Special Considerations in Diabetes Mellitus

Overview 

• Total Parenteral Nutrition
• Glucocorticoids
• Diabetes Management in Older Adults
• Reproductive Issues 
• Lipodystrophic Dm
• HIV-Associated Lipodystrophy

Total Parenteral Nutrition (TPN) / Total Enteral Nutrition (TEN)         

• TPN/TEN generally increases insulin requirement. It contains high quantities of glucose.  The individual having underlying insulin resistance, inflammatory issues, stress responses. Individuals not previously known to have DM: They become hyperglycaemic. For TPN, IV insulin infusion is the preferred treatment for hyperglycaemia. Rapid titration of the required dose of insulin: It should ensure that glucose levels are normalised.
• After the total insulin dose has been determined: A proportion of insulin is given within the Total parenteral nutrition. It will cover the nutritional requirements of the glucose. The remaining quantity of insulin is given via IV insulin infusion. In TEN, hyperglycaemia may be limited by using: High protein formation. Short-acting insulin will cover the bolus in the form iv infusion. Patient with insulin deficiency as in type 1 DM and pancreatogenic DM. Long-acting insulins given (0.1-0.2 unit/kg/day). It will cover basal insulin requirements.

Glucocorticoids

• Glucocorticoids increase: Insulin resistance, decrease glucose utilisation, Increase hepatic gluconeogenesis, Will impair the insulin secretion. These changes lead to a worsening of Glycaemic control. This supplementation will precipitate hyperglycaemia.

Steroid-induced diabetes

• In chronic treatment disorder of Autoimmune disorder. Supraphysiological doses of steroids e.g., prednisolone > 5mg. It will cause a new onset of hyperglycemia.  The effects of glucocorticoids on glucose homeostasis are: Dose-related - More the dose, more the hyperglycaemia, usually, reversible. Most pronounced during the postprandial period also depends upon the timings and type of glucocorticoids. If the FPG (Fasting Plasma Glucose) level is near the normal range: Oral hypoglycemic agents (orally) are given: Sulfonylurea, Metformin. If the FPG is > 200 mg/dL: Insulin is given to the patients. Short-acting insulin should be combined with long-acting glucose to control postprandial glucose excursions.

Also Read: Management of Inflammatory Bowel Disease (Ulcerative Colitis and Crohn's Disease) 

Management of Diabetes Mellitus in Older Agents

Diabetes is prevalent in older ages > 65 years. Chances are almost 25%, Type 2 diabetes mellitus.

Patient having Long-standing type 1 DM

Individualised therapeutic goals and modalities in older adults. Should consider: The biological age of the individual. More age requires insulin rather than OHA. Comorbidities, Neurocognitive abnormalities, Living arrangements of the individuals and social support & medication.

For example,

• The HbA1c goals for a highly functional 80 years old- HbA1c goal < 7.0 - 7.5%. In an individual with diabetes in long-term cases Like in nursing facilities- HbA1c < 8.0- 8.5%

Critical to diabetes management in all older individuals

• Avoidance of hypoglycaemia: Strict cut off need not be maintained. If a patient develops hypoglycemia, that will further worsen the cardiovascular disease & cognitive impairment of the individual. Thus, medications that can cause hypoglycemia are: Sulfonylurea, Insulin should be used carefully.
• In choosing the medication for diabetes, the adverse effect should be considered:  Metformin should be avoided in case of Renal insufficiency. Thiazolidinediones can lead to congestive heart failure due to fluid overdose. Hypertension and dyslipidemia should be treated in elderly individuals with diabetes because: Control the blood pressure benefit to control DM.

Reproductive issues

• Reproductive capacity in either men or women with DM appears to be normal. The menstrual cycle may be associated with alteration in the glycaemic control in women with Diabetes Mellitus. Pregnancy is associated with marked insulin resistance: Pregnancy causes increased insulin requirement that will result in profound diabetes mellitus. It leads to the diagnosis of gestational diabetes mellitus.

Also Read: Acromegaly- Clinical Features, Diagnosis, Treatment

Gestational Diabetes Mellitus

Is the glucose at a high level considered teratogen?

