Metabolic Syndrome and Type 2 Diabetes Mellitus Flashcards
What are the 5 elements that are needed for the diagosis of metabolic syndrome (need three)?
1. Insulin Resistance 2. Low HDL 3. Elevated Triglycerides 4. Visceral Obesity 5. Hypertension
Each element of Metabolic syndrome increases CVD risk. How are these caused?
1. Abdominal obesity
- Hyperglycemia
- Dyslipidemia
- Hypertension
- Impaired glucose and fatty acid utilization
- Insulin resistance = increased blood sugar
- Elevated triglycerides and low HDL
- Endothelial dysfunction
There are 2 different criterias for the diagnosis of Metabolic syndrome. What is the difference between the two?
- National Cholesterol Education Program/ Adult Treatment Panel III (NCEP/ATP III)
- International Diabetes Federation (IDF)
Major differences between the two
adjusting for race in the waist circumference measurement in IDF
IDF guidelines must have increased waist circumference
NCEP/ATP III criteria for diagnosis of metabolic syndrome:
Abdominal obesity
1. Waist?
- Triglycerides
- HDL cholesterol
- BP
- Fasting plasma glucose
- ≥ 40 inches (102 cm) men
Waist ≥ 35 inches (88cm) women - ≥ 150 mg/dL
- less than 40 mg/dL men, less than 50 mg/dL women
- ≥ 130/85
- ≥ 100 mg/dL
What is a normal fasting plasma glucose?
Prediabetic?
Diabetes?
less than a 100
100-125
126 and over
What is the normal oral glucose tolerance?
Prediabetic?
Normal?
less than 140
140-199
200 and over
A1C criteria for DM and Pre-DM:
Diabetes?
Prediabetic?
Normal?
HOw many readings to you need to be diabetic or prediabetic?
Diabetes ≥ 6.5%
Prediabetes 5.8-6.4%
Normal less than 5.7%
2
Obesity causes metabolic chaos. What specific things does it cause?
6
- Reduction in mitochondrial 2. ATP generation from glycolysis
- Triglyceride accumulation
- Free fatty acid accumulation
- Proinflammatory
- -Increased CRP, IL-6 - Prothrombotic
- -Increased plasminogen activator inhibitor
Prevalence of metabolic syndrome increases with increasing BMI
How many normal weight, overweight and obese pts have metabolic syndrome?
5% of patients with normal weight
22% of overweight patients
60% of obese patients
Other obesity related disorders associated with metabolic syndrome?
6
- Fatty liver disease
- Hepatocellular and intrahepatic cholangiocarcinoma
- Chronic kidney disease
- Polycystic ovarian syndrome
- Sleep apnea
- Hyperuricemia and gout
Further risk factors
for diabetes?
8
- Postmenopausal status
- Smoking
- Low household income
- High carbohydrate diet
- No alcohol consumption
- Physical inactivity
- Soft drink consumption
- Family history
Up to ____ of people with metabolic syndrome have a positive family history
____ of people with Type 2 DM have at least 1 parent with the disease
50%
39%
Treatment of metabolic syndrome focuses on what?
2
What are our two targets?
- risk factor reduction and
- weight loss
- Lifestyle modification
focused on weight loss and increased physical activity - Treat cardiovascular risk factors
Weight reduction targets what?
insulin sensitivity
Reduction of CVD risk factors. What are the three goals mentioned?
- Lipid management
- Treatment of hypertension
- Tobacco cessation
What improves HDL? 2
What improves Triglycerides?
- Niacin, Gemfibrozil
2. Lopid
Treatment of impaired glucose metabolism (IGT/IFG)?
4
- Dietary counseling
- Exercise
- Weight loss
Goal to start is 10% of baseline - Role for metformin?
Improves insulin sensitivity
Treatment with metformin plus lifestyle modifications if IFG/IGT plus these following factors:
7
- less than 60 years old
- BMI ≥ 35
- Family hx of DM in 1st degree relative
- Elevated triglycerides
- Reduced HDL cholesterol
- Hypertension
- A1C > 6 %
Medical therapy for “pre-diabetes”
2
- If opting for metformin need to complete an OGTT
2. Need to document both IFG and IGT if metformin is used prior to diagnosis of DM
Treatment of metabolic syndrome focuses on what?
2
risk factor reduction and weight loss
- -Lifestyle modification
- -CV risk factors
2 pathogenic defects characterize type 2 diabetes?
What organs are involved in the pathology of diabetes?
3
- Impaired insulin secretion
- Insulin resistance
Pancreas
Liver
Peripheral tissue
Natural history of Type 2 DM in the years preceding diagnosis:
1. How does the endocrine system compensate?
- What happens to the beta cells in the pancreas?
