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Epidemiology • The worldwide prevalence of DM has risen dramatically over the past two decades, from an estimated 30 million cases in 1985 to 177 million in 2000. Pathophysiology • Type 2 DM is characterized by impaired insulin secretion, insulin resistance, excessive hepatic glucose production, and abnormal fat metabolism. Metabolic Abnormalities • Abnormal Muscle and Fat Metabolism Insulin resistance, the decreased ability of insulin to act effectively on target tissues (especially muscle, liver, and fat), is a prominent feature of type 2 DM and results from a combination of genetic susceptibility and obesity.
Impaired Insulin Secretion • In type 2 DM, insulin secretion initially increases in response to insulin resistance to maintain normal glucose tolerance. Increased Hepatic Glucose and Lipid Production • In type 2 DM, insulin resistance in the liver reflects the failure of hyperinsulinemia to suppress gluconeogenesis, which results in fasting hyperglycemia and decreased glycogen storage by the liver in the postprandial state. Acute Complications of DM • Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute complications of diabetes. Mechanisms of Complications • One theory is that increased intracellular glucose leads to the formation of advanced glycosylation end products (AGEs) via the nonenzymatic glycosylation of intra- and extracellular proteins. Ophthalmologic Complications of Diabetes Mellitus • Blindness is primarily the result of progressive diabetic retinopathy and clinically significant macular edema. Renal Complications of Diabetes Mellitus • Like other microvascular complications, the pathogenesis of diabetic nephropathy is related to chronic hyperglycemia. Neuropathy and Diabetes Mellitus • As with other complications of DM, the development of neuropathy correlates with the duration of diabetes and glycemic control.
Cardiovascular Morbidity and Mortality • The increase in cardiovascular morbidity and mortality appears to relate to the synergism of hyperglycemia with other cardiovascular risk factors. Lower Extremity Complications • The reasons for the increased incidence of these disorders in DM involve the interaction of several pathogenic factors: neuropathy, abnormal foot biomechanics, PAD, and poor wound healing. Goals of Treatment • Glycosylated hemoglobin (HbA1c) <7% is the goal for patients in general. Combination Therapy with Glucose-Lowering Agents • A number of combinations of therapeutic agents are successful in type 2 DM, and the dosing of agents in combination is the same as when the agents are used alone. Insulin Treatments Insulin should be considered as the initial therapy in type 2 DM, particularly in lean individuals or those with severe weight loss, in individuals with underlying renal or hepatic disease that precludes oral glucose-lowering agents, or in individuals who are hospitalized or acutely ill. Prevention • Type 2 DM is preceded by a period of IGT, and a number of lifestyle modifications and pharmacologic agents prevent or delay the onset of DM. Assessment of Long-Term Glycemic Control • Measurement of glycated hemoglobin is the standard method for assessing long-term glycemic control. You will receive an email whenever this article is corrected, updated, or cited in the literature. AbstractThe incidence and prevalence of type 2 diabetes mellitus (T2DM) in the United States continue to rise, and the disease has become an enormous health concern. Diabetes is a significant and growing health concern in the United States with incidence and prevalence rates rising to staggering levels.
Evidence supports the benefits of glycemic control in reducing the risk of cardiovascular disease and other diabetes-related complications. The present report includes a comprehensive review of T2DM with an emphasis on the importance of glycemic control. Evidence from clinical studies indicates that poor glycemic control is associated with an increased risk for cardiovascular disease.4 Additionally, data suggest that glycemic control is most important in early diabetes and support the notion of a legacy effect when patients are treated aggressively early in the course of their diseases.
The earlier glycemic control is achieved in patients with diabetes, the more benefit is potentially derived in terms of slowing the rate of complications or halting the progression of ?-cell loss and deterioration of diabetic control. Other clinical trials involving patients with established disease demonstrated that intensive treatment interventions affect outcomes.
The Veterans Affairs Diabetes Trial (VADT) was a large prospective randomized study designed to investigate whether intensive glycemic control would reduce the incidence of macrovascular disease events. The suggestion that intensive glycemic control may not be effective in patients with advanced vascular disease could also explain why glucose-lowering therapy in the ACCORD and ADVANCE trials did not significantly reduce the incidence of cardiovascular disease.
There has been considerable debate regarding the level of HbA1c that represents an optimal therapeutic goal.
