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  • Why is it interesting to do research in diabeets
  • “ Standards of Medical Care in Diabetes—2011” contains all of the current and key clinical recommendations of the American Diabetes Association (ADA) These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to affect health outcomes of patients with diabetes favorably The slides are organized to correspond with sections within the “Standards of Medical Care in Diabetes—2011” While not every section in the document is represented, these slides do incorporate the most salient points from the Position Statement These standards of care are revised annually by the ADA’s multidisciplinary Professional Practice Committee, incorporating new evidence; subsequently, they are reviewed and approved by the Executive Committee of ADA’s Board of Directors Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S11-12. Available online at http://care.diabetesjournals.org/content/34/Supplement_1
  • The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 1 of 2) includes: Testing should be considered in all adults who are overweight (BMI ≥25 kg/m 2 ) and have additional risk factors Testing should be considered in adults of any age with BMI ≥25 kg/m 2 and one or more of the known risk factors listed on this slide It is important to know that the at-risk BMI may be lower in some ethnic groups, such as Asians Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S14. Table 4.
  • The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 2 of 2) includes: In the absence of criteria (risk factors on previous slide), testing diabetes should begin at age 45 years If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status Age is a major risk factor for diabetes; therefore, testing of individuals without other risk factors should begin no later than at age 45 years The rationale for the 3-year interval is that false negatives will be repeated before substantial time elapses, and there is little likelihood that an individual will develop significant complications of diabetes within 3 years of a negative test result Given the need for follow-up and discussion of abnormal results, testing should be conducted within the health care setting Community screening outside a health care setting is not recommended because people with positive tests may not seek, or have access to, appropriate follow-up testing and care Conversely, there may be failure to ensure appropriate repeat testing for individuals who test negative Community screening may also be poorly targeted; i.e., it may fail to reach the groups most at risk and inappropriately test those at low risk (the worried well) or even those already diagnosed Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S14. Table 4.
  • Table 2, current diagnostic criteria for the diagnosis of diabetes, is divided into five slides On this slide, all four criteria are included: A1C ≥6.5% Fasting plasma glucose (FPG) ≥126 mg/dl (7.0 mmol/l) Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT A random plasma glucose ≥200 mg/dl (11.1 mmol/l), in patients with classic symptoms of hyperglycemia or hyperglycemic crisis The subsequent slides examine each of the four criteria in greater detail Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S13. Table 2.
  • A1C In 2009, an International Expert Committee that included representatives of the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the European Association for the Study of Diabetes (EASD) recommended the use of the A1c test to diagnose diabetes, with a threshold of ≥6.5% 1 , and ADA adopted this criterion in 2010 2 The diagnostic test should be performed using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay 3 Point-of-care A1C assays are not sufficiently accurate at this time to use for diagnostic purposes 3 References International Expert Committee: International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327-1334. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33(suppl 1):S62-S69. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S13. Table 2.
  • Optional DISCUSSION POINTS: Both fasting and postprandial glucose contribute to overall glycemic control as measured by A1C. The typical 24-h blood glucose profiles differ in healthy patients without diabetes (purple area) and patients with uncontrolled type 2 diabetes (turquoise and yellow area). In healthy individuals, fasting plasma glucose generally ranges between 70 and 110 mg/dL and postprandial glucose levels rarely exceed 140 mg/dL. Patients with uncontrolled diabetes typically have high fasting glucose and also have exaggerated postprandial glucose excursions. Both contribute to overall glucose control as measured by the A1C.
  • Table 9, as shown on this slide, contains the correlation between A1C levels and mean plasma glucose (PG) levels based on data from the international A1C-Derived Average Glucose (ADAG) trial using frequent SMBG and continuous glucose monitoring (CGM) in 507 adults (83% Caucasian) with type 1, type 2, and no diabetes 1 The ADA and the American Association of Clinical Chemistry have determined that the correlation ( r = 0.92) is strong enough to justify reporting both an A1C result and an estimated average glucose (eAG) when a clinician orders the A1C test 2 A calculator for converting A1C results into eAG, in either mg/dl or mmol/l, is available at http://professional.diabetes.org/eAG. Reference Nathan DM, Kuenen J, Borg R, et al., for the A1c-Derived Average Glucose Study Group. Translating the A1C assay into estimated average glucose values. Diabetes Care . 2008;31:1473-1478. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S18, Table 9.
  • Two-hour plasma glucose (2-h PG) The two-hour plasma glucose test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water The established glucose criteria for the diagnosis of diabetes (FPG, previous slide, and 2-h PG) remain valid Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S13. Table 2.
  • Random Plasma Glucose As with most diagnostic tests, a test result diagnostic of diabetes should be repeated to rule out laboratory error, unless the diagnosis is clear on clinical grounds, such as a patient with a hyperglycemic crisis or classic symptoms of hyperglycemia and a random plasma glucose ≥200 mg/dl Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S13. Table 2.
  • In 1997 and 203, The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus 1,2 recognized an intermediate group of individuals whose glucose levels, although not meeting criteria for diabetes, are nevertheless too high to be considered normal This group was defined as having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) IFG: fasting plasma glucose (FPG) of 100-125 mg/dl (5.6-5.9 mmol/l) IGT: two-hour plasma glucose (2-h PG) on the 75-g oral glucose tolerance test (OGTT) of 140-199 mg/dl (7.8-11.0 mmol/l) It should be noted that the World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dl (6.1 mmol) Individuals with IFG and/or IGT have been referred to as having prediabetes, indicating a relatively high risk for future development of diabetes IFG and IGT should not be viewed as clinical entities in their own right but rather risk factors for diabetes as well as cardiovascular disease (CVD) IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension Individuals with an A1C of 5.7-6.4% should be informed of their increased risk for diabetes as well as CVD and counseled about effective strategies to lower their risks (see Prevention/Delay of Type 2 Diabetes ) References Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-1197. Genuth S, Alberti KG, Bennett P, et al., for the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160-3167. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S13. Table 3.
  • ADA and AACE Guidelines: Treatment Goals for A1C, FPG, and PPG The table presents guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). 1 – 3 ADA and AACE recommend slightly different treatment goals for FPG, PPG, and A1C for patients with type 2 diabetes. 1,2 Both organizations emphasize the importance of good glycemic control. The ADA suggests that the goal of treatment in the management of diabetes should be an A1C value less than 7%. 1,2 The AACE has recommended an A1C goal of ≤ 6.5%. 1,3 The ADA target of FPG levels between 90 and 130 mg/dL is based on the estimate of the range of average glucose values that would be associated with low risk of hypoglycemia and A1C <7%. The AACE target of <110 mg/dL is an effort to achieve normal levels of glycemia. 1 The ADA recommends reducing average PPG values (peak posprandial glucose level <180 mg/dL), 2 whereas the AACE recommends targeting 2-hour postchallenge PPG values of <140 mg/dL. 1 Purpose To provide a reminder of current guidelines for type 2 diabetes. Takeaway All 3 parameters (A1C, FPG, and PPG) are important in attaining glycemic control. References 1. Buse JB, Polonsky KS, Burant CF. Type 2 diabetes mellitus. In: Larsen PR, Kronenberg HM, Melmed S, Polonsky KS, eds. Williams Textbook of Endocrinology . 10th ed. Philadelphia: WB Saunders; 2003:1427–1483. 2. ADA. Standards of Medical Care in Diabetes–2007. Diabetes Care . 2007;30:S4–S41. 3. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus. Endocrine Practice . 2007;13(suppl 1):3–68.
  • Section II, “Testing for Diabetes in Asymptomatic Patients,” includes three slides: Testing for Diabetes in Asymptomatic Patients Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2 slides)
  • Recommendations for testing for diabetes in asymptomatic patients are summarized on this slide For many illnesses, there is major distinction between screening and diagnostic testing; however, for diabetes, the same tests are used for “screening” as for diagnosis A1C, fasting plasma glucose (FPG), or two-hour oral glucose tolerance test (2-h OGTT) are appropriate to test for diabetes The 2-h OGTT identifies people with either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT); therefore, more people at increased risk for the development of diabetes and cardiovascular disease (CVD) Type 2 diabetes has a long asymptomatic phase and significant clinical risk markers Testing for diabetes will also detect individuals at increased future risk for diabetes; i.e., those who may have prediabetes Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S13-S14.
  • Section III, “Detection and Diagnosis of Gestational Diabetes Mellitus,” includes eight slides: Detection and Diagnosis of GDM (2 slides) Screening for and Diagnosis of GDM (6 slides)
  • Recommendations for the detection and diagnosis of gestational diabetes mellitus (GDM) are summarized on two slides; this slide ( Slide 1 of 2 ) includes: As the ongoing epidemic of obesity and diabetes has led to more type 2 diabetes in women of childbearing age, the number of pregnant women with undiagnosed type 2 diabetes has increased[24] Because of this, it is reasonable to screen women with risk factors for type 2 diabetes for diabetes at their initial prenatal visit, using standard diagnostic criteria; women with diabetes found at this visit should receive a diagnosis of overt, not gestational, diabetes References American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S15. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25:1862-1868.
  • GDM carries risks for the mother and neonate 1 The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study, 2 a large-scale (25,000 pregnant women) multinational epidemiologic study, demonstrated that risk of adverse maternal, fetal, and neonatal outcomes continuously increased as a function of maternal glycemia at 24–28 weeks, even within ranges previously considered normal for pregnancy. For most complications, there was no threshold for risk. These results have led to careful reconsideration of the diagnostic criteria for GDM After deliberations in 2008–2009, the International Association of Diabetes and Pregnancy Study Groups (IADPSG), an international consensus group with representatives from multiple obstetrical and diabetes organizations, including ADA, developed revised recommendations for diagnosing GDM. The group recommended that all women not known to have diabetes undergo a 75-g OGTT at 24–28 weeks of gestation Additionally, the group developed diagnostic cut points for the fasting, 1-h, and 2-h plasma glucose measurements that conveyed an odds ratio for adverse outcomes of at least 1.75 compared with the mean glucose levels in the HAPO study Current screening and diagnostic strategies, based on the IADPSG statement, 3 are outlined in Table 6, which is summarized on this slide References American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S15. Table 6. Metzger BE, Lowe LP, Dyer AR, et al, for the HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358:1991–2002. Metzger BE, Gabbe SG, Persson B, et al, for the International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–682.
  • Recommendations for the detection and diagnosis of gestational diabetes mellitus (GDM) are summarized on two slides; this slide ( Slide 2 of 2 ) includes: Women with a history of GDM have a greatly increased subsequent risk for diabetes 2 ; therefore, they should be screened for diabetes 6-12 weeks postpartum, using nonpregnant oral glucose tolerance test (OGTT) criteria, and should be followed for the development of diabetes or prediabetes (see Section II, “Testing for Diabetes in Asymptomatic Patients” ) Information on the National Diabetes Education Program campaign to prevent type 2 diabetes in women with GDM can be found at: http://ndep.nih.gov/media/NeverTooEarly_Tipsheet.pdf References American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S15. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25:1862-1868.
