Diabetes Mellitus-

Laboratory Diagnosis and

Treatment

(Part-3)
Biochemistry for medics
www.namrata.co
Contents
1) Laboratory Diagnosis
o Urine Analysis
o Blood Biochemistry
o Immunological Assays
2) Management
o Management of type 1 DM
o Management of type 2 DM
3) Summary
URINE ANALYSIS
a) Detection of urinary glucose
(Glucosuria)
o First-line screening test for
diabetes mellitus
o Normally glucose does not appear
in urine until the plasma glucose
rises above 160-180 mg/dl.
o In certain individuals due to low
renal threshold glucose may be
present despite normal blood
glucose levels.
o Conversely renal threshold Positive
Benedicts
increases with age so many test
URINE ANALYSIS (Contd.)
o Detection of Glucosuria- A specific and
convenient method to detect glucosuria is
the paper strip impregnated with glucose
oxidase and a chromogen system (Clinistix,
Diastix), which is sensitive to as little as
0.1% glucose in urine.
o Diastix can be directly applied to the
urinary stream, and differing color
responses of the indicator strip reflect
glucose concentration.
o Benedicts and Fehlings test can also
detect glucosuria.
Diastix-
Reagent
strips
URINE ANALYSIS
(Contd.)
b) Ketonuria
o Qualitative detection of
ketone bodies can be
accomplished by
nitroprusside tests
(Acetest or Ketostix),
Rotheras test etc.
oThese tests do not
detect Beta-hydroxy Positive
butyric acid, which lacks Rothera
s test
a ketone group
o Ketone bodies may be
present in a normal Ketost
ix-
subject as a result of Reage
simple prolonged fasting. nt
URINE ANALYSIS (Contd.)
c)
Microalbuminu
ria
o May be defined as
an albumin excretion
rate intermediate
between normality
(2.5-25 mg/day) and
macroalbuminuria
(250mg/day).
oThe small increase
in urinary albumin
excretion is not
detected by simple
albumin stick tests
 URINE ANALYSIS (Contd.)
o The importance of
micro- albuminuria in
the diabetic patient is
that it is a signal of early
reversible renal damage.
o Performing an albumin-
to-creatinine ratio is
probably easiest.
o Microalbuminuria is a
common finding (even
at diagnosis) in type 2
Gradation of turbidity is
diabetes mellitus and is linked to protein
a risk factor for macro concentration
vascular (especially
coronary heart) disease.
11/7/2013 Biochemistry For Medics 7
BLOOD BIOCHEMISTRY
1) Blood Glucose Estimation
Choice of sample
Plasma or serum from venous blood
samples has the advantage over
whole blood of providing values for
glucose that are independent of
Haemtocrit and that reflect the
glucose concentration to which body
tissues are exposed.
Plasma and serum are more readily
measured on automated equipment,
they are used in most laboratories.

11/7/2013 Biochemistry For Medics 8

BLOOD BIOCHEMISTRY
Choice of sample (contd.)
If serum is used or if plasma is collected
from tubes that lack an agent to block
glucose metabolism (such as fluoride),
samples should be refrigerated and
separated within 1 hour after collection.
The glucose concentration is 1015%
higher in plasma or serum than in whole
blood because structural components of
blood cells are absent.

11/7/2013 Biochemistry For Medics 9

BLOOD BIOCHEMISTRY
Fasting blood Glucose
o Fasting blood glucose is
measured after an
overnight fast of 10 hrs.
o Fasting blood glucose
estimation is better than
random blood glucose.

