Diabetes Mellitus Type 2


Article Author:
Rajeev Goyal


Article Editor:
Ishwarlal Jialal


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
10/6/2019 9:12:27 AM

Introduction

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by persistent hyperglycemia. It may be due to impaired insulin secretion, resistance to peripheral actions of insulin, or both. Chronic hyperglycemia in synergy with the other metabolic aberrations in diabetic patients can cause damage to various organ systems, leading to the development of disabling and life-threatening health complications, most prominent of which are microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications leading to a 2-fold to a 4-fold increased risk of cardiovascular diseases. In this review, we provide an overview of the pathogenesis, diagnosis, clinical presentation, and principles of management of diabetes.

Etiology

DM is broadly classified into 3 types by etiology and clinical presentation, type 1 diabetes, type 2 diabetes, and gestational diabetes (GDM). Some other less common types of diabetes include monogenic diabetes and secondary diabetes.[1][2][3][4]

Type 1 Diabetes Mellitus (T1DM)

Type 1 diabetes mellitus (T1DM) accounts for 5% to 10% of DM and is characterized by autoimmune destruction of insulin-producing beta cells in the islets of the pancreas. As a result, there is an absolute deficiency of insulin. A combination of genetic susceptivity and environmental factors such as viral infection, toxins, or some dietary factors have been implicated as triggers for autoimmunity. T1DM is most commonly seen in children and adolescents though it can develop at any age.

Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) accounts for around 90% of all cases of diabetes. In T2DM, the response to insulin is diminished, and this is defined as insulin resistance. During this state, insulin is ineffective and is initially countered by an increase in insulin production to maintain glucose homeostasis, but over time, insulin production decreases resulting in T2DM. T2DM is most commonly seen in persons older than 45 years, but it is increasingly seen in children, adolescents, and younger adults due to rising levels of obesity, physical inactivity, and energy-dense diets.

Gestational Diabetes Mellitus

Hyperglycaemia which is first detected during pregnancy is classified as gestational diabetes mellitus (GDM), also known as hyperglycemia in pregnancy. Although it can occur anytime during pregnancy, GDM generally affects pregnant women during the second and third trimesters. According to American Diabetes Association (ADA), GDM complicates 7% of all pregnancies. Women with GDM and their offspring have an increased risk of developing type 2 diabetes mellitus in the future.

GDM can be complicated by hypertension, preeclampsia, and hydramnios and may also lead to increased operative interventions. The fetus can have increased weight and size (macrosomia) or congenital anomalies. Even after birth, such infants may have respiratory distress syndrome, and subsequent childhood and adolescent obesity. Older age, obesity, excessive gestational weight gain, history of congenital anomalies in previous children, or stillbirth, or a family history of diabetes are risk factors for GDM.

Monogenic Diabetes

A single genetic mutation in an autosomal dominant gene causes this type of diabetes. Examples of monogenic diabetes include conditions like neonatal diabetes mellitus and maturity-onset diabetes of the young (MODY). Around 1% to 5% of all diabetes cases are due to monogenic diabetes. MODY is familial disorder and usually presents under age of 25 years.

Secondary Diabetes

Secondary diabetes is caused due to the complication of other diseases affecting pancreas (for example, pancreatitis), hormone disturbances (for example, Cushing’s disease), or due to drugs (for example, corticosteroids).

Epidemiology

Diabetes is a worldwide epidemic. With changing lifestyle and increasing obesity, the prevalence of DM has increased worldwide. The worldwide prevalence of DM was 425 million in 2017. According to International Diabetes Federation (IDF), in 2015, about 10% of the American population had diabetes. Of these, 7 million were undiagnosed. With an increase in age, the prevalence of DM also increases. About 25% of the population above 65 years of age has diabetes.[4]

Pathophysiology

In T1DM, there is cellular-mediated, autoimmune destruction of pancreatic beta cells. T1DM has a strong genetic predisposition. The major histocompatibility complex (MHC), also known as human leukocyte antigens (HLA), is reported to account for approximately 40% to 50% of the familial aggregation of T1DM. The major determinants are polymorphisms of class II HLA genes encoding DQ and DR4-DQ8, with DR3-DQ2, found in 90% of T1DM patients.

Another form of T1DM is latent autoimmune diabetes of adults (LADA). It occurs in adulthood, often with a slower course of onset.