  • Sucrose and sucrose foods may be substituted for other carbohydrates; not added to male plan
  • Major discussion point: IN testine Se CRET ion IN sulin
  • Required DISCUSSION POINTS: --Upon food ingestion, GLP-1 is secreted into the circulation from L cells of small intestine. --GLP-1 increases beta-cell response by enhancing glucose-dependent insulin secretion. --GLP-1 decreases beta-cell workload and hence the demand for insulin secretion by: --Regulating the rate of gastric emptying such that meal nutrients are delivered to the small intestine and, in turn, absorbed into the circulation more smoothly, reducing peak nutrient absorption and insulin demand (beta-cell workload) --Decreasing postprandial glucagon secretion from pancreatic alpha cells, which helps to maintain the counterregulatory balance between insulin and glucagon --Reducing postprandial glucagon secretion, GLP-1 has an indirect benefit on beta-cell workload, since decreased glucagon secretion will produce decreased postprandial hepatic glucose output --Having effects on the central nervous system, resulting in increased satiety (sensation of satisfaction with food intake) and a reduction of food intake --By decreasing beta-cell workload and improving beta-cell response, GLP-1 is an important regulator of glucose homeostasis. SLIDE BACKGROUND: --Effect on Beta-cell: Drucker DJ. Diabetes. 1998; 47:159-169 --Effect on Alpha cell: Larsson H, et al. Acta Physiol Scand. 1997; 160:413-422 --Effects on Liver: Larsson H, et al. Acta Physiol Scand. 1997; 160:413-422 --Effects on Stomach: Nauck MA, et al. Diabetologia. 1996; 39:1546-1553 --Effects on CNS: Flint A, et al. J Clin Invest. 1998; 101:515-520
  • DISCUSSION: Classic understanding of the pathogenesis of type 2 diabetes consists of progressive insulin resistance coupled with gradual deterioration of beta-cell function The literature makes it clear there is another fundamental defect in the pathogenesis of type 2 diabetes: dysregulation of incretin hormones such as GLP-1 The acute effects of incretin hormones play a major role in insulin secretion from the beta cell In fact, the incretin effect accounts for up to 70% of the insulin response to oral glucose intake 1 REFERENCE: Holst JJ, Gromada J. Role of incretin hormones in the regulation of insulin secretion in diabetic and nondiabetic humans. Am J Physiol Endocrinol Metab . 2004;287(2):E199-E206. *Note to speakers: This is a graphic that is used in other speaker slide decks. Please note that the title and graphics have been changed slightly to reflect the core message of this deck.
  • Not Required DISCUSSION POINTS: --The half-life of GLP-1 is less than 2 minutes – meaning a continuous infusion of exogenous GLP-1 would be necessary to overcome the enzymatic degradation of GLP-1 by DPP-IV. --Inhibition of DPP-IV, which would extend the half-life of endogenous GLP-1, is one avenue of research. --Incretin mimetics are compounds that mimic GLP-1’s glucoregulatory effects, but are resistant to DPP-IV degradation. Examples are: --Analogs of the natural GLP-1 molecule. --Exenatide, a naturally occurring incretin mimetic that mimics multiple glucoregulatory effects of GLP-1 and is resistant to DPP-IV enzymatic degradation, is the first FDA-approved incretin mimetic. Exenatide is the active ingredient in BYETTA.
  • Beta-Cell Function Declines as Diabetes Progresses The reason that diabetes develops and progresses is because there is a loss of beta-cell function. The data points for the time of diagnosis (0) and the subsequent 6 years were taken from a subset of the UKPDS population and were determined by the homeostatic assessment model (HOMA). The beginning of b eta -cell loss was estimated by extrapolation back to 100% function and the lack of significant insulin secretion by extrapolation forward. In the earliest phase, when b eta -cell function is not impaired, the ability of the b eta cells to hypersecrete insulin masks the impaired glucose tolerance, often for years. As b eta cell function declines further, mild postprandial hyperglycemia develops, reflecting the inability of the b eta cell to hypersecrete enough insulin to overcome insulin resistance. Based on this hypothetical model, at the time of diagnosis, b eta -cell function has typically declined by 50%. Reference Lebovitz HE. Insulin secretagogues: old and new. Diabetes Reviews. 1999;7:139-153.
  • Possible Barriers to the Initiation of Insulin There are patient-related and health care professional – related barriers to initiating insulin, some of which overlap. Patient-related barriers include: Fear of needles Negative misconceptions about insulin Inconvenience Patient perception as personal failure Health care professional – related barriers include: Lack of available educational tools/resources Lack of familiarity/comfort with insulin Time constraints Overlapping barriers include: Fear of hypoglycemia Weight gain Complexity of dosing regimen Cost References Korytkowski M. When oral agents fail: practical barriers to starting insulin. Int J Obes . 2002;26(suppl 3):S18-S24. Larme AC, Pugh JA. Evidence-based guidelines meet the real world: the case of diabetes care. Diabetes Care. 2001;24:1728-1733. Snoek FJ. Breaking the barriers to optimal glycaemic control-what physicians need to know from patients’ perspectives. Int J Clin Pract Suppl . 2002;129:80-84.
  • Peak time refers to time to peak insulin levels (PK) vs. time to peak glucose-lowering action (PD) Replacement of the proline amino acid residue by aspartic acid disrupts the monomer-monomer interface between proline B28 and glycine B23. Repulsion between the negatively charged aspartic acid and the nearby glutamic acid B21 also contributes to the rapid dissociation of insulin aspart into monomers. NovoLog ® therefore has less tendency to form hexamers in solution and is absorbed more rapidly after subcutaneous injection than is regular human insulin.
  • Recommended glycemic goals for nonpregnant adults (Table 10) are shown on three slides Slide 1 of 3 These recommendations are based on those for A1C values, with listed blood glucose levels that appear to correlate with achievement of an A1C of <7% The issue of preprandial versus postprandial self-monitoring of blood glucose (SMBG) is complex; in some epidemiological studies, elevated postchallenge two-hour oral glucose tolerance test (2-h OGTT) glucose values have been associated with increased cardiovascular risk independent of fasting plasma glucose (FPG) In diabetic subjects, some surrogate measures of vascular pathology, such as endothelial dysfunction, are negatively affected by postprandial hyperglycemia Postprandial hyperglycemia, like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution being higher at A1C levels that are closer to 7% However, outcome studies have clearly shown A1C to be the primary predictor of complications, and landmark trials such as the Diabetes Control and Complications Trial (DCCT) and the UK Prospective Diabetes Study (UKPDS) relied overwhelmingly on preprandial SMBG For individuals who have premeal glucose values within target but A1C values above target, a reasonable recommendation for postprandial testing and targets is monitoring postprandial plasma glucose 1-2 hours after the start of the meal and treatment aimed at reducing PPG values to <180 mg/dl to help lower A1C Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S20-21. Table 10.
  • Recommended glycemic goals for nonpregnant adults (Table 10) are shown on three slides Slide 2 of 3 Glycemic goals should be individualized, based on a patient’s duration of diabetes, age, life expectancy, comorbid conditions, known cardiovascular disease (CVD) or advanced microvascular complications, unawareness of hypoglycemia, and other considerations Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S21. Table 10.
  • Recommended glycemic goals for nonpregnant adults (Table 10) are shown on three slides Slide 3 of 3 For individual patients, more or less stringent glycemic goals may be appropriate If A1C goals are not met despite reaching preprandial glucose goals, postprandial glucose may be targeted Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S21. Table 10.
  • For patients using multiple insulin injections or insulin pump therapy, self-monitoring of blood glucose (SMBG) should be conducted three or more times daily (A) 1 SMBG may be used as a guide to the success of therapy if patients are using less frequent insulin injections, noninsulin therapy, or medical nutrition therapy (MNT) alone (E) 1 In non–insulin-treated patients, however, several recent clinical trials have called into question the clinical utility and cost-effectiveness of routine SMBG 2-4 References American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S17. Farmer A, Wade A. Goyder E, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ . 2007;335:132. O’Kane MJ, Bunting B, Copeland M, et al., for the ESMON Study Group. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ . 2008;336-1174-1177. Simon J, Gray A, Clarke P, et al., for the Diabetes Glycaemic Education and Monitoring Trial Group. Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ . 2008;336:1177-1180.
  • A1C testing should be performed routinely in all patients with diabetes, at initial assessment and then as part of continuing care For any individual patient, the frequency of A1C testing depends on the clinical situation, treatment regimen used, and clinician judgment Recommendations for A1C testing are summarized on this slide An A1C test should be performed at least twice a year in patients who are meeting their treatment goals and have stable glycemic control (E) In patients whose therapy has changed or who are not meeting glycemic goals, the A1C test should be performed quarterly (E); this helps determine whether a patient’s glycemic targets are being reached and maintained When needed for timely decisions on when to change therapy, point-of-care testing for A1C may be used (E); availability of A1C results when a patient is seen has been reported to result in increased intensification of therapy and improvement in glycemic control The A1C test is subject to certain limitations: conditions that affect erythrocyte turnover (e.g., hemolysis, blood loss) and hemoglobin variants must be considered, particularly when the A1C result does not correlate with the patient’s clinical situation; in addition, A1C does not provide a measure of glycemic variability or hypoglycemia For patients prone to glycemic variability (especially type 1 diabetic patients, or type 2 diabetic patients with severe insulin deficiency), glycemic control is best judged by the combination of result of self-monitoring of blood glucose (SMBG) testing and A1C The A1C may also serve as a check on the accuracy of a patient’s meter and adequacy of the SMBG testing schedule Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S18.
  • Recommended glycemic goals for nonpregnant adults (Table 10) are shown on three slides Slide 1 of 3 These recommendations are based on those for A1C values, with listed blood glucose levels that appear to correlate with achievement of an A1C of <7% The issue of preprandial versus postprandial self-monitoring of blood glucose (SMBG) is complex; in some epidemiological studies, elevated postchallenge two-hour oral glucose tolerance test (2-h OGTT) glucose values have been associated with increased cardiovascular risk independent of fasting plasma glucose (FPG) In diabetic subjects, some surrogate measures of vascular pathology, such as endothelial dysfunction, are negatively affected by postprandial hyperglycemia Postprandial hyperglycemia, like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution being higher at A1C levels that are closer to 7% However, outcome studies have clearly shown A1C to be the primary predictor of complications, and landmark trials such as the Diabetes Control and Complications Trial (DCCT) and the UK Prospective Diabetes Study (UKPDS) relied overwhelmingly on preprandial SMBG For individuals who have premeal glucose values within target but A1C values above target, a reasonable recommendation for postprandial testing and targets is monitoring postprandial plasma glucose 1-2 hours after the start of the meal and treatment aimed at reducing PPG values to <180 mg/dl to help lower A1C Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S20-21. Table 10.
  • The general recommendations for medical nutrition therapy (MNT) are included on this slide 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 (A) When delivered by a registered dietitian according to nutrition practice guidelines, MNT is reimbursed as part of the Medicare program as overseen by the Centers for Medicare and Medicaid Services (http://www.cms.gov/medicalnutritiontherapy/) Because it can result in cost savings and improved outcomes (B), MNT should be covered by insurance and other payors (E) Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists The best mix of carbohydrates, protein, and fat appears to vary depending on individual circumstances Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S22.
  • Look AHEAD (Action for HEAlth in Diabetes) is a large clinical trial designed to determine whether long-term weight loss will improve glycemia and prevent cardiovascular events in subjects with type 2 diabetes 1 One-year results of the intensive lifestyle intervention in this trial show an average of 8.6% weight loss, significant reduction of A1C, and reduction in several cardiovascular disease (CVD) risk factors, with benefits sustained at 4 years 2 When completed, the Look AHEAD study should provide insight into the effects of long-term weight loss on important clinical outcomes References Pi-Sunyer X, Blackburn G, Brancati FL, et al, for the Look AHEAD Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the Look AHEAD trial. Diabetes Care . 2007;30:1374-1383. Wing RR, Egan C, Bahnson JL, et al, for the Look AHEAD Research Group. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med 2010;170:1566–1575.
