Difference between revisions of "Type 2 diabetes"

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(major rewrite to facilitate residency)
(update guidelines)
 
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S
 
S
 +
* Voiced concerns
 +
* Psych screen
 
* Smoking
 
* Smoking
 
* Ophthalmology '''yearly'''.
 
* Ophthalmology '''yearly'''.
* Feet '''every visit'''
+
* Feet '''every visit'''. Note last microfilament or vibration (annual)
 
* Lipids  
 
* Lipids  
** Target: Triglyceride <2; LDL-C <  
+
** Target: LDL-C &le; 2; TC/HDL-C < 4; no target for TG, but <1.5 considered optimal
 
* Glucose
 
* Glucose
* HbA1C '''every 3 months'''
+
** [[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
 +
 
 +
* Hb<sub>A1C</sub> '''every 3 months'''
 +
** Target: 6.0%[http://www.annals.org/cgi/content/full/147/6/417]
 +
 
 
* Microalbumin:Urea Ratio '''yearly'''
 
* Microalbumin:Urea Ratio '''yearly'''
 +
* Creatinine '''yearly'''
 
* BP History - Target 130/80
 
* BP History - Target 130/80
 +
* Exercise - Target &ge; 150 minutes moderate-intensity aerobic exercise over 3 non-consecutive days
 
* Meds:
 
* Meds:
 
** [[ECASA]] unless contraindicated
 
** [[ECASA]] unless contraindicated
** [[ACE]] or [[ARB]] for renal protection unless contraindicated
+
** [[ACE inhibitor]] or [[ARB]] for renal protection unless contraindicated
  
 
O
 
O
 
* HR BP WT HT
 
* HR BP WT HT
* Fundoscopy
+
* Fundoscopy (not in the guidelines)
 
* CVS
 
* CVS
 
* Resp
 
* Resp
* Feet: Monofilament, pulses, ulcers
+
* Feet: Monofilament of great toe (Annually), Vibration of great toe (annually) pulses, ulcers
  
 
P
 
P
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** Family history
 
** Family history
 
** Gestational diabetes
 
** 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==
 
==Signs and Symptoms==
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==Drugs==
 
==Drugs==
 +
* Lifestyle management for 2-3 months to get target. Hb<sub>A1C</sub> target within 6-12 months.
 
* General rule:
 
* General rule:
 
** Initial treatment: Sulfonylureas
 
** Initial treatment: Sulfonylureas
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== 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]]
 
[[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