T2DM (Shubrook)

Terms in this set (68)

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?

what are the normal values of 2-h PG?

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

2-hour PG diabetes

random PG diabetes

≥ 200 + symptoms

A1c in diabetes

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?

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

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?

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)?

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?

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

microabluminuria

nephrotic range proteinuria

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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