Philippine Clinical Practice Guidelines for the Diagnosis and Management of Type 2 Diabetes Mellitus

Philippine Practice Guidelines for the
Diagnosis & Management of
Type 2 Diabetes Mellitus
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM
Chief, Medical Informatics Unit
Associate Professor IV, UP College of Medicine
Adapted from the presentation of Dr. Cecilia Jimeno
Tuesday, April 23, 13

UNITE FOR DIABETES PHILIPPINES
Diabetes Philippines
Institute for Studies on Diabetes Foundation, Inc.
Philippine Society of Endocrinology & Metabolism
Philippine Center for Diabetes Education Foundation, Inc.

Goals & Areas of
Collaboration
Establishment of a
national diabetes
database
Encourage best diabetes practices -
development of a uniﬁed CPG
Spearhead the ﬁght
for patients’ rights &
safety - vigilance on
false claims
UNITE FOR DIABETES
PHILIPPINES

Objectives for the
Clinical Practice
Guideline
UNITE FOR DIABETES
PHILIPPINES
To develop clinical practice guidelines on the
screening, diagnosis and management of diabetes
which reﬂect the current best evidence and
which incorporate local data into the
recommendations, in view of aiding clinical
decision making for the beneﬁt of the
Filipino patient
GUIDELINES THAT ARE SUITED FOR LOCAL REALITIES

Organizations in the Consensus Panel
Diabetes Philippines
Institute for Studies on Diabetes Foundation, Inc.
Philippine Society of Endocrinology & Metabolism
Philippine Center for Diabetes Education Foundation, Inc.
23 other specialty, subspecialty organizations
lay representatives of persons with diabetes
UNITE FOR DIABETES
PHILIPPINES

Scope of the Philippine
CPG development
Outpatient
setting
Screening and diagnosis
Screening for complications
Prevention and treatment
Special groups: GDM, elderly

Philippine Clinical
Practice Guideline for
Diabetes Mellitus
Part 1:
SCREENING & DIAGNOSIS

UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 2.1
All individuals being seen at any physician’s
clinic or by any healthcare provider should be
evaluated annually for risk factors
for type 2 diabetes.
(Table 1) [Grade D, Level 5]

Statement 2.2
Universal screening using laboratory
tests is NOT recommended as it would
identify very few individuals who are at risk.
[Grade D, Level 5]

Table 1. Demographic and Clinical Risk Factors
for Type 2 Diabetes
Testing should be considered in all
adults >40 years old.

Consider earlier testing if with at least
one other risk factor as follows:
•history of IGT or IFG
•history of GDM or delivery of a baby weighing 8 lbs
or above
•polycystic ovary syndrome (PCOS)
•overweight (BMI >23 kg/m2
) or obese (BMI >25
kg/m2
)
•waist circumference >80 cm (♀) and >90 cm (♂)
or waist-hip ratio (WHR) >1 (♂) and >0.85 (♀)

Consider earlier testing if with at least one
other risk factor as follows (con’t):
•ﬁrst-degree relative with type 2 diabetes
•sedentary lifestyle
•hypertension (BP >140/90 mm Hg)
•diagnosis or history of any vascular diseases including
stroke, peripheral arterial occlusive disease, coronary
artery disease

Consider earlier testing if with at least one
other risk factor as follows (con’t):
•acanthosis nigricans
•schizophrenia
•serum HDL <35 mg/dL (0.9 mmol/L) and/or
•serum triglycerides >250 mg/dL (2.82 mmol/L)

Which of the following
will you NOT screen for diabetes?
a.42/F on follow-up for hypertension
b.35/M consulting for cough
c.45/M with tuberculosis
d.28/F diagnosed with PCOS

Why 40?
Recommendation
from other guidelines
ADA
2010
CDA
2008
AACE
2007
IDF 2005
All >45 y (B)
Earlier if BMI
>25 kg/m2
and with >1
risk factor(s)
(B)
All > 40 y
Earlier if with
risk factors
>30 y with
risk factor
(B)
Target high
risk people
by risk
factor
assessment

