De pancreas Anatomie van de pancreas De ductus pancreaticus komt in het duodenum uit De ductus levert het pancreassap af De ductus heeft vele vertakkingen De dunne takjes komen uit in de klierblaasjes (acini) Endocriene cellen tussen de acini aanwezig

De pancreas De pancreas Figuur 16-13(a)

De pancreas De pancreas Figuur 16-13(b)

De pancreas Secreties van de pancreas Endocriene secretie (hormonen) Insuline Glucagon Exocriene secretie (vertering) Water Ionen Enzymen Carbohydrasen Lipasen Proteasen Nucleasen

Pathofysiologie van diabetes Verschillende vormen….: Diabetes mellitus type 1 (DM1); Latent auto-immune diabetes in adults (LADA); Diabetes mellitus type 2 (DM2); Maturity-onset diabetes of the young (MODY); Maternal-inherited diabetes and deafness (MIDD); Zwangerschapsdiabetes Algemeen kenmerk: te hoge bloedglucosewaarden.

Pathofysiologie van diabetes Globale indeling diabetes + kenmerken: Type 1: voorheen: insuline-afhankelijk Absoluut insuline gebrek (geen functionerende β-cellen) Jonge patiënten (vaak < 18 jaar) zonder overgewicht Acute complicaties van diabetes (keto-acidose) Type 2: voorheen: insuline onafhankelijk Relatief insuline gebrek (wel functionerende β-cellen) Oudere patienten met overgewicht Chronische complicaties (mn. vasculair) Verminderde respons op insuline Insuline-resistentie (centrale adipositas, hypertensie, gestoorde glucosetolerantie en stoornissen in het vetspectrum: metabool syndroom)

Pathofysiologie van diabetes Complicaties ten gevolge van diabetes: Korte termijn: acute situaties polydipsie/-urie: vaak dorst, veel plassen vermoeidheid schimmelinfecties keto-acidose Acute complicaties komen relatief minder vaak voor: Betere genees- en hulpmiddelen Betere instelling op bloedglucosewaarden (o.a. nuchter, HbA1c) Intensievere begeleiding in 1e en 2e lijn (ketenzorg)

Pathofysiologie van diabetes Complicaties ten gevolge van diabetes: Lange termijn: chronische gevolgen Microvasculaire complicaties: nefropathie: nierschade (nierfunctiestoornissen) neuropathie: (tast)zenuwschade (ulcera, impotentie, gastroparese) retinopathie: oogzenuwschade (visusstoornissen) Macrovasculaire complicaties: hypertensie hypercholesterolemie Veel co-morbiditeiten: bron voor problemen…. Poly-farmacie: meer kans op farmacologische problemen (interacties!) Therapietrouw patiënt wordt snel slechter…. (o.a. bijwerkingen) 8

Behandeling van diabetes Algemene doelstellingen therapie1,2: Preventie van complicaties op korte EN lange termijn! Normalisering glucose- / HbA1c-waarden: Glucose: nuchter: 4 – 7 mmol/l; 2 uur postprandiaal: < 9 mmol/l HbA1c: < 7 % Behandeling hypertensie (systolisch < 140mm) Regulatie van lipiden/cholesterol (o.a. statines) 1: NHG-standaard Diabetes Mellitus 2 (2006) 2: NHG-standaard Cardiovasculair Risico Management (2006)

Farmacotherapeutische opties: Diabetes type 1: Insulines: Kortwerkend Middellangwerkend Langwerkend Bi-fasische mengsels Diabetes type 2: Metformine Sulfonylureum-derivaten Thiazolidinedionen Dipeptidylpeptidase-4-remmers Glucagonachtig peptide-1-agonisten Insulines

Metformine: Plaats in de therapie: Farmacologisch werkingsmechanisme: 1e keus bij onvoldoende effect leefstijl adviezen Dosering: 500-850 2-3dd; max. 3dd 1000mg (tijdens/na eten). Farmacologisch werkingsmechanisme: Remming gluconeogenese + glycogenolyse (lever/spieren) Toename perifere gevoeligheid insuline Verhoging intracellulaire opname + verbruik glucose Remming opname glucose

