Philippine Practice Guidelines for theDiagnosis & Management ofType 2 Diabetes MellitusIris Thiele Isip Tan MD, MSc, FPCP,...
UNITE FOR DIABETES PHILIPPINESDiabetes PhilippinesInstitute for Studies on Diabetes Foundation, Inc.Philippine Society of ...
Goals & Areas ofCollaborationEstablishment of anational diabetesdatabaseEncourage best diabetes practices -development of ...
Objectives for theClinical PracticeGuidelineUNITE FOR DIABETESPHILIPPINESTo develop clinical practice guidelines on thescr...
Organizations in the Consensus PanelDiabetes PhilippinesInstitute for Studies on Diabetes Foundation, Inc.Philippine Socie...
Scope of the PhilippineCPG developmentOutpatientsettingScreening and diagnosisScreening for complicationsPrevention and tr...
Philippine ClinicalPractice Guideline forDiabetes MellitusPart 1:SCREENING & DIAGNOSISTuesday, April 23, 13
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 2.1All individuals being seen at any physician’sclinic or by any health...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 2.2Universal screening using laboratorytests is NOT recommended as it w...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSTable 1. Demographic and Clinical Risk Factorsfor Type 2 DiabetesTesting should b...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSConsider earlier testing if with at leastone other risk factor as follows:•histor...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSConsider earlier testing if with at least oneother risk factor as follows (con’t)...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSConsider earlier testing if with at least oneother risk factor as follows (con’t)...
Which of the followingwill you NOT screen for diabetes?a.42/F on follow-up for hypertensionb.35/M consulting for coughc.45...
Why 40?Recommendationfrom other guidelinesADA2010CDA2008AACE2007IDF 2005All >45 y (B)Earlier if BMI>25 kg/m2and with >1ris...
Why 40?NNHeS 2008Age (y)Prevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes MellitusPreva...
You screen the 42 y.o. hypertensive.FBS is 5.2 mmol/L. What next?a.Reassure patient she is not diabetic. There isno need t...
If initial test(s) are negative, whenshould repeat testing be done?Repeat testing should ideally be doneannually for Filip...
CANDI ManilaFojas MC, Lantion-Ang FL, Jimeno CA, Santiago D, Arroyo M, Laurel A, Sy H, See J.Complications and cardiovascu...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommended tests for diagnosing diabetes:•Fasting plasma glucose (FPG) - 8-14 ho...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSCriteria for diagnosis of diabetes (Level 2, Grade B)•FPG >126 mg/dL (7.0 mmol/L)...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSFasting plasma glucose (FPG) is the preferredtest due to its wide availability, l...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSAmong asymptomatic individuals with positiveresults, any of the three tests shoul...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSDiabetes can be diagnosed when any of thethree tests are positive in a symptomati...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSA 75-g OGTT is preferred as the first test for thefollowing (Level 3, Grade B):•Pr...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSAt the present time, we cannot recommend theroutine use of the following tests in...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUS•HbA1c•Capillary blood glucose•Fructosamine•UrinalysisInterpret an available resu...
Why NOT Hba1C?Until standardization has been done in thePhilippines, use HbA1c only as a tool formonitoring control among ...
You screen the 42 y.o. hypertensive.FBS is 5.2 mmol/L. What next?a.Reassure patient she is not diabetic. There isno need t...
Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsTuesday, ...
Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk fact...
Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk fact...
Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk fact...
Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk fact...
Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CA...
Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CA...
Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CA...
Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CA...
Philippine ClinicalPractice Guideline forDiabetes MellitusPart 2:MANAGEMENT & MONITORINGTuesday, April 23, 13
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSInitial evaluation - comprehensive medical historyand PE•Coronary heart disease r...
RED FLAGSof dental diseasetooth achepain when chewingsensitivity tocold/hot drinksbadly broken teethswelling of gumsbad br...
Prevalence among T2DM68% (SLMC, n =192)Bitong et al PJIM 2010PERIODONTITISgum bleedingon brushingswelling andredness of gu...
Which of the following will you NOT requestas initial tests for a person with diabetes?a.Fasting blood glucose, HbA1cb.Com...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSMinimal initial tests to be requested• Fasting blood glucose, complete lipid profi...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSOptional tests• ECG and TET• TSH in type 1 diabetes, dyslipidemia or womenover ag...