The rate of destruction is generally rapid in children and faster in adults. Autoantibodies against islet cells, insulin, glutamic acid decarboxylase-65 (GAD-65), and zinc transporter 8 (Zn T8) may be detected in the serum of such patients. These antibodies wane over time and do not have sufficient diagnostic accuracy to be used routinely for diagnosis especially after the first year. With the progressive destruction of beta cells, there is little or no secretion of insulin. These patients are generally not obese. They are more prone to develop other autoimmune disorders such as Addison disease, Graves' disease, Hashimoto thyroiditis, celiac disease, among others. A subset of T1DM not associated with insulin autoimmunity and not associated with the above HLA is termed idiopathic T1DM and is commoner in African and Asians and present with episodic diabetic ketoacidosis (DKA).

T2DM is an insulin-resistance condition with associated beta cell dysfunction. Initially, there is a compensatory increase in insulin secretion which maintains glucose levels in normal range. As the condition progresses, beta cells change, and the insulin secretion is unable to maintain glucose homeostasis, producing hyperglycemia.  Most of the patients with T2DM are obese or have higher body fat percentage, distributed predominantly in the abdominal region. This adipose tissue itself promotes insulin resistance through various inflammatory mechanisms including increased FFA release and adipokine dysregulation. Lack of physical activity, prior GDM in those with hypertension, or dyslipidemia also increase the risk of developing T2DM. Evolving data suggest a role for adipokine dysregulation, inflammation, abnormal incretin biology with decreased incretins such as glucagon-like peptide-1 (GLP-I) or incretin resistance, hyperglucagonemia, increased renal glucose reabsorption and abnormalities in gut microbiota.

History and Physical

Diabetic patients most commonly present with increased thirst, increased urination, lack of energy and fatigue, bacterial and fungal infections, and delayed wound healing. Some patients can also complain of numbness or tingling in hands or feet or with blurred vision.

These patients can have modest hyperglycemia which can proceed to severe hyperglycemia or ketoacidosis due to infection or stress. T1DM patients can often present with ketoacidosis (DKA) coma as the first manifestation in about 30%.

Height, weight, and body mass index (BMI) of diabetic patients should be recorded. Retinopathy needs to be excluded in such patients by an ophthalmologist. All pulses should be palpated to examine for peripheral arterial disease. Neuropathy should be ruled out by physical examination and history and nephropathy by early morning urine albumin/creatinine ratios of less than 30 mg/g creatinine.

Evaluation

Screening

Persons older than 40 years of age should be screened annually. More frequent screening is recommended for individuals with additional risk factors for diabetes.[5][6][7][8][9]

  • Certain races/ethnicities (Native American, African American, Hispanics  or Asian American, Pacific Islander), 
  • Overweight or obese persons with BMI greater than or equal to 25 kg/m2 or 23 kg/m2 in Asian Americans,
  • First-degree relative with diabetes
  • History of CVD, hypertension
  • Low HDL-cholesterol or hypertriglyceridemia, 
  • Women with polycystic ovarian syndrome
  • Physical inactivity
  • Conditions associated with insulin resistance, for example, Acanthosis nigricans.

Women diagnosed with gestational diabetes mellitus (GDM) should have lifelong testing at least every 3 years. For all other patients, testing should begin at age 45 years, and if results are normal, patients should be tested at a minimum of every 3-years.

The same tests are used to both screen for and diagnose diabetes. These tests also detect individuals with prediabetes.

Diagnosis

Diabetes can be diagnosed either by A1C criteria or plasma glucose concentration (fasting or 2-hour plasma glucose).

Fasting Plasma Glucose (FPG)

A blood sample is taken after an 8 hour overnight fast. As per ADA, FPG level of more than 126 mg/dL (7.0 mm/L) is consistent with the diagnosis.

Two-Hour Oral Glucose Tolerance Test (GTT)

In this test, plasma glucose level is measured before and 2 hours after ingestion of 75 gm of glucose. DM is diagnosed if plasma glucose (PG) level in the 2-hour sample is more than 200 mg/dL (11.1 mmol/L). It is also a standard test but is inconvenient and more costly than FPG and has major variability issues. Patients need to consume a diet with at least 150 g per day of carbohydrate for 3 to 5 days and not take any medications that can impact glucose tolerance such as steroids and thiazide diuretics.

Glycated Hemoglobin (A1C)

This test gives an average of blood glucose over last 2 to 3 months. Patients with A1C greater than 6.5% (48 mmol/mol) are diagnosed as having DM. A1C is a convenient, rapid, standardized test and shows less variation due to pre-analytical variables. It is not much affected by acute illness or stress.