Metformine: Meest voorkomende bijwerkingen: Contra-indicaties: > 10%: maagdarmklachten (braken, diarree; vaak reversibel!) 1-10%: smaakstoornissen < 1%: huidreacties (jeuk, roodheid), Vit B12 tekort Contra-indicaties: Lactaat-acidose! Verminderde nierfunctie (invloed op klaring) Hypoxie: door verstoorde circulatie of longlijden (zie boven) Leverfunctiestoornis, vasten, slecht ingestelde diabetes

Insulines: Plaats in de therapie: Farmacologisch werkingsmechanisme: 1e keus bij DM1; eindbehandeling DM2 (falen orale therapie) DM2: vaak gecombineerd met orale therapie Dosering: afhankelijk van de behoefte (individueel instellen) Start: middellang werkend voor de nacht Vervolg: 2 dd (mix) of 4dd (kortw) schema (zn. geheel insuline regime) Farmacologisch werkingsmechanisme: Nabootsing werking van lichaamseigen insuline (recombinant!) Bevorderen opname van glucose in lever-, spier- en vetweefsel Rem gluconeogenese (lever) Stimulans glycogeen-, vet- en eiwitsynthese (glucoseverbruik) Manipulatie van insuline/toedienvorm: aanpassen afgifteprofiel 13

Insulines: Meest voorkomende bijwerkingen: Contra-indicaties: Hypoglykemie (erger bij scherper instellen) Hyperglykemie (indien te laag ingesteld) Injectiereacties (overgevoeligheden, atrofie) Insulineresistentie Sommige patiënten hebben baat bij een continue infusie van insuline. Contra-indicaties: Overgevoeligheid (hulp)stoffen (zink, protamine, M-cresol) Hypoglykemie 14

Insulines: Interacties: Bijzonderheden: β-blokkers: maskeren symptomen + vertragen herstel hypoglykemie Hypoglykemie : ACE, alcohol, anabolen, anti-diabetica, thyreomimetica, octreotide en hoge doses salicylaten Hypoglykemie ↓: anticonceptiva, epinefrine, glucosteroiden, thiazide- en lisdiuretica, somatropine en sympathicomimetica Bijzonderheden: Oude middelen, nieuwe toedienvormen: therapie-optimalisatie! Nieuwe opties: continue glucosemonitoring, stamcellen? Nog geen definitieve oplossing voor een ziekte met grote impact… 15

Informatiebronnen: NHG-Standaard DM2 (nhg.artsennet.nl) NHG-Standaard Cardiovasculair Risico Management Uw eigen huisarts, apotheker of internist/diabetoloog! Farmacotherapeutisch Kompas (www.fk.cvz.nl) College Beoordeling Geneesmiddelen (www.cbg-meb.nl) European Medicine Agency (www.emea.europa.edu) Apothekerskoepel KNMP – www.apotheek.nl 16

Diabetes Mellitus: Type 1 Versus Type 2 Age Develops at any age, but usually before 302 Can develop at any age, but usually after 301 Body constitution Frequently lean2 90% overweight1 Pathogenesis Autoimmune destruction of the beta cells1 Insulin resistance is usually present1 Insulin deficiency Absolute insulin deficiency1 Dependent on exogenous insulin for life Strong tendency for ketoacidosis Greater glucose variability Relative insulin deficiency1 Endogenous insulin levels may be low, normal, or high Not prone to ketosis KEY POINTS Type 1 Diabetes The condition develops usually before the age of 30.2 The patients are usually lean.2 It occurs due to autoimmune destruction of the beta cells of the pancreas.1 Absolute insulin deficiency is seen resulting in the patients’ dependence on exogenous insulin for life.1 These patients have greater blood glucose variability and are prone to develop ketoacidosis.2 Type 2 diabetes The condition usually develops after the age of 30.1 Most patients are usually obese.1 Variable degrees of insulin resistance are often present.1 These patients present with relative insulin deficiency with low, normal, or high endogenous insulin levels. These patients are not prone to develop ketoacidosis. REFERENCES American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus. Endocr Prac. 2007;13 (Suppl 1):1-68. Frier BM, Fisher M. Diabetes mellitus. Davidson's Principles and Practice of Medicine, 20th ed. Edinburgh: Churchill Livingstone;2006:805-847. 1. American Association of Clinical Endocrinologists. Endocr Prac. 2007;13:1-68. 2. Frier BM et al. Davidson's Principles and Practice of Medicine, 20th ed. 2006;805-847.

