Diabetes part 1 - waldron Flashcards
what does anaerobic breakdown by glycolysis yield
8-10 ATP
what does aerobic respiration by Krebs cycle yield
25 ATP
what are the main subtypes of Diabetes
Type 1 (T1DM) and Type 2 (T2DM)
what populations do we typically see T1DM in
children or adolescents
what population do we typically see T2DM in
affects more middle-age and older adults with prolonged hyperglycemia due to poor lifestyle and diet
what secretes insulin
pancreas
where are the islets of langerhans
in the pancrease
what are the two subclasses of endocrine cells
alpha cells: glucagon secreting
beta cells: insulin producing
what is the etiology of T1DM
characterized by destruction of pancreatic beta cells, usu caused by autoimmune process
result: absolute destruction of beta cells and absent/extremely low insulin levels
what is the etiology of T2DM
insidious onset of imbalance btwn insulin levels and insulin sensitivity, causing functional deficit of insulin
insulin resistance is multifactorial but commonly develops from obesity and aging
what type of DM have more complex interplay between genetics and lifestyle
T2DM
what does polymorphisms influence the risk for
T1DM
What is MODY
mature onset diabetes of young
non-insulin dependent diabetes diagnosed at young age (usu. < 25)
autosomal dominant transmission, does not involve autoantibodies as in T1DM
genetics unclear
what is diabetes during pregnancy
gestational diabetes
what are endocrinopatheis
acromegaly, cushings syndrome, glauconoma, hyperthyroidism, hyperaldosteronism, somatostatinomas: all associated with glucose intolerance and DM
what ethnic groups have the most prevalence of diabetes
native american
non-hispanic black
hispanic
what is the epidemiology of T1DM
peaks 4-6yo and 10-14 yo
F > M with aging (not as much in children)
what is the epidemiology of T2DM
onset usually later in life (adolescent obesity causing increase in younger people)
2-6x more prevalent in african american, native american, etc
what can hyperglycemia alone impair
pancreatic beta-cell function and contributes to impaired insulin secretion
what serum glucose levels are likely to cause symptoms of polyuria and polydipsia
> 250 mg/dL
what is insulin resistance
excess fatty acids and pro-inflammatory cytokines lead to impaired glucose transport and increased fat breakdown
inadequate production of insulin to compensate for their insulin resistance
what does chronic hyperglycemia cause
non-enzymatic glycation of proteins and lipids measurable via glycated hemoglobin (HbA1c)
what does glycation lead to
microvascular damage in retina, kidney and peripheral nerves; higher glucose levels hasten process
what does the damage from glycation lead to
classic diabetic complications: diabetic retinopathy, nephropathy and neuropathy (preventable blindness, dialysis and amputation)
what are the typical presentation of diabetes
polyuria, polydipsia and weight loss (catabolism)
what is seen on PE with hyperglycemia
fatigue, poor skin turgor, distinctive fruity odor on their breath (ketosis): if DKA Kussmaul respirations, N/V
what will be seen on fundoscopic exam with DM
macular hemorrhages or exudates; neovascularization
What is the presentation of T2DM
overweight/obese with signs of insulin resistance
acanthosis nigricans, blurry vision, frequent yeast/fungal infections, numbness/neuropathic pain
what is the presentation of hyperglycemia
dry mouth
increase thirst
blurred vision
weakness
AH
frequent urination
how do you diagnose DM
fasting plasma glucose (FPG) levels
HbA1c (glycosylated Hb)
OGTT (oral glucose tolerance testing)
Urine “spilling”
what is a HbA1c for T2DM
> 6.5%
what is the diagnostic criteria per the ADA
one of the following:
fasting plasma glucose (FPG) > 126mg/dL
random glucose > 200 mg/dL with symptoms of hyperglycemia
2-hr plasma glucose > 200 mg/mL during 75g OGTT
with is the OGTT
oral glucose tolerance testing
2 hour after ingesting of concentrated glucose solution
more sensitive for diagnosing DM and impaired gluocse tolerance but less convenient and reporducible than FPG
rare as routine testing except for gestational diabetes and research
*best test
what is the BG to make the A1c of 7
155BG
what is the diagnostic criteria for pre-diabetes
one of the following:
FBG >100-125 mg/dL
2-hr OGTT plasma glucose of 140-199 mg/dL
HbA1c 5.7-6.4%
what tests are useful in the management of chronic (already diagnosed) DM
home glucose testing
HbA1c
urine albumin
serum lipid monitoring
what other test is strongly recommended for chronic DM management
monitor thyroid status annually via TSH (higher associated incidence of hypothyroidism)
what is a normal PPG level
<139
what is a normal HbA1c
< 5.6%
what level is a a random plasma glucose considered diabetes
> 200
what is a normal FPG
<99
what is always the first step in DM treatment
diet (carbs and caloric restriction) and exercise ( more than 150min weekly)
What is SDOH
social determinants of health
access to healthy food, housing, social support, ability to afford meds, etc. need to be considered
barriers to care need to be addressed/remove if any treatment is to be effective
what are key patient characteristics that need to be assessed with glycemic management
current lifestyle
comorbidities
clinical characteristics (age, HbA1c, weight, etc)
issues such as motivation and depression
cultural and socio-economic context
what are treatment complication of DM
hypoglycemia
too much insulin or medicine / too much exercise / NOT eating an anticipated scheduled meal
what is the BG for hypoglycemia
< 50 mg/dL
what are the signs/symptoms of hypoglycemia
sleepiness, sweating, pallor, lack or coordination, irritability, hunger
what is the treatment for hypoglycemia
glucose
tabs, icing, candy vs IM injection/IV if unable to protect airway
what are the microvascular disease complications of DM
retinopathy
nephropathy
neuropathy
also - impaired skin healing
what is the treatment for diabetic retinopathy
intensive glycemic and blood pressure control
advanced: retinal laser photocoagulation, vitrectomy, vascular endothelial growth factor (VEGF) inhibitors etc.
