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Subject: Diabetes Mellitus, Type 2
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Diabetes mellitus (DM) type 2 can manifest as nonketotic hyperglycemia and is due to a progressive insulin secretory defect in the setting of insulin resistance.
Significant contributing factor to blindness, renal failure, and lower limb amputations
In 2012, 29.1 million Americans or 9.3% of the population had DM; men and women equally affected
7.6% of non-Hispanic Caucasians, 12.8% of Hispanics, 13.2% of non-Hispanic African Americans, 9% of Asian Americans, and 15.9% of Native Americans.
Peripheral insulin resistance
Defective insulin secretion
Genetic factors: monogenic (e.g., PPARγ and insulin gene mutations) and polygenic
Drug- or chemical-induced (e.g., glucocorticoids, highly active antiretroviral therapy [HAART], atypical antipsychotics, posttransplant immunosuppressants)
Family history: first-degree relative
Gestational diabetes or history of baby with birth weight ≥4 kg (9 lb)
Polycystic ovary syndrome (PCOS)
Obesity (body mass index [BMI] ≥25 kg/m2) and visceral adiposity
Hypertriglyceridemia or low high-density lipoprotein (HDL)
Ethnicity: African American, Latino, Native American, Asian, and Pacific Islander
Impaired fasting glucose (IFG)/impaired glucose tolerance (IGT)
Thiazides and fluoroquinolones associated with dysglycemia 1[A]
Weight loss of 5-10% body weight, exercise 150 min/week, and decrease in fat and caloric intake. Moderate-intensity exercise and resistance training are recommended. Follow USDA dietary recommendation of 14 g fiber/1,000 kcal; metformin, orlistat, α-glucosidase inhibitors, or TZDs (high-risk prediabetics with cardiovascular risk factors) 1[A].
Use of text messages and smart phone applications are also encouraged. Consider GoMeals or MyFitnessPal 1[A].
Type 1 DM
Cushing syndrome, acromegaly, and glucagonoma
HbA1c ≥6.5% is diagnostic.
Hyperglycemic crisis + random plasma glucose ≥200 mg/dL (11.1 mmol/L) or
Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) on 2 occasions or
2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during oral glucose tolerance test (OGTT) with 75-g glucose load
If equivocal, repeat testing.
Use patient-centered approach (individualized).
FPG goal is ≪110 mg/dL (5.5 mmol/L) and 2 hour postprandial goal is ≪140 mg/dL):
Diabetic foot exam at every visit
Nephropathy: annual urine microalbumin-to-creatinine ratio
Retinopathy: annual diabetic eye exam
If 40 to 75 years old, begin a statin—moderate intensity for low-risk and high-intensity statin if ≥7.5% ASCVD risk 2[A].
Hypertension: goal BP ≪140/80 mm Hg (SBP ≪130 preferred if tolerated)
Angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker: first-line hypertension drug. If contraindicated, consider calcium channel blocker.
Hepatitis B to unvaccinated adults age 19 to 59 years
Limit protein to 0.8 to 1 g/kg weight/day for diabetics with early stages of chronic kidney disease (CKD).
Limit protein intake to 1 g/kg body weight/day for diabetic patients with advanced CKD.
Diabetes self-management education and support by certified diabetes educator
Lifestyle modifications with pharmacotherapy delays prediabetes progression to diabetes 1,2[A].
Dipeptidyl peptidase-4 inhibitors
GLP-1 (glucagon-like peptide-1) receptor agonist (incretins)
Insulin: rapid (aspart, lispro, glulisine), short (regular insulin), intermediate (neutral protamine hagedorn), long-acting (glargine, detemir), ultra long-acting (degludec)
Avoid in renal insufficiency and bowel diseases.
Bile acid sequestrants
Titrate oral medications every 3 months.
Monitor glucose, HbA1c, BP, body weight, lipid profile, and renal and liver function.
A1c twice a year for patients with well-controlled blood glucose and quarterly for patients with hyperglycemia or recent changes in therapy
Emergencies: hyperosmolar coma, diabetic ketoacidosis (DKA), Charcot joints
Atherosclerotic CVD, peripheral vascular disease, stroke
Microvascular: peripheral neuropathy, proliferative retinopathy, erectile dysfunction, and diabetic CKD
Ophthalmic: blindness, cataracts, glaucoma, retinopathy
GI: nonalcoholic fatty liver disease, gastroparesis, diarrhea
Neurologic: autonomic dysfunction
Foot ulcers and soft tissue infections
Diabetes Mellitus, Type 1; Diabetic Ketoacidosis (DKA); Hypertension, Essential
Algorithm: Diabetes Mellitus, Type 2
E11.9 Type 2 diabetes mellitus without complications
E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.59 Type 2 diabetes mellitus with oth circulatory complications
E11.8 Type 2 diabetes mellitus with unspecified complications
E11.29 Type 2 diabetes mellitus w oth diabetic kidney complication
E11.22 Type 2 diabetes mellitus w diabetic chronic kidney disease
250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled
250.40 Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
250.70 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled
250.02 Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled
44054006 Diabetes mellitus type 2 (disorder)
422034002 Diabetic retinopathy associated with type II diabetes mellitus (disorder)
420279001 Renal disorder associated with type II diabetes mellitus (disorder)
422166005 peripheral circulatory disorder associated with type II diabetes mellitus (disorder)
771000119108 Chronic renal impairment associated with type 2 diabetes mellitus
313436004 Type II diabetes mellitus without complication