Which of the following will you NOT requestas initial tests for a person with diabetes?a.Fasting blood glucose, HbA1cb.Com...
Which of the following statements is trueabout monitoring diabetes?a. Monitor Hba1c ideally twice a year.b. Check FBS and ...
Glycemic targetsIndividualize targets.FBS <4-7 mmol/L(72-126 mg/dL)2h PPG <5-10 mmol/L(90-180 mg/dL)Capillary (ADA)fasting...
Glycemic targetsIndividualize targets.FBS <6 mmol/L2h PPG <8 mmol/LNewly diagnosedRelatively young (age <60 y)No complicat...
Ideally, HbA1c every 3-6 months;2x a year if controlled on stable therapyFBS, postprandial sugar every 2-4 weeksCapillary ...
Glycemic targets should beachieved within 6 months ofdiagnosis or first prescription.Tuesday, April 23, 13
Which of the following statements is trueabout monitoring diabetes?a. Monitor Hba1c ideally twice a year.b.Check FBS and p...
Targets toDecrease CV RiskBP controlLipid controlASATuesday, April 23, 13
Which of the following statements is trueabout reducing CV risk in diabetes?a. Statins should be given regardless of basel...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSThe goal BP for most persons with diabetes is<140/80 mm Hg.•Lifestyle therapy alo...
Weight loss if overweightDASH-style dietary pattern(reduce Na, increase K,moderation of alcohol,increased physical activit...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 7.3ACE inhibitors & ARBs are generally recommendedas initial therapy. I...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendations are consistent with PhilippinePractice Guidelines for the Treatme...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 8.1.1Statin therapy should be added to lifestyletherapy, regardless of ...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 8.1.2For patients at lower risk (e.g. without overtCVD and <40 y), stat...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSThe 100-70 rule•Without overt CVD, goal is LDL-C <100 mg/dL (2.6 mmol/L) [A]•With...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendation 9.2Insufficient evidence to recommend aspirin forprimary prevention...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendation 9.3Use aspirin therapy for secondary preventionstrategy in those w...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendation 9.4Combination therapy of ASA (75-162 mg/day)and clopidogrel (75 m...
Which of the following statements is trueabout reducing CV risk in diabetes?a. Statins should be given regardless of basel...
Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsTuesday, April 23, 13
Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsHbA1c <9%FBS < 250HbA1c >9%FBS...
Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsHbA1c <9%FBS < 250HbA1c >9%FBS...
Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsHbA1c <9%FBS < 250HbA1c >9%FBS...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 10.1Initiate treatment with metformin formonotherapy unless with contra...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSWhen optimization of therapy is needed, choosethe second drug according to the fo...
Adapted from AACE Diabetes Mellitus Guidelines Endocr Pract 2007Drug Therapy HbA1c reduction (%)MONOTHERAPYMONOTHERAPYSulf...
Safety and TolerabilityInsulinsecretagoguesMetforminalpha-glucosidaseinhibitorsTZDs InsulinRisk ofhypoglycemia✔ ✔Weight ga...
ContraindicationsSulfonylurea Meglitinide Biguanide AGI TZDRenalinsufficiency✔ ✔ ✔Liver disease ✔ ✔ ✔ ✔ ✔Inflammatorybowel d...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSSince HbA1c reduction is the overriding goal, theprecise combination used may not...
UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 10.4.2The following patients must be referred tointernists or diabetes ...
Clinical practice guidelines aim to help physiciansand patients reach the best healthcare decisions.Steinbrook R. NEJM 200...
“If you write it, andit is good, then theywill follow.”Keefer JH. Clin Chem 2001Tuesday, April 23, 13
THANK YOUhttp://www.endocrine-witch.nethttp://www.facebook.com/EndocrineWitchhttp://endocrine-witch.tumblr.com@endocrine_w...
