diabetes mellitus

see also:

• endocrinology
• Mx of 1st presentation diabetes mellitus
• Mx of the diabetic patient in ED
• insulin
• DDx of hyperglycaemia
• oral hypoglycaemic agents
• metformin
• hypoglycaemia
• diabetic ketoacidosis
• diabetes mellitus in children
• risk factors and aetiology of diabetes mellitus

• JAMA 2008: Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?(pdf)
• Aust Presc 2008 - Preventing foot ulcers
• MJA 2008 - Contemporary management of type 2 diabetes: blood glucose-lowering therapies and glycaemic targets - editorial
• Aust Presc 2008 - Incretin mimetics and enhancers: mechanisms of action
• Aust Presc 2008 - Incretin mimetics and enhancers: clinical applications
• Aust Presc 2008 - Editorial - Have glitazones lost their sparkle?
• Aust Presc 2007 - Managing foot infections in patients with diabetes
• Aust Presc 2007 - Metformin in pregnancy and lactation
• Aust Presc 2007 - Prescribing exercise for diabetes
• Aust. NHMRC 2005 - EBM guidelines for Mx of diabetes
• incidence and age of onset of IDDM (pdf)

• juvenile onset autoimmune type 1 diabetes
• adult onset diabetes:
  • type 1 diabetes:
    • severe autoimmune diabetes (SAID), including type 1 diabetes and latent autoimmune diabetes in adults (LADA)
  • type 2 diabetes:
    • severe insulin-deficient diabetes (SIDD)
    • severe insulin-resistant diabetes (SIRD)
    • mild obesity-related diabetes (MOD)
    • mild age-related diabetes (MARD)
• gestational diabetes
  • Womens Hospital Melbourne guidelines
  • https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/maternity/gestational-diabetes
    • Perform a random blood glucose level (RBGL) on all pregnant women at booking; ensure that they have not been fasting. Refer all women with risk factors and/or a RBGL >11.0 mmol/L for an oral glucose tolerance test (OGTT) at 14-16 weeks;

• genetic factors
  • especially for type 1 diabetes and MOD
  • having a parent, brother, or sister with type 1 diabetes is a risk factor for juvenile onset type 1 diabetes
  • in the United States:
    • White people are more likely to develop type 1 diabetes than African American and Hispanic or Latino people
    • higher risk for type 2 diabetes is in those who are African American, Hispanic or Latino, American Indian, or Alaska Native person as well as Pacific Islanders and Asian American people
  • however, genes promoting childhood adiposity are largely distinct from those promoting diabetes during adulthood.¹⁾
• other risk factors for type II diabetes:
  • childhood obesity:
    • 62% increased risk of LADA, a doubling of the risk of SIDD, a near-trebling of the risk of SIRD, and a 7-times increased risk of MOD ²⁾
  • adult obesity, non-alcoholic fatty liver disease
  • have prediabetes
    • intra-personal variability in fasting glucose levels in non-diabetics or pre-diabetics makes diagnosis harder when relying upon only a single fasting glucose measure - Mean FG was 96.2 ± 12.87 mg dl−1, rising by 0.234 mg dl−1 per year with age. Intraperson, day-to-day variability expressed as FG standard deviation was 7.52 ± 4.31 mg dl−1.³⁾
  • increasing age over 45yrs
  • sedentary lifestyle
  • PCOS - is associated with insulin resistance and more than half of women with PCOS develop type 2 diabetes by age 40
  • history of gestational diabetes which is more likely if
    • FH type 2 diabetes
    • overweight
    • polycystic ovary syndrome (PCOS)
    • an African American, Hispanic or Latino, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander person
    • NB. having gestational diabetes increases the risk of the baby developing childhood obesity and later type 2 diabetes

• a 50 year old with type 2 diabetes with no history of vascular disease has life expectancy reduced by 6 years compared to non-diabetics (these compares to 7 years reduction for smokers vs non-smokers)⁴⁾
  • ~40% of the years lost from diabetes can be attributed to nonvascular conditions including 10% attributable to death from cancer
  • vascular, cancer and noncancer, nonvascular mortality rises with fasting glucose above 6 mmol/L to 50% greater at levels of 7mmol/L, and 100% greater for vascular deaths at levels of 8mmol/L or higher.
• intensive glucose lowering with HbA1c target of < 6% instead of usual 7-7.9% target resulted in INCREASED 5 year mortality in type 2 diabetics.⁵⁾

• see also:
  • insulin
  • oral hypoglycaemic agents
    • sulphonylurea oral hypoglycaemics
    • metformin
    • glucagon-like peptide-1 (GLP-1) peptide analogs (eg. Ozempic)

• agents which block the renin-angiotensin-aldosterone-system (RAAS) have been used in the hope that they will reduce risk of chronic renal impairment in diabetics.
• in 2013, several trials of dual therapy (eg. ACEI with aldosterone inhibitor) called this strategy into question as risks of hyperkalaemia and episodes of acute renal failure appeared to outweigh benefits despite showing increased efficacy at lowering BP and decreasing albuminuria ⁶⁾:
  • VA NEPHRON-D trial: ARB +/- ACEI - trial stopped for safety reasons
  • ALTITUDE: (ACEI or ARB) + aliskiren (a direct renin inhibitor) - trial stopped for safety reasons
  • ONTARGET: ACEI + ARB

• concentrated extract from the desert berry Nitraria roborowskii Kom (NRK-C)
  • a 2025 mice study⁷⁾ suggested that 7 weeks of NRK-C acting via reactivation of PI3K/AKT pathway produced very positive results in diabetic mice:
    • dose dependent 30-40% reduction in fasting blood glucose levels
    • restored insulin sensitivity by approximately 50% compared to untreated diabetic controls
    • normalizing cholesterol profiles
    • reducing oxidative stress markers by up to 60%