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DIABETES MELLITUS TYPE 2

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Learning Objectives
 To list the screening recommendations for diabetes mellitus
type 2.
 To identify the risk factors.
 To define diagnostic criteria for diabetes mellitus.
 To explore the pharmacologic and non-pharmacologic
management of diabetes mellitus.
 To follow patients with diabetes mellitus.
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DEFINITION
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Definition
 Type 2 diabetes mellitus is a chronic metabolic disease.
 It is characterized by chronic hyperglycemia resulting from a
progressive defect in insulin secretion.
 It is associated with insulin resistance and progressive beta cells
failure.
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Symptoms
 Most patients do not have any symptoms.
 Classic symptoms of polyuria, polydipsia, polyphagia and
weight loss.
 Other symptoms: blurred vision, lower extremities paresthesia,
and yeast infections.
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Associated Co-morbidities
 Obesity
 Hypertension
 Dyslipidemia
 Hearing impairment
 Sleep apnea
 Fatty liver disease
 Periodontal diseases
 Cognitive impairment
 Depression
 Fractures
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Complications
 Nephropathy
 Retinopathy
 Neuropathy
 Accelerated Atherosclerosis (coronary, cerebral and peripheral
vascular diseases)
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SCREENING
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Screening Recommendations
 Testing all adults of any age who are overweight (BMI ≥ 25
Kg/m2) and have additional risk factors for diabetes (Grade B
recommendation).
 Testing all adults aged 40 years and above regardless of the
presence of risk factors for diabetes mellitus, as recommended
by the World Health Organization (WHO).
 WHO supports conducting the initial screening using capillary
plasma glucose when laboratory services are not available.
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Frequency of Screening
 Screening should be repeated at three (3) year interval if the
results were normal.
 In case of pre-diabetes, testing should be done on yearly basis.
 More frequent testing is also indicated in individuals with risk
factors for diabetes.
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RISK FACTORS
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Risk Factors
 Physical inactivity
 Obesity
 Hypertension
 Dyslipidemia
 History of cardiovascular diseases
 Women with a history of gestational diabetes or who delivered
a baby weighing 4 kilograms or more
 Women with polycystic ovary syndrome
 Family history of diabetes mellitus
 Clinical conditions with insulin resistance
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DIAGNOSIS
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For Diagnosis of Diabetes Mellitus

 Can use FBS, Hba1c, OGTT and even Random BS with presence
of symptoms
 Two abnormal readings on different days are needed.
 Fasting BS means no caloric intake for at least 8 hours.
 Interpreting of Hba1c levels can be challenging in the presence
of certain hemoglobinopathies and anemia.
 Diagnosing Diabetes Mellitus

Normal Blood Pre-Diabetes Diabetes Mellitus

sugar level

Fasting Blood sugar FPG< 100 mg/dl 100≤FPG<126 FPG≥126

(FPG)(mg/dl)

Casual Plasma CPG< 200 CPG≥200

Glucose (CPG) with
symptoms (mg/dl)

Hba1c (%) < 5.7 5.7-6.4 ≥ 6.5

Oral Glucose 2hPG<140 140≤2hPG<200 ≥ 200
Tolerance Test
(OGTT) (mg/dl)
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ASSESSMENT
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Objectives of the Evaluation

 To assess the characteristics of the onset of diabetes mellitus.
 To check the presence of risk factors.
 To document the presence of diabetes mellitus complications.
 To assist the patient in developing a management plan.
 To provide the patient with the basis for continuing care.
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History
 Check for symptoms of diabetes mellitus if any.
 Lifestyle factors including eating habits, physical activity habits.
 Cardiovascular risk factors.
 Presence of diabetes-related complications.
 Psychosocial history including screening for depression and/or
anxiety.
 Dental diseases.
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Physical Exam
 Measurement of height and weight with calculation of BMI.
 Measurement of Blood Pressure.
 Fundoscopic examination to check for diabetic retinopathy.
 Palpation of the thyroid.
 Examination of the skin (for Acanthosis Nigricans).
 Comprehensive foot examination.
Comprehensive Foot Exam
 Inspection
o skin status: color, thickness, dryness, Cracking
o infection: check between toes for fungal infection
o Ulceration, open wounds
o calluses/blistering
 Inspection
o Deformity: claw toes, prominent metatarsal heads
o muscle wasting
 Neurological assessment (2 or more abnormal – loss of peripheral sensation)
o 10-g monofilament
o vibration using 128-Hz tuning fork
o pinprick sensation
o ankle reflexes
 Vascular assessment
o foot pulses
o Check hair growth
o Check difference in temperature
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Laboratory Tests
 Fasting lipid profile
 Fasting Blood Glucose
 Hba1c if not done within the last 2-3 months
 Liver function tests (SGPT, SGOT)
 Test for urine albumin excretion with spot urine albumin-to-
creatinine ratio
 Serum creatinine
 Thyroid stimulating hormone (TSH) in dyslipidemia or women
over the age of 50 years.
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MANAGEMENT OF PATIENTS
WITH PREDIABETES
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Management of Patients with Prediabetes

