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At what age do ppl with Type 1 DM usually become diagnosed?
peak age of onset = 12
75% of ppl dx'd by age 18
How does DM1 happen?
autoimmune destruction of beta islet cells by lots of antibodies --> absolute insulin deficiency (C-peptide <250)
What cells are resistant to insulin in DM2?
1. liver
2. skeletal muscle
3. adipose
What % of DM2 ppl are obese, with BMI >30?
80%
What is "prediabetes?"
impaired fasting glucose of 100-125 after 8-hr fast

tx diet/exercise
What are the macrovascular complications of DM?
1. coronary athersclerosis
2. cerebral atherosclerosis
3. peripheral vascular dz
What are the microvascular complications of DM?
1. retinopathy (see Ophtho once a year)
2. nephropathy
3. neuropathy
What are the diagnostic criteria for DM?
1. gluc >126 after 8-hr fast
2. random gluc >200 with polyuria/polydipsia/wt loss
3. or A1C >6.3%
What does the ADA recommend on screening ppl for DM?
fasting gluc in everyone over 45 yo, begin younger if BMI >25 (overweight)
What are key elements of the physical in a diabetic?
1. BP goal <130/85
2. fundoscopic exam for retinopathy
3. check feet for lesions
4. monofilament test on feet for neuropathy
Normal A1C =
Target A1C for diabetic =
<6.3%
<7%

Check A1C q3 months!
Besides A1C, what other labs are important to check in a diabetic?
1. lytes (gluc/K/BUN/Cr) at every visit
2. UA for alb/Cr ratio (want <30 otherwise it is microalbuminuria and person needs ACEi)
biguanides =
metformin (Glucophage)

1. reduce gluconeogenesis and increase tissue sensitivity
2. max eff dose 1000 mg bid
3. reduces mortality!
4. not for ppl acidotic or with Cr >1.3 (F) >1.5 (M)
thiazolidinediones =
1. pioglitazone (Actose) max dose 45 mg daily
2. rosiglitazone (Avandia) max dose 8 mg daily
3. beneficial effects on lipids
4. wt gain, edema
5. not for class 3/4 CHF
6. check LFTs q3 months
sulfonylureas =
glyburide

1. hypoglycemia, wt gain, hyperinsulinemia
2. max eff dose 5 mg bid
a-glucosidase inhibitors =
acarbose (Precose)

1. interfere with starch breakdown
2. diarrhea, flatulence, stomachache, tid dosing a pain
meglitinides =
non-sulfonylurea secretagogues
repaglinide (Prandin) max eff dose 4 mg tid before meals

1. short-acting, stimulates prandial insulin release
2. lowers post-prandial sugar level
3. lowers A1C
Insulin should be started on what sort of DM2 patients?
Those who can't get A1C <8% on max oral therapy.
lispro =
Humalog, fast-acting bolus insulin what works in 5 min and lasts only 3 h
glargine =
Lantus, long-acting basal insulin that works for 24 h
NPH =
Novolin N, intermediate-acting insulin that works in 1.5 h and lasts for ~10 h
What is the most physiologic insulin regimen?
Lantus at bedtime + sliding scale Humalog tid before meals
Target fingerstick before meals =
90-130

If FS <80, eat immediately
FS >200, wait 1 h to eat
Target fingerstick after meals =
<180 1-2 h after eating
Humulin =
50/50 NPH/regular insulin
Novolin =
70/30 NPH/regular insulin on BHC formulary