Академический Документы
Профессиональный Документы
Культура Документы
AAs additional subtypes are discovered it is anticipated that they will be reclassified
within their own specific category.
AAIncludes the former categories of gestational impaired glucose tolerance and gestational
diabetes.
I. Type 1 (betaBcell destruction, usually leading to absolute insulin deficiency)
1
". "utoimmune Diabetes Mellitus
#ynonyms$ InsulinBdependent diabetes (I**(), 5ype diabetes, or CuvenileB onset
diabetes,
It results from autoimmune mediated destruction of the beta cells of the pancreas.
Variations
5he rate of destruction is Duite variable, being rapid in some individuals and slow in
others.
o The rapidly pro%ressi&e form$ commonly observed in children, but also may
occur in adults.
o The slo'ly pro%ressi&e formE generally occurs in adults and is sometimes
referred to as latent autoimmune diabetes in adults (4A*A).
pathophysiology
>ome patients, particularly children and adolescents, may present with -etoacidosis
as the first manifestation of the disease.
)thers have modest fasting hyperglycaemia that can rapidly change to severe
hyperglycaemia and8or -etoacidosis in the presence of infection or other stress.
>till others, particularly adults, may retain residual betaBcell function, sufficient to
prevent -etoacidosis, for many years. Individuals with this form of 5ype diabetes
often become dependent on insulin for survival eventually and are at ris- for
-etoacidosis. At this stage of the disease, thereis little or no insulin secretion as
manifested by low or undetectable levels of plasma !Bpeptide.
Mar(ers of immune destruction$
Islet cell autoantibodies, and8or autoantibodies to insulin, and Autoantibodies to
glutamic acid decarbo7ylase (GA*) are present in 31BF# G of individuals with 5ype
diabetes mellitus when fasting diabetic hyperglycaemia is initially detected. 5he
pea- incidence of this form of 5ype diabetes occurs in childhood and adolescence,
but the onset may occur at any age, ranging from childhood to the ninth decade of life.
5here is a genetic predisposition to autoimmune destruction of beta cells, and it is also
related to environmental factors that are still poorly defined. Although patients are
usually not obese when they present with this type of diabetes, the presence of obesity
is not incompatible with the diagnosis. 5hese patients may also have other
autoimmune disorders such as Graves: disease, $ashimoto:s thyroiditis, and
Addison:s disease.
). Idiopathic
pathophysiology
5here are some forms of 5ype diabetes which have no -nown aetiology. >ome of these
patients have permanent insulinopenia and are prone to -etoacidosis, but have no evidence of
autoimmunity. 5his form of diabetes is more common among individuals of African and
Asian origin. In another form found in Africans an absolute reDuirement for insulin
replacement therapy in affected patients may come and go, and patients periodically develop
-etoacidosis.
II. Type 2 (predominantly insulin resistance 'ith relati&e insulin deficiency or
predominantly an insulin secretory defect 'ith*'ithout insulin resistance
1
#ynonyms$ %onB insulinBdependent diabetes (%I**(), or adultBonset diabetes.
It is a term used for individuals who have relative (rather than absolute) insulin deficiency.
/eople with this type of diabetes freDuently are resistant to the action of insulin. At least
initially, and often throughout their lifetime, these individuals do not need insulin treatment to
survive.
&eaturesE
5his form of diabetes is freDuently undiagnosed for many years because the
hyperglycaemia is often not severe enough to provo-e noticeable symptoms of
diabetes.
%evertheless, such patients are at increased ris- of developing macrovascular and
micro vascular complications.
5here are probably several different mechanisms which result in this form of diabetes,
and it is li-ely that the number of people in this category will decrease in the future as
identification of specific pathogenic processes and genetic defects permits better
differentiation and a more definitive classification with movement into =)ther types?.
pathophysiology
Although the specific aetiologies of this form of diabetes are not -nown, by definition
autoimmune destruction of the pancreas does not occur.
5he maCority of patients with this form of diabetes are obese, and obesity itself causes
or aggravates insulin resistance. (any of those who are not obese by traditional
weight criteria may have an increased percentage of body fat distributed
predominantly in the abdominal region.
III. Other #pecific Types
1
". Genetic defects of betacell function
(any genetic defects have been identified in association with diabetes mellitus such as
(onogenic defects in betaBcell function, freDuently characteri;ed by onset of mild
hyperglycaemia at an early age (generally before age "1 years). 5hey are usually
inherited in an autosomal dominant pattern. /atients with these forms of diabetes,
formerly referred to as maturityB onset diabetes of the young (()*+), have impaired
insulin secretion with minimal or no defect in insulin action.
Abnormalities at three genetic loci on different chromosomes have now been
characteri;ed.
o 5he most common form is associated with mutations on chromosome " in a
hepatic nuclear transcription factor referred to as $%&H.
o A second form is associated with mutations in the gluco-inase gene on
chromosome ,p. Gluco-inase converts glucose to glucoseB2Bphosphate, the
metabolism of which in turn stimulates insulin secretion by the beta cell. 5hus,
gluco-inase serves as the =glucose sensor? for the beta cell. Because of defects
pathophysiology
in the gluco-inase gene, increased levels of glucose are necessary to elicit
normal levels of insulin secretion.
o A third form is associated with a mutation in the $%&'H gene on chromosome
"#D. $%&'H is a transcription factor which is involved in the regulation of the
e7pression of $%&H.
o A fourth variant has recently been ascribed to mutations in another
transcription factor gene, I/&B, which in its homo;ygous form leads to total
pancreatic agenesis.
