d (> 200 ug/min)
SmokingSmoking
Reducing risk in diabetesReducing risk in diabetes
Glycemic control: New insulins New oral agents CBG testing: new sites (forearm), smarter monitors
BP control ACE inhibitors Cholesterol control Aspirin Smoking cessation
Future…Future…
Non-invasive BS testingContinuous BS monitor + insulin pump
“Artificial Pancreas”
Islet cell transplants Stem-cell research
Energy homeostasis breakthroughs…
Cause for insulin resistance?Cause for Type 2 DM?Cause for obesity?
An exercise pill?