II. Epidemiology

  1. Represents 90% of all Diabetes Mellitus
  2. Typically occurs over age 40 years in obese patients

III. Pathophysiology

  1. Triad of factors contributing to Diabetes Mellitus
    1. Impairment of pancreatic beta-cell function
      1. Decreased beta cell response to Glucose
        1. Abnormal Glucagon secretion
      2. Amyloidosis of islet cells (40% of patients)
      3. Pancreatic fibrosis (66% of patients)
        1. Associated fatty infiltration, vessel sclerosis
    2. Decreased Insulin sensitivity (60-80% of patients)
      1. See Insulin Resistance
      2. Obesity
    3. Incretin Deficiency
  2. Course
    1. 12 years before diagnosis: Impaired Glucose Tolerance
      1. Insulin Resistance starts
      2. Insulin levels start to rise
      3. Fasting and post-meal Glucose normal
    2. 8 years before diagnosis: Postprandial Hyperglycemia
      1. Beta cell function at 75%
      2. Insulin levels increase to 150% of normal
      3. Fasting and post-meal Glucose normal
    3. 2 years before diagnosis: Type 2 diabetes phase I
      1. Beta cell function at 50%
      2. Insulin levels increase to 200% of normal (peak)
      3. Post-prandial Glucose 150-200 mg/dl
      4. Normal Fasting Glucose
    4. 2 years after diagnosis: Type 2 diabetes phase II
      1. Insulin levels fall to 150% of normal
      2. Post-prandial Glucose 200 mg/dl
      3. Fasting Glucose >140-150 mg/dl
    5. 8 years after diagnosis: Type 2 diabetes phase III
      1. Beta cell function at 25%
      2. Insulin levels fall to 100% of normal
    6. 14 years after diagnosis
      1. Beta cell function approaches 0%
      2. Insulin levels fall below 50% and approach 0

IV. Etiology

V. Risk Factors:

  1. Obesity (especially Apple Obesity)
  2. Previous Gestational Diabetes (GDM)
  3. Family History of Type II Diabetes Mellitus
  4. Age over 40 years (risk increases with age)
    1. Type II Diabetes Mellitus does occur in children
  5. Sedentary lifestyle (decreased Physical Activity)
  6. Previously Impaired Glucose Tolerance (IGT)
  7. Western diet
    1. Red meats and processed meats
    2. High fat foods (french fries, high fat dairy, eggs)
    3. High sugar foods, desserts and drinks
    4. Van Dam (2002) Ann Intern Med 136:201-9 [PubMed]
  8. Ethnicity
    1. Native American
    2. African American or Black
    3. Asian Type II Diabetics may be thin
    4. Hispanic
  9. Cigarette smoking decreases Insulin sensitivity
    1. Targher (1997) Clin Endocrinol Metab 82:3619-23 [PubMed]

VI. Risk Factors: Protective Factors (based on initial study findings)

VII. Symptoms and Signs

VIII. Diagnostic Criteria

IX. Associated Conditions

X. Labs

  1. Urine Ketones: Usually negative
    1. Exception: Children with Type II Diabetes
  2. See Diabetes Mellitus

XI. Precautions: Accord Trial

  1. Suggests higher risk of aggressively lowering Blood Glucose in Type II Diabetes
  2. Risk increased with Hemoglobin A1C of 6.4% compared with 7.5%
  3. Mortality was higher in the 6.4% A1C group by 3 per thousand patients
  4. Endocrinologists still recommend goal of <7.0% and await larger trial (Advance)
  5. References: NHLBI Questions and Answers regarding Accord Study
    1. http://www.nhlbi.nih.gov/health/prof/heart/other/accord/q_a.htm