  • Exercise is an important part of the diabetes management plan Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well being 1 Regular exercise may also prevent type 2 diabetes in high-risk individuals 1 A new joint position statement of the American Diabetes Association and the American College of Sports Medicine summarizes the evidence for the benefits of exercise in people with type 2 diabetes 2 Recommendations for physical activity for people with diabetes 3 are summarized on this slide People with diabetes should be advised to perform at least 150 minutes per week of moderate-intensity aerobic physical activity (50-70% of maximum heart rate) (A) In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week (A) References Knowler WC, Barrett-Connor E, Fowler SE, et al, for the Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med . 2002;346:393-403. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010;33:2692-2696. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S24.
  • Psychological and social problems can impair the ability of the individual 1-3 or the family to carry out diabetes care tasks and therefore compromise health status Opportunities exist for the clinician to assess psychosocial status in a timely and efficient manner so that referral for appropriate services can be accomplished 4 Recommendations for psychosocial assessment and care 4 are summarized on this slide Assessment of psychological and social situation should be included as an on-going part of the medical management of diabetes (E) Psychosocial screening and follow-up should include, but is not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history (E) Screen for psychosocial problems such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self-management is poor (C) References Anderson RJ, Grigsby AB, Freedland KE, et al. Anxiety and poor glycemic control: a meta-analytic review of the literature. Int J Psychiatry Med 2002;32:235-247. Delahanty LM, Grant RW, Wittenberg E, et al. Association of diabetes-related emotional distress with diabetes treatment in primary care patients with Type 2 diabetes. Diabet Med 2007;24:48-54. American Diabetes Association: Psychosocial factors affecting adherence, quality of life, and well-being: Helping Patients cope. In Medical Management of Type 1 Diabetes. 5 ed. Francine R. Kaufman, Ed. Alexandria, VA, American Diabetes Association, 2008, p. 173-193. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S25.
  • Hypoglycemia is the leading limiting factor in the glycemic management of patients with type 1 and insulin-treated type 2 diabetes 1 Recommendations for treating hypoglycemia 2 are summarized on this slide Glucose (15-20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used If, after 15 minutes of treatment, SMBG shows continued hypoglycemia, the treatment should be repeated; once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia (E) Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers or family members of these individuals should be instructed in its administration Glucagon administration is not limited to health care professionals (E) Individuals with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should be advised to their glycemic targets strictly to avoid further hypoglycemia for at least several weeks to reverse hypoglycemia unawareness (at least partially) and reduce risk of future episodes (B) References Cryer PE. Hypoglycaemia: the limiting factor in the glycaemic management of Type I and Type II diabetes. Diabetologia 2002;45:937-948. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S25.
  • Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in the elderly and in people with chronic disease 1 Although studies reporting the morbidity and mortality of influenza and pneumococcal pneumonia specifically in people with diabetes are limited, observational studies of patients with a variety of chronic illnesses, including diabetes, show that these conditions are associated with an increase in hospitalizations for influenza and its complications 1 Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases 1 Recommendations for the immunization of people with diabetes 2 are summarized on this slide Annually provide an influenza vaccine to all diabetes patients ≥6 months of age (C) Administer pneumococcal polysaccharide vaccine to all diabetes patients ≥2 years of age (C) A one-time revaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered >5 years ago (C) Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation (C) References Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care 2000;23:95–108. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S27.
  • Section IV, “Prevention/Delay of Type 2 Diabetes,” includes one slide: Recommendations: Prevention/Delay of Type 2 Diabetes
  • Recommendations for the prevention/delay of type 2 diabetes are summarized on this slide Individuals at high risk for developing diabetes (i.e., those with impaired fasting glucose [IFG], impaired glucose tolerance [IGT] or both) can be given interventions that significantly decrease rate of onset of diabetes 1 Based on results of clinical trials and known risks of progression of prediabetes to diabetes, person with an A1C of 5.7%-6.4%, IGT or IFG should be counseled on lifestyle changes: 7% weight loss and moderate physical activity of at least 150 minutes/week Regarding the more controversial issue of drug therapy for diabetes prevention, a consensus panel believed that metformin should be the only drug considered[39] Metformin may be recommended for very high-risk individuals (those with risk factors for diabetes and/or those with more severe or progressive hyperglycemia) Of note, in the Diabetes Prevention Program (DPP), metformin was most effective compared to lifestyle in individuals with BMI ≥35 kg/m 2 and was not significantly better than placebo in those over age 60 years For other drugs, issues of cost, side effects, and lack of persistence of effect in some studies led the panel to not recommend use for diabetes prevention References American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S16. Nathan DM, Davidson MB, DeFronzo RA, et al., for the American Diabetes Association. Impaired fasting glucose and impaired glucose tolerance: implications for care. Diabetes Care 2007;30:753-759.
  • Section VI, “Prevention and Management of Diabetes Complications,” includes 48 slides (1 slide unless otherwise noted): Cardiovascular Disease (CVD) in Individuals with Diabetes Recommendations: Hypertension/Blood Pressure Control (8 slides) Recommendations: Dyslipidemia/Lipid Management (7 slides) Secondary Prevention: Reduction in 10-Year Risk of Major CVD Endpoints Primary Prevention: Reduction in 10-Year Risk of Major CVD Endpoints Recommendations: Glycemic, Blood Pressure, Lipid Control in Adults Recommendations: Antiplatelet Agents (3 slides) Recommendations: Smoking Cessation Recommendations: Coronary Heart Disease Screening Recommendations: Coronary Heart Disease Treatment (2 slides) Recommendations: Nephropathy Recommendations: Nephropathy Screening Recommendations: Nephropathy Treatment (5 slides) Definitions of Abnormalities in Albumin Excretion Stages of Chronic Kidney Disease Management of CKD in Diabetes Recommendations: Retinopathy Recommendations: Retinopathy Screening (4 slides) Recommendations: Retinopathy Treatment (2 slides) Recommendations: Neuropathy Screening/Treatment (2 slides) Recommendations: Neuropathy Foot Care (4 slides)
  • Hypertension is a common comorbidity of diabetes that affects the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity Hypertension is a major risk factor for both CVD and microvascular complications In type 1 diabetes, hypertension is often the result of underlying nephropathy, while in type 2 diabetes it usually coexists with other cardiometabolic risk factors The following eight slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 1 of 8 – Screening and Diagnosis Blood pressure should be measured at every routine diabetes visit Patients found to have systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg should have blood pressure confirmed on a separate day Repeat systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg confirms a diagnosis of hypertension (C) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S27.
  • This set of eight slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 2 of 8 – Goals A goal systolic blood pressure <130 mmHg is appropriate for most patients with diabetes (C) Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate (B) Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (B) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S27.
  • This set of eight slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 5 of 8 – Treatment (Slide 3 of 6) Lifestyle therapy for hypertension consists of weight loss if overweight, DASH-style dietary pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity (B) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S27.
  • This set of eight slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 6 of 8 – Treatment (Slide 4 of 6) Pharmacologic therapy for patients with diabetes and hypertension should be paired with a regimen that included either an ACE inhibitor or an angiotensin II receptor blocker (ARB); if one class is not tolerated, the other should be substituted If needed to achieve blood pressure targets, a thiazide diuretic should be added to those with an estimated glomerular filtration rate (GFR) ≥30 ml x min/1.73 m 2 and a loop diuretic for those with an estimated GFR <30 ml x min/1.73 m 2 (C) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S27.
  • This set of eight slides summarize recommendations for screening and diagnosis, goals, and treatment for hypertension/blood pressure control in patients with diabetes Slide 7 of 8 Treatment (Slide 5 of 6) Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets (B) If ACE inhibitors, angiotensin II receptor blockers (ARBs), or diuretics are used, kidney function and serum potassium levels should be closely monitored (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S27.
  • Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 1 of 7 – Screening In most adult patients, measure fasting lipid profile at least annually In adults with low-risk lipid values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.
  • This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 2 of 7 – Treatment Recommendations and Goals (Slide 1 of 6) Lifestyle modification focusing on the reduction of saturated fat, trans fat, and cholesterol intake; increase of n-3 fatty acids, viscous fiber, and plant stanols/sterols; weight loss (if indicated) and increased physical activity should be recommended to improve the lipid profile in patients with diabetes (A) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.
  • This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 3 of 7 – Treatment Recommendations and Goals (Slide 2 of 6) Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients With overt CVD (A) Without CVD who are over the age of 40 years and have one or more other CVD risk factors (A) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.
  • This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 4 of 7 – Treatment Recommendations and Goals (Slide 3 of 6) For patients at lower risk than described on Slide 2 of 6 (e.g., without overt CVD and under the age of 40 years), statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains >100 mg/dl or in those with multiple CVD risk factors (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.
  • This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 5 of 7 – Treatment Recommendations and Goals (Slide 4 of 6) In individuals without overt CVD, the primary goal is an LDL cholesterol <100 mg/dl (2.6 mmol/l) (A) In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option (B) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.
  • This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 6 of 7 – Treatment Recommendations and Goals (Slide 5 of 6) If drug-treated patients do not reach the targets outlined on the previous slide (Slide 4 0f 6) on maximal tolerated statin therapy, a reduction in LDL cholesterol of ~30-40% from baseline is an alternative therapeutic goal (A) Triglyceride levels <150 mg/dl (1.7 mmol/l) and HDL cholesterol >40 mg/dl (1.0 mm/l) in men and >50 mg/dl (1.3 mmol/l) in women, are desirable; however, LDL cholesterol-targeting statin therapy remains the preferred strategy (C) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.
  • This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes Slide 7 of 7 – Treatment Recommendations and Goals (Slide 6 of 6) If targets are not reached on maximally tolerated doses of statins, combination therapy using statins and other lipid-lowering agents may be considered to achieve lipid targets but has not been evaluated in outcome studies for either CVD outcomes or safety (E) Statin therapy is contraindicated in pregnancy (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.
  • The ADA and the American Heart Association have, in the past, jointly recommended low-dose aspirin therapy be used as a primary prevention strategy in those with diabetes at increased cardiovascular risk, including those who are >40 years of age or with additional risk factors, such as family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria 1 ; these recommendation were derived from several older trials that included small numbers of patients with diabetes Aspirin has been shown to be effective in reducing cardiovascular morbidity and mortality in high-risk patients with previous MI or stroke (secondary prevention); its net benefit in primary prevention among patients with no previous cardiovascular events is more controversial, both for patients with and without a history of diabetes 2 Recommendations for the use of antiplatelet agents 3 are summarized in three slides Slide 1 of 3 Consider aspirin therapy (75-162 mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%) This includes most men >50 years of age or women >60 years of age who have at least one additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) (C) References Buse JB, Ginsberg HN, Bakris GL, et al., for the American Heart Association, American Diabetes Association. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 2007;30:162-172. Baigent C, Blackwell L, Collins R, et al., for the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials . Lancet 2009;373:1849-1860. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S31.
  • Recommendations for the use of antiplatelet agents are summarized in three slides Slide 2 of 3 Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (10-year CVD risk <5%, such as in men <50 and women <60 years of age with no major additional CVD risk factors), since the potential adverse effects from bleeding likely offset the potential benefits (C) In patients in these age groups with multiple other risk factors (e.g., 10-year risk 5%-10%) clinical judgment is required (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S31.
  • Recommendations for the use of antiplatelet agents are summarized in three slides Slide 3 of 3 Use aspirin therapy (75-162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD (A) For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used (B) Combination therapy with ASA (75-162 mg/day) and clopidogrel (75 mg/day) is reasonable for up to a year after an acute coronary syndrome (B) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S31.