A1C is costly and has many issues as discussed below including lower sensitivity. A1C should be measured using National Glycohemoglobin Standardization Program (NGSP) certified method standardized to Diabetes Control and Complications Trial (DCCT) assay. It is affected by numerous conditions such as sickle cell disease, pregnancy, hemodialysis, blood loss or transfusion, or erythropoietin therapy. It has not been well validated in non-Caucasian populations.

Anemia due to deficiency of iron or vitamin B12 leads to spurious elevation of A1C, limiting its use in countries with high prevalence of anemia. Also, in children and elderly, the relation between A1C and FPG is suboptimal.

For all of the above tests, if the person is asymptomatic, testing should be repeated later to make a diagnosis of diabetes.

In patients with classic symptoms of hyperglycemia (increased thirst, increased hunger, increased urination), random plasma glucose more than 200 is also sufficient to diagnose DM.

FPG, 2-hour PG during 75-g GTT, and A1C are equally appropriate for diagnosis of DM. There is no concordance between the results of these tests.

Diagnosis of Gestational Diabetes Mellitus

Pregnant women not previously known to have diabetes should be tested for GDM at 24 to 28 weeks of gestation. ADA and ACOG recommend using either 1-step or 2-step approach for diagnosing GDM.

One-Step Strategy

75 gm OGTT is performed after an overnight fast. Blood samples are collected at fasting for 1 hour, and 2 hours. GDM is diagnosed if fasting glucose meet or exceed 92 mg/dl (5.1 mmol/l), 1-hour serum glucose of 180 mg/dl (10.0 mmol/l) or 2-hour serum glucose of 153 mg/dl (8.5 mmol/l).

Two-Step Strategy

  • Step one: Perform 50-gram glucose challenge test irrespective of last meal. If PG at 1-hour after the load is ≥ 140mg/dl (7.8 mmol/l), proceed to step 2.
  • Step 2: 100 g glucose OGTT is performed after overnight fasting. Cut off values are fasting PG 95 or 105 mg/dl (5.5/5.8 mmol/l), 1-hour PG of 180 or 190 mg/dl (10.0/10.6 mmol/l), 2-hour PG of 155 or 165 mg/dl (8.6/9.2 mmol/l) or 3-hour PG of 140 or 145 mg/dl (7.8/8.0 mmol/l). GDM is diagnosed if 2 or more PG levels equal or exceed these cutoffs.

Treatment / Management

For both T1DM and T2DM, the cornerstone of therapy is diet and exercise.[10][11][12]

A diet low in saturated fat, refined carbohydrates, fructose corn syrup, and high in fiber and monounsaturated fats needs to be encouraged. Aerobic exercise for a duration of 90 to 150 minutes per week is also beneficial. The major target in T2DM patients, who are obese, is weight loss.

If adequate glycemia cannot be achieved, metformin is the first line therapy. Following metformin many other therapies such as oral sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors. GLP-I receptor agonists, SGLT-2 inhibitors, pioglitazone especially if the patient has a fatty liver disease, alpha-glucosidase inhibitors and insulin are available. Recent studies have shown that the SGLT2 inhibitor, empagliflozin (EMPA) and the GLP-1 receptor agonist, liraglutide reduce both major cardiovascular (CV) events and mortality. Hence, in patients with CV disease, these drugs should be considered next. For patients with T1DM, a regime of basal-bolus insulin is the mainstay of therapy. Also, insulin-pump therapy is a reasonable choice. Since hypoglycemia portends increased mortality, preference should be given to therapies that do not induce hypoglycemia, for example, DPP-4 Inhibitors, SGLT-2 inhibitors, GLP-I receptor agonists, and pioglitazone with metformin. The other advantages of SGLT-2 inhibitors and GLP-I receptor agonists is reduction in body weight, blood pressure (BP), and albuminuria.

To reduce microvascular complications in the majority, the goal A1C should be less than 7%. Also, the BP goal should be less than 130/85 with a preference for angiotensin-converting enzyme (ACE)/angiotensin receptor blocker (ARB) therapy. Fundal exams should be undertaken as proposed by guidelines and urine albumin excretion at least twice a year.

The goals should be an LDL-C less than 100 mg/dl if no ASCVD or less than 70 mg/dl if ASCVD present to prevent atherosclerotic cardiovascular disease (ASCVD). The drug of choice is a statin since these drugs reduce CV events and CV mortality. Consider adding ezetimibe and PCSK9 inhibitors for patients with ASCVD who are not at goal.

