Diagnosis and Labs
What are three diagnostic criteria (lab values) for DM II?
Symptomatic and a random glucose >200 or 2 hour 75 gram glucose tolerance test ≥ 200 mg/dL
Hemoglobin A1C > 6.5
Fasting glucose >126 mg/dl (confirm with repeat testing)
American Diabetes Association; 2. Classification and Diagnosis of Diabetes. Diabetes Care 1 January 2016; 39 (Supplement_1): S13–S22. https://doi.org/10.2337/dc16-S005
Pathogenesis of Type 1 Diabetes
Pathogenesis of Type 2 Diabetes
Type 1: An autoimmune disorder characterized by T-cell-mediated destruction of pancreatic β-cells, which results in insulin deficiency and ultimately hyperglycemia.
Type 2: insulin resistance and β-cell dysfunction.
Banday MZ, Sameer AS, Nissar S. Pathophysiology of diabetes: An overview. Avicenna J Med. 2020 Oct 13;10(4):174-188. doi: 10.4103/ajm.ajm_53_20. PMID: 33437689; PMCID: PMC7791288.
Metformin
Metformin accumulates within mitochondria --> inhibits complex I of respiratory chain --> decreases ATP production --> increased ADP / ATP and AMP / ATP ratios --> activate AMPK --> inhibits hepatic gluconeogenesis
Side effects: LACTIC ACIDOSIS, Bloating, Gas, Diarrhea, Belly pain, Constipation, Little appetite.
Rena G, Hardie DG, Pearson ER. The mechanisms of action of metformin. Diabetologia. 2017 Sep;60(9):1577-1585. doi: 10.1007/s00125-017-4342-z. Epub 2017 Aug 3. PMID: 28776086; PMCID: PMC5552828.
What is the threshold BP to start anti-hypertensives, and what is a good first-line anti-hypertensive?
140/90, ACE-I
Armstrong, C. JNC 8 Guidelines for the Management of Hypertension in Adults. Am Fam Physician. 2014;90(7):503-504
This BP medication can increase your risk of diabetes:
Thiazides
American Diabetes Association; 2. Classification and Diagnosis of Diabetes. Diabetes Care 1 January 2016; 39 (Supplement_1): S13–S22. https://doi.org/10.2337/dc16-S005
The USPSTF recommends screening for prediabetes and type 2 diabetes in who?
Adults aged 35 to 70 years who are overweight or obesity. B recommendation.
Which complications are more prevalent, macrovascular or microvascular? Name a few.
The prevalence of microvascular complications—CKD (defined as microalbuminuria), foot problems (defined as foot/toe amputation, foot lesion, or numbness), and eye damage (defined as being told that diabetes has affected the eyes or has retinopathy)—are much higher than the prevalence of macrovascular complications (heart attack, chest pain, coronary heart disease, congestive heart failure, and stroke).
Deshpande AD, Harris-Hayes M, Schootman M. Epidemiology of diabetes and diabetes-related complications. Phys Ther. 2008 Nov;88(11):1254-64. doi: 10.2522/ptj.20080020. Epub 2008 Sep 18. PMID: 18801858; PMCID: PMC3870323.
Thiazolidinediones
PPAR-gamma agonists improve insulin resistance by increasing adiponectin, GLUT4 expression, and opposing the effect of TNF-alpha in adipocytes. Increased GLUT 4 expression will increase glucose uptake in adipocytes and skeletal muscle cells in response to insulin.
Side effects: Edema and Congestive Heart Failure, Weight Gain, Fractures, Bladder Cancer, Hepatotoxicity.
Eggleton JS, Jialal I. Thiazolidinediones. [Updated 2022 Jun 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551656/
American Diabetes Association 2019 suggested that (medication) was appropriate in diabetics >50 y/o for men with increased 10 year risk of CAD and for women with increased 10 year risk of stroke.
low-dose aspirin
Lin MH, Lee CH, Lin C, Zou YF, Lu CH, Hsieh CH, Lee CH. Low-Dose Aspirin for the Primary Prevention of Cardiovascular Disease in Diabetic Individuals: A Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis. J Clin Med. 2019 May 5;8(5):609. doi: 10.3390/jcm8050609. PMID: 31060297; PMCID: PMC6572181.
Carbohydrate digestion first occurs where in the body?
Enzymatic activity occurs in the mouth (amylase)
An A1C goal for many diabetics adults of ___ without significant hypoglycemia is appropriate.
___ may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits.
<7%, <8%
American Diabetes Association Professional Practice Committee; 6. Glycemic Targets: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S83–S96. https://doi.org/10.2337/dc22-S006
What is the most common complication DM?
Diabetic Retinopathy, assess annually.
Nentwich MM, Ulbig MW. Diabetic retinopathy - ocular complications of diabetes mellitus. World J Diabetes. 2015 Apr 15;6(3):489-99. doi: 10.4239/wjd.v6.i3.489. PMID: 25897358; PMCID: PMC4398904.
-Gliptins
DPP-4 inhibitors that increase the levels of GLP-1 and GIP. DPP-4 degrades these hormones immediately due to their short half-life.
Side effects: Upper respiratory tract infection, nasopharyngitis, headache, urinary tract infection, arthralgia.
Kasina SVSK, Baradhi KM. Dipeptidyl Peptidase IV (DPP IV) Inhibitors. [Updated 2022 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542331/
diabetics over age 40:
moderate-to-high dose statin for all diabetics over age 40
Higher doses of statins are required for the secondary prophylaxis of diabetic patients with coronary artery disease or at increased CVD risk such as those with abnormal LDL-C levels, smokers, hypertension, or albuminuria.
