diabetes melitis type 2

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DR SALIM ULLAH POST GRADUATE RESIDENT MEDICAL “C” LADY READING HOSPITAL PESHAWAR

Diabetes mellitus type 2 : 

Diabetes mellitus type 2 formerly non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes

Signs and symptoms : 

Signs and symptoms Polyuria Polydipsia polyphagia fatigue and weight loss

Prevention and Risk Factors : 

Prevention and Risk Factors BMI over 25 Physical Inactivity 1st degree relative with DM African American, Asian, Pacific islander, Native American, Latino GDM or women w/infants weighing more than 9 pounds

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HTN HDL<35; TRIG>250 PCOS or other signs of insulin resistance Prior IFG(impaired fasting glucose); IGT(impaired glucose tolerance); or A1c >5.7% History of CAD Environmental toxins (bisphenol A) a constituents of plastics.

Conditions exacerbating type 2 DM : 

Conditions exacerbating type 2 DM obesity Hypertension elevated cholesterol (combined hyperlipidemia) metabolic syndrome (it is also known as Syndrome X, Reavan's syndrome, or CHAOS). Other causes include acromegaly, Cushing's syndrome, thyrotoxicosis, pheochromocytoma, chronic pancreatitis, cancer and drugs.

DRUGS INTERFERING WITH INSULIN REGULATION : 

DRUGS INTERFERING WITH INSULIN REGULATION Atypical Antipsychotics Beta-blockers Calcium Channel Blockers Corticosteroids Fluoroquinolones Niacin Phenothiazines Thiazide Diuretics

Assessing the Diabetic Patient : 

Assessing the Diabetic Patient History Current medications – recent changes Orals – relation to meals COMPLIANCE???? Other medication which may affect control History of episodes of hypoglycemia Diet Caloric intake – Are they counting calories? Do they eat a regular diet?

Assessing the Diabetic Patient : 

Assessing the Diabetic Patient Physical Exam Vital Signs – Weight – for insulin calculations Retinopathy Neuropathy

Recommended Screening : 

Recommended Screening Fasting glucose levels Oral glucose tolerance testing using 75g of Glucose Fasting glucose of 100-125mg/dL=pre- diabetes Fasting level >126 is diagnostic OGTT>200 is diagnostic

Diagnostic criteria : 

Diagnostic criteria

The World Health Organization definition of diabetes : 

The World Health Organization definition of diabetes is for a single raised glucose reading with symptoms, otherwise raised values on two occasions, of either: fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl) or With a glucose tolerance test, two hours after the oral dose a plasma glucose ≥ 11.1 mmol/l (200 mg/dl) sensitivity about 50% Specificity greater than 95%

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A random capillary blood glucose > 6.7 mmol/L (120 mg/dL) diagnoses current diabetes with: sensitivity = 75% specificity= 88%

Glycosylated hemoglobin : 

Glycosylated hemoglobin Measures blood levels over 2-3 months. values that are elevated (over 5%), but not in the diabetic range (not over 7.0%) are predictive of subsequent clinical diabetes This equates to a glycosylated hemoglobin value of 6.0% or more having: sensitivity= 16.7% specificity= 98.9%

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People with a confirmed diagnosis of diabetes are tested routinely for complications. This includes yearly urine testing for microalbuminuria and examination of the retina of the eye for retinopathy.

Prevention : 

Prevention Onset of type 2 diabetes can often be delayed through proper nutrition regular exercise.

Management : 

Management Nutritional Exercise Monitoring Pharmacologic Education

GOALS OF TREATMENT : 

GOALS OF TREATMENT There are two main goals of treatment: reduction of mortality and concomitant morbidity (from assorted diabetic complications) preservation of quality of life

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The first goal can be achieved through close glycemic control (i.e., to near 'normal' blood glucose levels); . The second goal is often addressed (in developed countries) by support and care from teams of diabetic health workers (usually physician, PA, nurse, dietitian or a certified diabetic educator).

Dietary Management : 

Dietary Management Type 2 diabetes is initially treated by adjustments in diet and exercise, and by weight loss, most especially in obese patients. Carbohydrate 45-65% total daily calories Protein-15-20% total daily calories Fats—less than 30% total calories, saturated fats only 10% of total calories

Dietary Management : 

Dietary Management Fiber—lowers cholesterol; soluble—legumes, oats, fruits Insoluble—whole grain breads, cereals and some vegetables. Both increase satiety. Slowing absorption time seems to lower glycemic index. Consistent, well-balanced small meals several times per day Exchange system or counting carbohydrates

Exercise and Diabetes : 

Exercise and Diabetes Exercise increases uptake of glucose by muscles and improves utilization, alters lipid levels, increases HDL and decreases TG and TC If on insulin, eat 15g snack before beginning Check BS before, during and after exercising if the exercise is prolonged

