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Flashcards in Metabolic syndrome and Type 2 DM Deck (64):
1

Why is ID of metabolic syndrome so important?

- because ID risk of developing diabetes
- Id pts at high risk of developing CVD

2

When does prevalence of metabolic syndrome increase?

- with age and obesity
- 44% of those in 60-69 age range

3

What ethnicity has highest % of metabolic syndrome?

- mexican Americans (both men and women)

4

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

- visceral obesity
- HTN
- insulin resistance
- elevated TGs
- low HDL

5

How do these elements of metabolic syndrome increase CVD?

- 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

6

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

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

7

IDF criteria for dx of metabolic syndrome?

- 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

8

Fasting plasma glucose levels?

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

9

Oral glucose tolerance levels?

- greater or equal to 200: diabetes
- greater or equal to 140 and less than 199: prediabetes
- normal: less than 140

10

A1C criteria for DM and pre-DM?

- diabetes - equal or greater than 6.%
- prediabetes - 5.7-6.4%
- normal: less than 5.7%

11

How does obesity cause metabolic chaos?

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

12

Prevalence of metabolic sydrome increases with increasing BMI, stats?

- 5% of pts with normal wt
- 22% of overweight pts
- 60% of obese pts

13

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

- fatty liver disease
- hepatocellular and intrahepatic cholangiocarcinoma
- CKD
- polycystic ovarian syndrome
- sleep apnea
- hyperuricemia and gout

14

What are other risk factors to metabolic syndrome?

- 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

15

How impt is family hx risk factor for metabolic syndrome?

- 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

16

Tx of metabolic syndrome foucses on what?

- on RF reduction and wt loss
- lifestyle modification: focused on wt loss and increased physical activity
- Tx cardiovascular risk factors

17

What improves insulin sensitivity?

- 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

18

How much exercise is needed daily?

- 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)

19

How can you reduce CVD risk factors?

- lipid management: improve HDL - lifestyle: eat healthy, exercise, take Niacin, Tricor, statins
improve TG levels: take fibric acids - tricor

- tx hypertension
- tobacco cessation

20

How does IGT prevent disease progression?

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

21

Tx of impaired glucose metabolism (IGT/IFG)?

- 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)

22

Tx of impaired glucose metabolism? Goals?

- wt loss of 5-10%
- moderate physical activity of 30 minutes per day

23

Who qualifies for metformin that has IFG/IFT?

- 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

24

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

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

25

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

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

26

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

- imparied insulin secretion
- insulin resistance

27

What organs are involved in type 2 diabetes?

- 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

Natural hx of type 2 DM in years preceding dx?

- 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

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

- levels above 180-200

30

Sxs of type II diabetes?

- 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

RFs of type 2 DM?

- 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

beta blockers effect on blood sugar?

(propanolol, metoprolol)
- Mech: decreased insulin sensitivity

33

hypolipidemic effect on blood sugar?

- niacin (at higher doses)
- altered hepatic metabolism of glucose

34

Thiazide diuretic effect on blood sugar?

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

35

Glucocorticoid effect on blood sugar?

- increased glucose production and increased glucose resistance

36

Oral contraceptive effect on blood sugar?

- altered hepatic glucose metabolism
- increased insulin resistance

37

Criteria for dx of DM II?

- 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

Tx goals for adults?

- 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

Tx of DMII?

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

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

- 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

Pharmacotherapy for type 2 DM Drug classes?

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

42

First line drug therapy for T2DM?

- metformin (biguanide drug class)

43

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

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

44

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

- all pts will eventually end up on insulin
- natural progression of disease leads to eventual lack of beta cell function

45

How often should you follow up with DMII pt?

- 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

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

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

47

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

- limit sugar sweetened drinks
- limit alcohol intake
- fiber 14g/1000 kcal
- no trans fats

48

What are the physical activity recommendations for diabetics?

- 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

Psychosocial assessment of diabetic pt?

- screen and tx depression, anxiety, and eating disorders

50

What is key to successful diabetes tx?

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

51

What are the sxs of hypoglycemia?

- 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

Who is recommended for bariatric surgery?

- 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

Immunization that diabetics need?

- 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

Complications of DM?

- HTN
- Dyslipidemia
- CVD
- nephropathy
- retinopathy
- neuropathy
- foot ulcers or charcot foot

55

Tx of HTN?

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

56

Lipid control and tx?

- 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

Whe are statins indicated in DM pts?

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

58

Who should be taking aspirin?

- 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

Coronary disease screening and therapy?

- 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

Nephropathy prevention?

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

61

Tx of albuminuria?

- more than 30 mg/day urinary albumin excretion - take ACEI or ARB

62

Retinopathy prevention?

-- 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

Neuropathy screening?

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

64

Foot care for diabetics?

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