Module 3 (b) Flashcards
Type 2 Diabetes
-Risk Factors
- Obesity
- Primary risk factor — (more common with central distribution — male pattern obesity) - Men are TWICE as likely as women to develop T2DM
- High risk Heritage: Native Americans, Black, Hispanic, Asian American & Pacific Islander
- Hx of Prediabetes, Gestational DM, or PCOS
- Hx of insulin resistance (Acanthosis Nigerians, severe obesity)
- Hx of CVD
- HTN, Dyslipidemia
Symptoms of Type 2 Diabetes
- In a patient with recurrent infections, T2DM should be a differential
- If a female patient presents with Candida vaginitis multiple times, consider T2DM
Acanthosis Nigrans
Leathery skin in the neck or armpit folds
-Linked to obesity, T2DM, or some Cancers tumors (liver cancer
Treatment is aimed at underlining condition
Xanthelasma
Yellowish elevated lesions on the skin of the eyelids
- Soft to touch and flat and yellowish in appearance
- Appear on upper and lower eyelids and are symmetric
- Usually NOT painful or itchy And rarely cause visual changes
Can indicate:
-High cholesterol, hypothyroidism, or liver condition
Criteria for Testing for Diabetes or Pre-diabetes in Asymptomatic Adults??
**Overweight or Obese BMI >= 25kg/m2 or 23Kg/m2 in Asian Americans
Who have one or more of the following Risk factors
1. 1st degree relative with DM
2. High-risk race/ethnicity (AfricanA, latino, Native A, Asian A, Pacific Islander)
3. Hx of CVD
4. Hypertension (>= 140/90 or on a BP medication with controlled BP)
5. HDL <35 mg/dl or triglyceride level >250 mg/dl
6. Women with Polycystic ovary syndrome PCOS
7. Physical inactivity
8. Other conditions that cause insulin resistance
-Ex: Severe obesity, Acanthosis nigrans, xanthelasma
T2DM
-Diagnostic Tests
- Serum Glucose (random or fasting)
- HbA1C
Oral glucose Tolerance test — NOT done in CLINIC setting.
T2DM
-Diagnostic Criteria
- Fasting Glucose >= 126 mg/dl after 8hr fast
- Random Plasma Glucose >= 200 with classic symptoms
- Oral Glucose Tolerance Test >= 2000 mg/dl
- HbA1C >=6.5%
You need a SECOND blood test to confirm diagnosis if BS is high on first test.
TIDM vs T2DM
Onset: Is Rapid in T1 vs Gradual in T2
Age: T1 is usually younger than T2
Cause: T1 = No insulin vs T2 = ominous octet
Keto acidosis: Common in Type 1 but rare in T2
Treatment: T1 = Insulin, T2 =Diet, lifestyle, oral meds, and/or insulin
Ominous Octet Pathways & Medications to treat them?
-Increased Hepatic Glucose Output Treatment?
Metformin (Glitazones)
Ominous Octet Pathways & Medications to treat them?
-Renal Glucose Excretion Treatment?
SGLT2 Inhibitor (Sodium-glucose contransporter 2 inhibitor)
Ominous Octet Pathways & Medications to treat them?
-Decreased Peripheral Glucose Uptake Treatment?
Metformin (Glitazones)
Ominous Octet Pathways & Medications to treat them?
-Glucose Influx Treatment
- alpha Glucosidase inhibitors
- GLP-1 RA (Glucagon-like Peptide 1 receptor agonist)
- Pramlintide
Ominous Octet Pathways & Medications to treat them?
-Increase Glucose Secretion Treatment
- Incretines
- Pramlintide
Ominous Octet Pathways & Medications to treat them?
-Decreased Insulin Secretion Treatment?
- Insulin
- SFU
- Glinides
- GLP-1 RA
- DPP-4 I (Dipeptidyl peptidase inhibitors)
Ominous Octet Pathways & Medications to treat them?
-CNS Dysfunction treatment
-Cycloset (Dopamine Receptor Agonist)
Diabetes Care
-Personalized care!
DM treatment is not one size fits all! Consider: -Efficacy -Side effects -Side benefits (Weight loss addition) -Cost
Non-Insulin Therapies in T2DM
-(Biguanides) Metformin
- Recommended initial therapy for T2DM **
- ONLY for pt’s with eGFR >= 45;
- DO NOT initiate Metformin for eGFR between 30 - 44 ml
- Consider extended release if GI side effects occur
- Inform Pt about METALLIC taste
- Risk of B12 deficiency
Insulin Therapy
-Rapid Acting Insulin
- Lispro
- Aspart
- Glulisine
Given before, during or after meal. Med is provider and patient preference.
Insulin Therapy
-Long-Acting Insulin
- Glargine
- Detemir
- Degludec
T2DM
-Combination Therapy
- Metformin is used with another medication with atherosclerotic CVD is present. CAD, MI, renal dz, or hypoglycemia is a risk factor.
T2DM
-HbA1C Goals
- New onset, no complication, no CVD = A1c goal of <7%
- Significant CVD = 7-8%
- Many Co-morbidities, low life expectancy = 8-9%
Approach for Individualize HbA1C targets
-usually non-modifiable
- Less Stringent approach if pt has risk of hypoglycemia or drug adverse effects
- More stringent approach if pt is newly diagnosed diabetic
- Less stringent approach if pt has short life expectancy
- Less stringent with important co-morbidities
- Less stringent with established vascular complications
Pt preference and resources and support system are potentially modifiable factors
Anti-hyperglycemic Therapy in Adults w/ T2DM
-Monotherapy
For A1c < 9%
1. Lifestyle management + Metformin
ALWAYS initiate LIFESTYLE management (Diet, exercise, smoking cessation, weight control)
-Always discuss smoking cessation with smokers
-Monitor Pt’s in 3 months due to A1c measuring effectiveness over 3 months.
