ΠωΣ θα διαγνΩσω τον σακχαρΩδη διαβΗτη στο εξωτερικΟ ιατρεΙο και στη ΜΕΘ ΚΩΝΣΤΑΝΤΙΝΟΣ ΜΑΚΡΥΛΑΚΗΣ ΑΝΑΠΛ. ΚΑΘΗΓΗΤΗΣ ΠΑΝ/ΜΙΟΥ ΑΘΗΝΩΝ Α´ ΠΡΟΠΑΙΔΕΥΤΙΚΗ ΠΑΘΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ & ΔΙΑΒΗΤΟΛΟΓΙΚΟ ΚΕΝΤΡΟ ΛΑΪΚΟ ΝΟΣΟΚΟΜΕΙΟ ΑΘΗΝΩΝ

ΔΗΛΩΣΗ ΣΥΓΚΡΟΥΣΗΣ ΣΥΜΦΕΡΟΝΤΩΝ (Disclosure) Τίποτα που να αφορά την παρούσα ομιλία Συμβουλευτικές υπηρεσίες/διαλέξεις/ερευνητική υποστήριξη την τελευταία διετία: Astra Zeneca, Βιανέξ/MSD, Boehringer Ingelheim, Sanofi, Novartis Hellas, Novo Nordisk Hellas, Φαρμασέρβ-ΛΙΛΛΥ ΑΕΒΕ, Takeda, Angelini, Ελπέν

ΚΑΤΑΤΑΞΗ ΣΑΚΧΑΡΩΔΗ ΔΙΑΒΗΤΗ ΚΑΤΑΤΑΞΗ ΣΑΚΧΑΡΩΔΗ ΔΙΑΒΗΤΗ Τύπος 1 (Ινσουλινοεξαρτώμενος) - 10% Τύπος 2 (Μη ινσουλινοεξαρτώμενος - τουλάχιστον αρχικά) - 90% Άλλοι ειδικοί τύποι ΣΔ της Κύησης

Υποψία Διαβήτη – Κλασσικά συμπτώματα ΔΙΑΓΝΩΣΗ Υποψία Διαβήτη – Κλασσικά συμπτώματα Πολυουρία Πολυδιψία Πολυφαγία Νυκτουρία Ανεξήγητη απώλεια βάρους Λοιμώξεις γεννητικών οργάνων (βαλανοποσθίτιδα, κυστίτιδα, κνησμός γεν. οργάνων) Διαταραχές όρασης Νευροπαθητικά συμπτώματα (πόνος, μουδιάσματα κάτω άκρων)

ΚΑΤΕΥΘΥΝΤΗΡΙΕΣ ΟΔΗΓΙΕΣ ΕΔΕ 2017

Επιβεβαίωση με 2η μέτρηση ΚΡΙΤΗΡΙΑ ΔΙΑΓΝΩΣΗΣ ΣΔ Σάκχαρο πλάσματος νηστείας 126 mg/dl Σάκχαρο πλάσματος 2 ώρες μετά φόρτιση με 75 g γλυκόζης  200 mg/dl Σάκχαρο πλάσματος σε τυχαίο δείγμα αίματος (ανεξάρτητα από λήψη τροφής) 200 mg/dl, μαζί με συμπτώματα διαβήτη HbA1c 6.5% Επιβεβαίωση με 2η μέτρηση

ΠΑΡΑΓΟΝΤΕΣ ΚΙΝΔΥΝΟΥ ΓΙΑ ΑΝΑΠΤΥΞΗ ΣΔ2 IGT (Impaired Glucose Tolerance) Σάκχαρο νηστείας <126 mg/dl (7.0 mmol/l), και 2 ώρες μετά φόρτιση με 75-g γλυκόζης: 140-199 mg/dl (7.8-11.0 mmol/l) IFG (Impaired Fasting Glucose) Σάκχαρο νηστείας 110-126 mg/dl Προδιαβήτης: HbA1c: 5.7-6.4% Ισοδύναμος κίνδυνος μετάπτωσης σε ΣΔ τύπου 2 (περίπου 30% σε 5 έτη) Αλληλοεπικάλυψη μόνο σε 20-25% των περιπτώσεων Άτομα με IFG & IGT κίνδυνος ~50% σε 5 έτη