 Refer patients with prediabetes to an intensive diet behavioral
counseling program targeting a loss of 7% of body weight .
 Increase their moderate-intensity physical activity to at least 150
min/week.
 Follow-up counseling and maintenance programs should be offered
for long term success in preventing diabetes.
 Consider Metformin therapy for prevention of type 2 diabetes in
patients with prediabetes, mainly in those with BMI> 35 kg/m2,
those aged less than 60 years, and women with prior gestational
diabetes mellitus.
 Monitor annually for the development of diabetes in patients with
prediabetes.
 Screen for and treat modifiable risk factors for cardiovascular
diseases.
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MANAGEMENT OF PATIENTS
WITH DIABETES MELLITUS
TYPE 2
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General Management Strategy

 Most patients should begin with lifestyle changes.
 When lifestyle efforts alone do not achieve or maintain
glycemic goals, Metformin should be added at, or soon after,
diagnosis, unless there are contraindications or intolerance.
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Non-Pharmacologic Management
 Dietary modification
o The right mix of carbohydrate, protein and fat.
o Carbohydrate counting.
o Monitoring of Carbohydrate intake is key.
o Glycemic Index.
 Weight reduction: A low-carbohydrate, or low-fat calorie-
restricted, or Mediterranean diets may be effective in the short
term weight reduction.
 Exercise.
 Smoking cessation.
 Moderate alcohol consumption.
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Pharmacologic Management (1)

 Follow a patient-centered approach when selecting
pharmacological treatment, taking into consideration the
efficacy, cost, potential side effects, and patient preferences.
 Metformin therapy is the first line hypoglycemic medication
and it should be added at, or soon after diagnosis, in patients
who do not have renal insufficiency, liver disease or hypoxia.
 Give sulfonylurea to patients who have contraindications to
Metformin or in whom Metformin does not improve glycemic
control.
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Pharmacologic Management (2)

 Add a second oral agent if the initial non-insulin monotherapy
at maximal tolerated dose does not achieve or maintain the
target Hba1c over 3-6 months.
 Oral Medications
Medication Action Advantages Side Effects

Metformin Decrease Hepatic Weight neutral Gastrointestinal side effects (diarrhea), vitamin B12
Gluconeogenesis deficiency- contraindicated in renal insufficiency or
liver failure
Sulfunylurea Increase Insulin Rapidly effective Weight gain, hypoglycemia especially with
secretion glibenglamide or chloropropamide
Thiazolidinedione Increase Insulin Improved lipid profile Fluid retention, heart failure, weight gain, bone
TZD sensitivity in adipose (pioglitazone), potential fractures, expensive, potential increase in MI
tissue and muscle decrease in MI (rosiglitazone)
(pioglitazone)
Alpha-glucosidase Decrease intestinal Weight neutral Frequent GI side effects, three times per day dosing,
inhibitor absorption of expensive
carbohydrates
Glinide Increase Insulin Rapidly effective Weight gain, 3 times per day, expensive,
secretion hypoglycemia
Pramlintide Delays gastric Weight loss Three injections daily, frequent GI symptoms, long-
emptying, decrease term safety not established, expensive
glucagon
Dipeptidyl Blocks degradation of Weight neutral long-term safety not established, expensive
peptidase-4 (DPP- GLP1
4 inhibitor)
Sodium – glucose Promotes glucosuria Weight loss, reduction in Vulvovaginal candidiasis, urinary tract infections,
cotransporter 2 systolic blood pressure long term safety not established
(SGLT2 inhibitor)
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Insulin
 Basal insulin alone is the most convenient initial insulin
regimen, beginning at 10 units or 0.1–0.2 units/kg, depending
on the degree of hyperglycemia.
 Basal insulin is usually prescribed as augmentation.
 It can be given as a replacement with a starting dose of 0.6 to 1
unit per kilogram.
 Human insulin is similar in general to analogue insulin in
controlling diabetes mellitus.
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Bariatric Surgery
 Bariatric surgery may be considered for adults with BMI >35
kg/m2 and type 2 diabetes, especially if diabetes or associated
co-morbidities are difficult to control with lifestyle and
pharmacological therapy.
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Vaccinations
 Annual Influenza vaccine to all diabetic patients.
 Pneumococcal polysaccharide vaccine to all diabetic patients.
 Hepatitis B vaccination to unvaccinated adults with diabetes
who are aged 19 through 59 years.
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Monitoring of Patients with Diabetes Mellitus

