Diabetes In Adults Flashcards
What are other names used to describe latent autoimmune diabetes of adulthood (LADA)?
Type 1.5 diabetes
Antibody positive type 2
Slowly progressive IDDM
Youth overt diabetes of maturity
Progressive insulin-dependent diabetes mellitus
What characteristics of type 1 and type 2 DM does Latent autoimmune diabetes of adulthood (LADA) show?
Type 1:
- possess autoimmune antibodies
- indolent decline in insulin production
- is NOT insulin resistance at diagnosis
Type 2:
- usually later onset (>35 yrs)
- slower progression to insulin use (1-6yrs)
is essentially type 1 but follows Type 2’s time line (is slowly progressive)
Prevalence of DM2
9.4% of the US population has this
34% of people have pre-diabetes leading to DM2 soon
It is the 7th leading cause of death in US
What are common risk factors for DM2
History of onset gestational diabetes
Obesity and abdominal fat distribution
PCOS
Ethnicity (Indians, Asian, Hispanic, African Americans)
Hypertriglyceridemia
HTN
Drug use
Insulin resistance
High intake of sweetened beverages
Sedentary lifestyle
1st degree relative with DM2
Highly refined carbohydrate diets
What drugs induce diabetes (Iatrogenic diabetics)
Corticosteroids
BBs (especially atenolol and metoprolol)
Anti-psychotics
Anti-epileptics (especially valproic acid and phenytoin)
Statins (increases with length of use)
Thiazides diuretics (secondary to hypokalemia)
HIV anti-retrovirals (especially protease and NRTIs)
GrHG agonists
High does oral contraceptives of estradiol
Cyclosporine, tacrolimus and sirolimus (immunosuppressants)
iatrogenic DM may be permanent (even higher risk if weight gain sets in)
What amount of the pancreatic B-cell function is usually lost before DM2 patients become symptomatic
50-70%
- this usually occurs within 10 years and now requires insulin therapy
life expectancy is 10 years shorter for DM2
How does DM2 produce a snowball effect?
Hyperglycemia impairs beta cell function by increasing insulin production initially and producing a burnout effect will also increasing insulin resistance peripherally
How does truncal obesity cause DM2 increased risk?
Truncal obesity (in the stomach/ “apple body”) leads to increased inflammatory cytokines due to pressure and increase weight put on surrounding structures
Increased inflammatory cytokines increase lipogenesis and lipolysis activity
- this increases FFAs in the blood which enter the portal vein in the liver
This increases lipogenesis and gluconeogenesis which increases insulin release in the presence of both. This increases insulin resistance slowly
this is from both visceral AND subcutaneous truncal fat
How much diabetics are due to obesity and lifestyle choices compared to genetics or iatrogenic causes
80-85%
- the vast majority of diabetes cases are caused by this
What are the highest risk factors based on laboratory values?
The highest risk factor/ most alarming lab value = fasting glucose level is 100-126 mg/dL
- this means your prediabetic
Other high risk lab values
- BMI greater than 30
- HDL-C level <40mg in men or <50mg in women
Moderate risk lab values
- triglyceride
What are the three lab values that determine actual diabetes diagnosis
1) A1C over 6.5
2) Fasting plasma glucose over 125 mg/dL
3) OGTT glucose over 199 mg/dL
What conditions can erronesously impact A1C?
Lowers A1C to erroronouisly low levels - hemolytic anemia - anything that increases turn over of RBCs - splenomegaly Increases A1C to erroneously high levels - iron deficiency - anemia of chronic disease - acute internal bleeding
this is rare through, A1C is still the best bench mark for diagnosis in diabetes
What is hyperosmolarity, hyper glue ic non-ketosis syndrome?
A rare presentation of DM2
- will present with very high sugar levels and the 3 P’s. Always presents with dehydration but NEVER shows DKA
- will develop into coma and AMS if you dont find it
this biggest risk for this is elderly patients with uncontrolled DM2 that cant hydrate properly for whatever reason
Retinopathy in DM
Most common complication of DM
- responsible for 10,000 new onset blindness cases every year
Can also cause glaucoma and cataracts
- glaucoma is caused by excessive angiogenesis blocking the ciliary bodies preventing proper aqueous solution escape and leading to increased intraocular pressure
In chronic stages = shows retinal hemorrhages and cotton wool; spots due to excessive angiogenesis in the eye due to inflammation results in friable new vessels which burst easily
Nephropathy in DM
Is the leading casue of renal failure and dialysis in the US
- *Definition of diabetic nephropathy= >500mg per 24 hrs of proteinuria with DM diagnosis
- can also check for microalbuminemia = 2% per year increase within 10 yrs of DM2 diagnosis**
Diabetic neuropathy
Most common cause of non-traumatic amputations
Frequently coexists with diabetic peripheral arterial disease
- *most common type of neuropathy = “glove and stocking” distribution which is distal symmetric polyneuropathy**
- causes “pins and needles tinging, burning and loss of vibration and spatial recognition**
may also experience autonomic neuropathies which says gastropathy, silent cardiac ischemia, orthostasis
Heart disease in diabetes
Silent ischemia is very common
2-3x risk for CAD a
60% of dying form heart disease (leading cause of death)
Cerebral vascular disease in diabetes
Have a 2-4x increase risk of stroke
Have a 2-3x increased risk of vascular dementia
Also have a increased risk of Alzheimer’s
Goal of treatment for DM2
#1 is always lifestyle chances and metformin - DONT give metformin if GFR is <30mL/min
Overall goal = get A1c below 7.0 in most (between 7.5-8.0 is okay for elderly)
Also need to treat aggressively any cofactors for atherosclerosis
- BP under 140/90
- get lipids <100
- watch salt and carb intakes
Need to screen for foot checks, urine microalbumina no ophthalmology at all check ups. Also make sure vaccinations are always up to date.
What is commonly added to a patients DM2 drug regiment if they are initially at a very high A1C (usually >9.0)
Injectable GLP-1 agonists, DPP4 inhibitors or TZDs approximately 3-6 months after metformin
What are common preventive measures can reverse the progression of DM2
1) 7% wt loss + 150 minutes of activity per week prevents 70% of prediabetics from progressing to DM2
2) 800kcal liquid diet for 5 months has been shown to cause roughly 20lb weight loss on average which can prevent DM2 progression
3) bariatric surgery in patients with a BMI >35 by itself of >30 BMI with comorbid diseases results in 15-20% wt loss and reliable remission of DM2
4) patients with a family history of DM2 staying at a healthy weight <25 BMI reduces risk by 70-90%