>pecific genetic defects in other individuals who have a similar clinical presentation are
currently being defined.
/oint mutations in mitochondrial *%A have been found to be associated with
diabetes mellitus and deafness. 5he most common mutation occurs at position ."'. in
the t6%A leucine gene, leading to an A to G substitution. An identical lesion occurs in
the (94A> syndrome ((itochondrial myopathy, 9ncephalopathy, 4actic Acidosis,
and >tro-eBli-e syndrome)0 however, diabetes is not part of this syndrome, suggesting
for un-nown reasons different phenotypic e7pressions of this genetic lesion.
Genetic abnormalities that result in the inability to convert pro-insulin to insulin have
been identified in a few families. >uch traits are usually inherited in an autosomal
dominant pattern and the resultant carbohydrate intolerance is mild.
(utant insulin molecules with impaired receptor binding have been identified in a
few families. 5hese are also associated with autosomal inheritance and either normal
or only mildly impaired carbohydrate metabolism
). Genetic defects in insulin action
pathophysiology
5here are some unusual causes of diabetes which result from genetically determined
abnormalities of insulin action.
5he metabolic abnormalities associated with mutations of the insulin receptor may
range from hyperinsulinaemia and modest hyperglycaemia to symptomatic diabetes
.>ome individuals with these mutations has acanthosis nigricans.
@omen may have virili;ation and have enlarged, cystic ovaries. In the past, this
syndrome was termed 5ype A insulin resistance.
4eprechaunism and 6absonB(endenhall syndrome are two paediatric syndromes that
have mutations in the insulin receptor gene with subseDuent alterations in insulin
receptor function and e7treme insulin resistance .5he former has characteristic facial
features while the latter is associated with abnormalities of teeth and nails and pineal
gland hyperplasia.
+. Diseases of the e,ocrine pancreas
Any process that diffusely inCures the pancreas can cause diabetes.
AcDuired processes include pancreatitis, trauma, infection, pancreatic carcinoma, and
pancreatectomy.
@ith the e7ception of cancer, damage to the pancreas must be e7tensive for diabetes
to occur. $owever, adenocarcinomas that involve only a small portion of the pancreas
have been associated with diabetes. 5his implies a mechanism other than simple
reduction in betaBcell mass.
If e7tensive enough, cystic fibrosis and haemochromatosis will also damage beta cells
and impair insulin secretion.
pathophysiology
&ibrocalculous pancreatopathy may be accompanied by abdominal pain radiating to
the bac- and pancreatic calcification on IBray and ductal dilatation. /ancreatic
fibrosis and calcified stones in the e7ocrine ducts are found at autopsy.
D. -ndocrinopathies
>everal hormones (e.g. growth hormone, cortisol, glucagon, and epinephrine) antagoni;e
insulin action. *iseases associated with e7cess secretion of these hormones can cause
diabetes (e.g. Acromegaly, !ushing:s syndrome, Glucagonoma and /haeochromocytoma).
5hese forms of hyperglycaemia typically resolve when the hormone e7cess is
removed. >omatostatinoma, and aldosteronomaBinduced hypo-alaemia, can cause diabetes,
at least in part by inhibiting insulin secretion. $yperglycaemia generally resolves following
successful removal of the tumour.
-. Dru% or chemicalinduced diabetes
(any drugs can impair insulin secretion. 5hese drugs may not, by themselves cause diabetes
but they may precipitate diabetes in persons with insulin resistance .In such cases, the
classification is ambiguous, as the primacy of betaB cell dysfunction or insulin resistance is
un-nown.
!ertain to7ins such as Jacor (a rat poison) and pentamidine can permanently destroy
pancreatic beta cells.
5here are also many drugs and hormones which can impair insulin action. 97amples
include nicotinic acid and glucocorticoids.
5he following list shows the more commonly recogni;ed drug, hormone, or to7in induced
forms of diabetes and hyperglycaemia.
pathophysiology
Dru%. or +hemical.induced Diabetes
%icotinic acid
Glucocorticoids
5hyroid hormone
Alpha-adrenergic agonists
Beta-adrenergic agonists
5hia;ides
*ilantin
/entamidine
Jacor
Interferon-alpha therapy
)thers
/. Infections
!ertain viruses have been associated with betaBcell destruction. *iabetes occurs in some
patients with congenital rubella. In addition, !o7sac-ie B, cytomegalovirus and other viruses
(e.g. adenovirus and mumps) have been implicated in inducing the disease
G. 0ncommon but specific forms of immunemediated diabetes mellitus
*iabetes may be associated with several immunological diseases with a pathogenesis or
aetiology different from that which leads to the 5ype diabetes process.
pathophysiology
/ostprandial hyperglycaemia of a severity sufficient to fulfil the criteria for diabetes
has been reported in rare individuals who spontaneously develop insulin
autoantibodies. $owever, these individuals generally present with symptoms of
hypoglycaemia rather than hyperglycaemia.
