Difference between revisions of "Type 2 diabetes"

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'''Type 2 diabetes''' has traditionally been known as ''late-onset diabetes'', and it is the great scourge of the Western or supposedly developed world.
+
==Follow-up Visit==
The main difference between [[Type 1 diabetes]] and Type 2 diabetes is that Type 2 patients - at least initially - have "normal" [[insulin]] in their blood streams, though their body doesn't know how to use it (they are said to be [[insulin resistant]]).
+
ID
Another important difference is that Type 2 diabetic patients are much less prone to ''ketoacidosis'', though they are not totally exempt from it.
+
CC
 +
PMH - note CAD or prev. MI/stroke
  
Because Type 2 diabetics are initially different from [[Type 1 diabetes|Type 1]] diabetics (''i.e.'', they have [[insulin]] initially), they are treated differently.
+
S
Since their cells are [[insulin resistant]], one way of treating it is by inducing increased insulin production.
+
* Smoking
As the days turn into months, and the months into years, the β-cells of the [[pancreas]] stop producing insulin, though the reason for this is not clear.
+
* Ophthalmology '''yearly'''.
Once the &beta-cells have stopped producing insulin, they might as well be Type 1 diabetics.
+
* Feet '''every visit'''
 +
* Lipids
 +
** Target: Triglyceride <2; LDL-C <
 +
* Glucose
 +
* HbA1C '''every 3 months'''
 +
* Microalbumin:Urea Ratio '''yearly'''
 +
* BP History - Target 130/80
 +
* Meds:
 +
** [[ECASA]] unless contraindicated
 +
** [[ACE]] or [[ARB]] for renal protection unless contraindicated
  
In general, diabetic patients have high serum [[glucose]], which leads (by mass action) to increased glycosylated [[hemoglobin]] ([[Hemoglobin|HbA<sub>1c</sub>]]) and [[Dictionarycom:sorbitol|sorbitol]].
+
O
 +
* HR BP WT HT
 +
* Fundoscopy
 +
* CVS
 +
* Resp
 +
* Feet: Monofilament, pulses, ulcers
  
Being overweight is one of the key risk factors for Type 2 diabetes, since it increases [[insulin resistance]].
+
P
Therefore, at least initially, Type 2 diabetes can be easily treated with exercise and weight loss.
+
* FU q2-4 months
Sadly, this is the one treatment patients do not want, instead preferring a magic pill or silver bullet.
+
* ?Nurse FU q1mo
So, physicians do what they gotta do, but should always understand that exercise and weight loss are the best treatment of Type 2 diabetes before the patient becomes [[insulin]]-dependent (''i.e.'', [[Type 1 diabetes]]).
 
  
Since Type 2 diabetics are frequently not ''completely'' [[insulin resistant]], increasing [[insulin]] production (''i.e.'', inducing [[OMD:hyperinsulinemia|hyperinsulinemia]]) may suffice.
+
==Info==
One of the drugs involved in this is sulfonylurea, which stimulates the [[pancreas]] to produce more insulin.
+
* Nonketosis-prone hyperglycemia and glucose intolerance;
This is univerally considered a bad idea, but is still widely used.
+
* 80% of diabetic cases
Another drug used for Type 2 diabetics is '''metformin''' (generic name), which improves the use of [[glucose]].
 
  
 +
* 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
 +
 +
==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 &beta;-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==
 +
* 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
 +
* &alpha;-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 ==
 
== Resources ==

Revision as of 00:34, 18 November 2007

Follow-up Visit

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

S

  • Smoking
  • Ophthalmology yearly.
  • Feet every visit
  • Lipids
    • Target: Triglyceride <2; LDL-C <
  • Glucose
  • HbA1C every 3 months
  • Microalbumin:Urea Ratio yearly
  • BP History - Target 130/80
  • Meds:
    • ECASA unless contraindicated
    • ACE or ARB for renal protection unless contraindicated

O

  • HR BP WT HT
  • Fundoscopy
  • CVS
  • Resp
  • Feet: Monofilament, 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

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

  • 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