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Endocrinology > Metabolic syndrome and Type 2 DM > Flashcards

Metabolic syndrome and Type 2 DM Flashcards

1
Q

Why is ID of metabolic syndrome so important?

A
  • because ID risk of developing diabetes

- Id pts at high risk of developing CVD

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2
Q

When does prevalence of metabolic syndrome increase?

A
  • with age and obesity

- 44% of those in 60-69 age range

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3
Q

What ethnicity has highest % of metabolic syndrome?

A
  • mexican Americans (both men and women)
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4
Q

What 3 out of 5 elements are needed for dx of metabolic syndrome?

A
  • visceral obesity
  • HTN
  • insulin resistance
  • elevated TGs
  • low HDL
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5
Q

How do these elements of metabolic syndrome increase CVD?

A
  • abdominal obesity: impaired glucose and fatty acid utilization (hyperglycemia and dyslipidemia are also related to abdominal obesity)
  • hyperglycemia: insulin resistance = increased blood sugar
  • dyslipidemia: elevated TGs and low HDL
  • HTN: endothelial dysfunction -> lead to increase likelihood of thrombotic events
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6
Q

NCEP/ATP III criteria for dx of metabolic syndrome? (3 out of 5)

A

abdominal obesity: for men - waist of 40 inches or greater
women - waist of 35 or greater

  • TGs: more than 150 mg/dL
  • HDL cholesterol: less than 40 in men and less than 50 in women
  • BP: greater than 130/85
  • fasting plasma glucose greater or equal to 100 mg/dL
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7
Q

IDF criteria for dx of metabolic syndrome?

A 
- increased waist circumference (ethnic specific) plus 2 of the following:
TGs greater than 150
HDL less than 40 men, less than 50 women
BP greater than 130/85
fasting glucose: greater than 100
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8
Q

Fasting plasma glucose levels?

A
  • greater or = to 126: diabetes
  • less than 125 and greater or equal to 100 - prediabetes
  • normal: less than 100
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9
Q

Oral glucose tolerance levels?

A
  • greater or equal to 200: diabetes
  • greater or equal to 140 and less than 199: prediabetes
  • normal: less than 140
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10
Q

A1C criteria for DM and pre-DM?

A
  • diabetes - equal or greater than 6.%
  • prediabetes - 5.7-6.4%
  • normal: less than 5.7%
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11
Q

How does obesity cause metabolic chaos?

A
  • reduction in mito ATP generation from glycolysis
  • TG acccum
  • Free FA accumulation
  • proinflammatory: increased CRP, IL-6
  • prothrombic: increased plasminogen activator inhibitor
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12
Q

Prevalence of metabolic sydrome increases with increasing BMI, stats?

A
  • 5% of pts with normal wt
  • 22% of overweight pts
  • 60% of obese pts
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13
Q

What are other obesity related disorders that are associated with metabolic syndrome?

A
  • fatty liver disease
  • hepatocellular and intrahepatic cholangiocarcinoma
  • CKD
  • polycystic ovarian syndrome
  • sleep apnea
  • hyperuricemia and gout
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14
Q

What are other risk factors to metabolic syndrome?

A
  • postmenopausal status
  • smoking
  • low household income ( low education, can’t afford healthy food)
  • high carb diet
  • no alcohol consumption
  • physical activity
  • soft drink consumption
  • family history
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15
Q

How impt is family hx risk factor for metabolic syndrome?

A
  • up to 50% of people with metabolic syndrome have positive family hx
  • 39% of people with type 2 DM have at least 1 parent with the disease
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16
Q

Tx of metabolic syndrome foucses on what?

A
  • on RF reduction and wt loss
  • lifestyle modification: focused on wt loss and increased physical activity
  • Tx cardiovascular risk factors
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17
Q

What improves insulin sensitivity?

A
  • weight reduction
  • doesn’t matter what kind of diet as long as it is tailored towards weight loss
  • mediterranean diet
  • DASH diet
  • low glycemic index foods
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18
Q

How much exercise is needed daily?

A
  • 30 minutes at minimum moderate intensity (break a sweat, hard to hold a conversation)
  • or a goal of 10,000 steps a day
  • reduction in abdominal obesity (liposuction isn’t beneficial) -process of weight loss: exercise is what improves metabolism of glucose
  • exercise: improves insulin sensitivity (for up to 48 hrs after exercise)
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19
Q

How can you reduce CVD risk factors?

A
  • lipid management: improve HDL - lifestyle: eat healthy, exercise, take Niacin, Tricor, statins
    improve TG levels: take fibric acids - tricor
  • tx hypertension
  • tobacco cessation
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20
Q

How does IGT prevent disease progression?

A
  • intensive lifestyle interventions
  • goal is to delay/prevent development of diabetes
  • tx may reduce long term CVD events
  • delay the onset of diabetes
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21
Q

Tx of impaired glucose metabolism (IGT/IFG)?

