Type 2 diabetes

From IKE

Contents 1 Follow-up Visit 2 Info 3 Screening 4 Signs and Symptoms 5 Differential diagnosis 6 Associated conditions 7 Laboratory 8 Drugs 9 Drug warnings 10 Complications 11 Resources

Follow-up Visit

ID CC PMH - note CAD or prev. MI/stroke

S

• Voiced concerns
• Psych screen
• Smoking
• Ophthalmology yearly.
• Feet every visit. Note last microfilament or vibration (annual)
• Lipids
  • Target: LDL-C ≤ 2; TC/HDL-C < 4; no target for TG, but <1.5 considered optimal
• Glucose
  • Preprandial blood glucose: 4.0 to 6.0 mmol/L[1]
  • 2-hour postprandial blood glucose: 5.0 to 8.0 mmol/L

• Hb_A1C every 3 months
  • Target: 6.0%[2]

• Microalbumin:Urea Ratio yearly
• Creatinine yearly
• BP History - Target 130/80
• Exercise - Target ≥ 150 minutes moderate-intensity aerobic exercise over 3 non-consecutive days
• Meds:
  • ECASA unless contraindicated
  • ACE inhibitor or ARB for renal protection unless contraindicated

O

• HR BP WT HT
• Fundoscopy (not in the guidelines)
• CVS
• Resp
• Feet: Monofilament of great toe (Annually), Vibration of great toe (annually) pulses, ulcers

P

• FU q2-4 months
•  ?Nurse FU q1mo

Info

• Nonketosis-prone hyperglycemia and glucose intolerance;
• 80% of diabetic cases

• Incidence (USA): 300/100,000 (M 230/100k; F 340/100k)
• Prevalence (USA):
  • Age: >40
  • Sex: F > M (whites)

• Risk factors:
  • Hispanic, Polynesian, or Native American ancestry
  • Genetic factors
  • Obesity
  • Family history
  • Gestational diabetes

Screening

• All individuals: Annual evaluation on the basis of demographic and clinical criteria
• FPG q3 years in individuals > 40 years of age
• More frequent and earlier testing with either an FPG or 2hPG in a 75-g OGTT should be considered in people with additional risk factors for diabetes, including:
  • First-degree relative with diabetes
  • Member of high-risk population (e.g. people of Aboriginal, Hispanic, Asian, South Asian or African descent)
  • History of IGT or IFG
  • Presence of complications associated with diabetes
  • Vascular disease
  • History of GDM
  • History of delivery of a macrosomic infant
  • Hypertension
  • Dyslipidemia
  • Overweight
  • Abdominal obesity
  • Polycystic ovary syndrome
  • Acanthosis nigricans
  • Schizophrenia

• If FPG is 5.7 - 6.9 mmol/L, then 2hPG in a 75-g OGTT

• In individuals with IGT, a structured program of lifestyle modification that includes moderate weight loss and regular physical activity should be implemented to reduce the risk of type 2 diabetes

• If IGT, metformin (biguanide) or acarbose (alpha-glucosidase inhibitor) should be considered to reduce the risk of type 2 diabetes.

Signs and Symptoms

• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Weakness
• Fatigue
• Frequent infections

Differential diagnosis

• If pregnant, think Gestational diabetes mellitus
• Type 1 diabetes mellitus
• Other specific types of diabetes mellitus:
  • Genetic defects of β-cell function
  • Genetic defects in insulin action
  • Diseases of exocrine pancreas
  • Endocrinopathies
  • Drug or chemical induced
  • Infections
  • Immune mediated
  • Genetic syndromes sometimes associated with diabetes
  • Hemochromatosis

Associated conditions

• Hypertension
• Hyperlipidemia
• Impotence
• Infertility
• Syndrome X
• Renal insufficiency/failure
• Cardiovascular disease
• Retinopathy
• Stroke

