Download Diabetes mellitus typus 2 in primary care

Diabetes mellitus
 Diabetes mellitus (DM)
is a heterogeneous group
of disorders caused by a
relative or absolute
insulin deficiency,
resulting in
abnormalities of
carbohydrate and fat
metabolism.
Clasification of diabetes
Pathophysiology
 Type 2 diabetes is
characterized by a
combination of
peripheral insulin
resistance and
inadequate insulin
secretion by pancreatic
beta cells.
Pathogenesis
The major risk factors for type 2 DM
 Age greater then 45
 Weight greater than 120% of desirable body weight
 Family history of type 2 diabetes in first-degree
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relative
History of previous impaired glucose tolerance(IGT) or
impaired fasting glucose(IFG)
Hypertension (>140/90) or dyslipidemia ( low HDL,
high TG>150)
History of gestational diabetes mellitus
Polycystic ovarian syndrome
Epidemiology
 The prevalence of type 2
DM is increasing,
mirroring the increase in
the prevalence of obesity
 prevalence of the disease
increases with advancing
age.Type 2 diabetes
mellitus occurs most
commonly in adults aged
40 years or older
 The prevalence of type 2
diabetes mellitus varies
widely among various
racial and ethnic groups.
Epidemiology
 USA:Diabetes affects 8.3% of Americans of all ages,
11.3% of adults aged 20 years and older, and 25% of
persons age 65 and older, Prediabetes affects 35% of
adults aged 20 years and older
 POLAND: 10,8% people diabetes near 17 % prediabetes
Diagnosis Symptoms and signs
 Many patients with type 2 DM are relatively asymptomatic
 Classic symptom:polyuria, polydipsia, polyphagia weight
loss, fatigue
 Blurred vision
 Lower-extremity paresthesias
 Yeast infection
 Ketoacidosis at the time of diagnosis is rare
Screning test for DM
 recommends testing for prediabetes and diabetes beginning at age 45
years all patients.If results are normal, testing should be repeated at
least every 3 years.
 recommends considering testing for prediabetes and diabetes in
asymptomatic adults who are overweight and have 1 or more of the
following additional risk factors :
Physical inactivity
First-degree relative with diabetes
Member of a high-risk ethnic population
Delivered a baby weighing over 9 lb or diagnosed with gestational diabetes
mellitus
Hypertension (≥140/90 mm Hg or on therapy for hypertension)
HDL cholesterol level under 35 mg/dL (0.90 mmol/L) and/or a triglyceride level
above 250 mg/dL (2.82 mmol/L)
Polycystic ovary disease
IGT or IFG on previous testing
Other clinical conditions associated with insulin resistance (severe obesity,
acanthosis nigricans)
History of cardiovascular disease
Laboratory tests: FPG, OGTT
Diagnostic criteria by ADA,EASD
include the following:
 A fasting plasma glucose (FPG) level of 126 mg/dL (7.0
mmol/L) or higher, or
 A 2-hour plasma glucose level of 200 mg/dL (11.1
mmol/L) or higher during a 75-g oral glucose tolerance
test (OGTT), or
 A random plasma glucose of 200 mg/dL (11.1 mmol/L)
or higher in a patient with classic symptoms of
hyperglycemia or hyperglycemic crisis
 Whether a hemoglobin A1c (HbA1c) level of 6.5% or
higher should be a primary diagnostic criterion or an
optional criterion remains a point of controversy
Type 2 DM is a progressive disease
Complications of diabetes.
 The prognosis in patients
with diabetes mellitus is
strongly influenced by the
degree of control of their
disease
 the typical patient with
type 2 diabetes had
diabetes for at least 4-7
years at the time of
diagnosis, 25% had
retinopathy; 9%,
neuropathy; and 8%,
nephropathy at the time of
diagnosis
Approaches to prevention of diabetic
complications include the following:
 HbA1c every 3-6 months
 Yearly dilated eye examinations
 Annual microalbumin checks
 Foot examinations at each visit
 Blood pressure < 130/80 mm Hg, lower in diabetic
nephropathy
 Statin therapy to reduce low-density lipoprotein
cholesterol
Diabetes mellitus-associated
mortality and morbidity
 DM causes morbidity and mortality because of its role in
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the development of cardiovascular, renal, neuropathic, and
retinal disease.