A
  • dietary counseling
  • exercise
  • wt loss: goal to start is 10% of baseline
  • role for metformin is that it improves insulin sensitivity (can be used in pre diabetic state)
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22
Q

Tx of impaired glucose metabolism? Goals?

A
  • wt loss of 5-10%

- moderate physical activity of 30 minutes per day

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23
Q

Who qualifies for metformin that has IFG/IFT?

A
  • less than 60
  • BMI of 35 or more
  • family hx of DM in first degree relative
  • elevated TGs
  • reduced HDL cholesterol
  • HTN
  • A1C >6%

Metformin + lifestyle changes

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24
Q

What is more effective: drug therapy or lifestyle modification for DM prevention?

A

Studies show that lifestyle modification more effective at reduction of BG then metformin alone
- Drug therapy seems to be more beneficial in younger pts

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25
Q

what needs to be done if pt going to receive metformin for pre-diabetes?

A
  • need to complete OGTT

- need to doculemtn both IFG and IGT if metformin used prior to dx of DM

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26
Q

What are the 2 pathogenic defects that characterize type 2 diabetes?

A
  • imparied insulin secretion

- insulin resistance

27
Q

What organs are involved in type 2 diabetes?

A
  • pancreas (alpha and beta cells)
  • liver (gluconeogenesis, liver can manufacture glucose, gets feedback from peripheral tissues to shut production off)
  • peripheral tissues: adipose tissue, muscle uptake of glucose
28
Q

Natural hx of type 2 DM in years preceding dx?

A
  • endocrine system compensates by increasing insulin secretion
  • over time the beta cells of pancreas wear out because of resistance
  • liver then loses the inhibitory effect of insulin and increases production of glucose
    = dx of diabetes
29
Q

What fasting glucose level indicates almost complete loss of beta cell function?

A
  • levels above 180-200
30
Q

Sxs of type II diabetes?

A
  • blurry vision
  • increased thirst or need to urinate
  • feeling tired or ill
  • recurring skin, gum or bladder infections
  • dry, itchy skin
  • unexpected wt loss
  • slow healing cuts or bruises
  • loss of feeling or tingling in the feet
31
Q

RFs of type 2 DM?

A
  • impaired glucose tolerance
  • impaired fasting glucose
  • age over 45
  • family hx
  • overweight
  • obese
  • lack of exercise
  • HTN
  • low HDL, high TG
  • gestation DM ( 50% lifetime risk of developing DM 2 after pregnancy)
  • baby thats 9 or more pounds at birth
32
Q

beta blockers effect on blood sugar?

A

(propanolol, metoprolol)

- Mech: decreased insulin sensitivity

33
Q

hypolipidemic effect on blood sugar?

A
  • niacin (at higher doses)

- altered hepatic metabolism of glucose

34
Q

Thiazide diuretic effect on blood sugar?

A
  • HCTZ, chlorthalidone

- mech: decreased K, decreased insulin secretion, increased insulin resistance

35
Q

Glucocorticoid effect on blood sugar?

A
  • increased glucose production and increased glucose resistance
36
Q

Oral contraceptive effect on blood sugar?

A
  • altered hepatic glucose metabolism

- increased insulin resistance

37
Q

Criteria for dx of DM II?

A
  • A1C has to be equal or greater than 6.5%
  • fasting plasma glucose is equal or greater than 126 mg/dL
  • 2 hr plasma glucose has to be equal or greater than 200 during OGTT
  • classic sxs of hyperglycemia or hyperglycemic crisis and random plasma glucose of 200 or greater (polydypsia, polyuria)
38
Q

Tx goals for adults?

A
  • A1C less than 7%
  • intensive tx in some pts to an A1C goal of 6.5 or less
  • if hx of severe hypoglycemia consider A1C of less than 8%
    (in some pts like the elderly you don’t want A1C to get too low because they are more likely to have hypoglycemic episodes and have worse outcomes
39
Q

Tx of DMII?

A

multifaceted
- target tx of elevated glucose:
meds, medicatl nutritional therapy, exercise, wt loss
- management of CV RFs: exercise, management of BP and lipids, wt loss

40
Q

What disease complications should you monitor for in pts with DM II?

A
  • peridontal disease: refer to dentist
  • retinopathy: dilated fundoscopic exam yearly with specialist
  • nephropathy: urine albumin to creatinine ratio yearly (ACEI or ARB)
  • neuropathy: foot exam, monofilament testing, vibration and propioception testing
  • vascular disease: foot exam for ulcers, pulse exa for feet, groin, and B/L brachial BP
41
Q

Pharmacotherapy for type 2 DM Drug classes?

A
  • biguanides: first line therapy, metformin
  • sulfonylureas
  • meglitinides
  • TZDs
  • alpha-glucosidase inhibitors
  • DPP-4 inhibitors
  • SGLT2 inhibitors
  • GLP-1 receptor agonists
  • Amylin memetics
  • insulin
42
Q

First line drug therapy for T2DM?