T1DM: Unmet Needs A1c control – difficult to reach goal Multiple insulin injections – negative impact on activities of daily living Multiple glucose self-tests – negative impact on activities of daily living Hypoglycemia – major concern for both patients and their caregivers; can be life-threatening Hyperglycemia/diabetic ketoacidosis – can be life-threatening Chronic complications – nephropathy (dialysis), retinopathy (vision loss), neuropathy (amputations), macrovascular disease (MI/stroke) KEY POINTS The unmet needs of type 1 diabetes are: A1c control – difficult to reach goal Multiple insulin injections – negative impact on activities of daily living Multiple glucose self-tests – negative impact on activities of daily living Hypoglycemia – major concern for both patients and their caregivers – can be life- threatening1 Hyperglycemia/diabetic ketoacidosis – can be life-threatening1 Chronic complications – nephropathy (dialysis), retinopathy (vision loss), neuropathy (amputations), macrovascular disease (MI/stroke)1 REFERENCE Frier BM, Fisher M. Diabetes mellitus. Davidson's Principles and Practice of Medicine, 20th ed. Edinburgh: Churchill Livingstone;2006:805-847. Frier BM et al. Diabetes mellitus. Davidson's Principles and Practice of Medicine, 20th ed. 2006:805-847.

T1DM: Psychosocial Impact on the Patient “Life with type 1 diabetes poses challenges for every member of the family. A new diagnosis of type 1 diabetes can spark a range of reactions, including anger, sadness, and guilt.” KEY POINT JDRF has one mission – to find a cure for diabetes and its complications through the support of research. REFERENCE Newly diagnosed. Available at: http://www.jdrf.org/index.cfm?page_id=103432. Accessed 8 April, 2010. “As time goes by, everyone will gain knowledge and confidence, and be able to celebrate successes, learn from mistakes, and move away from the intense feelings common after diagnosis.” Newly diagnosed. Available at: http://www.jdrf.org/index.cfm?page_id=103432. Accessed 8 April, 2010. Image courtesy of Michelle Meiklejohn / FreeDigitalPhotos.net.

T1DM - Epidemiology: Incidence Overall Age-standardized Incidence of Type I DM in Children Ages 0-14, 1990-1999 KEY POINTS DIAMOND is a Multinational Project for Childhood Diabetes funded by the WHO The study included 43,013 children ≤14 years of age diagnosed with Type 1 DM between the years 1990 and 1999. The incidence of Type 1 DM has been found to be very high in Finland, United Kingdom, Canada, and the United State; it is low in Italy and France, and very low in Japan. REFERENCE DIAMOND Project Group. Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999. Diabet Med. 2006;23:857-866. DIAMOND Project Group. Diabet Med 2006;23:857-866.

T1DM - Risk Factors: Genetic Genetic Factors Details Impact Family History Increased lifetime risks among relatives First-degree relative: 5%; identical twin: 50% é Major Histocompatibility Complex (MHC) Genes (in HLA region) Genotypes HLA-DR3,DQ2 and HLA-DR4,DQ8 have increased susceptibility > 90% of T1D have 1 haplotype, Non-MHC Genes Changes in the insulin gene (IDDM2), and cytotoxic T-lymphocyte-associated antigen-4 gene (CTLA-4) have been associated with risk, but the association is much less strong than the association with HLA KEY POINTS Specific genes have been linked to type 1 diabetes. The concordance for type 1 diabetes is approximately 50% for monozygotic twins, and the risk to a first degree relative is approximately 5%. More than 90% of patients who develop type 1 diabetes have either DR3, DQ2 or DR4, DQ8 haplotypes, whereas fewer than 40% of normal controls have these haplotypes. Changes in the insulin gene (IDDM2), and cytotoxic T-lymphocyte-associated antigen-4 gene (CTLA-4) have been associated with risk; but the association is much less strong than the association with human leukocyte antigen (HLA). REFERENCE Devendra D, Liu E, Eisenbarth GS. Type 1 diabetes: recent developments. BMJ. 2004;328:750-754. Devendra et al. BMJ 2004;328:750-754.

