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.
+
* Voiced concerns
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.
+
* Psych screen
Once the &beta-cells have stopped producing [[insulin]], they might as well be [[Type 1 diabetes|Type 1]] diabetics.
+
* Smoking
 +
* Ophthalmology '''yearly'''.
 +
* Feet '''every visit'''. Note last microfilament or vibration (annual)
 +
* Lipids
 +
** Target: LDL-C &le; 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[http://www.diabetes.ca/cpg2003/chapters.aspx]
 +
** 2-hour [[postprandial]] blood glucose: 5.0 to 8.0 mmol/L
  
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]].
+
* Hb<sub>A1C</sub> '''every 3 months'''
 +
** Target: 6.0%[http://www.annals.org/cgi/content/full/147/6/417]
  
Being overweight is one of the key risk factors for Type 2 diabetes, since it increases [[insulin]] resistance.
+
* Microalbumin:Urea Ratio '''yearly'''
Therefore, at least initially, Type 2 diabetes can be easily treated with exercise and weight loss.
+
* Creatinine '''yearly'''
Sadly, this is the one treatment patients do not want, instead preferring a magic pill or silver bullet.
+
* BP History - Target 130/80
So, physicians do what they gotta do, but should always understand that the best treatment of Type 2 diabetes before the patient becomes [[insulin]]-dependent (''i.e.'', [[Type 1 diabetes]]).
+
* Exercise - Target &ge; 150 minutes moderate-intensity aerobic exercise over 3 non-consecutive days
 +
* Meds:
 +
** [[ECASA]] unless contraindicated
 +
** [[ACE inhibitor]] or [[ARB]] for renal protection unless contraindicated
  
Since Type 2 diabetics are frequently not ''completely'' resistant to [[insulin]], increasing [[insulin]] production (''i.e.'', inducing [[OMD:hyperinsulinemia|hyperinsulinemia]]) may suffice.
+
O
One of the drugs involved in this is sulfonylurea, which stimulates the [[pancreas]] to produce more [[insulin]].
+
* HR BP WT HT
This is univerally considered a bad idea, but is still widely used.
+
* Fundoscopy (not in the guidelines)
Another drug used for Type 2 diabetics is '''metformin''' (generic name), which improves the use of [[glucose]].
+
* CVS
 +
* Resp
 +
* Feet: Monofilament of great toe (Annually), Vibration of great toe (annually) pulses, ulcers
  
Exam factoids:
+
P
*One of the differences between Type 1 and Type 2 diabetes is that only type 1 gets ketotic
+
* FU q2-4 months
*Type 2 diabetes has lots of serum insulin - they are insulin resistant
+
* ?Nurse FU q1mo
*6.5% of [[hemoglobin]] should be glycosylated. When sugars are high, more [[hemoglobin]] becomes glycosylated.
 
*Sulfonyl urea increases serum insulin by encouraging the [[pancreas]]
 
  
== Objectives ==
+
==Info==
Discuss:
+
* Nonketosis-prone hyperglycemia and glucose intolerance;
*Intermediary metabolism, from a 2 DM viewpoint
+
* 80% of diabetic cases
*High blood glucose leading by mass action to increased glycosylated hemoglobin HbA<sub>1c</sub> and sorbitol
+
 
*The fact that the greatest concern in type 2 DM is not acute care, but management of the multi-organ system failure that results from molecular issues such as high blood sugar and hyperinsulinemia
+
* Incidence (USA): 300/100,000 (M 230/100k; F 340/100k)
*The fact that type 2 DM patients are much less prone to ketoacidosis
+
* Prevalence (USA):
*The fact that there are typically classic differences in the initial presentation of type 2 vs type 1 DM patients
+
** Age: >40
*The fact that type 2 patients are treated differently (from type 1) early in their course
+
** Sex: F > M (whites)
*The importance of lifestyle issues and patient education in DM management
+
 
*Some basic groups of drugs used in management of type 2 DM
+
* 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 &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==
 +
* Lifestyle management for 2-3 months to get target. Hb<sub>A1C</sub> 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
 +
* &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 ==
 +
* [http://www.diabetes.ca/cpg2003/chapters.aspx Canadian Diabetes Guidelines]
 
*[[Media:Q4Biochemistry2004DrFlanagan.pdf | Quarter 4 biochemistry notes (PDF)]]
 
*[[Media:Q4Biochemistry2004DrFlanagan.pdf | Quarter 4 biochemistry notes (PDF)]]
 
*[[Wikipedia:Diabetes]]
 
*[[Wikipedia:Diabetes]]
 +
 +
[[Category:Disease]] [[Category:Endocrinology]]

Latest revision as of 19:55, 25 November 2007

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