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1.
PODCAST
TRANSCRIPT:
MANAGEMENT
OF
PREVIOUSLY
UNDIAGNOSED
PATIENTS
WITH
T2DM
Joel Zonszein, MD, CDE, FACE, FACP: We need to do primary prevention of the disease, but
this is in the hands of society and the Department of Health. Secondary disease prevention –
prevention of complications - is in the hands of the Health Care System. Often, we have
patients who present to the hospital without them knowing theyhave diabetes, and in the
coronary care unit we find out that they had a massive heart attack and indeed they did have a
little bit of high blood sugar, a little bit of high blood pressure, and a little bit of high cholesterol.
Soactually, that individual heart attack is the result of having metabolic syndrome a condition
that was silent and not diagnosed because the patient never went to see a physician or because
maybe the primary care physician who made the diagnosis of metabolic syndrome felt no need
for therapy.So the patient comesin with a massive heart attack with an anterior wall injury of the
left ventricle, damage that leads to congestive heart failure,a tremendous catastrophe for that
patient because their quality of life is going to get much worse and as we know patients who
have congestive heart failure, particularly grade 3 and 4 of the New York American Heart
Association,don’t do well and often go back and forward to the hospital. The cardiologist takes
over the care of the patient because even more important than controlling the blood sugar,
cholesterol, and blood pressure, is management of the congestive heart failure.
So, the cardiologists really take over the care of these patients with congestive heart failure or
ischemic heart disease. If I see somebody who has chronic kidney disease stage III or IV or on
dialysis, these patients are basically managed by the nephrologist because of the follow up of
the renal function and medications for the renal function and their need to be prescribed and
monitored by the nephrologist.Often patients are sent to us because they do not respond to
certain medications, as they do not tolerate certain medications and the nephrologist asks what
will be the best agent to use, but the day to day care will be by the nephrologist. Then, we have
something that we see less often than before, but again having so much diabetes, we continue
to see amputations, complications of the feet that threatened the legs and often the patient ends
up having an amputation. Many of these patients have peripheral vascular disease with
compromise circulation, they are seen by the vascular surgeon, they often have very abnormal
kidney functions and cardiac functions so they are seen by a nephrologist and cardiologist. The
endocrinologist plays much less of a roll.
Developed
in
collaboration
with
the
Center
for
Continuing
Medical
Education
at
Albert
Einstein
College
of
Medicine
and
Montefiore,
and
the
American
Academy
of
Nurse
Practitioners,
through
a
strategic
educational
facilitation
by
Medikly,
LLC.
Supported
by
an
unrestricted
educational
grant
from
Lilly
USA,
LLC.

2.
By the way, we learn a lot from the ACCORD trial that waspublished maybe two years ago. It
showed that with patientswho live with an A1c close to 8-9% for around 10 years, when we
intervene aggressively by lowering the blood sugar or by trying to lower the blood pressure too
much or by giving combination therapy or fibrates and statins, it does not work.We learn from
ACCORD that intervening too aggressively too late for blood sugar, blood pressure or lipids do
not work too well. So, endocrinologists like to help primary care physicians who see most of
these patients very early in the disease; we cannot do that much when we see them late in their
disease with complications. I emphasize again on the importance of treating those patients very
aggressive very early in the disease before they get complications. There is a time in the life of
the patient that we switch from disease prevention to quality of life because they already are
burdened with so much disease.
Lenora Lorenzo, DNP, APRN, FNP/ADM: Another thing to keep in mind is that with the public
health successes, the populations are aging and we are increasingly seeing people who are
living with more and more chronic conditions like diabetes for decades. As we know diabetes
often has very vague symptoms including hyperglycemia, which remains undiagnosed with
prediabetes for 5-10 years; that is well documented in the literature. Therefore, with the growing
rates of unrecognized prediabetes, I think we are going to more frequently see the patients who
first come in with complications already of type 2. Dr. Vojta and the United Health Group
reported the growing rate of unrecognized prediabetes will rise to 52% by 2020 thus we earn the
title of the United States of Diabetes, which is phenomenal when you think about.
We already know that there are increasing rates and there are higher complications as a result
of this. Many patients will first present with complications of diabetes, but were not previously
diagnosed, and these can include retinopathies or peripheral neuropathy and pain. Where to
start and how to evaluate is a good question. First, I think as health care providers, we have to
have a very high index of suspicion and often base differential diagnosis on risk factors of
individual patients and their chief complaint on presentation.Some other risks factors I look at for
diabetes include obesity, metabolic syndrome, family history, any pancreatic, hepatitic
disorders, and alcohol abuse. And then we need to look at the kind of complications that we
may have in undiagnosed patients who present with symptoms; we could have either acute type
of symptoms or we could have more of the chronic long-term complications types of symptoms.
In the acute symptoms what I see a lot is hyperglycemia, infections, and some of the more life
threatening kind of consequences of uncontrolled diabetes, such as ketoacidosis, which is very
rare or nonketotic hyperosmolar type of syndrome. As I said both of these are rare and we
hardly ever see them in the first undiagnosed patient, but it does happen from time to time. The
symptoms of marked hyperglycemia including the three P’s, the polyuria, polydipsia, weight gain
or dehydration and blurred vision, are actually very common and patients complain of extreme
Developed
in
collaboration
with
the
Center
for
Continuing
Medical
Education
at
Albert
Einstein
College
of
Medicine
and
Montefiore,
and
the
American
Academy
of
Nurse
Practitioners,
through
a
strategic
educational
facilitation
by
Medikly,
LLC.
Supported
by
an
unrestricted
educational
grant
from
Lilly
USA,
LLC.

