DM II

Question 1

Diabetes Mellitus – Type 2

general

Answer 1

Accounts for 90% of diabetic patients in the United States
Often occurs in middle-aged and older adults

Genetic and environmental factors combine to cause:
Progressive loss of beta-cell insulin secretion

Insulin resistance
-Constant high serum glucose level → constant demand forinsulin
-Hyperinsulinemia leads to decreased sensitivity of theinsulin receptors inliver, muscle, andadipose cells

Additional mechanisms:
Impaired hepatic sensitivity toinsulin leads to lack of inhibition of glycogenolysis andgluconeogenesis

Question 2

Obesity & DM Type 2

visceral fat is the most concerning

Answer 2

Obesity is a cofactor in 75-80% of patients
Central obesity – highest risk
Waist circumference ♂ - > 40 inches
Waist circumference ♀ - > 35 inches

Visceral fat that forms around organs → insulin resistance

Body Mass Index (BMI)
Weight (kg)/Height (m2)

Question 3

DM II

RF

Answer 3

First-degree relative with diabetes
Advancing age
History of CVD
Hypertension (≥140/90 mm Hg or on therapy for HTN)
HDL cholesterol level <35 mg/dL and/or a triglyceride level >250 mg/dL
Use of glucocorticoids
Physical inactivity

Other conditions associated with insulin resistance (severe obesity, acanthosis nigricans, women with polycystic ovarian syndrome)

Women who were Dx with gestational diabetes or delivered a baby weighing more than 9 pounds

High-risk ethnicity (African-American, Latino, Native American, Asian American, Pacific Islander)

Question 4

Effects of Chronic Hyperglycemia

development of the 3 P’s

Answer 4

High serumglucose level (> 180 mg/dL) exceeds renal thresholdcausing:
Glucosuria
Increase inurine osmolality leads topolyuria
Dehydrationleading topolydipsia
Intracellularglucose deficiency, causing polyphagia

Question 5

Effects of Chronic Hyperglycemia

Chronic complications of diabetes:

Answer 5

Cardiovascular disease
Nerve damage (neuropathy)
Nephropathy
Retinopathy

Question 6

Prediabetes

Answer 6

Affects 88 million adults in the United States; ~80% are undiagnosed
Increased risk for diabetes

Question 7

prediabetes

is defined as

Answer 7

Defined as:
HbA1C: 5.7-6.4%

Impaired glucose tolerance: 140-199 mg/dL (2 hours after 75 g of oral glucose)

Impaired fasting glucose: 100-125 mg/dL

Question 8

prediabetes

Tx
Drug indications

Answer 8

Intensive lifestyle modification can significantly decrease the rate of diabetes onset
Weight loss (7-10% of body weight)
Moderate-intense physical activity at least 150 minutes weekly

Metformin therapy
Recommended for patients with a BMI > 35, ≥ 60 years of age, or history of gestational diabetes

Question 9

Answer 9

Test published by the American Diabetes Association that evaluatesa patient’srisk of having or developing type 2 diabetes. Includes seven easy questions. A score of five or higher, means a patient is at increased risk.

Question 10

child and adolescent screening

Answer 10

Children and adolescents (after age 10 or after the onset of puberty) who are overweight (BMI ≥ 85th percentile) or obese (BMI ≥ 95th percentile) and who have one or more risk factor for diabetes

Testing is normal → repeat at 3-year intervals

Question 11

DM II

clin man

Answer 11

Most often asymptomatic
Detectable by routine screening tests
Signs & Symptoms – gradually over years
Overweight or obese
Hypertension
Hyperlipidemia
Recurrent skin infections (Candida infections), poor wound healing, acanthosis nigricans
Blurry vision
Fatigue
Weakness
Polyuria
Polydipsia
Polyphagia
Numbness/tingling in feet

Question 12

DM II

UA

Answer 12

Urinalysis shows glucosuria

Question 13

DM II

AIC, random plasma glucose, fasting plasma glucose, 2-hour oral glucose tolerance test

Answer 13

Hemoglobin A1C
≥ 6.5% → diabetes

Random plasma glucose
≥ 200 mg/dL with symptoms of hyperglycemia → diabetes

Fasting plasma glucose (FPG)
≥ 126 mg/dL on more than 1 occasion → diabetes

2-hour oral glucose tolerance test (OGTT)
≥ 200 mg/dL → diabetes

Question 14

DM II

Lipid profile

Answer 14

“Diabetic dyslipidemia” - ↑ triglycerides (300-400 mg/dL), ↓ high-density lipoprotein (good cholesterol) < 30 mg/dL, and ↑ low-density lipoprotein (bad cholesterol)

Question 15

DM II

diet and smoking changes

Answer 15

individualized to each patient
Limit carbohydrate intake
Saturated fat should be less than 10% of daily calories

Recommend discontinuation of cigarettes, other tobacco products, and e-cigarettes

Question 16

DM II

weight loss/exercise goals

Answer 16

Initial loss of ≥5% total body weight
Metabolic surgery recommended as an option for patients with a BMI ≥40 who have failed a trial of weight loss
Regular exercise
150 minutes per week

Question 17

DM II

Tx categories

Answer 17

Medication regimen and medication-taking behavior should be re-evaluated at regular intervals (every 3–6 months) and adjusted as needed

A1C 6.5-7.5% - monotherapy
A1C 7.6-9.0% - dual therapy
A1C >9.0% - triple therapy (short-term insulin)

Question 18

Metformin

Answer 18

Preferred initial pharmacologic agent
Should be continued as long as it is tolerated and not contraindicated

Question 19

Glucagon-like peptide 1 receptor agonist
Indications and contraindicated

Answer 19

Preferred inpatients who already have cardiac or renal comorbidities

dont use if Hx of MEN 2A/B

Question 20

DMII

early introduction of Insulin should be considered when

Answer 20

Early introduction should be considered for persistent symptoms of hyperglycemia, A1C levels >10%, blood glucose levels ≥ 300 mg/dL

Question 21

HbA1C Monitoring and targets

Answer 21

Monitor at least 2x/year for patients at treatment goal

Target 7% without hypoglycemia
< 7% does not appear to result in reduced risk of mortality or macrovascular events

Target 8% may be appropriate for patients with limited life expectancy, or where the harms of treatment > benefits

Monitor as needed for patient not at treatment goal or with therapy changes

Question 22

Glucose monitoring

Acceptable glucose levels

Answer 22

Patient should monitor glucose levels as often as necessary to achieve desired control

Acceptable glucose levels
70-130 mg/dL before meals and after an overnight fast
180 mg/dL or less at 1 hour after eating
150 mg/dL or less at 2 hours after eating

Question 23

DM II

when to refer

Answer 23

Type 2 diabetics should be referred to an endocrinologist if treatment goals are not met or if a complex regimen to maintain glycemic control is needed
All diabetics should be referred to an ophthalmologist or optometrist for a dilated eye examination
Patients with peripheral neuropathy or structural foot problems should be referred to a podiatrist

Question 24