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  • ICM I November 29, 2000
  • DID 9/97 slide 14 remember must repeat on another day no longer have to note be on medication discussion in the report re drug induced such as NA and glucocorticoids likely early type 2 imply to reclassify once off the drug and follow more closely for dm
  • DID 9/97 slide 14 remember must repeat on another day no longer have to note be on medication discussion in the report re drug induced such as NA and glucocorticoids likely early type 2 imply to reclassify once off the drug and follow more closely for dm
  • DID 9/97 slide 14 remember must repeat on another day no longer have to note be on medication discussion in the report re drug induced such as NA and glucocorticoids likely early type 2 imply to reclassify once off the drug and follow more closely for dm
  • DID 9/97slide 5 note that do not have to have total lack of insulin secretion and thus may be able to have time off insulin without DKA
  • DID 9/97 slide 6 ICA GAD 65 autoantibodies to tyrosine phosphatsases IA-2 and IA-2ß human leukocyte antigen HLA region on chromosome 6 associated with HLA DR3 and DR4
  • varying degrees of each
  • DID 9/97 slide 9 if obese and no dka, likely to be type 2
  • DID 9/97 slide 11 during the workshop last time I noticed fair amount of interest in this topic, so I will review it for diagnosis treatment will not be addressed but it is diet or diet and insulin none of the oral agents should be used in pregnancy
  • DID 9/97 slide 10 many specific types if interested see your report from the expert committee just wish to make the point that these are not type 1 or 2 8 ca tegories, 53 types listed in the report
  • Conventional Policy : n = 1138 initially with diet alone aim for : near normal weight best fasting plasma glucose 270 mg/dl) develops on sulfonylurea: add metformin, move to insulin therapy on insulin: transfer to complex regimens

the main lecture the main lecture Presentation Transcript

  • Caring for Patients with Chronic Illness Introduction to Diabetes Mellitus Debra L. Simmons, MD Assistant Professor of Medicine Director, Arkansas Diabetes Program Director, Training Program Endocrinology, Diabetes and Metabolism University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System
  • General Attributes of Medical Visits
    • Acute
    • patient seeks doctors advice for a problem
    • frequently a “complaint”
      • headache
      • chest pain
      • cough
    • Chronic
    • regularly scheduled appointment
    • usually no “complaint”
      • fu effectiveness of treatment
      • monitor for complications of treatment or disease
  • General Attributes of Medical Visits cont.
    • Acute
    • History and physical
      • focuses on determining the cause of the complaint
    • More likely to be physician directed for treatment
    • Chronic
    • History and physical
      • focuses on issues related to the chronic disease
    • Usually requires the patient actively deciding goals of therapy and treatment
    View slide
  • Introduction to Diabetes Mellitus
    • Epidemiology
    • Diagnosis and classification
    • Goals of diabetes management
    View slide
  • Epidemiology of Diabetes
    • 15.7 million Americans have diabetes
      • 10.3 million diagnosed
      • 5.4 million not diagnosed
    • 90% have type 2 diabetes
    • 8.2% of people aged 45 to 64 in Arkansas have diabetes
    NDEP
  • Percentage of US Population by Age and Race With Diagnosed Diabetes Harris MI et al. Diabetes Care . 1998;21:518-524. *% based on medical history interview in subjects asked about previous Dx by physician. % Age group (yr) 
  • Seriousness of Diabetes
    • Diabetes increases risk of
      • death
      • cardiovascular disease
      • stroke
    • Diabetes is the leading cause of
      • adult blindness
      • end stage renal disease
      • nontraumatic amputations
  • Mortality in People With Diabetes: US Population Age (yr) Men Women Relative risk Risk vs nondiabetic Ford ES et al. Am J Epidemiol . 1991;133:1220-1230. 45-64 65-74 >74 0 2 4 6
  • Mortality in People With Diabetes: Causes of Death % of deaths Ischemic heart disease Other heart disease Diabetes Cancer Stroke Infection Other Geiss LS et al. In: Diabetes in America . 2nd ed. 1995; chap 11. 0 10 20 30 40 50
  • New Blindness in US Adults: Contribution From Diabetes % of new cases of blindness Age (yr) Due to diabetes Due to diabetic retinopathy 45 65 75 85 0 10 20 30 Klein R et al. In: Diabetes in America . 2nd ed. 1995; chap 14.
  • Prevalence of ESRD by Primary Diagnosis, 1996* *Prevalence as of December 31, 1998 derived from Medicare billing records. 32.5% Diabetes 24.5% Hypertension Other 20.6% Glomerulo- nephritis 17.7% Cystic kidney disease 4.7% NIDDK. USRDS1998 Annual Report .
  • Diabetes and Lower Extremity Amputations: Prevalence of All Lower Extremity Amputations % of population Reiber GE et al. In: Diabetes in America . 2nd ed. 1995; chap 18.
