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TYPE 2 DIABETES MELLITUS

TYPE 2 DIABETES MELLITUS. Cynthia Brown, MN, ANP, CDE. Type 2 Diabetes Mellitus. Epidemiology: 25 million Americans or 8.3% 7 million undiagnosed 1.9 million older than 20 diagnosed in 2010 7 th leading cause of death In 2007, cost of treating $174 billion

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TYPE 2 DIABETES MELLITUS

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  1. TYPE 2 DIABETES MELLITUS Cynthia Brown, MN, ANP, CDE

  2. 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 >20 diagnosed per year

  3. 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

  4. Type 2 Diabetes Mellitus • Populations at risk: • Those older than 30 • Some children now diagnosed • African Americans • Native Americans • Hispanics • Asians • Pacific Islanders

  5. Type 2 Diabetes Mellitus • Populations at risk: • Family history in 1st or 2nd degree relative • Hx gestational diabetes or baby >9 lbs • Signs of insulin resistance • Hx pre-diabetes • Hx vascular disease • Physical inactivity

  6. Type 2 Diabetes Mellitus • Diagnosing: • 1979: original WHO criteria- • FBS >140 • 2 hour >200 • 1997: ADA • Type 1 • Type 2 • Eliminated all other references to age, insulin usage

  7. Type 2 Diabetes Mellitus • Diagnosing: • 1998: ADA • Lowered FBS to 126 • Based on association between glucose levels & development of retinopathy • 2011: ADA accepted A1c >6.5% as diagnostic; <6.5% does not exclude diagnosis

  8. Type 2 Diabetes Mellitus • Today’s testing methods: • Fasting plasma glucose • 1-2 hour post meal can be used; if >140, further testing indicated • FPG <100mg/dl=normal • FPG >100 & <126 = IFG & pre-diabetes • FPG >126=diabetes

  9. 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

  10. 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 >140 but <200 • IFG: FPG >100 but <126

  11. 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

  12. 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

  13. 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

  14. Type 2 Diabetes Mellitus • Chronic disease syndrome associated with insulin resistance: • Metabolic Syndrome • Dysmetabolic Syndrome • Syndrome X

  15. Type 2 Diabetes Mellitus • Syndrome features: • Central or visceral obesity • Dyslipidemia • Atherosclerosis • Endothelial dysfunction • Decreased fibrinolytic activity=pro-thrombotic • Hypertension • Acanthosis

  16. Type 2 Diabetes Mellitus • Syndrome Features: • PCOS • Hyperuricemia • Pre-diabetes

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. Type 2 Diabetes Mellitus • Precose, Glyset (alpha glucosidase inhibitors) • Act locally in intestine • Slows digestion of carbohydrates • Delays absorption of glucose • GI side effects

  26. Type 2 Diabetes Mellitus • Insulins: • Basal: Lantus, Levemir, NPH • Bolus: Humalog, Novolog, Apidra, Regular • Given in patterns to mimic mother nature

  27. Type 2 Diabetes Mellitus • Thank you very much for your attention! • Questions?

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