  • In patients with known CVD, ACE inhibitor (C), aspirin (A), and statin therapy (A) (if not contraindicated) should be used to reduce the risk of cardiovascular events In patients with a prior MI, β -blockers should be continued for at least 2 years after the event (B) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S32.
  • Longer-term use of β -blockers in the absence of hypertension is reasonable if well tolerated, but data are lacking (E) Avoid thiazolidinedione (TZD) treatment in patients with symptomatic heart failure (C) Metformin may be used in patients with stable CHF if renal function is normal; it should be avoided in unstable or hospitalized patients with CHF (C) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S32.
  • Diabetic nephropathy occurs in 20-40% of patients with diabetes and is the single leading cause of end-stage renal disease (ESRD) Persistent albuminuria in the range of 30-299 mg/24 h (microalbuminuria) has been shown to be the earliest stage of diabetic nephropathy in type 1 diabetes and a marker for development of nephropathy in type 2 diabetes Microalbuminuria is also a well-established marker of increased CVD risk 1,2 General recommendations for the care of patients with diabetes and nephropathy 3 are summarized on this slide To reduce the risk or slow the progression of nephropathy, optimize glucose control (A) To reduce the risk or slow the progression of nephropathy, optimize blood pressure control (A) References Garg JP, Bakris GL. Microalbuminuria: marker of vascular dysfunction, risk factor for cardiovascular disease. Vasc Med 2002;7:35-43. Klausen K, Borch-Johnsen K, Feldt-Rasmussen B, et al. Very low levels of microalbuminuria are associated with increased risk of coronary heart disease and death independently of renal function, hypertension, and diabetes. Circulation 2004;110:32-35. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S33.
  • Perform an annual test to assess urine albumin excretion in type 1 diabetic patients with diabetes duration of 5 years and in all type 2 diabetic patients, starting at diagnosis (E) Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion The serum creatinine should be used to estimate GFR and stage the level of chronic kidney disease (CKD), if present (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S33.
  • Recommendations for the treatment of nephropathy in patients with diabetes are summarized in five slides Slide 1 of 5 In the treatment of the nonpregnant patient with micro- or macroalbuminuria, either ACE inhibitors or angiotensin II receptor blockers (ARBs) should be used (A) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S33.
  • Recommendations for the treatment of nephropathy in patients with diabetes are summarized in five slides Slide 2 of 5 While there are no adequate head-to-head comparisons of ACE inhibitors and angiotensin II receptor blockers (ARBs), there is clinical trial support for each of the following statements: In patients with type 1 diabetes, hypertension, and any degree of albuminuria, ACE inhibitors have been shown to delay the progression of nephropathy (A) In patients with type 2 diabetes, hypertension, and microalbuminuria, both ACE inhibitors and ARBs have been shown to delay the progression to macroalbuminuria (A) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S33.
  • Recommendations for the treatment of nephropathy in patients with diabetes are summarized in five slides Slide 3 of 5 In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine 1.5 mg/dl), angiotensin II receptor blockers (ARBs) have been shown to delay the progression of nephropathy (A) If one class is not tolerated, the other should be substituted (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S33.
  • This table defines abnormalities of albumin excretion Because of variability in urinary albumin excretion, two of three specimens collected within a 3- to 6-month period should be abnormal before considering a patient to have crossed one of these diagnostic thresholds Exercise within 24 h, infection, fever, CHF, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline values Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S34. Table 13.
  • Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, with prevalence strongly related to duration of diabetes Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20–74 years Glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people with diabetes In addition to duration of diabetes, other factors that increase the risk of, or are associated with, retinopathy include chronic hyperglycemia 1 , the presence of nephropathy 2 , and hypertension 3 Recommendations for the care of patients with diabetes with respect to retinopathy 4 are summarized on this slide To reduce the risk or slow the progression of retinopathy, optimize glycemic control (A) To reduce the risk or slow the progression of retinopathy, optimize blood pressure control (A) References Klein R. Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care 1995;18:258-268. Estacio RO, McFarling E, Biggerstaff S, Jeffers BW, Johnson D, Schrier RW. Overt albuminuria predicts diabetic retinopathy in Hispanics with NIDDM. Am J Kidney Dis 1998;31:947-953. Leske MC, Wu SY, Hennis A, et al., for the Barbados Eye Study Group. Hyperglycemia, blood pressure, and the 9-year incidence of diabetic retinopathy: the Barbados Eye Studies. Ophthalmology 2005;112:799-805. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S35.
  • Results of eye examinations should be documented and transmitted to the referring health care professional Recommendations for the screening of nephropathy in patients with diabetes are summarized in four slides Slide 1 of 4 Adults and children aged 10 years or older with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes (B) Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes (B) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S35.
  • Recommendations for the screening of nephropathy in patients with diabetes are summarized in four slides Slide 2 of 4 Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist Less frequent exams (every 2-3 years) may be considered following one or more normal eye exams, if recommended by the eye care professional Examinations will be required more frequently if retinopathy is progressing (B) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S35.
  • Recommendations for the screening of nephropathy in patients with diabetes are summarized in four slides Slide 3 of 4 High-quality fundus photographs can detect most clinically significant diabetic retinopathy. Interpretation of the images should be performed by a trained eye care provider While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S35.
  • The diabetic neuropathies are heterogeneous with diverse clinical manifestations; they may be focal or diffuse Most common among the neuropathies are chronic sensorimotor diabetic peripheral neuropathy (DPN) and autonomic neuropathy; although DPN is a diagnosis of exclusion, complex investigations to exclude other conditions are rarely needed Early recognition and appropriate management of neuropathy in the patient with diabetes is important for a number of reasons: 1) nondiabetic neuropathies may be present in patients with diabetes and may be treatable; 2) a number of treatment options exist for symptomatic diabetic neuropathy; 3) up to 50% of DPN may be asymptomatic, and patients are at risk of insensate injury to their feet; 4) autonomic neuropathy may involve every system in the body; and 5) cardiovascular autonomic neuropathy causes substantial morbidity and mortality Specific treatment for the underlying nerve damage is not currently available, other than improved glycemic control, which may slow progression but not reverse neuronal loss; effective symptomatic treatments are available for some manifestations of DPN and autonomic neuropathy Recommendations for the screening and treatment of neuropathy in patients with diabetes are summarized in two slides Slide 1 of 2 All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter using simple clinical tests (B) Electrophysiological testing is rarely needed, except in situations where the clinical features are atypical (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S36.
  • This section, “VII. Diabetes Care in Specific Populations,” includes 17 slides (1 slide unless otherwise indicated): Recommendations: Pediatric Glycemic Control (Type 1 Diabetes) Recommendations: Pediatric Nephropathy (Type 1 Diabetes) Recommendations: Pediatric Hypertension (Type 1 Diabetes) (3 slides) Recommendations: Pediatric Dyslipidemia (Type 1 Diabetes) (4 slides) Recommendations: Retinopathy (Type 1 Diabetes) Recommendations: Celiac Disease (Type 1 Diabetes) (2 slides) Recommendations: Hypothyroidism (Type 1 Diabetes) Recommendations: Preconception Care (2 slides) Recommendations: Older Adults (2 slides)
  • While current standards for diabetes management reflect the need to maintain glucose control as near to normal as safely possible, special consideration should be given to the unique risks of hypoglycemia in young children Glycemic goals may need to be modified to take into account the fact that most children <6 or 7 years of age have a form of “hypoglycemic unawareness,” including immaturity of and a relative inability to recognize and response to hypoglycemic symptoms, placing them at greater risk for severe hypoglycemia and its sequelae In addition, and unlike the case in adults, young children under the age of 5 years may be at risk for permanent cognitive impairment after episodes of severe hypoglycemia In selecting glycemic goals, the benefits on long-term health outcomes of achieving a lower A1C should be balanced against the risks of hypoglycemia and the developmental burdens of intensive regimens in children and youth Recommendations Clinicians should consider age when setting glycemic goals in children and adolescents with type 1 diabetes (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S38.
  • Recommendations for the care of diabetes in older adults are summarized in two slides Slide 1 of 2 Older adults who are functional, are cognitively intact, and have significant life expectancy should receive diabetes care using goals developed for younger adults (E) Glycemic goals for older adults not meeting the above criteria may be related using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoid in all patients (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S42.
  • This section, “VIII. Diabetes Care in Specific Settings,” includes six slides: Recommendations: Diabetes Care in the Hospital (4 slides) Diabetes Care in the Hospital: NICE-SUGAR (2 slides)
  • Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on four slides Slide 1 of 4 As noted on this slide, patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record (E) and an order for blood glucose monitoring, with results available to all members of the health care team (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S43.
  • Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on four slides Slide 2 of 4 Goals for blood glucose levels as are follows: Critically Ill Patients Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of ≤180 mg/dl (10 mmol/) Once insulin therapy is started, a glucose range of 140-180 mg/dl (7.8-10 mmol/l) is recommended for the majority of critically ill patients (A) These patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia (E) Selected Patients More stringent goals, such as 110–140 mg/dl (6.1–7.8 mmol/l) may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia (C) Non-Critically Ill Patients There is no clear evidence for specific blood glucose goals If treated with insulin, premeal blood glucose target should generally be <140 mg/dl (7.8 mmol/l) with random blood glucose <180 mg/dl (10.0 mmol/l), provided these targets can be safely achieved More stringent targets may be appropriate in stable patients with previous tight glycemic control. Less stringent targets may be appropriate in those with severe comorbidites (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S43.
  • Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on four slides Slide 3 of 4 Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in non-critically ill patients (C) Using correction dose or “supplemental” insulin to correct premeal hyperglycemia in addition to scheduled prandial and basal insulin is recommended (E) Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications (B) If hyperglycemia is documented and persistent, treatment is necessary; such patients should be treated to the same glycemic goals as patients with known diabetes (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S43.
  • Recommendations for the care of patients with diabetes who are admitted to the hospital are summarized on four slides Slide 4 of 4 A plan for treating hypoglycemia should be established for each patient; episodes of hypoglycemia in the hospital should be tracked (E) All patients with diabetes admitted to the hospital should have an A1C obtained if the result of testing in the previous 2-3 months is not available (E) Patients with hyperglycemia in the hospital who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge (E) Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S43.
  • 2-CYC10529 Low hypothalamic dopamine release, particularly at the suprachiasmatic nuclei (SCN), is coupled with elevated norepinephrine and serotonin release at the ventromedial hypothalamus (VMH) and each are characteristic neurophysiological features of diabetes This hypothalamic alteration potentiates increases in circulating glucose, free fatty acids and triglycerides, which in turn contribute to insulin resistance in the liver and muscle, and ß-cell dysfunction via lipotoxicity and glucotoxicity. CYCLOSET administration produced a beneficial impact on glucose intolerance in an animal model of type 2 diabetes. Timed pulse CYCLOSET administration both increased SCN (and elsewhere in the CNS) dopaminergic tone and decreased VMH norepinephrine and serotonin release in insulin-resistant animal models. These neurophysiological activities are believed to represent a target-response system responsible for the subsequent multiple downstream biochemical effects of timed CYCLOSET administration in peripheral tissues such as adipose tissue and the liver.
