Untitled Quiz

• Diabetes mellitus (DM) involves inadequate control of blood glucose levels.
• Cardinal signs of DM include Polydipsia, Polyuria, and Polyphagia.
• Type 1 DM results from low or absent insulin, positive β-cell autoantibodies, and ketosis.
• Type 2 DM is is due to a progressive insulin secretory defect and insulin resistance.
• Type 1 is characterized by a lack of insulin, while in Type 2, insulin does not function correctly.

Screening Guidelines

• Organizations like the American Association of Clinical Endocrinologists recommend screening for diabetes in individuals with risk factors.

Classic Presentation

• Most patients are asymptomatic, with hyperglycemia detected during routine lab evaluations.
• Common symptoms: polydipsia, polyuria, nocturia, blurred vision, fatigue, slow wound healing, frequent infections, and tingling in hands and feet.
• Polyuria occurs when serum glucose concentration exceeds 180mg/dL, which is the renal threshold.
• Type 2 diabetes may present with subtle symptoms for weeks, months, or years before detection.

Pathophysiology

• Type 2 DM involves insufficient insulin secretion and increased insulin resistance.
• Genetic and environmental factors contribute to the development of Type 2 DM.
• Genes, viruses, microbiome, activity levels, and diet all play a role.
• Inflammation and metabolic stress along with autoimmune functions contribute.
• β-Cell destruction and dysfunction may occur.
• Hyperglycemia can lead to complications like retinopathy and neuropathy.

Type 2 DM

• Previously known as "non-insulin-dependent diabetes" or "adult-onset diabetes".
• Type 2 DM accounts for 90-95% of all diabetes cases.
• Individuals with insulin resistance and insulin deficiency are usually those with Type 2 DM.

DM Screening in Asymptomatic Adults – Risk Factors

• Overweight or obese adults with a BMI >25, or >23 for Asian Americans.
• Physical inactivity.
• First-degree relative with diabetes.
• Ethnicity: African American, Latino, Native American, Asian American or Pacific Islander.
• Women who delivered a baby weighing 9 lbs or who were diagnosed with GDM.
• Hypertension (>140/90 mmHg or on therapy).
• HDL cholesterol level 35 mg/dL or a triglyceride level 250 mg/dL (2.82 mmol/L).
• Women with polycystic ovary syndrome.
• A1C 5.7%, IGT, or IFG on previous testing.
• Clinical conditions associated with insulin resistance, like severe obesity and acanthosis nigricans.
• History of CVD.

Screening Criteria

• Testing should start for all patients at age 45.
• If results are normal, repeat testing at least every 3 years.
• More frequent testing is recommended if earlier results were prediabetic.

Diagnostic Tests

• Normal fasting serum glucose is <100 mg/dl.
• Prediabetes: 100-125mg/dl.
• Diabetes: ≥126 mg/dl on two separate occasions.
• Normal HbA1c is <5.7%.
• Prediabetes: 5.7-6.4%.
• Diabetes: >6.5%.
• Normal result for the oral glucose tolerance test is <140mg/dl.
• Prediabetes: 140-199mg/dl
• Diabetes: >200mg/dl after 2 hours.
• Urinalysis may show proteinuria or glucosuria.
• Normal C peptide is 0.51-2.72 ng/dl.
• C peptide for Type 1 DM <0.51 ng/dl.
• C peptide for Type 2 DM >2.72 ng/dl.
• Fasting lipid profile and liver function tests should be conducted if not performed in the past year.
• A spot urinary albumin-to-creatinine ratio, serum creatinine, and estimated GFR measurement.
• If dyslipidemia testing shows that the female patient is over 50, test TSH levels.

Comprehensive Medical Evaluation Includes:

• Age and characteristics of diabetes onset.
• Nutritional status, weight history, and physical activity habits, include nutrition education and behavioral support.
• Common comorbidities, psychosocial problems, and dental disease.
• Screening for depression using PHQ-2 or PHQ-9.
• Screening for diabetes distress using DDS or PAID-1.
• History of smoking, alcohol, and substance use.
• Diabetes education, self-management, and support history and needs.

Physical Examinations should include;

• Height, weight, BMI (growth and pubertal development in children and adolescents).
• Blood pressure measurement (including orthostatic measurement).
• Eye examination (fundoscopy).
• Oral cavity inspection (for gum disease, fungal infections, or lesions).
• Neck palpation (thyroid).
• Cardiac assessment (HR, rate, rhythm, murmurs, clicks, or extra heart sounds).
• Skin assessment (for irritation, infection, redness, ulcers, dryness, acanthosis nigricans).
• Foot assessment (pulses, reflexes, sensation, and overall skin condition).

Glycemic Targets

• HgbA1C should be <7.0% for most non-pregnant adults.
• Pre-prandial capillary plasma glucose should be between 80-130 mg/dL.
• Peak postprandial capillary should be <180 mg/dL (1-2 hours after meals).
• More stringent A1C goals (such as 6.5%) are acceptable if hypoglycemia or other adverse effects of treatment can be avoided.
• Less stringent A1C goals (8%) may be suitable for patients with severe hypoglycemia, advanced microvascular or macrovascular complications.

