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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
  • Transcript

    • 1. Diabetes Guidelines Kevin H McKinney MD University of Texas Medical Branch at Galveston Division of Endocrinology/Stark Diabetes Center
    • 2. DIABETES MELLITUS
      • Inability of the body to metabolize blood sugar
      • A disease of inadequate insulin secretion and action
      • Hyperglycemia is the main manifestation
    • 3. COMPLICATIONS
      • Chronic hyperglycemia may cause:
        • retinal damage
        • chronic kidney disease
        • nerve damage
        • vascular disease
    • 4. COMPLICATIONS (cont.)
      • Blindness
      • Dialysis
      • Lower Limb Amputation
      • Stroke
      • Myocardial infarction
      • Claudication
    • 5. 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
    • 6. PREVALENCE OF TYPE 1 DIABETES IN THE US
      • 1 million people
      • Caucasians constitute the majority of
      • type 1 diabetics
      • Most prominent during childhood
    • 7. 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
    • 8. 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
    • 9. METABOLIC SYNDROME
      • Insulin resistance (type 2 diabetes)
      • Hypertension
      • Dyslipidemia
      • Polycystic ovary syndrome
      • Hyperuricemia
      • Hypercoagulability
    • 10. 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
    • 11. 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
    • 12. 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
    • 13. 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
    • 14. 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
    • 15. 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
    • 16. 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
    • 17.
      • 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.
    • 18. 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.
    • 19. 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.
    • 20.
      • RISK REDUCTION OF MACROVASCULAR COMPLICATIONS
        • Glycemic Control
        • Smoking Cessation
        • Blood Pressure Control
        • Lipoprotein Management
        • Prothrombotic State Improvement
    • 21. 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
    • 22. 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
    • 23. 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
    • 24.  
    • 25. 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
    • 26. 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
    • 27.
      • 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.
    • 28. 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
    • 29. 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
    • 30. 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
    • 31.  
    • 32. 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
    • 33. 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
    • 34. ORAL MEDICAL THERAPY
      • First line: metformin useful except where contraindicated
      • Sulfonylureas or meglitinides also frequently used
      • Second line: thiazolidinediones
      • Used uncommonly: acarbose
    • 35. 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
    • 36. ADJUNCTS
      • Cardiovascular
        • Aspirin
      • Renal
        • ACE inhibitor/Angiotensin receptor blocker
      • Hypertension
        • Diuretics
      • Cholesterol
        • Statins
    • 37. 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
    • 38. Reference
      • American Diabetes Association. Diabetes Care 28:S4, 2005 Jan.
      • American Association of Clinical Endocrinologists. Endocrine Practice 8:S40, 2002 Jan/Feb.