  • Optional DISCUSSION POINTS: Excessive glucose fluctuations are common in diabetes and are not measured by the A1C. People without diabetes are able to maintain their glucose concentrations within a narrow band (approximately 80 to 140 mg/dL) throughout the day. For patients with diabetes, this level of glucose control is difficult. Even “optimally-treated” patients, whose A1C would predict near target glucose control, can experience wide glucose fluctuations throughout the day. In a recent study, Amylin Pharmaceuticals, Inc. assessed 24-h glucose profiles of 9 subjects with type 1 diabetes whose A1C averaged 6.7% (range of 5.8% to 7.1%), near or within the ADA A1C target range. Subjects used insulin lispro in their insulin pumps. Click: The individual glucose profiles of the 9 patients appear on the graph Despite excellent A1C levels, these patients experienced wide glucose fluctuations throughout the day as measured with continuous glucose monitoring system (CGMS) SLIDE BACKGROUND: CGMS = Medtronic MiniMed Continuous Glucose Monitoring System Mean duration of diabetes for these 9 subjects was 21.5 years (range 2.5 to 40.4 years).
  • The American Diabetes Association has developed a grading system for clinical recommendations (Table 1) This grading system was used to clarify and codify evidence that forms the basis for each of the recommendations in the “Standards of Medical Care in Diabetes—2011” The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E This slide summarizes the description for each of these levels of evidence Reference American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S12. Table 1.

Transcript

  • 1. Standards of Medical Care in Diabetes Dr. Ahmed Al Montasir Resident Physician Department of Medicine Rafatullah Community Hospital
  • 2. 1991 World Diabetes Day begins 5 The International Diabetes Federation and the World Health Organization created World Diabetes Day in response to diabetes epidemic
  • 3. Every year on November 14, World Diabetes Day brings diabetes to the attention of the world.
  • 4. November 14 is the birthday of Frederick Banting, one of the discoverers of insulin. (c) Banting House National Historic Site of Canada
  • 5. The theme is set by the International Diabetes Federation and the World Health Organization.
  • 6. In 2006, the United Nations passed resolution 61/225. It asks the world to observe November 14 as World Diabetes Day and to take action to address the diabetes threat.
  • 7. The campaign evolved from one day in the year to a multi-year campaign
  • 8. The campaign has grown in strength from humble beginnings. . .
  • 9. . . .to become a truly global event.
  • 10. 2009-2013 Diabetes Education and Prevention The campaign slogan is: Let's Take Control of Diabetes. Now.
  • 11. 2009-2013 Understand diabetes and take control
  • 12. 2009-2013 Let’s Take Control of Diabetes. Now. 15
  • 13. The global symbol for diabetes was developed during the Unite for Diabetes campaign. Why a circle? A positive symbol across cultures, the circle symbolizes life and health. Why blue? The colour blue reflects the sky that unites all nations. The blue border of the circle reflects the colour of the sky and the flag of the United Nations. The blue circle signifies the unity of the global diabetes community in response to the diabetes epidemic.
  • 14. Follow World Diabetes Day English, French and Spanish campaign website http://www.worlddiabetesday.org News & Events RSS feeds “days to go” countdown newsletter Facebook Group (English, French, Spanish) http://www.worlddiabetesday.org/facebook http://www.worlddiabetesday.org/facebook-es http://www.worlddiabetesday.org/facebook-fr Become a fan of World Diabetes Day Twitter http://twitter.com/wdd YouTube World Diabetes Day Channel International Diabetes Federation Channel Flickr World Diabetes Day group - http://www.flickr.com/groups/wdd
  • 15. Epidemiology
  • 16. An ancient problemAn ancient problem
  • 17. • Diabetes mellitus had been known since ancient times. Egyptian writings from as early as 1500BC described a wasting disease in which the sufferer produced sweet-tasting urine. Egyptian physician Hesy Ra makes the first mention about it from Egypt on the Ebers Papyrus.
  • 18. • Greeks & RomansGreeks & Romans • History of Diabetes reveals the contributions of Greeks and Romans. The famous Greek physician Aretaeus coined the Greek word Diabetes which means siphon. It acts like a siphon, melting down flesh and limbs in urine. • He lived in the first Century AD. His work on Diabetes is a relic of antiquity. Diabetes was researched by the Egyptians as well. From the Ancient Greek διαβαίνω (diabainō, “to pass through”), via the participle διαβήτης (diabētēs, “passing through”). This refers to the excessive amounts of urine produced by sufferers.
  • 19. • Indian FindingsIndian Findings • History of diabetes is 2500 years old. Diabetes mentioned in the old Indian medical texts. • Ayurvedic authorities Sushruta and Charaka had described it as Madhu Meha. It meant Honey Urine. • They found that its victims passed large amounts of sugar laden urine which attracted ants. • Hence they called it Madhu Meha before 2500 years, a term which is even now commonly used.
  • 20. • The medical identification of the disease: • Paracelsus for the first time identified the gravity of the disease. • The word diabetes mellitus was first used by the English physician Thomas Willis in the year 1675. In nineteenth century chemical tests were conducted in laboratory to diagnose the type of this disease. • The French researcher Claude Bernard examined the working of pancreas and rate of metabolism in the liver area. • The breakthrough occurred in 1869 by the German medical student, Paul Langerhans, who discovered the two systems of cells in pancreas. The one system is responsible for normal production of juice, while the function of the other system still remained a mystery.
  • 21. • From the 1850's onwards, autopsies of people who had died from diabetes suggested that the problem was caused when the pancreas did not function properly. • Many physicians speculated that specialised cells, called the islets of Langerhans, produced a chemical that allowed the body to regulate its blood sugar level. Diabetes was caused when this chemical was not produced.
  • 22. • 346 million people worldwide have diabetes. • In 2004, an estimated 3.4 million people died from consequences of high blood sugar. • More than 80% of diabetes deaths occur in low- and middle-income countries. • WHO projects that diabetes deaths will double between 2005 and 2030. • Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of type 2 diabetes.
  • 23. • RESULTS— The prevalence of diabetes for all age- groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. • The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. • The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people 65 years of age. • DIABETES CARE, VOLUME 27, NUMBER 5, MAY 2004
  • 24. • The Worst Affected • If the same trend continues in India, this country will have 184 million diabetics in 2030 whereas WHO estimated it as 79 million. The true facts about diabetes are staggering indeed!
  • 25. • RESULTS—The prevalence of type 2 diabetes was 4.3% and IFG was 12.4%. • The subjects with higher family income had significantly higher prevalence of type 2 diabetes (5.9 vs. 3.5%), and IFG (15.6 vs. 10.8%), than those with lower income. • Wealthy class, family history of diabetes, reduced physical exercise, and increased age, BMI, and WHR were the important predictors of diabetes. • Diabetes and Impaired Fasting Glycemia in a Rural Population of Bangladesh • M. Abu Sayeed, MD, PHD
  • 26. Increasing mortality from diabetesIncreasing mortality from diabetes mellitusmellitus J. Olefsky, JAMA 2010:285:628- 632
  • 27. Type 2 DM - global epidemic - why ? Prevalence depends on: • Age • Residence(urban/rural) • Obesity • Physical activity • Ethnicity
  • 28. 0 20 40 60 80 15 20 25 30 35 BMI(kg/m 2 ) PrevalenceofDM(%) Europe Malta India China Japan Prevalence of DM in 60 years old Men Decoda:Nakagami; Diabetologia 2010
  • 29. • Diabetes AssociationsDiabetes Associations • American Association of Clinical Endocrinologists 245 Riverside Ave. Suite 200 Jacksonville, FL 32202 (904) 353-7878 • American Dietetic Association 120 South Riverside Plaza, Suite 2000 Chicago, Illinois 60606-6995 (800) 877-1600 • American Association of Diabetes Educators 200 W. Madison Suite 800 Chicago, IL 60606 (800)338-3633 • American Diabetes Association 1701 North Beauregard Street Alexandria, VA 22311 (800)342-2383 • President's Council on Physical Fitness and Sports Department W - 200 Independence Ave., SW Room 738-H Washington, D.C. 20201-0004 (202) 690-9000 • Diabetes AssociationsDiabetes Associations British Diabetes AssociationBritish Diabetes Association Diabetes UK Central Office 10 Parkway, London NW1 7AA 020 7424 1000 Canadian Diabetes Association 1400-522 University Ave Toronto ON M5G 2R5 (800) 226-8464 Centers for Disease Control and Prevention's Diab 4770 Buford Highway NE, Mailstop K-10, Atlanta, GA 30341-3717 (770) 488-5000 International Diabetic Federation Avenue Emile De Mot 19 - B-1000 Brussels, Belgium +32-2-5385511 l Diabetes Exercise and Sports Association Formerly International Diabetic Athletes Association 8001 Montcastle Dr. Nashville, TN 37221 (800) 898-4322 • Juvenile Diabetes Research Foundation International 120 Wall Street New York, NY 10005-4001 (800) 533-2873
  • 30. Classification of diabetes • The classification of diabetes includes four clinicalThe classification of diabetes includes four clinical classes:classes: • Type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency) • Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance) • Other specific types of diabetes due to other causes, e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced (such as in the treatment of HIV/AIDS or after organ transplantation) • Gestational diabetes mellitus (GDM) (diabetes diagnosed during pregnancy that is not clearly overt diabetes)
  • 31. Criteria for Testing for Diabetes inCriteria for Testing for Diabetes in Asymptomatic Adult IndividualsAsymptomatic Adult Individuals •Physical inactivity •First-degree relative with diabetes •High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) •Women who delivered a baby weighing >9 lb or were diagnosed with GDM •Hypertension (≥140/90 mmHg or on therapy for hypertension) • HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l) • Women with polycystic ovarian syndrome (PCOS) • A1C ≥5.7%, IGT, or IFG on previous testing • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) • History of CVD *At-risk BMI may be lower in some ethnic groups. 1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2 *) and have additional risk factors: ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.
  • 32. 2. In the absence of criteria (risk factors on previous slide), testing for diabetes should begin at age 45 years 3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4. Criteria for Testing for Diabetes inCriteria for Testing for Diabetes in Asymptomatic Adult IndividualsAsymptomatic Adult Individuals
  • 33. Criteria for the Diagnosis of DiabetesCriteria for the Diagnosis of Diabetes A1C ≥6.5% OR Fasting plasma glucose (FPG) ≥126 mg/dl (7.0 mmol/l) OR Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT OR A random plasma glucose ≥200 mg/dl (11.1 mmol/l) ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
  • 34. Criteria for the Diagnosis of DiabetesCriteria for the Diagnosis of Diabetes A1C ≥6.5% The test should be performed in a laboratory using an NGSP-certified method standardized to the DCCT assay* *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2. “National Glycohemoglobin Standardization Program”. American Association for Clinical Chemistry (AACC)
  • 35. Both Fasting and Postprandial Hyperglycemia Contribute to A1C Plasma Glucose (mg/dL) Adapted from Riddle MC. Diabetes Care. 1990;13:676-686 300 200 100 0 Time of Day 6 AM 12 PM 6 PM 12 AM 6 AM Normal glycemic exposure A1C ~5% Uncontrolled Diabetes With A1C ~8% Postprandial Hyperglycemia Fasting Hyperglycemia
  • 36. Correlation of A1C with EstimatedCorrelation of A1C with Estimated Average Glucose (eAG)Average Glucose (eAG) Mean plasma glucose A1C (%) mg/dl mmol/l 6 126 7.0 7 154 8.6 8 183 10.2 9 212 11.8 10 240 13.4 11 269 14.9 12 298 16.5 ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9. These estimates are based on ADAG data of ~2,700 glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dl or mmol/l, is available at http://professional.diabetes.org/GlucoseCalculator.aspx.
  • 37. Criteria for the Diagnosis of DiabetesCriteria for the Diagnosis of Diabetes Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water* *n the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
  • 38. Criteria for the Diagnosis of DiabetesCriteria for the Diagnosis of Diabetes In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dl (11.1 mmol/l) ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 2.
