Fig. 11.1 Plasma [glucose] changes in response to an oral glucose tolerance test. The shaded
area indicates the approximate limits within which responses to a 75 g load of anhydrous
glucose normally fall.
Glucose can be detected in urine specimens collected after the renal threshold for glucose
has been exceeded; the normal threshold corresponds to a plasma [glucose] of 10 mmol/L, and
the lowered threshold in patients with renal glucosuria to a lower level of plasma [glucose]. The
various responses to the glucose tolerance test are described in greater detail in the text
Oral glucose tolerance test (GTT) (Fig. 11.1)
The main value of a GTT is that it may help to establish the
diagnosis of diabetes mellitus or impaired glucose tolerance at
a time when the metabolic abnormality is mild. The GTT is
particularly valuable in the diagnosis of impaired glucose
tolerance in pregnancy (p. 316). Several precautions must be
observed in preparing for and in performing the test.
Before the test
It should not be performed on patients who are suffering from
the effects of trauma or recovering from a serious illness. It
should also be delayed if the patient has an intercurrent
infection. Drugs such as corticosteroids and diuretics may
impair glucose tolerance; they should be stopped before the
test, if possible
Islet cell antibodies that react specifically with the [3-cells of the
pancreas have been demonstrated in serum from over 90% of patients
with newly diagnosed type Ia diabetes; over the subsequent few years,
these antibodies usually disappear. They have also sometimes been
demonstrated in serum several years before clinical and biochemical
features of diabetes develop. Individuals with certain human leucocyte
antigens (HLA) have also been shown to have a particularly high risk of
developing type la diabetes. The importance of these immunological
findings is in their application to relatives of diabetic patients. If a
sibling has islet cell antibodies, or HLA characteristics identical with the
patient's, the sibling is potentially diabetic and has an increased
probability of developing impaired glucose tolerance or frank diabetes
mellitus.
Type lb patients show persistent islet cell antibodies and their
diabetes mellitus shows a clear association with other forms of auto-
immune endocrine disease. The age of presentation is, on average,
older than for the type Ia patients.
Present in older (over 40) patients who are obese, a condition that used to be
called`maturity onset' diabetes; it usually presents less,acutely than type I
diabetes. type II diabetes occurs in young patients.
Measurable levels of insulin are normally present, and the metabolic defect
awears to lie either in defective insulin secretion or in insulin resistance. Insulin
levels tend to be lower in the non-obese type II patient. In general, insulin is not
eciiiired for the prevention of ketosis as these patients are relatively resistant to
its ,1(welopment. However, insulin may be needed to correct abnormalities of
blood {glucose}
There appears to be no association between type H diabetes and either the
HLA system or the development of auto-immunity. However, there is a strong
c;c1 ietic element to the disorder. For instance, if one identical twin develops type
II diabetes,Thetes, there is a high probability that the other twin will develop it.
Secondary diabetes
The use of simple chemical 'side-room' tests by patients testing their own
urine specimens regularly for glucose and ketone bodies (p. 13, Table 2.2),
recording the results, and in some cases adjusting their treatment on the basis of
the glucose results, had been standard practice for many years before home-
monitoring of blood [glucose] was introduced. Proper control of diabetes mellitus
is essential if long-term complications are to be avoided or their onset delayed.
As a result of developments in methods for blood [glucose] measurement (p. 17),
their use in home-monitoring now provides a practical and preferable alternative
to urine testing. Nevertheless, many diabetic patients continue to achieve good
control using only urine testing to monitor and regulate their treatment.
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