ΠΡΟΔΙΑΒΗΤΗΣ IFG IGT

ΔΙΑΓΝΩΣΗ ΣΔ ΣΤΗ ΜΕΘ

Definition of Inpatient Hyperglycemia The American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) consensus on inpatient hyperglycemia defined stress hyperglycemia or hospital-related hyperglycemia as any blood glucose concentration >140 mg/dl

Prevalence of hyperglycemia in inpatients (575 American hospitals in 2009) Objective: To provide data on glucose control in hospitals in the United States, analyzing measurements from the largest number of facilities to date. Methods: Point-of-care bedside glucose (POC-BG) test results were extracted from 575 hospitals from January 2009 to December 2009 by using a laboratory information management system. Glycemic control for patients in the intensive care unit (ICU) and non-ICU areas was assessed by calculating patient-day-weighted mean POC-BG values and rates of hypoglycemia and hyperglycemia. The relationship between POC-BG levels and hospital characteristics was determined. Results: A total of 49,191,313 POC-BG measurements (12,176,299 ICU and 37,015,014 non-ICU values) were obtained from 3,484,795 inpatients (653,359 in the ICU and 2,831,436 in non-ICU areas). The mean POC-BG was 167 mg/dL for ICU patients and 166 mg/dL for non-ICU patients. The prevalence of hyperglycemia (>180 mg/dL) was 32.2% of patient-days for ICU patients and 32.0% of patient-days for non-ICU patients. The prevalence of hypoglycemia (<70 mg/dL) was 6.3% of patient-days for ICU patients and 5.7% of patient-days for non-ICU patients. Patient-day-weighted mean POC-BG levels varied on the basis of hospital size (P<.01), type (P<.01), and geographic location (P<.01) for ICU and non-ICU patients, with larger hospitals (≥400 beds), academic hospitals, and US hospitals in the West having the lowest mean POC-BG values. The percentage of patient-days in the ICU characterized by hypoglycemia was highest among larger and academic hospitals (P<.05) and least among hospitals in the Northeast (P<.001). Conclusion: Hyperglycemia is common in hospitals in the United States, and glycemic control may vary on the basis of hospital characteristics. Increased hospital participation in data collection may support a national benchmarking process for the development of optimal practices to manage inpatient hyperglycemia. ~12 million BG readings from 653,359 ICU patients; mean POC-BG: 167 mg/dL. Swanson CM, et al. Endocr Pract. 2011;17:853-861.

Hyperglycemia after AMI Diabetes No Diabetes 50 40 30 20 10 50 40 30 20 10 Patients, % 26% 78% Using a national database derived from electronic medical records at 39 medical centers, investigators analyzed patterns of blood glucose (BG) control and documented insulin therapy among 16,534 patients hospitalized with acute myocardial infarction from January 2000 to December 2005. Of the 4940 patients (30%) with recognized diabetes mellitus (DM), nearly half (2412 patients, 49%) had mean BG >200 mg/dL during the first 24 hours after hospital admission. When the entire hospitalization was considered, 34% of DM patients had mean BG >200 mg/dL, while 61% had mean BG between 110 and 200 mg/dL, and only 5% maintained mean BG <110 mg/dL. Among patients without recognized DM, 8% had mean BG >200 mg/dL during the first 24 hours. When the entire hospitalization was considered, 4% of patients without known DM had mean BG >200 mg/dL, while 65% had mean BG between 110 and 200 mg/dL, and 31% had mean BG <110 mg/dL. <110 110-140 140-170 170-200 >200 <110 110-140 140-170 170-200 >200 Mean BG, mg/dL Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A. Kosiborod M, Inzucchi S, Clark B, et al. National patterns of glucose control among patients hospitalized with acute myocardial infarction. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A.

