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DM is a syndrome with disordered metabolism and inappropriate hyperglycemia duc to cither a deficiency of (Type 1) or to a combination of and inadequate to compensate (Type 2). ANSWER¥ ¥ insulin secretion, insulin resistance, insulin secretion Diabetes Mellitus Numbers are growing in proportions ANSWERV ¥ epidemic Highest incidence of DM in the US: ANSWERV ¥ - African-Americans - Latino/Hispanics - Native Americans/Alaska Natives - Asian Americans - Pacific Islanders - Caucasians much of the burden of DM could be prevented with 55 ,and ANSWERV ¥ early detection, improved delivery of care, and better education on diabetes self- management. Criteria for the diagnosis of DM -AIC>__or - Fasting (at least 8 hrs.) plasma glucose of > or - 2-h plasma glucose > during a 75g glucose load OGTT (WHO criteria) or - Ina patient with classic symptoms of hyperglycemia or hyperglycemia crisis, a random plasma glucose of > ANSWERS ¥ 6.5%, 126 mg/dl, 200 mg/dl, 200 mg/dl Criteria for the diagnosis of DM In the absence of unequivocal hyperglycemia, the first three criteria should be confirmed by ANSWERV ¥ repeat testing. Consider testing adults of any age who are overweight or obese with BMI > and who have one or more additional . In those without risk factors, begin screening at age $ If results are normal, re-sercen at least every ANSWERV V 25, risk factors, 45, 3 years DM Risk Factors ANSWERV ¥ Physical inactivity 1st degree relative with DM High-risk race/ethnicity Women who deliver baby >9 Ib. or had GDM HTN (>140/90 or on meds -HDL <35 mg/dl or trig level >250 mg/dl -Women with PCOS -A1C >5.7%, IGT, or IFG on previous exam -Other clinical conditions - severe obesity, acanthosis nigricans Women who have had gestational diabetes have a 35% to 60% chance of developing diabetes in the next ANSWERV V 10- 20 years Progression to diabetes is not inevitable. Studies have shown that people with pre- diabetes who and can prevent or delay diabetes and even return their blood glucose levels to normal ANSWERV ¥ lose weight and increase their physical activity Categories of Increased Risk for Diabetes ANS WERV V FPG 100-125 mg/dl (IFG) -Poly_ -Poly_ - Rapid weight -AIC> - Fasting plasma glucose > ___ mg/dl (on more than one occasion) - 2-h plasma glucose > mg/dl - Class symptoms of ____ crisis - positive in blood or urine - Presence of selected markers ANSWERV V uria dipsia loss 6.5% 126 200 hyperglycemia ketones autoimmune The toxic effect of persistently high circulating glucose and fatty acids can ultimately lead to complications such as retinopathy, nephropathy, and neuropathy ANS WERVJ/ microvascular Type 2 DM - Is the more prevalent form and results from with a defect in compensatory insulin secretion. - Is the type of diabetes that does or does not occur within families (has a genetic predisposition). ANS WERV ¥ insulin resistance, docs Type 2 DM being diagnosed in ever-increasing numbers; MODY ANSWERV / young people; MODY - maturity-onset diabetes in youth Progression to Type 2 DM - and lead to insulin resistance - Hyperinsulinemia -___ insulin resistance leads to normal glucose tolerance - Impaired glucose tolerance - cell failure ANSWER¥ V Genetics and lifestyle, Compensated, Beta Type 2 DM Most pts. tend to be over age and are ANSWERV ¥ 40 and are obese Type 2 DM s/s: (ketonuria and wt. loss are uncommon at diagnosis) ANSWERV / Polyuria and polydipsia may be initial manifestation of Type 2 DM in women ANSWERV V Candidal vaginitis Due to damage to the system from hyperinsulinemia, type 2 diabetics are at risk for complications, such as myocardial infarction, stroke, and peripheral vascular disease. Over time, if poorly controlled, they may also develop problems ANSWERV ¥ endothelial, macrovascular, microvascular Triglycerides ANSWERV ¥ <200 <100 >40 men > 50 women < 150 intake should be limited to the (RDA) (0.8 g/kg) in those with any degree of chronic kidney disease ANSWERV ¥ Protein Serum creatinine should be measured at least for estimation of glomerular filtration rate regardless of the degree of urine albumin excretion ANS WERV V annually Nutritional guidelines for those at risk for DM - High fiber, nutrient-rich foods (___g of fiber for every 1000 calories), with whole grains making up of all grain intake ANSWERV V 14, half; second slide page 12 DM risk nutrition: high fiber gm for every calories and whole grains making up of grain intake ANSWERV ¥ 14, 1000, half DM nutrition: avoid diets, sustained moderate weight loss and increased are recommended ANS WERV V fad, physical