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  • Diabetes

    1. 1. Chief’s Conference: Standards of Medical Care in Diabetes - 2008 Sarah A. Bailey PGY3 Family Medicine Emory University
    2. 2. Standards of Medical Care in Diabetes - 2008 <ul><li>Recommendations by the American Diabetes Association. </li></ul><ul><li>Include screening, diagnostic, and therapeutic actions for patients with diabetes. </li></ul><ul><li>Grading system developed by ADA to code the evidence that forms basis for these recommendations. </li></ul>
    3. 3. Level of Evidence <ul><li>Level A – clear evidence from well-conducted, generalizable, randomized control trials that are equally powered. </li></ul><ul><li>Level B – supportive evidence from well-documented cohort studies. </li></ul><ul><li>Level C – supportive evidence from poorly controlled or uncontrolled studies. </li></ul><ul><li>Level E – expert consensus or clinical experience. </li></ul>
    4. 4. Diagnosis of Diabetes <ul><li>To test for pre-diabetes or diabetes, either an FPG test or 2 hour oral Glucose Tolerance Test (OGTT 75 gm glucose load), or both, is appropriate. (B) </li></ul><ul><li>An OGTT may be considered in patients with impaired fasting glucose (IFG). (E) </li></ul><ul><li>HbA1c level is not recommended at this time to diagnose diabetes. (E) </li></ul>
    5. 5. Diagnosis <ul><li>Diagnosis of Pre- Diabetes </li></ul><ul><li>IFG = FPG 100 mg/dl to 125 mg/dl </li></ul><ul><li>IGT = 2 hour plasma glucose 140 mg/dl to 199 mg/dl. </li></ul><ul><li>Diagnosis of Diabetes </li></ul><ul><li>FPG > = 126 mg/dl </li></ul><ul><li>OR </li></ul><ul><li>Symptoms hyperglycemia (polyuria, polydipsia, and weight loss) AND causal plasma glucose >= 200 mg/dl </li></ul><ul><li>OR </li></ul><ul><li>2 hour OGTT >= 200 mg/dl at 2 hours. </li></ul>
    6. 6. Screening Diabetes in Asymptomatic Adults <ul><li>Adults who are overweight (BMI >= 25) or obese AND who have one or more risk factors for DM. Otherwise testing should begin at age 45. (B) </li></ul><ul><li>If tests are normal, repeat testing at least at 3-year intervals. (E) </li></ul><ul><li>In those identified with pre-diabetes, treat other CVD risk factors. (B) </li></ul><ul><li>Monitoring for development of DM in pre-diabetics is every year. (E) </li></ul>
    7. 7. Criteria for testing for pre-diabetes and diabetes in asymptomatic adult individuals <ul><li>Testing should be considered in all adults who are overweight (BMI _25 kg/m2*) AND </li></ul><ul><li>have additional risk factors: </li></ul><ul><li>physical inactivity </li></ul><ul><li>first-degree relative with diabetes </li></ul><ul><li>members of a high-risk ethnic population (e.g., African American, Latino, Native </li></ul><ul><li>American, Asian American, and Pacific Islander) </li></ul><ul><li>women who delivered a baby weighing > 9 lb or were diagnosed with GDM </li></ul><ul><li>hypertension (>=140/90 mmHg or on therapy for hypertension) </li></ul><ul><li>HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 </li></ul><ul><li>mg/dl (2.82 mmol/l) </li></ul><ul><li>women with polycystic ovarian syndrome (PCOS) </li></ul><ul><li>IGT or IFG on previous testing </li></ul><ul><li>other clinical conditions associated with insulin resistance (e.g., severe obesity </li></ul><ul><li>and acanthosis nigricans) </li></ul><ul><li>history of CVD </li></ul>
    8. 8. Screening for DM type II in Children <ul><li>Screen those who are overweight (BMI >85 th % for age and sex, weight for height >85%, or weight >120% if ideal for height) </li></ul><ul><li>AND 2 of the following risk factors: (E) </li></ul><ul><ul><li>Family hx of DM in 1 st or 2 nd degree relative. </li></ul></ul><ul><ul><li>Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) </li></ul></ul><ul><ul><li>Signs of insulin resistance (acanthosis nigrans, htn, dyslipidemia, or PCOS) </li></ul></ul><ul><ul><li>Maternal h/o DM or GDM </li></ul></ul>
