68 terms

T2DM (Shubrook)

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what is the epidemiology of T2DM in the US?
29 million people with diabetes
90% have T2DM
1:10 people

76 million have pre-DM = only 10% know they have it, i.e. 90% do not know they have it
what does CDC predict about people born in 2000?
1 in 3 will develop DM
40% in at risk populations
50% in hispanic populations (1 in 2)
what is the only diagnostic test that does not have to be repeated?
Randome postprandial glucose (PG)
what are the normal values of FPG?
<100 mg/dl
what are the normal values of 2-h PG?
<140 mg/dl
what are the risk factors of pre diabetes?
overweight, obesity (pro-inflammatory & oxidative states), lipid disorders, altered glucose metabolism, HTN
what are intervention methods for diabetes prevention had the greatest impact?
Lifestyle intervention (intensive)
- reduction in fat & calorie intake
- physical activity of 150 minutes per week
- weight loss of >7% body weight and maintained of weight loss
who should be tested for T2DM?
any pt with BMI ≥ 25 and a risk factor:
- Physical inactivity
- First-degree relative with DM
- High-risk race/ethnicity: African American, Latino, Native American, Asian American, Pacific Islander
History of Gestational Diabetes or delivery of macrosomic infant (> 9 lbs)
- Hypertension
- HDL < 35 or Triglycerides > 250
- History of Polycystic Ovarian Syndrome (PCOS)
- HgbA1c ≥ 5.7 or fasting glucose > 100
- Acanthosis nigricans
- History of CVD
what should you do if a person has no risk factor and normal BMI?
begin testing at age 45
repeat testing every 3 years
what does the US preventive services task force recommend?
screen asymptomatic pt for DM if BP > 135/80
pre-diabetes FPG
≥100-125 mg/dl
pre-diabetes 2-hour PG
≥140-199 mg/dl
A1c in prediabetes
5.7-6.4%
diabetes FPG
≥ 126 mg/dl
2-hour PG diabetes
≥ 200 mg
random PG diabetes
≥ 200 + symptoms
A1c in diabetes
≥6.5%
what should you always do with the A1c and FPG?
repeat them (do it twice), because invariably one will be + and one will not
what is the most sensitive test done for diabetes?
FPG
what are the treatment goals for T2DM?
Normalize BS's & HGB-A1C
Diabetes education
Dietary instruction, Regular exercise
CV Risk Factor Reduction to secondary intervention levels
Smoking cessation
Prevention of microvascular & macrovascular complications
glycemic control ADA recommendations for adults with diabetes
A1C < 7%
Preprandial BG 80 - 130 mg/dl
Peak postprandial BG <180 mg/dl
blood pressure ADA recommendations for adults with diabetes
< 140/90 mmHg
lipid ADA recommendations for adults with diabetes
based upon ACC risk stratification
diabetes self-management education and support
All people with diabetes should receive DSME S at diagnosis, in life changes and as the disease progresses or treatments change

YET 6% of people receive DSME in the first year of DM
why is it so difficult to treat T2DM?
because it is progressive and waiting can increase A1c
what is the stepwise treatment?
1) lifestyle modification
2) oral medications
3) incretins
4) insulin

most physicians enlist the "treat to fail algorithm"
what is the "treat to fail algorithm"?
treat the the pt until they fail and add medication when its already too late, and then treat again when they fail again = very discouraging
what is the ADA recommendation for treatment of diabetes?
1) lifestyle modification + metformin
If after 3 months there is improvement but not to the extent that is wanted
2) add a second drug = dual therapy
If after another 3 months there is not the right amount of improvement
3) add a third drug
if none of that works after another 3 months
add insulin
what is the order of treatment most physicians apply?
1) glucose control
2) lipids
3) blood pressure
what treatment causes the greatest decrease in mortality?
BP control
what is an important preventative measure in nephropathy treatment?
early nephrology referral
what are the stages of chronic kidney disease?
what should you treat LDL levels (according to BOARDs)?
< 100
what is the result of lowering A1c in a short period (2-3 years) of observation?
large reduction in microvascular problems, retinopathy, nephropathy, neuropathy but less reduction in macrovascular disease (MI, CV disease)
why do short period (2-3 years) studies not show glucose control benefits for CV disease?
because there needs to be long term data to look at the benefits i.e. 10 year follow up
what are guidelines for glucose monitoring?
Glucose measurement should match the intensity of treatment
- tell pts what they are doing it for, what the levels should be
- rare checks if no meds
- 3-7 checks per week on insulin sensitizers only
what is the glucose monitoring if on insulin?
FSG for each time injecting insulin (unsafe to take insulin without knowing the glucose before)
AVOID sliding scale insulin alone
AVOID insulin that have variable absorption
what are the follow-up visits (KNOW THIS)?
what is the frequency of skin examination? assessment?
annually