Since the different complications and therapies have been detailed in other Statpearls review articles, we have outlined only the principles of therapy.[13][14]

Prognosis

DM is associated with increased ASCVD, and treating BP, statin use, regular exercise, and smoking cessation are of great importance in ameliorating risk. The overall excess mortality in those with T2DM is around 15% higher but varies widely. Prevalence of vision-threatening diabetic retinopathy in the United States is about 4.4% among adults with diabetes, while it is 1% for the end-stage renal disease. Today, with pharmacotherapy for hyperglycemia, as well as lowering LDL cholesterol and managing BP with ACE/ARB therapy, with other BP medications and aspirin in secondary prevention, vascular complications can be managed adequately resulting in a reduction in morbidity and mortality.

Complications

Persistent hyperglycemia in uncontrolled diabetes can cause several complications, both acute and chronic. Diabetes is one of the leading causes of cardiovascular disease (CVD), blindness, kidney failure, and amputation of lower limbs. Acute complications include hypoglycemia, diabetic ketoacidosis, hyperglycemic hyperosmolar state, and hyperglycaemic diabetic coma. Chronic microvascular complications are nephropathy, neuropathy, and retinopathy, whereas chronic macrovascular complications are coronary artery disease (CAD), peripheral artery disease (PAD), and cerebrovascular disease. It is estimated that every year 1.4% to 4.7% of middle-aged people with diabetes have a CVD event.

Deterrence and Patient Education

Patients must be educated about the importance of blood glucose management to avoid complications associated with DM. Stress must be given on lifestyle management, including diet control and physical exercise. Self-monitoring of blood glucose is an important means for patients taking responsibility for their diabetes management. Regular estimation of glucose, glycated hemoglobin, and lipid levels are necessary.

Healthcare professionals should educate patients about the symptoms of hypoglycemia (such as tachycardia, sweating, confusion) and required action (ingestion of 15 to 20 gm of carbohydrate).

Patients should be motivated to stop smoking. Emphasis is required on regular eye check ups and foot care.

Pearls and Other Issues

T1DM is characterized by autoimmune destruction of pancreatic beta cells in the majority.

T2DM is caused due to duel defects in insulin resistance and insulin secretion.

Gestational diabetes is associated with maternal as well as fetal complications.

Exercise and a healthy diet are beneficial in both type 1 and type 2 diabetes.

Novel therapies such as GLP-1 receptor agonists and SGLT2 inhibitors are safer since they do not cause hypoglycemia, are weight neutral or result in weight loss and BP and impact vascular complications favorably.

Enhancing Healthcare Team Outcomes

The diagnosis and management of Type 2 diabetes is with a multidisciplinary team. These patients need an appropriate referral to the ophthalmologist, nephrologist, cardiologist and vascular surgeon. In addition, patients need to be educated about lifestyle changes that can help lower blood glucose. All obese diabetics should be encouraged to lose weight, exercise and eat a healthy diet. It is vital that the primary care provider and diabetic nurse encourage all diabetics top smoking and abstain from drinking alcohol. The complications of diabetes are limb and life-threatening and seriously diminish the quality of life.[15][16][17]


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Diabetes Mellitus Type 2 - Questions

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A 65-year old man presents for evaluation and management of his diabetes mellitus type 2. Three months ago his urinalysis showed microalbuminuria and a hemoglobin A1c of 7 percent. Conservative management of diet and exercise was attempted for three months, a timeframe in which he gained one pound. Today, his hemoglobin A1C remained at 7 percent. Which of the following pharmacological interventions is the best next step in this patient?



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In a patient with recent onset type 2 diabetes, which enzyme mutation could be responsible for the disorder?



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A 55-year-old obese male with a long history of hypertension, gout, and arthritis presents with recent blurred vision, weight gain, polydipsia, polyuria, and confusion. His random blood glucose is more than 222 mg/dl. Which diagnosis is most probable?



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An obese male who has recently been diagnosed with diabetes has a Hgb A1c of 7.1. The value has not improved after 3 months of exercise and diet. Select the most appropriate treatment.



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In a patient with obesity, diabetes mellitus, hypertension, retinopathy, and moderate claudication, what is the best treatment for high blood pressure?



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Which of the following is true about diabetes mellitus (DM) type 2?



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An obese Hispanic female presents with fatigue, polyuria, polyphagia, and polydipsia. Her vital signs are normal. Her BMI is 37 kg/m2. The exam is normal except for extreme obesity. Fasting blood sugars are 135 mg/dL and 137 mg/dL on separate days. Which study would determine if the patient has type 1 or type 2 diabetes mellitus?



