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Foundations III- Endocrine > Type 2 Diabetes Mellitus > Flashcards

Type 2 Diabetes Mellitus Flashcards

(101 cards)

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1
Q

How many diabetes cases are type 2?

A

> 90%

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2
Q

Characteristics of DM type 2?

A

Characterized by hyperglycemia and varying degrees of insulin deficiency and resistance

Micro- and macrovascular complications

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3
Q

What is impaired glucose tolerance?

A

during an OGTT, blood glucose values are between normal and overt diabetes (140-199 mg/dL)

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4
Q

What glucose level is considered impaired fasting glucose?

A

fasting BS 100-125

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5
Q

What is pre diabetes?

A

increased risk for DM

IGT or IFG or A1c of 5.7-6-4%

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6
Q

% of ppl who have DM but are not diagnosed?

A

25-40%

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7
Q

Risk factors for DM?

A

Genetic

Anthropometric factors (BMI, waist circumference)

Environmental/lifestyle factors

  • physical inactivity
  • smoking
  • diet
  • meds
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8
Q

What drugs can impair glucose tolerance?

A

LOTS

Fluroquinolones

Thiazide diuretics *

glucocorticoids

oral contraceptives

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9
Q

What comorbidities put pts at increased risk for development of DM?

A

Prediabetes

Gestational diabetes

CV disease (HF, MI, HTN)

Dyslipidemia

Hyperuricemia

PCOS

Metabolic syndrome

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10
Q

Metabolic syndrome is also known as…

A

Insulin resistance syndrome or syndrome X

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11
Q

Definition of metabolic syndrome?

A

Abdominal obesity
Measured by waist circumference
(≥ 102 cm (40 inches) in men
≥ 88 cm (35 inches) in women)

Triglycerides ≥ 150

Low HDL
(< 40 mg/dL in men
< 50 mg/dL in women)

Blood pressure ≥ 130/85 mmHg

FPG ≥ 100 mg/dL

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12
Q

Metabolic syndrome increases with…

A

age

also higher prevalence with overweight/obese

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13
Q

How common is metabolic syndrome?

A

22% in US

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14
Q

Management goals for metabolic syndrome?

A

Treat underlying causes

Treat CVD risk factors

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15
Q

What should be included in tx of metabolic syndrome?

A

aggressive lifestyle modification

weight reduction

increases physical activity

reduction of other risk factors

pharm options

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16
Q

Weight loss goal for pts with metabolic syndrome?

A

Goal of 7-10% reduction in body weight within 1 year

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17
Q

How much physical activity should you recommend for a patient with metabolic syndrome?

A

150 min/wk

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18
Q

Where do we get blood glucose from?

A

diet

gluconeogenesis

glucogeneolysis of liver glycogen

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19
Q

How is glucose regulated?

A

Glucose homeostasis requires hepatic glucose production to be balanced with peripheral glucose uptake and utilization

Insulin produced by beta cells –> causes glucose transport into adipose tissue and muscle

Glucagon produced by alpha cells –> stimulates glycogenolysis and gluconeogenesis

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20
Q

What regulates insulin secretion?

A

glucose

also influenced by amino acids, ketones, various nutrients, GI peptides, & neurotransmitters

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21
Q

Insulin/glucagon levels during fasting state?

during postprandial state?

A

low insulin, high glucagon

high insulin, low glucagon

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22
Q

How does the body compensate when there is insulin resistance? What does this eventually lead to?