Why 40?
NNHeS 2008
Age (y)
Prevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes Mellitus
Age (y) Based on
FBSa
Based on 2h
postprandial
glucose
Based on DM
questionnaire
True
Diabetes
20-29 0.4 0.4 0.5 0.9
30-39 3.2 1.1 1.4 3.8
40-49 5.7 3.9 4.2 8.2
50-59 9.0 5.0 8.1 13.0
60-69 9.1 5.9 9.5 15.9
>70 4.4 5.5 7.1 11.8
Overall 4.8 3.0 4.0 7.2
a Based on FBS >125 mg/dL
b Based on 2h-PPG > 200 mg/dL
c Based on DM questionnaire (previous diagnosis by nurse or physician or on medication)
d True diabetes (positive in any of the three assessment methods

You screen the 42 y.o. hypertensive.
FBS is 5.2 mmol/L. What next?
a.Reassure patient she is not diabetic. There is
no need to repeat the test.
b.Repeat FBS after 1 year.
c.Order an OGTT after 6 months.
d.Ask for an HbA1c after 3 months.

If initial test(s) are negative, when
should repeat testing be done?
Repeat testing should ideally be done
annually for Filipinos with risk factors owing to the
signiﬁcant prevalence and burden of diabetes in our
country. (Level 5, Grade D)

CANDI Manila
Fojas MC, Lantion-Ang FL, Jimeno CA, Santiago D, Arroyo M, Laurel A, Sy H, See J.
Complications and cardiovascular risk factors among newly-diagnosed type 2 diabetics in
Manila. Phil. J. Internal Medicine, 47: 99-105, May-June, 2009
Local study: newly-diagnosed diabetics in Manila
20% peripheral neuropathy
42% proteinuria
2% diabetic retinopathy
COMPLICATIONS FOUND AT DIAGNOSIS!

Recommended tests for diagnosing diabetes:
•Fasting plasma glucose (FPG) - 8-14 hours
•Random plasma glucose (RPG)
•2-h plasma glucose in 75-g OGTT

Criteria for diagnosis of diabetes (Level 2, Grade B)
•FPG >126 mg/dL (7.0 mmol/L)
•Random plasma glucose >200 mg/dL (11.1 mmol/L)
in a patient with classic symptoms of hyperglycemia
(weight loss, polyuria, polyphagia, polydipsia) or with signs
and symptoms of hyperglycemic crisis
•2-h plasma glucose in 75-g OGTT >200 mg/dL (11.1
mmol/L)

Fasting plasma glucose (FPG) is the preferred
test due to its wide availability, lower cost and
better reproducibility (Level 3, Grade B)
•If the FPG falls within the impaired fasting glucose
range (5.6-6.9 mmol/L) then a 75-g OGTT is
recommended (Level 3, Grade B)
•Symptomatic patients - random or FPG

Among asymptomatic individuals with positive
results, any of the three tests should be
repeated within two weeks for conﬁrmation
(Level 4, Grade C).

Diabetes can be diagnosed when any of the
three tests are positive in a symptomatic
patient (weight loss, polyuria, polyphagia, polydipsia).

A 75-g OGTT is preferred as the ﬁrst test for the
following (Level 3, Grade B):
•Previous FBS showing IFG 100-125 mg/dL (5.6-6.9
mmol/L)
•Previous diagnosis of CVD (CAD, stroke, peripheral
arteriovascular disease) or who are at high risk of CVD
•A diagnosis of Metabolic Syndrome

At the present time, we cannot recommend the
routine use of the following tests in the
diagnosis of diabetes (Level 3, Grade C):
•HbA1c
•Capillary blood glucose
•Fructosamine
•Urinalysis (Level 3, Grade B)
• Plasma insulin (Level 3, Grade B)

•HbA1c
•Capillary blood glucose
•Fructosamine
•Urinalysis
Interpret an available result with caution and
conﬁrm with any of the three standard tests
(Level 2, Grade B).

