DM II Flashcards
Diabetes Mellitus – Type 2
general
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
Obesity & DM Type 2
visceral fat is the most concerning
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)
DM II
RF
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)
Effects of Chronic Hyperglycemia
development of the 3 P’s
High serumglucose level (> 180 mg/dL) exceeds renal thresholdcausing:
Glucosuria
Increase inurine osmolality leads topolyuria
Dehydrationleading topolydipsia
Intracellularglucose deficiency, causing polyphagia
Effects of Chronic Hyperglycemia
Chronic complications of diabetes:
Cardiovascular disease
Nerve damage (neuropathy)
Nephropathy
Retinopathy
Prediabetes
Affects 88 million adults in the United States; ~80% are undiagnosed
Increased risk for diabetes
prediabetes
is defined as
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
prediabetes
Tx
Drug indications
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
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.
child and adolescent screening
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
DM II
clin man
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
DM II
UA
Urinalysis shows glucosuria
DM II
AIC, random plasma glucose, fasting plasma glucose, 2-hour oral glucose tolerance test
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
DM II
Lipid profile
“Diabetic dyslipidemia” - ↑ triglycerides (300-400 mg/dL), ↓ high-density lipoprotein (good cholesterol) < 30 mg/dL, and ↑ low-density lipoprotein (bad cholesterol)
DM II
diet and smoking changes
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
DM II
weight loss/exercise goals
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
DM II
Tx categories
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)
Metformin
Preferred initial pharmacologic agent
Should be continued as long as it is tolerated and not contraindicated
Glucagon-like peptide 1 receptor agonist
Indications and contraindicated
Preferred inpatients who already have cardiac or renal comorbidities
dont use if Hx of MEN 2A/B
DMII
early introduction of Insulin should be considered when
Early introduction should be considered for persistent symptoms of hyperglycemia, A1C levels >10%, blood glucose levels ≥ 300 mg/dL
HbA1C Monitoring and targets
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
Glucose monitoring
Acceptable glucose levels
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
DM II
when to refer
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