A

beta cells compensate by increasing insulin

–> impaired glucose tolerance (beta cells can’t keep up)

–> overt diabetes (fasting hyperglycemia, beta cell failure)

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23
Q

Describe insulin resistance

A

decreased ability of insulin to act effectively on target tissues

impairs glucose utilization by insulin sensitive tissues

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24
Q

Describe impaired insulin secretion

A

in response to insulin resistance insulin secretion is initially increased >

beta cell failure >

chronic hyperglycemia impairs islet func., >

reduced insulin secretion

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25
Why is there excessive hepatic glucose production in DM?
insulin resistance in the liver results in failure of hyperinsulinemia to suppress gluconeogenesis
26
Why is there abn. fat metabolism in DM?
Insulin resistance in adipose tissue > increased liplysis and free fatty acid flux from adipocytes causing increased VLDL & TG synthesis in liver lipid storage in liver > NAFLD and dyslipidemia
27
Clinical presentation of DM?
Usually asymptomatic Hyperglycemia on routine labs Symptoms of hyperglycemia: - Polyuria - Polydipsia - Nocturia - Blurred vision - Weight loss
28
ADA screening recommendation for DM?
All adults with BMI ≥ 25 + additional risk factor(s) q 3 years Start at age 45 if no risk factors Screen patients with prediabetes annually Women with GDM should be screened q 3 years
29
USPSTF screening recommendations for DM?
Adults aged 40-70 y/o who are overweight or obese should be screened as a part of CV risk assessment q 3 years
30
Diagnostic criteria for DM?
sxs + random blood glucose > 200 If asxs - FPG >126 - 2 hour glucose >200 during OGTT - A1C >6.5 repeat on different day
31
Normal 2 hour glucose during OGTT? normal FPG?
<140mg/dL <100
32
IFG? IGT?
100-125 mg/dl 2 hr glucose during OGTT between 140-199
33
Glucated hemoglobin (A1c) correlates with? what can effect this?
mean glucose concentration and DM complication RBC turnover -low cell turnover: false high -high cell turnover: false low Hemoglobinopathy, CKD
34
What should you eval for in a DM pt?
Assess nutrition, weight, physical activity Assess CV risk Evaluate for diabetes related comps Inquire about hypoglycemic episodes
35
What labs should you check regularly in a DM pt?
A1c Fasting lipids Liver enyzmes Urine albumin excretion Serum creatinine
36
What should be included in annual DM visit?
vitals orthostatic BP fundoscopic exam thyroid palpation skin exam comprehensive foot exam
37
What labs should you check annually in pt with DM?
A1c lipid panel LFTs urine albumin-Cr ratio TSH (type 1 DM) +/- Vit B12 Serum K in pt on ACE/ARB or diuretics
38
What is included in management of DM?
glycemic control: pharm/nonpharm monitoring/prevent comps Pt education health maintenance
39
What kind of pt education should you give to DM pt?
nutrition hypoglucemia CV risk vision kidneys
40
Target A1c for DM?
individualized based on pt most: <7.0% more stringent less stringent: hx severe hypoglycemia, limit life expectancy, older pts, comorbid conditions
41
How freq. should you monitor A1c?
at least 2x/yr in controlled, quarterly in pts with changes in therapy or not meeting goals
42
What else should be included in management for DM type 2?
self monitor blood glucose, more often when titrating medications assoc. with hypoglycemia several times per wk more freq. with illness/change in diet/exercise
43
Nonpharm therapy for DM type 2?
diet exercise weight reduction psychological interventions diabetes education
44
goals of pharm therapy for DM type 2?
Increase insulin availability Improve sensitivity to insulin Delay delivery and absorption of carbohydrates from the GI tract Increase urinary glucose excretion
