Studied by 13 people
What is the main regulator of blood sugar?
Insulin
What pattern do basal insulin levels follow?
low and constant overnight and between meals, allowing the body to release sugar and other fuels from the liver
In healthy individuals, what do blood sugar levels peak at after eating before falling back to baseline?
<140 mg/dL
What is considered a normal blood sugar level?
60-100
In healthy individuals, when is glucagon released?
Overnight & Between meals
What are incretin hormones?
GLP-1 & GIP
What effect do incretin hormones have on beta cells?
Increase insulin secretion
What effect do incretin hormones have on alpha cells?
Decrease glucagon secretion
What is the role of GLP-1?
slows down stomach emptying and acts on the brain to make you feel full
Diabetics have (increased/decreased) GLP-1
Decreased
What hormone is released along with insulin and has nearly the same effect as GLP-1?
Amylin
What is the overall effect of GLP-1, GIP, & amylin?
reduce sugar production by liver during meals
What are "Gluco-counter-regulatory" hormones?
Epi, Cortisol, GH, Glucagon
If under stress, cortisol levels become elevated and you can become what?
Insulin resistant
Which type of diabetes is associated with HLA?
Type 1A DM
What type of diabetes is an “Absolute insulin deficiency”?
T1DM
What causes Type 1A DM?
Cellular-mediated autoimmune destruction of the beta cells of the pancreas
What is the pathogenesis behind T1DM?
Stress-induced epi release → insulin inhibited → honeymoon period → permanent diabetes
T1DM pts are completely deficient in what?
both insulin AND amylin
What is Type 1B DM?
Idiopathic diabetes without evidence of autoimmunity or HLA association
In T2DM, insulin secretion is initially (high/low), eventually leading to insulin resistance
High
In T2DM, insulin resistance leads eventually leads to what?
relative deficiency
Do genetics play a stronger role in T1DM or T2DM?
T2DM
What are the components of metabolic syndrome associated with T2DM/Glucose intolerance?
Insulin resistance, Hyperinsulinemia, Obesity, HTN, Dyslipidemia
What may further impair insulin secretion by beta cells in pts with T2DM?
glucose toxicity & lipotoxicity
What are the 4 factors that affect blood glucose levels?
Carb intake, Hepatic glucose production, Pancreatic insulin secretion, Peripheral glucose uptake
Do all overweight individuals have insulin resistance?
Yes
What hormones are insulin antagonists in gestational DM and work to promote lipolysis and dec glucose use?
Human placental lactogen (AKA chorionic somatomammotropin) and cortisol
What enzyme is produced by the placenta in response to increased insulin requirements during pregnancy?
Insulinase
What is dipeptidyl peptidase (DDP-4)?
Major enzyme responsible for degrading incretin hormones in vivo
Glucose intolerance/T2DM can cause __________ hyperglucagonemia
Postprandial
(T1DM/T2DM) is reaching epidemic proportions
T2DM
Diabetes is the leading cause of what conditions?
End-stage renal disease & Blindness
Gestational DM has a high risk of what obstetric complication?
Shoulder dystocia
What is the most consistent predictor of progression from pre-diabetes to diabetes?
Baseline plasma glucose
Pre-diabetes puts patients at increased risk of (macrovascular/microvascular) complications even prior to developing T2DM
Macrovascular
What races have the highest risk for glucose intolerance?
Native Americans and Pacific islanders
Is impaired glucose tolerance more common in women or men?
Women
Is diabetes more prevalent in women or men?
No consistent trend
While childhood and adolescent cases are increasing, T2DM usually beings after what age?
30
What are warning sx of T1DM?
polyuria, polydipsia, polyphagia; unexplained wt loss and easy fatigue
What is a Hyperosmolar nonketotic coma characterized by?
severe dehydration secondary to osmotic diuresis from hyperglycemia
What is Prediabetes?
categories of impaired glucose tolerance and impaired fasting glucose
What is DKA?
Overt hyperglycemia that has progressed to diabetes, resulting in signs of dehydration (hypotension, hemodynamic compensation, worsening hyperglycemia)
What are clinical signs of DKA?
Kussmaul respirations & altered level of consciousness
What is the most common cutaneous finding in DM?
Diabetic dermopathy (shin spots)
What is Diabetic dermopathy (shin spots)?
Round/oval atrophic hyperpigmented macules to the pretibial areas bilaterally
What is Xanthoma eruptiva?
Pink papules with "creamy" center due to elevated TRGs, usually seen in diabetes on extensor surfaces & popliteal region
What is Necrobiosis lipodica diabeticorum?
