S17C219 - Type 2 Diabetes Flashcards
T2DM pathophys: Insulin resistance
-occurs at major sites such as liver, muscle, adipose tissue
T2DM pathophys: impaired insulin secretion
- impaired in part due to high free fatty acid levels
- also glutotoxic effects
T2DM pathophys: impaired regulatn of hepatic glucose production
- liver becomes resistant to insulin and therefore overproduces and underuses glucose
- kidney’s also involved in gluconeogenesis
T2DM complications: vascular
Microvascular
-retinopathy, neuropathy, nephropathy
Macrovascular
-CAD, CVA, PVD
T2DM complications: non-vascular
- ifxns
- dermatologic changes
- UT involvement
- sexual dysfunction
- GI involvement (gastroparesis, diarrhea)
- cataract/glaucoma
T2DM: manifestation
- fatigue, weakness, polyuria, polyphagia, polydipsia, blurred vision
- assoc with obesity, age >30, HTN, CAD/CVA, dyslipidemia, PCOS
T2DM: neuropathy - DDx
- must first r/o:
- chronic inflammatory demyelinating polyneuropathy
- B12 deficiency
- hypothyroid
- uremia
T2DM: neuropathy Sx
- electrical/stabbing sensations
- paresthesias
- hyperesthesia
- deep aching pain
- stocking glove pattern
- loss of vibration, pressure, pain, temp
T2DM complication: Diabetic mononeuropathies
- difficult to differentiate from a TIA
- sudden onset, assoc with pain
- isolated cranial nerve or large peripheral nerve (median/peroneal)
Diabetic complications: infxns
- staph aureus and mycobacterium tuberculosis are more common in diabetics with PNA
- candida spp more comming UTI in diabetics
- malignant otitis externa: unilateral otalgia, decr hearing, purulent ear d/c, fever, tender inflamed ext auditory canal, granular-appearing tissue (pseudomonas, staph, fungi, gm-)
- emphysematous cholecystitis and pyelonephritis (medical emergencies, u/s should be done on any diabetic with unexplained fever)
- rhinocerebral mucormycosis
T2DM: foot ulcers
- pathogen: aerobic gm+ cocci (staph), gm- rods if recent Abx or chronic wound
- venous ulcers: above malleoli with irregular borders
- arterial ulcers: toes/shins with pale punhed out borders
- diabetic ulcers: occur at areas of increased pressure or friction (sole of foot)
- if able to probe to bone this is sign for osteomyelitis
- xr diabetc ulcers to r/o OM, subcu gas, FB, charcot joint
T2DM: Ophthalmologic complications
- diabetic retinopathy, maculopathy, CRVA/BRVO, tractional retinal detachments
- optic nerve dz: NAION, glaucoma, papillitis
- 3/4/5 CN palsies
- cataract
- decr corneal sensation
- vitreous hemorrhage
- recurrent styes, blepharoconjuctivitis, xanthelasma
-retinopathy: proliferative, nonproliferative
T2DM: derm complications
- protracted healing, ulcers
- acanthosis nigricans, necrobiosis lipoidica, scleredema
- infx: erythrasma, necrotizing fasciitis, mucormycosis
- lipoatrophy, lipohypertrophy
Classes of Antidiabetics
-insulin
Oral Antihyperglycemics
- Biguanides (metformin) sensitize cells to insulin in liver, decreases gluconeogenesis
- Thiazolidinediones (glitazones) sensitize cell to insulin in tissues
- Insulin secretagogues (sulfonylureas - glyburide) promotes secretion of insulin
- alpha-glucosidase inhibitors (acarbose) slow the absorption of carbohydrates
Antidiabetic complications/side effects
- metformin: lactic acidosis, nausea, diarrhea
- glitazones: worsening of liver disease, CHF, bone loss, wt gain
- sulfonylureas: hypoglycemia, GI
Gastroparesis
- tx: frequent small meals
- prokinetic agent (maxeran)
Limb threatening ulcer
- > 2cm of cellulitis
- pus, weeping, malodarous
- ascending lymphangitis
- deep full-thickness ulceration or abscess
- large area of necrotic tissue
- involvement of bone
- gangrene
- absence of pulses due to lower limb ischemia
- fever
- or associated with sepsis
- Cx, image, blood Cx, CRP
- admit, surgical debridement, empiric Abx
- cefoxitin, clinda plus cipro
Diabetic infections
- cover strep and staph
- if malodarous or gangrenous or ischemic cover for gm- and anaerobes
T2DM and hyperglycemia:
> 16
- underlying causes: drug interactions – corticosteroids, sympathomimetics, diuretics, anticonvulsants, salicylates, beta adrenergic receptor agonists
- infxn, acute illness, ACS, CVA, noncompliance
- tx: insulin (IV) – SC may not work well in a volume deplete pt (not reliable) – bolus 0.1 unit/kg IV of regular insulin, rpt in 2h if glucose levels have not fallen by 3
Non limb-threatening ulcer
-
Hypoglycemia defn
-diabetic:
Hypoglycemia symptoms
- neuroglycopenic: aLOC, lethargy, confusion, combative, agitated, sx, focal neurodeficit, unresponsive
- autonomic: anxiety, nervousness, irritability, n/v, palpitations, tremor
Hypoglycemia Tx:
- D50W bolus (50cc) = 25g of glucose
- dextrose infusion D10W to maintain sugars >60
- do blood sugars q30 x2h
Sulfonylurea hypoglycemia
- give octreotide
- 50-100mcg SC
