type 2 diabetes

are islet cells endocrine or exocrine?

endocrine

are acinar cells endocrine or exocrine?

exocrine

what is the 5th leading cause of death worldwide?

type 2 diabetes

what are risk factors for type 2 diabetes?

family hx (both parents)

insulin resistance in 1st degree relative

race/ethnicity

physical inactivity

metabolic/endocrine disorders

obesity

CAD

hx GDM

what lab values are risk factors for type 2 DM?

fasting glucose > 100

impaired glucose tolerance

HDL < 35

HTN > 140/90

how does your body try to compensate for insulin resistance?

pancreatic beta cells increase insulin output

islet cells are unable to keep up

impaired glucose tolerance

decline in insulin secretion

fasting hyperglycemia

progressive beta cell failure

which cells secrete insulin?

beta cells

where are beta cells?

in islet cells

what other cell is in islet cells?

alpha cells

what do alpha cells secrete?

glucagon

when do alpha cells secrete glucagon?

when blood glucose is low

what does glucagon stimulate?

glycogenolysis and gluconeogenesis at the liver

what is the normal hormonal response to eating?

increased glucose load

rise in insulin

fall in glucagon

is insulin anabolic or catabolic?

anabolic

what is the function of insulin?

promotes storage of carbs, fat, and protein

is the brain using glucose dependent or independent of insulin release?

independent

what are the 3 things that result in type 2 diabetes?

peripheral insulin resistance

increased hepatic glucose production

inadequate insulin secretion

what is decreased ability of insulin to act on target tissue that results from a combination of genetic predisposition and obesity?

insulin resistance

what are the main effects of insulin resistance?

impairs utilization of glucose by insulin sensitive tissues

increases hepatic glucose output

what is increased in response to insulin resistance?

insulin secretion

what causes increased hepatic glucose production?

failure of hyperinsulinemia from the pancreas to suppress gluconeogenesis

what is the result of increased hepatic glucose production?

fasting hyperglycemia

what are signs and symptoms of type 2 DM?

fatigue

blurred vision

nausea

polyphagia

weight gain or loss

numbness in extremities

hypertriglyceridemia

low HDL

fasting glucose > 100

what is an advanced sign of type 2 DM that you should not wait for in preventing/treating DM?

increased thirst and urination

what are physical exam signs of type 2 DM?

obesity

HTN

eye hemorrhages

acanthosis nigricans

decreased neuro sensations/reflexes

ulcers

muscle atrophy

what are labs for diagnosing type 2 DM?

fasting glucose > 126

random glucose > 200 w symptoms

glucose tolerance test, BG > 200

A1c > 6.5%

how do you perform a glucose tolerance test?

75g glucose load

2 hours later, take BG

if > 200, do repeat test to confirm

what are labs for diagnosing prediabetes?

fasting glucose > 100

glucose tolerance test, BG 140-199 mg/dL

A1c 5.7-6.4%

what are macrovascular complications of type 2 DM?

CAD

carotid artery/cerebrovascular disease

PAD

what do over half of diabetics die of?

heart disease

what is the #1 non traumatic cause of amputations?

diabetes

what are microvascular complications of type 2 diabetes?

neuropathy

nephropathy

retinopathy

what is the leading cause of end stage renal disease?

diabetes

true or false - a T2DM pt without prior MI is at equal risk for cardiac event as a nondiabetic who has had their 1st MI?

true

what explains increased CV event risk in diabetes?

insulin resistance and diabetes elevates:

plasminogen activator inhibitors

fibrinogen

thrombosis

why do T2DM pts get foot ulcers?

disordered proprioception and neuropathy results in abnormal gait and callus formation

*think of the gift of pain book*

what does peripheral vascular disease PLUS neuropathy result in?

amputation

what is charcot's foot?

motor and sensory neuropathy of the foot accompanied by structural changes that worsen outcomes in PAD

what in conjunction with diabetes worsens risk for foot ulcers?

smoking

what are you at high risk for if you have a chronic open wound open for longer than 10 days?

osteomyelitis

what complication is seen in half of patients that have had T2DM for at least 10 yrs?

diabetic neuropathy

what is the most common form of diabetic neuropathy?

distal symmetric polyneuropathy

what are symptoms of distal symmetric polyneuropathy?

numbness

tingling

burning

begins in feet and spreads proximally

what is the screening for nephropathy in diabetics?

spot urine q6-12 months (albumin/Cr > 30)

CMP q3 months (Cr and GFR)

refer to nephrology if:

macroalbuminuria > 300

GFR < 35 in blood test

what are the effects of ACEI/ARBS in pt with T2DM?

slow progression to end stage renal disease

reduces intraglomerular pressure

antifibrotic effect

what do you need to monitor with ACEI/ARB use?

potassium and GFR

what is secreted in the urine in pts who have had DM for 5-10 yrs?

albumin

what does macroalbuminuria make you susceptible to?