 Follow Up visits every 3 – 6 months.
 Measure BP and Weight, Perform Foot Exam.
 Reminder of Lifestyle changes.
 Monitor compliance with medications and possible side
effects.
 FBS and Hba1c are done every 3-6 months.
 Creatinine & lipid profile & Urine Microalbumin (albumin-to-
creatinine ratio) once per year.
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Target for Treatment of Diabetes Mellitus

 Hemoglobin A1C:
o The reasonable goal is Hba1c <7.0%.
o Lower level of <6.5% is suggested in some patients: those with short
duration of diabetes, diabetes treated with lifestyle or Metformin only,
long life expectancy or no significant cardiovascular disease.
o Higher level of <8% can be accepted in patients with: a history of severe
hypoglycemia, limited life expectancy, advanced microvascular or
macrovascular complications, extensive co-morbid conditions, or long-
standing diabetes in whom the general goal is difficult to attain despite
multiple efforts.
 Blood pressure <140/90 mmHg.
 LDL cholesterol <100 mg/dL (should be ≤70mg/dl if the 10 year
cardiovascular risk is very high).
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REFERRAL
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Referrals
 Ophtalmologist for annual dilated eye exam starting from the
time of diagnosis
 Dietician
 Dentist for comprehensive periodontal examination
 Mental health professional if needed
 Vascular surgeon in case of foot ulcer
 Other specialties as needed.
CHECK DIABETES
 Cardiovascular risk factors yearly assessment
 HbA1c every 6 months if controlled DM, and every 3 months if not,
Hypoglycemia symptoms
 Eye exam yearly by ophthalmologist
 Care for the foot
 Kidney function tests yearly (GFR, Spot urine albumin/creatinine ratio)
 Diet, Dental visit
 Involve the patient in DM care
 ACEIs or ARBs if comorbid HTN, and monitor GFR, and potassium level
 BP measurement at every routine visit, target <140/90 mmHg
 Exercise
 Test for lipid profile, on diagnosis
 Educate the patient about the disease
 SBGM- self blood glucose monitoring
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References
• American Diabetes Association. Standards of Medical Care in Diabetes-
2016. Diabetes Care 2016; 39 (Suppl.1):S1-112.
• American Diabetes Association. Standards of Medical Care in Diabetes-
2015: Abridged for Primary Care Providers. Diabetes Care 2015;38(Suppl. 1):
S1–S94.
 McCulloh D. Overview of medical care in adults with diabetes mellitus. In:
UpToDate, Nathan D(Ed), UpToDate, Waltham MA, 2014.
www.uptodate.com.
 Patel P, Macerello A. Diabetes Mellitus: Diagnosis and Screening. American
Family Physician. 2010; 81(7): 863-870.
 Petznick A. Insulin Management of Type 2 Diabetes Mellitus. American
Family Physician. 2011; 84(2): 183-190.
 Rispin C, Kang H, Urban R. Management of Blood Glucose in Type 2 Diabetes
Mellitus. American Family Physician. 2009; 79(1): 29-36.
 World Health Organization. Package of essential non-communicable (PEN)
disease interventions for primary health care in low-resource settings.2014.