5he =stiff man syndrome? is an autoimmune disorder of the central nervous system,
characteri;ed by stiffness of the a7ial muscles with painful spasms. Affected people
usually have high titres of the GA* autoantibodies and appro7imately one-half will
develop diabetes. /atients receiving interferon alpha have been reported to develop
diabetes associated with islet cell autoantibodies and, in certain instances, severe
insulin deficiency.
AntiBinsulin receptor antibodies can cause diabetes by binding to the insulin receptor,
thereby reducing the binding of insulin to target tissue. $owever, these antibodies also
can act as an insulin agonist after binding to the receptor and can thereby cause
hypoglycaemia. AntiBinsulin receptor antibodies are occasionally found in patients
with systemic lupus erythematosus and other autoimmune diseases. As in other states
of e7treme insulin resistance, patients with antiBinsulin receptor antibodies often have
acanthosis nigricans. In the past, this syndrome was termed 5ype B insulin resistance.
1. Other %enetic syndromes sometimes associated 'ith diabetes
(any genetic syndromes are accompanied by an increased incidence of diabetes mellitus.
5hese include the chromosomal abnormalities of *own:s syndrome, Klinefelter:s syndrome
and 5urner:s syndrome.
@olfram:s syndrome is an autosomal recessive disorder characteri;ed by insulinB
deficient diabetes and the absence of beta cells at autopsy. Additional manifestations
pathophysiology
include diabetes insipidus, hypogonadism, optic atrophy, and neural deafness. 5hese
and other similar disorders are listed in the following 5able.
Other Genetic #yndromes #ometimes "ssociated 'ith Diabetes
*ownLs syndrome
&riedreichLs ata7ia
$untingtonLs chorea
KlinefelterLs syndrome
4awrence-(oon-Biedel syndrome
(yotonic dystrophy
/orphyria
/rader-@illi syndrome
5urnerLs syndrome
@olframLs syndrome
)thers
IV.Gestational 1yper%lycaemia and Diabetes
1
DefinitionE Gestational diabetes is carbohydrate intolerance resulting in hyperglycaemia of
variable severity with onset or first recognition during pregnancy.
*ifference between =diabetes mellitus and pregnancy? and Gestational $yperglycaemia
It does not e7clude the possibility that the glucose intolerance may antedate
pregnancy but has been previously unrecogni;ed. 5he definition applies irrespective
of whether or not insulin is used for treatment or the condition persists after
pregnancy.
@omen who become pregnant and who are -nown to have diabetes mellitus which
antedates pregnancy do not have gestational diabetes but have =diabetes mellitus and
pregnancy? and should be treated accordingly before, during, and after the pregnancy.
pathophysiology
In the early part of pregnancy (e.g. first trimester and first half of second trimester)
fasting and postprandial glucose concentrations are normally lower than in normal,
nonB pregnant women. 9levated fasting or postprandial plasma glucose levels at this
time in pregnancy may well reflect the presence of diabetes which has antedated
pregnancy, but criteria for designating abnormally high glucose concentrations at this
time have not yet been established. 5he occurrence of higher than usual plasma
glucose levels at this time in pregnancy mandates careful management and may be an
indication for carrying out an )G55 .%evertheless, normal glucose tolerance in the
early part of pregnancy does not itself establish that gestational diabetes may not
develop later.
Individuals at high ris- for gestational diabetes include older women, those with previous
history of glucose intolerance, those with a history of large for gestational age babies, women
from certain highBris- ethnic groups, and any pregnant woman who has elevated fasting, or
casual, blood glucose levels. It may be appropriate to screen pregnant women belonging to
highBris- populations during the first trimester of pregnancy in order to detect previously
undiagnosed diabetes mellitus. &ormal systematic testing for gestational diabetes is usually
done between "' and "3 wee-s of gestation
V."l2heimer3s Disease Is Type ! Diabetes
2
5he term =type . diabetes? accurately reflects the fact that A* represents a form of
diabetes that selectively involves the brain and has molecular and biochemical features that
overlap with both type diabetes mellitus and 5"*(
Al;heimer:s disease (A*) has characteristic histopathological, molecular, and
biochemical abnormalities, including cell loss0 abundant neurofibrillary tangles0 dystrophic
pathophysiology
neurites0 amyloid precursor protein, amyloid-M (A//-AM) deposits0 increased activation of
prodeath genes and signaling pathways0 impaired energy metabolism0 mitochondrial
dysfunction0 chronic o7idative stress0 and *%A damage. Gaining a better understanding of
A* pathogenesis will reDuire a framewor- that mechanistically interlin-s all these
phenomena.
5he pathophysiology of *( revolves around impairment of insulin secretion, insulin
resistance, or both, resulting in reduced utili;ation of glucose, hyperglycemia, and
impairment of fatty acid metabolism. >ymptoms and complications of *( are due to
hyperglycemia as well as lac- of adeDuate insulin action.