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Philippine Clinical Practice Guidelines for the Diagnosis and Management of Type 2 Diabetes Mellitus

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

  1. 1. Philippine Practice Guidelines for theDiagnosis & Management ofType 2 Diabetes MellitusIris Thiele Isip Tan MD, MSc, FPCP, FPSEMChief, Medical Informatics UnitAssociate Professor IV, UP College of MedicineAdapted from the presentation of Dr. Cecilia JimenoTuesday, April 23, 13
  2. 2. UNITE FOR DIABETES PHILIPPINESDiabetes PhilippinesInstitute for Studies on Diabetes Foundation, Inc.Philippine Society of Endocrinology & MetabolismPhilippine Center for Diabetes Education Foundation, Inc.Tuesday, April 23, 13
  3. 3. Goals & Areas ofCollaborationEstablishment of anational diabetesdatabaseEncourage best diabetes practices -development of a unified CPGSpearhead the fightfor patients’ rights &safety - vigilance onfalse claimsUNITE FOR DIABETESPHILIPPINESTuesday, April 23, 13
  4. 4. Objectives for theClinical PracticeGuidelineUNITE FOR DIABETESPHILIPPINESTo develop clinical practice guidelines on thescreening, diagnosis and management of diabeteswhich reflect the current best evidence andwhich incorporate local data into therecommendations, in view of aiding clinicaldecision making for the benefit of theFilipino patientGUIDELINES THAT ARE SUITED FOR LOCAL REALITIESTuesday, April 23, 13
  5. 5. Organizations in the Consensus PanelDiabetes PhilippinesInstitute for Studies on Diabetes Foundation, Inc.Philippine Society of Endocrinology & MetabolismPhilippine Center for Diabetes Education Foundation, Inc.23 other specialty, subspecialty organizationslay representatives of persons with diabetesUNITE FOR DIABETESPHILIPPINESTuesday, April 23, 13
  6. 6. Scope of the PhilippineCPG developmentOutpatientsettingScreening and diagnosisScreening for complicationsPrevention and treatmentSpecial groups: GDM, elderlyTuesday, April 23, 13
  7. 7. Philippine ClinicalPractice Guideline forDiabetes MellitusPart 1:SCREENING & DIAGNOSISTuesday, April 23, 13
  8. 8. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 2.1All individuals being seen at any physician’sclinic or by any healthcare provider should beevaluated annually for risk factorsfor type 2 diabetes.(Table 1) [Grade D, Level 5]Tuesday, April 23, 13
  9. 9. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 2.2Universal screening using laboratorytests is NOT recommended as it wouldidentify very few individuals who are at risk.[Grade D, Level 5]Tuesday, April 23, 13
  10. 10. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSTable 1. Demographic and Clinical Risk Factorsfor Type 2 DiabetesTesting should be considered in alladults >40 years old.Tuesday, April 23, 13
  11. 11. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSConsider earlier testing if with at leastone other risk factor as follows:•history of IGT or IFG•history of GDM or delivery of a baby weighing 8 lbsor above•polycystic ovary syndrome (PCOS)•overweight (BMI >23 kg/m2) or obese (BMI >25kg/m2)•waist circumference >80 cm (♀) and >90 cm (♂)or waist-hip ratio (WHR) >1 (♂) and >0.85 (♀)Tuesday, April 23, 13
  12. 12. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSConsider earlier testing if with at least oneother 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 includingstroke, peripheral arterial occlusive disease, coronaryartery diseaseTuesday, April 23, 13
  13. 13. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSConsider earlier testing if with at least oneother 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)Tuesday, April 23, 13
  14. 14. Which of the followingwill you NOT screen for diabetes?a.42/F on follow-up for hypertensionb.35/M consulting for coughc.45/M with tuberculosisd.28/F diagnosed with PCOSTuesday, April 23, 13
  15. 15. Why 40?Recommendationfrom other guidelinesADA2010CDA2008AACE2007IDF 2005All >45 y (B)Earlier if BMI>25 kg/m2and with >1risk factor(s)(B)All > 40 yEarlier if withrisk factors>30 y withrisk factor(B)Target highrisk peopleby riskfactorassessmentTuesday, April 23, 13