    9. 9. Testing for DM type II in Children <ul><li>Testing should begin at age 10 years or at onset of puberty, if puberty occurs at a younger age, and be repeated every 2 years (E). </li></ul><ul><li>The FPG is the preferred test (E). </li></ul>
    10. 10. Detection and Diagnosis of GDM <ul><li>Screen for GDM using risk factor analysis and, if appropriate, use of an OGTT. (C) </li></ul><ul><li>Women with GDM should be screened for DM at 6-12 weeks postpartum and should be followed up with subsequent screening for the development of diabetes or pre-diabetes. (E) </li></ul>
    11. 11. Screening for GDM <ul><li>Carry out GDM risk assessment at the first prenatal visit. </li></ul><ul><li>Women at very high risk for GDM should be screened for diabetes as soon as possible after the confirmation of pregnancy. </li></ul><ul><li>Criteria for very high risk are: </li></ul><ul><li>Severe obesity </li></ul><ul><li>Prior history of GDM or delivery of large-for-gestational-age infant </li></ul><ul><li>Presence of glycosuria </li></ul><ul><li>Diagnosis of PCOS </li></ul><ul><li>Strong family history of type 2 diabetes </li></ul><ul><li>Screening/diagnosis at this stage of pregnancy should use standard diagnostic testing (FPG, OGTT) </li></ul>
    12. 12. Screening for GDM <ul><li>All women of higher than low risk of GDM, including those above not found to have diabetes early in pregnancy, should undergo GDM testing at 24–28 weeks of gestation. </li></ul><ul><li>Low risk status, which does not require GDM screening, is defined as women with ALL of the following characteristics: </li></ul><ul><li>Age <25 years </li></ul><ul><li>Weight normal before pregnancy </li></ul><ul><li>Member of an ethnic group with a low prevalence of diabetes </li></ul><ul><li>No known diabetes in first-degree relatives </li></ul><ul><li>No history of abnormal glucose tolerance </li></ul><ul><li>No history of poor obstetrical outcome </li></ul>
    13. 13. Diagnosis of GDM <ul><li>Two approaches may be followed for GDM screening at 24–28 weeks: </li></ul><ul><li>1. Two-step approach: </li></ul><ul><li>A . Perform initial screening by measuring plasma or serum glucose 1 h after a 50-g oral glucose load. A glucose threshold after 50-g load of > =140 mg/dl identifies approx 80% of women with GDM, while the sensitivity is further increased to approx 90% by a threshold of > =130 mg/dl. </li></ul><ul><li>B . Perform a diagnostic 3 hr 100-g OGTT on a separate day in women who exceed the chosen threshold on 1 hr 50-g screening. </li></ul>
    14. 14. Diagnosis of GDM <ul><li>2. One-step approach (may be preferred in clinics with high prevalence of GDM): Perform a diagnostic 100-g OGTT in all women to be tested at 24–28 weeks. </li></ul><ul><li>The 100-g OGTT should be performed in the morning after an overnight fast of at least 8 h. </li></ul><ul><li>A diagnosis of GDM requires at least two of the following plasma glucose values: </li></ul><ul><li>Fasting: >=95 mg/dl </li></ul><ul><li>1 h: >=180 mg/dl </li></ul><ul><li>2 h: >=155 mg/dl </li></ul><ul><li>3 h: >=140 mg/dl </li></ul>
