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SOURCE

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Source: Triplitt CL, Repas T, Alvarez C. Diabetes mellitus. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146065891. Accessed January 22, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Adult onset diabetes mellitus (DM)

  • Non-insulin–dependent diabetes mellitus (NIDDM)

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DEFINITION

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  • Disorder of carbohydrate regulation associated with.

    • Reduced pancreatic insulin production.

    • Progressive loss of β-cells over time.

    • Peripheral insulin resistance.

    • Impaired regulation of hepatic glucose production.

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ETIOLOGY

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  • Excessive caloric intake, inadequate exercise, and obesity coupled with susceptible genotype.

  • Uncommon causes.

    • Endocrine disorders (eg, acromegaly, Cushing syndrome)

    • Gestational diabetes.

    • Diseases of exocrine pancreas (eg, pancreatitis)

    • Hereditary hemochromatosis.

    • Medications (glucocorticoids, pentamidine, niacin, alfa-interferon)

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PATHOPHYSIOLOGY

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  • Caused by multiple defects:

    • Impaired insulin secretion.

    • Deficiency and resistance to incretin hormones.

    • Insulin resistance involving muscle, liver, and adipocytes.

    • Excess glucagon secretion.

    • Sodium-glucose cotransporter upregulation in the kidney.

  • Insulin resistance manifested by.

    • Increased lipolysis and free fatty acid production.

    • Increased hepatic glucose production.

    • Decreased skeletal muscle uptake of glucose.

  • β-Cell dysfunction is progressive and contributes to worsening blood glucose control over time.

  • Microvascular complications:

    • Retinopathy.

    • Neuropathy.

    • Nephropathy.

  • Macrovascular complications:

    • Coronary heart disease.

    • Stroke.

    • Peripheral vascular disease.

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EPIDEMIOLOGY

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  • Accounts for 90% of DM cases.

  • Prevalence in the United States is about 11.3% in persons age 20 or older.

  • In 2012, an estimated 29 million Americans 20 years of age or older, about 12–14% of the population, have DM.

  • 86 million are at high risk for developing DM.

  • More prevalent among Hispanics, Native Americans, African Americans, and Asians/Pacific Islanders than in non-Hispanic whites.

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PREVENTION AND SCREENING

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  • Prevention.

    • Maintain healthy diet, increased physical activity, and appropriate body weight.

    • Medications (metformin) may help prevent progression to type 2 DM in individuals with impaired glucose tolerance.

  • Screening.

    • Screen for type 2 DM in adults who are overweight and have at least one other risk factor.

    • For all people, testing should begin at age 45 years.

    • Recommended screening tests include.

      • Fasting plasma glucose.

      • HbA1c

      • 2-hour OGTT

    • If tests are normal, repeat testing every 3 years.

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RISK FACTORS

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  • Age >45 years.

  • A1C >5.7%

  • Family history of diabetes.

  • Impaired glucose tolerance.

  • Impaired fasting glucose.

  • Diagnosed prediabetes.

  • Hypertension.

  • Obesity.

  • Low physical activity level.

  • Dyslipidemia.

  • High triglycerides.

  • Diabetes during previous pregnancy.

  • Polycystic ovarian syndrome.

  • History of vascular disease.

  • Acanthosis nigricans.

  • Ethnicity (African Americans, Hispanic Americans, Asian Americans, Pacific Islanders, Native Americans)

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Often asymptomatic; diagnosed during routine blood testing or screening.

  • Symptoms:

    • Lethargy.

    • Polyuria.

    • Nocturia.

    • Polydipsia.

    • Significant weight loss less common.

  • Presence of complications (eg, retinopathy, neuropathy, nephropathy) may indicate long-term disease presence.

  • Most patients are overweight or obese.

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