1. How Manage Outpatient of Diabetes Mellitus?

2. 1921 – Banting and Best Began to Isolate the “ Internal Secretion of the Pancreas”

5. 1923 Banting and Best Awarded Nobel Prize for Discovery And Use of Insulin in the Treatment of IDDM

6. Islets of Langerhans  -cell destruction Insulin Deficiency Adipo- cytes Muscle Liver Decreased Glucose Utilization Glucagon Excess Increased Protein Catabolism Increased Ketogenesis Gluconeogenesis IncreasedLipolysis Hyperglycemia Ketoacidosis Polyuria Volume Depletion Ketonuria

8. Classification of Different Forms of Diabetes Mellitus

10. Progression to Type 1 DM Autoimmune destruction “ Diabetes threshold” Honeymoon 100% Islet loss Autoimmune markers (ICA, IAA, GAD

11. Disease-Free Survival is Shortened with More Numerous Antibodies

21. Definition of Various Levels of Glycemic Control

23. Hyperglycemia: Microangiopathic complications Hypoglycemia: Neuronal loss Poor school performance seizures

24. Microangiopathic complications from DM can occur by the time of diagnosis but typically 10 – 15 yr

28. Typical Split-Dose NPH-REG BID Regimen

29. BID NPH / REG AM NPH / REG DINNER REG HS NPH

34. The DCCT is a clinical study conducted from 1983 to 1993 by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The study showed that keeping blood glucose levels as close to normal as possible slows the onset and progression of eye, kidney, and nerve diseases caused by diabetes. NEJM 342:381-389, 2000 DCCT Study Findings Lowering blood glucose reduces risk: Eye disease 76% reduced risk Kidney disease 50% reduced risk Nerve disease 60% reduced risk

35. RS is a 12 yr old female with T1 DM for 6 yrs. A1C = 7.3, insulin dose is AM: 8 Reg / 18 NPH; Dinner: 7Reg; HS: 20 NPH. BGs

36. Continuous Glucose Monitor - Overnight Unsuspected and Asymptomatic Hypoglycemia – Common up to 85% of episodes are nocturnal

39. BG Breakfast Lunch Dinner Insulin

51. Components

58. Different Forms of MODY

61. Obesity Acanthosis Nigricans Adolescence

63. T2 DM vs T1 DM T2 - DM T1 - DM Polyuria/dypsia + + Ketonuria + / - + / - DKA + / - + / - Autoimmunity + / - + Initial insulin Often required Required Honeymoon + + Worse @ illness + +

64. T2 DM vs T1 DM T2 DM T1 DM Obesity 95% > 85%tile Not Common + Family Hx T2 72 – 85% Not Common Acanthosis Nigricans 60 – 86% 7% all school aged children Maternal Gestational DM + Not Common IUGR + Not common