Metabolic syndrome and Type 2 DM Flashcards
Why is ID of metabolic syndrome so important?
- because ID risk of developing diabetes
- Id pts at high risk of developing CVD
When does prevalence of metabolic syndrome increase?
- with age and obesity
- 44% of those in 60-69 age range
What ethnicity has highest % of metabolic syndrome?
- mexican Americans (both men and women)
What 3 out of 5 elements are needed for dx of metabolic syndrome?
- visceral obesity
- HTN
- insulin resistance
- elevated TGs
- low HDL
How do these elements of metabolic syndrome increase CVD?
- abdominal obesity: impaired glucose and fatty acid utilization (hyperglycemia and dyslipidemia are also related to abdominal obesity)
- hyperglycemia: insulin resistance = increased blood sugar
- dyslipidemia: elevated TGs and low HDL
- HTN: endothelial dysfunction -> lead to increase likelihood of thrombotic events
NCEP/ATP III criteria for dx of metabolic syndrome? (3 out of 5)
abdominal obesity: for men - waist of 40 inches or greater
women - waist of 35 or greater
- TGs: more than 150 mg/dL
- HDL cholesterol: less than 40 in men and less than 50 in women
- BP: greater than 130/85
- fasting plasma glucose greater or equal to 100 mg/dL
IDF criteria for dx of metabolic syndrome?
- increased waist circumference (ethnic specific) plus 2 of the following: TGs greater than 150 HDL less than 40 men, less than 50 women BP greater than 130/85 fasting glucose: greater than 100
Fasting plasma glucose levels?
- greater or = to 126: diabetes
- less than 125 and greater or equal to 100 - prediabetes
- normal: less than 100
Oral glucose tolerance levels?
- greater or equal to 200: diabetes
- greater or equal to 140 and less than 199: prediabetes
- normal: less than 140
A1C criteria for DM and pre-DM?
- diabetes - equal or greater than 6.%
- prediabetes - 5.7-6.4%
- normal: less than 5.7%
How does obesity cause metabolic chaos?
- reduction in mito ATP generation from glycolysis
- TG acccum
- Free FA accumulation
- proinflammatory: increased CRP, IL-6
- prothrombic: increased plasminogen activator inhibitor
Prevalence of metabolic sydrome increases with increasing BMI, stats?
- 5% of pts with normal wt
- 22% of overweight pts
- 60% of obese pts
What are other obesity related disorders that are associated with metabolic syndrome?
- fatty liver disease
- hepatocellular and intrahepatic cholangiocarcinoma
- CKD
- polycystic ovarian syndrome
- sleep apnea
- hyperuricemia and gout
What are other risk factors to metabolic syndrome?
- postmenopausal status
- smoking
- low household income ( low education, can’t afford healthy food)
- high carb diet
- no alcohol consumption
- physical activity
- soft drink consumption
- family history
How impt is family hx risk factor for metabolic syndrome?
- up to 50% of people with metabolic syndrome have positive family hx
- 39% of people with type 2 DM have at least 1 parent with the disease
Tx of metabolic syndrome foucses on what?
- on RF reduction and wt loss
- lifestyle modification: focused on wt loss and increased physical activity
- Tx cardiovascular risk factors
What improves insulin sensitivity?
- weight reduction
- doesn’t matter what kind of diet as long as it is tailored towards weight loss
- mediterranean diet
- DASH diet
- low glycemic index foods
How much exercise is needed daily?
- 30 minutes at minimum moderate intensity (break a sweat, hard to hold a conversation)
- or a goal of 10,000 steps a day
- reduction in abdominal obesity (liposuction isn’t beneficial) -process of weight loss: exercise is what improves metabolism of glucose
- exercise: improves insulin sensitivity (for up to 48 hrs after exercise)
How can you reduce CVD risk factors?
- lipid management: improve HDL - lifestyle: eat healthy, exercise, take Niacin, Tricor, statins
improve TG levels: take fibric acids - tricor - tx hypertension
- tobacco cessation
How does IGT prevent disease progression?
- intensive lifestyle interventions
- goal is to delay/prevent development of diabetes
- tx may reduce long term CVD events
- delay the onset of diabetes
Tx of impaired glucose metabolism (IGT/IFG)?
- dietary counseling
- exercise
- wt loss: goal to start is 10% of baseline
- role for metformin is that it improves insulin sensitivity (can be used in pre diabetic state)
Tx of impaired glucose metabolism? Goals?