• Yes. Glucose at high levels is a teratogen in developing foetuses.  The teratogenicity associated with glucose is Macrosomia. Insulin is not a teratogen, but glucose is.
• Glucose from the maternal circulation: Enters the foetus, In the foetus, there will be stimulation of insulin secretion. This insulin has anabolic and growth effects? resulting in macrosomia.

Gestational Diabetes Mellitus complication

GDM impacts 7% of pregnancies. The incidence of GDM is significantly increased ethnic groups: , Blacks, Latinas. Current recommendations advise screening for glucose intolerance between 24- 28 weeks of pregnancy if the woman is not diabetic. Therapy for GDM is similar to that for individuals who are pregnant with diabetes and already on Insulin. Dietary treatment – lifestyle. If the hyperglycaemia persists in pregnancy, that baby will have macrosomia.

Oral hypoglycemic agents

• Are not approved for use in pregnancy. The use of metformin and glyburide has been shown in studies that these can be given. No toxicity is found. With current practice, the morbidity and mortality rates in mothers with gestational DM and the foetus: Similar to the non-diabetic population because of the advent of new treatments for DM
• These females have markedly increased the risk of developing type 2 diabetes mellitus.  Need periodic screening for DM. Most individuals with GDM revert to average glucose level. Only some will progress to have DM.
• In addition, children of women with GDM appear to be at risk: Risk for obesity, Glucose intolerance. Increased risk of having diabetes mellitus in later stages of adolescence. Pregnancy with the individual with known DM requires:  Proper planning to avoid macrosomia.

Treatment

• Intensive insulin therapy and near normalisation of the HbA1c- HbA1c < 6.5%. Essential for individuals with existing DM and planning for pregnancy. Insulin infusion and CGM (Continuous Glucose Monitoring) devices that may help to improve glycaemic control: Glycaemic control must be achieved before conception. The most crucial period immediately after fertilisation.
• The risk of foetal malfunction is increased:  4-10times if the blood glucose levels are not controlled. Normal blood glucose during the preconception and throughout the pregnancy is very important. More frequent monitoring of HbA1c- Every 2-3 months, HbA1c < 6-6.5 %. It will reduce the incidence of foetal macrosomia. Reduce the incidence of foetal hypoglycemia secondary to the foetal increase in the insulin.

Lipodystrophy DM

Lipodystrophy is the loss of subcutaneous fat tissue. It is seen in: Genetic conditions like leprechaunism (severe form of insulin resistance). Have abnormalities in the endocrine system. Secondary to acquired conditions that are autoimmune disorders. Generalised lipodystrophy is associated with a decrease or deficiency in leptin.  There will be a very severe form of insulin resistance. Have cutaneous manifestations like: Acanthosis nigricans, Hepatic steatosis, Severe hypertriglyceridemia.

Treatment 

Recombinant human leptin – metreleptin. Allow metabolic control in case of generalised lipodystrophy. Associated with the development of neutralising antibodies also.

Partial Lipodystrophy

Seen in: HIV infection and taking antiretroviral therapy. Metabolic syndrome of insulin resistance. Hepatic steatosis, ectopic fat deposition.

HIV- associated Lipodystrophy

Protease inhibitors and nucleoside reverse transcriptase inhibitors used in the treatment of HIV disease have been associated with: Centripetal accumulation of fat- visceral and abdominal, accumulation of fat in dorsocervical region- buffalo hump, Loss of extremity fat, Decreased insulin sensitivity. Dyslipidemia. This appearance will resemble Cushing Syndrome. Therapy for HIV-related lipodystrophy and associated metabolic dysfunction may include the following: Metformin, it will cause weight loss by reducing abdominal fat accumulation. Pioglitazone, for lipoatrophy and for hepatic steatosis.

Tesamorelin, a growth hormone-releasing hormone analogue: Reduces the excessive abdominal fat.IGF-1 level – should be monitoring; if not corrected, then the patient can go into stage of acromegaly, further precipitate DM.

Hope you found this blog helpful for your NEET SS Endocrinology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.