Degenerative disease of collagen that presents as atrophic, waxy telangiectatic plaques that ulcerate or fluid filled bullae typically associated w/ peripheral neuropathy
What may be the first presentation of elevated glucose?
repeated yeast infections(Candidiasis)
What is Kyrle's disease (AKA reacting perforating collagenosis)?
Pruritic papules with keratotic plug on the extensor surfaces of legs (may also affect face/arms); typically associated with kidney disease
What study is the preferred diagnostic test for DM per the ADA?
Fasting plasma glucose
The standard oral glucose tolerance test (OGTT) involves measurement of plasma glucose ___ hours after a 75g oral glucose load
2
Diabetes HBA1C:
> 6.5%
Pre-diabetes HBA1C:
5.6-6.4%
Normal HBA1C:
< 5.6%
Normal OGTT result:
Glucose <140 mg/dL
Pre-diabetes fasting plasma glucose:
100-125 mg/dL
Pre-diabetes 2-hour OGTT result:
140-199 mg/dL
Diabetes fasting plasma glucose
> 126 mg/dL
Random plasma glucose ______ = diabetes
> 200 mg/dL
2-hour OGTT of ______ = diabetes
> 200 mg/dL
When should screening for T2DM should be considered?
at 3 year intervals in all individuals over age 45
For diagnosis of T2DM in children, the child must be >85th percentile, plus 2/4 risk factors. What are the 4 risk factors?
1. FHx of T2DM
2. High risk race/ethnicity
3. Signs of insulin resistance
4. Maternal hx of DM/gestational DM
When screening for gestational diabetes, at what intervals should you perform a 75g OGTT?
Fasting, 1 hr, 2 hr
When should patients should be screened for gestational DM?
24-28 weeks gestation
How often should women with gestational DM should be screened for persistent DM?
6-12 weeks postpartum, then every 3 years
What urinalysis findings are indicators of acute decompensation in a diabetic patient?
Ketonuria & Massive glycosuria
What urinalysis finding is a marker of early renal impairment and endothelial dysfunction?
Urine microalbumin
LFTs are necessary to assess baseline function prior to starting which antihyperglycemic medications?
Biguanides, TZDs
*continue periodic LFTs w/ TZDs
What lipid panel findings might be seen in a diabetic pt?
Elevated TRGs, Increased cholesterol, LDLs
What is a CBC finding in a patient with ketoacidosis?
Leukocytosis
What is the major goal in the management of glucose intolerance?
Glycemic control
What diet is recommended as lifestyle modification for diabetic patients?
Mediterranean
What is the minimum amount of activity recommended for lifestyle modifications for a diabetic patient?
150 mins/week of moderate exercise
How is Gestational DM treated?
insulin ± lifestyle changes
*oral agents are CI in pregnancy
Bariatric surgery is recommended for patients with a BMI >______
35
At what levels of fasting glucose, OGTT, and HbA1C should pharmacologic therapy be considered?
Fasting glucose >126
OGTT >160
HbA1C > 7%
What is the first drug of choice for oral T2DM treatment?
Metformin
What is the primary effect of metformin?
Decrease hepatic gluconeogenesis
What is the CI for metformin?
Renal impairment
Which sulfonylurea has the longest half life?
Glyburide (Diabeta, Glynase)
What sulfonylurea has the lowest risk for hypoglycemia and weight gain?
Glipizide (Glucotrol)
What drug classes are secretagogues (stimulate insulin release from pancreas)?
Sulfonylureas & Meglitinides
What drug class slows digestion & absorption of carbs in the GI tract?
Alpha-glucosidase inhibitors (Acarbose, Miglitol)
What drug class causes lots of bowel gas?
Alpha-glucosidase inhibitors (Acarbose, Miglitol)
Which TZD is linked to slightly increased risk for bladder cancer?
Pioglitazone (Actos)
What is the MOA of TZDs?
Reduce insulin resistance in fat and muscle
What drug class is injected SC and promotes moderate weight loss?
GLP-1 agonists
What drug class inactivates the major enzyme responsible for degrading incretin hormones, prolonging the action of incretins?
DDP-4 inhibitors
-glutide
GLP-1 agonists
-gliptin
DDP-4 inhibitors
What drug class increases urinary glucose excretion by lowering the renal glucose threshold?
SGLT-2 inhibitors
-gliflozin
SGLT-2 inhibitors
What drug class mimics an endogenous hormone by delaying gastric emptying, decreasing postprandial glucagon release, and modulating apetite?
Amylin analogue (Pramlintide aka SymlinPen)
What macrovascular complications may arise from prediabetes/diabetes?
CAD, PVD, stroke
What microvascular complications may arise from diabetes?
Retinopathy, Neuropathy, Nephropathy, Acute metabolic conditions