XII. Management: General

  1. Intensive Diabetic Education
    1. Goal Hemoglobin A1C <7.0 to 8.0
      1. Goal relaxed to 8% in 2009 based on ACCORD and ADVANCE results
    2. Fasting plasma Glucose: 70 to 140 mg/dl (ideal <105)
      1. New guidelines may suggest 70 to 120 mg/dl
    3. 2 hour postprandial Glucose: <160 mg/dl (ideal <135)
      1. Ideally, only 20-40 mg/dl rise over pre-meal
    4. Bedtime Glucose: 100-140 mg/dl
  2. Weight loss if Overweight
    1. Recommend 10-20 pound weight loss
    2. Lower Caloric Intake by 250-500 calories per day
  3. Cardiovascular Disease Prevention
    1. Lower LDL Cholesterol <80-100 (Statin)
    2. Lower Blood Pressure <130/80 (ACE Inhibitor or ARB as first line medication)
      1. Keep systolic Blood Pressure between 120 and 130 mmHg
    3. Aspirin 81-160 mg PO qd
    4. ACE Inhibitor (Indicated in Proteinuria)

XIII. Management: Oral Glycemic Protocol

  1. See Diabetes Mellitus Glucose Management
  2. See Oral Hypoglycemic agents
  3. Sample Initial Protocol based on Glucose
    1. Fasting Blood Sugar <200 or random Glucose <250
      1. Consider trial of diet and Exercise for 1-2 months
      2. Strongly consider concurrent Oral Hypoglycemic
    2. Fasting Blood Sugar <300 or random Glucose <350
      1. Start Oral Hypoglycemic agent (see above)
    3. Fasting Blood Glucose >250 mg/dl and Glucose toxicity
      1. Start Insulin replacement protocol (see above)
      2. Concurrently start Oral Hypoglycemic (Metformin)
    4. Fasting Blood Sugar >300 or random Glucose >350
      1. Start Insulin replacement protocol (see above)
      2. Concurrently start Oral Hypoglycemic (Metformin)
  4. Medical nutrition therapy (adjunct to all other management)
    1. Efficacy: A1C decrease 1%
    2. Obese patients (Fasting Glucose high)
      1. Insulin Resistance primary problem in early phase
      2. Focus on weight loss and activity
    3. Lean patients (Postprandial Glucose high)
      1. Insulin deficiency is primary problem
      2. Focus on Carbohydrate Counting
  5. Single Oral Agents
    1. See Oral Hypoglycemic
    2. Indications to start at presentation
      1. Hemoglobin A1C >6.5% or
      2. Fasting Blood Glucose >126 mg/dl or
      3. Random Blood Glucose >250 mg/dl or
      4. Glucose Tolerance Test 2 hour >200 mg/dl
    3. Efficacy: A1C decrease 1-2% (combined with above)
    4. First-Line agents
      1. Metformin (Glucophage)
        1. First-line (regardless of weight) unless otherwise contraindicated
        2. Contraindicated if GFR <30 ml/min/kg
    5. Second-Line agents
      1. Glitazone (e.g. Pioglitazone, Rosiglitazone)
        1. Especially obese patients with Insulin Resistance (Fasting Glucose high)
      2. Oral secretagogue (e.g. Sulfonylurea)
        1. Especially lean patients (Postprandial Glucose high)
  6. Dual Drug Therapy
    1. Indications to add a second agent
      1. Inadequate Glucose control after 3 months on single oral agent (as above)
    2. Indications to start two agents at presentation
      1. Hemoglobin A1C 9-11%
      2. Fasting BG 251-300 mg/dl
      3. Random or casual BG 301-350 mg/dl
    3. Efficacy: A1C decrease 2-4% (combined with above)
    4. First-line combinations: Metformin AND
      1. Sulfonylurea (esp. lean patients) or
      2. Glitazone (esp. obese patients) or
      3. Incretin (choose only 1)
        1. Gliptin or DPP-4 Inhibitor (e.g.Sitagliptin or Januvia)
        2. GLP-1 Agonist (e.g. Exenatide or Byetta)
        3. Avoid using 2 Incretins in combination (raises cost, risk of Pancreatitis without significant benefit)
          1. (2012) Presc Lett 19(8): 45
    5. Second-Line combinations (with something other than Metformin)
      1. Insulin Secretagogue with Glitazone
      2. Incretin with Sulfonylurea (use caution)
      3. Basal Insulin (e.g. Lantus) with Sulfonylurea, Glitazone, Gliptin or Incretin
  7. Triple Drug Therapy
    1. Add a third drug from the agents listed above if inadequate control on dual agents
  8. Insulin Therapy
    1. Indications to start at presentation
      1. Hemoglobin A1C >10-11%
      2. Fasting BG >300 mg/dl (or >250 mg/dl and Glucose toxicity)
      3. Random or casual BG >350 mg/dl
    2. Protocol: Options
      1. See below
      2. Basal Insulin
      3. Basal with Bolus Insulin
      4. Mixed Insulin

