Type 2 diabetes

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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
  • HbA1C 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:

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. HbA1C 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