Diabetes Guidelines
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Diabetes Guidelines

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  • Slide 4. Hospitalization Costs for Chronic Complications of Diabetes in the US These data from the ADA emphasize that 1) type 2 diabetes is extremely costly, and 2) cardiovascular disease constitutes 64% of total costs. Reference: American Diabetes Association. Economic Consequences of Diabetes Mellitus in the US in 1997. Alexandria, Va: American Diabetes Association, 1998:1-14. [no PubMed link (book)] Keywords: complications, cost, diabetes Slide type: graph

Diabetes Guidelines Diabetes Guidelines Presentation Transcript

  • Diabetes Guidelines Kevin H McKinney MD University of Texas Medical Branch at Galveston Division of Endocrinology/Stark Diabetes Center
  • DIABETES MELLITUS
    • Inability of the body to metabolize blood sugar
    • A disease of inadequate insulin secretion and action
    • Hyperglycemia is the main manifestation
  • COMPLICATIONS
    • Chronic hyperglycemia may cause:
      • retinal damage
      • chronic kidney disease
      • nerve damage
      • vascular disease
  • COMPLICATIONS (cont.)
    • Blindness
    • Dialysis
    • Lower Limb Amputation
    • Stroke
    • Myocardial infarction
    • Claudication
  • PRIMARY CLASSES OF DIABETES MELLITUS
    • Type 1
      • Autoimmune destruction of islets
      • No insulin secretion
    • Type 2 Diabetes
      • Insulin resistance with progressive insulin secretory defect
      • 90% are obese
  • PREVALENCE OF TYPE 1 DIABETES IN THE US
    • 1 million people
    • Caucasians constitute the majority of
    • type 1 diabetics
    • Most prominent during childhood
  • PREVALENCE OF TYPE 2 DIABETES IN THE US
    • Most common type of diabetes among
    • all ethnic groups
    • 17 million patients with known diabetes
    • 45% of children and teens with new
    • diagnoses
  • PREVALENCE OF TYPE 2 DIABETES IN THE US
    • Caucasian women experience higher
    • prevalence rates than men (57% vs. 26%)
    • By age 70, African American prevalence
    • rates increase to 42% of the population
  • METABOLIC SYNDROME
    • Insulin resistance (type 2 diabetes)
    • Hypertension
    • Dyslipidemia
    • Polycystic ovary syndrome
    • Hyperuricemia
    • Hypercoagulability
  • PREVALENCE OF METABOLIC SYNDROME IN THE US
    • Third NHANES Study (Prevalence Rates)
      • 21.6% African American Adults
      • 31.9% Mexican American Adults
      • 23.8% Caucasian Adults
  • OBESITY—A PUBLIC HEALTH PROBLEM
    • Rise in metabolic syndrome is related to increasing prevalence of obesity
    • Multifactorial causes for obesity including
      • A sedentary lifestyle
      • Decline in exercise
      • Increased access to unhealthy foods
      • Greater food portions
  • GESTATIONAL DIABETES
    • Occurs after the onset of pregnancy
    • Is secondary to the production of human
    • placental lactogen and other hormones
    • needed to sustain pregnancy
    • Most common in people of color
  • GESTATIONAL DIABETES
    • If untreated, may result in fetal macrosomia
    • Fetal macrosomia may lead to
      • Cesarean section
      • Shoulder dystocia
      • Fetal hypoglycemia
    • High risk women should be screened at first prenatal visit
    • Low-risk women should be screened from 24 to 28 weeks of gestation
  • Hospitalization Costs for Chronic Complications of Diabetes in the US American Diabetes Association. Economic Consequences of Diabetes Mellitus in the US in 1997 . Alexandria, VA: American Diabetes Association, 1998:1-14.
    • Total costs 12 billion US $
    • CVD accounts for 64% of total costs
    Others Ophthalmic disease Cardiovascular disease Renal disease Neurologic disease Peripheral vascular disease
  • DISPARITIES IN DIABETES COMPLICATIONS IN AFRICAN AMERICANS
    • Contributing factors
      • Average delay in diagnosis of 4-7 years
      • Longer duration of poorly controlled type 2
      • diabetes
      • Development of equally devastating
      • complications
  • MICROVASCULAR COMPLICATIONS OF DIABETES
    • Diabetic retinopathy
      • 46% higher in African Americans and 86% higher in Mexican Americans than in Caucasians
    • Diabetic Nephropathy
      • African Americans, Latinos, and Native Americans have 3-4 times higher rates of renal failure than Caucasians
    • DIABETIC NEUROPATHY
    • Primary contributor to the loss of limb protection through the diminution or absence of pain and sensory perception.
    • Diminution or absence of pain and sensory perception leads to limb trauma, open ulcers and polymicrobial foot infections often culminating in gangrene that is treated by limb amputation.
    • Lower extremity limb amputation is 2-3 times higher in African Americans and Mexican Americans than in Caucasians.
  • MACROVASCULAR RISKS OF DIABETES
    • Risk of stroke, coronary artery disease, and peripheral vascular disease is increased 2-4 times in all patients with diabetes.
    • The presence of diabetes is viewed as an independent risk factor for first acute myocardial infarction compared to those with recurrent myocardial infarction without diabetes.
  • MACROVASCULAR RISKS OF DIABETES
    • The rates for myocardial infarction and stroke among African Americans, Asian Americans and Hispanic Americans are the same or lower than in Caucasians; however, the mortality from CAD is disproportionately high in minorities.
