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Goals
Understand how type 2 diabetes affects many organs and how this changes over the course of the illness Understand how each class of oral diabetes medications works Using the above, be able to pick the best medication or combination of medications for our patients with type 2 diabetes
Insulin Resistance
Muscle = Postprandial Hyperglycemia Fat = Increased FFA Concentration and Hepatic VLDL-TG
UK Study - 1998
Traditional glycemic control (secretagogues) reduced microvascular complications Retinopathy -29% Nephropathy -33% Neuropathy -40% But not macrovascular complications MIs -16% Stroke +11% Deaths -6%
UK Study 1998
Metformin decreased macrovascular complicatons (lower insulin levels) MI -39% Coronary Deaths -50% Diabetes Related Deaths -42% All Cause Mortality -36%
Insulin Resistance
Muscle = Postprandial Hyperglycemia Fat = Increased FFA Concentration and Hepatic VLDL-TG
Case #1
30 y.o. woman with a history of gestational diabetes with her first pregnancy at age 21 presents with frequent urination, thirst, weight loss and a random glucose of 250. She has an IUD in place. Her BMI is 33. BP is 140/80. Is this enough information to diagnose diabetes? What other tests would you order?
Test Results
HbA1C 9.2 Alb/Cr 0.010 Cr 0.6 LFTs WNL CBC WNL TSH 2.3 Fasting Insulin C-peptide 3.5 b-HCG Neg
Anything else?
Refer to ophthalmologist Do microfilament check for neuropathy See frequently to reinforce diet, exercise, home glucose monitering Start Metformin XL Treat BP with ACEI if remains over 130/80
Summary
Type 2 diabetes affects many organs Type 2 diabetes changes over time Diabetes treatment changes over time Medications can now be selected to work where the problem is Combinations of medications, because they work at different sites, in the body usually work better than monotherapy