About this blog 💬

This is a blog about medicine that is intended to be used by doctors, medical students or anyone else that is curious to learn about diseases.

I am a medical doctor, my area of expertise is internal medicine. This is a very complex medical specialty that comprises  diseases from all of the organs, diseases that intricate and superimpose and this means a continuous intellectual challenge. Adding to this the continuous  progress and changes due to research, most of us feel like no matter how  many books you read you are still long behind with your  knowledge. Medicine is not all about studying, but studying is a big part of medicine so my plan is to make it easier, this  is the purpose of this blog. I believe that we need to have some "pillar of rock", the  basic knowledge, that something to build on. After achieving this, we can then  start  making connections, deduct, imagine, invent.

So my plan is to read medicine from reliable sources and to write in this blog the facts that are  relevant in my daily practice, those that I would like to know and remember. I usually use charts and diagrams to gather the information in  a more simpler and visual way.

I will not go deep,  I will make it short!

✌ Tania

Hyperglycemic emergencies

Diabetes Mellius type 2 - Oral and Insulin therapy-

Pharmacological Therapy for Type 2 Diabetes

Recommendations

• Metformin is the preferred initial pharmacological agent for type 2 diabetes. A

 Metformin may be safely continued down to glomerular filtration rate (GFR) of 45 mL/min/1.73 m2 or even 30 mL/min/1.73 m2. If metformin is used in the lower GFR range, the dose should be reduced and patients should be advised to stop the medication for nausea, vomiting, and dehydration.

• If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target over 3 months, then add a second oral agent, a glucagon-like peptide 1 receptor agonist, or basal insulin. 

• For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed. B

Insulin therapy

Basal insulin is usually prescribed in conjunction with metformin and possibly one additional noninsulin agent. 

Resources:
American Diabetes Association. Approaches to glycemic treatment. Sec. 7. In Standards of Medical Care in Diabetes—2016. Diabetes Care 2016;39(Suppl. 1):S52–S59

Diabetes mellitus

Types of DM

DM type 2 is characterised by hyperglycemia and variable degrees of insulin deficiency and resistance. Accounts for 90% of diabetes un adults

DM type 1 is characterised by destruction of the pancreatic beta cells leading to absolute insulin deficienc. Accounts fod 10% of diabetes in adults.
 Testing for islet cell antibodies (ICA) or other islet autoantibodies (antibodies to glutamic acid decarboxylase [GAD] 65, insulin, and to the tyrosine phosphatases, insulinoma-associated protein 2 [IA-2] and IA-2 beta, and zinc transporter ZnT8) in serum may be helpful if establishing the diagnosis is important. 

LADA (Latent autoimmune diabetes in adults) is DM with debut in adult ages that progresses to a insulin dependent phase. These patients may be  ICA or GAD antibodies positive.

Maturity onset diabetes of the young — Maturity onset diabetes of the young (MODY) is a clinically heterogeneous disorder characterized by non-insulin dependent diabetes diagnosed at a young age (<25 years) with autosomal dominant transmission and lack of autoantibodies [1]The diagnosis of MODY is made by performing diagnostic genetic testing by direct sequencing of the gene. It has features of both impaired insulin secretion and insulin resistance. 

Diseases of the exocrine pancreas 
Diseases that damage the pancreas, or removal of pancreatic tissue, can result in diabetes. Ex: pancreatectomy, pancreas cancer, pancreatitis, hemocromatosis. It uw usually insulin requiring but is even more prone to hypoglycemia than DM because glucagon producing cells are also demaged.

DRUG-INDUCED HYPERGLYCEMIA — Drugs can impair glucose tolerance by decreasing insulin secretion, increasing hepatic glucose production, or causing resistance to the action of insulin.
Included in this list are glucocorticoids, oral contraceptives, several classes of antihypertensive drugs such as beta blockers, thiazide diuretics, nicotinic acid, statins, protease inhibitors used for the treatment of human immunodeficiency virus (HIV) infection, gonadotropin-releasing hormone (GnRH) agonists used for the treatment of prostate cancer, tacrolimus

When to look for  antibodies?

We measure autoantibodies when the diagnosis of type 1 or type 2 diabetes is uncertain by clinical presentation:

●In patiens with poor response to initial therapy with sulfonylureas or metformin

●Personal or family history of autoimmune disease

●Overweight or obese children or adolescents presenting with apparent type 2 diabetes, who actually may have an early presentation of type 1 diabetes

References:

1. A difference between the inheritance of classical juvenile-onset and maturity-onset type diabetes of young.people. Tattersall RB, Fajans SS, Diabetes. 1975;24(1):44
2.Drug-induced hyperglycemia Luna B, Feinglos MNJAMA. 2001;286(16):1945.