XIV. Management: Insulin Protocol

  1. Indications
    1. Glucose toxicity
      1. Fasting Blood Glucose >250 mg/dl and
      2. Ketosis or weight loss
    2. Hemoglobin A1C > 10% or random Blood Glucose consistently >300 mg/dl
    3. Inadequate Blood Sugar control on oral agents and Hemoglobin A1C >9%
    4. Late stage Type II Diabetes (>5-10 years)
    5. Perioperative Diabetes Management
    6. Chronic Renal Failure
    7. Pregnancy
    8. Acute illness
  2. Protocol
    1. See Insulin Dosing
    2. See Insulin Dosing in Type II Diabetes
    3. Option 1: Insulin augmentation
      1. Start Dose: 0.15 to 0.20 units/kg daily (10-14 units/day)
      2. Titrate Dose: Increase by 2 units every 3 days
      3. Preparations
        1. Insulin Glargine (Lantus) daily or
        2. NPH (Novolin N, Humulin N) at bedtime or twice daily
    4. Option 2: Insulin replacement
      1. Titrate dose up to 0.5 units/kg daily
      2. Long-acting basal Insulin (NPH or Lantus) and
      3. Short-acting Bolus Insulin (Lispro, Aspart, Reg)
  3. Efficacy
    1. Insulin therapy does not reduce quality of life
    2. No increase in hypoglycemic episodes
    3. Significant improvement in glycemic control
    4. De Grauw (2001) Br J Gen Pract 51:527-32 [PubMed]

XV. Management: Follow-up Adjustment Phase

  1. Weekly phone call to review Blood Glucose log
  2. Monthly clinic visits
  3. Dietician or nutritionist every 2-4 weeks
  4. Goal Blood Glucose not met (Hemoglobin A1C >7.0 to 8.0)
    1. Oral Hypoglycemics
      1. Advance from single therapy to dual therapy to triple therapy every 3 months as needed
      2. See Oral Hypoglycemic for protocol (also described above)
    2. Oral Hypoglycemics maximized or contraindicated
      1. Start Insulin augmentation (see above)
    3. Insulin augmentation has already been started
      1. Start Insulin replacement (see above)

XVI. Management: Follow-up Maintenance Phase

  1. Clinic visits every 3-4 months
    1. Review Blood Sugar log and Hypoglycemic episodes
    2. Review medication dosages
    3. Evaluate comorbid conditions
      1. Evaluate weight or BMI
      2. Check Blood Pressure
    4. Clean and check Glucometer
    5. Diabetic Foot Exam (examine feet at every visit or at a minimum annually)
  2. Education
    1. Nutrition in Diabetes Mellitus
    2. Exercise in Diabetes Mellitus
    3. Diabetic Foot Care
  3. Examination
    1. Annual Health Maintenance Exam
    2. Annual Eye Examination with Pupil Dilation
    3. Annual Dental Exam
  4. Labs
    1. Daily
      1. Home Glucose monitoring before meals and bedtime
      2. Postprandial Glucose (2 hours after meal)
        1. May be better marker for control
    2. Every 3 months
      1. Hemoglobin A1C
    3. Annual
      1. Fasting Lipid Profile
      2. Renal Function tests (BUN and Creatinine)
      3. Urinalysis
      4. Urine Microalbumin

Images: Related links to external sites (from Google)

Related Studies (from Trip Database) Open in New Window

Ontology: Diabetes Mellitus, Non-Insulin-Dependent (C0011860)

Definition (MEDLINEPLUS)

Diabetes means your blood glucose, or blood sugar, levels are too high. With type 2 diabetes, the more common type, your body does not make or use insulin well. Insulin is a hormone that helps glucose get into your cells to give them energy. Without insulin, too much glucose stays in your blood. Over time, high blood glucose can lead to serious problems with your heart, eyes, kidneys, nerves, and gums and teeth.

You have a higher risk of type 2 diabetes if you are older, obese, have a family history of diabetes, or do not exercise.

