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  1. 1. American Diabetes Association (ADA) 2010 American College of Endocrinology (ACE) &American Association of Clinical Endocrinologists (AACE)Consensus Statement on DM2
  2. 2. Standardized A1C assay, Fasting atleast 8 hrs, GTT with 75 g of anhydrous glucose inwater, Symptoms of Hyperglycemis* In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed withrepeat assay.
  3. 3. For all three tests risk is continuous, exceeding below the lower limit of therange and becoming disproportionately greater at higher end of the range.
  4. 4. Criteria for Diabetes Testing in asymptomatic Adults• Overweight BMI ≥25 kg/m2• Physical Inactivity• First degree relative with Diabetes• Members of High risk ethnic populations• HTN ≥140/90 or on HTN therapy• HDL <35 and/or TG >250• A1C ≥5.7%, IGT, IFG on previous testing• History of CVD• Women with baby >9lbs or H/O GDM• Insulin resistance (acanthosis, obesity, PCOD)• In absence of above at 45 yr of age• If testing is normal repeat after 3 years*
  5. 5. Standardized A1C assay, Fasting atleast 8 hrs, GTT with 75 g of anhydrous glucose inwater, Symptoms of Hyperglycemis* In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed withrepeat assay.
  6. 6. Components of Comprehensive Diabetes Evaluation Medical history• Age, onset & characteristics of onset of DM• Eating patterns, Physical activity, weight history, growth and developmental history.• Diabetes education history• Review of previous treatment regimens and response to therapy (A1C records)• Current treatment of diabetes• DKA frequency, severity, and cause• Hypoglycemia awareness and episodes• History of diabetes-related complications
  7. 7. Components of Comprehensive Diabetes Evaluation Physical Exam• Height, weight, BMI• Blood pressure determination• Fundoscopic examination• Thyroid palpation• Skin examination• Comprehensive foot examination including inspection, Palpation of pulses, Reflexes, Sensations, Vibration, Propioception.
  8. 8. Components of Comprehensive Diabetes Evaluation Laboratory evaluation• A1C, if results not available within past 2–3 months• If not performed/available within past year:• Fasting lipid profile, including total, LDL- and HDL cholesterol and triglycerides• Liver function tests• Test for urine albumin excretion with spot urine albumin/creatinine ratio• Serum creatinine and calculated GFR• TSH in type 1 diabetes, dyslipidemia, or women over age 50 years
  9. 9. Components of Comprehensive Diabetes Evaluation Referrals• Annual dilated eye exam• Family planning for women of reproductive age• Registered dietitian for MNT• DSME• Dental examination• Mental health professional, if needed
  10. 10. Components of Comprehensive Diabetes Evaluation
  11. 11. Treatment• DSME (Diabetes Self Management Education)• Glucose Monitoring• MNT (Medical Nutrition Therapy)• Physical Activity• Drugs• Insulin• Prevention & Management of Diabetic Complications• Psychological Assessment and Care
  12. 12. DSME• People with diabetes should receive DSME according to national standards when their diabetes is diagnosed and as needed thereafter.• Effective self-management and quality of life are the key outcomes of DSME and should be measured and monitored as part of care.• DSME should address psychosocial issues, since emotional well-being is associated with positive diabetes outcomes.• Because DSME can result in cost-savings and improved outcomes, DSME should be reimbursed
  13. 13. Glucose Monitoring• SMBG• CGM (Continuous Glucose Monitoring)• HbA1C & eAG – Two Times a year if meeting goals & stable Glycemia – Quarterly if not meeting goals or Change in Therapy – eAG (estimated average glucose)
  14. 14. Glycemic Recommendations
  15. 15. Glycemic Recommendations• Postprandial Glucose may be targeted if A1C are not met despite reaching preprandial goal.• A1C is the primary target for glycemic control• Goals should be induvidualized on – Duration of diabetes – Age/life expectancy – Comorbid conditions – Known CVD or advanced microvascular comp – Hypoglycemic episodes and awareness