    15. 15. Prevention and Delay of DM type II <ul><li>Patients with IGT (140 to 199 mg/dl after 2h) should be given counseling on weight loss (5-10%) and increasing physical activity (150 min/week of moderate activity). (A) </li></ul><ul><li>Diet includes reduced calories, saturated fat (<7%) calories. (A) Increased whole grain dietary fiber. (B) </li></ul><ul><li>Follow-up counseling important for success. (B) </li></ul><ul><li>Metformin, in addition to lifestyle, may be considered for those patients with the following risk factors: (E) </li></ul><ul><ul><li>Obese AND </li></ul></ul><ul><ul><li>Under 60 years of age AND </li></ul></ul><ul><ul><li>Combined IFG and IGT PLUS </li></ul></ul><ul><ul><li>Other risk factors for development of diabetes </li></ul></ul>
    16. 16. Medical Nutrition Therapy (MNT) <ul><li>Individuals who have pre-DM or DM should receive MNT, preferably provided by a registered dietician. (B) </li></ul><ul><li>Weight loss is recommended for all overweight or obese individuals with insulin resistance. (A) </li></ul><ul><li>Physical activity and behavioral modification are most helpful in maintenance of wt loss. (B) </li></ul><ul><li>People with DM should receive diabetes self-mgt educ (DSME) when their DM is diagnosed and as needed thereafter. (B) </li></ul>
    17. 17. Carbohydrate and other nutrition in diabetes managment <ul><li>Monitoring carbs remains key strategy in glycemic control. (A) Use of glycemic index (B). </li></ul><ul><li>Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable FDA levels (A). </li></ul><ul><li>Do not advise routine supplementation w/ antioxidants (Vit E, Vit C, carotene). (A) </li></ul><ul><li>Monitor carbs by carb counting, exchanges, and experience estimations. </li></ul>
    18. 18. Self-Monitoring of Blood Glucose (SMBG) and A1C <ul><li>SMBG should be done 3 or more x per day for patients using multiple insulin injections or insulin pump therapy. (A) </li></ul><ul><li>Patient on less frequent insulin dosing or noninsulin therapy then SMBG may be useful in achieving glycemic control. (E) </li></ul><ul><li>Point of Care testing A1C allowing timely decisions on therapy when needed. (E) </li></ul><ul><li>Perform A1C test at leat two times per year in patients who are meeting treatment goals with stable glycemic control. (E) </li></ul><ul><li>A1C test quarterly in patients whose therapy has changed or not meeting glycemic goals. (E) </li></ul>
    19. 19. Glycemic goals <ul><li>The A1C goal for nonpregnant adults is <7%. (A) </li></ul><ul><li>A1C goal <6% is in select patients without significant hypoglycemia. (B) </li></ul><ul><li>Less stringent A1C goals may be appropriate for patients with severe hypoglycemia, limited life expectancy, children, comorbid conditions, longstanding DM. (E) </li></ul>
    20. 20. Glycemic Goals <ul><li>Pre-Prandial glucose 70 to 130 mg/dl </li></ul><ul><li>Peak postprandial glucose < 180 mg/dl 1 to 2 hr after beginning of meal. </li></ul><ul><li>A1C is the primary target for glycemic control. </li></ul><ul><li>Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. </li></ul>
    21. 21. Hypertension (HTN) and Blood Pressure Control in DM <ul><li>Hypertension defined as either systolic blood pressure (SBP) >= 130 mmHg OR a diastolic blood pressure (DBP) >= 80 mmHg on two different days. (C) </li></ul><ul><li>DM patients treat to SBP < 130. (C) </li></ul><ul><li>DM patietns treat to DBP < 80. (B) </li></ul><ul><li>Severe HTN w/ SBP>=140 or DBP>= 90 should receive pharmacotherapy in addition to lifestyle modification. (A) </li></ul>
    22. 22. HTN and BP Control in DM <ul><li>Pharmacotherapy should include ACE inh or angiotensin receptor blocker (ARB). Thiazide if needed for estimated GFR >=50 or loop diuretic w/ GFR <50. (E) </li></ul><ul><li>One or more agents at maximal dose is generally required to achieve blood pressure targets. (B) </li></ul><ul><li>Pregnant DM patients w/ chronic HTN BP goal 110-129/ 65-79 mmHg. (E) </li></ul>