AKI

can we prevent the need for dialysis?

yes

what does blindness result from in the context of T2DM?

diabetic retinopathy

macular edema

what is the hallmark of proliferative diabetic retinopathy?

neovascularization in response to retinal hypoxemia

how can neovascularization be treated if detected early?

laser therapy

what can be used for treatment of macular edema?

VEGF injections

what is the mechanism of action for VEGF injections?

decreases amount of VEGF and other inflammatory cytokines to reduce macular edema

what are examples of VEGF injections?

avastin

ozurdex

lucentis

eylea

what are signs on fundoscopic exam of diabetic retinopathy?

blot hemorrhages

cotton wool spots

micro aneurysms

what is treatment of painful neuropathy?

antidepressant - duloxetine

gabapentin or pregabalin

B complex vitamins or multivitamin

what needs to be done at each health maintenance visit for T2DM pt?

smoking cessation discussion

glucometer reading

A1c q3 months

does A1c determine med changes?

no

do glucose patterns determine med changes?

yes

what predicts mortality of T2DM pt?

A1c level achieved within 3 months of initial diagnosis

if T2DM pt has uncontrolled blood sugar, when should you follow up?

sooner than 3 months

what is the treatment for T2DM?

lifestyle changes (lose 10% of weight and keep it off)

meds (metformin ER 500 mg BID)

insulin therapy

surgery

what are specific dietary changes that should be made for type 2 DM?

mediterranean diet

low carb snacks

you are working with your patient to decide dietary changes in treating their type 2 DM. they say they eat cake every night for dessert and are not willing to give it up. what idea could you suggest?

no carbs with dinner - for example, meat and veggies but no dinner roll

if pt is already on a low carb diet, what med approach should you take?

start metformin ER 2000mg daily (titrate)

med for postprandial coverage

what meds can be added for postprandial coverage with metformin ER?

glipizide 5-10 mg BID

DPP-4 inhibitor

SGLT2

if A1c > 10% at initial diagnosis or despite oral meds, what is your treatment?

insulin therapy

true or false - no oral med or oral med combo lowers A1c more than 2.5%?

true

is basal insulin rapid or long acting?

long acting

what are examples of basal insulin?

basaglar

lantus

levemir

toujeo U-300

tresiba U-100 or 200

which med is a combo of basal insulin and GLP-1?

Soliqua

what is xultophy?

combo of liraglutide and degludec basal insulin

it is very expensive, but what is the benefit of xultophy?

can decrease A1c > 2.5%

why do type 2 DM pts need additional basal insulin?

to improve fasting glucose levels (bedtime, b/w meals)

what is the onset of action for rapid acting insulin?

within 15 mins

what are examples of bolus/correction insulin?

novolog

humalog U-100 or 200

apidra

fiasp

why do you want to keep prandial insulin injections 3 hrs apart?

to prevent hypoglycemia

how should you store insulin? why?

refrigerator; ineffective if overheated or frozen

what management tool is especially important for making dosage and med choices if A1c is initially > 10%?

home glucose monitoring

why are older insulins such as NPH or regular not used much anymore?

they are dosed BID but due to their half lives there ends up being overlap of insulin doses therefore increasing risk of hypoglycemia

what is the only known cure for T2DM?

gastric bypass surgery

when should you consider gastric bypass for your T2DM patient?

BMI > 40

BMI 35-39.99 if not controlled on meds

what is the mainstay drug for diabetes?

metformin

what type of drug is a biguanide?

metformin

what is the dose for metformin?

500-1000 mg

what is the mechanism of action of biguanides?

increases hepatic adenosine monophosphate activated protein kinase activity to decrease hepatic glucose production

what are the effects of biguanides?

reduces hepatic gluconeogenesis

decreases insulin resistance

anti-oxidative properties

improves fasting and post prandial glucose

what is a requirement for putting a pt on metformin?

GFR > 45

what do you do if pt is taking metformin and GFR drops below 45?

monitor closely

weight risks and benefits

discontinue if GFR < 30

what is the risk of using metformin in pts w severe CKD?

lactic acidosis

pt just did a CT with IV contrast dye. what do you instruct them about regarding their metformin?

hold for 48 hrs

which formulation of metformin is better tolerated? why?

metformin XR or ER; less GI effects

how should metformin be administered?

with a meal

can you use metformin in pregnancy?

yes

what are risks of long term metformin use?

vit B12 deficiency

hypoglycemia

if pt is unable to tolerate metformin, what med could we consider?

pioglitazone

what is the mechanism of action for thiazolidinediones?

binds nuclear receptor PPAR gamma & affects gene expression

what type of drug is pioglitazone?

thiazolidinediones

what are the effects of pioglitazone?

improves glucose absorption

decreases hepatic gluconeogenesis