Diabetes management requires control of sugars, blood pressure, and lipids; achieving optimal glycemic control without reaching therapeutic goals for the other parameters may not reduce cardiovascular risk. The importance of tailoring therapies to achieve specific glycemic targets has become increasingly apparent in the management of patients with T2DM.


The relative contributions of FPG and PPG levels vary and depend on the patient's overall glycemic control. Diab a e b t e es e s Co C nt n rol ro an a d d Co C m o p m lica c t a ions n s Trial a (DCCT) C ? 1400 patients with Type 1 DM ? Randomized to intensive vs. Thiaz a o z l o idined e ione n s e s (Gl (G itaz a o z n o e n s e ) s s Contraindicated in CHF class III & IV. Nep e h p ropath a y ? Occurs in ~6% of patients with Type 2 DM (30% – 40% of patients with Type 1 DM) ? 40% of new ESRD diagnoses are patients with Type 2 DM ? Persistent microalbuminuria predicts progression to nephropathy. If you interesting in "DIABETES MELLITUS TYPE 2" powerpoint themes, you can download to use this powerpoint template for your own presentation template. Insulin resistance impairs glucose utilization by insulin-sensitive tissues and increases hepatic glucose output; both effects contribute to the hyperglycemia. DKA was formerly considered a hallmark of type 1 DM, but it also occurs in individuals who lack immunologic features of type 1 DM • HHS is primarily seen in individuals with type 2 DM. Among other actions, PKC alters the transcription of genes for fibronectin, type IV collagen, contractile proteins, and extracellular matrix proteins in endothelial cells and neurons. The mechanisms by which chronic hyperglycemia leads to ESRD, though incompletely defined, involve the effects of soluble factors (growth factors, angiotensin II, endothelin, AGEs), hemodynamic alterations in the renal microcirculation (glomerular hyperfiltration or hyperperfusion, increased glomerular capillary pressure), and structural changes in the glomerulus (increased extracellular matrix, basement membrane thickening, mesangial expansion, fibrosis).
The presence of cardiovascular disease, elevated triglycerides, and hypertension is also associated with diabetic peripheral neuropathy.
It most frequently presents with distal sensory loss, but up to 50% of patients do not have symptoms of neuropathy.
The reasons for this include incompletely defined abnormalities in cell-mediated immunity and phagocyte function associated with hyperglycemia, as well as diminished vascularization. The goal for the individual patient is an HbA1c as close to normal (<6%) as possible without significant hypoglycemia. One drink is defined as 12 oz of beer, 5 oz of wine or 1.5 oz of distilled spirits (each of which contains 15g of alcohol). Sulfonylurea (SU)- increases insulin secretion (pancreas), ideal for lean patient, early in disease, use with caution in kidney diseasea. Non-SU insulin secretagogue – increases insulin secretion (pancreas), ideal for post-meal hyperglycemia, variable schedule, alternative to sulfonylurea, may use in renal insufficiency a. Alpha-Glucosidase inhibitor – delays GI absorption of carbohydrates (GUT), ideal for post-meal hyperglycemia a. Because mechanisms of action of the first and second agents are different, the effect on glycemic control is usually additive. Several distinct types of DM are caused by a complex interaction of genetics and environmental factors. Gavin, III, MD, PhD, Healing Our Village, Inc, 10104 Senate Dr, Suite 210, Lanham, MD 20706-4393. Improving Outcomes in Patients With Type 2 Diabetes Mellitus: Practical Solutions for Clinical Challenges. While effective glycemic management reduces the risk of diabetes-related complications in patients with T2DM, many patients are unable to reduce their glucose levels to target goals. It provides practical strategies for overcoming some of the challenges in achieving and maintaining glycemic control and ultimately improving outcomes in patients with T2DM.
The data suggest, when adjusted for any confounding variables, that instituting early glycemic control makes the difference. Additionally, because T2DM is a chronic disease, unlike previous treatment approaches that assessed glycemic control and clinical success on a visit-to-visit basis, maintaining achievement of clinical goals over the long-term is critical to optimizing patient outcomes. Microvascular and macrovascular benefits of intensive therapy vs conventional therapy based on the 10-year follow-up of the United Kingdom Prospective Diabetes Study. Review of the ACCORD, ADVANCE, and VADT studies prompted the publication of a recent position statement by the American Diabetes Association (ADA), American College of Cardiology Foundation, and American Heart Association.