  16. 16. Why 40?NNHeS 2008Age (y)Prevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes MellitusAge (y) Based onFBSaBased on 2hpostprandialglucoseBased on DMquestionnaireTrueDiabetes20-29 0.4 0.4 0.5 0.930-39 3.2 1.1 1.4 3.840-49 5.7 3.9 4.2 8.250-59 9.0 5.0 8.1 13.060-69 9.1 5.9 9.5 15.9>70 4.4 5.5 7.1 11.8Overall 4.8 3.0 4.0 7.2a Based on FBS >125 mg/dLb Based on 2h-PPG > 200 mg/dLc Based on DM questionnaire (previous diagnosis by nurse or physician or on medication)d True diabetes (positive in any of the three assessment methodsTuesday, April 23, 13
  17. 17. You screen the 42 y.o. hypertensive.FBS is 5.2 mmol/L. What next?a.Reassure patient she is not diabetic. There isno 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.Tuesday, April 23, 13
  18. 18. If initial test(s) are negative, whenshould repeat testing be done?Repeat testing should ideally be doneannually for Filipinos with risk factors owing to thesignificant prevalence and burden of diabetes in ourcountry. (Level 5, Grade D)Tuesday, April 23, 13
  19. 19. CANDI ManilaFojas 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 inManila. Phil. J. Internal Medicine, 47: 99-105, May-June, 2009Local study: newly-diagnosed diabetics in Manila20% peripheral neuropathy42% proteinuria2% diabetic retinopathyCOMPLICATIONS FOUND AT DIAGNOSIS!Tuesday, April 23, 13
  20. 20. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommended tests for diagnosing diabetes:•Fasting plasma glucose (FPG) - 8-14 hours•Random plasma glucose (RPG)•2-h plasma glucose in 75-g OGTTTuesday, April 23, 13
  21. 21. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSCriteria 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 signsand symptoms of hyperglycemic crisis•2-h plasma glucose in 75-g OGTT >200 mg/dL (11.1mmol/L)Tuesday, April 23, 13
  22. 22. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSFasting plasma glucose (FPG) is the preferredtest due to its wide availability, lower cost andbetter reproducibility (Level 3, Grade B)•If the FPG falls within the impaired fasting glucoserange (5.6-6.9 mmol/L) then a 75-g OGTT isrecommended (Level 3, Grade B)•Symptomatic patients - random or FPGTuesday, April 23, 13
  23. 23. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSAmong asymptomatic individuals with positiveresults, any of the three tests should berepeated within two weeks for confirmation(Level 4, Grade C).Tuesday, April 23, 13
  24. 24. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSDiabetes can be diagnosed when any of thethree tests are positive in a symptomaticpatient (weight loss, polyuria, polyphagia, polydipsia).Tuesday, April 23, 13
  25. 25. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSA 75-g OGTT is preferred as the first test for thefollowing (Level 3, Grade B):•Previous FBS showing IFG 100-125 mg/dL (5.6-6.9mmol/L)•Previous diagnosis of CVD (CAD, stroke, peripheralarteriovascular disease) or who are at high risk of CVD•A diagnosis of Metabolic SyndromeTuesday, April 23, 13
  26. 26. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSAt the present time, we cannot recommend theroutine use of the following tests in thediagnosis of diabetes (Level 3, Grade C):•HbA1c•Capillary blood glucose•Fructosamine•Urinalysis (Level 3, Grade B)• Plasma insulin (Level 3, Grade B)Tuesday, April 23, 13
  27. 27. UNITE PHILIPPINE CPGFOR DIABETES MELLITUS•HbA1c•Capillary blood glucose•Fructosamine•UrinalysisInterpret an available result with caution andconfirm with any of the three standard tests(Level 2, Grade B).Tuesday, April 23, 13
  28. 28. Why NOT Hba1C?Until standardization has been done in thePhilippines, use HbA1c only as a tool formonitoring control among those withestablished DM.•HbA1c not readily available in some areas•NGSP certification not easily verified in laboratories•Studies needed to determine effect of ethnicityTuesday, April 23, 13
  29. 29. You screen the 42 y.o. hypertensive.FBS is 5.2 mmol/L. What next?a.Reassure patient she is not diabetic. There isno 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.Tuesday, April 23, 13