  • 39. • The Expert Committee . . . recognized an intermediate group of individuals whose glucose levels do not meet criteria for diabetes, yet are “higher than those considered normal."
  • 40. Prediabetes: IFG, IGT, Increased A1CPrediabetes: IFG, IGT, Increased A1C Categories of increased risk for diabetes (Prediabetes)* FPG 100-125 mg/dl (5.6-6.9 mmol/l): IFG or 2-h plasma glucose in the 75-g OGTT 140-199 mg/dl (7.8-11.0 mmol/l): IGT or A1C 5.7-6.4% *For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range. ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. Table 3.
  • 41. • Progression to diabetes among those with prediabetes is not inevitable. Studies suggest that weight loss and increased physical activity among people with prediabetes prevent or delay diabetes and may return blood glucose levels to normal. • People with prediabetes are already at increased risk for other adverse health outcomes such as heart disease and stroke.
  • 42. ADA and AACE/ACE Guidelines: Treatment Goals for A1C, FPG, and PPG Parameter Normal1,2 Level ADA3 Goal AACE/ACE2 Goal FPG, mg/dL <100 90–130 <110 PPG, mg/dL <140 <180 <140 A1C, % 4–6 <7 ≤6.5 FPG=fasting plasma glucose; PPG=postprandial glucose; ADA=American Diabetes Association; AACE=American Association of Clinical Endocrinologists; ACE=American College of Endocrinology. 1. Adapted from Buse J et al. In: Williams Textbook of Endocrinology. 10th ed. 2003. Permission requested. 2. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocr Pract. 2007;13:(suppl 1)3–68. 3. ADA. Diabetes Care. 2007;30:S4–S41. a The goal for an individual patient is to achieve an A1C as close to normal (<6%) as possible without significant hypoglycemia.
  • 43. TESTING FOR DIABETES INTESTING FOR DIABETES IN ASYMPTOMATIC PATIENTSASYMPTOMATIC PATIENTS
  • 44. Recommendations: Testing for Diabetes inRecommendations: Testing for Diabetes in Asymptomatic PatientsAsymptomatic Patients • Consider testing overweight/obese adults with one or more additional risk factors – In those without risk factors, begin testing at age 45 years (B) • If tests are normal – Repeat testing at least at 3-year intervals (E) • Use A1C, FPG, or 2-h 75-g OGTT (B) • In those with increased risk for future diabetes – Identify and, if appropriate, treat other CVD risk factors (B) ADA. II. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S13-S14.
  • 45. DETECTION AND DIAGNOSIS OFDETECTION AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUSGESTATIONAL DIABETES MELLITUS
  • 46. Gestational Diabetes Mellitus • DefinitionDefinition • Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. • Approximately 7% of all pregnancies are complicated by GDM, resulting in more than 200,000 cases annually. The prevalence may range from 1 to 14% of all pregnancies, depending on the population studied and the diagnostic tests employed.
  • 47. • The American Diabetes Association released new guidelines for diagnosing gestational diabetes. • Women without diabetes will still be tested for gestational diabetes between weeks 24 and 28. • But the criteria for gestational diabetes have been broadened, and more diagnoses of the condition are expected. Blood glucose cutoff points have been lowered, and only one test showing high levels is needed, not two as in the past. • The new guidelines aim to catch more cases of gestational diabetes, which can lead to a large baby, posing risks for both newborn and mother. Gestational diabetes can also lead to type 2 diabetes. • Source: Diabetes Care, January 2011
  • 48. Recommendations:Recommendations: Detection and Diagnosis of GDMDetection and Diagnosis of GDM • Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria (B) • In pregnant women not previously known to have diabetes, screen for GDM at 24-28 weeks gestation, using a 75-g OGTT and the diagnostic cut points.(B) ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15.
  • 49. • Low-risk status requires no glucose testing, but this category is limited to those women meeting all of the following characteristics: • Age <25 years • Weight normal before pregnancy • Member of an ethnic group with a low prevalence of GDM • No known diabetes in first-degree relatives • No history of abnormal glucose tolerance • No history of poor obstetric outcome
  • 50. • One-step approach:
  • 51. • Two-step approach:
  • 52. Screening for and Diagnosis of GDMScreening for and Diagnosis of GDM • Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24-28 weeks of gestation in women not previously diagnosed with overt diabetes • Perform OGTT in the morning after an overnight fast of at least 8 h • GDM diagnosis: when any of the following plasma glucose values are exceeded – Fasting ≥92 mg/dl (5.1 mmol/l) – 1 h ≥180 mg/dl (10.0 mmol/l) – 2 h ≥153 mg/dl (8.5 mmol/l) ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15. Table 6.
  • 53. • With either approach, the diagnosis of GDM is based on an OGTT. Diagnostic criteria for the 100-g OGTT are derived from the original work of O’Sullivan and Mahan, modified by Carpenter and Coustan. • Alternatively, the diagnosis can be made using a 75-g glucose load and the glucose threshold values listed for fasting, 1 h, and 2 h ; however, this test is not as well validated for detection of at-risk infants or mothers as the 100-g OGTT.
  • 54. Recommendations:Recommendations: Detection and Diagnosis of GDMDetection and Diagnosis of GDM • Screen women with GDM for persistent diabetes 6-12 weeks postpartum (E) • Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every three years (E) ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15.
  • 55. Management of Diabetes Mellitus
  • 56. Nutrition Recommendations • Carbohydrate – 60-70% calories from carbohydrates and monounsaturated fats • Protein – 10-20% total calories
  • 57. Nutrition Recommendations • Fat – <10% calories from saturated fat – 10% calories from PUFA – <300 mg cholesterol • Fiber – 20-35 grams/day • Alcohol – Type I – limit to 2 drinks/day, with meals – Type II – substitute for fat calories
  • 58. Physical activity Recommendations • 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). (A) • In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week. (A)
  • 59. • Exercise is an important part of the diabetes management plan. Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being. • Furthermore, regular exercise may prevent type 2 diabetes in high-risk individuals. • Structured exercise interventions of at least 8 weeks' duration have been shown to lower A1C by an average of 0.66% in people with type 2 diabetes, even with no significant change in BMI.
  • 60. Old and new drugs… • Combination therapy • Favorites: metformin, sulfonylureas, thiazolidinediones • New classes… • -DPP4 inhibitors: Sitagliptin and Vildagliptin (Galvus) • -GLP-1 agonists: Exenatide and Liraglutide • -Glitazars: Muraglitazar
  • 61. Which oral drug to start with? • Although there are numerous options in oral medications for type 2 diabetes, an older drug -- metformin -- may be the best first-line option, according to a new analysis of research on diabetes medications. • The analysis included six classes of oral diabetes medications, and found that all of them lower blood sugar levels by a similar amount. The authors suggest that metformin is probably the best first-line choice because it has fewer side effects than other drugs and, because it's an older medication and available in a generic form, it also costs less.
  • 62. • Metformin………Welcome back? • Metformin is usually the first oral medication chosen to treat elevated blood sugars in Type 2 diabetics. Its main action is to decrease glucose production in the liver. It may cause gastrointestinal upset, such as nausea and diarrhea, but these effects can be minimized by starting with a low dose and increasing gradually. Often, metformin leads to weight loss which is usually a beneficial side effect. • References • American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Manage 2011 • Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and • "American Family Physician"; Management of Blood Glucose in Type 2 Diabetes Mellitus; Cynthia Ripsin , M.D., Helen Kang, M.D. and Randall Urban, M.D.; January 2009 • Centers for Disease Control and Prevention: National Diabetes Fact Sheet 2007
  • 63. Why the Interest in Incretins ?
  • 64. GLP-1 secreted upon the ingestion of food
  • 65. 78 The Incretin Defect in Type 2 Diabetes Insulin Resistance Incretin “Defect” Relative Insulin Deficiency Hyperglycemia Type 2 Diabetes Incretin effect accounts for up to 70% of the insulin response to oral glucose intake1 1. Holst JJ, Gromada J. Role of incretin hormones in the regulation of insulin secretion in diabetic and nondiabetic humans. Am J Physiol Endocrinol Metab. 2004;287(2):E199-E206.
  • 66. DPP4 inhibitors • Sitagliptin and Vildagliptin • Incretins are hormones released by the GI tract in response to nutrient ingestion that stimulate beta cells to secrete insulin—these effects are diminished in T2DM • DPP4 is a protease that breaks down the endogenous incretin glucagon-like peptide (GLP)-1 • This class prevents the degradation of GLP-1 by competitively and reversibly inhibiting the protease DPP4, and leads to longer presence and actions of GLP-1 • Side Effects: No weight gain! rare hypoglycemia. • Both to be used as a combination, both oral. Sitagliptin approved in 2006, Vildagliptin awaiting approval.
  • 67. GLP-1 agonists • Exenatide and Liraglutide • Exogenous GLP-1 products that are resistant to DPP4 degradation, same actions as the endogenous incretin. • Also known as incretin mimetics. • Exenatide a 2xd inj. approved 2005 for use with metformin and/or a sulfonylurea. • Side effects: hypoglycemia (esp with sulfonylureas), weight loss. • Contra: GI dz, renal Cr <30mL/min. Current trials for once weekly injection. • Liraglutide is awaiting approval. Has longer half life than exenatide thus only requiring once daily injections. Same side effects, no contraindications identified yet.
  • 68. Glitazars • Muraglitazar • Approved by FDA, then withdrawn in Spring 2006. Other trials in this category are in progress. • Glitazars activate two subtypes of receptors called peroxisome proliferator–activated receptors (PPARs). • PPARgamma activation reduces insulin resistance and improves glycemic control, while activation of PPARalpha reduces triglycerides and increases HDL concentration by increasing fatty acid oxidation. • Oral dose. Side effects: w. gain, edema, low incidence of coronary and cerebral vascular events, possible congestive heart failure-FDA decided it was of enough significance. • Goodbye Glitazars?Goodbye Glitazars?
  • 69. Why Insulin in Type 2 Diabetes?
  • 70. • Studies show that insulin may slow the progression of diabetes mellitus Type 2 and delay its devastating consequences, because taking insulin eliminates the stress that the beta cells of the pancreas go through to make and release the hormone.