peripheral neuropathy
what is the frequency of neurologic examination? assessment?
annually

autonomic and peripheral neuropathy
what is the frequency of dilated eye exam? assessment?
annually

retinopathy
what is the frequency of microalbuminuria? assessment?
anually

target < 30 mg/g creatinine
what is the frequency of cardiac exam? assessment?
annually (more often if CVD present)

development/progression of CVD
A1c <7.0% treatment summary
Attempt lifestyle
Metformin or Incretin if obese
TZD if not
A1c >7.0%, < 8.5% treatment summary
need at least one medication
consider combination tx modalities
A1c > 8.5% treatment summary
need 2-3 agents or insulin
Macrovascular T2DM complication
Cardiovascular
Peripheral Arteries
Erectile Dysfunction
Microvascular T2DM complication
Renal
Ophtalmic
Neurological:
- peripheral polyneuropathy
- autonomic
- gastroparesis
CV & lipid management in T2DM
moderate intensity statin for low risk

high intensity statin for high risk
peripheral vascular disease in DM
May cause pain in legs with exertion

Over time, pain may diminish as loss of sensation/neuropathy sets in

PVD can inhibit foot ulcers from healing, resulting in necrosis, infections, and limb amputations
what percentage of DM amputations can be prevented?
> 90%
Neuropathy in diabetes
60-70% of T2DM pts

Pain: sharp, burning, aching, numb, can cause weakness, loss of reflexes

best prevented with glycemic control
treatment of neuropathy in diabetes
gabapentin
duloxetine
tricyclics
pregabalin
screening tool to identify early nephropathy
urine albumin:creatinine ratio
ways to slow progression of diabetic nephropathy
Tight glycemic control
Blood pressure < 130/80
ACE-inhibitors => only if HTN or nephropathy
No ACE/ARB combo
diabetic retinopathy
damage to retinal blood vessels

leading cause of blindness in adults in the US

DM also increases risk for cataracts & glaucoma
reproductive issues in T2D
Women with insulin resistance or T2DM can have infertility related to anovulation (PCOS)

Pre-conception counseling: HgbA1C should be < 7% or there is an increased risk of birth defects

T2DM pregnancies are HIGH-RISK from the start

Men can develop erectile dysfunction
what is the national diabetes prevention program (NDPP)?
a community evidence based program that works to prevent type 2 diabetes in adults
how does A1c control reduce vascular complications?
each 1% reduction can decrease risk of microvascular complications by 40%
how does blood pressure control reduce vascular complications?
reduces CV risk in pts by 33-50%

reduces the risk of microvascular complications by approximately 33%

every 10mmHg reduction in SBP decreases the risk of any complication by 12%
how does lipid control reduce vascular complications?
improved LDL-cholesterol control can reduce CV complications by 20-50%
what medications should be used for treating HTN in DM?
ACE/ARB = titrate to max tolerated dose

thiazide diuretics next
beta-blockers
CCB

do not combine RAAS agents
what are the results of lifestyle therapy for HTN?
weight reduction = 5-20 mmHg/10 kg

DASH diet = 8-14 mmHg
Physical activity = 4-9 mmHg
Salt restriction = 2-8 mmHg
EtOH moderation = 2-4 mmHg
normal protein level
< 30
microabluminuria
30-300 mg/g
proteinuria
300-4500 mg/g
nephrotic range proteinuria
>4500 mg/g
what are some tips to get control of T2DM?
lifestyle should always be used but only part of the treatment
start aggressively and then back off
assume each medication reduces A1c by 1%

never substitute meds = always add new agent first, titrate to get control, then stop first agent
ask the pt what they want = shots vs. pills
develop a plan that prevents hypoglycemia
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