Diabetes In Adults

Question 1

What are other names used to describe latent autoimmune diabetes of adulthood (LADA)?

Answer 1

Type 1.5 diabetes

Antibody positive type 2

Slowly progressive IDDM

Youth overt diabetes of maturity

Progressive insulin-dependent diabetes mellitus

Question 2

What characteristics of type 1 and type 2 DM does Latent autoimmune diabetes of adulthood (LADA) show?

Answer 2

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)

Question 3

Prevalence of DM2

Answer 3

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

Question 4

What are common risk factors for DM2

Answer 4

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

Question 5

What drugs induce diabetes (Iatrogenic diabetics)

Answer 5

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)

Question 6

What amount of the pancreatic B-cell function is usually lost before DM2 patients become symptomatic

Answer 6

50-70%
- this usually occurs within 10 years and now requires insulin therapy

life expectancy is 10 years shorter for DM2

Question 7

How does DM2 produce a snowball effect?

Answer 7

Hyperglycemia impairs beta cell function by increasing insulin production initially and producing a burnout effect will also increasing insulin resistance peripherally

Question 8

How does truncal obesity cause DM2 increased risk?

Answer 8

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

Question 9

How much diabetics are due to obesity and lifestyle choices compared to genetics or iatrogenic causes

Answer 9

80-85%

- the vast majority of diabetes cases are caused by this

Question 10

What are the highest risk factors based on laboratory values?

Answer 10

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

Question 11

What are the three lab values that determine actual diabetes diagnosis

Answer 11

1) A1C over 6.5
2) Fasting plasma glucose over 125 mg/dL
3) OGTT glucose over 199 mg/dL

Question 12

What conditions can erronesously impact A1C?

Answer 12

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

Question 13

What is hyperosmolarity, hyper glue ic non-ketosis syndrome?

Answer 13

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

Question 14

Retinopathy in DM

Answer 14

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

Question 15

Nephropathy in DM

Answer 15

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**

Question 16

Diabetic neuropathy

Answer 16

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

Question 17

Heart disease in diabetes

Answer 17

Silent ischemia is very common

2-3x risk for CAD a

60% of dying form heart disease (leading cause of death)

Question 18

Cerebral vascular disease in diabetes

Answer 18

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

Question 19

Goal of treatment for DM2

Answer 19

#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.

Question 20

What is commonly added to a patients DM2 drug regiment if they are initially at a very high A1C (usually >9.0)

Answer 20

Injectable GLP-1 agonists, DPP4 inhibitors or TZDs approximately 3-6 months after metformin

Question 21

What are common preventive measures can reverse the progression of DM2

Answer 21

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%