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Diabetes Mellitus Type 2
Diabetes is a huge topic. I continue to struggle with how much information to put into these review topics. How much is too much detail for a physician assistant exam review. How much is not enough? I guess I’ll find out when I take my PANRE. For our purposes I have decided to split up DM1 and DM2 and cover them separately. Some of the symptoms and information will overlap, but I think it makes the most sense to cover this topic in two parts.
General information
- 90% of DM is Type 2
- 30% of DM Type 2 patients require insulin
- Overweight – specifically abdominal fat
- Middle aged or older
- DM 2 patients produce insulin however, they have developed an insulin resistance. Receptors and tissues do not respond to the insulin.
- Genetic component
- affects African-Americans, Hispanics and Pima Indians at a high rate
- DM is the leading cause of blindness in the United States
- DM accounts for approximately 30% of end stage renal disease om U.S.
- DM patients are at increased risk for atherosclerosis
Clinical Findings
- Patients generally have no symptoms initially and the diagnosis is suspected secondary to routine blood work or due to body habitus. The onset of DM2 is insidious.
- Insulin response is enough to prevent ketoacidosis
- Increase rate of yeast infection in women
- Poor wound healing
- Eye
- blurred vision
- glaucoma
- cataracts
- Orthostatic hypotension due to to autonomic neuropathy and low plasma volume
- Neuropathy
- loss of sensation in limbs in a stocking glove distribution.
- 50-80% of non traumatic lower extremity amputations are secondary to DM. Video of 2nd toe debridement in a patient with a diabetic necrotic wound.
- atonic bladder
- erectile dysfunction
- delayed gastric emptying
Labs
- fasting blood glucose levels of >126 mg/dL on more than once occasion is diagnostic
- nonfasting 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. 3.8-6.3% is normal.
- patients may have glucosuria and ketonuria
- Lipid panel changes
- Elevated triglycerides 300-400 mg/dl
- Low HDL <30 mg/dl
Treatment
- Diet, Education and Exercise
- This is the first and most important step for DM2 patients.
- Weight loss and exercise can reduce risk significantly and may restore insulin sensitivity.
- Increase fiber and complex carbohydrates
- Monitor carbohydrate intake
- Eat snacks and meals at regular intervals
- Patient glucometer if necessary
- Medications
- Stimulation of insulin secretion – the most common class is sulfonylureas
- glypburide
- glipizede
- glimepiride
- Glucose lowering drugs
- Metformin – reduces hepatic glucose production. First line therapy
- alpha-Glucosidase inhibitors – decrease carbohydrate absorption from the intestine
- acarbose
- miglitol
- Thiazolidinediones – increase tissue sensitivity to insulin
- rosiglitazone
- pioglitazone
- Insulin therapy for patients who do not have an adequate response to other medications.
- Patients have increased risk for cardiovascular events
- Treat HTN aggressively
- Manage hyperlipidemia
- Regular visits to podiatrist for foot care.
- Regular diabetic eye exam
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