- wt loss of 5-10%
- moderate physical activity of 30 minutes per day
Who qualifies for metformin that has IFG/IFT?
- less than 60
- BMI of 35 or more
- family hx of DM in first degree relative
- elevated TGs
- reduced HDL cholesterol
- HTN
- A1C >6%
Metformin + lifestyle changes
What is more effective: drug therapy or lifestyle modification for DM prevention?
Studies show that lifestyle modification more effective at reduction of BG then metformin alone
- Drug therapy seems to be more beneficial in younger pts
what needs to be done if pt going to receive metformin for pre-diabetes?
- need to complete OGTT
- need to doculemtn both IFG and IGT if metformin used prior to dx of DM
What are the 2 pathogenic defects that characterize type 2 diabetes?
- imparied insulin secretion
- insulin resistance
What organs are involved in type 2 diabetes?
- pancreas (alpha and beta cells)
- liver (gluconeogenesis, liver can manufacture glucose, gets feedback from peripheral tissues to shut production off)
- peripheral tissues: adipose tissue, muscle uptake of glucose
Natural hx of type 2 DM in years preceding dx?
- endocrine system compensates by increasing insulin secretion
- over time the beta cells of pancreas wear out because of resistance
- liver then loses the inhibitory effect of insulin and increases production of glucose
= dx of diabetes
What fasting glucose level indicates almost complete loss of beta cell function?
- levels above 180-200
Sxs of type II diabetes?
- blurry vision
- increased thirst or need to urinate
- feeling tired or ill
- recurring skin, gum or bladder infections
- dry, itchy skin
- unexpected wt loss
- slow healing cuts or bruises
- loss of feeling or tingling in the feet
RFs of type 2 DM?
- impaired glucose tolerance
- impaired fasting glucose
- age over 45
- family hx
- overweight
- obese
- lack of exercise
- HTN
- low HDL, high TG
- gestation DM ( 50% lifetime risk of developing DM 2 after pregnancy)
- baby thats 9 or more pounds at birth
beta blockers effect on blood sugar?
(propanolol, metoprolol)
- Mech: decreased insulin sensitivity
hypolipidemic effect on blood sugar?
- niacin (at higher doses)
- altered hepatic metabolism of glucose
Thiazide diuretic effect on blood sugar?
- HCTZ, chlorthalidone
- mech: decreased K, decreased insulin secretion, increased insulin resistance
Glucocorticoid effect on blood sugar?
- increased glucose production and increased glucose resistance
Oral contraceptive effect on blood sugar?
- altered hepatic glucose metabolism
- increased insulin resistance
Criteria for dx of DM II?
- A1C has to be equal or greater than 6.5%
- fasting plasma glucose is equal or greater than 126 mg/dL
- 2 hr plasma glucose has to be equal or greater than 200 during OGTT
- classic sxs of hyperglycemia or hyperglycemic crisis and random plasma glucose of 200 or greater (polydypsia, polyuria)
Tx goals for adults?
- A1C less than 7%
- intensive tx in some pts to an A1C goal of 6.5 or less
- if hx of severe hypoglycemia consider A1C of less than 8%
(in some pts like the elderly you don’t want A1C to get too low because they are more likely to have hypoglycemic episodes and have worse outcomes
Tx of DMII?
multifaceted
- target tx of elevated glucose:
meds, medicatl nutritional therapy, exercise, wt loss
- management of CV RFs: exercise, management of BP and lipids, wt loss
What disease complications should you monitor for in pts with DM II?
- peridontal disease: refer to dentist
- retinopathy: dilated fundoscopic exam yearly with specialist
- nephropathy: urine albumin to creatinine ratio yearly (ACEI or ARB)
- neuropathy: foot exam, monofilament testing, vibration and propioception testing
- vascular disease: foot exam for ulcers, pulse exa for feet, groin, and B/L brachial BP
Pharmacotherapy for type 2 DM Drug classes?
- biguanides: first line therapy, metformin
- sulfonylureas
- meglitinides
- TZDs
- alpha-glucosidase inhibitors
- DPP-4 inhibitors
- SGLT2 inhibitors
- GLP-1 receptor agonists
- Amylin memetics
- insulin
First line drug therapy for T2DM?