3.
thirst, dehydration, hunger, and fatigue. I have one patient that presented with a gallon of water
and symptoms of dehydration, thirst and fatigue. It was like a huge hint, this patient sitting there
drinking a gallon of water because he is so thirsty and dehydrated from the hyperglycemia. He
was pretty easily diagnosed in that case. Another frequently seen first undiagnosed symptom
includes blurred vision and they often present to the optometrist for corrective lenses because of
the blurred vision. In this case they have never been diagnosed prior to that and may be
diagnosed by the optometrist at that point.
Another area is the impairment of the growth and susceptibility to certain infections that we see
with acute hyperglycemia or prediabetes. Some of these patient that I have seen have been on
a high dose of steroids for prolonged periods for treatments such as asthma, transplant or
rheumatoid arthritis. In the case of females, they often present to me with complaints of chronic
or intermittent vaginal yeast type of infections. Therefore we must have a high index of
suspicion thinking what could be going on here, it is not just a yeast infection, or is this is
somebody who has diabetes. Also in both genders, you may see skin conditions like tinea or
fungal infections of the nails or other kind of chronic intermittent infections. So that is the other
area we see in the more acute presentations.
The long-term complications unfortunately may be the first presentation of diabetes and this
could include life threatening loss of vision from retinal detachment from retinopathy and
nephropathy, which would be evidenced by proteinuria or elevated creatinine, which then could
lead to the chronic kidney disease. Peripheral neuropathy - I have had patients come in
complaining of having burned their feet with blisters from just stepping on the hot sand and not
realizing that they had neuropathy and undiagnosed diabetes. They are coming in with
secondary infections, foot ulcers that could lead to amputations. I have seen them quite a bit in
Hawaii because of the hot sand and going to the beach.
I rarely see any of the autonomic neuropathy kinds of things other than urinary incontinence
especially in women. We do from time to time see cardiovascular symptoms, arrhythmias, and
sexual dysfunction as a chief complaint with undiagnosed diabetes. Probably the most
worrisome are the patients who come in with a CVA or an MI. I have had a patient who was
driving and suddenly felt very faint, pulled over, and the ambulance took him to the hospital and
he was having a stroke as well as hyperglycemic episodes so he was then diagnosed with
diabetes.That can be the first ominous type of presentation.
I think we also have to be very aware that when they do come in with whatever type of
symptoms, that with diabetes they have a lot of hypertension and abnormalities in their lipids so
we need to fully work them up for the cardiac kinds of things.
Developed
in
collaboration
with
the
Center
for
Continuing
Medical
Education
at
Albert
Einstein
College
of
Medicine
and
Montefiore,
and
the
American
Academy
of
Nurse
Practitioners,
through
a
strategic
educational
facilitation
by
Medikly,
LLC.
Supported
by
an
unrestricted
educational
grant
from
Lilly
USA,
LLC.

4.
Developed
in
collaboration
with
the
Center
for
Continuing
Medical
Education
at
Albert
Einstein
College
of
Medicine
and
Montefiore,
and
the
American
Academy
of
Nurse
Practitioners,
through
a
strategic
educational
facilitation
by
Medikly,
LLC.
Supported
by
an
unrestricted
educational
grant
from
Lilly
USA,
LLC.