Insulin is a hormone that turns sugars and other foods into another form or energy that can be used by the cells that make up the entire body.
If you interesting in "Diabetes Mellitus Type 2" powerpoint themes, you can download to use this powerpoint template for your own presentation template.
For viewing only, you can play with our flash based presentation viewer instead of downloading the ppt file. The assumption is that a second genetic defect—superimposed upon insulin resistance—leads to beta cell failure.


Both disorders are associated with absolute or relative insulin deficiency, volume depletion, and acid-base abnormalities.
Three or more times daily for those using multiple insulin injections – Optimal frequency and timing of SMBG for those on oral agents is not known. Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production. The authors review key elements in the management of T2DM with an emphasis on achieving and maintaining glycemic control. The patients in the intensive management [group], who had the highest HbA1c levels and were not responding, and therefore were not accruing significant hypoglycemia, had the highest mortality.
The study was halted after 3.5 years because of an increased rate of mortality in the intensive arm compared with the standard arm.
However, the Risk Factors, Atherosclerosis, and Clinical Events in Diabetes (RACED) study, a subanalysis of VADT data, revealed that patients with lower baseline levels of coronary artery calcium who were treated with intensive glucose-lowering therapies had reduced cardiovascular events compared with patients treated with standard therapy.
These organizations concluded that lowering HbA1c to less than 7.0% can reduce the microvascular and neuropathic complications of T2DM (Table). Therefore, it is difficult to compare the impact of cholesterol lowering or blood pressure control to the effects of glycemic control unless the HbA1c was at more physiologic level (ie, 5.0%). The ADA recommends screening for distal symmetric neuropathy beginning with the initial diagnosis of diabetes and screening for autonomic neuropathy 5 years after diagnosis of type 1 DM and at the time of diagnosis of type 2 DM. Insulin resistance, as reflected by elevated serum insulin levels, is associated with an increased risk of cardiovascular complications in individuals with and without DM. Thiazolidinedione (TZD) – increases insulin sensitivity (muscles and fats), ideal for insulin- resitance, inappropriate for metformin, can be used for renal insufficiency a. Individuals with a strong family history of type 2 DM and individuals with IFG or IGT should be strongly encouraged to maintain a normal BMI and engage in regular physical activity. The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system. Strategies are offered to provide practical solutions to the challenges faced by healthcare providers and patients with T2DM.
Other surrogate markers such as microalbumin, inflammatory markers, and retinopathy also have been used to measure patient outcomes and may help stratify risk among patients with diabetes who are at greater risk for the development of complications. A further decline in insulin secretion and an increase in hepatic glucose production lead to overt diabetes with fasting hyperglycemia.
The most prominent GI symptoms are delayed gastric emptying (gastroparesis) and altered small- and large-bowel motility (constipation or diarrhea).
In the United States, DM is the leading cause of end-stage renal disease (ESRD), nontraumatic lower extremity amputations, and adult blindness. The importance of implementing evidence-based practice guidelines while empowering patients to participate in self-management of their disease is highlighted.
But they were specifically designed, in some instances, to test the effect of an agent on improving glycemic control and to see whether or not it modified outcomes.
Type 2 Diabetes -Those with low activity level, excess body weight, hypertension, high blood pressure, high cholesterol, and history of gestational diabetes in family. Gastroparesis may present with symptoms of anorexia, nausea, vomiting, early satiety, and abdominal bloating. So in order to truly compare the impact of cholesterol lowering, blood pressure lowering, and glycemic control as valid interventions, you would have to compare an HbA1c of 5.0%.
With an increasing incidence worldwide, DM will be a leading cause of morbidity and mortality for the foreseeable future.Spectrum of glucose homeostasis and diabetes mellitus (DM). That would be impossible and unnecessary to achieve clinically, but by accepting non-physiologic glycemia in our risk management, we diminish the overall importance of glycemic control. Individualize Insulin Dose • Use outpatient dose for baseline and increase (infection, steroids) or decrease (fewer calories ingested than when at home) as needed. Glargine 21 units qhs or Ultralente 10 units bid), and the other half as mealtime insulin ( Lispro 7 units with each meal).



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