  30. 30. Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsTuesday, April 23, 13
  31. 31. Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk factors(Table 1)YESTuesday, April 23, 13
  32. 32. Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk factors(Table 1)YESLab testing using FBS, RBS, OGTT (Fig 3)YESTuesday, April 23, 13
  33. 33. Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk factors(Table 1)YESLab testing using FBS, RBS, OGTT (Fig 3)YESAge>40 yNOYESTuesday, April 23, 13
  34. 34. Screen for risk factors forDM, prediabetes and MetSAlgorithm for Screening DiabetesAmong Asymptomatic IndividualsRisk factors(Table 1)YESLab testing using FBS, RBS, OGTT (Fig 3)YESAge>40 yNOYESNo further testing;re-evaluate annuallyfor risk factorsNOTuesday, April 23, 13
  35. 35. Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CAD, PAD,CVD or with MetSSymptomatic (polyuria,polydipsia, polyphagia,weight loss)Tuesday, April 23, 13
  36. 36. Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CAD, PAD,CVD or with MetSSymptomatic (polyuria,polydipsia, polyphagia,weight loss)Fasting plasmaglucose<100mg/dL100-125mg/dL>126mg/dLNodiabetesRepeattestingafter 1 y75-gOGTTDiabetesTuesday, April 23, 13
  37. 37. Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CAD, PAD,CVD or with MetSSymptomatic (polyuria,polydipsia, polyphagia,weight loss)Fasting plasmaglucose<100mg/dL100-125mg/dL>126mg/dLNodiabetesRepeattestingafter 1 y75-gOGTTDiabetes75-g oral glucosetolerance test(OGTT)FBS<100 &2h <140mg/dLFBS100-125or 2h140-199mg/dLFBS>126mg/dLor 2h>200NodiabetesRepeattestingafter 1 yIFG orIGTRepeatafter 6mosDiabetesTuesday, April 23, 13
  38. 38. Age >40 yAge <40 y with risk factors for DMNo 3 P’s or weight loss(asymptomatic)No known CAD, PAD,CVD, No MetSDiagnosed CAD, PAD,CVD or with MetSSymptomatic (polyuria,polydipsia, polyphagia,weight loss)Fasting plasmaglucose<100mg/dL100-125mg/dL>126mg/dLNodiabetesRepeattestingafter 1 y75-gOGTTDiabetes75-g oral glucosetolerance test(OGTT)FBS<100 &2h <140mg/dLFBS100-125or 2h140-199mg/dLFBS>126mg/dLor 2h>200NodiabetesRepeattestingafter 1 yIFG orIGTRepeatafter 6mosDiabetesRandom plasmaglucose<140mg/dL140-199mg/dL>200mg/dLNodiabetesRepeattestingafter 1 y75-gOGTTDiabetesTuesday, April 23, 13
  39. 39. Philippine ClinicalPractice Guideline forDiabetes MellitusPart 2:MANAGEMENT & MONITORINGTuesday, April 23, 13
  40. 40. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSInitial evaluation - comprehensive medical historyand PE•Coronary heart disease risk assessment•Foot evaluation: assess risk for foot ulcer (identifyhigh-risk feet)•Eye exam: fundoscopy on diagnosis•Dental history or oral health historyTuesday, April 23, 13
  41. 41. RED FLAGSof dental diseasetooth achepain when chewingsensitivity tocold/hot drinksbadly broken teethswelling of gumsbad breathTuesday, April 23, 13
  42. 42. Prevalence among T2DM68% (SLMC, n =192)Bitong et al PJIM 2010PERIODONTITISgum bleedingon brushingswelling andredness of gumslooseness ormobility of teethteeth that falloff in adultsTuesday, April 23, 13
  43. 43. Which of the following will you NOT requestas initial tests for a person with diabetes?a.Fasting blood glucose, HbA1cb.Complete lipid profilec.Blood uric acid, 12-lead ECGd.ALT, AST, serum creatinineTuesday, April 23, 13
  44. 44. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSMinimal 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 GFRTuesday, April 23, 13
  45. 45. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSOptional tests• ECG and TET• TSH in type 1 diabetes, dyslipidemia or womenover age 50 yTuesday, April 23, 13
  46. 46. Which of the following will you NOT requestas initial tests for a person with diabetes?a.Fasting blood glucose, HbA1cb.Complete lipid profilec.Blood uric acid, 12-lead ECGd.ALT, AST, serum creatinineTuesday, April 23, 13
  47. 47. Which of the following statements is trueabout monitoring diabetes?a. Monitor Hba1c ideally twice a year.b. Check FBS and postprandial blood sugarevery 2-4 weeks.c. Estimate trends in blood sugar control bychecking CBGs once a week.d. Achieve glycemic goals within three months.Tuesday, April 23, 13