activity DM nutrition: Carb percent, protein percent, sat fat, servings of fish (not fried) per week ANSWERV V 45-65, 10-35, <7, two DM nutrition: limit fats, restrict choleserol to < mg/day, weight maintenance by monitoring consumption ANSWERV V trans, 200, caloric Bariatric surgery should be considered in DM if BMI> ANSWERVV 35 Subjective info for DM: age and characteristics of onset, previous and current regimens and response, meal plans, activity, glucose monitoring and use ANSWERV ¥ treatment, ALC Subjective info for DM: frequency, severity, causes ANSWERVV DKA episodes (awareness, frequency, causes, treatment), complications ANSWERV / hypoglycemic DM physical exam: ht, wt, BMI, B/P. , ANSWERV ¥ fundoscopics, thyroid, skin DM foot exam should include: inspection, pulses, & reflexes, senses of and ANSWERY ¥ patellar, Achilles, proprioception, vibration, monofilament AIC should be checked if eatment changes or not meeting goals, per year if stable ANSWERV V quarterly, twice Referrals for DM: dilated eye exam every planning for women, registered for medical nutrition therapy, dental exam, diabetes education, this if needed ANSWERYV ¥ year, family, dietician, self-mgt, mental health Drugs that sensitize body to insulin and/or control hepatic glucose production ANSWERV V thiazolidincdiones, biguanides, GLP-1 receptor agonist Drugs that stimulate pancreas to make more insulin ANS WERV V sulfonylureas, meglitinides, GLP-1 receptors, DPP-4 inhibitors Drugs that slow absorption of starches ANS WERV ¥ alpha-glucosidase inhibitors The sulfonylureas do this examples, effect on AIC, SE, least ANSWERVJY inerease endogenous insulin scerction, glimepiride (amaryl), glyburide (micronase), glipizide (glucotrol), 1-2%, hypoglycemia, wt gain, expensive The biguanides do this, examples, effect on AIC, SE ANSWERV Vv decrease hepatic glucose production and increase insulin-mediated peripheral glucose uptake (reduce fasting plasma glucose), metformin (glucophage), 1-2%, diarrhea/abd discomfort, lactic acido: small decrease LDL and triglycerides, possible small wt loss, contraindicated with impaired creatnine Fast secretagogues (meglitinides) work by, effect on AIC ANSWERY ¥ stimulate insulin secretion (rapid/short duration) decreases post prandial glucose and plasma glucose, repaglinide (prandin), nateglinide (starlix), 1-2%, hypoglycemia (less than with sulfonylureas if variable eating schedule), wt gain, no chhange lipids, safe at higher creatnine than sulfonylureas Alpha-glucosidasc inhibitors work by. examples, effect on AIC, SE ANSWERV blocking enzymes that digest starches in small intestine, decrease post prandial and fasting, acarbose (precose), miglitol (glyset), 0.5-1%, flatulence/abd discomfort, no change lipids/bp/wt, contraindicated in inflammatory bowel disease and cirrhosis DPP-4 inhibitors, effect on AIC ANSWER V sitagliptin (januvia), saxagliptin (onglyza), 0.6-0.8% Amylin agonist, effect on AIC ANSWERV ¥ pramlintide (symlin), 0.5-0.7% Thiazolidinediones work like this. examples, effect on AIC, take this long to work, SE ANSWERV ¥ decrease insulin resistance by making muscle and adipose more sensitive to insulin and suppress hepatic glucose production, decrease fasting glucose, pioglitazone (actos), rosiglitazone (avandia), 0.5-1%, 6 weeks, wt gain, edema, hypoglycemia if taken with insulin or stimulators, contraindicated in abnormal livers and CHF, macular edema, improves HDL and triglycerides, LDL neutral Rosiglitazone (Avandia) has this due to associated higer risk ANSWERV ¥ black box, CV Incretin mimetics, indicated as to improve control in pts taking these 3 5 effect on AIC ANSWERV V GLP-1 exenatide (byetta), (bydurcon), liraglutide (victoza), adjunctive, metformin, sulfonylure, byetta insulin, 0.5-1% Pramlintide (symlin) amlyin effects ANSWER 4 Vv inhibit inappropriately high postprandial glucagon secretion, slows gastric emptying, promotes satiety and reduces caloric intake Incretin enhancers: DPP-4 inhibitors retard this ; enhance secretion, ihibit secretion, improve function, examples ANS WERV V degradation of endogenous GLP-1, insulin, glucagon, beta-cell, sitagliptin (januvia) and saxagliptin (onglyza) Saxagliptin and sitagliptin are agents require dosing, are neutral, reduce Ig, a and glucose levels ANSWERV ¥ oral, daily, fasting, postprandial add insulin to oral agent when AIC is > on oral agents ANSWERV ¥ 6.5, two Add single, evening basal insulin dose of units of these types ANSWERV ¥ ten, glargine (lantus), detemir (levemir), or NPH When adding insulin to oral agents, increase insulin dose by units for FPG 