—If at goal, follow up A1c in 3-6 months
—If not at goal, CONSIDER medication taking behavior**; consider dual therapy
Anti-hyperglycemic Therapy in Adults w/ T2DM
-Dual Therapy
A1c >= 9%
- Lifestyle management + Metformin + Additional agent (depending on problem)
- If patient has atherosclerotic CVD, add a medication that lowers risk of CVD adverse events
Assess A1c at target after 3 months
—If at goal, follow up A1c in 3-6 months
—If not at goal, CONSIDER medication taking behavior**; consider triple therapy
Anti-Hyperglycemic Therapy in Adults with T2DM
-Triple Therapy
HbA1C >= 10%, BG >= 300 mg/dl, or patient is markedly symptomatic
-Lifestyle management + Metformin + 2 additional agents
-Monitor Pt’s in 3 months due to A1c measuring effectiveness over 3 months.
—If at goal, follow up A1c in 3-6 months
—If not at goal, CONSIDER medication taking behavior**; consider combination injectable therapy
Medications with Proved CVD & CKD Benefit
- SGLT2 Inhibitors
- Medication names end in “Flozin” - GLP-1 Analogs
- Medication names end in “Lutide”
Medications Proven Heart Failure Benefit
- SGLT2 Inhibitors
- Medication name ends in “Flozin”
If Cost is a Major Issue??
-Ex of Affordable Meds?
- Biguanide - Metformin
- Sulfonylurea (SU)
- Thiazolidineodiones (TZD)
- Insulin
T2DM Medications
-Weight Loss Meds?
- GLP-1 Analogs
2. SGLT-2 Inhibitors
T2DM Medications
-Weight Maintenance
- Metformin
2. DPP4 Inhibitors
T2DM Medications
-Weight Gain
- Insulin
- Sulfonylureas
- Thiazolidinediones
- Meglitinides
T2DM Medications
-High Risk for Hypoglycemia
- Insulin
- Sulfonylureas
- Meglitinides
T2DM Medications
-Low Risk for Hypoglycemia
- Metformin
- GLP-1 Analogs
- SGLT-2 Inhibitors
- DPP4 Inhibitors
- Thiazolidineodiones
What Medication has high efficacy and reduces the risk of worsening Diabetic Nephropathy?
- Liraglutide (GLP1-RA)
Non-Pharmacologic Management
-Exercise
- Aerobic (moderate): 30 min/day, 5-6 days/week (>/= 150 minutes)
- Resistance Training: 2-3 days/week
Nonpharmacologic Management
-Psychosocial Care?
- Symptoms of diabetes distress, depression, anxiety and eating disorders.
All diabetic patients should be screened for DEPRESSION
-PHQ2 and PHQ-9
Healthy weight loss is always recommended
T2DM in Older Adults
-Stats
- 1 in 4 adults (25%) over 65 years old
- Aging is major risk factor (insulin production decreases w/ age w/ increase insulin resistance)
- More subtle new onset s/s
- HbA1C target of 7.5% - 8% (American Geriatric Society Guidelines)
Risk Factors for Hypoglycemia in Older Adults?
- Use of Insulin and other medications that can also cause hypoglycemia
- Irregular meals
- Unpredictable exercise patterns
- Decreased renal function
- Polypharmacy
- Hospitalization
- Co-existing co-morbidities
DM in Older Adults
-Glycemic control and reduced Medication are achieved by?
- Healthy eating
- Physical activity (W/ Strong consideration for safety, hypoglycemia risk)
- Weight reduction
DM in Older Adults
-Treatment Goal
- Avoid Hypoglycemia ***
2. Achieve best glycemic control
DM in Older Adults
-Health Promotion
- Yearly dilated eye exam
- Evaluation of feet at least Annually
- FOOT INSPECTION should occur in EVERY visit in patients with Diabetes
- Proper footwear and assess w/out socks and between toes - Yearly influenza vaccine
- Pneumococcal vaccine
- Depression Screening
Pharmacological Therapy in T2DM
-Older Adult Consideration
- Declining renal and hepatic function
- Increased risk for polypharmacy
- Increased risk for hypoglycemia
- Limited clinical trials in older adults
- Patient’s functional and cognitive status
- CV risks and comorbidities
Pharmacological Therapy in T2DM in Older Adults
-1st line oral treatment?
- Metformin is the 1st line agent for oral therapy
- LOWER RISK for hypoglycemia
Pharmacological Therapy in T2DM in Older Adults
-Medications to Use with Caution??
- Insulin and insulin secretagogues
- Use with caution; glycemic goals should be less strict - Sulfonylureas (SU)
- Use w/ caution; associated with hypoglycemia - Thiazolidinediones (TZD’s)
- Use w/ caution in elderly
- CONTRAINDICATED in pre-existing HF, edema, hepatic failure**
Pharmacological Therapy in T2DM in Older Adults
-Medications to Avoid?
- Glyburide should be AVOIDED
- Associated with hypoglycemia in older adults
Pharmacological Therapy in T2DM in Older Adults
-Thiazolidinediones (TZD) Contraindicated in Pt w/?
- TZD’s are contraindicated in patients with preexisting:
- Heart Failure, Edema, & Hepatic failure