    • Cardiovascular disease (CVD) remains the leading cause of death in individuals with diabetes, up to 70% of type 2 diabetes patients.
    • RISK REDUCTION OF MACROVASCULAR COMPLICATIONS
      • Glycemic Control
      • Smoking Cessation
      • Blood Pressure Control
      • Lipoprotein Management
      • Prothrombotic State Improvement
  • SCREENING GUIDELINES
    • Adults 45 years of age and older esp with BMI > 25
      • Fasting Plasma Glucose at 3 year intervals
    • Overweight or obese individuals with risk factors for diabetes, African Americans, Latinos
      • Fasting Plasma Glucose screened at an earlier age and more frequently
    • Children with BMI > 85 th percentile
      • Screened at age 10 and every 2 years thereafter
  • DIAGNOSTIC CRITERIA
    • Fasting Plasma Glucose > 126 mg/dL
    • Casual Blood Sugar > 200 mg/dL or greater as with diabetic symptoms
    • 2-hour postprandial serum glucose of 200 mg/dL as stimulated by a glucose tolerance test
    • Test reconfirmation required
  • PRE-DIABETIC STATES
    • Impaired glucose tolerance (IGT)
      • 2-hour glucose between 140 and 199
    • Impaired fasting glucose (IFG)
      • Fasting glucose beteween 100 and 125
    • Above are risk factors for future diabetes and cardiovascular disease
  •  
  • TREATMENT GOALS FOR DIABETES MELLITUS
    • Maintaining:
    • Pre-meal blood glucose in the range of 90 mg/dL to 130 mg/dL
    • Bedtime blood glucose in the range of 100 mg/dL to 140 mg/dL
    • A hemoglobin A 1c value from 6.5% to 7% over 3 months
  • Increased A 1c Raises Vascular Event Risk * Updated mean A 1c is adjusted for age, sex, and ethnic group, expressed for white men aged 50-54 years at diagnosis and with mean duration of diabetes of 10 years. Stratton IM et al. BMJ. 2000;321:405-412. Myocardial Infarction Microvascular Complications Updated Mean A 1c (%)* Adjusted Incidence per 1000 Patient-Years (%) 0 5 6 7 8 9 10 11
    • Position in Model Variable P Value*
    • First Low-density lipoprotein cholesterol <.0001
    • Second High-density lipoprotein cholesterol .0001
    • Third Hemoglobin A 1c .0022
    • Fourth Systolic blood pressure .0065
    • Fifth Smoking .056
    Established Modifiable Cardiovascular Risk Factors In Type 2 Diabetes UKPDS 23 * Significant for CAD (n = 280). P values are significance of risk factors after controlling for all other risk factors in model. Adjusted for age and sex in 2693 white patients with type 2 diabetes with dependent variable as time to first event. Turner RC et al. BMJ. 1998;316:823-828.
  • TREATMENT GOALS FOR DIABETES MELLITUS (Cont.)
    • Maintaining:
    • Blood pressure < 130/80 mm Hg
    • LDL Cholesterol < 100 mg/dL, triglycerides < 150 mg/dL, and HDL cholesterol > 40 mg/dL in men (> 50 mg/dL in women)
    • High risk cardiovascular patients should aim for LDL cholesterol < 70 mg/dL
  • MANAGEMENT PLAN
    • Must be individualized for each individual patient
    • Diabetes education: initial and subsequent
    • Lifestyle modifications
      • Diet (improve your nutrition)
      • Exercise (increase your activity)
    • Home blood glucose monitoring
      • At least once/day for oral medications
      • Three times daily for insulin users
    • Medications
  • FOLLOW-UP CARE
    • Annual eye exam
    • Physician visits every 3 months, more frequently for poor control
      • Fundoscopic exam
      • Foot exam
    • HbA 1c quarterly for poor control, every biannually for good control
    • Lipogram yearly
    • Microalbumin yearly
  •  
  • MEDICAL NUTRITIONAL THERAPY
    • Must be individualized for each patient
      • Children must be allowed enough calories for growth, development, and activity
      • Pregnant women, elderly also deserve special consideration
    • Permanent low-carbohydrate diets not recommended
      • “ carbohydrate counting” can be done with insulin users
  • MEDICAL NUTRITIONAL THERAPY (cont)
    • Weight management
      • One should aim for 500-1000 Calorie reduction in intake per day
      • 1000-1200 Calories/day for women, 1200-1600 Calories/day for men for weight reduction
      • Bariatrics?
    • Activity should consist of 3-5 sessions per week
      • 30-45 minutes for health
      • Weight loss: 1 hour of walking, 30 minutes of vigorous exercise
  • ORAL MEDICAL THERAPY
    • First line: metformin useful except where contraindicated
    • Sulfonylureas or meglitinides also frequently used
    • Second line: thiazolidinediones
    • Used uncommonly: acarbose
  • INSULIN
    • Traditional regimens
      • Type 1: Basal insulin (NPH, glargine) with bolus regular or short-acting insulin (lispro, aspart, glulisine) by sliding scale; split-mix regimen; insulin pump
      • Type 2: split-mix regimen; fixed combination (70/30, 50/50, 75/25); basal-bolus
    • Transitional type 2 insulin regimens: oral agents with bedtime NPH or glargine
  • ADJUNCTS
    • Cardiovascular
      • Aspirin
    • Renal
      • ACE inhibitor/Angiotensin receptor blocker
    • Hypertension
      • Diuretics
    • Cholesterol
      • Statins
  • WHEN TO REFER
    • Poor control for 6 months despite patient adherence and physician manipulation (HbA 1c >10%)
    • Multiple episodes of decompensation (DKA, HONK)
    • Frequent hypoglycæmic episodes
  • Reference
    • American Diabetes Association. Diabetes Care 28:S4, 2005 Jan.
    • American Association of Clinical Endocrinologists. Endocrine Practice 8:S40, 2002 Jan/Feb.