Glucose (etabolismE
!arbohydrates, bro-en down mainly into glucose, are an important source of energy in
humans. !onsideration of glucose and insulin metabolic pathways is crucial to understanding
the pathophysiology of *( (&igure ).
.
Glucose is derived from three sourcesE intestinal absorption following digestion of dietary
carbohydrates0 glycogenolysis, the brea-down of glycogen, which is the polymeri;ed storage
form of glucose0 and gluconeogenesis, the formation of glucose from precursors including
lactate (and pyruvate), amino acids (especially alanine and glutamine), and to a lesser e7tent,
glycerol.
'
)nly the liver and -idneys are capable of releasing glucose into circulation by
glycogenolysis and gluconeogenesis. All tissues can utili;e glucose as a substrate for energy
production, but only the brain is wholly dependent upon glucose as its main energy source.
5hus mechanisms to maintain a steady-state supply of glucose to the central nervous system
are integral to metabolic control. Both insulin-dependent and non- insulin independent
pathways can determine whole body clearance of glucose.
'
Glucose is transported into the
cells by specific transporters, activated by phosphorylation to glucose-2- phosphate by the
&igure . Action of Insulin N Glucagon under &eeding N &asting !onditions
&eeding, satiety, and the neurohumoral response to feeding are integrated by the brain, especially the
hypothalamus. 5his consists of the vagal system, incretin hormone secretion, and gut motility hormones, among
other mechanisms.
<pon feeding, the neurohormonal response, as well as direct glucose stimulation of the pancreas, results in
activation of pathways that will lead to efficient insulin secretion as well as a decrease in glucagon secretion
from the Islets of 4angerhans in the pancreas into the portal tract. 5his results in increased liver upta-e of
glucose, inhibition of hepatic gluconeogenesis, increased fatty acid synthesis, and J4*4 secretion and increased
glycogen storage. Although the maCority of insulin is cleared by the liver, it also reaches the central circulation
where in the fat, it increases glucose upta-e and triglyceride storage, and inhibits free fatty acid release. In
muscle, insulin increases glucose upta-e and glycogen storage0 in the -idney it inhibits gluconeogenesis.
<nder fasting conditions, the neurohumoral response is switched to maintenance of glucose levels, resulting in
decreased insulin and increased glucagon secretion, with the resultant opposite effects on the above-described
target organs. In the liver, gluconeogenesis, glycogenolysis, and fatty acid brea-down is stimulated. In adipose
tissues, fat is mobili;ed with increased lipolysis and free-acid release. In muscle, decreased glucose upta-e and
increase fatty acid catabolism ta-e place. All of these actions are tightly regulated and coordinated to account for
all physiological processes, ranging from short-term energy e7penditure (such as e7ercise) to both short- and
long term fasting. In addition, many other hormones (e.g., cortisol, growth hormones, catecholamines) are
tissue-specific en;ymes he7o-inase or gluco-inase, allowing it to enter metabolic pathways
such as the glycolysis, glycogen synthesis, he7osamine biosynthesis (alternative pathway to
glycolysis), or pentose phosphate pathways.
'
5hese pathways are subCect to regulation by
insulin, as well as glucagon. It is important to note that entry of glucose into different tissues
is regulated by e7pression of different glucose transporters0 in muscle and fat, glucose entry
is allowed only via an insulin-dependent translocation of the glucose transporter (G4<5)-',
to the cell surface, whereas in the brain, G4<5- is constitutively active and not dependent
upon insulin action. Insulin regulates glucose upta-e, inhibits glycogen brea-down and
gluconeogenesis, whereas glucagon has the opposite effects.3 $ence, absolute deficiency of
insulin (as in 5ype *(), or relative (as in 5ype " *(), is associated with decreased
clearance of blood glucose from the body and leads to hyperglycemia.
.
6ole of Insulin in the Body
Insulin is secreted by b-cells of Islets of 4angerhans, an endocrine organ, present in the
pancreas. 5he pancreatic islet comprises a group of cells, termed O-, P-, and Q-cells,
surrounded by e7ocrine pancreas. 5hese islets synthesi;e and release a number of hormones,
the classic ones being insulin and amylin from the P -cell, glucagon from the O cell,
somatostatin from the Q -cell, as well as a number of other bioactive polypeptides. Insulin is
synthesi;ed as a pro-hormone, transported to granules where it is processed by a pro-protein
convertase, resulting in mature insulin, !-peptide (by product of proinsulin processing), and
amylin. 5hese are stored in these mature granules until released upon stimulation of the b-
cell. Insulin production usually e7ceeds the need, so the unreleased granules are stored or
destroyed in the lysosomal compartment of the b-cell. Glucose is the primary stimulant of
insulin secretion, and o7idative metabolism of glucose is reDuired for glucose to stimulate
granule e7ocytosis. A number of other secretagogues, including hormones, gut peptides, and
amino acids also have the ability to provo-e insulin secretion.
Insulin:s primary physiologic function in the body can be described as anabolic, resulting in
storage of fuels from ingested carbohydrate and fat and regulating catabolism of stored fuel.
