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S2 E036 DM2

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DM Type 2

Patients usually produce less than normal amounts of insulin AND have an insensitivity to insulin.

Risk factors

  • Age < 45
  • Overweight or obesity
  • Sedentary lifestyle
  • Family history of diabetes mellitus
  • History of impaired glucose regulation
  • Gestational diabetes mellitus or delivery of a baby > 4.1 kg
  • History of hypertension
  • Dyslipidemia (HDL cholesterol < 35 mg/dL or triglyceride level > 250 mg/dL)
  • History of cardiovascular disease
  • Polycystic ovary syndrome
  • Black, Hispanic, Asian American, or American Indian ethnicity

Clinical Presentation

  • Early disease
    • Most patients are asymptotic and will be diagnosed on routine screening.
  • Late Disease Symptoms
    • Eyes
      • Diabetic Retinopathy
    • Orthostatic hypotension due to to autonomic neuropathy and low plasma volume
    • Acanthosis nigricans
    • Neuropathy
      • Loss of sensation in limbs in a stocking glove distribution.
      • 50–80% of non traumatic lower extremity amputations are secondary to DM. Â
    • Atonic bladder
    • Erectile dysfunction
    • Delayed gastric emptying

Labs

  • Fasting blood glucose levels of >126 mg/dL on more than once occasion is diagnostic
  • Non-fasting blood glucose of >200 mg/dL
  • If above tests are negative but symptoms persist an oral glucose tolerance can be diagnostic.  Fasting patient consumes 75 g oral glucose. Two hours later glucose level > 200 mg/dL is diagnostic
  • Hemoglobin A1c — indicates sugar levels over previous 3 months and is used for monitoring glucose control.  3.8–5.7% is normal. 5.7–6.3% is considered at risk. Over 6.3% is diagnostic.
  • Patients may have glucosuria and ketonuria

Treatment

  • Medications
    • Biguanides
      • Reduces glucose production from the liver
      • Increase peripheral tissue sensitivity to insulin
      • Metformin
        -First line therapy for DM type 2
    • Thiazolidinediones
      • Increase peripheral tissue sensitivity to insulin
      • Pioglitazone (associated with an increased risk of bladder cancer)
      • Rosiglitazone (associated with increased risk of cardiovascular disease)
    • Sulfonylureas
      • The first oral antihyperglycemics
      • Increase secretion of insulin (can not be used in DM type 1 or during pregnancy)
      • Older agents glipizide, glyburide
      • Newer agents repaglinide and nateglinide,
        • Side effects
        • Hypoglycemia
        • Weight gain
    • Alpha-glucosidase inhibitors
      • Slow the digestion of carbohydrates in the small intestine – Miglitol , acarbose, voglibose
      • Side effects
        • Bloating
        • Flatulence
    • Injectable glucagon-like peptide (GLP) analogs and agonists
      • When the GLP receptor is activated it stimulates the release insulin from the beta cells of the pancreas
      • Exenatide, liraglutide
      • Side effects
        • Slowing of gastric motility
        • N/V
        • Weight loss
        • Acute pancreatitis
    • Inhibitors of dipeptidyl peptidase 4
      • Causes an increase in GLP
      • Saxagliptin, sitagliptin, vildagliptin, linagliptin
      • Side effects
        • Slowing of gastric motility
        • N/V
        • Weight loss
        • Headaches
        • Acute pancreatitis
      • Pramlintide
        • Injectable amylin analog
          • Amylin is secreted by the pancreas along with insulin (it is not produced in DM type 1 its)
        • Only approved if patient is already on insulin
        • Decreases glucagon secretion
        • Slows gastric emptying and increases satiety


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