T2DM + Other Chronics

What is Type 2 Diabetes Mellitus (T2DM)?

A chronic metabolic disorder characterized by insulin resistance and progressive beta-cell dysfunction resulting in hyperglycemia.

What is the underlying pathophysiology of T2DM?

Insulin resistance with progressive pancreatic beta-cell dysfunction.

Which tissues are primarily affected by insulin resistance?

• Liver

• skeletal muscle

• adipose tissue

What A1C level is diagnostic of diabetes?

≥6.5%.

What fasting plasma glucose level is diagnostic of diabetes?

≥126 mg/dL.

What random plasma glucose level is diagnostic of diabetes in a symptomatic patient?

≥200 mg/dL.

What 2-hour oral glucose tolerance test (OGTT) result is diagnostic of diabetes?

≥200 mg/dL.

What is a normal A1C?

What A1C range is considered prediabetes?

5.7%-6.4%.

What are common risk factors for T2DM?

• Obesity

• physical inactivity

• family history

• increasing age

• hypertension

• hyperlipidemia

• metabolic syndrome.

What BMI defines obesity?

≥30 kg/m².

Why is obesity an important risk factor for T2DM?

Excess adipose tissue contributes to insulin resistance.

What are common symptoms of uncontrolled T2DM?

• Polyuria

• polydipsia

• polyphagia

• fatigue

• blurred vision

• weight loss

What symptoms may suggest diabetic neuropathy?

• Numbness

• tingling

• burning

• decreased sensation in the extremities.

What laboratory tests are routinely monitored in patients with T2DM?

• A1C

• urine albumin-to-creatinine ratio (UACR)

• lipid panel

• BMP/CMP

Why is A1C monitored in patients with diabetes?

It reflects average blood glucose levels over approximately 3 months.

How often is A1C typically monitored?

Every 3-6 months depending on glycemic control.

Why is a urine albumin-to-creatinine ratio (UACR) obtained?

To screen for diabetic kidney disease.

What does an elevated UACR suggest?

Early diabetic nephropathy.

Why is diabetic nephropathy screened for annually?

Kidney damage may occur before symptoms develop.

Why is renal function monitored in diabetic patients?

Diabetes is a leading cause of chronic kidney disease.

What physical examination should be performed routinely in diabetic patients?

Monofilament foot examination.

What does a monofilament foot examination assess?

Peripheral neuropathy and loss of protective sensation.

What finding on monofilament testing suggests diabetic neuropathy?

Loss of protective sensation.

Why is loss of protective sensation concerning?

It increases the risk of foot ulcers, infection, and amputation.

Why should diabetic patients receive regular eye examinations?

To screen for diabetic retinopathy.

What diabetic complication is screened for during annual eye examinations?

Diabetic retinopathy.

When should ankle-brachial indices (ABIs) be considered in diabetic patients?

When peripheral arterial disease is suspected.

What is the general A1C goal for most adults with diabetes?

Should A1C goals be individualized?

Yes, goals should be individualized based on age, comorbidities, life expectancy, and risk of hypoglycemia.

When might a less stringent A1C goal be appropriate?

• older adults

• patients with significant comorbidities

• those at increased risk of hypoglycemia.

When may treatment de-escalation be considered?

When A1C is <6.5% and treatment risks outweigh benefits.

What is the first-line medication for Type 2 Diabetes Mellitus?

Metformin.

What is the mechanism of action of metformin?

Decreases hepatic gluconeogenesis and glycogenolysis while increasing insulin sensitivity.

Does metformin stimulate insulin secretion?

No, it does not directly stimulate pancreatic beta cells.

Why does metformin have a low risk of hypoglycemia?

It does not increase insulin production.

Why is metformin generally considered first-line therapy?

It effectively lowers A1C, has minimal hypoglycemia risk, may promote modest weight loss, and is inexpensive.

What is a major contraindication to metformin?

Severe kidney disease with eGFR <30 mL/min/1.73 m².

What are common side effects of metformin?

• Diarrhea

• nausea

• vomiting

• abdominal discomfort.

What rare but serious adverse effect is associated with metformin?

Lactic acidosis.

What laboratory test is used to monitor hyperlipidemia?

Lipid panel.

What components are included in a lipid panel?

• Total cholesterol

• LDL cholesterol

• HDL cholesterol

• triglycerides.

What LDL goal is often recommended for patients with diabetes and elevated cardiovascular risk?

Why are LDL goals more aggressive in patients with diabetes?

Diabetes significantly increases cardiovascular disease risk.

What medication class is first-line for hyperlipidemia?

Statins.

What medication was highlighted in this case?

Atorvastatin.

What is the mechanism of action of statins?

Inhibition of HMG-CoA reductase, reducing hepatic cholesterol synthesis and lowering LDL cholesterol.

What atorvastatin doses are considered moderate-intensity therapy?

10-20 mg daily.

What atorvastatin doses are considered high-intensity therapy?

40-80 mg daily.

What blood pressure is considered hypertensive?

≥130/80 mmHg.

What blood pressure goal is recommended for most patients with diabetes?

Why is blood pressure control important in diabetic patients?

It reduces the risk of cardiovascular disease, stroke, and diabetic nephropathy.

What medication class is commonly recommended as first-line therapy in diabetic patients with hypertension?

ACE inhibitors.

What medication was highlighted in this case?

Enalapril.

What is the mechanism of action of ACE inhibitors?

Inhibit conversion of angiotensin I to angiotensin II, causing vasodilation and decreased aldosterone production.

Why are ACE inhibitors preferred in many diabetic patients?

They provide renal protection and slow progression of diabetic kidney disease.

What are the three major microvascular complications of diabetes?

• Retinopathy

• nephropathy

• neuropathy.

What is diabetic retinopathy?

Progressive retinal damage caused by chronic hyperglycemia that may lead to vision loss.

What is diabetic nephropathy?

Kidney damage caused by chronic hyperglycemia that can progress to chronic kidney disease.

What is diabetic neuropathy?

Nerve damage caused by chronic hyperglycemia resulting in sensory, motor, or autonomic dysfunction.

What are the major macrovascular complications of diabetes?

• Coronary artery disease

• cerebrovascular disease

• peripheral arterial disease.

Why are patients with diabetes at increased cardiovascular risk?

Chronic hyperglycemia accelerates atherosclerosis and vascular damage.

Why are annual foot examinations important in diabetic patients?

To identify neuropathy and prevent ulcers, infections, and amputations.

Why are annual eye examinations important in diabetic patients?

To detect diabetic retinopathy before vision loss occurs.

Why is routine monitoring essential in diabetes management?

Early identification of complications improves outcomes and reduces morbidity.