- What does the liver lose the ability to do?
This all leads to the diagnosis of diabetes
- Endocrine system compensates by increasing insulin secretion
- Over time the beta cells of the pancreas wear out
- Liver then loses the inhibitory effect of insulin and increases production of glucose
What fasting glucose level indicates the almost complete loss of beta cell function?
above 180-200 mg/dL
Symptoms of Diabetes?
8
- blurry vision
- Increased thirst or the need to urinate
- Feeling tired or ill
- Recurring skin, gum or bladder infections
- Dry, itchy skin
- Unexpected weight loss
- Slow healing cuts or bruises
- Loss of feeling in the feet or tingling feet
Risk factors for diabetes?
11
- Impaired glucose tolerance
- Impaired fasting glucose
- Age > 45
- Family history
- Overweight
- Obese
- Lack of exercise
- HTN
- Low HDL, high triglycerides
- Gestational DM
- Baby 9 ≥ pounds at birth
Meds that may affect blood sugar.
Name the meds in that category and the mechanism of action:
Beta blockers? (3 meds)
Hypolipidemic? (1 med)
Thiazide diuretics? (3 meds) (3 mechanisms)
Glucocorticoids? (2 mechanisms)
Oral contraceptives? (2 meds) (2 mechansims)
Beta blockers
- Atenolol, metoprolol, propranolol
- Decreased insulin sensitivity
Hypolipidemic
- Niacin
- Altered hepatic metabolism of glucose
Thiazide diuretics
- HCTZ, chlorthalidone, chlorothiazide
- Decreased potassium, decreased insulin secretion, increased insulin resistance
Glucocorticoids
- All of them
- Increased glucose production and increased glucose resistance
Oral contraceptives
- Estrogen + progesterone combos, progesterone only
- Altered hepatic glucose metabolism, increased insulin resistance
Criteria for diagnosis of type 2 diabetes
4
- A1C ≥ 6.5%
- Fasting plasma glucose ≥ 126 mg/dL
At least an 8 h fast - 2 h plasma glucose ≥ 200 mg/dL during an OGTT
- Classic symptoms of hyperglycemia or hyperglycemic crisis and a random plasma glucose of ≥ 200 mg/dL
A1C Treatment goals for adults
with diabetes?
3 (moderate to severe)
- A1C less than 7%
- Intensive treatment in some patients to an A1C goal of less than 6.5%
- If history of severe hypoglycemia consider A1C goal of less than 8 %
Treatment of T2DM is multifaceted. What are we targeting?
4
- Target treatment of elevated glucose
- Management of CV risk factors
- Monitor for disease complications
- Drug therapy
Target treatment of elevated glucose consists of what?
4
Management of CV risk factors consists of what? 3
Monitoring for disease complications for T2DM? 5
- Medications
- Medical nutritional therapy
- Exercise
- Weight loss
- Exercise
- Management of BP and lipids
- Weight loss
- Peridontal disease
- Retinopathy
- Nephropathy
- Neuropathy
- Vascular disease
How do we monitor for the following diseases:
- Peridontal disease
- Retinopathy
- Nephropathy (2)
- Neuropathy (4)
- Vascular disease (2)
- – refer to dentist
- Dilated fundoscopic exam yearly with specialist
- Urine albumin to creatinine ratio yearly and
ACEI or ARB - Foot exam, monofilament testing, vibration and proprioception testing
- Foot exam for ulcers,
Pulse exam feet, groin and B/L brachial BP
Pharmacotherapy for Type 2 DM. Drug class types? 10
What is the main one?
Biguanides***** Sulfonylureas Meglitinides TZDs Alpha-glucosidase inhibitors DPP-4 inhibitors SGLT2 inhibitors GLP-1 receptor agonists Amylin memetics Insulin
What is first line therapy for diabetes?
Severe symptoms or markedly elevated A1C consider what?
If you are not to goal with max noninsulin monotherapy in_____then add another agent.
First line drug therapy is metformin (biguanide drug class)
Insulin therapy
3-6 months
If lifestyle and metformin do not get you to goal range what can we add? 2
Basal insulin
Sulfonylureas
If Addition of basal insulin does not work what should we do?
If addition of Sulfonylureas do not work what should we add?
Intenstive insulin therapy
basal insulin then intensive if that doesnt work
All patients eventually end up on insulin. Why?
Natural progression of the disease leads to eventual lack of beta cell function
How often should we follow up with a newly diagnosed DM pt?
If at goal and therapy isn’t changing how often should we follow up?
