DM 1 Flashcards
obsolete terms
-Insulin-dependent diabetes mellitus (IDDM)
-Noninsulin-dependent diabetes mellitus (NIDDM)
-not used anymore -> type 2 can become insulin dependent
-Adult-onset diabetes mellitus - not always children
-children can also get type 2 diabetes
-Non-ketotic diabetes mellitus -> implies there are no ketones but there is always ketones present (not as much as DKA)
-dx is based on the pathogenic process
DKA
-lactic acidosis takes over
-not enough insulin to utilize glucose -> body starts to break down fats
-type 1 higher levels of ketones
-acidotic
insulin Function
Main action:
- facilitates uptake of glucose from blood into cells (muscle, fat, liver)
- stores excess energy as glycogen and fat
- builds tissue by protein synthesis (anabolic)
Stimulates skeletal muscle fibers:
-Glucose to glycogen
-Amino acid to protein (does protein synthesis too!)
Acts on liver cells :
-inhibits gluconeogenesis + glycogenolysis = increase glycogen storage
-Acts on adipose cells to synthesize fat
Hypothalamus:
- reduce appetite
hyperglycemia
-excessive glucose production -> hyperglycemia
-impaired glucose clearance -> hyperglycemia
-hyperglycemia -> tissue injury
Type 1 vs type 2 DM definition
Type 1 DM
- Autoimmune condition in which immune system destroys pancreatic beta cells which make insulin
- risk factors: genetics and environment
Type 2 DM:
- progressive insulin resistance that gradually becomes an inability to produce insulin
- associated with lifestyle factors like obesity and physical inactivity, (genetics can play a role too)
type 1 epidemiology
-High-risk HLA alleles among ethnic groups in different geographic locations – increases the risk of type 1 DM
-Highest incidence: Scandinavia
-Insulin- 1A and 1B
Risk factors:
-1/3 - genetic (HLA alleles –DR3 & 4)
-2/3 – environment
Age of onset:
- generally young but can be later
type 2 epidemiology
Highest in certain Pacific islands
-Intermediate in: India; US
Variability is likely due to:
- genetic
- behavioral
- environmental factors
Age of onset- can be young too but generally oldre
diabetes triad
-polyuria
-polydipsia
-polyphagia
type 1 symptoms
-acute
-polyuria, polydipsia, polyphagia- not really chronic -> acute
-Unexplained weight loss and easy fatigability
-Ketoacidosis- life threatening
-Irritability, drowsiness, and loss of consciousness
-Dehydration, electrolyte abnormalities (Na, K), osmolality*, and acid-base disturbances (pH <7.2)
-Honeymoon remission- After ketoacidosis, may briefly revert to normoglycemia without requiring therapy (temporary phase)
-dx is usually from DKA -> acute (not insidious)
Lipid Profile
LDL, TG, and TC are all mildly elevated
Returns to baseline once glucose is controlled
HDL remains at baseline
type 2 symptoms
-Often asymptomatic -> need to screen because of complications
-Weight loss initially- but overall BMI tends to be high
-acute presentation- Hyperosmolar nonketotic coma, severe dehydration -> Secondary to osmotic diuresis (peeing water and Na out)
PMH:
- Frequent/recurrent infections
- poor wound healing
- blurring of vision,
- numbness or tingling in the extremities
risk factors for and complications of diabetes
risk factors:
-over weight and obesity
-genetics
-HTN
-gestational diabetes- dont use A1c - past 3 months -> not accurate to the baby
complications
-retinopathy
-neuropathy
-nephropathy
-cardiovascular disease
-amputation
components of the comprehensive diabetes evaluation- medical hx
-Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic lab finding)
-Eating patterns (nutritionist), physical activity habits, nutritional status, and wt hx; growth and development in children and adolescents
-Diabetes education hx
-Review of previous tx regimens and response to therapy (A1C records)
-Current tx of diabetes, including meds, meal plan, physical activity patterns, and results of glucose monitoring and patient’s use of data
-DKA frequency, severity, and cause
-PATIENT COMPLIANCE IS EVERYTHING!
-Hypoglycemic episodes
-Hypoglycemia awareness- worse
-Any severe hypoglycemia: frequency and cause
-History of diabetes-related complications
-Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
-Macrovascular: CHD, cerebrovascular disease, PAD
-Other: psychosocial problems, dental disease
physical exam
-Height, weight, BMI
-Blood pressure determination, including orthostatic measurements when indicated
-Fundoscopic examination- 1st appt -> if normal f/u 1 year
-Thyroid palpation- other autoimmune problems
-Skin examination (for acanthosis nigricans and insulin injection sites)
Comprehensive foot examination:
-Inspection
-Palpation of dorsalis pedis and posterior tibial pulses
-Presence/absence of patellar and Achilles reflexes
-Determination of proprioception, vibration, and monofilament sensation
BMI
-Underweight = <18.5
-Normal weight = 18.5–24.9
-Overweight = 25–29.9
-Obesity = BMI of 30 or greater
why do we screen?
-Screening test is recommended because:
-(1) a large number of individuals who meet the current criteria for DM are asymptomatic and unaware that they have the disorder
-(2) epidemiologic studies suggest that type 2 DM may be present for up to a decade before diagnosis
-(3) as many as 50% of individuals with type 2 DM have one or more diabetes-specific complications at the time of their diagnosis
-(4) treatment of type 2 DM may favorably alter the natural history of DM
criteria for dx of prediabetes and diabetes
- Glycated hemoglobin (A1C) ≥6.5%.
The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program (NGSP) certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay.
OR - Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) -> repeat it if high to confirm
OR - 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT) -> 2 hours after eating you should have glucose and insulin go down
OR - In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis (triad), a random plasma glucose ≥200 mg/dl (11.1 mmol/L)
criteria for screening diabetes or prediabetes in asymptomatic adults
-1. testing considered in adults with overweight or obesity (BMI >= 25 or 23 in asians) who have 1 or more risk factors:
-1st degree relative with diabetes
-high risk race/ethnicity (african american, latino, native american, asian, pacific islander)
-hx of CVD
-women who delivered a baby weight >9 lbs or were dx with GDM
-hypertension (>130/80 or on med for HTN)- use ACE
-HDL cholesterol < 35 and/or triglyceride level >250
-pts with PCOS
-physical inactivity
-other clinical assoc with insulin resistance (severe obesity, acanthosis nigricans)
-2. people with prediabetes (A1C >= 5.7) -> should be tested yearly
-3. people dx with GDM should have lifelong testing at least every 3 years
-4. all others -> testing should begin at age 35
-5. if results are normal -> repeat at min of 3 years -> consider more frequent testing depending on initial results and risk status
-6. pts with HIV
criteria for the dx diabetes mellitus
-Fasting is defined as no caloric intake for at least 8 h.
-test should be performed using a glucose load containing the equivalent of 75g (50 in pregnant) anhydrous glucose dissolved in water; not recommended for routine clinical use.
-Random is defined as without regard to time since the last meal
-Note: In the absence of unequivocal hyperglycemia and acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day.
OGTT results
-NO DIABETES
-fasting- <= 100
-2 hours- <140
-no excess micro- nor macro-vascular risk
-PREDIABETES
-fasting- 100-125
-2 hours- 140-199
-excess macro- but not micro-vascular risk
-DIABETES
-fasting- >= 126
-2 hours- >=200
-excess macro- and micro vascular risk
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