  48. 48. Glycemic targetsIndividualize 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/dLPPBG <180 mg/dLHbA1c <7%Tuesday, April 23, 13
  49. 49. Glycemic targetsIndividualize targets.FBS <6 mmol/L2h PPG <8 mmol/LNewly diagnosedRelatively young (age <60 y)No complicationsNo risk factors for hypoglycemiaHbA1c <6.5%Tuesday, April 23, 13
  50. 50. Ideally, HbA1c every 3-6 months;2x a year if controlled on stable therapyFBS, postprandial sugar every 2-4 weeksCapillary blood glucose2x a week to estimate trendsTuesday, April 23, 13
  51. 51. Glycemic targets should beachieved within 6 months ofdiagnosis or first prescription.Tuesday, April 23, 13
  52. 52. Which of the following statements is trueabout monitoring diabetes?a. Monitor Hba1c ideally twice a year.b.Check FBS and postprandial blood sugarevery 2-4 weeks.c. Estimate trends in blood sugar control bychecking CBGs once a week.d. Achieve glycemic goals within three months.Tuesday, April 23, 13
  53. 53. Targets toDecrease CV RiskBP controlLipid controlASATuesday, April 23, 13
  54. 54. Which of the following statements is trueabout reducing CV risk in diabetes?a. Statins should be given regardless of baselinelipid levels.b. There is insufficient evidence to recommendaspirin for primary prevention in men <60 y.c. Give clopidogrel 75 mg/day for those withdiabetes and a history of CVD.d. The goal BP for most persons with diabetes is<140/80 mm Hg.Tuesday, April 23, 13
  55. 55. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSThe goal BP for most persons with diabetes is<140/80 mm Hg.•Lifestyle therapy alone for 3 months ifpre-hypertensive (SBP 130-139 mm Hg orDBP 80-89 mm Hg)•Pharmacologic + lifestyle therapy if SBP>140 mm Hgor DBP >90 mm Hg, or pre-hypertensive uncontrolledwith lifestyle therapy aloneTuesday, April 23, 13
  56. 56. Weight loss if overweightDASH-style dietary pattern(reduce Na, increase K,moderation of alcohol,increased physical activity).Lifestyle therapyTuesday, April 23, 13
  57. 57. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 7.3ACE inhibitors & ARBs are generally recommendedas initial therapy. If one class is not tolerated,the other should be substituted.Multiple drug therapy (>2 agents at maximaldoses) is generally required to achieve BP targets.Thiazide-type diuretics, calcium channel blockers andB-blockers may be given as additional agents.Tuesday, April 23, 13
  58. 58. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendations are consistent with PhilippinePractice Guidelines for the Treatment ofDyslipidemia.•LDL is the primary target for dyslipidemiamanagement in persons with diabetes.Tuesday, April 23, 13
  59. 59. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 8.1.1Statin therapy should be added to lifestyletherapy, regardless of baseline levels for diabetics•with overt CVD (A)•without CVD who are >40 y and have >1moreother CVD risk factors (A)Tuesday, April 23, 13
  60. 60. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 8.1.2For patients at lower risk (e.g. without overtCVD and <40 y), statin therapy should beconsidered in addition to lifestyle therapy if -•LDL-C remains >100 mg/dL•those with multiple risk factors (hypertension, familialhypercholesterolemia, LVH, smoking, family history of premature CAD,male sex, age >55 y, proteinuria, albuminuria, BMI>25)Tuesday, April 23, 13
  61. 61. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSThe 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 anoption. [B]Tuesday, April 23, 13
  62. 62. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendation 9.2Insufficient evidence to recommend aspirin forprimary prevention in lower risk individuals•Men < 50 y•Women <60 y* Clinical judgement if with multiple risk factorsTuesday, April 23, 13
  63. 63. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendation 9.3Use aspirin therapy for secondary preventionstrategy in those with DM and a history of CVD[A].•For patients with CVD and documented aspirinallergy, clopidogrel (75 mg/day) should beused.Tuesday, April 23, 13
