Diabetes Mellitus Type I

DM I

Department of Family Medicine

and General Practice
RCSI
Format of module
Learning objectives
Epidemiology
Diagnosis & differential diagnosis
Investigation
Prognosis
Therapy
Continuing care
Formative assessment
Learning objectives

By the end of this module you should be

able to:
Make a diagnosis of DM I
Be aware of the medications involved in
the management of DM I
Understand some of the complications
of DM I
Epidemiology
2.4% of adults diagnosed
with DM
Represents 1.5 million
people in UK
10-15% DM I
Average GP has 48 DM
patients on his/her list
DM I usually presents in
people < 30yrs, but can
occur at any age
Peak age of onset is 10-14 yrs
Risk factors for DM I
Geographic origin
Family history
Presence of human
leucocyte antigen
DR3 or DR4 genotype
Pancreatic disease
Drugs
Endocrinopathies
Genetic syndromes
Diagnosis
DM I tends to present
acutely over several days
to include:
Rapid weight loss
Polyuria
Thirst
Tiredness and lethargy
Ketoacidosis
Diagnosis contd.
Subacute symptoms develop
over weeks to several
months and include:
Thirst
Polyuria/nocturia/urinary
incontinence
Tiredness and lethargy
Weight loss
Recurrent skin infections
Thrush infections (genital)
Blurred vision
Examination at diagnosis
Measurement of height,
weight and body mass
index (BMI)
Blood pressure
Eye examination
Cardiovascular
examination
Foot examination
Implications
Important legal and
medical
implications for the
patient

Essential you are

certain of the
diagnosis
World Health Organisations
diagnostic criteria for DM
Adopted by Diabetes UK
Laboratory estimates of glucose concentration in venous plasma
(mmol/l)

Fasting Oral Glucose Tolerance Test Random

(OGTT)
7.0 11.1 11.1

If patient symptomatic one raised glucose reading sufficient

If asymptomatic repeat the test on another day
A diagnosis of DM should never be made on the basis of
glycosuria or fingerprick glucose readings
Investigations
FBC
Serum creatinine
Urea and electrolytes
Liver function tests
Thyroid function test
Fasting lipid profile
Haemoglobin A1c
Urinalysis for glucose,
ketones protein
Microalbuminuria
ECG
Prognosis
Mortality rates twice as
high among middle aged
people with DM than
among middle aged
people without DM
Intensive control of
hyperglycaemia prevents
microvascular and
neuropathic
complications in DM I
Therapy
Non pharmacological

Explain aims of treatment

relation between blood glucose,
diet and exercise
Dietician review
Healthy lifestyle physical activity
Smoking cessation
Self-monitoring with home
glucose testing
Explain poor glucose control will
lead to complications
Importance of screening for
complications
Regular foot care and foot hygeine
Therapy
Pharmacological
DM I Insulin therapy/ 4
main types
Started at hospital
GPs should be aware of
insulin drugs and how to
adjust the regimen
Insulin usually initiated at
0.25-0.5units/kg/day and
will be titrated according to
blood glucose control
Choice of insulin
Compliance or
resistance to
injections
Risk of
hypoglycaemia
Lifestyle
Age
Complications
Important points to remember
with insulin

Injection technique
Site of injection
Sick day rules
Complications from
injecting insulin
Insulin regimens
Multiple injection or
basal bolus therapy
Twice daily therapy
Three times daily
therapy
Insulin glargine and
insulin detemir
Continuous
subcutaneous insulin
infusion therapy
Intensive control of
hyperglycaemia
Benefits
Side effects
Evidence
Goals
Monitoring
Regimens
When to refer?
Emergency referral
Acute-onset symptoms
suggestive of DM I
Children with DM
should be referred on
the same day as
diagnosis
Blood glucose >
25mmol/l and ketones
in urine
When to refer contd.?
Routine referral
Uncontrolled hyperglycaemia
Uncontrolled hypertension
Persistent proteinuria
Creatinine level >150mol/l
Retinopathy or visual impairment
Painful neuropathy/
mononeuropathy/ amyotrophy
At risk feet (foot ulcers urgent
referral)
Pyschological problems related to
diagnosis
Continuing care

Eyes
Feet
Kidneys/microalbuminuria
Screening for complications
is thus important
Complications
When to refer?

Eyes opthalmologist
annually
Feet 6 monthly by
podiatrist
Foot ulcers urgent referral
Ischaemic DM foot vascular surgeon
Diabetic renal disease nephrologist once
serum creatinine >
150mol/l
How to treat complications
Eye problems - medical ACE inhibitors
- surgical laser
Foot ulcers - medical IV abs/rest
- surgical debridement
Microalbuminuria- medical glycaemic
control
BP
ACE inhibitors
Final aims in DM I

Aim for
Haemoglobin A1c < 7.0%
Blood Pressure < 130/80 mm Hg
Fasting plasma glucose <4.46.1mmol/l
Total cholesterol < 4.0 mmol/l
Low-density lipoprotein < 2.0 mmol/l
Fasting triglycerides <1.7 mmol/l
Formative assessment