Glycemic Testing

• Perform an A1C test twice a year, as patients with stable, controlled diabetes will benefit.
• Perform an A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals.
• Continuous Glucose Monitoring (CGM) has been approved by the FDA for those over 18.

AIC Goals

• Patient factors to consider include age, disease duration, life expectancy, hypoglycemia risk, presence of comorbid conditions.
• Also consider the degree of social support, and they ability and attitude patient has toward implementing the treatment.
• Younger and newly diagnosed patients should have stricter AIC goals.

Treatment

• Once blood sugar targets are identified, treatment should focus on an agent that has minimum hypoglycemia and weight gain.
• Treatment should primarily be directed toward comorbid CV and renal risk factors as a primary consideration.
• Metformin (500mg - 2,000mg/day) is the foundational treatment for Type 2 DM, and lifestyle modification (weight loss, increased physical activity and healthy eating).

Medications

• Metformin lowers A1C by 1.0-2.0% and has high efficacy and a neutral effect on weight.
• SGLT2 inhibitors lower A1C by <1.0% and result in weight loss.
• DPP-4 inhibitors lowers A1C by 0.5-0.8% with moderate high efficacy and has a neutral effect on weight..
• TZD pioglitazone lowers A1C by 0.5-1.0% with moderate high efficacy and causes weight gain
• SU glimepiride lowers A1C by 1.0-2.0% with high efficacy and may cause hypoglycemia and weight gain.
• GLP-1 RA semaglutide lowers A1C by 0.6-1.5% with high efficacy and results in weight loss.
• Glinides nateglinide lowers AIC by 0.4-0.9% with high efficacy, but may cause hypoglycemia with weightgain.

Treatment Strategies

• Treatments are added stepwise if patients do not achieve their AIC goals after monotherapy.
• Combination therapy can be considered as an initial line if a patient A1C is greater or equal to 9%, or greater than 7% if they were only on monotherapy.
• Be mindful of inducing hypoglycemia when lowering a patients glucose as part of aggressive treatment.
• Medication choice is based on patient co-morbidities and cost.
• Sulfonaureas are cheap but they have a high association with hypoglycemia weight gain.
• Assess the effectiveness of the treatment every 3 months.
• Aggressive and early treatment leads to a reduction in micro and macro vascular risks.

Treatment focus

• Treatment addresses fasting plasma (FPG) and post prandial Glucose (PPG) for A1C goals.
• Hyperglycemia is driven by FPG at higher A1c levels, but PPG predominates when AIC drops below 7.5%.
• Largely, basal insulin targets FPG.
• When DM-2 patients are using 50 to 60 units/day of basal insulin, they must seek treatment improvement that involves FPG.

Non-Pharmacologic Interventions

• Exercise at least 150 minutes/week of moderate-intensity aerobic physical activity, spread over at least 3 days/week.
• Resistance training ≥2 times/wk, reducing sedentary time by breaking it (>90 minutes).
• Avoid alcohol and avoid smoking (including e-cigarettes).
• Weight loss – 5-10%.
• Medical Nutrition Therapy (MNT) with 3 registered dietician visits and ongoing follow-ups.

Follow Up Plan

• Monthly follow ups should be scheduled during the initial treatment.
• A1c should be measured every 3 months if treated with medication
• A1c should be less than 7 percent
• Get serum creatinine, ECG,TSH measure yearly.
• An exam of the feet and if necessary refer out to Podiatry.
• Make sure the patients vaccinations are appropriated for their age.

Screenings for Comorbid Conditions:

• Coronary heart disease screenings should be done to identify at risk patients for elevated BP, fasting lipid profile, and smoking history.
• Sedentary adults older than 50 EKG should be completed before starting exercise program.
• Fatty liver disease screenings.
• Hearing test to screen for hearing impairment.
• Obstructive sleep apnea screening.
• Patients should to get a dental exam and periodontal disease screenings.
• Cognitive impairment assessment/screening.
• Depression and fractures assessments/ screenigns.
• Renal impairment tests.
• Annual eye exam should be done .

Referrals/Consultations:

• Ophthalmologist is needed for annual dilated eye exam.
• Women of reproductive age should have family planning.
• Registered dietitian is needed for medical nutrition therapy (MNT).
• Type 2 DM - Endocrinologist if hyperglycemia persists despite use of oral agents and/or insulin.
• Patients should have a diabetes self-management education (DSME).
• Patients should have a diabetes self-management support (DSMS).
• Patients need a Dentist for comprehensive dental and periodontal examination.
• Patients need to see a podiatrist.

Evaluation

• Review of current management and response to therapy.
• Review of current results of glucose and patient's use of data.
• Understand frequency, severity, and cause of prior episodes of Diabetic ketoacidosis.
• Understand frequency, severity, and cause of possible Hypoglycemia.
• History of elevated BP, lipids and tobacco use.
• Assess microvascular complications, including retinopathy, nephropathy, and neuropathy.
• Assess macrovascular complications, including coronary heart disease, cerebrovascular disease, and peripheral arterial disease.