- metformin (biguanide drug class)
If pt has severe sxs or markedly elevated A1C what tx should you consider starting?
- insulin
(have blood glucose of 180-200)
– if not to goal with max noninsulin montherapy in 3-6 months then add another agent
what should you inform pts of when they are dx of diabetes? what med will they end up on?
- all pts will eventually end up on insulin
- natural progression of disease leads to eventual lack of beta cell function
How often should you follow up with DMII pt?
- F/U with A1C every 3 months
- if at goal and therapy isn’t changing may move checks to every 6 months
- monitor for complications of DM and tx comorbidities
What kind of medical therapy for DM and prediabetes should be done with pt?
- meet with registered dietician
- wt loss if overweight or obese
- low carb, low fat, calorie restricted or mediterranean diet
- physical activity
What kind of diet should you follow being pre diabetic or diabetic?
- limit sugar sweetened drinks
- limit alcohol intake
- fiber 14g/1000 kcal
- no trans fats
What are the physical activity recommendations for diabetics?
- 150 min/week moderate intensity exercise
- 50-70% of max heart rate
- spread over 3 days/week
- resistance training 2x per week
- exercise Rx - agreed upon exercise regimen
Psychosocial assessment of diabetic pt?
- screen and tx depression, anxiety, and eating disorders
What is key to successful diabetes tx?
- ongoing pt education
- self blood glucose monitoring (if on insulin)
- tx and recognize hypoglycemia
- continual dietary and physical activity support and reinforcement
What are the sxs of hypoglycemia?
- confusion, diaphoresis, tachycardia, palpitations, weakness
- need to give 15-20 g of glucose or any form of carb
- recheck BG in 15 min and repeat tx if necessary
- meal post episode
Who is recommended for bariatric surgery?
- BMI of 35 or more
- especially for difficult to control DM with assoc comorbidities
- does make a difference in blood sugar afterwards, and can reverse diabetes for period after surgery
- pt has to be motivated
Immunization that diabetics need?
- influenza: all persons older then 6 months
- pneumococcal: older than 2 years, revaccination one time if vaccine giver before 64 and it has been more than 5 years
- PCV13 and PSSV23
- Hep B
Complications of DM?
- HTN
- Dyslipidemia
- CVD
- nephropathy
- retinopathy
- neuropathy
- foot ulcers or charcot foot
Tx of HTN?
- goal SBP is less than 140
- goal DBP: less than 90
- ACEI or angiotensin receptor blocker is first line therapy if no CIs
Lipid control and tx?
- evaluate fasting lipids at least once yearly
- want LDLs less than 100
- LDL if CVD less than 70
- TGs less than 150
- HDLs greater than 40 in men, 50 in women
- LDL is the main target for tx
- combo therapy: studies shown that it doesn’t reduce CVD risk, and may icnrease risk for myopathy
Whe are statins indicated in DM pts?
- pts with CVD
- w/o CVD and older than 40 and one of the following:
family hx of CVD
HTN
smoking dyslipidemia
albuminuria
Who should be taking aspirin?
- 75-162 mg/ day
- men older than 50 and women older than 60 if:
family hx of CVD
HTN
smoking
dyslipidemia
albuminuria (indicates renal failure)
Coronary disease screening and therapy?
- not recommended to screen asx pts
- ACEI and statin therapy
- B blocker for at least 2 years post MI
- avoid thiazolidineodine tx with heart failure
- metformin ok if CHF with normal renal function: not for unstable CHF or renal compromised pts
Nephropathy prevention?
prevention: BP and blood glucose control
- yearly albumin excretion (need baseline at dx)
- at least yearly creatinine and BUN levels
Tx of albuminuria?
- more than 30 mg/day urinary albumin excretion - take ACEI or ARB
Retinopathy prevention?
- BP and blood sugar control for prevention
- at dx need dilated fundoscopic exam and need this done yearly - want to have ophtho look at them yearly
Neuropathy screening?
- screening for distal polyneuropathy at dx and yearly
- monofilament test
- autonomic neuropathy:
gastroparesis (delayed gastric empytying)
erectile dysfunction
cardiovascular autonomic dysfuntion (ortho hypotension)
Foot care for diabetics?
- inspection
- pulses: screen for sxs of PVD, consider ABIs
- sensation: monofilament test and 1 of the following:
vibration, pin prick, ankle reflexes
