Diabetes Lecture 1 Flashcards
Epidemiology of Diabetes
25.8 million Americans have DM
33-40% of males/females born in 2000 respectively will have DM (type 1 or type 2) in their lifetime
Pt.diagnosed at<40y/o will have a life expectancy by about 12-19 years
7th leading cause of death in the US
Diabetes is the number one cause:
1. Non-traumatic amputation
2. Kidney disease
3. BlindnessClassification of Type 1 Diabetes
Absolute deficiency of insulin secretion
Autoimmune destruction of the pancreatic cells
Viruses that cause cell destruction; congenital rubella, coxsackievirus B, cytomegalovirus, adenovirus, and mumps
Prevalence: <10% of all DM cases
Classification of Type 2 Diabetes
Combination of complex metabolic disorders
1. Insulin resistance in muscle and adipose tissue
2. Progressive decline in pancreatic insulin secretion
3. Unrestrained hepatic glucose production
4. Other hormonal deficiencies
Amylin and incretin
Prevalence: >90% of all DM Cases
Action of alpha cells, beta cells and amylin
alpha cell secrete glucagon
Beta cells secrete insulin
amylin suppresses insulin
Signs and Symptoms of Hyperglycemia
Polyuria: Frequent urination
Polydipsia: Inability to quench thirst
Polyphagia: Losing weight while eating a lot
Fatigue
Risk Factors for Type 2 Diabetes
- Overweight or obese state
- Sedentary lifestyle
- Family history of diabetes
- Cardiovascular disease
- Latino/Hispanic, NonñHispanic black, Asian American, Native American, or Pacific Islander ethnicity
- Previously identified impaired glucose tolerance or impaired fasting glucose
- Hypertension (>140/90 or on HTN meds)
- Increased levels of triglycerides (>250), low concentrations of high-density lipoprotein cholesterol (<35), or both
Risk Factors for GDM
History of gestational diabetes
History of delivery of an infant with a birth weight >9 lbs
Polycystic ovary syndrome
Diabetes Screening
- Asymptomatic people with a BMI greater than or equal to 25 kg/M2 in adults of any age and who have one or more additional risk factors for DM
- In those without these risks, testing should start at age 45
- If tests are negative with these risk factors, test again at 3 year intervals
A1C and Daily Blood Glucose
A1C Mean Glucose 6 126 7 154 8 183 9 212 10 240 11 269 12 298
Diagnostic Criteria for Type 1 and 2 Diabetes
Lab Normal Pre-Diabetes Diabetes
A1C < 5.7 % 5.7-6.4% ≥ 6.5%
Fasting
Plasma
Glucose < 100 mg/dL 100-125 mg/dL ≥ 126 mg/dL
Oral Glucose
Tolerance Test <140 mg/dL 140-199 mg/dL ≥ 200 mg/dL
Random Glucose
+ Symptoms N/A N/A ≥ 200 mg/dL
Treatment Goals
-A1C: <180mg/dL
Pre- Diabetes
If a patient is determined to have pre-diabetes (IGT, IFG, or A1C 5.7-6.4%), then metformin could be considered as a therapy, especially if any of the following are met:
1. BMI > 35kg/m2
2. <60 years of age
3. Women with prior GDM
Annual monitoring for development of DMComplications of Diabetes
Macrovascular Complications
1. Coronary artery disease
2. HTN
3. Dyslipidemia
Microvascular Complications
1. Retinopathy
2. Neuropathy
3. NephropathyNon- Pharmacological Therapy
Exercise
1. 30 minutes for most days of the week
Diet
1. Avoid foods high in saturated fats, carbohydrates and sugar 2. Increase fiber
CAD Complication Management
ASA 81mg daily
Men >50 years of age or women >60 years of age with at least one additional risk factor (family history of CVD, HTN, smoking, dyslipidemia, or albunemia)
HTN Complication Management
Goal: 140/80…..130/80 for certain populations
ACE-I or ARB
Dyslipidemia Complication Management
Goal: LDL <100
Statin initiate therapy for those with a PMH of an MI,or greater than 40 y/o with other risk factors
Retinopathy Complication Management
Manage HTN and glucose
Laser treatment
Neuropathy Complication Management
Manage HTN and glucose ï
Peripheral:
Numbness/tingling in the hands and feet (yearly foot exams)
Gabapentin (2400-3600mg daily in divided doses titrate up due to drowsiness), Lyrica and Cymbalta (both FDA approved), TCA ís (dose at night)
Autonomic:
Erectile dysfunction; PDE-5 inhibitors
Gastropyresis: Reglan and erythromycin
Constipation: Stool softeners
Nephropathy Complication Management
Manage HTN and glucose
ACE-I or ARB to help slow progression from micro to
macroalbumenia
Special Populations of DM
Gestational DM
Children and adolescents
Older adults
Incidence of GDM
Complicates ~7% (~200,000 cases annually) of all pregnancies in the U.S.
Prevalence may range from 1 to 14% of pregnancies depending on the population studied
Complications of GDM
Macrosomia
Cesarean delivery
Shoulder dystocia and birth trauma
Neonatal metabolic problems ï Perinatal mortality
Hypertension/preeclampsiaRisk Factors of GDM
- > 25 year old
- Overweight/obese
- Family history of DM2 (first degree relative)
- History of abnormal glucose metabolism
- History of poor obstetric outcomes
- History of delivery of an infant > 9 lbs
- History of polycystic ovarian disease
- Ethnicity: Latino/Hispanic, non-Hispanic black, Asian American, Native American, Pacific Islander
Diagnostic Criteria of GDM
- Screen at first prenatal visit in those with risk factors
- If a woman does not have known DM test using OGTT at 24-28 weeks
Treatment for GDM
- Dietary modifications and insulin remain first line treatment for GDM
- Clinicaltrialsarecurrentlyinvestigatingnewer options with oral hypoglycemic agents and insulin analogs
- Treat meant plans should be individualized keeping the safety of both the mother and fetus in mind
Oral Agents
Biguanides and TZD ís: NOT RECOMMENDED
Sulfonylureas: Glipizide and Glyburide possible treatment options
Follow for GDM
- If a women does have GDM they need to be tested 6-12 weeks postpartum
- If a women does have GDM they should be screen every 3 years for the development of DM or pre-diabetes
Children and Adolescence
3/4 of all type 1 DM cases are diagnosed before the age of 18
Differences compared to adults:
1. Changes in insulin sensitivity due to hormone changes 2. Growth patterns 3. Supervision at school and daycare 4. Unique vulnerability to hypoglycemia and DKA
Goals for Children and Adolescence
Lax compared to adults because of their risk of hypoglycemia (unable to detect and act on the signs and if the pt. < 5 years of age they have a risk of developing severe neurological damage from hypoglycemia)
Incidence for Older Adults
~ 20% of the population over the age of 65 has DM
Increased rates of
Premature death
Functional and cognitive impairment
Co-morbid conditions (heart disease, stroke etc)
Overall Goals for Older Adults
Should be the same for younger adults if the patient
Has significant life expectancy
Functional
Cognitively intact
Therapy Goals for Older Adults
- Glycemic goal may be relaxed ñ Want to avoid hypoglycemia
- Treat all heart conditions and provide all therapy to patients that are able to benefit from this