Why NOT Hba1C?
Until standardization has been done in the
Philippines, use HbA1c only as a tool for
monitoring control among those with
established DM.
•HbA1c not readily available in some areas
•NGSP certiﬁcation not easily veriﬁed in laboratories
•Studies needed to determine effect of ethnicity

Screen for risk factors for
DM, prediabetes and MetS
Algorithm for Screening Diabetes
Among Asymptomatic Individuals

Risk factors
(Table 1)
YES

Risk factors
(Table 1)
YES
Lab testing using FBS, RBS, OGTT (Fig 3)
YES

Risk factors
(Table 1)
YES
YES
Age
>40 y
NO
YES

Risk factors
(Table 1)
YES
YES
Age
>40 y
NO
YES
No further testing;
re-evaluate annually
for risk factors
NO

Age >40 y
Age <40 y with risk factors for DM
No 3 P’s or weight loss
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
Symptomatic (polyuria,
polydipsia, polyphagia,
weight loss)

Age >40 y
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
weight loss)
Fasting plasma
glucose
<100
mg/dL
100-125
mg/dL
>126
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes

Age >40 y
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
weight loss)
Fasting plasma
glucose
<100
mg/dL
100-125
mg/dL
>126
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes
75-g oral glucose
tolerance test
(OGTT)
FBS
<100 &
2h <140
mg/dL
FBS
100-125
or 2h
140-199
mg/dL
FBS
>126
mg/dL
or 2h
>200
No
diabetes
Repeat
testing
after 1 y
IFG or
IGT
Repeat
after 6
mos
Diabetes

Age >40 y
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
weight loss)
Fasting plasma
glucose
<100
mg/dL
100-125
mg/dL
>126
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes
75-g oral glucose
tolerance test
(OGTT)
FBS
<100 &
2h <140
mg/dL
FBS
100-125
or 2h
140-199
mg/dL
FBS
>126
mg/dL
or 2h
>200
No
diabetes
Repeat
testing
after 1 y
IFG or
IGT
Repeat
after 6
mos
Diabetes
Random plasma
glucose
<140
mg/dL
140-199
mg/dL
>200
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes

Philippine Clinical
Practice Guideline for
Diabetes Mellitus
Part 2:
MANAGEMENT & MONITORING

Initial evaluation - comprehensive medical history
and PE
•Coronary heart disease risk assessment
•Foot evaluation: assess risk for foot ulcer (identify
high-risk feet)
•Eye exam: fundoscopy on diagnosis
•Dental history or oral health history

RED FLAGS
of dental disease
tooth ache
pain when chewing
sensitivity to
cold/hot drinks
badly broken teeth
swelling of gums
bad breath

Prevalence among T2DM
68% (SLMC, n =192)
Bitong et al PJIM 2010
PERIODONTITIS
gum bleeding
on brushing
swelling and
redness of gums
looseness or
mobility of teeth
teeth that fall
off in adults

Which of the following will you NOT request
as initial tests for a person with diabetes?
a.Fasting blood glucose, HbA1c
b.Complete lipid proﬁle
c.Blood uric acid, 12-lead ECG
d.ALT, AST, serum creatinine

Minimal initial tests to be requested
• Fasting blood glucose, complete lipid proﬁle
• HbA1c
• Liver function tests
• Urinalysis; spot urine albumin-to-creatinine ratio
• Serum creatinine and calculated GFR

Optional tests
• ECG and TET
• TSH in type 1 diabetes, dyslipidemia or women
over age 50 y

Which of the following statements is true
about monitoring diabetes?
a. Monitor Hba1c ideally twice a year.
b. Check FBS and postprandial blood sugar
every 2-4 weeks.
c. Estimate trends in blood sugar control by
checking CBGs once a week.
d. Achieve glycemic goals within three months.