A
  • metformin (biguanide drug class)
43
Q

If pt has severe sxs or markedly elevated A1C what tx should you consider starting?

A
  • insulin
    (have blood glucose of 180-200)
    – if not to goal with max noninsulin montherapy in 3-6 months then add another agent
44
Q

what should you inform pts of when they are dx of diabetes? what med will they end up on?

A
  • all pts will eventually end up on insulin

- natural progression of disease leads to eventual lack of beta cell function

45
Q

How often should you follow up with DMII pt?

A
  • F/U with A1C every 3 months
  • if at goal and therapy isn’t changing may move checks to every 6 months
  • monitor for complications of DM and tx comorbidities
46
Q

What kind of medical therapy for DM and prediabetes should be done with pt?

A
  • meet with registered dietician
  • wt loss if overweight or obese
  • low carb, low fat, calorie restricted or mediterranean diet
  • physical activity
47
Q

What kind of diet should you follow being pre diabetic or diabetic?

A
  • limit sugar sweetened drinks
  • limit alcohol intake
  • fiber 14g/1000 kcal
  • no trans fats
48
Q

What are the physical activity recommendations for diabetics?

A
  • 150 min/week moderate intensity exercise
  • 50-70% of max heart rate
  • spread over 3 days/week
  • resistance training 2x per week
  • exercise Rx - agreed upon exercise regimen
49
Q

Psychosocial assessment of diabetic pt?

A
  • screen and tx depression, anxiety, and eating disorders
50
Q

What is key to successful diabetes tx?

A
  • ongoing pt education
  • self blood glucose monitoring (if on insulin)
  • tx and recognize hypoglycemia
  • continual dietary and physical activity support and reinforcement
51
Q

What are the sxs of hypoglycemia?

A
  • confusion, diaphoresis, tachycardia, palpitations, weakness
  • need to give 15-20 g of glucose or any form of carb
  • recheck BG in 15 min and repeat tx if necessary
  • meal post episode
52
Q

Who is recommended for bariatric surgery?

A
  • BMI of 35 or more
  • especially for difficult to control DM with assoc comorbidities
  • does make a difference in blood sugar afterwards, and can reverse diabetes for period after surgery
  • pt has to be motivated
53
Q

Immunization that diabetics need?

A
  • influenza: all persons older then 6 months
  • pneumococcal: older than 2 years, revaccination one time if vaccine giver before 64 and it has been more than 5 years
  • PCV13 and PSSV23
  • Hep B
54
Q

Complications of DM?

A
  • HTN
  • Dyslipidemia
  • CVD
  • nephropathy
  • retinopathy
  • neuropathy
  • foot ulcers or charcot foot
55
Q

Tx of HTN?

A
  • goal SBP is less than 140
  • goal DBP: less than 90
  • ACEI or angiotensin receptor blocker is first line therapy if no CIs
56
Q

Lipid control and tx?

A
  • evaluate fasting lipids at least once yearly
  • want LDLs less than 100
  • LDL if CVD less than 70
  • TGs less than 150
  • HDLs greater than 40 in men, 50 in women
  • LDL is the main target for tx
  • combo therapy: studies shown that it doesn’t reduce CVD risk, and may icnrease risk for myopathy
57
Q

Whe are statins indicated in DM pts?

A
  • pts with CVD
  • w/o CVD and older than 40 and one of the following:
    family hx of CVD
    HTN
    smoking dyslipidemia
    albuminuria
58
Q

Who should be taking aspirin?

A
  • 75-162 mg/ day
  • men older than 50 and women older than 60 if:
    family hx of CVD
    HTN
    smoking
    dyslipidemia
    albuminuria (indicates renal failure)
59
Q

Coronary disease screening and therapy?

A
  • not recommended to screen asx pts
  • ACEI and statin therapy
  • B blocker for at least 2 years post MI
  • avoid thiazolidineodine tx with heart failure
  • metformin ok if CHF with normal renal function: not for unstable CHF or renal compromised pts
60
Q

Nephropathy prevention?

A

prevention: BP and blood glucose control
- yearly albumin excretion (need baseline at dx)
- at least yearly creatinine and BUN levels

61
Q

Tx of albuminuria?

A
  • more than 30 mg/day urinary albumin excretion - take ACEI or ARB
62
Q

Retinopathy prevention?

A
    • BP and blood sugar control for prevention

- at dx need dilated fundoscopic exam and need this done yearly - want to have ophtho look at them yearly

63
Q

Neuropathy screening?

A
  • screening for distal polyneuropathy at dx and yearly
  • monofilament test
  • autonomic neuropathy:
    gastroparesis (delayed gastric empytying)
    erectile dysfunction
    cardiovascular autonomic dysfuntion (ortho hypotension)
64
Q

Foot care for diabetics?

A
  • inspection
  • pulses: screen for sxs of PVD, consider ABIs
  • sensation: monofilament test and 1 of the following:
    vibration, pin prick, ankle reflexes

Endocrinology (22 decks)

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