A1C every 3 months
A1C every 6 months
Physical activity recommendations
How many min per week?
What should max heart rate be at?
Spread over how many days?
Resistance training how often?
150 min/week moderate intensity exercise
50-70% of Max heart rate
Spread over 3 days per week
Resistance training 2 X per week
Symptoms of Hypoglycemia?
5
How should we treat it?
When should we recheck the BG?
Post episode what should we do?
confusion, diaphoresis, tachycardia, palpitations, weakness
15-20 g glucose or any form of carbohydrate
Recheck BG in 15 min and repeat treatment if necessary
Meal post episode
When would we consider bariatric surgery?
2
- BMI ≥ 35
2. Especially for difficult to control DM with associated comorbidities
Immunizations that T2DM pts need? 3
Influenza
Pneumoccal (PCV13 and PSSV23)
Hep B
The complications of DM are extensive?
6
- HTN
- Dyslipidemia
- CVD
- Nephropathy
- Retinopathy
- Neuropathy
Treatment of Hypertension goals for DM pts?
What will be our first line therapy? (2)
Goal SBP less than 140 mmHg
Goal DBP less than 90 mmHg
ACE inhibitor or angiotensin receptor blocker first line therapy if no contraindications
How often should we evaluate fasting lipid for DM pts?
What is our LDL goal?
CVD LDL goal?
TG goal?
HDL goal: Men?
Women?
What is the main target for therapy?
Evaluate fasting lipids at least once yearly
LDL less than 100 mg/dL
LDL if CVD less than 70 mg/dL
Triglycerides less than 150 mg/dL
HDL > 40 men; > 50 women
LDL is the main target for treatment
Statin therapy regardless of baseline lipid levels in DM patients with?
2
- CVD
2. Without CVD and > 40 + one or more risk factors
What are the risk factors that would warrant prescribing a statin for DM pts that do not have CVD?
5
Family history of CVD HTN Smoking Dyslipidemia Albuminuria
What should we use for primary prevention of CVD for DM pts?
Who should be taking this? 5
75-162 mg per day
aspirin
Men > 50 and women > 60 if 1. Family hx of CVD
- HTN
- Smoking
- Dysplipidemia
- Albuminuria
Do DM pts need to monitor their blood glucose levels every day?
Only if they are on insulin really
- For pts with coronary disease what meds should they be on?
- What about post MI pts?
- What treatment should we avoid with heart failure?
- When is metformin ok in pts with CHF?
- WHo is metformin not reccommended for? 2
Not recommended to screen asymptomatic patients
- ACEI and statin therapy
- B-blocker for at least 2 years post MI
- Avoid thiazolidineodine (TZDs) treatment with heart failure
- Metformin ok if CHF with normal renal function
- Not for unstable CHF or renal compromise
How do we control nephropathy for DM pts? 2
Two tests to screen for this and how often should they be done?
Prevention: blood pressure and blood glucose control
- Yearly albumin excretion (need baseline at diagnosis)
- At least yearly creatinine levels
Treatment of albuminuria
in DM pts? 2
At what level do we start treatment?
ACE inhibitor or angiotensin receptor blocker (ARB)
> 30 mg/day urinary albumin excretion
Retinopathy prevention is aimed at what? 2
Screening?
Blood pressure and blood sugar control for prevention
At diagnosis need dilated fundoscopic exam and yearly
What do we screen for yearly with neuropathy in DM pts?
What test do we do?
Screening for distal polyneuropathy at diagnosis and yearly
Monofilament test
What other kinds of neuropathy do we need to watch out for and what are the types (3)?
Autonomic neuropathy
- Gastroparesis
- Erectile dysfunction
- Cardiovascular autonomic dysfunction (orthostatic hypotension)
What three things do we need to look at for foot care in DM pts?
Inspection
Pulses
Sensation
For foot pulses in DM pts what are we looking for?
Screen for symptoms of peripheral vascular disease. Consider ABIs
For foot sensations in DM pts what tests should we do?
4
- Monofilament test and 1 of the following
- Vibration
- Pin prick
- Ankle reflexes
Yearly diabetic needs?
4 referrals
4 tests
Refer: Optho for Retinopathy
Refer: Dentist
Refer: Dietician (DM education groups)
Refer: Pediatrists
Tests: Fasting Lipid Panal Creatinine/BUN Urine microalbumin BP on both arms
Every 3 month needs? 3
History? 5
BP
A1C (med titration)
Foot exam (visual inspection, check vibration and monofilament test, check pulse and reflexes)
Hypoglycemia episodes Diet Mental Health Exercise Tobacco Cessation
What are we looking at for on the foot exam? 2
Shape of foot and ulcers
