Diabetes Mellitus, Type 2

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Diabetes mellitus (DM) type 2 is due to a progressive insulin secretory defect in the setting of insulin resistance.

Geriatric Considerations
Monitor elderly for hypoglycemia; adjust doses for renal/hepatic dysfunction and cognitive function; less aggressive glucose targets than in younger patients

Pediatric Considerations
Incidence is increasing and parallels obesity epidemic.

Pregnancy Considerations
Diet, metformin, glyburide, and insulin are all options for treatment of gestational diabetes.


1.5 million new cases in the United States each year

Estimated 30.3 million Americans (9.4% of the population); 90–95% are likely type 2.

Etiology and Pathophysiology

  • Peripheral insulin resistance and/or defective insulin secretion with increased hepatic gluconeogenesis
  • Genetic factors: usually polygenic; rarely monogenic (e.g., peroxisome proliferator-activated receptor (PPAR) γ and insulin gene mutations)
  • Obesity (body mass index [BMI] ≥25 kg/m2) and visceral adiposity
  • Gut microbiome changes
  • Drug or chemical induced (e.g., glucocorticoids, highly active antiretroviral therapy [HAART], atypical antipsychotics, organ transplant immunosuppressants)

  • Genome-wide association studies show many common variants confer small causal effect; 50% concordance in monozygotic twins
  • Family history is strongly predictive of risk.

Risk Factors

  • Parental history of type 2 diabetes
  • Gestational diabetes or history of baby with birth weight ≥4 kg (9 lb)
  • Polycystic ovarian syndrome (PCOS)
  • Hypertriglyceridemia or low high-density lipoprotein (HDL)—marker for insulin resistance
  • Ethnicity: African American, Latino, Native American, Asian, and Pacific Islander
  • Sedentary lifestyle, visceral obesity
  • Use of thiazides, antipsychotics, glucocorticoids, and statins

General Prevention

  • Maintenance of normal weight, or weight loss of 7% body weight, decrease intake of carbohydrates and overall calories. Moderate-intensity exercise and resistance training. Exercise 150 min/week.
  • Use of metformin, α-glucosidase inhibitors, thiazolidinediones (TZDs), and glucagon-like peptide-1 receptor agonist (GLP-1 RA) in select patients with prediabetes (1)[A]

Commonly Associated Conditions

Hypertension, dyslipidemia, metabolic syndrome, fatty liver disease, infertility, PCOS, acanthosis nigricans, hemochromatosis

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