  • 71. Insulin Analogs • Analogs are more predictable and more reliable and consistent in action. Less chance of hypoglycemia. • Rapid Acting: -Humalog (Lispro) -Novolog (Aspart) -Apidra (Glulisine) • Long Acting (Basal): - Lantus (Glargine) - Levemir (Detemir) Mixes: Novolog 70/30 and Humalog 75/25 & 50/50
  • 72. Insulin analogs Regular insulin Peak Time = 80 – 120 min Peak Time = 40 – 50 min Capillary membrane Subcutaneoustissue Dissociation and Absorption of Analogs
  • 73. Glycemic Recommendations for Non-PregnantGlycemic Recommendations for Non-Pregnant Adults with DiabetesAdults with Diabetes A1C <7.0%* Preprandial capillary plasma glucose 70–130 mg/dl* (3.9–7.2 mol/l) Peak postprandial capillary plasma glucose† <180 mg/dl* (<10.0 mmol/l) *Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes. ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
  • 74. • Goals should be individualized based on –Duration of diabetes –Age/life expectancy –Comorbid conditions –Known CVD or advanced microvascular complications –Hypoglycemia unawareness –Individual patient considerations –Hypoglycemia unawareness –Individual patient considerations Glycemic Recommendations for Non-Glycemic Recommendations for Non- Pregnant Adults with DiabetesPregnant Adults with Diabetes ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
  • 75. • Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals • More or less stringent glycemic goals may be appropriate for individual patients Glycemic Recommendations for Non-Glycemic Recommendations for Non- Pregnant Adults with DiabetesPregnant Adults with Diabetes ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
  • 76. • Metformin for gestational diabetes in routine clinical practice • J. E. L. Goh1, L. Sadler2, J. Rowan2 • Article first published online: 15 AUG 2011 • © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK • Diabetic Medicine • Volume 28, Issue 9, pages 1082–1087, September 2011 • Keywords: • gestational diabetes;metformin;pregnancy • Diabet. Med. 28, 1082–1087 (2011) • Abstract • Aims  To compare maternal and neonatal outcomes in women with gestational diabetes treated with diet, metformin and/or insulin in routine clinical practice in a single centre. • Methods  We analysed prospectively collected data from the National Women’s Health database for all women with gestational diabetes who delivered between January 2007 and December 2009. Since June 2007, women requiring medication have been given a choice of either metformin or insulin treatment, except women with a fetal abdominal circumference less than the 10th percentile, who were not offered metformin. • Results  There were 1269 women with gestational diabetes; treatment was diet in 371, insulin in 399 and metformin in 465 (249 metformin alone, 216 metformin and insulin). Women treated with metformin and/or insulin had significantly higher BMIs compared with those in the diet group (P < 0.001) and had a higher fasting glucose at diagnosis (p < 0.001). Women treated with insulin had higher rates of Caesarean delivery (45.6% insulin, 37% metformin, 34% diet, P = 0.02) than women treated with metformin or diet. They also had higher rates of preterm births (19.2% insulin, 12.5% metformin, 12.1% diet, P = 0.005), customized large-for-gestational-age infants (18.5% insulin, 12.5% metformin, 12.4% diet, P = 0.02), neonatal admissions (18.7% insulin, 12.7% metformin, 14.0% diet, P = 0.04) and neonatal intravenous dextrose use (11.1% insulin, 5.1% metformin, 7.4% diet, P = 0.004). Neonatal outcomes were similar between diet- and metformin-treated women. • Conclusions  In routine practice, use of metformin in gestational diabetes was associated with fewer adverse outcomes compared with insulin.
  • 77. Recommendations: Glucose MonitoringRecommendations: Glucose Monitoring • Self-monitoring of blood glucose should be carried out 3+ times daily for patients using multiple insulin injections or insulin pump therapy (A) • For patients using less frequent insulin injections, noninsulin therapy, or medical nutrition therapy alone – SMBG may be useful as a guide to success of therapy (E) – However, several recent trials have called into question clinical utility, cost-effectiveness, of routine SMBG in non–insulin-treated patients ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S17.
  • 78. Recommendations: A1CRecommendations: A1C • Perform A1C test at least twice yearly in patients meeting treatment goals (and have stable glycemic control) (E) • Perform A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals (E) • Use of point-of-care testing for A1C allows for timely decisions on therapy changes, when needed (E) ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18.
  • 79. Glycemic Recommendations for Non-Glycemic Recommendations for Non- Pregnant Adults with DiabetesPregnant Adults with Diabetes A1C <7.0%* Preprandial capillary plasma glucose 70–130 mg/dl* (3.9–7.2 mol/l) Peak postprandial capillary plasma glucose† <180 mg/dl* (<10.0 mmol/l) *Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes. ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
  • 80. Recommendations:Recommendations: Medical Nutrition Therapy (MNT)Medical Nutrition Therapy (MNT) ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S22. • Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals (A) – For people with diabetes, it is unlikely one optimal mix of macronutrients for meal plans exists – The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances
  • 81. Look AHEAD (Action for Health in Diabetes):Look AHEAD (Action for Health in Diabetes): One-Year ResultsOne-Year Results 1. Look AHEAD Research Group. Diabetes Care. 2007;30:1374-1383; 2. Look AHEAD Research Group. Arch Intern Med. 2010;170:1566–1575. • Intensive lifestyle intervention resulted in1 – Average 8.6% weight loss – Significant reduction of A1C – Reduction in several CVD risk factors • Benefits sustained at 4 years2 • Final results of Look AHEAD to provide insight into effects of long-term weight loss on important clinical outcomes
  • 82. Recommendations: Physical ActivityRecommendations: Physical Activity • Advise people with diabetes to perform at least 150 min/week of moderate-intensity aerobic physical activity (50-70% of maximum heart rate) (A) • In absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week (A) ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S24.
  • 83. Recommendations:Recommendations: Psychosocial Assessment and CarePsychosocial Assessment and Care • Ongoing part of medical management of diabetes (E) • Psychosocial screening/follow-up: attitudes about diabetes, medical management/outcomes expectations, affect/mood, quality of life, resources, psychiatric history (E) • When self-management is poor, screen for psychosocial problems: depression, diabetes- related anxiety, eating disorders, cognitive impairment (C) ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S25.
  • 84. Recommendations: HypoglycemiaRecommendations: Hypoglycemia • Glucose (15-20 g) is preferred treatment for conscious individual with hypoglycemia (E) • Glucagon should be prescribed for all individuals at significant risk of severe hypoglycemia, and caregivers/family members instructed in administration (E) • Those with hypoglycemia unawareness or one or more episodes of severe hypoglycemia should raise glycemic targets to reduce risk of future episodes (B) ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S25.
  • 85. Recommendations: ImmunizationRecommendations: Immunization • Provide an influenza vaccine annually to all diabetic patients ≥6 months of age (C) • Administer pneumococcal polysaccharide vaccine to all diabetic patients ≥2 years • One-time revaccination recommended for those >64 years previously immunized at <65 years if administered >5 years ago • Other indications for repeat vaccination: nephrotic syndrome, chronic renal disease, immunocompromised states (C) ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S27.
  • 86. PREVENTION/DELAY OF TYPE 2 DIABETESPREVENTION/DELAY OF TYPE 2 DIABETES
  • 87. Recommendations:Recommendations: Prevention/Delay of Type 2 DiabetesPrevention/Delay of Type 2 Diabetes • Refer patients with IGT (A), IFG (E), or A1C 5.7- 6.4% (E) to support program – Weight loss 7% of body weight – At least 150 min/week moderate activity • Follow-up counseling important (B); third-party payors should cover (E) • Consider metformin if multiple risk factors, especially if hyperglycemia (e.g., A1C>6%) progresses despite lifestyle interventions (B) • In those with prediabetes, monitor for development of diabetes annually (E) ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2011;34(suppl 1):S16.
  • 88. PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS
  • 89. Recommendations: Hypertension/BloodRecommendations: Hypertension/Blood Pressure ControlPressure Control Screening and diagnosis • Measure blood pressure at every routine diabetes visit • If patients have systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg – Confirm blood pressure on a separate day – Repeat systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 confirms a diagnosis of hypertension (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
  • 90. Recommendations: Hypertension/BloodRecommendations: Hypertension/Blood Pressure ControlPressure Control Goals • A goal systolic blood pressure <130 mmHg is appropriate for most patients with diabetes (C) • Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate (B) • Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
  • 91. Recommendations: Hypertension/BloodRecommendations: Hypertension/Blood Pressure ControlPressure Control Treatment Lifestyle therapy for hypertension – Weight loss if overweight – DASH-style dietary pattern including reducing sodium, increasing potassium intake – Moderation of alcohol intake – Increased physical activity (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
  • 92. Recommendations: Hypertension/BloodRecommendations: Hypertension/Blood Pressure ControlPressure Control Treatment Pharmacologic therapy for patients with diabetes and hypertension – Pair with a regimen that includes either an ACE inhibitor or angiotensin II receptor blocker – If one class is not tolerated, the other should be substituted • If needed to achieve blood pressure targets – Thiazide diuretic should be added to those with estimated GFR ≥30 ml x min/1.73 m2 – Loop diuretic for those with an estimated GFR <30 ml x min/1.73 m2 (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
  • 93. Recommendations: Hypertension/BloodRecommendations: Hypertension/Blood Pressure ControlPressure Control Treatment Multiple drug therapy (two or more agents at maximal doses) – Generally required to achieve blood pressure targets (B) • If ACE inhibitors, ARBs, or diuretics are used – Kidney function, serum potassium levels should be monitored (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
  • 94. Recommendations:Recommendations: Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management Screening • In most adult patients – Measure fasting lipid profile at least annually • In adults with low-risk lipid values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl) – Lipid assessments may be repeated every 2 years (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
  • 95. Recommendations:Recommendations: Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management Treatment recommendations and goals • To improve lipid profile in patients with diabetes, recommend lifestyle modification (A), focusing on – Reduction of saturated fat, trans fat, cholesterol intake – Increased n-3 fatty acids, viscous fiber, plant stanols/sterols – Weight loss (if indicated) – Increased physical activity ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
  • 96. Recommendations:Recommendations: Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management Treatment recommendations and goals • Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients: – with overt CVD (A) – without CVD who are >40 years of age and have one or more other CVD risk factors (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
  • 97. Recommendations:Recommendations: Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management Treatment recommendations and goals • For patients at lower risk (e.g., without overt CVD and <40 years of age) (E) – Statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains >100 mg/dl – In those with multiple CVD risk factors ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
  • 98. Recommendations:Recommendations: Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management Treatment recommendations and goals • In individuals without overt CVD – Primary goal is an LDL cholesterol <100 mg/dl (2.6 mmol/l) (A) • In individuals with overt CVD – Lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of a statin, is an option (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
  • 99. Recommendations:Recommendations: Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management Treatment recommendations and goals • If targets not reached on maximal tolerated statin therapy – Alternative therapeutic goal: reduce LDL cholesterol ~30–40% from baseline (A) • Triglyceride levels <150 mg/dl (1.7 mmol/l), HDL cholesterol >40 mg/dl (1.0 mmol/l) in men and >50 mg/dl (1.3 mmol/l) in women, are desirable – However, LDL cholesterol–targeted statin therapy remains the preferred strategy (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
  • 100. Recommendations:Recommendations: Dyslipidemia/Lipid ManagementDyslipidemia/Lipid Management Treatment recommendations and goals • If targets are not reached on maximally tolerated doses of statins – Combination therapy using statins and other lipid lowering agents may be considered to achieve lipid targets – Has not been evaluated in outcome studies for either CVD outcomes or safety (E) • Statin therapy is contraindicated in pregnancy ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
  • 101. Recommendations:Recommendations: Antiplatelet AgentsAntiplatelet Agents • Consider aspirin therapy (75–162 mg/day) (C) – As a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%) – Includes most men >50 years of age or women >60 years of age who have at least one additional major risk factor • Family history of CVD • Hypertension • Smoking • Dyslipidemia • Albuminuria ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
  • 102. Recommendations:Recommendations: Antiplatelet AgentsAntiplatelet Agents • Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk, since potential adverse effects from bleeding likely offset potential benefits (C) • 10-year CVD risk <5%: men <50 and women <60 years of age with no major additional CVD risk factors • In patients in these age groups with multiple other risk factors (e.g., 10-year risk 5%-10%) clinical judgment is required (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
  • 103. Recommendations:Recommendations: Antiplatelet AgentsAntiplatelet Agents • Use aspirin therapy (75–162 mg/day) – Secondary prevention strategy in those with diabetes with a history of CVD (A) • For patients with CVD, documented aspirin allergy – Clopidogrel (75 mg/day) should be used (B) • Combination therapy with ASA (75–162 mg/day) and clopidogrel (75 mg/day) – Reasonable for up to a year after an acute coronary syndrome (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31.