45
A1c of .....at rx you should start Rx. A1c of ....at dx, you can start with 3-6 months of lifestyle modifications
>7.5-8% <7.5
46
Initial pharm therapy for DM type 2?
Metformin for most pts | Insulin is an alternative
47
What are the classes of drugs that can be used for tx of DM type 2?
Metformin Sulfonylureas GLP-1 receptor agonist Dipeptidyl peptidase-4 inhibitors (DPP-4) Sodium-glucose co-transporter 2 (SGLT2) inhibitor Thiazolidinediones (TZD) Meglitinides Alpha-glucosidase inhibitor Insulin
48
Drug class for Metformin? MOA?
Biguanide Decrease hepatic glucose output by inhibiting gluconeogenesis Increases insulin-mediated glucose utilization in peripheral tissues (muscle, liver)
49
1st line drug tx for DM?
METFORMIN 1-2% drop in A1c weight neutral
50
ADE of Metformin?
GI sxs can reduce intestinal absorption of vit B12
51
Contraindications for Metformin?
renal insufficiency IV contrast concerns
52
MOA of sulfonylureas? effect?
Stimulate insulin secretion from pancreatic beta cells 1-2% decrease in A1c
53
ADEs of sulfonylureas?
risk of hypoglycemia weight gain
54
Examples of Sulfonylureas?
Glipizide (Glucotrol) Glyburide (Diabeta, Glynase) Glimepiride (Amaryl)
55
MOA of GLP- 1 agonists?
GLP-1 stimulates glucose dependent insulin release from pancreatic islet cells GLP-1 slows gastric emptying GLP-1 inhibits post-meal glucagon release
56
Incretin effect of GLP-1 agonists?
oral glucose better stimulates insulin secretion than IV glucose secondary To GI peptides (GLP-1) released in response to a meal stimulating insulin synthesis and secretion
57
How is GLP-1 agonist typically prescribed?
as an add on therapy (to Metformin) 0.5-1% drop in A1c weight loss
58
ADEs of GlP-1 agonists?
Possible improved cardiovascular outcomes with liraglutide and semaglutide GI side effects: N/V/D (10-50%)
59
Examples of GLP-1 agonists?
Exenatide (Bydureon, Byetta) Liraglutide (Victoza) Dulaglutide (Trulicity) etc.
60
MOA of DPP-4 inhibitors ?
GLP-1 secreted in response to nutrients > GLP-1 stimulates glucose dependent insulin release from pancreatic islet cells GLP-1 slows gastric emptying GLP-1 inhibits post-meal glucagon release DPP-4 is an enzyme that deactivates GLP-1
61
How is DPP-4 inhibitors usually prescribed? effect on weight?
usually add on therapy 0.5-.8 drop in A1c weight neutral
62
Examples of DPP-4 inhibitors?
Sitagliptan (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Alogliptin (Nesina)
63
MOA of SGLT2 inhibitor? effect on A1c?
SGLT2 inhibitors increase urinary glucose excretion leading to reduced blood glucose 0.5-0.7% decrease in A1c usually add on therapy, Weight loss, reduced BP, possible reduced CV mortality
64
ADEs of SGLT2 inhibitors?
vulvovaginal candidiasis, UTIs
65
Examples of SGLT2 inhibitors?
Empagliflozin (Jardiance) Canagliflozin (Invokana) Dapagliflozin (Farxiga)
66
MOA of TZDs?
Improve insulin action Increase insulin sensitivity by acting on adipose, muscle, and liver to increase glucose utilization and decrease glucose production
67
effect of TZDs?
usually used as add on therapy 0.5-1.4% drop in A1c
68
ADEs of TZDs?
Fluid retention, HF, weight gain, bone fractures, possible increase in MI (rosiglitazone), possible increase in bladder cancer (pioglitazone)
69
Contraindications for TZDs?
symptomatic or class III-IV HF, bladder cancer, high fracture risk, liver disease
70
Examples of TZDs?
Pioglitazone (Actos)*preferred Rosiglitazone (Avandia)
71
MOA of Meglitinides? effect?
Stimulate insulin secretion from pancreatic beta cells Add on therapy 0.5-1% decrease in A1c
72
Admin of Meglitinides?
take with meals to reduce postprandial hyperglycemia
73
ADEs of Meglitinides?
hypoglycemia weight gain
74
Examples of Meglitinides?