Its main target tissues are liver s-eletal muscle, and adipose tissue and its action on these
tissues (or lac- thereof) is responsible for the systemic effects of insulin. If insulin is the
=+in,? a group of hormones such as glucagon, cortisol, and growth hormone comprise the
=+ang? to counteract and -eep the metabolism in balance for energy needs. <nder feeding
conditions, with entry of nutrients, insulin increases and glucagon decreases, resulting in
storage of the incoming nutrients. <nder fasting conditions, insulin decreases, glucagon
increases, resulting in increased lipolysis from fat to allow fatty acids to be transported to the
liver and other tissues, and increased gluconeogenesis from the liver (and -idney) to maintain
blood glucose, and some glycogenolysis. <nder prolonged starvation, fatty acids are
metaboli;ed to -etone bodies to supply the central nervous system with fuel, in addition to
the glucose.
Insulin e7erts its action by binding to a cell-surface receptor, the insulin receptor (I6), which
has an e7tracellular and intracellular domain. Intracellular domain possesses tyrosine-specific
protein -inase activity, which activated by insulin binding, phosphorylates several intra-
cellular proteins, specifically insulin receptor substrates (I6>) -, -", -., and -' (&igure ").
5hese phosphorylated I6>s lead to activation of multiple downstream signaling pathways and
ultimately to activation of metabolic pathways, including increased upta-e of glucose by
muscle and fat, activation of glycogen synthesis, and suppression of gluconeogenesis by liver
and lipolysis by fat. In addition to carbohydrate metabolism, insulin has several other actions.
Its principle effect on adipose tissue is to suppress lipolysis, increase upta-e of fatty acids,
and synthesi;e triglycerides, thus -eeping circulating free fatty acid levels in chec-.
Insulin >ignaling /athways
1
9levated free fatty acids inhibit glucose utili;ation by peripheral tissues and also increase
hepatic gluconeogenesis. *isordered metabolism of fatty acids has been proposed as having a
maCor effect on pathophysiology in diabetes. Insulin:s effect on adipose tissue appears to be
as important as its effects on carbohydrate metabolism. 5he development of *( thus
involves not only pancreatic b-islet cell dysfunction8 destruction, but also involves action of
insulin in the periphery. Although attention is usually focused on insulin, it is important to
Insulin signaling occurs via many pathways and leads to the various actions of insulin. 5hese signaling
pathways interact with many other pathways that are not depicted (e.g., cortisol, epinephrine, glucagon) and
the concept of critical nodes has been evo-ed to e7plain some -ey interactions. !ritical nodes form an
important part of the signaling networ- that functions downstream of the insulin receptor (I6Rblac-
arrows) and the insulin growth factor- receptor (IG&6Rblue arrows). >ignaling pathways that are
activated by cyto-ines such as tumor necrosis factor-O (5%&-O), interleu-in-2 (I4-2), and leptin interfere
with insulin signaling through crosstal- (orange and red arrows). 5hree important nodes in the insulin
pathway are the I6, the I6 substrates (I6> -'Rlight blue bo7), the phosphatidylinositol .--inase (/I.K)
with its several regulatory and catalytic subunits (light green bo7), and the three AK58protein -inase B
(/KB) isoforms (pin- bo7). *ownstream or intermediate effectors as well as modulators of these critical
nodes includeE
S A-t substrate of 2# -*a (A>2#)
S atypical protein -inase ! (a/K!)
S !as-Br-( (murine)
S !bl-associated protein (!A/)
S !otropic retroviral transforming seDuence homo logue (!bl)
S !ell-division cycle '" (!*!'")
S c-Tun-%-terminal -inase (T%K)
S 97tracellular signal-regulated -inase and " (96K and 96K")
S &or-head bo7 ) (&)I))
S Glycogen synthase -inase . (G>K.)
S Tanus -inase (TAK)
S mammalian target of rapamycin (m5)6)
S pF# ribosomal protein >2 -inase (pF#6>K)
S /hosphatase and tensin homologue (/59%)
S /hosphoinositide-dependent -inase and " (/*K and ")
S /rotein tyrosine phosphatase-B (/5/B)
S 6ac
S 6as
S 6as homologue gene family, member U (A6$U0 also called 5!#)
S >ignal transducer and activator of transcription (>5A5)
S >rc-homology-"-containing protein (>hc)
S >uppressor of cyto-ine signaling (>)!>)
ac-nowledge the role counter-regulatory hormones (the =+ang?) play to fully understand the
pathophysiology of *(.
The Oral Glucose Tolerance Test
4
5he oral glucose tolerance test ()G55) is principally used for diagnosis when blood glucose
levels are eDuivocal, during pregnancy, or in epidemiological studies.
5he )G55 should be administered in the morning after at least three days of unrestricted diet
(greater than 1# g of carbohydrate daily) and usual physical activity. 6ecent evidence
suggests that a reasonable (.#B1#g) carbohydrate containing meal should be consumed on the
evening before the test. 5he test should be preceded by an overnight fast of 3B' hours,
during which water may be drun-. >mo-ing is not permitted during the test. 5he presence of
factors that influence interpretation of the results of the test must be recorded (e.g.
medications, inactivity, infection, etc.).
