Diabetes
mellitus, Type 2
Pt with
symptoms AND
2 fasting glu levels >125mg/dL
then =
diabetes (no GTT)
Non-ketosis prone hyperglycemia and glucose intolerance due to defects
in insulin secretion and peripheral insulin action.
80% of diabetic cases.
Genetics:
Strong polygenic familial susceptibility. Concordance is nearly complete in
identical twins.
SIGNS AND
SYMPTOMS
Related to
hyperglycemia and complications including nephropathy, neuropathy, and
retinopathy
Polyuria
Polydipsia
Polyphagia
Weight loss
Weakness
Fatigue
Frequent
infections
LABORATORY
Criteria
for diagnosis
Symptoms
of diabetes (polyuria, polydipsia,
weight loss) plus casual (random) plasma glucose >=200 mg/dL (11.1 mmol/L)or
Fasting
plasma glucose >=126 mg/dL (7.0 mmol/L) on 2 occasionsor
2 hour
plasma glucose >=200 mg/dL (11.1 mmol/L) during OGTT with 75 g glucose load
LFTs,
amylase, lipase - abd pain
TREATMENT
APPROPIATE
HEALTH CARE
Regular
outpatient follow-up except for complicating emergencies such as severe
hyperglycemia, hyperosmolar coma, and severe
infections
GENERAL
MEASURES
Home
monitoring of blood glucose
Regular
examination for complications: retinopathy, neuropathy, nephropathy
ACTIVITY
Regular
aerobic exercise can improve glucose tolerance and decrease medication
requirements
DIET
American
Diabetes Association (ADA) provides dietary recommendations for NIDDM. The
emphasis is on achieving glucose, lipid, and blood pressure goals. Mild caloric
restriction is recommended to achieve mild to moderate weight loss (5-10 kg).
Food
choices are similar to Dietary Guidelines for Americans and the Food Guide
Pyramid:
10-20% of
calories from protein
< 10%
of calories each from saturated and polyunsaturated fat
Remainder
of calories from monounsaturated fat and carbohydrates, depending on individual
patient factors
Sugar is
not specifically prohibited
PATIENT
EDUCATION
Education
is critical for patients with NIDDM. Include information on the disease,
medication treatment, self-monitoring, foot care, physical activity and diet
management
Support
groups and classes certified by the
The
MEDICATIONS
DRUG(S) OF
CHOICE
The
following classes of agents may be used alone or in combination-
Biguanide
Metformin (Glucophage)
500-850 mg bid-tid. Avoid metformin
in situations which increase risk for lactic acidosis: renal insufficiency, radiocontrast agents, surgery or acute illnesses such as
liver disease, cardiogenic shock, pancreatitis
or hypoxia. Use caution in CBF, alcohol abuse, elderly or with tetracycline.
Sulfonylureas
Glimepiride (Amaryl) 1-8 mg/d in 1 dose
Glipizide
(Glucotrol) 2.5-40 mg/d in 1-2 doses (1st 20 mg in
AM)
Glipizide
extended release tablets 5-20 mg/d in 1 dose
Glyburide
(DiaBeta, Micronase)
1.25-20 mg/d in 1-2 doses (1st 10 mg in AM)
Note: sulfonylureas may be taken with meals except glipizide which should be taken 30 min before meals
Thiazolidinediones
Pioglitazone (Actos) 15-45 mg qd
Rosiglitazone (Avandia) 2-4 mg bid. Monitor serum transaminase q 2 mo for 1st year.
a-Glucosidase inhibitors
Acarbose(Precose)25-100 mg tid
Miglitol (Glyset)
25-100 mg tid taken at beginning of meals to decrease
postprandial glucose peaks. Avoid use in renal insufficiency, inflammatory bowel
disease, colonic ulceration or partial bowel obstruction.
Contraindications:
To oral
agents: type I (insulin dependent) diabetes mellitus, ketotic
patient, pregnancy, history of specific drug allergy
Use
caution in liver or renal disease and acute infection or stress
Precautions:
Warn
patients of signs of hypo- and hyperglycemia
Home
glucose monitoring (1-4 times/d) recommended for most
patients taking insulin
Significant
possible interactions:
Drugs
which may potentiate sulfonylureas
include: salicylates, clofibrate,
warfarin (Coumadin), chloramphenicol, ethanol, and ACE inhibitors
Beta-blockers
may mask symptoms of hypoglycemia and delay return to normoglycemia
Thiazolidinedione pioglitazone may decrease
effectiveness of oral contraceptives
Drugs
which bind others in the intestine, such as cholestyramine
resin, should be taken at least 2 hours apart from a-glucosidase
inhibitors
ALTERNATIVE
DRUGS
First
generation sulfonylureas
Chlorpropamide (Diabinese) 100-500 mg/d in 1 dose
Tolazamide
(Tolinase) 100-1000 mg/d in 1-2 doses
Tolbutamide (Orinase) 500-3000 mg/d in 2-3 doses
Insulin - lispro, regular, NPH, Lente, Ultralente in 1 or preferably 2-3 injections per day.
Insulin may be used in combination with oral agents. Most
often required in late stages of Type 2 diabetes mellitus when oral agents fail
to control blood glucose.
Meglitinide
Repaglinide (Prandin)
0.5-4 mg before meals tid. May be useful in
patients with sulfa allergy who are not candidates for sulfonylureas.
FOLLOWUP
PATIENT
MONITORING
Frequency
of followup depends on compliance and degree of
metabolic control. Every two to four months is typical.
Review of
symptoms and home blood glucose levels
Hemoglobin
A1c
Funduscopy
Cardiopulmonary
exam
Foot exam
for ulcers, arterial insufficiency, neuropathy
After five
years, perform yearly: Ophthalmologist exam, monitor for proteinuria
and renal insufficiency
PREVENTION/AVOIDANCE
Avoidance
of weight gain and obesity and maintenance of regular physical activity may
prevent or delay NIDDM
EXPECTED
COURSE/PROGNOSIS
Maintenance
of normal blood sugar levels may delay or prevent complications of diabetes
In susceptible
individuals, complications begin to appear 10-15 years after onset, but can be
present at time of diagnosis since disease may go undetected for years
AGE-RELATED
FACTORS
Pediatric:
Occasional cases of nonketosis-prone diabetes
mellitus have been seen in children
Geriatric:
Common in the elderly and is a significant contributing factor to blindness,
renal failure, and lower limb amputations
Others:
Generally diagnosed after age 40
PREGNANCY
Diabetes
can cause significant maternal complications and fetal wasting. Intensive
management has improved the outcome dramatically.