Glycemic targets
Individualize targets.
FBS <4-7 mmol/L
(72-126 mg/dL)
2h PPG <5-10 mmol/L
(90-180 mg/dL)
Capillary (ADA)
fasting 90-130 mg/dL
PPBG <180 mg/dL
HbA1c <7%

Glycemic targets
Individualize targets.
FBS <6 mmol/L
2h PPG <8 mmol/L
Newly diagnosed
Relatively young (age <60 y)
No complications
No risk factors for hypoglycemia
HbA1c <6.5%

Ideally, HbA1c every 3-6 months;
2x a year if controlled on stable therapy
FBS, postprandial sugar every 2-4 weeks
Capillary blood glucose
2x a week to estimate trends

Glycemic targets should be
achieved within 6 months of
diagnosis or ﬁrst prescription.

about monitoring diabetes?
a. Monitor Hba1c ideally twice a year.
b.Check FBS and postprandial blood sugar
every 2-4 weeks.
c. Estimate trends in blood sugar control by
checking CBGs once a week.
d. Achieve glycemic goals within three months.

Targets to
Decrease CV Risk
BP control
Lipid control
ASA

about reducing CV risk in diabetes?
a. Statins should be given regardless of baseline
lipid levels.
b. There is insufﬁcient evidence to recommend
aspirin for primary prevention in men <60 y.
c. Give clopidogrel 75 mg/day for those with
diabetes and a history of CVD.
d. The goal BP for most persons with diabetes is
<140/80 mm Hg.

The goal BP for most persons with diabetes is
<140/80 mm Hg.
•Lifestyle therapy alone for 3 months if
pre-hypertensive (SBP 130-139 mm Hg or
DBP 80-89 mm Hg)
•Pharmacologic + lifestyle therapy if SBP>140 mm Hg
or DBP >90 mm Hg, or pre-hypertensive uncontrolled
with lifestyle therapy alone

Weight loss if overweight
DASH-style dietary pattern
(reduce Na, increase K,
moderation of alcohol,
increased physical activity).
Lifestyle therapy

Statement 7.3
ACE inhibitors & ARBs are generally recommended
as initial therapy. If one class is not tolerated,
the other should be substituted.
Multiple drug therapy (>2 agents at maximal
doses) is generally required to achieve BP targets.
Thiazide-type diuretics, calcium channel blockers and
B-blockers may be given as additional agents.

Recommendations are consistent with Philippine
Practice Guidelines for the Treatment of
Dyslipidemia.
•LDL is the primary target for dyslipidemia
management in persons with diabetes.

Statement 8.1.1
Statin therapy should be added to lifestyle
therapy, regardless of baseline levels for diabetics
•with overt CVD (A)
•without CVD who are >40 y and have >1more
other CVD risk factors (A)

Statement 8.1.2
For patients at lower risk (e.g. without overt
CVD and <40 y), statin therapy should be
considered in addition to lifestyle therapy if -
•LDL-C remains >100 mg/dL
•those with multiple risk factors (hypertension, familial
hypercholesterolemia, LVH, smoking, family history of premature CAD,
male sex, age >55 y, proteinuria, albuminuria, BMI>25)

The 100-70 rule
•Without overt CVD, goal is LDL-C <100 mg/
dL (2.6 mmol/L) [A]
•With overt CVD, goal is LDL-C <70 mg/dL
(1.8 mmol/L). Use of high dose statin is an
option. [B]

Recommendation 9.2
Insufﬁcient evidence to recommend aspirin for
primary prevention in lower risk individuals
•Men < 50 y
•Women <60 y
* Clinical judgement if with multiple risk factors

Recommendation 9.3
Use aspirin therapy for secondary prevention
strategy in those with DM and a history of CVD
[A].
•For patients with CVD and documented aspirin
allergy, clopidogrel (75 mg/day) should be
used.