  64. 64. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSRecommendation 9.4Combination therapy of ASA (75-162 mg/day)and clopidogrel (75 mg/day) is reasonable up toa year after an acute coronary syndrome [B].Tuesday, April 23, 13
  65. 65. Which of the following statements is trueabout reducing CV risk in diabetes?a. Statins should be given regardless of baselinelipid levels.b. There is insufficient evidence to recommendaspirin for primary prevention in men <60 y.c. Give clopidogrel 75 mg/day for those withdiabetes and a history of CVD.d.The goal BP for most persons withdiabetes is <140/80 mm Hg.Tuesday, April 23, 13
  66. 66. Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsTuesday, April 23, 13
  67. 67. Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsHbA1c <9%FBS < 250HbA1c >9%FBS > 250Tuesday, April 23, 13
  68. 68. Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsHbA1c <9%FBS < 250HbA1c >9%FBS > 250Mono-therapyOption forcombinationtherapyTuesday, April 23, 13
  69. 69. Newly diagnosed T2DMInitiation of Drug Therapy among NewlyDiagnosed Type 2 Diabetes PatientsHbA1c <9%FBS < 250HbA1c >9%FBS > 250Mono-therapyOption forcombinationtherapyCombinationtherapyInsulintherapyTuesday, April 23, 13
  70. 70. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 10.1Initiate treatment with metformin formonotherapy unless with contraindications orintolerance of its ADE’s -• diarrhea• severe nausea• abdominal painTuesday, April 23, 13
  71. 71. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSWhen optimization of therapy is needed, choosethe second drug according to the following -•degree of HbA1c lowering•hypoglycemia risk•weight gain•patient profile (dosing complexity, renal/hepaticproblems, other contraindications and age)Tuesday, April 23, 13
  72. 72. Adapted from AACE Diabetes Mellitus Guidelines Endocr Pract 2007Drug Therapy HbA1c reduction (%)MONOTHERAPYMONOTHERAPYSulfonylureas 0.9 to 2.5Biguanide (Metformin) 1.1 to 3.0Thiazolidinedione 1.5 to 1.6Alpha-glucosidase inhibitors 0.6 to 1.3DPP-4 inhibitors 0.8NON-INSULIN INJECTABLENON-INSULIN INJECTABLEExenatide 0.8 to 0.9COMBINATION THERAPYCOMBINATION THERAPYSU + Metformin 1.7SU + Pioglitazone 1.2SU + Acarbose 1.3Repaglinide + Metformin 1.4Pioglitazone + Metformin 0.7DPP-4 inhibitor + Metformin 0.7DPP-4 inhibitor + Pioglitazone 0.7Tuesday, April 23, 13
  73. 73. Safety and TolerabilityInsulinsecretagoguesMetforminalpha-glucosidaseinhibitorsTZDs InsulinRisk ofhypoglycemia✔ ✔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.Tuesday, April 23, 13
  74. 74. ContraindicationsSulfonylurea Meglitinide Biguanide AGI TZDRenalinsufficiency✔ ✔ ✔Liver disease ✔ ✔ ✔ ✔ ✔Inflammatorybowel disease✔Congestiveheart failure✔ ✔Knownhypersensitivity✔ ✔ ✔ ✔ ✔Tuesday, April 23, 13
  75. 75. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSSince HbA1c reduction is the overriding goal, theprecise combination used may not be as importantas the glucose level achieved.•There is no evidence that a specific combination is anymore effective in lowering glucose levels or preventingcomplications than another.SU + Pio = SU + Metformin (Hanefield et al, 2004 & Nagasaka et al, 2004)SU + Met = SU + DPP-IV inhibitors (?)Tuesday, April 23, 13
  76. 76. UNITE PHILIPPINE CPGFOR DIABETES MELLITUSStatement 10.4.2The following patients must be referred tointernists or diabetes specialists (endocrinologistsor diabetologists) -• Type 1 diabetes• Moderate to severe hyperglycemia• Co-morbid conditions (infections, acute CV events i.e. CHF oracute MI)• Significant hepatic and renal impairment• Women with diabetes who are pregnantTuesday, April 23, 13
  77. 77. Clinical practice guidelines aim to help physiciansand patients reach the best healthcare decisions.Steinbrook R. NEJM 2007Tuesday, April 23, 13
  78. 78. “If you write it, andit is good, then theywill follow.”Keefer JH. Clin Chem 2001Tuesday, April 23, 13
  79. 79. THANK YOUhttp://www.endocrine-witch.nethttp://www.facebook.com/EndocrineWitchhttp://endocrine-witch.tumblr.com@endocrine_witchTuesday, April 23, 13

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