5rocedure
After collection of the fasting blood sample, the subCect should drin- ,1 g of
anhydrous glucose or 3".1 g of glucose monohydrate (or partial hydrolysates of starch
of the eDuivalent carbohydrate content) in "1#B.## ml of water over the course of 1
minutes.
&or children, the test load should be .,1 g of glucose per -g body weight up to a total
of ,1 g of glucose.
5iming of the test is from the beginning of the drin-. Blood samples must be collected
" hours after the test load.
<nless the glucose concentration can be determined immediately, the blood sample
should be collected in a tube containing sodium fluoride (2 mg per ml whole blood)
and immediately centrifuged to separate the plasma0 the plasma should be fro;en until
the glucose concentration can be estimated.
Methods for measurin% substances in blood and urine
4
(easurement of glucose in blood
6eductiometric methods (the >omogyiB%elson, the ferricyanide and neocuprine autoanalyser
methods) are still in use for blood glucose measurement.
5he oBtoluidine method also remains in use but en;ymeBbased methods are widely available,
for both laboratory and nearBpatient use.
$ighly accurate and rapid (B" min) devices are now available based on immobili;ed glucose
o7idase electrodes.
$e7o-inase and glucose dehydrogenase methods are used for reference.
@hole blood samples preserved with fluoride show an initial rapid fall in glucose of up to #
G at room temperature, but subseDuent decline is slow0 centrifugation prevents the initial fall.
@hole blood glucose values are 1 G lower than corresponding plasma values in patients
with a normal haematocrit reading, and arterial values are about , G higher than
corresponding venous values.
5he use of reagentBstrip glucose o7idase methods has made bedside estimation of blood
glucose very popular. $owever, the cost of the reagentBstrips remains high.
>ome methods still reDuire punctilious techniDue, accurate timing, and storage of strips in
airtight containers. 6easonably Duantitative results can be obtained even with visual colourB
matching techniDues. 9lectrochemical and reflectance meters can give coefficients of
variation of well under 1G. 6eagentBstrip methods have been validated under tropical
conditions, but are sensitive to e7treme climatic conditions.
*iabetes may be strongly suspected from the results of reagentBstrip glucose estimation, but
the diagnosis cannot be confidently e7cluded by the use of this method. !onfirmation of
diagnosis reDuires estimation by laboratory methods.
/atients can easily collect small blood samples themselves (either in specially prepared
plastic or glass capillary tubes or on filterBpaper), and selfBmonitoring using glucose
reagentBstrips with direct colourBmatching or meters is now widely practised. /atients should
be properly trained in the appropriate techniDues to avoid inaccurate or misleading results.
Glycemic profile$ 5he insulinBtreated patient is commonly reDuested to build up a
=glycaemic profile? by selfBmeasurement of blood glucose at specific times of the day (and
night). A =,Bpoint profile? is useful, with samples ta-en before and F# min after brea-fast,
before and F# min after lunch, before and F# min after an evening meal, and Cust before going
to bed. )ccasionally patients may arrange to wa-e at #.## h to collect and measure a
nocturnal sample. 5he complete profile rarely needs to be collected within a single "'Bhour
period, and it may be compiled from samples collected at different times over several days.
2
(easurement of glucose in urine
2
InsulinBtreated patients who do not have access to facilities for selfBmeasurement of blood
glucose should test urine samples passed after rising, before main meals, and before going to
bed.
%onBinsulinBdependent patients do not need to monitor their urine so freDuently. <rine tests
are of somewhat limited value, however, because of the great variation in urine glucose
concentration for given levels of blood glucose. 5he correlation between blood and urine
glucose may be improved a little by collecting shortBterm fractions (1B.# min) of the urine
output. Benedict:s Duantitative solution or selfBboiling, caustic soda8copper sulphate tablets
may be used or the more convenient, but costly, semiBDuantitative en;ymeBbased testB strips.
6etone bodies in urine and blood
2
5he appearance of persistent -etonuria associated with hyperglycaemia or high levels of
glycosuria in the diabetic patient points to an unacceptably severe level of metabolic
disturbance and indicates an urgent need for corrective action. 5he patient should be advised
to test for -etone bodies (acetone and acetoBacetic acid) when tests for glucose are repeatedly
positive, or when there issubstantial disturbance of health, particularly with infections.
6othera:s sodium nitroprusside test may be used or, alternatively, reagentBstrips that are
sensitive to -etones. In emergency situations such as diabetic -etoacidosis, a greatly raised
concentration of plasma -etones can be detected with a reagentBstrip and roughly Duantified
by serial in " dilution of plasma with water.
Values for dia%nosis of diabetes mellitus and other cate%ories of hyper%lycaemia (71O.
