DM 2 Flashcards
dx of metabolic syndrome
≥ 102 cm abdominal obesity in Men
≥ 88 cm abdominal obestity in Women
Elevated triglycerides (≥ 150 mg/dL)
Low HDL (men < 40 mg/dL ; women < 50 mg/dL)
Elevated blood pressure (≥ 130/85 mmHg)
Elevated fasting glucose (≥ 100 mg/dL)
atleast 3 of the above
syndrome X
AKA
metabolic syndrome
OR
insulin resistance syndrome
metabolic syndrome definition
metabolic risk factors for BOTH diabetes & cardiovascular disease
metabolic syndrome has a higher prevalance with what 2 things
overweight
obesity
pharmacologic tx of metabolic syndrome
metformin
if you have prediabetes, how often should you monitor for T2DM?
annually
Prediabetes drug tx
metformin
what type of diabetes should you consider in children & adults dx in early adulthood?
monogenic dx in first 6 months of life
clinical px of monogenic diabetes
no diabetes associated antibodies
nonobese
no other metabolic features
stable, mild fasting hyperglycemia
impaired fasting glucose
hepatic insulin resistance
impaired glucose tolerance
muscle insulin resistance
what consists of prediabetes?
IGT or IFG or both
or
A1c of 5.7-6-4%
Main risk factors of T2DM
Prediabetes, metabolic syndrome, insulin resistance conditions (PCOS, AN)
Overweight
> 45 y/o
Immediate relative with T2DM
< 3 days/week physical activity
PMH gestational DM or given birth to baby weighing > 9 lbs
African American, Hispanic/Latino American, American Indian, Alaska Native
Genes/lifestyle/env/meds
what cells produce insulin?
Insulin produced by beta cells in the islets of Langerhans in the pancreas
what stimulates insulin production?
hyperglycemia
insulin causes glucose transport into which tissues?
Insulin causes glucose transport into adipose tissue and muscle
Physiology of fasting state
low insulin, high glucagon
+ glucagon further stimulates gluconeogenesis & glycogenolysis
Postprandial physiology
high insulin, low glucagon
+ carbohydrate storage
+ fat and protein synthesis
+ skeletal muscle uptake
Clinical Px of T2DM
usually asx
hyperglycemia (polyuria, polydipsia, nocturia, blurred vision, weight loss)
ADA Screening guidelines
All adults with BMI ≥ 25 + additional risk factor(s): q 3 years
Start at age 45 for everybody else
pts with prediabetes: annually
Women with GDM: q 3 years
T2DM USPSTF screening
Adults 40-70 y/o who are overweight/obese should be screened as a part of CV risk assessment q 3 years
T2DM Dx criteria if sx
Symptoms + random blood glucose ≥ 200 mg/dL
T2DM Dx criteria if asx
If asymptomatic:
FPG ≥ 126 mg/dL
2 hour glucose ≥ 200 mg/dL during OGTT
A1c ≥ 6.5%
Repeat on a different day
What are normal lab values of FPG, OGTT, A1c?
FPG < 100 mg/dL
2-hr glucose during OGTT < 140 mg/dL
A1c: <5.7
Pre-diabetic Dx criteria
IFG: FPG 100-125 mg/dL
IGT: 2-hr glucose during OGTT 140-199 mg/dL
A1c: 5.7 – 6.4%
What can cause falsely high levels of A1c?
Low cell turnover = falsely high levels
Iron, vitamin B12, or folate deficiency
What can cause falsely low levels of A1c?
High cell turnover = falsely low levels
Hemolytic anemia, treated iron/B12/folate deficiency, erythropoietin use`
Main mgmt goals for T2DM
- Glycemic control
- Monitoring/prevent micro/macrovascular complications
- Patient education: Nutrition, Hypoglycemia, CV risk, vision, kidneys
- Health maintenance
how do you approach a T2DM pt?
pt centered: active listening
multi-disciplinary:
- Primary care
- Specialty care: Podiatry, Ophthalmology, Mental health, Ob/gyn, Endocrine, Dieticians, Exercise specialists
How often do you monitor glycemic control in controlled T2DM pts?
2x/yr
How often do you manage glycemic control in T2DM pts with changes in therapy or those who are not meeting goals?