o FPG < 5.6 mmol/L (100 mg/dL) is considered

normal;
o FPG = 5.66.9 mmol/L (100125 mg/dL) is
defined as IFG; and
o FPG >7.0 mmol/L (126 mg/dL) warrants the
BLOOD
BIOCHEMISTRY(contd.)
Random blood Glucose
o Random is defined as without regard to time
since the last meal.
o RBG measurement is required only during
emergency.
oThe current criteria for the diagnosis of DM
emphasize that the FPG is the most reliable and
convenient test for identifying DM in
asymptomatic individuals.
o A random plasma glucose concentration
>11.1 mmol/L (200 mg/dL) accompanied by
classic symptoms of DM (polyuria, polydipsia,
weight loss) is sufficient for the diagnosis of DM
BLOOD
BIOCHEMISTRY(contd.)
Glucose tolerance test
o When the fasting plasma glucose level is
126 mg/dL or higher on more than one
occasion, further evaluation of the patient
with a glucose challenge is unnecessary.
oHowever, when fasting plasma glucose is
less than 126 mg/dL in suspected cases, a
standardized oral glucose tolerance test
may be done .
BLOOD
BIOCHEMISTRY(contd.)
Glucose tolerance test
Methodology
75 g of glucose dissolved in 300
mL of water is given after an
overnight fast to a person who has
been receiving at least 150200 g
of carbohydrate daily for 3 days
before the test.
BLOOD
BIOCHEMISTRY(contd.)
Glucose tolerance test- Data
Interpretation-
The Diabetes Expert Committee criteria for
evaluating the standard oral glucose
Normal
tolerance test. Impaired Diabetes
Glucose Glucose Mellitus
Tolerance Tolerance
Fasting < 110 110125 >126
plasma
glucose
(mg/dL)
Two hours < 140 140199 >200
after
glucose load
 Glucose Tolerance Test
Concentration in mg/dl

(mg/dl)

Time in minutes

NormalBiochemistry
Glucose tolerance
11/7/2013 For Medics 15
curve
BLOOD
BIOCHEMISTRY(contd.)
b) Glycated hemoglobin (Hb1C)
measurements
o HbA1c comprises 46% of total
hemoglobin A1.
o Since glycohemoglobins circulate within
red blood cells whose life span lasts up to
120 days, they generally reflect the state
of glycemia over the preceding 812
weeks, thereby providing an improved
method of assessing diabetic control.
o Any condition that shortens erythrocyte
survival or decreases mean erythrocyte
age (eg, recovery from acute blood loss,
BLOOD
BIOCHEMISTRY(contd.)
Glycated hemoglobin (Hb1C)
measurements

Methods for measuring HbA1c include electrophoresis,

cation-exchange chromatography, boronate affinity
chromatography, and immunoassays.
11/7/2013 Biochemistry For Medics 17
BLOOD
BIOCHEMISTRY(contd.)
c) Serum
fructosamine
estimation
oSerum fructosamine is
formed by nonenzymatic
glycosylation of serum
proteins (predominantly
albumin).
oSerum albumin has a much
shorter half-life than
hemoglobin, serum
fructosamine generally
reflects the state of glycemic
BLOOD
BIOCHEMISTRY(contd.)
Serum fructosamine
Estimation
o Normal values vary in relation to
the serum albumin concentration
are 1.52.4 mmol/L when the
serum albumin level is 5 g/dL.
o When abnormal hemoglobins or
hemolytic states affect the
interpretation of
glycohemoglobins or when a
narrower time frame is required,
such as for ascertaining glycemic
control at the time of conception
in a diabetic woman who has
recently become pregnant, serum
fructosamine assays offer some
advantage.
11/7/2013 Biochemistry For Medics 19
BLOOD
BIOCHEMISTRY(contd.)
Self-monitoring of blood
glucose
o Capillary blood glucose
measurements performed
by patients themselves, as
outpatients, are extremely
useful.
o In type 1 patients in
whom "tight" metabolic
control is attempted, they A reflectance photometer
are indispensable. or an amperometric
oThere are several paper system is then used to
strip (glucose oxidase, measure the reaction
glucose dehydrogenase, or that takes place on the
hexokinase) methods for reagent strip.
measuring glucose on
capillary blood samples.
 BLOOD
BIOCHEMISTRY(contd.)
Lipid profile
o Serum Total cholesterol is
elevated
o Serum triglycerides are high
o Serum HDLc is low
o Qualitative change in LDL
particles, producing a smaller
dense particle whose
membrane carries
supranormal amounts of free
cholesterol.
oThese smaller dense LDL
particles are more susceptible
BLOOD
BIOCHEMISTRY(contd.)
Additional Tests
o The patient should be screened for DM-
associated conditions (e.g., kidney, liver
and thyroid dysfunction).
o Individuals at high risk for
cardiovascular disease should be
screened for asymptomatic CAD by
appropriate cardiac stress testing, when
indicated.
oThe classification of the type of DM may
be facilitated by laboratory assessments.
BLOOD
BIOCHEMISTRY(contd.)