The symptoms of type 2 diabetes appear slowly. Some people do not notice symptoms at all. The symptoms can include

  • Being very thirsty
  • Urinating often
  • Feeling very hungry or tired
  • Losing weight without trying
  • Having sores that heal slowly
  • Having blurry eyesight

A blood test can show if you have diabetes. Many people can manage their diabetes through healthy eating, physical activity, and blood glucose testing. Some people also need to take diabetes medicines.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Definition (NCI) A type of diabetes mellitus that is characterized by insulin resistance or desensitization and increased blood glucose levels. This is a chronic disease that can develop gradually over the life of a patient and can be linked to both environmental factors and heredity.
Definition (MSH) A subclass of DIABETES MELLITUS that is not INSULIN-responsive or dependent (NIDDM). It is characterized initially by INSULIN RESISTANCE and HYPERINSULINEMIA; and eventually by GLUCOSE INTOLERANCE; HYPERGLYCEMIA; and overt diabetes. Type II diabetes mellitus is no longer considered a disease exclusively found in adults. Patients seldom develop KETOSIS but often exhibit OBESITY.
Definition (CSP) subclass of diabetes mellitus that is not insulin responsive or dependent; characterized initially by insulin resistance and hyperinsulinemia and eventually by glucose intolerance, hyperglycemia, and overt diabetes; type II diabetes mellitus is no longer considered a disease exclusively found in adults; patients seldom develop ketosis but often exhibit obesity.
Concepts Disease or Syndrome (T047)
MSH D003924
ICD10 E11
SnomedCT 44054006, 154672006, 267468009, 190384004, 190323008
LNC LA10552-0
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Swedish Typ 2-diabetes
Czech diabetes mellitus non insulin dependentní, MODY, diabetes mellitus 2. typu, diabetes mellitus bez ketolátek, diabetes mellitus vzniklý v dospělosti, diabetes mellitus stabilizovaný, diabetes mellitus - slow-onset, Inzulin nondependentní diabetes mellitus, Diabetes mellitus s manifestací v dospělosti, Diabetes mellitus typu 2, Diabetes s manifestací v dospělosti, Diabetes mellitus II.typu, monogenní diabetes mellitus
Spanish Diabetes mellitus tipo II, Diabetes mellitus no dependiente de insulina, Diabetes mellitus no insulinodependiente, Diabetes mellitus de comienzo en la edad adulta, Diabetes mellitus tipo 2, Diabetes de aparición en la madurez, DIABETES MELLITUS NO-INSULINO DEP, diabetes mellitus tipo 2 (trastorno), diabetes mellitus tipo 2, diabetes mellitus no dependiente de insulina (trastorno), diabetes mellitus no dependiente de insulina, diabetes mellitus no insulinodependiente, diabetes mellitus no insulino - dependiente, diabetes mellitus tipo II, DMIM, DMNID, Diabetes Mellitus de Inicio Adulto, Diabetes Mellitus de Inicio en la Madurez, Diabetes Mellitus de Inicio Lento, Diabetes Mellitus Estable, Diabetes Mellitus no Insulino-Dependiente, Diabetes Mellitus Resistente a la Cetosis, Diabetes Mellitus Tipo 2
French Diabète sucré non dépendant d'insuline, Diabète sucré de la maturité, Diabète sucré non insulino-dépendant, Diabète sucré non insulino dép, Diabète sucré de type II, DIABETE NON INSULINO-DEPENDANT, DID2, Diabète avec insulinorésistance, Diabète avec intolérance au glucose, Diabète de la maturité, Diabète de type II, Diabète gras, Diabète non insulinodépendant, DNID, Diabète de type 2, DSNID, Diabète sucré de type 2