Recommendation 9.4
Combination therapy of ASA (75-162 mg/day)
and clopidogrel (75 mg/day) is reasonable up to
a year after an acute coronary syndrome [B].

about reducing CV risk in diabetes?
a. Statins should be given regardless of baseline
lipid levels.
b. There is insufﬁcient evidence to recommend
aspirin for primary prevention in men <60 y.
c. Give clopidogrel 75 mg/day for those with
diabetes and a history of CVD.
d.The goal BP for most persons with
diabetes is <140/80 mm Hg.

Newly diagnosed T2DM
Initiation of Drug Therapy among Newly
Diagnosed Type 2 Diabetes Patients

HbA1c <9%
FBS < 250
HbA1c >9%
FBS > 250

HbA1c <9%
FBS < 250
HbA1c >9%
FBS > 250
Mono-
therapy
Option for
combination
therapy

HbA1c <9%
FBS < 250
HbA1c >9%
FBS > 250
Mono-
therapy
Option for
combination
therapy
Combination
therapy
Insulin
therapy

Statement 10.1
Initiate treatment with metformin for
monotherapy unless with contraindications or
intolerance of its ADE’s -
• diarrhea
• severe nausea
• abdominal pain

When optimization of therapy is needed, choose
the second drug according to the following -
•degree of HbA1c lowering
•hypoglycemia risk
•weight gain
•patient proﬁle (dosing complexity, renal/hepatic
problems, other contraindications and age)

Adapted from AACE Diabetes Mellitus Guidelines Endocr Pract 2007
Drug Therapy HbA1c reduction (%)
MONOTHERAPYMONOTHERAPY
Sulfonylureas 0.9 to 2.5
Biguanide (Metformin) 1.1 to 3.0
Thiazolidinedione 1.5 to 1.6
Alpha-glucosidase inhibitors 0.6 to 1.3
DPP-4 inhibitors 0.8
NON-INSULIN INJECTABLENON-INSULIN INJECTABLE
Exenatide 0.8 to 0.9
COMBINATION THERAPYCOMBINATION THERAPY
SU + Metformin 1.7
SU + Pioglitazone 1.2
SU + Acarbose 1.3
Repaglinide + Metformin 1.4
Pioglitazone + Metformin 0.7
DPP-4 inhibitor + Metformin 0.7
DPP-4 inhibitor + Pioglitazone 0.7

Safety and Tolerability
Insulin
secretagogues
Metformin
alpha-glucosidase
inhibitors
TZDs Insulin
Risk of
hypoglycemia
✔ ✔
Weight gain ✔ ✔ ✔
GI side effects ✔ ✔
Lactic acidosis ✔
Edema ✔
1DeFronzo RA. Ann Intern Med 1999; 131:281–303. 2UKPDS. Lancet 1998; 352:837–853.
3Nesto RW, et al. Circulation 2003; 108:2941–2948.

Contraindications
Sulfonylurea Meglitinide Biguanide AGI TZD
Renal
insufﬁciency
✔ ✔ ✔
Liver disease ✔ ✔ ✔ ✔ ✔
Inﬂammatory
bowel disease
✔
Congestive
heart failure
✔ ✔
Known
hypersensitivity
✔ ✔ ✔ ✔ ✔

Since HbA1c reduction is the overriding goal, the
precise combination used may not be as important
as the glucose level achieved.
•There is no evidence that a speciﬁc combination is any
more effective in lowering glucose levels or preventing
complications than another.
SU + Pio = SU + Metformin (Haneﬁeld et al, 2004 & Nagasaka et al, 2004)
SU + Met = SU + DPP-IV inhibitors (?)

Statement 10.4.2
The following patients must be referred to
internists or diabetes specialists (endocrinologists
or diabetologists) -
• Type 1 diabetes
• Moderate to severe hyperglycemia
• Co-morbid conditions (infections, acute CV events i.e. CHF or
acute MI)
• Signiﬁcant hepatic and renal impairment
• Women with diabetes who are pregnant

Clinical practice guidelines aim to help physicians
and patients reach the best healthcare decisions.
Steinbrook R. NEJM 2007

“If you write it, and
it is good, then they
will follow.”
Keefer JH. Clin Chem 2001

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