Insulin Luminescence assay kit C-Peptide Luminescence

assay kit
Serum insulin or C-peptide measurements do not
always distinguish type 1 from type 2 DM, but a low
C-peptide level confirms a patient's need for insulin.
11/7/2013 Biochemistry For Medics 23
IMMUNOLOGICAL
ASSAYS
o Antibodies to insulin, islet cells, or
Glutamic acid decarboxylase (GAD)
can be estimated to differentiate
between the types of diabetes
mellitus
oThey are absent in type 2 diabetes
mellitus.
o Latent autoimmune diabetes
of adults, or LADA, is a form of
slow-onset type 1 diabetes that
occurs in middle-aged (usually
white) adults.
oIt can be differentiated from type 2
Management of Diabetes
Mellitus
The goals of therapy for type 1 or
type 2 DM are to:
(1)eliminate symptoms related to
hyperglycemia,
(2)reduce or eliminate the long-
term micro vascular and macro
vascular complications of DM, and
(3)allow the patient to achieve as
normal a lifestyle as possible.
Management of Type 1
Diabetes Mellitus
o Because individuals with type 1 DM
partially or completely lack endogenous
insulin production, administration of
basal, exogenous insulin is essential for
regulating glycogen breakdown,
gluconeogenesis, lipolysis, and
ketogenesis.
o Likewise, insulin replacement for
meals should be appropriate for the
carbohydrate intake and promote
Management of Type 1
Diabetes Mellitus
Insulin Preparations
oInsulin is indicated for type 1 diabetes
as well as for type 2 diabetic patients
with insulinopenia whose hyperglycemia
does not respond to diet therapy either
alone or combined with other
hypoglycemic drugs.
oWith the development of highly purified
human insulin preparations,
immunogenicity has been markedly
reduced, thereby decreasing the
incidence of insulin allergy, immune
insulin resistance, and localized
lipoatrophy at the injection site.
Management of Type 1
Diabetes Mellitus
oInsulins can be classified as short-acting or
long-acting
oThe short-acting preparations are regular
insulin and the rapidly acting insulin analogs .
oThey are dispensed as clear solutions at
neutral pH and contain small amounts of zinc to
improve their stability and shelf life.
oThe long-acting preparations are NPH insulin
and the long-acting insulin analogs.
oNPH insulin is dispensed as a turbid
suspension at neutral pH with protamine in
phosphate buffer.
oThe long-acting insulin analogs are also
dispensed as clear solutions.
Management of Type 1
Diabetes Mellitus
Mixed insulin preparations
oSince intermediate insulins require
several hours to reach adequate
therapeutic levels, their use in
patients with type 1 diabetes requires
supplements of regular or rapidly
acting insulin analogs preprandially.
oFor convenience, regular or rapidly
acting insulin analogs and NPH insulin
may be mixed together in the same
syringe and injected subcutaneously
in split dosage before breakfast and
supper.
Management of Type 1
Diabetes Mellitus
Methods of insulin administration
1) Insulin syringes and needles-Plastic
disposable syringes are available in 1-mL,
0.5-mL, and 0.3-mL sizes.
2) Insulin pen injector devices-Insulin
pens eliminate the need for carrying insulin
vials and syringes.
3) Insulin pumps-Insulin infusion pumps
are used for subcutaneous delivery of
insulin. These pumps are small (about the
size of a pager) and very easy to program.
4) Inhaled insulin-A novel method for
delivering a pre-prandial powdered form of
insulin by inhalation (Exubera) has been
approved by the FDA.
Management of Type 1
Diabetes Mellitus
Methods of insulin administration