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Which of the following correctly describes the pathology of diabetes mellitus type 2?



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An obese female has fasting blood sugars of 130 mg/dL and 140 mg/dL, two days apart. Which of the following interventions is most appropriate for a newly diagnosed diabetic?



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A female is newly diagnosed with diabetes mellitus type 2. Her blood pressure has been above 140/90 mmHg on three separate occasions, 2 weeks apart. Which of the following medications would be most appropriate for this patient?



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An obese female is diagnosed with diabetes mellitus type 2. After 3 months of dieting and increased activity, her hemoglobin A1c has not reached its target level. Which of the following medications would be most appropriate for this patient?



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Which of the following is the simplest insulin regimen for a patient with diabetes mellitus type 2 who wishes to minimize the number of injections?



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Which of the following is considered appropriate home blood glucose monitoring for patients taking oral hypoglycemic agents?



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Which of the following is a common theme in patients with type 2 diabetes?



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A patient has been controlling elevated glucose levels with a dietary regimen. The patient has just begun receiving prednisone for the treatment of lymphoma. The serum glucose is elevated. Which of the following is responsible for this rise in serum glucose?



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A patient is admitted with acute appendicitis. The patient is to receive nothing by mouth (NPO). The patient says, "I am supposed to take glyburide 5 mg by mouth daily." His glucose level on admission is 362 mg/dl. He is to receive 10 units regular human insulin subcutaneously without delay. Which of the following explanations should be given the patient?



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What is the most appropriate management of an adult male with a history of type 2 diabetes mellitus and gastroesophageal reflux disease who has had systolic blood pressure readings over 150 mmHg at three separate appointments?



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What is the primary physiologic defect in diabetes mellitus type 2?



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Which of the following tests is most useful in the diagnosis of type 2 diabetes mellitus?



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What is the primary physiologic defect in type 2 diabetes mellitus?



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Which of the following is the most significant risk factor in the development of diabetes mellitus type 2?



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What is the drug of choice for a 56-year-old with well-controlled diabetes mellitus and microalbuminuria?



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Which of the following is the most appropriate addition in a 66-year-old patient with type 2 diabetes who is on the maximum dose of metformin and who refuses shots?



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During a recent hospitalization, a 65-year-old diabetic patient was placed on a sliding scale. Which of the following is the best outpatient insulin regimen for this patient?



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What is the most common initial complication of type 2 diabetes mellitus?



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The presence of microalbuminuria in an overweight, diabetic male with hypertension is indicative of which of the following?



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Which clinical feature is often associated with type 2 diabetes?



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What is the basic pathology of type 2 diabetes?



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Which diagnosis is more common in Hispanic patients?



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What is the first treatment for a patient who has just been diagnosed with diabetes mellitus (DM) type 2?



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What is the goal LDL cholesterol level in a patient with type 2 diabetes mellitus?



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What is the best choice for a type 2 diabetes mellitus patient on maximal therapy with glipizide and metformin with an A1C of 10%?



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An elderly patient with diabetes mellitus type 2 is working with macrame to maintain fine motor skills. Which of the following would be the most important safety issue?



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A 50-year-old patient with recent total hip arthroplasty is seen in physical therapy for gait training. She has diabetes mellitus (DM) type 2. Her blood glucose was just checked and is 130 mg/dL. Select appropriate treatment at this time.



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A home exercise program for a patient with type 2 diabetes mellitus is being planned. What should be recommended?



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Which of the following is used with patients with type 2 diabetes for prevention of the development of microvascular disease?



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What is the most important predisposing factor for the development of type 2 diabetes mellitus?



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A patient with type 2 diabetes mellitus presents to the emergency room with a blood glucose of 500 mg/dL and serum potassium of 4.2 mEq/L. What is the most appropriate initial intravenous fluid?



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A 63-year-old man (5'10", 178 lbs) with hypertension, heart failure (NHYA Class I), GERD, urinary hesitancy, and history of glaucoma is newly diagnosed with type 2 diabetes. Medications include finasteride 5 mg daily, tamsulosin 0.4 mg 1 capsule daily, omeprazole 20 mg 1 capsule daily, and doxazosin 2 mg 1 tab daily. Lab results for today include hemoglobin A1c 8.2%, ALT 30 IU/L, and creatinine 1.6 mg/dL. The patient receives a prescription for metformin. What best describes the assessment of this therapy?