Cautions for diabetics : 

Cautions for diabetics Avoid trauma to the feet Avoid pounding activities that could cause vitreous hemorrhage Caution if CAD Baseline stress test may be indicated (especially in those older than 30 and with 2 or more risk factors for CAD)

THE TARGETS : 

THE TARGETS HbA1c of 6% to 7.0% Preprandial blood glucose: 4.0 to 6.0 mmol/L (72 to 108 mg/dl) 2-hour postprandial blood glucose: 5.0 to 8.0 mmol/L (90 to 144 mg/dl)

Glucose monitoring : 

Glucose monitoring Patients on insulin should check sugars 2-4 times per day Not on insulin, two or three times per week Should check before meals and 2 hours after meals

Oral antidiabetic agents : 

Oral antidiabetic agents Biguanides—metformin. Lactic acidosis. Sulfonylureas—glipizide, glyburide and glimepiride. Hypoglycemia Alpha-glucosidase inhibitors—acarbose. Delay absorption of CHO

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A systematic review of randomized controlled trials found that metformin and second-generation sulfonylureas are the preferred choices for most with type 2 diabetes, especially those early in the course of the condition

Biguanides (Metformin) : 

Biguanides (Metformin) MOA: Decreases hepatic glucose output / increases peripheral glucose uptake Pros: May facilitate weight loss, does not cause hypoglycemia For patients who also have heart failure, metformin may be the best tolerated drug Cons: Lactic Acidosis

Sulfonylureas : 

Sulfonylureas MOA: Close ATP / K+ channel in the B-cell Insulin release Cons: Can cause hypoglycemia Metabolism affected by Renal / Hepatic impairment Glyburide should be avoided Renal Insufficiency Blocks Ischemic Preconditioning

Thiazolidinediones (TZD’s) : 

Thiazolidinediones (TZD’s) MAO: Enhance peripheral insulin sensitivity Cons: Concerns for increased fluid retention Should not be used in setting of Hepatic Impairment

Other Oral Agents : 

Other Oral Agents Meglitinides and Alpha-Glucosidase Inhibitors Not well studied in the inpatient setting Potential for hypoglycemia is low Mainly act by affecting post-prandial glycemic levels, thus role in patient with reduced PO or NPO is limited.

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The variety of available agents can be confusing, and the clinical differences among type 2 diabetes patients compounds the problem. At present, choice of drugs for type 2 diabetics is rarely straightforward and in most instances has elements of repeated trial and adjustment.

Injectable peptide analogs : 

Injectable peptide analogs DPP-4 inhibitors (also known as glyptins) lowered HbA1c by 0.74% (points), comparable to other antidiabetic drugs. GLP-1 analogs resulted in weight loss and had more gastrointestinal side effects, while DPP-4 inhibitors were generally weight neutral and increased risk for infection and headache, but both classes appear to present an alternative to other antidiabetic drugs. However, weight gain and/or hypoglycaemia have been observed when DPP-4 inhibitors were used with sulfonylureas; effect on long-term health and morbidity rates are still unknown.

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Non-sulfonylurea secretagogues—repaglinide. Cause secretion of insulin. Thiazolidinediones—pioglitazone and rosiglitazone. Sensitize. Weight gain.Fertility. Liver. Pramlintide (Symlin). Analogue of amylin. Used with insulin. Injection. Exanatide (Byetta). Incretin mimetic. Causes satiety. Wt loss. Januvia.

Insulin Regimens – where to START : 

Insulin Regimens – where to START In rare cases, if antidiabetic drugs fail (i.e., the clinical benefit stops), insulin therapy may be necessary – usually in addition to oral medication therapy – to maintain normal or near normal glucose levels.

INSULIN DOSSAGE : 

INSULIN DOSSAGE Typical total daily dosage of insulin is 0.6 U/kg. But, of course, best timing and indeed total amounts depend on diet (composition, amount, and timing) as well the degree of insulin resistance. More complicated estimations to guide initial dosage of insulin are For men, [(fasting plasma glucose [mmol/liter]–5)x2] x (weight [kg]÷(14.3xheight [m])–height [m]) For women, [(fasting plasma glucose [mmol/liter]–5)x2] x (weight [kg]÷(13.2xheight [m])–height [m])

Insulin Regimens – where to START : 

Insulin Regimens – where to START History -- home dosing? Weight based dosing (SQ administration) Type 2 DM – 0.3-0.6 Units/kg/day for most patients 0.6 to 1.0 Units/kg/day if insulin resistant IF NPO, cut dose in half, and do not use Ultra-short acting Insulin

The initial insulin regimen : 

The initial insulin regimen based on the patient's blood glucose profile. Initially, adding nightly insulin to the patients failing to oral medications may be best.Insulin combines better with metformin than with sulfonylureas. The initial dose of nightly insulin (measured in IU/d) should be equal to the fasting blood glucose level (measured in mmol/L). If the fasting glucose is reported in mg/dl, multiply by 0.05551 to convert to mmol/L.