    23. 23. Dyslipidemia and Lipid Management in DM <ul><li>Screening annually by fasting lipid profile in most adult patients. Every 2 years in patients with low-risk lipid values. (E) </li></ul><ul><ul><li>LDL cholesterol < 100 mg/dl </li></ul></ul><ul><ul><li>HDL cholesterol > 50 mg/dl </li></ul></ul><ul><ul><li>Triglycerides < 150 mg/dl </li></ul></ul><ul><li>Lifestyle modification (including reducation saturated fat, trans fat, weight loss, and increased physical activity) recommended to improve lipid profile in DM patients. (A) </li></ul>
    24. 24. Statin Therapy <ul><li>Statin therapy added to LTM regardless of baseline lipid values for diabetic patients: </li></ul><ul><ul><li>With overt cardiovascular disease (CVD) (A) </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>>40 yoa without CVD but one or more CVD risk factors. (A) </li></ul></ul><ul><li>Consider adding statin in other patients (<40 yoa without overt CVD) if LDL>100 OR w/ mult CVD risk factors.(E) </li></ul><ul><li>CVD RF including dyslipidemia, hypertension, smoking, a positive family history of premature CAD, or presence of micro or macroalbuminuria. </li></ul>
    25. 25. Goals of Treatment <ul><li>Primary goal of LDL < 100 without overt CVD. (A) </li></ul><ul><li>Optional goal of LDL <70 with overt CVD using high dose statin therapy (E). </li></ul><ul><li>Alternative therapeutic goal of LDL reduction of 40%, if above LDL goal not achieved with maximal therapy. (A) </li></ul><ul><li>LDL cholesterol targeted statin therapy remains the preferred strategy. (C) </li></ul>
    26. 26. Triglycerides and HDL <ul><li>Triglyceride levels < 150 mg/dl and HDL > 40 mg/dl in men and >50 in women are desirable. However, LDL cholesterol targeted stain therapy remains preferrd strategy. (C) </li></ul><ul><li>Combination therapy using statins and other lipid lowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either CVD outcomes or safety. (E) </li></ul><ul><li>Combined therapy w/ statin/fibrate or statin/niacin associated with increased risk of abnormal transaminases levels, myositis, or rhabdomyolysis. </li></ul>
    27. 27. Antiplatelet Agents <ul><li>Use Aspirin (ASA) 75-162 mg/day as a secondary prevention in DM with h/o CVD. (A). </li></ul><ul><li>Use ASA (75-162 mg/day) as a primary prevention in those w/ type I or type II DM with increased CVD risk: (A) </li></ul><ul><ul><li>>40 years of age OR </li></ul></ul><ul><ul><li>Fmhx CVD, hypertension, dyslipidemia, smoking, or albuminuria. </li></ul></ul>
    28. 28. Antiplatelet agents <ul><li>Not recommended in people <30 yoa because lack of evidence of benefit(E) </li></ul><ul><li>Contraindicated in pateints <21 yoa because of risk of Reye Syndrome(E) </li></ul><ul><li>Combination therapy, such as clopidrogel in addition to ASA should be used in patients with severe and progressive CVD. (C) </li></ul><ul><li>Advise all patients to stop smoking. (A) Include counseling or other treatment as part of diabetes care. (B) </li></ul>
    29. 29. Coronary Heart Disease (CHD) <ul><li>Screen asymptomatic patients by evaluating risk factors to stratify patients by 10-year risk, and treat risk factors accordingly. (B) </li></ul><ul><li>In patients with known CVD, ACE inh, ASA, and statin therapy should be used to reduce the risk CVD events. (A) </li></ul><ul><li>In patients with prior MI, add beta blockers to reduce mortality. (A) </li></ul><ul><li>Candidates for further cardiac testing: </li></ul><ul><li>1. Typical or atypical cardiac symptoms </li></ul><ul><li>AND </li></ul><ul><li>2. Abnormal resting EKG </li></ul>
