6 The major risk factors for type 2 DM Age greater then 45Weight greater than 120% of desirable body weightFamily history of type 2 diabetes in first-degree relativeHistory of previous impaired glucose tolerance(IGT) or impaired fasting glucose(IFG)Hypertension (>140/90) or dyslipidemia ( low HDL, high TG>150)History of gestational diabetes mellitusPolycystic ovarian syndrome
7 EpidemiologyThe prevalence of type 2 DM is increasing, mirroring the increase in the prevalence of obesityprevalence of the disease increases with advancing age.Type 2 diabetes mellitus occurs most commonly in adults aged 40 years or olderThe prevalence of type 2 diabetes mellitus varies widely among various racial and ethnic groups.
8 EpidemiologyUSA:Diabetes affects 8.3% of Americans of all ages, 11.3% of adults aged 20 years and older, and 25% of persons age 65 and older, Prediabetes affects 35% of adults aged 20 years and olderPOLAND: 10,8% people diabetes near 17 % prediabetes
9 Diagnosis Symptoms and signs Many patients with type 2 DM are relatively asymptomaticClassic symptom:polyuria, polydipsia, polyphagia weight loss, fatigueBlurred visionLower-extremity paresthesiasYeast infectionKetoacidosis at the time of diagnosis is rare
10 Screning test for DMrecommends testing for prediabetes and diabetes beginning at age 45 years all patients.If results are normal, testing should be repeated at least every 3 years.recommends considering testing for prediabetes and diabetes in asymptomatic adults who are overweight and have 1 or more of the following additional risk factors :Physical inactivityFirst-degree relative with diabetesMember of a high-risk ethnic populationDelivered a baby weighing over 9 lb or diagnosed with gestational diabetes mellitusHypertension (≥140/90 mm Hg or on therapy for hypertension)HDL cholesterol level under 35 mg/dL (0.90 mmol/L) and/or a triglyceride level above 250 mg/dL (2.82 mmol/L)Polycystic ovary diseaseIGT or IFG on previous testingOther clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans)History of cardiovascular disease
12 Diagnostic criteria by ADA,EASD include the following: A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher, orA 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), orA random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisisWhether a hemoglobin A1c (HbA1c) level of 6.5% or higher should be a primary diagnostic criterion or an optional criterion remains a point of controversy
14 Complications of diabetes. The prognosis in patients with diabetes mellitus is strongly influenced by the degree of control of their diseasethe typical patient with type 2 diabetes had diabetes for at least 4-7 years at the time of diagnosis, 25% had retinopathy; 9%, neuropathy; and 8%, nephropathy at the time of diagnosis
15 Approaches to prevention of diabetic complications include the following: HbA1c every 3-6 monthsYearly dilated eye examinationsAnnual microalbumin checksFoot examinations at each visitBlood pressure < 130/80 mm Hg, lower in diabetic nephropathyStatin therapy to reduce low-density lipoprotein cholesterol
16 Diabetes mellitus-associated mortality and morbidity DM causes morbidity and mortality because of its role in the development of cardiovascular, renal, neuropathic, and retinal disease.DM is the major cause of blindness in adultsDM is the leading contributor to end-stage renal diseaseDM is the leading cause of nontraumatic lower limb amputationsThe risk for coronary heart disease (CHD) is 2-4 times greater in patients with diabetes than in individuals without diabetes. Cardiovascular disease is the major source of mortality in patients with type 2 DMPeople with type 2 DM are at an increased risk for many types of cancer
17 Goals of treatment of DM are as follows: Microvascular ( eye and kidney disease) risk reduction through control of glycemia and blood pressureMacrovascular ( coronary, cerebrovascular, peripheral vascular) risk reduction through control of lipids and hypertension, smoking cessationMetabolic and neurologic risk reduction through control of glycemia
18 TreatmentDiabetes care is best provided by a multidisciplinary team of health professionals working in collaboration with the patient and family. Management includes the following:Appropriate goal settingDietary and exercise modificationsMedicationsAppropriate self-monitoring of blood glucose (SMBG)Regular monitoring for complicationsLaboratory assessment
