Endo Pancreatic Disorders

Diabetes

I. Diabetes Insipidus

• – Pathway/Axis:
  • arginine vasopressin
    
• – Major cause:
  • deficiency in arginine vasopressin secretion from posterior pituitary (central or neurological form)
  • or insensitivity of kidneys to AVP (nephrogenic form)
    
• – Major symptoms:
  • excessive thirst ad excretion of large amounts of highly dilute urine (urine does NOT include much glucose)
• – Management:
  • Push PO fluids in all cases
    
  • Central (acute): Desmopressin + PO or IV (hypo) fluids
    
  • Central (chronic): Desmopressin + PO fluids
    
  • Nephrogenic: Restrict sodium; HCTZ; tx underlying cause

II. Diabetes Mellitus

A. Diabetes Criteria

• Dx:
  • Fasting glucose ≥ 126 mg/dL
  • Random glucose ≥ 200 mg/dL with hyperglycemia symptoms
  • 2-hour glucose tolerance test ≥ 200 mg/dL
  • Hemoglobin A1c ≥ 6.5%

B. Diabetes Mellitus Type 1

• – Pathway/Axis:
  • Hypothalamus/Pituitary/Thyroid (HPT) axis, insulin production
    
• – Major cause:
  • disorder of glucose homeostasis via a lack of insulin production/secretion from the pancreas.
    
• – Major symptoms:
  • frequent urination, urine contains high glucose levels, increased thirst, increased hunger, weight loss
• – Management:
  • insulin to 80-120 FSBS and A1c <7%
    
  • Basal: Glargine (Lantus)
    Plus
    
  • Bolus: Lispro (Humalog) or Aspart (Novolog)

C. Diabetic Ketoacidosis

• Presentation:
  • Polyuria
  • Polydipsia
  • Nausea/vomiting
  • Abdominal Pain
  • Neurological Problems
    • Altered mental status
    • Coma
• Physical Exam:
  • Volume depletion
  • tachycardia
  • hypotension
  • Kussmaul breathing
    • regular, deep, labored breathing
  • sweet or fruity breath
• Labs:
  • high glucose
  • anion gap
  • high kidney function
  • high potassium
• Dx:
  • ABG
  • Urine Ketones
  • Plasma Ketones
  • Plasma osmolality
  • CBC
  • Urinalysis
  • CXR
  • EKG
  • Lipase
  • LFTs
  • HbA1c
• Plan:
  • Admit to ICU
  • Central IV access
  • IV fluids (1L NS IV per hour until FSBS 250 then 1/2 NS)
  • IV regular insulin
  • IV potassium repletion at 3 hours unless severe
  • Stop the insulin drip when the anion gap is normal
  • Search for the underlying cause of DKA
    

D. Diabetes Mellitus Type 2

• – Pathway/Axis:
  • Bloodstream/Pancreas/Liver
• – Major cause:
  • insulin resistance or not enough insulin production from the pancreas in response to high glucose levels in the blood.
  • Blood glucose stays high and has negative effects on the body.
  • May be caused by beta-cell dysfunction. (which produces insulin)
• – Major symptoms:
  • high blood glucose levels, body cells are deprived of energy even though blood glucose is high.
  • Over time, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, kidney disease, blindness, dental disease, and amputations
• – Risk:
  • increased susceptibility to other diseases, loss of mobility with aging, depression, and pregnancy problems.
• – Management:
  • Lifestyle changes, diet, and exercise
  • Metformin 500 PO every day -> Insulin
    
  • >40 = statin
    
  • HTN = ACEi or ARB

E. Hyperosmolar hyperglycemic state

• Presentation:
  • more gradual onset
  • minimal ketosis
  • no significant acidosis
  • worse hyperglycemia
  • worse hyperosmolarity -> more neurological symptoms
    • obtundation 
    • coma
• Plan:
  • ICU admission
  • IV fluids (1L NS IV per hour until FSBS 250 then 1/2 NS)
  • Regular Insulin IV
  • Potassium repletion at 3 hours unless severe
    

F. DMI vs DMII Summary Table

III. Gestational Diabetes

• – Pathway/Axis:
  • Hypothalamus/Pituitary/ Liver (HPL) Axis
• – Major cause:
  • Improper insulin response by the body’s insulin receptors during pregnancy when the presence if human placental lactogen is interfering with the woman’s insulin receptors.
• – Major symptoms:
  • noticeable symptoms not common, screening often taken.
  • Increased thirst and urination frequency are rarely noticed as symptoms.
• – Management:
  • Tight glucose control <95:
    
    • 50/25/25 diet
      
    • Exercise
      
    • NPH + regular insulin

IV. LADA

• Management:
  • Diet
    
  • Insulin

V. MODY

• Management:
  • It depends on the genotype.
  • Need meds if prego
    
  • MC genotype = no tx

VI. Anti-Diabetic Drugs

DPP4 inhibitors

• Sitagliptin
  
• Saxagliptin
  
• Linagliptin
  
• Alogliptin

GLP1

• Exenatide
• Liraglutide

Sodium Glucose Co-Transporter-2 (SGLT2) Inhibitors

• Canagliflozin
  
• Dapagliflozin
  
• Empagliflozin

Alpha-glucosidase inhibitors

• Acarbose
  
• Miglitol

Rapid Insulin

• MOA: Binds insulin receptor and increases glycogen
• Types:
  • lispro
  • aspart
  • glulisine

Intermediate acting insulin

• NPH

Long acting insulin

• MOA: Binds albumin
• Types:
  • Detemir
  • Glargine