  16. 16. Medical Nutrition Therapy (MNT)• Individuals who have pre-diabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT• For weight loss, either low carbohydrate or low-fat calorie- restricted diets• 14 g fiber/1,000 kcal and foods containing whole grains• Saturated fat intake should be 7% of total calories• Reducing intake of trans fat lowers LDL cholesterol and increases HDL cholesterol• Monitoring carbohydrate intake, whether by carbohydrate counting, exchanges, or experience-based estimation, remains a key strategy in achieving glycemic control
  17. 17. Physical Activity• People with diabetes should be advised to perform at least 150 min/week of moderate- intensity aerobic physical activity (50–70% of maximum heart rate)• In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week.• emphasizing lifestyle changes that include moderate weight loss (7% body weight)
  18. 18. Overview of DrugsAbbreviation Class Generic Names Trade NamesAGI α Glucosidase Acarbose Precose Inhibitor Miglitol GlysetDPP-4 Dipeptidyl- Sitagliptin Januvia peptidase-4 Saxagliptin Onglyza InhibitorGLP-1 Incretin Mimetics Exenatide Byetta (Glucagonlike peptide-1 agonistMetformin Biguanide Metformin Glucophage XRSU Sulfonylurea Glyburide DiaBeta Glipizide Glucotrol Glimipride AmarylGlitinides PrandinTZD Thiazolidinedione Rosiglitazone Avandia Pioglitazone Actose
  19. 19. A1C 6.5% to 7.5%• Monotherapy  Metformin• Dual Therapy : – Metformin + Incretin Mimetic (GLP-1 agonist)/DPP-4 inhibitor/SU/Glitinides *If metformin is contraindicated TZD may be used as foundation for the group• Triple Therapy : – Metformin+GLP-1+TZD/Glitinide/SU – Metformin+DPP-4+TZD/Glitinide/SU• Insulin Therapy
  20. 20. A1C 7.6% to 9%• Dual Therapy : – Metformin + Incretin Mimetic (GLP-1 agonist)/DPP-4 inhibitor/TZD/SU/Glitinides• Triple Therapy : – Metformin+GLP-1 agonist +TZD – Metformin+DPP-4 inhibitor +TZD – Metformin+GLP-1 agonist + SU – Metformin+DPP-4 inhibitor +SU – Metformin +TZD + SU Glitinides/AGIs/Colesevelam are not considered in this group because of their limitied A1C potential• Insulin Therapy
  21. 21. A1C >9%• For Drug-naïve patients with these A1C levels, it is unlikely that use of 1/2/3 agents (other than insulin) will achive A1C <6.5%. Drug therapy can be used if patient is asymptomatic , recent onset and good probability that some beta cell function exists.• Combination Therapy: – Metformin+GLP-1 agonist – Metformin+GLP-1 agonist+SU – Metformin+DPP-4 inhibitor – Metformin+DPP-4 inhibitor+SU – Metformin+TZD – Metformin+TZD+SU – Metformin+GLP-1 agonist+TZD – Metformin+DPP-4 inhibitor+TZD• Insulin Therapy
  22. 22. Insulin Therapy
  23. 23. Insulin Therapy• Basal Insulin• Premixed Insulin• Basal-Bolus Insulin Regimens• Pramlintide (pancreatic amylin analogue), prandial injections• Insulin Pump, Maximal flexibility
  24. 24. Basal Insulin• Generally the initial choice for initiation of insulin therapy• Glargine and Detemir are preferred over NPH due to peak-less activity, consistent effect and lower chance of hypoglycemia.• Started at 10 U at bedtime and titrated up 1 to 3 U every 2-3 days until the FBS levels are in desired range• Dose is reduced if FBS levels are lower than Specified threshold.
  25. 25. Premixed Insulin• Therapy is titrated with the major meal of the day (typically dinner) and subsequently another injection is added with the second largest meal.• Dose before breakfastmeasure Pre dinner• Dose before Dinner Measure FBS in am• 2 injections in a day• Patient must have a constant lifestyle• Higher risk of hypoglycemia
  26. 26. Basal-Bolus Insulin Regimens• 4 injections per day• Long acting (glargine/detemir) Basal Once +short acting (regular/lispro) Bolus with meals• Greater flexibility, better for patients with variable lifestyle.• Before meal dose 5 U or 7% of total basal insulin dose.• Bolus insulin titrated 2-3U every 2-3 days on basis of 2- hr Postprandial Levels• Titration should achieve good control in A1C levels, Pre & postprandial Glycemia.