19 Dietary Modifications Modest weight losses of 5-10% have been associated with significant improvements in cardiovascular disease risk factors ( decreased HbA1c levels, reduced blood pressure, increase in HDL cholesterol, decreased plasma triglycerides) in patients with type 2 diabetes mellitus. Risk factor reduction was even greater with losses of 10-15% of body weightMediterranean-style diet
20 Activity Modifications Most patients with type 2 diabetes mellitus can benefit from increased activity. Aerobic exercise improves insulin sensitivityBariatric SurgeryIn morbidly obese patients, bariatric surgery has been shown to improve diabetes control and, in some situations, normalize glucose tolerance
21 Pharmacologic Therapy Early initiation of pharmacologic therapy is associated with improved glycemic control and reduced long-term complications in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following:BiguanidesSulfonylureasMeglitinide derivativesAlpha-glucosidase inhibitorsThiazolidinediones (TZDs)Glucagonlike peptide–1 (GLP-1) agonistsDipeptidyl peptidase IV (DPP-4) inhibitorsSelective sodium-glucose transporter-2 (SGLT-2) inhibitorsInsulins
22 MetforminMetformin is the preferred initial agent for monotherapy and is a standard part of combination treatments. Advantages of metformin include the following:EfficacyAbsence of weight gain or hypoglycemiaGenerally low level of side effectsHigh level of patient acceptanceRelatively low cost
23 MetforminMetformin lowers basal and postprandial plasma glucose levelsThe dose of metformin is titrated over 1-2 months to at least 2000 mg daily, administered in divided doses (during or after meals to reduce gastrointestinal [GI] side effects).Exercise increases metformin levels and interferes with its glucose-lowering effect.Metformin reduces macrovascular risk in patients who are obese[Metformin may decrease the risk of dementia associated with type 2 diabetes
24 SulfonylureasSulfonylureas ( glipizide, glimepiride) are insulin secretagogues that stimulate insulin release from pancreatic beta cells and probably have the greatest efficacy for glycemic lowering of any of the oral agentshypoglycemia the most common side effect.have the greatest efficacy for glycemic lowering of any of the oral agents.that effect is only short-term and quickly dissipates.
25 Alpha-glucosidase inhibitors These agents delay sugar absorption and help to prevent postprandial glucose surgesMeglitinide derivativesMeglitinides ( repaglinide, nateglinide) are much shorter-acting insulin secretagogues than the sulfonylureas areThiazolidinedionesTZDs ( pioglitazone , rosiglitazone ) act as insulin sensitizersGlucagonlike peptide–1 agonistsGLP-1 agonists (, exenatide, liraglutide) mimic the endogenous incretin GLP-1; they stimulate glucose-dependent insulin release, reduce glucagon, and slow gastric emptyingDipeptidyl peptidase IV inhibitorsDPP-4 inhibitors ( sitagliptin, saxagliptin, linagliptin) are a class of drugs that prolong the action of incretin hormones
28 Monitoring - goals must be individual HbA1c (%) <6.5 IFD <7.0 ADAFasting/preprandial glucose(mmol/L / mg/dL) <6.0 / <110 IFD / ADA2-h postprandial glucose(mmol/L / mg/dL) <7.8 / <140 IFD <10.0 / <180* ADA*ADA recommends that postprandial glucose measurements should be made 1–2 h after the beginning of the meal.
29 Self-monitoring of blood glucose in non-insulin treated type 2 diabetes (SMBG) SMBG should be considered at the time of diagnosis to enhance the understanding of diabetes as part of individuals’ education and to facilitate treatment initiation and titration optimization.SMBG should also be considered as part of ongoing diabetes self-management education to assist people with diabetes to better understand their disease and provide a means to actively and effectively participate in its control and treatment, modifying behavioural and pharmacological interventions as needed
31 Management of Hypertension Prefers inhibitors of the renin-angiotensin system (ACE inhibitors, ARBs) because of their proven renal protection effects in patients with diabetes.Diuretics or calcium channel blockers frequently are useful are second and third agents.The SBP goal is < 140 mm Hg in patients with diabetesThe target diastolic blood pressure (DBP) remains < 80 mm Hg.
32 Prevention of Type 2 Diabetes Mellitus Criteria for preventive metformin therapy are as follows:ObesityAge younger than 60 yearsBoth impaired fasting glucose (IFG) and impaired glucose tolerance (IGT)Other risk factors ( HbA1C >6%, hypertension, low HDL cholesterol, elevated triglycerides, or a family history of diabetes in a first-degree relativeWeight reductionProper nutritionRegular physical activityCardiovascular risk factor reductionAggressive treatment of hypertension and dyslipidemia