Management of Previously Undiagnosed Patients with Type 2 Diabetes Mellitus


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Management of Previously Undiagnosed Patients with Type 2 Diabetes Mellitus

  1. 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, butthis 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 havepatients who present to the hospital without them knowing theyhave diabetes, and in thecoronary care unit we find out that they had a massive heart attack and indeed they did have alittle 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 conditionthat was silent and not diagnosed because the patient never went to see a physician or becausemaybe the primary care physician who made the diagnosis of metabolic syndrome felt no needfor therapy.So the patient comesin with a massive heart attack with an anterior wall injury of theleft ventricle, damage that leads to congestive heart failure,a tremendous catastrophe for thatpatient because their quality of life is going to get much worse and as we know patients whohave congestive heart failure, particularly grade 3 and 4 of the New York American HeartAssociation,don’t do well and often go back and forward to the hospital. The cardiologist takesover 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 orischemic heart disease. If I see somebody who has chronic kidney disease stage III or IV or ondialysis, these patients are basically managed by the nephrologist because of the follow up ofthe renal function and medications for the renal function and their need to be prescribed andmonitored by the nephrologist.Often patients are sent to us because they do not respond tocertain medications, as they do not tolerate certain medications and the nephrologist asks whatwill be the best agent to use, but the day to day care will be by the nephrologist. Then, we havesomething that we see less often than before, but again having so much diabetes, we continueto see amputations, complications of the feet that threatened the legs and often the patient endsup having an amputation. Many of these patients have peripheral vascular disease withcompromise circulation, they are seen by the vascular surgeon, they often have very abnormalkidney functions and cardiac functions so they are seen by a nephrologist and cardiologist. Theendocrinologist 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. 2.  By the way, we learn a lot from the ACCORD trial that waspublished maybe two years ago. Itshowed that with patientswho live with an A1c close to 8-9% for around 10 years, when weintervene aggressively by lowering the blood sugar or by trying to lower the blood pressure toomuch or by giving combination therapy or fibrates and statins, it does not work.We learn fromACCORD that intervening too aggressively too late for blood sugar, blood pressure or lipids donot work too well. So, endocrinologists like to help primary care physicians who see most ofthese patients very early in the disease; we cannot do that much when we see them late in theirdisease with complications. I emphasize again on the importance of treating those patients veryaggressive very early in the disease before they get complications. There is a time in the life ofthe patient that we switch from disease prevention to quality of life because they already areburdened with so much disease.Lenora Lorenzo, DNP, APRN, FNP/ADM: Another thing to keep in mind is that with the publichealth successes, the populations are aging and we are increasingly seeing people who areliving with more and more chronic conditions like diabetes for decades. As we know diabetesoften has very vague symptoms including hyperglycemia, which remains undiagnosed withprediabetes for 5-10 years; that is well documented in the literature. Therefore, with the growingrates of unrecognized prediabetes, I think we are going to more frequently see the patients whofirst come in with complications already of type 2. Dr. Vojta and the United Health Groupreported the growing rate of unrecognized prediabetes will rise to 52% by 2020 thus we earn thetitle 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 resultof this. Many patients will first present with complications of diabetes, but were not previouslydiagnosed, and these can include retinopathies or peripheral neuropathy and pain. Where tostart and how to evaluate is a good question. First, I think as health care providers, we have tohave a very high index of suspicion and often base differential diagnosis on risk factors ofindividual patients and their chief complaint on presentation.Some other risks factors I look at fordiabetes include obesity, metabolic syndrome, family history, any pancreatic, hepatiticdisorders, and alcohol abuse. And then we need to look at the kind of complications that wemay have in undiagnosed patients who present with symptoms; we could have either acute typeof 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 lifethreatening kind of consequences of uncontrolled diabetes, such as ketoacidosis, which is veryrare or nonketotic hyperosmolar type of syndrome. As I said both of these are rare and wehardly ever see them in the first undiagnosed patient, but it does happen from time to time. Thesymptoms of marked hyperglycemia including the three P’s, the polyuria, polydipsia, weight gainor dehydration and blurred vision, are actually very common and patients complain of extremeDeveloped  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. 3.  thirst, dehydration, hunger, and fatigue. I have one patient that presented with a gallon of waterand symptoms of dehydration, thirst and fatigue. It was like a huge hint, this patient sitting theredrinking a gallon of water because he is so thirsty and dehydrated from the hyperglycemia. Hewas pretty easily diagnosed in that case. Another frequently seen first undiagnosed symptomincludes blurred vision and they often present to the optometrist for corrective lenses because ofthe blurred vision. In this case they have never been diagnosed prior to that and may bediagnosed by the optometrist at that point.Another area is the impairment of the growth and susceptibility to certain infections that we seewith acute hyperglycemia or prediabetes. Some of these patient that I have seen have been ona high dose of steroids for prolonged periods for treatments such as asthma, transplant orrheumatoid arthritis. In the case of females, they often present to me with complaints of chronicor intermittent vaginal yeast type of infections. Therefore we must have a high index ofsuspicion thinking what could be going on here, it is not just a yeast infection, or is this issomebody who has diabetes. Also in both genders, you may see skin conditions like tinea orfungal infections of the nails or other kind of chronic intermittent infections. So that is the otherarea we see in the more acute presentations.The long-term complications unfortunately may be the first presentation of diabetes and thiscould include life threatening loss of vision from retinal detachment from retinopathy andnephropathy, which would be evidenced by proteinuria or elevated creatinine, which then couldlead to the chronic kidney disease. Peripheral neuropathy - I have had patients come incomplaining of having burned their feet with blisters from just stepping on the hot sand and notrealizing that they had neuropathy and undiagnosed diabetes. They are coming in withsecondary infections, foot ulcers that could lead to amputations. I have seen them quite a bit inHawaii because of the hot sand and going to the beach.I rarely see any of the autonomic neuropathy kinds of things other than urinary incontinenceespecially in women. We do from time to time see cardiovascular symptoms, arrhythmias, andsexual dysfunction as a chief complaint with undiagnosed diabetes. Probably the mostworrisome are the patients who come in with a CVA or an MI. I have had a patient who wasdriving and suddenly felt very faint, pulled over, and the ambulance took him to the hospital andhe was having a stroke as well as hyperglycemic episodes so he was then diagnosed withdiabetes.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 ofsymptoms, that with diabetes they have a lot of hypertension and abnormalities in their lipids sowe 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. 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.