1888
1
Glucose concentration, mmol lB (mg dlB)
@hole blood /lasmaA
Jenous !apillary Jenous
Diabetes Mellitus$
&asting V 2. (V #) V 2. (V #) V ,.# (V "2)
or
"-h post glucose load
or both V #.# (V 3#) V . (V "##) V . (V "##)
Impaired Glucose
Tolerance (IGT$
&asting (if measured)
"nd
"-h post glucose load
W 2. (W #)
V 2., (V "#)
and
W # (W 3#)
W 2. (W #)
V ,.3 (V '#) and
W . (W "##)
W ,.# (W"2)
V ,.3 (V '#) and
W . (W "##)
Impaired /astin%
Glycaemia (I/G$
&asting
and (if measured)
"-h post glucose load
V 1.2 (V ##)and
W 2. (W #)
W 2., (W "#)
V 1.2 (V ##)and
W 2. (W #)
W,.3 (W '#)
V 2. (V #)and
W ,.# (W"2)
W ,.3 (W '#)
&or epidemiological or population screening purposes, the fasting or "-h value after ,1 g oral
glucose may be used alone. &or clinical purposes, the diagnosis of diabetes should always be
confirmed by repeating the test on another day unless there is uneDuivocal hyperglycaemia
with acute metabolic decompensation or obvious symptoms.
+9IT-9I" /O9 T-#TI:G /O9 DI")-T-# I: "#;M5TOM"TI+ "D0<T
I:DIVID0"<# . T")<- 1("merican Diabetes "ssociation.2=1!
>
*IAB959>
5+/9
6I>K &A!5)6> and &69U<9%!+ )& >!699%I%G
5ype 5ype prevention studies suggest that measurement of islet
autoantibodies identifies individuals at ris- for developing type
diabetes. >uch testing may be appropriate in highRris- individuals, such
as those with prior transient hyperglycemia or those who have relatives
with type diabetes, in the conte7t of clinical research studies
5ype " . 5esting should be considered for all adults who are overweight (B(I V
"1) and have additional
ris- factorsE
$istory of cardiovascular disease
habitual physical inactivity
first degree relative with diabetes
delivered baby X F lbs, G*(
polycystic ovary syndrome
$5% V '#8F# or on meds
$*4 .1 mg8dl or triglyceride "1# mg8dl
Al c V 1.,G, IG5 or l9G
)ther clinical conditions associated with insulin resistance
(obesity, A%)
$igh ris- ethnic population (African American, 4atino, %ative
American, Asian American, /acific Islanders)
".In the absence of the above ris-, start testing for diabetes at age '1
.. If results normal, repeat test at . year intervals or more freDuently
depending on ris-
59>5> 5) *IAG%)>9 *IAB959> R 5AB49 "
stage &or all the below tests, in the absence of uneDuivocal hyperglycemia,
results should be confirmed by repeat testing.
Al !
%G>/
certifiedN
standardi;ed
&asting /lasma
Glucose (&/G)
Y%o inta-e 3 8hrs
6andom /lasma
Glucose
)ral Glucose
5olerance
5est ()G55) ,1-
g
assay
*iabetes Al ! V .1G &/G V "2
mg8dl
6andom plasma
glucose V "##
mg8dI
/lus symptoms
6andom Z any
time of *ay
w8out regard to
time since last
meal, symptoms
include usual
polyuria,
polydipsia, and
une7plained
weight loss.
5woRhour
plasma
glucose ("h/G)
V "## mg8dl
Increased
ris- of
diabetes
A! 1.,- 2-'G Impaired
&asting BG
(I&G) Z
&/G ##-"1
mg8dl
Impaired
Glucose
5olerance (I!5)
Z "h/G
'# -FF mg8dl
%ormal A! W 1.,G &/G W ##
mg8dl
"h/G W '#
mg8dl
Gestational diabetes (G*()
*IAG%)>I> !6I596IA 59>5 *IAG%)>I> !6I596IA
At the first prenatal visit,
screen
for undiagnosed type " in
>tandard *iagnostic 5esting
and !riteria as
>tandard *iagnostic 5esting
and !riteria as listed in
those
w8 ris- factors as listed in
5able
listed in *iagnosing
*iabetes R5able "
*iagnosing *iabetes R5able
"
>creen for G*( at "'R"3
wee-s of gestation for all
pregnant women not -nown to
have diabetes.
>creen women with G*( for
diabetes 2R" w-s.
postpartum
/erform a ,1g )G55, with
plasma glucose
measurement fasting and at
and " h.
5he )G55 should be
performed in morning after
an overnight fast of at least
3 h.
5he diagnosis of G*( is
made when A%+ of
following BG values are
e7ceededE
&asting V F" mg8dl
h V 3# mg8dl
" h V 1. mg8dl
American *iabetes Association !linical /ractice 6ecommendations. >tandards of medical
care for patients with *(. Tanuary "#. vol. .1 >upplement >R>2.