Laboratory

• Diagnosis (any one is sufficient):
  • Symptoms of diabetes (polyuria, polydipsia, weight loss) plus casual (random) plasma glucose 11.1 mmol/L OR
  • Fasting plasma glucose >7.0 mmol/L on two occasions or 2-hour plasma glucose >11.1 mmol/L during oral glucose tolerance test with 75 g glucose load

• Drugs that may alter lab results:
  • Pentamidine
  • Nicotinic acid
  • Glucocorticoids
  • Thyroid hormone
  • Diazoxide
  • Beta-adrenergic agonists
  • Thiazides
  • Dilantin
  • Alpha-interferon
  • Some fluoroquinolones
  • Some second-generation (atypical) antipsychotics

Drugs

• Lifestyle management for 2-3 months to get target. Hb_A1C target within 6-12 months.
• General rule:
  • Initial treatment: Sulfonylureas
  • Metformin may be preferred first in obese patients.
  • If inadequate on one drug, add from different class.
  • If inadequate on two drugs, consider insulin.

• Biguanides:
  • Metformin: 500-850 mg bid-tid
  • Avoid increased lactic acidosis: Renal insufficiency, radiocontrast agents, surgery, or acute illnesses such as liver disease, cardiogenic shock, pancreatitis, or hypoxia.
  • Caution with congestive heart failure, alcohol abuse, elderly patients, or with tetracycline

• Sulfonylureas (CAUTION WHEN SULFA ALLERGY; may be taken with meals, except glipizide 30 minutes before meals):
  • Glyburide: 1.25-20 mg per day in one to two doses (first dose, 10 mg in morning)
  • Glimepiride: 1-8 mg per day in one dose
  • Glipizide: 2.5-40 mg per day in one to two doses (first dose, 20 mg in morning)
  • Glipizide extended-release tablets: 5?20 mg per day in one dose

• Thiazolidinediones:
  • Pioglitazone: 15-45 mg daily
  • Rosiglitazone: 2-4 mg bid; monitor serum transaminase every 2 months for first year
• α-Glucosidase inhibitors (Taken at beginning of meals to decrease postprandial glucose peaks):
  • Acarbose ( Precose ): 25?100 mg t.i.d.
  • Miglitol ( Glyset ): 25?100 mg t.i.d.
  • Caution with renal insufficiency, inflammatory bowel disease, colonic ulceration, or partial bowel obstruction.

• Insulin (home glucose monitoring qd-qid)
  • Can be started as 10 units combination intermediate/short acting with evening meal or intermediate (NPH) orinsulin glargine at bedtime.
  • Rapid-acting insulin: Aspart ( Novolog ), Glulisine ( Apidra ), and Lispro ( Humalog )
  • Short-acting insulin: Regular ( Humulin R , Novolin R )
  • Long-acting insulin: Glargine ( Lantus ), Ultralente ( Humulin U )

Drug warnings

• Drugs that may potentiate sulfonylureas: Salicylates, clofibrate, warfarin ( Coumadin ), chloramphenicol, ethanol, and angiotensin-converting inhibitors
• Beta-blockers may mask symptoms of hypoglycemia and delay return to normoglycemia
• Thiazolidinedione pioglitazone may decrease effectiveness of oral contraceptives
• Drugs that bind others in the intestine, such as cholestyramine resin, should be taken at least 2 hours apart from ?-glucosidase inhibitors.

Complications

• Appear to be due to effects of diabetes mellitus on arterial walls in one form or another
• Peripheral neuropathy
• Proliferative retinopathy
• Nephropathy and chronic renal failure
• Atherosclerotic cardiovascular and peripheral vascular disease
• Hyperosmolar coma
• Gangrene of extremities
• Blindness
• Glaucoma
• Cataracts
• Skin ulceration
• Charcot joints

Resources

• Canadian Diabetes Guidelines
• Quarter 4 biochemistry notes (PDF)
• Wikipedia:Diabetes