4x/yr
A1c goals for diff types of pts
Most patients < 7.0%
stringent goals: < 6.5%
Less stringent: < 8.0% if…
- Hx severe hypoglycemia
- Limited life expectancy
- Older adults
- Comorbid conditions
more often self monitoring of blood glucose in T1DM when…
titrating medications associated with hypoglycemia
Several times/wk – morning or before dinner
illness or changes in diet/exercise
Non-pharmacologic therapy options for T2DM
- Diet
- Physical activity
- Weight reduction/management
- Smoking cessation
- Psychological interventions (diabetes distress)
most imp nutrition pearls
- eat high fiber/nutrient dense foods (fruits & vegetables)
- count carbs for bolus insulin
- avoid carb sources high in protein
- meditteranean diet = good
- eat fatty fish and foods rich in long-chain n-3 fatty acids
dietary restrictions in T2DM
alcohol in moderation: (≤ 1/d women, ≤ 2/day men)
<2300mg/day Na
dec. nonnutritive sweeteners
Goals of pharmacologic tx
Inc. insulin availability
dec. sensitivity to insulin
Delay delivery and absorption of carbohydrates from the GI tract
Inc. urinary glucose excretion
A1c levels in regards to Rx
A1c > 7.5-8% at dx – start Rx
A1c < 7.5% at dx – 3-6 month trial of lifestyle modification (if highly motivated)
Initial pharmacologic therapy for T2DM pts
-Metformin
-Consider dual therapy
-Insulin may be considered
-Consider comorbidities (ASCVD, HF, CKD), hypoglycemia risk, impact on weight, cost, risk for side effects, patient preferences
Tx options
- Metformin
- Sulfonylureas
- GLP-1 RA
- (DPP-4)
- (SGLT2) inhibitor
- TZD
- Meglitinides
- Alpha-glucosidase inhibitor
- Insulin
Decrease hepatic glucose output by inhibiting gluconeogenesis
Increases insulin-mediated glucose utilization in peripheral tissues (muscle, liver)
MOA of which drug?
Metformin (biguanide)
1st line tx of DM2
Metformin
A1c % drop w/Metformin
1-2% drop in A1c
ADE/CI of metformin
GI side effects
Can reduce intestinal absorption of vitamin B12
Contraindicated with renal insufficiency, eGFR < 30 mL/min
IV contrast concerns
weight neutral meds
Metformin
DPP-4 Inhibitors
alpha-glucosidase inhibitors
which meds inc weight
TZD
Meglitinides
Insulin
sulfonylureas
which meds dc weight
GLP-1 RA
SGLT2-I
Stimulate insulin secretion from pancreatic beta cells
MOA of which drug?
sulfonylureas
- Glipizide
- Glyburide
- Glimepiride
ADE of sulfonylureas
risk of hypoglycemia
A1c% drop of sulfonylureas
1-2%
what is the incretin effect
oral glucose better stimulates insulin secretion than IV glucose secondary to GI peptides (GLP-1) released in response to a meal stimulating insulin synthesis and secretion
stimulates glucose dependent insulin release from pancreatic islet cells
slows gastric emptying
inhibits post-meal glucagon release
MOA of what drug?
GLP-1 RA
what special pt populations are you more likely to give a GLP-1 RA to?
pts w/ ASCVD
reduce risk of CKD progression and CV events
what are the add-on therapies?
SGLT2-Inhibitor
TZD
DPP-4 Inhibitors
Meglitinides
Possible improved CV outcomes with which GLP-1 RAs?
liraglutide
semaglutide
A1c% drop w/GLP-1 RA
0.5-1% drop
ADE of GLP-1 RA
GI: N/V/D
which drug has the same MOA as GLP-1 RA (this is the reason you cannot give both drugs at once)
DPP-4 Inhibitors
increase urinary glucose excretion leading to reduced blood glucose
MOA of which drug?
SGLT2 inhibitors
in which pt populations should you use SGLT2 Inhibitors with?
pts w/ASCVD
high risk of HF or w/comorbid HF
Shown to reduce risk of CKD progression and CV events
ADE of SGLT2 inhibitors
vulvovaginal candidiasis, UTIs
SGLT2 % decrease in A1c?
0.5-0.7%
Improve insulin action
Increase insulin sensitivity by acting on adipose, muscle, and liver to increase glucose utilization and decrease glucose production
MOA of which drug?
TZD
ADEs of TZD
Fluid retention, HF, weight gain, bone fractures,
possible increase in MI (rosiglitazone)
possible increase in bladder cancer (pioglitazone)
CIs of TZDs
symptomatic or class III-IV HF, bladder cancer, high fracture risk, liver disease
Administered with meals to reduce postprandial hyperglycemia
Which drug?
Meglitinides
ADE of meglitinides
risk of hypoglycemia
% dec in A1c
0.5-1% decrease in A1c
ADE of alpha-glucosidase inhibitors
flatulence and diarrhea
% decrease in A1c of alpha-glucosidase inhibitors
0.5-0.8%
types of insulin
Basal:
- NPH (Humulin N, Novolin N)
- Glargine (Lantus, Toujeo, Basaglar)
- Detemir (Levemir)
- Degludec (Tresiba)
Prandial
- Short-acting: Regular (Humilin R, Novolin R)
- Rapid-acting: lispro (Admelog, Humalog), aspart (Fiasp, Novolog), glulisine (Apidra)
Premixed combination of intermediate acting and short or rapid acting
If A1C is above target despite recommended first-line treatment and ASCVD predominates, what should you give?