Nateglinide (Starlix) | Repaglinide (Prandin)
75
MOA of alpha glucosidase Inhibitors?
decrease absorption of glucose 0.5-.8 % decrease weight neutral give with food
76
ADEs of Alpha glucosidase inhibitors?
flatulence and diarrhea
77
Examples of alpha glucosidase inhibitors?
Acarbose (Precose) | Miglitol (Glyset)
78
Options for insulin therapy?
Basal therapy: NPH, Glargine, Detemir, Degludec Intensive insulin therapy
79
ADEs of insulin?
weight gain hypoglycemia
80
Examples of Prandial insulin?
Short-acting: Regular (Humilin R, Novolin R) Rapid-acting: lispro (Admelog, Humalog), aspart (Fiasp, Novolog), glulisine (Apidra)
81
When should you considered dual therapy for T2DM? When should you considered combo injectable therapy?
if A1c grater than or equal to 9%? A1c greater than or equal to 10%, blood glucose >300 or pt very sxs
82
What are some microvascular diseases that may be complications of T2DM? what about macrovascular diseases?
Retinopathy Nephropathy Neuropathy Atherosclerosis (MI, CVA) -these may be present at dx
83
MCC of blindness in adults 20-74 yo?
diabetic retinopathy Chronic hyperglycemia causes vascular changes leading to retinal injury and ischemia
84
Why is there vision loss in diabetic retinopathy?
Macular edema Hemorrhage from new vessels Retinal detachment Neovascular glaucoma
85
Presentation of diabetic retinopathy?
asxs until late stages
86
Screening for diabetic retinopathy?
dilated and comprehensive eye exam by ophtho or optometrist at time of dx in type 2, within 5 yrs of type 1 repeat annually
87
Treatment for diabetic retinopathy?
laser therapy- photocoagulation Intravitreous injections of anti-vascular endothelial growth factor (ranibizumab) Vitrectomy
88
How can we prevent diabetic retinopathy?
glycemic control control BP
89
How can we screen for diabetic kidney disease?
assess urinary albumin Assess eGFR time of diagnosis in T2DM Within 5 years of diagnosis in T1DM In all patients with comorbid HTN Repeat annually
90
Dx for diabetic kidney disease?
mod increased albuminuria (mircoalbuminuria) - 30-300/day - > 300 = severe requires 2 of 3 specimens abn. over 3-6 months
91
Tx for diabetic kidney disease?
ACE/ARB Protein Intake - Non dialysis: 0.8 - dialysis: higher levels refere for renal replacement tx
92
How can we prevent diabetic kidney disease?
optimize glucose control optimize BP control
93
Presentation of diabetic neuropathy?
up to 50% asxs foot ulcers and amputation common dx of exclusion
94
other risk factors for ulcers/amputations?
smoking foot deformities pre-ulcerative callus/corn PAD visual impairment DKD
95
Screening for diabetic neuropathy?
Assess with hx + temp/pinprick sensation/vibration sensation annual monofilament testing At time of dx of T2DM, within 5 yrs for T1DM repeat annually
96
How can we prevent diabetic neuropathy?
optimize glucose control
97
Tx for diabetic neuropathy?
1st line: Pregabalin or Duloxetine foot self care education specialized footwear for high risk pts
98
Foot care for diabetic neuropathy?
comprehensive foot eval annually Consider ABI and/or vascular referral for symptoms of claudication or decreased or absent pedal pulses Consider podiatry for smokers or hx of prior LE complications, loss of protective sensation, structural abnormalities, or PAD
99
If a pt with DM and HTN has albuminuria, which kind of antihypertensive should they be placed on?
ACE or ARB
100
Anti platelet recommendations for T2DM pts?
ASA as secondary prevention Clopidogrel if ASA allergy
101
Routine health maintenance in pts with T2DM?
flu vaccine annually Pneumococcal vaccination HBV to unvaccinated adults age 19-59 Update tetanus and diphtheria Reproductive counseling Indicated screenings

Foundations III- Endocrine (5 decks)

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