When nightly insulin is insufficient : 

When nightly insulin is insufficient Premixed insulin with a fixed ratio of short and intermediate acting insulin; this tends to be more effective than long acting insulin, but is associated with increased hypoglycemia. Initial total daily dosage of biphasic insulin can be 10 units if the fasting plasma glucose values are less than 180 mg/dl or 12 units when the fasting plasma glucose is above 180 mg/dl“.

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Long acting insulins such as insulin glargine and insulin detemir. found "only a minor clinical benefit of treatment with long-acting insulin analogues for patients with diabetes mellitus type 2".

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Insulin Pump therapy in type 2 diabetes is gradually becoming popular.In an original published study, in addition to reduction of blood sugars, there is evidence of profound benefits in resistant neuropathic pain and also improvements in sexual performance.

Teaching Plan : 

Teaching Plan Education is critical Simple pathophysiology Treatment modalities Recognition, treatment and prevention of acute complications When to call the doctor Foot care, eye care, general hygiene, risk factor management

Acute Complications of Diabetes : 

Acute Complications of Diabetes Hypoglycemia—50-60 or less DKA HHNS

Hypoglycemia : 

Hypoglycemia Caused by too much insulin or oral agents, too little food or excessive physical activity Surge in epinephrine and norepinephrine results in sweating, tremors, tachycardia, palpitations, nervousness and hunger

Hypoglycemia : 

Hypoglycemia CNS effects—inability to concentrate, headache, lightheadedness, confusion, memory problems, slurred speech, incoordination, double vision, seizures and even loss of consciousness.

Hypoglycemic unawareness : 

Hypoglycemic unawareness Related to autonomic neuropathy Will not experience the sympathetic surge—with sweating, shakiness, HA, etc.

Treatment for hypoglycemia : 

Treatment for hypoglycemia 2-3 tsp. of sugar or honey 6-10 hard candies 4-6oz. of fruit juice or soda 3-4 commercially prepared glucose tablets Recheck BS 15 minutes, same s/s, repeat treatment. After improvement, then cheese and crackers or milk. Extreme situations, give glucagon. (can cause n/v). D50W.

Hyperglycemic Hyperosmolar Nonketotic Syndrome : 

Hyperglycemic Hyperosmolar Nonketotic Syndrome Predominated by hyperosmolarity and hyperglycemia Minimal ketosis Osmotic diuresis Glycosuria and increased osmolarity Occurs over time Blood sugar is usually over 600

HHNS : 

HHNS Occurs more often in older people Type 2 diabetes mellitus No ketosis Do not usually have the concomitant n/v Hyperglycemia, dehydration and hyperosmolarity may be more severe than in DKA

Medical Management : 

Medical Management Watch fluid resuscitation if history of heart failure ECG Electrolyte monitoring Fluids with potassium replacement

Nursing Management of HHNS : 

Nursing Management of HHNS Monitor neurologically Monitor ECG Monitor vital signs Labs Hourly blood glucose monitoring Insulin IV Cautious correction of hyperglycemia to avoid cerebral edema

Long term complications of Diabetes : 

Long term complications of Diabetes Increasing numbers of deaths from cardiovascular and renal complications Renal (microvascular) disease is more common in type 1 diabetics Cardiovascular disease (macrovascular) complications are more common in type 2 diabetics

Diabetic Vascular Diseases : 

Diabetic Vascular Diseases Chronic hyperglycemia causes irreversible structural changes in the basement membranes of vessels. Result is thickening and organ damage. Glucose toxicity affects cellular integrity Chronic ischemia in microcirculatory brances>>cause connective tissue hypoxia and microischemia

Diabetic Vascular Diseases : 

Diabetic Vascular Diseases Up to 21% of diabetics have retinopathy at time of diagnosis

Macrovascular Complications : 

Macrovascular Complications Coronary artery disease Cerebrovascular disease Peripheral arterial disease

Management of Macrovascular Diseases : 

Management of Macrovascular Diseases Modify/reduce risk factors Meds for hypertension and hyperlipidemia Smoking cessation Control of blood sugars which will help reduce TG

Microvascular Complications--Retinopathy : 

Microvascular Complications--Retinopathy Diabetic retinopathy-leading cause of blindness in those 20-74 Blood vessel changes—worst case scenario, proliferative retinopathy. Also an increased incidence of cataracts and glaucoma in diabetics. Need regular eye exams Control BP, control BS and cessation of smoking can help

Microvascular complications-Nephropathy : 