    30. 30. Coronary Heart Disease <ul><li>Patients > 40 yoa w/ addition CVD risk factors (hyperlipidemia, fmhx, dyslipidemia, microalbuminuria, cardiac autonomic neuropathy, or smoking) ACE inh, ASA, and statin therapy should be used to reduce CVD events. (B) </li></ul><ul><li>In patients with treated CHF, metformin and thiazolidinedione (TZD) use are contraindicated. (C) </li></ul>
    31. 31. Nephropathy Screening and Treatment <ul><li>To reduce the risk or slow progression of nephropathy, optimize glucose and blood pressure control. (A) </li></ul><ul><li>Perform an annual test to assess urine albumin excretion in Type I DM after 5 years of DM onset, and annually in type II DM patients. (E) </li></ul><ul><li>Measure serum creatinine at least annually to estimate GFR in all adults with DM regardless of degree of urine albumin excretion. (E) </li></ul>
    32. 32. Treatment of Nephropathy: ACE inh and ARBS <ul><li>In patients with type I DM, hypertension, and any degree of albuminuria, ACE inh have been shown to delay progression of nephropathy. (A) </li></ul><ul><li>In patients with type 2 DM, hypertension, and microalbuminuria both ACE inh and ARBs have been shown to delay progression to macroalbuminuria. (A) </li></ul><ul><li>In type 2 DM, HTN, macroalbuminuria, and renal insufficiency (Cr>1.5), ARBs have been shown to delay progression of nephropathy. (A) </li></ul><ul><li>If one class is not tolerated then the other should be substituted. (E) </li></ul><ul><li>Monitor serum Cr and K levels for development of acute kidney disease and hyperkalemia. (E) </li></ul>
    33. 33. Nephropathy Treatment <ul><li>Reduction of protein intake to 0.8 to 1.0 grams x kg body wt per day may improve measures of renal function (B). </li></ul><ul><li>Consider referral to nephrologist when there is uncertainty about the etiology of kidney disease, difficult mgt issues, or advanced kidney diseae. (B) </li></ul><ul><li>Monitor urine albumin excretion to asses both the response to therapy and progression of disease. </li></ul><ul><li>If active urine sediment, absence of retinopathy, or rapid delcine in GFR may not be DM nephropathy. </li></ul>
    34. 34. Retinopathy Screening and Treatment <ul><li>To reduce the risk and slow progression of retinopathy, optimize glycemic and blood pressure control. (A) </li></ul><ul><li>Type 1 DM patients should have initial dilated and comprehensive eye exam within 5 years of onset of disease. (B) </li></ul><ul><li>Type 2 DM patients should have eye exam shortly after dx of DM. (B) </li></ul><ul><li>Subsequent exams for Type 1 and 2 DM patients should be annually. (B) </li></ul>
    35. 35. DM Retinopathy <ul><li>Promptly refer patients to opthalmology with any level of macular edema, severe nonproliferative diabetic retinopathy (NPDR), or any proliferative diabetic retinopathy. (A) </li></ul><ul><li>Laser photocoagulation therapy indicated with high-risk PDR, sig macular edema, and severe NPDR. (A) </li></ul><ul><li>The presence of retinopathy is not CI to use of ASA and does not increase chance of retinal hemorrhage. (A) </li></ul>
    36. 36. Neuropathy <ul><li>All patients should be screened for DPN at dx of DM at least annually there after, using clinical tests including pinprick sensation, temperature, vibration perception, 10 gram monofilament pressure sensation, and ankle reflexes. (A) </li></ul><ul><li>Combination of more than one of these tests has >87% sensitivity in detecting DPN. </li></ul><ul><li>Simple inspection of insensate feet should be performed at 3 to 6 month intervals. An abnormality should trigger referral for special footwear, preventative specialist, or podiatric care. (B) </li></ul>