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A patient is on nothing by mouth status upon admission for pneumonia. He tells you that his glyburide dose is due. Blood work reveals a glucose level of 345 mg/dL. You respond by ordering and administering 10 units of regular insulin. The patient wants to know why he is getting insulin when he usually does not take it. How should you respond?



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A middle-aged patient with type 2 diabetes mellitus has been diagnosed with heart failure. He is worried about developing further complications from untreated diabetes. What does the American Heart Association recommend should be the target A1c goal when treating such patients?



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A middle-aged obese male presents to the clinic with complaints of recent weight gain, polyuria, polydipsia, and generalized fatigue. He was told several years ago to lose weight, but he did not bother with any exercise. Blood work reveals that he has a Hemoglobin A1c of 9.4% and elevated lipids. According to the American Diabetes Association, by the time patients with type 2 diabetes mellitus have a diagnosis of the disorder, what percentage have already developed one or more microvascular complications?



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A middle-aged patient with type 2 diabetes mellitus is on fixed-dose daily insulin for the past nine months. However, he now has had three severe episodes of hypoglycemia, which required visits to the emergency department. To reduce the risk of hypoglycemia what nutritional advice should be offered to this patient?



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A patient has just developed type 2 diabetes. He is obese and also has hypertension. He sincerely wants to control his diabetes to avoid complications. The provider recommends that he obsessively count the carbohydrate intake. Which of the following is a major benefit of such a dietary approach to diabetes?



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It is unclear whether or not a patient with insulin-dependent type 2 diabetes mellitus is using their insulin as prescribed. A urinalysis is performed. What is a possible finding in their urine? Select all that apply.



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A 65-year old man presents for evaluation and management of his diabetes mellitus type 2. Three months ago his urinalysis showed microalbuminuria and a hemoglobin A1c of 7 percent. Conservative management of diet and exercise was attempted for three months, a timeframe in which he gained one pound. Today, his hemoglobin A1C remained at 7 percent. Which of the following pharmacological interventions is the best next step in this patient?



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A patient presents with the complaint of polyphagia and polydipsia. After the relevant tests, he is diagnosed with diabetes mellitus. Which is the most appropriate nursing diagnosis?



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A patient's blood glucose is 48mg/dL. Which is a priority nursing action?



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The school nurse is screening students for type 2 diabetes mellitus. Which condition will the nurse assess for this patient?



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The nurse is caring for a patient with a blood glucose of 650 mg/dL who has a respiratory rate of 34 breaths per minute. Which orders does the nurse anticipate? Select all that apply.



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Which healthcare team members might be involved in the care of a patient with type 2 diabetes mellitus? Select all that apply.



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Diabetes Mellitus Type 2 - References