Microvascular complications-Nephropathy Accounts for 50% of patients with ESRD Earliest clinical sign of nephropathy is microalbuminuria. Warrants frequent periodic monitoring for microalbuminuria—if exceeds 30mg/24h on two consecutive random urines, need 24h urine sample

Nephropathy : 

Nephropathy Diabetes causes hypertension in renal vessels which cause leaking glomeruli, deposits in narrow vessels, scarring and vascular damage

Microvascular disease-Nephropathy : 

Microvascular disease-Nephropathy Medical management: control BP (ACE or ARB) Tx of UTIs Avoid nephrotoxic agents, contrast dyes Low sodium diet Low protein diet Tight glycemic control

Nephropathy : 

Nephropathy May require dialysis May have co-existent retinopathy Kidney transplantation—success now 75-80% for 5 years Pancreas transplantation may also be performed at time of kidney transplantation

Neuropathies : 

Neuropathies Group of diseases that affect all types of nerves. Includes peripheral, autonomic and spinal nerves. Prevalence increases with duration of the disease and degree of glycemic control

Neuropathies : 

Neuropathies Capillary basement membrane thickening and capillary closure may be present. May be demyelination of the nerves, nerve conduction is disrupted. Two most common types of neuropathy are: sensorimotor polyneuropathy and autonomic neuropathy.

Peripheral neuropathy : 

Peripheral neuropathy Manifestations:paresthesias, burning sensations, numbness, decrease in proprioception. Charcot foot can result from abnormal weight distribution on joints secondary to lack of proprioception

Management of Peripheral Neuropathies : 

Management of Peripheral Neuropathies Pain management in the form of TCAs, Dilantin, Tegretol, Neurontin, mexilitene, and TENS. Cymbalta has been recommended. Also, the drug Lyrica (pregabalin)

Autonomic Neuropathies : 

Autonomic Neuropathies Cardiac, gastrointestinal and renal systems Cardiac—myocardial ischemia may be painless GI—delayed gastric emptying with early satiety, nausea, bloating, diarrhea or constipation Urinary retention—decreased sensation of bladder, neurogenic bladder

Autonomic neuropathy—hypoglycemia unawareness : 

Autonomic neuropathy—hypoglycemia unawareness No longer feel shakiness, sweating, nervousness and palpitations associated with hypoglycemia The inability to detect warning signs of hypoglycemia can place the patient at very high risk

Autonomic neuropathy-sudomotor neuropathy : 

Autonomic neuropathy-sudomotor neuropathy Patient will have a decrease or absence of sweating of the extremities with compensatory increase in upper body sweating.

Autonomic neuropathy—sexual dysfunction : 

Autonomic neuropathy—sexual dysfunction Decreased libido in women Anorgasmia ED in men UTI and vaginitis Retrograde ejaculations

Management of neuropathies : 

Management of neuropathies Early detection, periodic f/u on patient’s with cardiac disease Monitor BP frequently for s/s orthostatic hypotension Low fat diet, frequent small meals, close BS monitoring and use of prokinetic medications Meticulous skin care

Foot and Leg Problems : 

Foot and Leg Problems Sensory loss Sudomotor neuropathy leads to dry, cracking feet PAD—so poor wound healing/gangrene Lowered resistance to infection

Management of Foot and Leg Problems : 

Management of Foot and Leg Problems Teaching patient foot care-inspect feet and shoes daily Examine feet every time goes to doctor See podiatrist at least annually Closed toe shoes Trimming toenails Good foot hygiene Glycemic control is the key to preventing complications

Using insulin in Type 2 DM : 

Using insulin in Type 2 DM Usually will meet patient resistance May benefit from a 70/30 combination Requires frequent blood glucose monitoring

Cardiac risk factors : 

Cardiac risk factors 50% of those with Type 2 Diabetes Mellitus have hypertension, 25% in type 1 Need ARB or ACE inhibitor Dyslipidemia needs to be addressed—goal of LDL <100 (<70 if DM and CAD); HDL >40 in men and >50 in women, TG <150

Cardiac risk factors : 

Cardiac risk factors Treat with statins, Zetia (ezetimibe) or fibrates if TG >400***

Type 2 diabetes : 

Type 2 diabetes Evaluate treatment response within 3 months HgbA1C >8% in patient who has been educated about DM should begin insulin therapy

Complication Management:Take Home Points : 

Complication Management:Take Home Points Ask about hypoglycemic episodes every visit. Individualize A1c levels Bariatric surgery is an option for T2DM patients with a BMI over 35, mortality data however is so far lacking (B) Tight lipid control decreases CVD mortality in diabetic patients (A) Tight BP control decreases complications and deaths from DM (A) Tight glucose control helps with microvascular complications but not macrovascular complications or mortality (A) Smoking cessation should be a primary treatment goal (A)

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THANKS