  27. 27. Prevention and management of Diabetes Complications• HTN/BP control – BP measurement every routine visit – If ≥130 / ≥80 should have a repeat measurement on a separate day, if repeat same then HTN – Target BP <130 systolic & <80 Diastolic – Lifestyle modification, wt loss, ↓Na, ↑ K intake, moderate alcohol intake and Physical activity. – ACE/ARB +Thiazide/loop diuretic (GFR)/calcium channel blocker/β blockers. – Monitor K levels when above drugs are used.
  28. 28. Prevention and management of Diabetes Complications• Dyslipidemia/Lipid management – FLP anually – Target LDL<100 mg/dl, HDL >50 mg/dl, TGs<150 mg/dl – If values as above FLP repeat in 2 years. – Lifestyle modifications, ↓ Saturated fats, Trans fat, cholesterol, ↑ Omega 3 FA, Fibers, Plant sterol, wt loss. – Statin therapy in pt with CVD and/or >40 yrs and/or LDL >100 with lifestyle mod. – LDL lowering is the main goal.
  29. 29. Prevention and management of Diabetes Complications• Antiplatelet Therapy• Asprin 75-162 mg/day if : – One additional risk factor e.g. (Smoking, HTN, Dyslipidemia, Family history), >50 men, >60 women – Secondary prevention in pt with h/o CVD – If allergic to asprin and CVD use clopidogril – Asprin+clopidogril for 1 year in patients after an Acute Coronary Synd.
  30. 30. Prevention and management of Diabetes Complications• Smoking cessation – Advise all not to smoke – Include smoking cessation counseling and other form of treatments as a routine component of Diabetes care..
  31. 31. Prevention and management of Diabetes Complications• Coronary Heart disease screening and Rx – In asymp pt evaluate risk factors by 10 yr risk – In pt with known CVD : ACEi+Asprin+Statin should be used if not contraindicated In pt with prior MI: β blocker for 2 atleast 2 yrs – Avoid TZD in pt with Symptomatic Heart faliure – Metformin can be used in pt with stable CHF if Renal func is normal – Metformin shoul be avoided in Hospitalized or Unstable pt with CHF.
  32. 32. Prevention and management of Diabetes Complications• Nephropathy Screening and Rx – Annual Creatinine & Urine Microalbumin testing – If Micro/Macro Albuminuria ACEi/ARB – ACEi/ARB delay progression to Macroalbuminuria – If DM 2 +HTN +Macroalbumin+Cr>1.5 ARB have shown to delay progress ion of nephropathy. – ↓ Protein to 0.8-1g/kg in pt with DM and early CKD – Monitor CR and K when using ACEi/ARB – Consider referral to a Nephrologist.
  33. 33. Prevention and management of Diabetes ComplicationsCategory Spot Collection (μg/mg creatinine)Normal <30Microalbuminuria 30-299Macroalbuminuria (Clinical) ≥300
  34. 34. Prevention and management of Diabetes Complications• Retinopathy Screening & Rx – Type 1 DM : Initial within 5 yrs of Onset – Type 2 DM : at the time of Dx – Then annually – Less frequent (q 2-3 yrs) if 2-3 exams are normal – Ophthalmology Referral – Retinopathy is not a contraindication for Asprin Therapy & doent ↑ the risk of Hemorrhage.
  35. 35. Prevention and management of Diabetes Complications• Neuropathy Screening & Rx – All should be screened for Distal Symmetric Polyneuropathy (DPN) at diagnosis & annually. – Diabetic Autonomic Neuropathy – Foot care – Annual Foot exam – General foot self care education – LOPS, PAD
  36. 36. Prevention and management of Diabetes Complications• Risk of Ulcers or Amputation increases in pat who have following – Previous amputation – Past foot ulcer history – Peripheral Neuropathy – PVD – Foot deformity – Visual Impairment – Diabetic Nephropathy (specially pt on Dialysis) – Poor glycemic control – Cigarette smoking