Sponsored by National Lipid Association Comprehensive
Cardiometabolic Risk-Reduction Program Phase 2 2009
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Insulin Resistance and Type 2 Diabetes Case Study
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Initial MD Appointment 59-year-old man was referred for
evaluation of cardiovascular disease (CVD) risk Previous history of
hypertension, but no knowledge of diabetes; nonsmoker No family
history of premature CVD, but he has a sister with obesity and type
2 diabetes Case Study
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Initial MD Appointment Physical examination Weight: 212 lbs,
height: 69 inches, body mass index (BMI): 31.3 kg/m 2, waist: 42
inches, blood pressure: 140/88 mm Hg (sitting, relaxed, lowest of
several repeats) Medications Metoprolol 100-mg BID Diet Includes 3
servings of fruit/vegetables daily, 2 servings of whole grains, and
no fish Physical activity Sedentary vocation with no planned
recreational activity Case Study
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Laboratory Results TC 197 mg/dL HDL-C 25 mg/dL LDL-C (direct)94
mg/dL TG340 mg/dL NonHDL-C172 mg/dL SCr1.2 mg/dL eGFR>60 mL/min
Glucose 182 mg/dL After fasting hyperglycemia was confirmed, type 2
diabetes was diagnosed and an HbA1 c test was ordered: HbA1 c 8.2%
Case Study TC=total cholesterol, HDL-C=high-density lipoprotein
cholesterol, LDL-C=low-density lipoprotein cholesterol,
TG=triglycerides, SCr=serum creatinine, eGFR=estimated glomerular
filtration rate, HbA1 c =hemoglobin A1 c
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A.HbA1 c >6.0% B.FPG >110 mg/dL on 2 consecutive visits
C.FPG >125 mg/dL on 2 consecutive visits D.OGTT >200 mg/dL
E.Answers C or D ARS Question According to the American Diabetes
Association, the diagnosis of diabetes is made by FPG= fasting
plasma glucose, OGTT=oral glucose tolerance test
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Pathogenesis of Type 2 Diabetes peripheral glucose uptake
hepatic glucose production gut carbohydrate delivery and absorption
pancreatic insulin secretion - pancreatic glucagon secretion - -
incretin effect
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Normal IFG/IGTType 2 diabetes Post- prandial glucose Abnormal
glucose tolerance Insulin resistance Increased insulin resistance
Fasting glucose Hyperglycemia Insulin secretion Hyperinsulinemia,
then -cell failure Adapted from International Diabetes Center. Type
2 Diabetes BASICS. 1st ed. Minneapolis, Minn.: International
Diabetes Center Publishing; 2000. Obesity Insulin Resistance -cell
Dysfunction Type 2 Diabetes IGT=impaired glucose tolerance
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20% of type 2 diabetes occurs in the absence of obesity
Clinical Pearl
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A.Aspirin B.Statin C.Calcium channel blocker D.A and B E.B and
C ARS Question Which of the following non-type 2 diabetes (T2D)
agent(s) is (are) recommended to add initially to the treatment of
this patient (T2D treatment later)?
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ADA: Standards of Medical Care In patients 40 years of age with
another cardiovascular risk factor, aspirin and statin therapy (if
not contraindicated) should be used to reduce the risk of
cardiovascular events Medication should be initiated for glycemic
control American Diabetes Association. Diabetes Care.
2009;32:S13-S61. ADA=American Diabetes Association
A.Sulfonylurea B.Metformin C.Pioglitazone D.Exenatide
E.Sitagliptin F.Insulin ARS Question Which initial choice for the
pharmacological treatment of diabetes in this patient would be
optimal?
Type 2 Diabetes: Consensus Algorithm on Pharmacological Therapy
for Hyperglycemia* EASD/ADA a Sulfonylurea other than glyburide or
chlorpropamide b Insufficient clinical use to be confident
regarding safety EASD=European Association for the Study of
Diabetes Metformin + sulfonylurea a Metformin + basal insulin
Metformin + intensive insulin At diagnosis Tier 2: Less
well-validated therapies STEP 2 STEP 3 Metformin + pioglitazone +
sulfonylurea Metformin Metformin + pioglitazone Metformin + GLP-1
agonist b Metformin + basal insulin *In combination with lifestyle
Nathan DM, et al. Diabetes Care. 2008;31:111.