References

Malek R,Hannat S,Nechadi A,Zohra Mekideche F,Kaabeche M, Diabetes and Ramadan: a multicenter study in Algerian population. Diabetes research and clinical practice. 2019 Feb 16;     [PubMed]
Choi YJ,Chung YS, Type 2 diabetes mellitus and bone fragility: Special focus on bone imaging. Osteoporosis and sarcopenia. 2016 Mar;     [PubMed]
Picke AK,Campbell G,Napoli N,Hofbauer LC,Rauner M, Update on the impact of type 2 diabetes mellitus on bone metabolism and material properties. Endocrine connections. 2019 Mar 1;     [PubMed]
Carrillo-Larco RM,Barengo NC,Albitres-Flores L,Bernabe-Ortiz A, The risk of mortality among people with type 2 diabetes mellitus in Latin America: A systematic review and meta-analysis of population-based cohort studies. Diabetes/metabolism research and reviews. 2019 Feb 13;     [PubMed]
Hussain S,Chowdhury TA, The Impact of Comorbidities on the Pharmacological Management of Type 2 Diabetes Mellitus. Drugs. 2019 Feb 11;     [PubMed]
Kempegowda P,Chandan JS,Abdulrahman S,Chauhan A,Saeed MA, Managing hypertension in people of African origin with diabetes: Evaluation of adherence to NICE Guidelines. Primary care diabetes. 2019 Jan 28;     [PubMed]
Martinez LC,Sherling D,Holley A, The Screening and Prevention of Diabetes Mellitus. Primary care. 2019 Mar;     [PubMed]
Thewjitcharoen Y,Chotwanvirat P,Jantawan A,Siwasaranond N,Saetung S,Nimitphong H,Himathongkam T,Reutrakul S, Evaluation of Dietary Intakes and Nutritional Knowledge in Thai Patients with Type 2 Diabetes Mellitus. Journal of diabetes research. 2018;     [PubMed]
Willis M,Asseburg C,Neslusan C, Conducting and interpreting results of network meta-analyses in type 2 diabetes mellitus: A review of network meta-analyses that include sodium glucose co-transporter 2 inhibitors. Diabetes research and clinical practice. 2019 Feb;     [PubMed]
Lai LL,Wan Yusoff WNI,Vethakkan SR,Nik Mustapha NR,Mahadeva S,Chan WK, Screening for non-alcoholic fatty liver disease in patients with type 2 diabetes mellitus using transient elastography. Journal of gastroenterology and hepatology. 2018 Dec 14;     [PubMed]
Eckstein ML,Williams DM,O'Neil LK,Hayes J,Stephens JW,Bracken RM, Physical exercise and non-insulin glucose-lowering therapies in the management of Type 2 diabetes mellitus: a clinical review. Diabetic medicine : a journal of the British Diabetic Association. 2019 Mar;     [PubMed]
Massey CN,Feig EH,Duque-Serrano L,Wexler D,Moskowitz JT,Huffman JC, Well-being interventions for individuals with diabetes: A systematic review. Diabetes research and clinical practice. 2019 Jan;     [PubMed]
Shah SR,Iqbal SM,Alweis R,Roark S, A closer look at heart failure in patients with concurrent diabetes mellitus using glucose lowering drugs. Expert review of clinical pharmacology. 2019 Jan;     [PubMed]
[National guidelines for the prevention and control of diabetes in primary care(2018)]. Zhonghua nei ke za zhi. 2018 Dec 1;     [PubMed]
Liakopoulos V,Franzén S,Svensson AM,Miftaraj M,Ottosson J,Näslund I,Gudbjörnsdottir S,Eliasson B, Pros and cons of gastric bypass surgery in individuals with obesity and type 2 diabetes: nationwide, matched, observational cohort study. BMJ open. 2019 Jan 15;     [PubMed]
Su YJ,Chen TH,Hsu CY,Chiu WT,Lin YS,Chi CC, Safety of metformin in psoriasis patients with diabetes mellitus: a 17-year population-based real-world cohort study. The Journal of clinical endocrinology and metabolism. 2019 Feb 19;     [PubMed]
Choi SE,Berkowitz SA,Yudkin JS,Naci H,Basu S, Personalizing Second-Line Type 2 Diabetes Treatment Selection: Combining Network Meta-analysis, Individualized Risk, and Patient Preferences for Unified Decision Support. Medical decision making : an international journal of the Society for Medical Decision Making. 2019 Feb 15;     [PubMed]
Geiss LS,Wang J,Cheng YJ,Thompson TJ,Barker L,Li Y,Albright AL,Gregg EW, Prevalence and incidence trends for diagnosed diabetes among adults aged 20 to 79 years, United States, 1980-2012. JAMA. 2014 Sep 24;     [PubMed]
Alotaibi A,Perry L,Gholizadeh L,Al-Ganmi A, Incidence and prevalence rates of diabetes mellitus in Saudi Arabia: An overview. Journal of epidemiology and global health. 2017 Dec;     [PubMed]
Rossello X,Dorresteijn JA,Janssen A,Lambrinou E,Scherrenberg M,Bonnefoy-Cudraz E,Cobain M,Piepoli MF,Visseren FL,Dendale P, Risk prediction tools in cardiovascular disease prevention: A report from the ESC Prevention of CVD Programme led by the European Association of Preventive Cardiology (EAPC) in collaboration with the Acute Cardiovascular Care Association (ACCA) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP). European heart journal. Acute cardiovascular care. 2019 Jun 25;     [PubMed]