11/7/2013 Biochemistry For Medics 31

Management of Type 1
Diabetes Mellitus

An insulin pump is an alternative to

multiple daily injections of insulin by Inhaled Insulin-The
insulin syringe or an insulin pen and FDA approved the
allows for intensive insulin therapy
when used in conjunction with blood first inhaled version
glucose monitoring.
of insulin
11/7/2013 Biochemistry For Medics 32
calledExuberafrom
Management of Type 1
Diabetes Mellitus
o Complications of
Insulin Therapy
Hypoglycemia, Insulin
allergy, immune insulin
resistance and
lipodystrophy at the
injection site are some
of the complications of
insulin therapy.
Injection site
o Besides insulin Lipodystrophy
therapy, life long
dietary and life style
modifications are
required to be done
 Management of Type 1
Diabetes Mellitus
o Islet cell
transplantation is a
minimally invasive
procedure, wide
application of this
procedure for the
treatment of type 1
diabetes is limited by
the dependence on Islet cell
multiple donors and transplantation
the requirement for
Management of Type 1
Diabetes Mellitus
Stem cell
therapy- Stem
cell therapy is
one of the most
promising
treatments for the
near future. It is
expected that this
kind of therapy
can ameliorate or
even reverse
some diseases.
11/7/2013 Biochemistry For Medics 35
Management of Type 2
Diabetes Mellitus
oThe goals of therapy for type 2 DM are
similar to those in type 1.
oThe care of individuals with type 2 DM
must also include attention to the
treatment of conditions associated with
type 2 DM (obesity, hypertension,
dyslipidemia, cardiovascular disease)
and
oDetection/management of DM-related
complications.
Management of Type 2
Diabetes Mellitus
a) Weight reduction
o Treatment is directed toward achieving
weight reduction, and prescribing a diet is
only one means to this end.
o Behavior modification to achieve
adherence to the diet
o Increased physical activity to expend
energyis also required.

11/7/2013 Biochemistry For Medics 37

Management of Type 2
Diabetes Mellitus
b) Hypoglycemic agents
If the patient is not able to achieve target
glycemic control with weight management and
exercise, then pharmacologic therapy is
indicated.
Based on their mechanisms of action, glucose-
lowering agents are subdivided into agents that
increase insulin secretion, reduce glucose
production and increase insulin sensitivity

11/7/2013 Biochemistry For Medics 38

Management of Type 2
Diabetes Mellitus
1) Insulin Secretagogues
o Insulin Secretagogues stimulate
insulin secretion by interacting with
the ATP-sensitive potassium channel
on the beta cells.
o These drugs are most effective in
individuals with type 2 DM of
relatively recent onset (<5 years),
who have residual endogenous
insulin production.
11/7/2013 Biochemistry For Medics 39
Management of Type 2
Diabetes Mellitus
a) Sulfonylurea b) Sulfonylurea c) Non
first second sulfonylureas
generation generation
Chlorpropamide Glimepiride Repaglinide
Tolazamide Glipizide Nateglinide
Tolbutamide Glipizide
(extended
release)
Glyburide
Glyburide
(micronized)

11/7/2013 Biochemistry For Medics 40

Management of Type 2
Diabetes Mellitus
Insulin Secretagogues are generally well
tolerated.
All of these agents, however, have the
potential to cause profound and persistent
hypoglycemia, especially in elderly individuals.
Hypoglycemia is usually related to delayed
meals, increased physical activity, alcohol
intake, or renal insufficiency.

11/7/2013 Biochemistry For Medics 41

Management of Type 2
Diabetes Mellitus
2) Biguanides
Metformin is representative of
this class of agents.
It reduces hepatic glucose
production through an undefined
mechanism and improves
peripheral glucose utilization
slightly.
Metformin reduces fasting
plasma glucose and insulin levels,
improves the lipid profile, and
promotes modest weight loss.
The major toxicity of metformin,
lactic acidosis, can be prevented
by careful patient selection.

