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
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