*iagnostic sensitivity and specificity of autoimmune mar-ers in patients with newly
diagnosed type diabetes mellitus
3
>ensitivity >pecificity
Glutamic acid decarbo7ylase
(GA*21)
,#BF#G FFG
Insulin (IAA) '#B,#G FFG
5yrosine phosphatase (IA-") 1#B,#G FFG
[inc transporter 3 ([n53) 1#-,#G FFG
Mana%ement of Diabetes Mellitus
+linical Trials in Diabetes
&indings of the *iabetes !omplications and !ontrol 5rial (*!!5) and of the <nited
Kingdom /rospective *iabetes >tudy (<K/*>), have confirmed the beneficial effects of
improved glycemic control in both type and type " diabetes, respectively. In addition, with
increased understanding of the pathophysiology of both type and type " diabetes, large
prospective studiesR*iabetes /revention 5rial (*/5-) and the *iabetes /revention
/rogram (*//)Rhave been performed in attempts to prevent onset of these disorders
". +linical Trials in Type 1 Diabetes
*iabetes /revention 5rial-(*/5-)
5his multicenter study sponsored by the %ational Institutes of $ealth (%I$) was designed to
determine whether the development of type diabetes mellitus could be prevented or delayed
by immune intervention therapy. *aily low-dose insulin inCections were administered for up
to 3 years in first-degree relatives of type diabetic patients who were selected as being at
high ris- for development of type diabetes because of detectable islet cell antibodies and
reduced early-insulin release. <nfortunately, this immune intervention failed to affect the
onset of type diabetes compared with a randomi;ed untreated group. A related study using
whose early insulin release remains intact also failed to show an effect on the onset of type
diabetes. After an average of '.. years of observation, type diabetes developed in about
.1G of persons in both the oral insulin and the placebo groups.
F
5he *iabetes !ontrol and !omplications 5rial
5his long-term therapeutic study involving '' patients with type diabetes mellitus
reported that =near? normali;ation of blood glucose resulted in a delay in the onset and a
maCor slowing of the progression of established microvascular and neuropathic complications
of diabetes during a follow-up period of up to # years. (ultiple insulin inCections (22G) or
insulin pumps (.'G) were used in the intensively treated group, who were trained to modify
their therapy in response to freDuent glucose monitoring. 5he conventionally treated groups
used no more than two insulin inCections, and clinical well-being was the goal with no
attempt to modify management based on $bAc determinations or the glucose results.
In half of the patients, a mean hemoglobin Ac of ,."G (normalE W 2G) and a mean blood
glucose of 11 mg8d4 (3.2 mmol84) were achieved using intensive therapy, while in the
conventionally treated group $bAc averaged 3.FG with an average blood glucose of ""1
mg8d4 (".1 mmol84). )ver the study period, which averaged , years, there was an
appro7imately 2#G reduction in ris- between the two groups in regard to diabetic
retinopathy, nephropathy, and neuropathy. 5he intensively treated group also had a
nonsignificant reduction in the ris- of macrovascular disease of 'G (F1G !I, B# to 23).
Intensively treated patients had a threefold greater ris- of serious hypoglycemia as well as a
greater tendency toward weight gain. $owever, there were no deaths definitely attributable to
hypoglycemia in any persons in the *!!5 study, and no evidence of posthypoglycemic
cognitive damage was detected.
>ubCects participating in the *!!5 study were subseDuently enrolled in a follow-up
observational study, the 9pidemiology of *iabetes Interventions and !omplications (9*I!)
study. 9ven though the between-group differences in mean $bAc narrowed over ' years, the
group assigned to intensive therapy had a lower ris- of retinopathy at ' years,
microalbuminuria at , to 3 years, and impaired glomerular filtration rate (W 2# m48min8.,.
m") at "" years of continued study follow-up. (oreover, by the end of the -year follow-up
period, the intensive therapy group had significantly reduced their ris- of any cardiovascular
disease events by '"G (F1G !I, FG to ".G0 / Z #.#"). 5hus, it seems that the benefits of
good glucose control persist even if control deteriorates at a later date.
5he general consensus of the A*A is that intensive insulin therapy associated with
comprehensive self-management training should become standard therapy in patients with
type diabetes mellitus after the age of puberty. 97ceptions include those with advanced
chronic -idney disease and the elderly, since in these groups the detrimental ris-s of
hypoglycemia outweigh the benefits of tight glycemic control.
#
Immune intervention trials in new-onset type diabetes
At the time of diagnosis of type diabetes, patients still have significant B cell function. 5his
e7plains why soon after diagnosis patients go into a partial clinical remission (=honeymoon?)
reDuiring little or no insulin. 5his clinical remission is short-lived, however, and eventually
patients lose all B cell function and have more labile glucose control. Attempts have been
made to prolong this partial clinical remission using medications such as cyclosporine,
a;athioprine, prednisone, and antithymocyte globulin. 5hese medications have had limited
efficacy, and there are concerns about to7icity and the need for continuous treatment.
%ewer agents that may induce immune tolerance and appear to have few side effects have
been used in patients with new-onset type diabetes mellitus. 5he !*. comple7 is the maCor
signal transducing element of the 5 cell receptor and the anti-!*. antibodies are believed to
modulate the autoimmune response by selectively inhibiting the pathogenic 5 cells or by
inducing regulatory 5 cells. /hase I8II and II8III clinical trials using the humani;ed
monoclonal antibodies against !*., h)K5.\ (Ala-Ala) (tepli;umab) and !hAgly!*.
(oteli7i;umab) delayed but did not completely arrest the decline in insulin production in
patients with newly diagnosed type diabetes. >tudies are ongoing to identify which
individuals may benefit from this therapy. A study using anti-!*. antibody prior to clinical
onset of diabetes is also under consideration. 5hese and other approaches that selectively
modulate the autoimmune 5 cell response hold promise that type diabetes may eventually
be preventable without prolonged immunosuppression.