11/7/2013 Biochemistry For Medics 42

Management of Type 2
Diabetes Mellitus
3) -Glycosidase Inhibitors
o -Glycosidase inhibitors (acarbose
and miglitol) reduce postprandial
hyperglycemia by delaying glucose
absorption; they do not affect
glucose utilization or insulin
secretion.
o These drugs, taken just before
each meal, reduce glucose
absorption by inhibiting the
enzyme that cleaves
oligosaccharides into simple
sugars in the intestinal lumen.
o The major side effects (diarrhea,
flatulence, abdominal distention)
are related to increased delivery of
oligosaccharides to the large bowel

11/7/2013 Biochemistry For Medics 43

Management of Type 2
Diabetes Mellitus
4) Thiazolidinediones
Thiazolidinediones reduce
insulin resistance.
Rosiglitazone, Pioglitazone
belong to this category.
Thiazolidinediones promote a
redistribution of fat from central
to peripheral locations.
Circulating insulin levels
decrease with use of the
thiazolidinediones, indicating a
reduction in insulin resistance

11/7/2013 Biochemistry For Medics 44

Management of Type 2
Diabetes Mellitus
5) Insulin Therapy in Type 2 DM
o Insulin should be considered as the initial therapy
in type 2 DM, particularly in lean individuals or
those with severe weight loss, in individuals with
underlying renal or hepatic disease that
precludes oral glucose-lowering agents, or in
individuals who are hospitalized or acutely ill.
o Insulin therapy is ultimately required by a
substantial number of individuals with type 2 DM
because of the progressive nature of the disorder
and the relative insulin deficiency that develops
in patients with long-standing diabetes.

11/7/2013 Biochemistry For Medics 45

Summary Of Type 1 DM
1) Diabetes mellitus type1 (Type1 diabetes, IDDM,
or juvenile diabetes) is a form of diabetes mellitus
that results from autoimmune destruction of insulin
producing beta cells of the pancreas.
2) The classical symptoms of Type1 diabetes are
polyuria, polydipsia, polyphagia and weight loss.
3) Type1 diabetes is fatal unless treated with insulin.
4) Injection is the most common method of
administering insulin; insulin pumps and inhaled
insulin has been available at various times.
5) Diabetic keto acidosis is the commonest
complication of Type 1 DM.

11/7/2013 Biochemistry For Medics 46

Summary of Type 2 DM
1)Type 2 DM is characterized by impaired insulin
secretion, insulin resistance, excessive hepatic
glucose production, and abnormal fat metabolism.
2) While many patients with type 2 diabetes
present with increased urination and thirst,
many others have an insidious onset of
hyperglycemia and are asymptomatic initially.
3) Hyperglycemic hyperosmolar state (HHS) is an
acute complication of Type 2 diabetes. Chronic
complications are micro and macro vascular
involving small and large blood vessels
respectively.

11/7/2013 Biochemistry For Medics 47

Summary of Type 2
DM(contd.)
4) Glucose lowering agents that either increase
insulin secretion, reduce glucose production,
increase insulin sensitivity, and enhance GLP-1
(Glucagon like peptide) action are used to treat
hyperglycemia.
5) The care of individuals with type 2 DM must
also include attention to the treatment of
conditions associated with type 2 DM (obesity,
hypertension, dyslipidemia, cardiovascular
disease) and detection/management of DM-
related complications.
11/7/2013 Biochemistry For Medics 48
For further details
Refer
A Case oriented Approach
Towards Biochemistry
A Book Of Clinical
Biochemistry-Jay pee
Brothers Medical Publishers.
http://www.jaypeebrothers
.com/pgDetails.aspx?cat=s
&book_id=978-93-5090-188-
5

11/7/2013 Biochemistry For Medics 49