Admission Glucose after AMI In 141,680 DM and non-DM patients (1994-1996) Median admission glucose: 150 mg/dl Only 30.4% had known DM Admission Glucose and Mortality in Elderly Patients Hospitalized With Acute Myocardial Infarction Implications for Patients With and Without Recognized Diabetes Mikhail Kosiborod, MD; Saif S. Rathore, MPH; Silvio E. Inzucchi, MD; Frederick A. Masoudi, MD; Yongfei Wang, MS; Edward P. Havranek, MD; Harlan M. Krumholz, MD, SM Background—The relationship between admission glucose levels and outcomes in older diabetic and nondiabetic patients with acute myocardial infarction is not well defined. Methods and Results—We evaluated a national sample of elderly patients (n =141 680) hospitalized with acute myocardial infarction from 1994 to 1996. Admission glucose was analyzed as a categorical (110, 110 to 140, 140 to 170, 170 to 240, 240 mg/dL) and continuous variable for its association with mortality in patients with and without recognized diabetes. A substantial proportion of hyperglycemic patients (eg, 26% of those with glucose 240 mg/dL) did not have recognized diabetes. Fewer hyperglycemic patients without known diabetes received insulin during hospitalization than diabetics with similar glucose levels (eg, glucose 240 mg/dL, 22% versus 73%; P0.001). Higher glucose levels were associated with greater risk of 30-day mortality in patients without known diabetes (for glucose range from 110 to 240 mg/dL, 10% to 39%) compared with diabetics (range, 16% to 24%; P for interaction 0.001). After multivariable adjustment, higher glucose levels continued to be associated with a graded increase in 30-day mortality in patients without known diabetes (referent, glucose 110 mg/dL; range from glucose 110 to 140 mg/dL: hazard ratio [HR], 1.17; 95% CI, 1.11 to 1.24; to glucose 240 mg/dL: HR, 1.87; 95% CI, 1.75 to 2.00). In contrast, among diabetic patients, greater mortality risk was observed only in those with glucose 240 mg/dL (HR, 1.32; 95% CI, 1.17 to 1.50 versus glucose 110 mg/dL; P for interaction 0.001). One-year mortality results were similar. Conclusions—Elevated glucose is common, rarely treated, and associated with increased mortality risk in elderly acute myocardial infarction patients, particularly those without recognized diabetes. (Circulation. 2005;111:3078-3086.) Kosiborod et al. Circulation 2005;111(23):3078-86

DM or IGT at discharge and 3 mo after AMI Bronisz et al. Cardiovascular Diabetology 2011, 10:21

New and Stress hyperglycemia Patients with hyperglycemia without a previous history of diabetes should be tested with a hemoglobin A1C during the hospital stay or with an oral glucose tolerance test after discharge to confirm the diagnosis of diabetes. Less than 35% of patients had normal glucose tolerance after 3 to 12 months of follow-up (Norhammar et al. Lancet 2002; 359(9324): 2140-4) Norhammar et al. Lancet 2002; 359(9324): 2140-4. Arora et al. Endocr Pract 2009; 15(5): 425-30. Greci et al. Diabetes Care 2003; 26(4): 1064-8.

Illness Leads to Stress Hyperglycemia  Stress Hormones cortisol, epinephrine  Glucose Production + FFAs  Glucose  Fatty Acids  Lipolysis  Glucose Uptake FFAs

Stress Hyperglycemia Exacerbates Illness  Stress Hormones cortisol, epinephrine  Glucose Production + Hemodynamic insult Electrolyte losses Oxidative stress Myocardial injury Hypercoagulability Altered immunity  Wound healing  Inflammation  Endothelial function FFAs  Glucose  Fatty Acids  Lipolysis  Glucose Uptake FFAs

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