GLP-1 RA or SGLT-2 I
If A1C is above target despite recommended first-line treatment and HF or CKD predominates, what should you give?
SGLT-2 I (1st choice)
or
GLP-1 RA
examples of micro & macrovascular dz
Microvascular disease: Retinopathy, Nephropathy, Neuropathy
Macrovascular disease: Atherosclerosis (MI, PAD, CVA)
Most common cause of blindness in adults aged 20-74
diabetic retinopathy
what 4 things cause diabetic retinopathy
Macular edema
Hemorrhage from new vessels
Retinal detachment
Neovascular glaucoma
Cotton wool spots
Intraretinal hemorrhages
Hard exudates
Microaneurysms
Occluded vessels
Dilated or tortuous vessels
Visual loss through macular edema
What type of diabetic retinopathy?
Nonproliferative diabetic retinopathy
Neovascularization
Preretinal and vitreous hemorrhage
Fibrosis
Retinal detachment
Visual loss from bleeding, retinal detachment ischemia of macula
What type of diabetic retinopathy?
proliferative
nonproliferative diabetic retinopathy: appearance of fundus
retinal hemorrhages
yellow lipid exudates
dull white cotton wool spots (nerve fiber layer infarcts)
proliferative diabetic retinopathy showing neovascularization at the disc
severe traction retinal detachment in proliferative Diabetic retinopathy
elevation & distortion of macula due to overgrowth and contraction of neovascular proliferations
vitreous hemorrhage: appearance on fundus
arising from neovascularization
clinical px of diabetic retinopathy
asx untul late stages
diabetic retinopathy screening
Dilated and comprehensive eye exam
At the time of diagnosis in type 2
Within 5 years in type 1
Repeat annually
diabetic retinopathy tx
Laser photocoagulation
Intravitreous injections of anti-vascular endothelial growth factor (ranibizumab)
leading cause of ESRD
diabetic kidney dz
diabetic kidney dz screening
Assess urinary albumin
Spot urinary albumin-to-creatinine ratio
- Assess eGFR
- At time of diagnosis in type 2
- Within 5 years of diagnosis in type 1
- In all patients with comorbid HTN
- Repeat annually
dx criteria for diabetic kidney dz
- Moderately increased albuminuria (“microalbuminuria”)
- 30-300 mg/day (normal < 30 mg/day)
- > 300 mg/day = severely increased albuminuria (“macroalbuminuria”)
- Requires 2 of 3 specimens abnormal over 3-6 months
diabetic kidney dz tx
Consider SGLT2 inhibitor or GLP1 receptor agonist
ACE-I or ARB: if modest UACR elevation (30-299 mg/g Cr) & Strongly recommended for UACR ≥ 300 mg/g Cr and/or eGFR < 60
Protein intake: Nondialysis-dependent: 0.8 g/kg/d & Dialysis-dependent: > 0.8
•Refer for renal replacement treatment if eGFR < 30
what is common in diabetic neuropathy?
foot ulcers & amputation
diabetic neuropathy screening
- Assess with history and either temperature or pinprick sensation and vibration sensation
- Annual monofilament testing
- At time of diagnosis for type 2
- Within 5 years of diagnosis for type 1
- Repeat annually
diabetic neuropathy tx
- First line Rx for neuropathic pain:pregabalin, duloxetine, or gabapentin
- Foot self care education to all patients
- Specialized therapeutic footwear for high-risk patients with severe neuropathy, foot deformities or history of amputation
what does the annual comprehensive foot evaluation consist of
Skin inspection
Assess for foot deformities
Neurologic assessment (monofilament + pinprick or temperature or vibration)
Vascular assessment
consider ABI/vascular referral for which sxs?
claudication or decreased or absent pedal pulses
consider podiatry for which pts?
smokers or
hx of prior LE complications
loss of protective sensation
structural abnormalities
PAD
goal BP for diabetics
High CV risk = < 130/80
Lower risk = < 140/90
at what BP do you implement lifestyle interventions?
BP > 120/80
at what BP do you implement dual therapy?
≥ 160/100
Meds with demonstrated reduction of CV events
ACE-I
ARB
Thiazide diuretic
Dihydropyridine CCB
ASCVD or 10-yr risk > 20%
OR
Multiple ASCVD risk factors
what tx?
high intensity statin therapy
< 40 y/o with ASCVD risk factors
OR
40-75 and > 75 without ASCVD risk factors
what tx?
moderate intensity statin
ASCVD and LDL ≥ 70 and on maximally tolerated statin
what tx?
additional LDL-lowering therapy (ezetimibe or PCSK9 inhibitor)
Secondary prevention in patients with ASCVD
what tx?
aspirin 75-162 mg/d
One year post ACS
what tx?
dual antiplatelet therapy with low dose aspirin and P2Y12 inhibitor
Primary prevention with what if inc CV risk?
aspirin