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Month 1: MD Follow-Up Visit 1 Physical examination Weight: 215
lbs, height: 69 inches, body mass index (BMI): 31.7 kg/m 2, waist:
42 inches, blood pressure: 140/88 mm Hg Action plan Initiate
metformin 850-mg BID, atorvastatin 10- mg QD, aspirin 162 mg/day
Discontinue metoprolol 100-mg BID, initiate ramipril 5-mg BID Refer
to certified diabetes educator Schedule follow-up appointment for 3
months Case Study
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Pharmacologic therapy for patients with diabetes and
hypertension should be with a regimen that includes either an ACE
inhibitor or an angiotensin receptor blocker Clinical Pearl
American Diabetes Association. Diabetes Care. 2009;32:S13-S61.
ACE=angiotensin-converting enzyme
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A.Significant improvement in microvascular complications, but
not macrovascular B.Significant improvement in microvascular and
macrovascular complications, but not mortality C.Significant
improvement in microvascular and macrovascular complications and
mortality ARS Question What benefits might be derived from early
glycemic control in a patient with new-onset diabetes?
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Aggregate Endpoint 19972007 Any diabetes related endpoint RRR:
12%9% P: 0.029 0.04 Microvascular disease RRR: 25%24% P:
0.00990.001 Myocardial infarction RRR: 16%15% P: 0.052 0.014
All-cause mortality RRR: 6%13% P: 0.44 0.007 Holman RR, et al. N
Engl J Med. 2008;359:1577-1589. UKPDS. Lancet. 1998;352:837-853.
UKPDS=United Kingdom Prospective Diabetes Study, RRR=relative risk
reduction, P=log rank UKPDS: Effect of Earlier Glucose Control
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Initial Certified Diabetes-Educator Visit Weight: 214 lbs,
height: 69 inches, body mass index (BMI): 31.7 kg/m 2, waist: 42
inches Patient has hypertension and is newly diagnosed with type 2
diabetes Was prescribed metformin 850-mg BID Diet 3 servings/day of
fruit/vegetables, 2 servings/day whole grains, no fish Has a sweet
tooth and a preference for red meat Breakfast: coffee cake; lunch:
cheeseburger, salad; dinner: barbequed ribs, potato, green beans;
snack: banana Patient does not exercise Patients readiness for
lifestyle changes Says he is scared and appears ready to adapt
behavior Case Study
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Initial Certified Diabetes-Educator Visit Plan Discuss patients
role in disease management Begin education Blood sugar monitoring
Medications General dietary and physical activity changes that will
improve glucose management Develop basic plan for lifestyle changes
Follow-up in 1 week Case Study
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Avoid Information Overload There is a lot of information for
the patient newly diagnosed with diabetes Blood sugar monitoring
Medications Diet and physical activity changes Initially choose 1
to 2 main topics to focus on and give an overview of lifestyle
changes Provide handouts Have patient complete food records
Follow-up within 1 week for in-depth lifestyle education and
goal-setting Clinical Pearl
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Follow-Up Certified Diabetes-Educator Visit 1 Week See if
patient has questions Questions will initiate education and
lifestyle-plan development Work with the patient, determine
realistic goals Write a prescription for lifestyle changes
Weight-loss goal: 1 pound/week for first 2 months Diet: patient
wants to follow a lowglycemic-index diet; food records Exercise: 20
minutes walking every other day at local track Discuss obstacles
and potential solutions Schedule follow-up appointment in 8 weeks
Case Study
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Glycemic Effects of Diet: High Cereal vs Low-Glycemic Index
Copyright restrictions may apply. Jenkins DJ, et al. JAMA.
2008;300:2742-2753. 6-month, randomized, parallel study 210
patients with type 2 diabetes Lowglycemic-index diet*: fasting
glucose, A1 c, HDL-C vs high-cereal fiber (P