Elnaem MH, Mohamed MHN, Huri HZ, Azarisman SM, Elkalmi RM. Statin Therapy Prescribing for Patients with Type 2 Diabetes Mellitus: A Review of Current Evidence and Challenges. J Pharm Bioallied Sci. 2017 Apr-Jun;9(2):80-87. doi: 10.4103/jpbs.JPBS_30_17. PMID: 28717329; PMCID: PMC5508420.
The ethnic group at greatest risk for Type 2 diabetes?
Native Americans
Banday MZ, Sameer AS, Nissar S. Pathophysiology of diabetes: An overview. Avicenna J Med. 2020 Oct 13;10(4):174-188. doi: 10.4103/ajm.ajm_53_20. PMID: 33437689; PMCID: PMC7791288.
What values constitute microalbuminuria and macroalbuminuria (in μg/min) AND what are the screening recommendations for Type I and Type II Diabetics?
microalbuminuria (>20 μg/min and ≤199 μg/min) and macroalbuminuria (≥200 μg/min)
Screening should be performed yearly, starting 5 years after diagnosis in type 1 diabetes or earlier in the presence of puberty or poor metabolic control. In patients with type 2 diabetes, screening should be performed at diagnosis and yearly thereafter.
Jorge L. Gross, Mirela J. de Azevedo, Sandra P. Silveiro, Luís Henrique Canani, Maria Luiza Caramori, Themis Zelmanovitz; Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care 1 January 2005; 28 (1): 164–176. https://doi.org/10.2337/diacare.28.1.164
Histopathological finding of diabetic nephropathy
Kimmelstiel-Wilson nodules - Nodules of pink hyaline material form in regions of glomerular capillary loops in the glomerulus. This is due to a marked increase in mesangial matrix from damage as a result of non-enzymatic glycosylation of proteins.
Jorge L. Gross, Mirela J. de Azevedo, Sandra P. Silveiro, Luís Henrique Canani, Maria Luiza Caramori, Themis Zelmanovitz; Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care 1 January 2005; 28 (1): 164–176. https://doi.org/10.2337/diacare.28.1.164
Sulfonylureas
Sulfonylureas bind to and inhibit the ATP-sensitive potassium channels (K) on the pancreatic beta cells. As a result, potassium efflux decreases, and the beta-cell membrane depolarizes. Membrane depolarization causes calcium channels to open, leading to calcium influx and increased intracellular calcium, which stimulates insulin secretion from the pancreatic beta cells. Sulfonylureas cause insulin release regardless of blood glucose levels.
Side effects: HYPOGLYCEMIA --> sweating, shakiness, irritability, confusion, tachycardia, and a feeling of hunger.
Costello RA, Nicolas S, Shivkumar A. Sulfonylureas. [Updated 2022 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513225/
Most experts agree that insulin-treated patients should monitor blood glucose at least four times a day, most commonly ____, _____, and _____. In addition, patients using insulin can benefit by obtaining postprandial blood glucose readings to help them more accurately adjust their insulin regimen.
fasting, before meals, and before bed.
Evan M. Benjamin; Self-Monitoring of Blood Glucose: The Basics. Clin Diabetes 1 January 2002; 20 (1): 45–47. https://doi.org/10.2337/diaclin.20.1.45
The B cells, that produce insulin, are located here in the pancreas.
Islets of Langerhans
Diabetic Ketoacidosis
Blood glucose: >__
Arterial pH: <__
Serum Bicarbonate: <__
Urinalysis shows: __
Blood glucose: >250
Arterial pH: <7.30
Serum Bicarbonate: <18
Urinanalysis shows: Ketones
Lizzo JM, Goyal A, Gupta V. Adult Diabetic Ketoacidosis. [Updated 2022 Jul 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560723/
It is recommended that all patients should be screened for Diabetic Polyneuropathy at the diagnosis of type 2 diabetes and five years after the diagnosis of type 1 diabetes and should receive one or more of the following tests annually: (name the 5 types of tests).
pinprick, temperature, ankle reflex, and vibration perception (128‐Hz tuning fork) or pressure sensation (10 g monofilament test)
Yang Z, Zhang Y, Chen R, Huang Y, Ji L, Sun F, Hong T, Zhan S. Simple tests to screen for diabetic peripheral neuropathy. Cochrane Database Syst Rev. 2018 Jul 30;2018(7):CD010975. doi: 10.1002/14651858.CD010975.pub2. PMCID: PMC6513498.
GLP-1 agonist (-tide)
(ALSO MENTION ANOTHER ~BIG~ INDICATION FOR PRESCRIBING GLP-1 AGONISTS)
Incretin hormones increase insulin secretion after an oral glucose load via the incretin effect. Delayed gastric emptying and inhibiting the production of glucagon from pancreatic alpha cells if blood sugar levels are high. Furthermore, GLP-1 receptor agonists can decrease pancreatic beta-cell apoptosis while promoting their proliferation.
WEIGHT LOSS
Side effects: Nausea, vomiting, and diarrhea. Injection-site pruritus and erythema are also common.
Collins L, Costello RA. Glucagon-like Peptide-1 Receptor Agonists. [Updated 2022 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551568/
Research shows that you can lower your risk for type 2 diabetes by 58% by:
losing __% of your body weight and exercising moderately __ mins / day, for __ days / week.
The three Ps of diabetes and the TIRED acronym (bonus 250 points).
Polydipsia, Polyuria, & Polyphagia
Tremors/tachycardia -Irritability -Restless -Excessive hunger -Diaphoresis
This is the acronym that is useful in remembering the s/s of hypoglycemia