    37. 37. DPN Reccomendations <ul><li>Provide general foot self-care education to all patients with DM. (B) </li></ul><ul><li>Refer patients who smoke, have loss of protectlie sensation and structural abnormalities or have h/o prior LE complication to foot care specialists. (C) </li></ul><ul><li>Initial screening for PAD include h/o caludiacation, assessment of pedal pulses, and ABI. (C) </li></ul><ul><li>Screening ABI performed in patients >50 yoa and <50 yoa if PAD RF (smoking, HTN, HLD, or DM >10 Years) </li></ul>
    38. 38. Immunizations <ul><li>Annually provide influenza vaccine to all diabetic patients >= 6 months of age. (C) </li></ul><ul><li>Provide at least one lifetime pneumococcal vaccine for adults with diabetes. A one-time revaccination recommended for adults 65 or older, who were previously immunized over 5 years ago. (C) </li></ul>
    39. 39. Components of the comprehensive diabetes evaluation <ul><li>Medical history </li></ul><ul><li>Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) </li></ul><ul><li>Eating patterns, nutritional status, and weight history; growth and development in children and adolescents </li></ul><ul><li>Diabetes education history </li></ul><ul><li>Review of previous treatment regimens and response to therapy (A1C records) </li></ul><ul><li>Current treatment of diabetes, including medications, meal plan, physical activity patterns, and results of glucose monitoring and patient’s use of data </li></ul><ul><li>DKA frequency, severity, and cause </li></ul><ul><li>Hypoglycemic episodes and awareness </li></ul><ul><li>Any severe hypoglycemia: frequency and cause </li></ul>
    40. 40. Diabetes Evaluation <ul><li>History of diabetes-related complications </li></ul><ul><li>Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis) </li></ul><ul><li>Macrovascular: CHD, cerebrovascular disease, PAD </li></ul><ul><li>Other: psychosocial problems, dental disease </li></ul>
    41. 41. Diabetes Evaluation <ul><li>Physical examination </li></ul><ul><li>Height, weight, BMI </li></ul><ul><li>Blood pressure determination, including orthostatic measurements when indicated </li></ul><ul><li>Fundoscopic examination </li></ul><ul><li>Thyroid palpation </li></ul><ul><li>Skin examination (for acanthosis nigricans and insulin injection sites) </li></ul><ul><li>Comprehensive foot examination: </li></ul><ul><li>Inspection </li></ul><ul><li>Palpation of dorsalis pedis and posterior tibial pulses </li></ul><ul><li>Presence/absence of patellar and Achilles reflexes </li></ul><ul><li>Determination of proprioception, vibration, and monofilament sensation </li></ul>
    42. 42. Diabetes Evaluation <ul><li>Laboratory evaluation </li></ul><ul><li>A1C, if results not available within past 2–3 months </li></ul><ul><li>If not performed/available within past year: </li></ul><ul><li>Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides </li></ul><ul><li>Liver function tests </li></ul><ul><li>Test for urine albumin excretion with spot urine albumin-to-creatinine ratio </li></ul><ul><li>Serum creatinine and calculated GFR </li></ul><ul><li>Thyroid-stimulating hormone in type 1 diabetes, dyslipidemia or women over age 50 </li></ul>
    43. 43. Diabetes Evaluation <ul><li>Referrals </li></ul><ul><li>Annual dilated eye exam </li></ul><ul><li>Family planning for women of reproductive age </li></ul><ul><li>Registered dietitian for MNT </li></ul><ul><li>Diabetes self-management education </li></ul><ul><li>Dental examination </li></ul><ul><li>Mental health professional, if needed </li></ul>
    44. 44. References <ul><li>American Diabetes Association. “Position Statement: Standards of Medical Care in Diabetes – 2008.” Diabetes Care. 31(1): S1-S54, 2008 </li></ul><ul><li>http://care.diabetesjournals.org/cgi/reprint/31/Supplement_1/S12 </li></ul>