DM is the major cause of blindness in adults
DM is the leading contributor to end-stage renal disease
DM is the leading cause of nontraumatic lower limb
amputations
The risk for coronary heart disease (CHD) is 2-4 times
greater in patients with diabetes than in individuals
without diabetes. Cardiovascular disease is the major
source of mortality in patients with type 2 DM
People with type 2 DM are at an increased risk for many
types of cancer
Goals of treatment of DM are as
follows:
 Microvascular ( eye and kidney disease) risk
reduction through control of glycemia and blood
pressure
 Macrovascular ( coronary, cerebrovascular, peripheral
vascular) risk reduction through control of lipids and
hypertension, smoking cessation
 Metabolic and neurologic risk reduction through
control of glycemia
Treatment
 Diabetes care is best provided by a multidisciplinary
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team of health professionals working in collaboration
with the patient and family. Management includes the
following:
Appropriate goal setting
Dietary and exercise modifications
Medications
Appropriate self-monitoring of blood glucose (SMBG)
Regular monitoring for complications
Laboratory assessment
Dietary Modifications
 Modest weight losses of 5-
10% have been associated
with significant
improvements in
cardiovascular disease risk
factors ( decreased HbA1c
levels, reduced blood
pressure, increase in HDL
cholesterol, decreased plasma
triglycerides) in patients with
type 2 diabetes mellitus. Risk
factor reduction was even
greater with losses of 10-15%
of body weight
 Mediterranean-style diet
 Activity Modifications
Most patients with type 2 diabetes mellitus can benefit
from increased activity. Aerobic exercise improves
insulin sensitivity
 Bariatric Surgery
In morbidly obese patients, bariatric surgery has been
shown to improve diabetes control and, in some
situations, normalize glucose tolerance
Pharmacologic Therapy
 Early initiation of pharmacologic therapy is associated with
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improved glycemic control and reduced long-term complications
in type 2 diabetes. Drug classes used for the treatment of type 2
diabetes include the following:
Biguanides
Sulfonylureas
Meglitinide derivatives
Alpha-glucosidase inhibitors
Thiazolidinediones (TZDs)
Glucagonlike peptide–1 (GLP-1) agonists
Dipeptidyl peptidase IV (DPP-4) inhibitors
Selective sodium-glucose transporter-2 (SGLT-2) inhibitors
Insulins
Metformin
 Metformin is the preferred initial agent for
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monotherapy and is a standard part of combination
treatments. Advantages of metformin include the
following:
Efficacy
Absence of weight gain or hypoglycemia
Generally low level of side effects
High level of patient acceptance
Relatively low cost
Metformin
 Metformin lowers basal and postprandial plasma glucose
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levels
The dose of metformin is titrated over 1-2 months to at
least 2000 mg daily, administered in divided doses (during
or after meals to reduce gastrointestinal [GI] side effects).
Exercise increases metformin levels and interferes with its
glucose-lowering effect.
Metformin reduces macrovascular risk in patients who are
obese[
Metformin may decrease the risk of dementia associated
with type 2 diabetes
Sulfonylureas
 Sulfonylureas ( glipizide, glimepiride) are insulin
secretagogues that stimulate insulin release from
pancreatic beta cells and probably have the greatest
efficacy for glycemic lowering of any of the oral agents
 hypoglycemia the most common side effect.
 have the greatest efficacy for glycemic lowering of any
of the oral agents.
 that effect is only short-term and quickly dissipates.
 Alpha-glucosidase inhibitors
 These agents delay sugar absorption and help to prevent postprandial
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glucose surges
Meglitinide derivatives
Meglitinides ( repaglinide, nateglinide) are much shorter-acting
insulin secretagogues than the sulfonylureas are
Thiazolidinediones
TZDs ( pioglitazone , rosiglitazone ) act as insulin sensitizers
Glucagonlike peptide–1 agonists
GLP-1 agonists (, exenatide, liraglutide) mimic the endogenous incretin
GLP-1; they stimulate glucose-dependent insulin release, reduce
glucagon, and slow gastric emptying
Dipeptidyl peptidase IV inhibitors
DPP-4 inhibitors ( sitagliptin, saxagliptin, linagliptin) are a class of
drugs that prolong the action of incretin hormones
insulins
Treatment of DM t 2 Management
of Glycemia
Monitoring - goals must be
individual
 HbA1c (%) <6.5 IFD <7.0 ADA
 Fasting/preprandial glucose
 (mmol/L / mg/dL)
<6.0 / <110 IFD
3.9-7.2 /
70-130
ADA
 2-h postprandial glucose
 (mmol/L / mg/dL)
<7.8 / <140 IFD <10.0 /
<180*
ADA
 *ADA recommends that postprandial glucose
measurements should be made 1–2 h after the
beginning of the meal.
Self-monitoring of blood glucose in noninsulin treated type 2 diabetes (SMBG)
 SMBG should be considered at the
time of diagnosis to enhance the
understanding of diabetes as part
of individuals’ education and to
facilitate treatment initiation and
titration optimization.
 SMBG should also be considered as
part of ongoing diabetes selfmanagement education to assist
people with diabetes to better
understand their disease and
provide a means to actively and
effectively participate in its control
and treatment, modifying
behavioural and pharmacological
interventions as needed
Management of Dyslipidemia
Management of Hypertension
 Prefers inhibitors of the renin-angiotensin system
(ACE inhibitors, ARBs) because of their proven renal
protection effects in patients with diabetes.
 Diuretics or calcium channel blockers frequently are
useful are second and third agents.
 The SBP goal is < 140 mm Hg in patients with diabetes
 The target diastolic blood pressure (DBP) remains <
80 mm Hg.
Prevention of Type 2 Diabetes
Mellitus
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Weight reduction
Proper nutrition
Regular physical activity
Cardiovascular risk factor
reduction
 Aggressive treatment of
hypertension and
dyslipidemia
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Criteria for preventive
metformin therapy are as
follows:
Obesity
Age younger than 60 years
Both impaired fasting glucose
(IFG) and impaired glucose
tolerance (IGT)
Other risk factors ( HbA1C
>6%, hypertension, low HDL
cholesterol, elevated
triglycerides, or a family
history of diabetes in a firstdegree relative