Nithun TM,Ranugha PSS,Betkerur JB,Shastry V, Association of Acanthosis Nigricans and Insulin Resistance in Indian Children and Youth - A HOMA2-IR Based Cross-Sectional Study. Indian dermatology online journal. 2019 May-Jun;     [PubMed]
Popa ML,Popa AC,Tanase C,Gheorghisan-Galateanu AA, Acanthosis nigricans: To be or not to be afraid. Oncology letters. 2019 May;     [PubMed]
Novotny R,Davis J,Butel J,Boushey CJ,Fialkowski MK,Nigg CR,Braun KL,Leon Guerrero RT,Coleman P,Bersamin A,Areta AAR,Barber LR Jr,Belyeu-Camacho T,Greenberg J,Fleming T,Dela Cruz-Talbert E,Yamanaka A,Wilkens LR, Effect of the Children's Healthy Living Program on Young Child Overweight, Obesity, and Acanthosis Nigricans in the US-Affiliated Pacific Region: A Randomized Clinical Trial. JAMA network open. 2018 Oct 5;     [PubMed]
Chamberlain JJ,Rhinehart AS,Shaefer CF Jr,Neuman A, Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Annals of internal medicine. 2016 Apr 19;     [PubMed]
Luo J,Gonsalves G,Greene J, Insulin for all: treatment activism and the global diabetes crisis. Lancet (London, England). 2019 May 25;     [PubMed]
Griffey RT,Schneider RM,Malone N,Peterson C,McCammon C, Diabetic Ketoacidosis Management in the Emergency Department: Implementation of a Protocol to Reduce Variability and Improve Safety. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2019 Jun 17;     [PubMed]
Levengood TW,Peng Y,Xiong KZ,Song Z,Elder R,Ali MK,Chin MH,Allweiss P,Hunter CM,Becenti A, Team-Based Care to Improve Diabetes Management: A Community Guide Meta-analysis. American journal of preventive medicine. 2019 Jul;     [PubMed]
Atallah R,Côté J,Bekarian G, [Evaluation of the effects of a nursing intervention on the therapeutic adherence of people with type 2 diabetes]. Recherche en soins infirmiers. 2019 Mar;     [PubMed]
Doupis J,Alexandrides T,Elisaf M,Melidonis A,Bousboulas S,Thanopoulou A,Pagkalos EM,Avramidis I,Pappas A,Arvaniti E,Karamousouli E,Voss B,Tentolouris N, Influence of Supervised Disease Understanding and Diabetes Self-Management on Adherence to Oral Glucose-Lowering Treatment in Patients with Type 2 Diabetes. Diabetes therapy : research, treatment and education of diabetes and related disorders. 2019 Aug;     [PubMed]
Miri SF,Javadi M,Lin CY,Griffiths MD,Björk M,Pakpour AH, Effectiveness of cognitive-behavioral therapy on nutrition improvement and weight of overweight and obese adolescents: A randomized controlled trial. Diabetes     [PubMed]
Daftarian Z,Bowen PG, Improving outcomes in patients with prediabetes through a lifestyle modification program. Journal of the American Association of Nurse Practitioners. 2019 Jun 19;     [PubMed]
Davis S,Johnson V,McClory M,Warneck J, Diabetes empowerment with a nurse-led shared medical appointment program. Nursing. 2019 Jul;     [PubMed]
Jenum AK,Brekke I,Mdala I,Muilwijk M,Ramachandran A,Kjøllesdal M,Andersen E,Richardsen KR,Douglas A,Cezard G,Sheikh A,Celis-Morales CA,Gill JMR,Sattar N,Bhopal RS,Beune E,Stronks K,Vandvik PO,van Valkengoed IGM, Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials. Diabetologia. 2019 Aug;     [PubMed]
LaManna J,Litchman ML,Dickinson JK,Todd A,Julius MM,Whitehouse CR,Hyer S,Kavookjian J, Diabetes Education Impact on Hypoglycemia Outcomes: A Systematic Review of Evidence and Gaps in the Literature. The Diabetes educator. 2019 Aug;     [PubMed]
Tao Z,Shi A,Zhao J, Epidemiological Perspectives of Diabetes. Cell biochemistry and biophysics. 2015 Sep;     [PubMed]
Diagnosis and classification of diabetes mellitus. Diabetes care. 2013 Jan;     [PubMed]
Su J,Qin Y,Pan XQ,Shen C,Gao Y,Pan EC,Zhang YQ,Zhou JY,Wu M, [Association between fresh fruit consumption and glycemic control in patients with type 2 diabetes]. Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi. 2019 Jun 10;     [PubMed]
Nikitara M,Constantinou CS,Andreou E,Diomidous M, The Role of Nurses and the Facilitators and Barriers in Diabetes Care: A Mixed Methods Systematic Literature Review. Behavioral sciences (Basel, Switzerland). 2019 Jun 14;     [PubMed]
Razaz JM,Rahmani J,Varkaneh HK,Thompson J,Clark C,Abdulazeem HM, The health effects of medical nutrition therapy by dietitians in patients with diabetes: A systematic review and meta-analysis: Nutrition therapy and diabetes. Primary care diabetes. 2019 Oct;     [PubMed]
Fletcher B,Gulanick M,Lamendola C, Risk factors for type 2 diabetes mellitus. The Journal of cardiovascular nursing. 2002 Jan;     [PubMed]

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