TYPE 2 DIABETES MELLITUS

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TYPE 2 DIABETES MELLITUS

• Cynthia Brown, MN, ANP, CDE

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Type 2 Diabetes Mellitus

• Epidemiology
• 25 million Americans or 8.3
• 7 million undiagnosed
• 1.9 million older than 20 diagnosed in 2010
• 7th leading cause of death
• In 2007, cost of treating 174 billion
• 1.5 million gt20 diagnosed per year

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Type 2 Diabetes Mellitus

• Epidemiology
• Leading cause of ESRD, blindness, amputation,
  impotence
• Heart disease stroke 2-4 times more common
• 90-95 of persons with diabetes have Type 2

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Type 2 Diabetes Mellitus

• Populations at risk
• Those older than 30
• Some children now diagnosed
• African Americans
• Native Americans
• Hispanics
• Asians
• Pacific Islanders

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Type 2 Diabetes Mellitus

• Populations at risk
• Family history in 1st or 2nd degree relative
• Hx gestational diabetes or baby gt9 lbs
• Signs of insulin resistance
• Hx pre-diabetes
• Hx vascular disease
• Physical inactivity

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Type 2 Diabetes Mellitus

• Diagnosing
• 1979 original WHO criteria-
• FBS gt140
• 2 hour gt200
• 1997 ADA
• Type 1
• Type 2
• Eliminated all other references to age, insulin
  usage

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Type 2 Diabetes Mellitus

• Diagnosing
• 1998 ADA
• Lowered FBS to 126
• Based on association between glucose levels
  development of retinopathy
• 2011 ADA accepted A1c gt6.5 as diagnostic lt6.5
  does not exclude diagnosis

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Type 2 Diabetes Mellitus

• Todays testing methods
• Fasting plasma glucose
• 1-2 hour post meal can be used if gt140, further
  testing indicated
• FPG lt100mg/dlnormal
• FPG gt100 lt126 IFG pre-diabetes
• FPG gt126diabetes

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Type 2 Diabetes Mellitus

• Oral glucose tolerance test still the gold
  standard
• 150 grams carb for 3 days prior
• 10-14 hour fast
• 75 gram glucose load
• No activity during test
• Do not perform in the ill, malnourished

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Type 2 Diabetes Mellitus

• Impaired Glucose Tolerance (IGT)
• Impaired Fasting Glucose (IFG)
• Glucose higher than normal, but not diagnostic of
  diabetes
• IGT random or 2-hour glucose gt140 but lt200
• IFG FPG gt100 but lt126

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Type 2 Diabetes Mellitus

• When to screen
• Start at age 45 every 3 years if normal
• Start younger if overweight or risk factors
  present
• Anytime fasting blood sugar not normal
• Easiest is a fingerstick
• Must note time of last food

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Type 2 Diabetes Mellitus

• Metabolic Defects
• Cellular resistance to effect of insulin
• Failing beta cells
• Loss of first phase response
• Decreased secretion of amylin
• Decreased secretion of incretins

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Type 2 Diabetes Mellitus

• Each metabolic defect causes a different problem
• Cellular resistance causes high circulating
  insulin levels
• Leads to fatigue and weight gain
• Low amylin-rapid emptying of stomach
• Low incretins-no sense of fullness
• Also problems with insulin secretion

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Type 2 Diabetes Mellitus

• Chronic disease syndrome associated with insulin
  resistance
• Metabolic Syndrome
• Dysmetabolic Syndrome
• Syndrome X

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Type 2 Diabetes Mellitus

• Syndrome features
• Central or visceral obesity
• Dyslipidemia
• Atherosclerosis
• Endothelial dysfunction
• Decreased fibrinolytic activitypro-thrombotic
• Hypertension
• Acanthosis

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Type 2 Diabetes Mellitus

• Syndrome Features
• PCOS
• Hyperuricemia
• Pre-diabetes

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Type 2 Diabetes Mellitus

• Inherited defect in insulin action
• Abnormal insulin signaling
• Abnormal glucose transport
• Abnormal glycogen synthesis
• Abnormal mitochondrial oxidation
• Hyperinsulinemia by downregulation of insulin
  receptor numbers post-receptor events

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Type 2 Diabetes Mellitus

• Enhanced lipolysis with elevation of free fatty
  acids aggravates insulin resistance
• Impairs glucose uptake at muscle
• Enhances hepatic glucose production
• Islet cell impaired in release of insulin

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Type 2 Diabetes Mellitus

• Impaired glucose tolerance overt diabetes
  develop when beta cells fail
• Cause of pancreatic exhaustion unknown
• When FBS 115, first phase insulin secretion lost

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Type 2 Diabetes Mellitus

• When FBS 180, all phases of insulin secretion
  markedly impaired.
• Gastric emptying accelerated
• Post prandial hyperglycemia
• Defects in appetite control satiety
• All treatments aimed at these metabolic defects

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Type 2 Diabetes Mellitus

• Insulin resistance
• Start with insulin sensitizers-
• Metformin (biguanide)
• Actos (TZD)
• Both re-sensitize person to own insulin
• Very different mechanisms
• Work at liver, muscle, islet cell

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Type 2 Diabetes Mellitus

• Pancreatic stimulators
• Glipizide, glyburide, glimepiride (sulfonylureas)
• Prandin, Starlix (secretagogues)
• Rapid acting beta cell stimulators
• Interact with ATP-dependent potassium channels of
  beta cells
• Glucose dependent action

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Type 2 Diabetes Mellitus

• Januvia, Onglyza, Tradjenta (DPP-4 inhibitors)
• Slows inactivation of incretin hormones
• Concentrations of GLP-1 GIP increase
• Enhances insulin release in glucose-dependent
  manner
• Suppress hepatic glucose production
• Lowers post-meal glucose levels

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Type 2 Diabetes Mellitus

• Byetta, Victoza (incretin mimetics)
• Glucoregulatory effects similar to glucogon-like
  peptide-1 (GLP-1)
• Secreted by gut in response to food
• Very short half-life
• Restore first-phase insulin response
• Suppress post-meal glucagon
• Slows gastric emptying

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Type 2 Diabetes Mellitus

• Precose, Glyset (alpha glucosidase inhibitors)
• Act locally in intestine
• Slows digestion of carbohydrates
• Delays absorption of glucose
• GI side effects

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Type 2 Diabetes Mellitus

• Insulins
• Basal Lantus, Levemir, NPH
• Bolus Humalog, Novolog, Apidra, Regular
• Given in patterns to mimic mother nature

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Type 2 Diabetes Mellitus

• Thank you very much for your attention!
• Questions?