T1DM - Risk Factors: Environmental Environmental Factors Details Impact Viruses May cause diabetes by infecting beta cells or by inducing an autoimmune attack (including enterovirus, Coxsackie, rubella)1,2 However, some believe that viruses have a protective effect1 é Dietary Early introduction to cow’s milk has been investigated as a potential etiologic factor, but conflicting results have been obtained1 Early introduction to cereal1 and nitrates3 have been suggested as risk factors Vitamin D supplements might be protective1 é/? é  KEY POINTS Less than 10% of genetically susceptible individuals progress to clinical disease implying the role of additional factors that trigger and drive beta-cell destruction in genetically predisposed subjects.1 There are several hypotheses on relevant environmental triggers.1,2,3 Viruses such as rotavirus, enterovirus, and rubella may cause diabetes by infecting beta cells or by inducing an autoimmune attack. However, some believe that viruses have a protective effect. Dietary interventions such as early introduction to cow’s milk (specifically, albumin and beta-casein proteins) has been studied with conflicting results. Early introduction to cereal (gluten) and nitrates in drinking water concentration have been suggested as risk factors. Vitamin D supplements might be protective. REFERENCES Knip M, Veijola R, Virtanen SM, et al. Environmental triggers and determinants of type 1 diabetes. Diabetes. 2005;54:S125-S136. Gillespie KM. Type 1 diabetes: pathogenesis and prevention. CMAJ. 2006;175(2):165-170. Devendra D, Liu E, Eisenbarth GS. Type 1 diabetes: recent developments. BMJ. 2004;328:750- 754. 1. Knip et al. Diabetes 2005;54:S125-S136. 2. Gillespie et al. CMAJ 2006;175(2):165-170. 3. Devendra et al. BMJ 2004;328:750-754.

Diabetes: Magnitude of Chronic Complications Diabetic Retinopathy Leading cause of blindness in working age adults Stroke 2- to 4-fold increase in cardiovascular mortality and stroke Diabetic Nephropathy Leading cause of end-stage renal disease Cardiovascular Disease Diabetes mellitus is associated with a wide variety of microvascular and macrovascular complications. Diabetic Neuropathy KEY POINTS Diabetic microvascular complications most commonly manifest in the eyes, kidneys, and nerves. Some of the complications are as follows: Diabetic retinopathy and diabetic macular edema: Diabetes is the leading cause of new cases of blindness in adults aged between 20 and 74 years Diabetic nephropathy: Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in 2005. People with diabetes constitute the fastest-growing group of renal dialysis and transplant recipients. Diabetic neuropathy and amputations: Diabetes is the leading cause of nontraumatic lower- extremity amputations, accounting for more than 60% of amputations in the United States. About 60% to 70% of people with diabetes have some degree of diabetic nerve damage. There is also a high frequency of atherosclerosis (macrovascular disease) leading to increased risk of stroke and/or heart attack. Cardiovascular disease: People with diabetes are 2 to 4 times more likely to die from heart disease than people without diabetes. Cardiovascular disease is responsible for 50% of diabetes-related deaths. Stroke: A person with diabetes is 2 to 4 times more likely to suffer a stroke than a person without diabetes. REFERENCE National Diabetes Information Clearinghouse. National Diabetes Statistics; 2007 – Complications of Diabetes. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#complications. Accessed 8 April, 2010. Leading cause of nontraumatic lower-extremity amputations National Diabetes Information Clearinghouse. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#complications. Accessed 8 April, 2010.