  • 104. Recommendations:Recommendations: Coronary Heart Disease TreatmentCoronary Heart Disease Treatment • To reduce risk of cardiovascular events in patients with known CVD, use – ACE inhibitor(C) – Aspirin (A) – Statin therapy (A) • In patients with a prior MI – Beta-blockers should be continued for at least 2 years after the event (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S32. *If not contraindicated.
  • 105. Recommendations:Recommendations: Coronary Heart Disease TreatmentCoronary Heart Disease Treatment • Longer-term use of beta-blockers in the absence of hypertension – Reasonable if well tolerated, but data are lacking (E) • Avoid TZD treatment – In patients with symptomatic heart failure (C) • Metformin use in patients with stable CHF – Indicated if renal function is normal – Should be avoided in unstable or hospitalized patients with CHF (C) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S32.
  • 106. Recommendations: NephropathyRecommendations: Nephropathy • To reduce risk or slow the progression of nephropathy – Optimize glucose control (A) – Optimize blood pressure control (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
  • 107. Recommendations:Recommendations: Nephropathy ScreeningNephropathy Screening • Assess urine albumin excretion annually (E) – In type 1 diabetic patients with diabetes duration of 5 years – In all type 2 diabetic patients at diagnosis • Measure serum creatinine at least annually (E) – In all adults with diabetes regardless of degree of urine albumin excretion – Serum creatinine should be used to estimate GFR and stage level of chronic kidney disease, if present ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
  • 108. Recommendations:Recommendations: Nephropathy TreatmentNephropathy Treatment • Nonpregnant patient with micro- or macroalbuminuria – Either ACE inhibitors or ARBs should be used (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
  • 109. Recommendations:Recommendations: Nephropathy TreatmentNephropathy Treatment • In patients with type 1 diabetes, hypertension, and any degree of albuminuria – ACE inhibitors have been shown to delay progression of nephropathy (A) • In patients with type 2 diabetes, hypertension, and microalbuminuria – Both ACE inhibitors and ARBs have been shown to delay progression to macroalbuminuria (A) ADA. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
  • 110. Recommendations:Recommendations: Nephropathy TreatmentNephropathy Treatment • In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dl) – ARBs have been shown to delay progression of nephropathy (A) • If one class is not tolerated, the other should be substituted (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
  • 111. Definitions of Abnormalities in Albumin ExcretionDefinitions of Abnormalities in Albumin Excretion Category Spot collection (µg/mg creatinine) Normal <30 Microalbuminuria 30-299 Macroalbuminuria (clinical) ≥300 ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S34. Table 13.
  • 112. Recommendations: RetinopathyRecommendations: Retinopathy • To reduce risk or slow progression of retinopathy – Optimize glycemic control (A) – Optimize blood pressure control (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
  • 113. • FACTS • Diabetic retinopathy is the leading cause of vision loss in adults of working age (20 to 65 years) in industrialised countries. It is estimated that more than 2.5 million people worldwide are affected by it. • 74 percent of people who have diabetes for 10 years or more will develop some form of diabetic retinopathy. • Approximately 14 per cent of people with diabetes have diabetic macular oedema and prevalence increases to 29 per cent for people with diabetes who use insulin for more than 20 years. • Left untreated, 25 per cent of people with diabetic macular oedema will develop moderate vision loss within three years. • Estimates of the rate of annual eye exams vary greatly by country and study, but the rate of screening is generally fairly low (from 40 to 65 percent).
  • 114. Recommendations:Recommendations: Retinopathy ScreeningRetinopathy Screening • Initial dilated and comprehensive eye examination by an ophthalmologist or optometrist – Adults and children aged 10 years or older with type 1 diabetes • Within 5 years after diabetes onset (B) – Patients with type 2 diabetes • Shortly after the diagnosis of diabetes (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
  • 115. Recommendations:Recommendations: Retinopathy ScreeningRetinopathy Screening • Subsequent examinations for type 1 and type 2 diabetic patients – Should be repeated annually by an ophthalmologist or optometrist • Less frequent exams (every 2–3 years) – May be considered following one or more normal eye exams • More frequent examinations required if retinopathy is progressing (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
  • 116. Recommendations:Recommendations: Retinopathy ScreeningRetinopathy Screening • High-quality fundus photographs – Can detect most clinically significant diabetic retinopathy • Interpretation of the images – Performed by a trained eye care provider • While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam – Perform comprehensive eye exam at least initially and at intervals thereafter as recommended by an eye care professional (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
  • 117. Recommendations:Recommendations: Neuropathy Screening, TreatmentNeuropathy Screening, Treatment • All patients should be screened for distal symmetric polyneuropathy (DPN) – At diagnosis – At least annually thereafter using simple clinical tests (B) • Electrophysiological testing rarely needed – Except in situations where clinical features are atypical (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S36.
  • 118. DIABETES CARE IN SPECIFIC POPULATIONS
  • 119. Recommendations:Recommendations: PediatricPediatric Glycemic ControlGlycemic Control • Consider age when setting glycemic goals in children and adolescents with diabetes (E) ADA. VII. Diabetes Care in Specific Populations. Diabetes Care. 2011;34(suppl 1):S38.
  • 120. Recommendations: Older AdultsRecommendations: Older Adults • Functional, cognitively intact older adults with significant life expectancies should receive diabetes care using goals developed for younger adults (E) • Glycemic goals for those not meeting the above criteria may be relaxed using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients (E) ADA. VII. Diabetes Care in Specific Populations. Diabetes Care. 2011;34(suppl 1):S42.
  • 121. DIABETES CARE IN SPECIFIC SETTINGS
  • 122. Recommendations:Recommendations: Diabetes Care in the HospitalDiabetes Care in the Hospital • All patients with diabetes admitted to the hospital should have – Their diabetes clearly identified in the medical record (E) – An order for blood glucose monitoring, with results available to the health care team (E) ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
  • 123. Recommendations:Recommendations: Diabetes Care in the HospitalDiabetes Care in the Hospital • Goals for blood glucose levels – Critically ill patients: 140-180 mg/dl (10 mmol/l) (A) – More stringent goals, such as 110-140 mg/dl (6.1-7.8 mmol/l) may be appropriate for selected patients, if achievable without significant hypoglycemia (C) – Non-critically ill patients: base goals on glycemic control, severe comorbidities (E) ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
  • 124. Recommendations:Recommendations: Diabetes Care in the HospitalDiabetes Care in the Hospital • Initiate glucose monitoring in any patients not known to be diabetic who receives therapy associated with high risk for hyperglycemia (B) ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
  • 125. Recommendations:Recommendations: Diabetes Care in the HospitalDiabetes Care in the Hospital • A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system – Establish a plan for treating hypoglycemia for each patient; document episodes of hypoglycemia in medical record and track (E) • Obtain A1C for all patients if results within previous 2-3 months unavailable (E) • Patients with hyperglycemia who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge (E)ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
  • 126. Goals of Inpatient DM Management • “Avoid hypoglycemia and marked hyperglycemia” • Target Blood sugar: 7.0 - 11.0 mmol/l • Avoid Hypoglycemia • Precipitating arrhythmia or other cardiac events • Inducing seizure, focal or cognitive defects periop • Avoid Marked Hyperglycemia (BS > 11.1 mM) • Treat (and avoid) DKA, HONC
  • 127. DM Inpatient Management 1. Eating 2. NPO: temporary (for a test or surgery) 3. NPO: prolonged
  • 128. DM Inpatient Management 1. Eating Diet (T2DM) OHA (T2DM) Insulin (T2DM and T1DM) 2. NPO: temporary (for a test or surgery) 3. NPO: prolonged
  • 129. Guideline for Insulin Adjustments 1. Adjust the insulin that accounts for the high or low reading. 2. Always compare an abnormal BS reading with the one previous. 3. If insulin dose is: • Less than 8U, adjust by 1U • 8-20U, adjust by 2U • > 20 U, adjust by 10% (increase), 20% (decrease)
  • 130. DM Inpatient Management 1. Eating 2. NPO: temporary (for a test) 3. NPO: prolonged
  • 131. NPO for a test: T2DM on Diet or OHA • Schedule test for the AM • Hold OHAs on AM of test • CBG @ 7AM: < 3.0 Consider postpone test 3.1-4.0 IV 5%DA @ 75-100 ml/h 4.1-11.0 Proceed with test, no Rx necessary > 11.1 Insulin R or analogue SC supplemental or IV insulin & IV 5%DA @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone test
  • 132. Insulin IV drip • Add 50 U of regular insulin to 500 ml 5%DA (1U/10cc). • Start insulin @ 0.9 U/h (9ml/h) or start at a rate dependent on patient’s insulin dose: IV insulin gtt rate = ( ½ TDD ) / 24
  • 133. DM Inpatient Management 1. Eating 2. NPO: temporary (for a test) 3. NPO: prolonged • Patient put on D5W if not on feeds or TPN • IV insulin drip • SC NPH or UL q12h (+/- supplemental scale) » Starting dose 0.2 U/Kg q12h
  • 134. Newer Directions • The role of Dopamine in type 2 Diabetes • The use of constant glucose monitors (CGMS).
  • 135. Proposed mechanism of action of Bromocriptine in relation to type 2 DM • Diabetes patients may have low morning levels of hypothalamic dopamine, which is thought to lead to hyperglycemia and dyslipidemia • CYCLOSET (special form of bromocriptine) is thought to reset aberrant low morning hypothalamic dopaminergic activity, which may reset neuroendocrine metabolic control Meier, Diabetes Reviews 2010: 476-487 Decreased lipolysis in adipose tissue Decreased postprandial hepatic glucose output Decreased insulin resistance
  • 136. Glucose Fluctuations Are Not Adequately Measured by A1C Type 1 diabetes, N = 9 24-h CGMS glucose sensor data Data on file, Amylin Pharmaceuticals, Inc. 100 200 300 400 12 AM 4 AM 8 AM 12 PM 4 PM 8 PM 12 AM Glucose Concentration (mg/dL) 0 Mean A1C = 6.7%
  • 137. Constant Glucose Monitoring Devices (CGMS)
  • 138. Match the Insulin to the Site • Fast acting insulin can be injected into any approved site. • If injecting regular insulin, the abdomen should be used. • NPH should be injected into the thigh or buttock.
  • 139. A Straight Shot is Best • On an angle or straight-in – patients have been told to inject both ways. So which won? • Straight-in, in almost all cases. No skin fold (pinch), use 90 degree—but if you use a skin fold, you should angle your injection.
  • 140. A summary of the Clinical Practice Recommendations as stated by the American Diabetes Association and WHO in 2011 • “Transitions in care for youth with diabetes” was added. • A section titled “Monogenic forms of diabetes” was added. • The use of the 75-g oral glucose tolerance test and new diagnostic criteria was revised in the section titled “Detection and diagnosis of gestational diabetes mellitus”. • “Prevention/Delay of Type 2 Diabetes”, the hypertension/BP control text was revised to incorporate new evidence reinforcing the importance of individualization of BP goals. • “Children and Adolescents”, the text was revised to remove lower limits on A1C targets and to include discussion on appropriate individualization and safety.
  • 141. ADA Evidence Grading System for ClinicalADA Evidence Grading System for Clinical RecommendationsRecommendations Level ofLevel of EvidenceEvidence DescriptionDescription A Clear or supportive evidence from adequately powered well-conducted, generalizable, randomized controlled trials Compelling nonexperimental evidence B Supportive evidence from well-conducted cohort studies or case-control study C Supportive evidence from poorly controlled or uncontrolled studies Conflicting evidence with the weight of evidence supporting the recommendation E Expert consensus or clinical experience ADA. Diabetes Care 2011;34(suppl 1):S12. Table 1.