100-120 ANSWERVV 2 When adding insulin to oral agents, increase insulin dose by units for FPG 121-140 ANSWERV V 3 When adding insulin to oral agents, increase insulin dose by units for FPG >=140 ANSWERV Vv 4 New insulins: rapid acting: ANS WERV V aspart (novolog), glulisine (apidra), lyspro (humalog) New insulins: long acting: ANSWERV ¥ glargine (lantus), detemir (levemir), neutral protamine hagedorn (NPH): humulin N, NPH Ilctin, Novolin N, and ultralente (humulin U) Rapid acting: Aspart (novalog) onset, peak, duration ANS WERV V 10-20 min, 1-3 hours, 305 hours Rapid acting: Lispro (humalog) onset, peak, duration ANSWERV V 15-30 min, 0.5-2.5 hours, 3-6.5 hours Rapid acting: Glulisine (apidra) onset, peak, duration ANSWERV V 10-15 min, 1-1.5 hours, 3-5 hours Short acting: (human) onset, peak, duration ANSWERV V 30-60 min, 1-5 hrs, 6-10 hrs Intermediate acting (human) NPH onset, peak, duration ANSWERV V 1-2h, 6-14 hrs, 16- 24> hours Long acting (analog) (basal) Detemir (Levemir) onset, peak, duration ANSWERV ¥ 0.8- 2hrs, no peak, up to 24 hrs DM care should be aligned with components of to ensure productive interactions between prepared proactive practice team and an informed activated patient ANSWERV 4 Chronic Care Model ‘Treatment decisions should be based on evidence-based guidelines that are tailored to individual patient FI and. ANSWERY ¥ preferences, prognoses, comorbidities A patient centered communication style should be employed that incorporates patient assesses literacy and numeracy, and addresses cultural barriers to care ANSWERV V preferences Failure to achieve goal is a result of failure to treat ANSWERYV ¥ to target Tf oral therapy with 2 agents fails to halt progression of DM, consider as early as possible to achieve goal ANSWERV ¥ insulin Even a modest reduction in reduces microvascular risk and very likely risk for macrovascular damage ANSWERV V AIC less stringent AIC goal of less than 8 can be appropriate if there is history of severe limited 5 or complications, extensive , or in those difficult to get to goal despite self management education, appropriate , and effective doses of multiple agents including ANSWERV ¥ hypoglycemia, life expectancy, co- morbidities, glucose monitoring, insulin DM BP goal ANSWERV ¥ <140/80, 130/80 or lower in select patients if asymptomatic and tolerable DM pharm therapy should include ANS WERV V ACEI or ARB Generally required to achieve BP targets in DM ANSWERV V multiple drugs (two or more at max doses) DM BP one or more of these should be given at ANSWERV ¥ bedtime DM cholesterol goals: TC ANSWERV V¥ < 200 DM cholesterol goals: LDL-C ANSWERV ¥ <100 or < 70 with overt CVD DM cholesterol goals: IDL-C ANSWERV ¥ > 40 men, > 50 women DM cholesterol goals: triglycerides ANSWERV V < 150 Statin therapy should be added to lifestyle therapy regardless of lipid levels for diabetic patients in these conditions ANSWERV ¥V with overt CVD or without CVD over age of 40 with one risk factor (family hx, htn, smoking, dyslipidemia, albuminuria) After metformin, If Alc remains above 7%, consider ANSWERV V additional oral class or insulin if initial Alc >=9% consider ANSWERV ¥ insulin (basal first, then bolus if needed) DM therapies: sulfonylureas ANS WERV V glimepiride (Amaryl) glyburide (Micronase) glipizide (Glucotrol) DM therapies: biguanides ANSWER V metformin (Glucophage) DM therapies: fast secretagogues (meglitinides) ANS WERV V repaglinide (Prandin) Nateglinide (Starlix) DM therapies: alpha-glucosidase inhibitors ANS WERV V Acarbose (Precose) Miglitol (Glyset) DM therapies: DPP-4 inhibitors ANSWER¥ ¥ Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Alogliptin (Nesina) DM therapies: Amylin agonists ANSWERV V pramlintide (Symlin) DM therapies: thiazolidinediones ANSWERV ¥ pioglitazone (Actos) Rosiglitazone (Avandia) DM therapies: Incretin mimetics ANSWERV J GLP-1 Exenatide (Byetta) Liraglutide (Victoza) DM therapies: SGLT2 inhibitors ANSWERV ¥ Canaglilozin (Invokana) Dapaglifozin (Farxiga) Sodium glucose cotransporter 2 inhibitors (SGLT2) work by -----; decrease renal glucose in the proximal tubules, lower the renal for glucose, increase excretion of ANSWERY ¥ inhibiting sodium glucose cotransport absorption; reabsorption, threshold, urinary glucose SGLT2I contraindications ANSWERV Vv severe renal impairment (GFR < 30, ESRD, dialysis) SGLT2I cautions ANSWERV¥ ¥ intravascular volume contraction (increases hypotension) RAAS agents, diurclics, polassium sparing drugs (hyperkalemia), hypoglycemia compounded if given with insulin or insulin secretagogues SGLT21 SE ANSWERYV ¥ hypotension 