what is the leading cause of chronic kidney disease in the US
diabetic nephropathy
what is diabetic nephropathy
thickening of glomerular basement membrane, mesangial expansion and glomerular sclerosis; causes glomerular hypertension and progressive decline in GFR
systemic HTN may accelerate progression
how do you diagnose diabetic nephropathy
urinary albumin
when is a urine dipstick positive
only if protein excretion > 300-500mg/day
what is the treatment of diabetic nephropathy
intensive glycemic and blood pressure control
ACE or ARB: renal protecting, treat HTN and prevent progression of renal disease
consider nephrology consult/co-management
how often is urinary albumin level monitored
minimally annually
what is diabetic neuropathy
result of nerve ischemia: direct effect of hyperglycemia, intracellular metabolic changes that impair nerve function
what are the different types of diabetic neuropathy
symmetric polyneuropathy (small and large-fiber variants)
autonomic neuropathy
radiculopathy
cranial neuropathy
mononeuropathy
what is systemic polyneuropathy
most common - affects distal feet and hands (stocking-glove distribution)
paresthesia, dysesthesia, painless loss of touch, vibration, proprioception or temp
what is the presentation of small-fiber symmetric polyneuropathy
pain, numbness, loss of temperature sensation with preserved vibration and position sense
what is the presentation of large-fiber symmetric polyneuropathy
muscle weakness, loss of vibration and position sense, lack of DTRs; atrophy of intrinsic muscles of feet (foot drop common)
what are signs of autonomic neuropathy
orthostatic hypotension
exercise intolerance
resting tachy
dysphagia
N/V due to gastroparesis
constipation and diarrhea etc
what are radiculopathies
most common proximal L2-L4 nerve roots; pain, weakness, atrophy of LEs (diabetic amyotrophy)
proximal T4-T12 nerve roots, causes abdominal pain (thoracic polyradiculopathy)
what are cranial neuropatheis
dipolpia, ptosis, an isocoria
what are mononeuropathies
finger weakness/numbness (median nerve) or foot drop (peroneal nerve) - prone to nerve compressive d/o - CTS
can occur at several places simultaneously
how are DM complications managed
glycemic control
regular foot care
management for pain
what are macrovascular disease associated with DM
atherosclerosis of large vessels; hyperinsulinemia, dyslipidemias, hyperglycemia
angina pectoris/MI
TIA/stroke
peripheral arterial disease
what is the treatment of macrovascular disease
intensive control of atherosclerotic risk factors; multifactorial
normalization of PG, lipids, GP
smoking cessation
ACEi (arb) - renal and cardiovascular management
what are diabetic cardiomyopathies
atherosclerosis, HTN esp with LVH, microvascular disease, endothelial and autonomic dysfunction, obesity, metabolic disturbances
what are infective complications of DM
prone to bacterial and fungal infections; AE of hyperglycemia on granulocyte and T-cell function
increased susceptibility to fungal infection
bacterial foot infections (increased osteomyelitis); exacerbated by LE vascular insufficiency, neuropathy
What is NAFLD
non-alcoholic fatty liver disease
increasingly common in T2DM
mainstay of treatment is diet, exercise and weight loss
what are routine screenings for DM
foot exam (minimally annually)
retinal exam (annually - min every 2 years)
HbA1c: based on control and disease severity
spot or 24-hr urine (annually with serum creatinine)
cardiac (min annual EKG and lipids, BP every visit)