Dutch type II diabetes mellitus, type 2 diabetes mellitus, ouderdomsdiabetes, diabetes mellitus, ouderdoms, NIADM, diabetes mellitus insuline-onafhankelijk, niet-insuline-afhankelijke diabetes mellitus, Niet insuline-afhankelijke diabetes, NIDDM; diabetes, adult-onset; diabetes, diabetes; NIDDM, diabetes; adult-onset, diabetes; maturity-onset, diabetes; niet-insuline-afhankelijk, diabetes; niet-ketotisch, diabetes; type II, maturity-onset; diabetes, niet-insuline-afhankelijk; diabetes, niet-ketotisch; diabetes, type II; diabetes, Niet-insuline-afhankelijke diabetes mellitus, 'Maturity-onset' diabetes mellitus, Diabetes mellitus type 2, Diabetes mellitus, 'adult-onset', Diabetes mellitus, 'maturity-onset', Diabetes mellitus, 'slow-onset', Diabetes mellitus, ketose-resistente, Diabetes mellitus, niet-insulineafhankelijke, Diabetes mellitus, stabiele, MODY ("maturity-onset diabetes of the young"), Mellitus, niet-insulineafhankelijke diabetes, NIDDM ("Non-Insulin-Dependent Diabetes Mellitus"), Niet-insulineafhankelijke diabetes mellitus
Portuguese Diabetes mellitus não insulinodependente, Dibetes mellitus tipo II, Diabetes mellitus com início na idade adulta, Diabetes do adulto, DIABETES MELLITUS NAO INSULINODEP, Diabetes Mellitus não Insulinodependente, Diabetes Mellitus não Dependente de Insulina, DMNID, MODY, Diabetes Mellitus de Início Gradativo, Diabetes Mellitus de Início na Maturidade, Diabetes Mellitus de Início no Adulto, Diabetes Mellitus Estável, Diabetes Mellitus Resistente a Cetose, Diabetes Mellitus Tipo 2
German Diabetes mellitus Typ 2, Diabetes mellitus mit Maturity-onset, Maturity-onset-Diabetes, nicht-insulinpflichtiger Diabetes mellitus, Typ II Diabetes mellitus, Diabetes mellitus nicht insulinpflichtig, DIABETES MELLITUS, NICHT INSULINA, Nicht primaer insulinabhaengiger Diabetes mellitus [Typ-II-Diabetes], Diabetes mellitus, Typ 2, Diabetes mellitus, nichtinsulinabhängiger, Diabetes mellitus, nichtinsulinpflichtiger, Altersdiabetes, Diabetes mellitus im Alter, Diabetes mellitus, Erwachsenen-, Diabetes mellitus, Typ II, Diabetes mellitus, ketoazidoseresistenter, Diabetes mellitus, langsamer Beginn, Diabetes mellitus, stabiler, MODY, NIDDM
Italian Diabete mellito di tipo 2, Diabete dell'adulto, Diabete mellito ad esordio in età matura, Diabete mellito non insulinodipendente, Diabete mellito a insorgenza in età matura, NIDDM, Diabete mellito non insulino-dipendente, Diabete mellito resistente alla chetosi, Diabete mellito stabile, Diabete mellito a insorgenza in età adulta, Diabete mellito a insorgenza lenta, Diabete mellito ad insorgenza lenta, Diabete mellito di tipo II
Japanese 2ガタトウニョウビョウ, 2型糖尿病, インスリンヒイゾンセイトウニョウビョウ, セイジンハッショウガタトウニョウビョウ, 糖尿病-インスリン非依存性, 安定型糖尿病, 2型糖尿病, インシュリン非依存型糖尿病, インスリン非依存型糖尿病, インスリン非依存性糖尿病, ケトーシス抵抗性糖尿病, 成人発症型糖尿病, 糖尿病-2型, 糖尿病-成人発症, 非インシュリン依存型糖尿病, II型糖尿病, インスリン非依存糖尿病, 成人型糖尿病, 成人発症糖尿病, 糖尿病-インシュリン非依存型, 糖尿病-インスリン非依存型, 糖尿病-ケトーシス抵抗性, 糖尿病-安定型, 糖尿病-成人発症型, 糖尿病2型
Finnish Tyypin 2 diabetes
Korean 인슐린-비의존 당뇨병
Polish Cukrzyca nie zależna od insuliny, Cukrzyca typu 2, Cukrzyca dorosłych
Hungarian NIDDM, Időskori diabetes, II típusú cukorbetegség, 2. típusú cukorbetegség, Időskori diabetes mellitus, Nem-insulinfüggő diabetes mellitus, Nem-insulindependens cukorbetegség
Norwegian Type 2 diabetes, Diabetes, type 2