  • Chronic Complications of Diabetes
    • Macrovascular
      • coronary artery disease
      • cerebral vascular disease
      • peripheral vascular disease
    • Microvascular
      • retinopathy
      • nephropathy
      • neuropathy
  • Introduction to Diabetes Mellitus
    • Epidemiology
    • Diagnosis and classification
    • Goals of diabetes management
  • ADA 1997 Diagnostic Criteria for Diabetes Mellitus
    • 1. Fasting plasma glucose > 126 mg/dl* or
    • 2. Symptoms plus random plasma glucose > 200 mg/dl* or
    • 3. Oral glucose tolerance test 2-hr plasma glucose > 200 mg/dl*
    • * Must confirm on another day unless DKA or HHNC; not for pregnancy
    ADA Diabetes Care 2000
  • ADA 1997 Diagnostic Criteria for Diabetes Mellitus
    • 1. Fasting plasma glucose > 126 mg/dl
      • 8 hour fast
      • preferred test for diagnosis
      • NOT capillary blood glucose
  • ADA 1997 Diagnostic Criteria for Diabetes Mellitus
    • 2. Symptoms plus random plasma glucose > 200 mg/dl
      • polyuria
      • polydipsia
      • polyphagia
      • weight loss
      • fatigue
      • poor healing
  • ADA 1997 Diagnostic Criteria for Diabetes Mellitus
    • 3. Oral glucose tolerance test plasma glucose 2-hr > 200 mg/dl
      • 75 gram glucose load
      • 2 hour post glucose load plasma glucose
      • primarily for research
  • ADA 1997 Etiologic Classification of Diabetes
    • Type 1 diabetes
    • Type 2 diabetes
    • Gestational diabetes
    • Other specific types
    ADA Diabetes Care 2000
  • Type 1 Diabetes
    •  -cell destruction
    • Usually leading to absolute insulin deficiency
    • Ketosis prone
    • Two forms
      • immune-mediated
      • idiopathic which is rare and without known cause
  • Type 1 Diabetes Immune-mediated
    • Commonly occurs in childhood
    • May occur any age, even 9th decade
    • Rate of  -cell destruction variable
      • usually rapid in childhood
      • may be slow in adults
    • Markers include
      • islet cell autoantibodies
      • autoantibodies to glutamic acid decarboxylase
  • Type 1 Diabetes: Typical Presentation
    • Young age
    • Thin
    • Classic symptoms
      • polyuria, polydipsia, polyphagia and weight loss
    • May have diabetic ketoacidosis
    • No family history of diabetes
  • Type 2 Diabetes
    • Impaired insulin action
      • insulin resistance
      • primarily peripheral tissue defect
    • Impaired insulin secretion
      • relative insulin deficiency
      • primarily  -cell defect
  • Causes of Hyperglycemia in Type 2 Diabetes Glucose Liver Peripheral Tissues (Muscle) Pancreas Increased glucose production Impaired insulin secretion Insulin resistance
  • Type 2 Diabetes
    • Most are obese
    • Spontaneous ketoacidosis rare
    • Ketoacidosis may occur with stress
    • Strong genetic predisposition
  • Type 2 Diabetes: Typical Presentation
    • Many people are asymptomatic
      • Routine physical
      • Preop labs
    • Not uncommon to present with complication
      • MI
      • Peripheral neuropathy
      • Foot ulcer
    • Frequently family history diabetes
  • Gestational Diabetes Mellitus
    • Any degree of glucose intolerance
    • First recognition during pregnancy
    • Reclassify 6 weeks postpartum
  • Other Specific Types
    • Diseases of the exocrine pancreas
      • pancreatitis
    • Drug- or chemical-induced
      • glucocorticoids
      • nicotinic acid
    • Many others
  • Introduction to Diabetes Mellitus
    • Epidemiology
    • Diagnosis and classification
    • Goals of diabetes management
  • Goals of Diabetes Management
    • Prevention of acute complications
      • significant hypoglycemia
      • symptomatic hyperglycemia including DKA
    • Prevention of microvascular complications
    • Prevention of macrovascular complications
    • Attainment of normal quality of life
  • Diabetes Control and Complication Trial
    • 1441 type 1 diabetes
    • Conventional therapy: 1-2 insulin injections per day
    • Intensive therapy: 3-4 insulin injections per day or insulin pump
    • Followed average of 6.5 years
    • Published 1993
  • Effect of Intensive Glycemic Control in the DCCT: HbA 1c Levels Diabetes Control and Complications Trial Research Group. N Engl J Med . 1993;329:977-986. HbA 1c (%) Study year Conventional therapy Intensive therapy 6.05 Normal 0 1 2 3 4 5 6 7 8 9 10 5 6 7 8 9 10 11
  • DCCT: Results of Intensive Therapy
    • Retinopathy 76%
    • Nephropathy 54%
    • Neuropathy 60%
    Diabetes Control and Complications Trial Research Group. N Engl J Med . 1993;329:977-986.
  • DCCT: Absolute Risk of Sustained Retinopathy Progression by HbA 1c and Years of Follow-up Rate/100 person- years 24 20 16 12 8 4 0 Mean HbA 1c = 11% 10% 9% 8% 7% Conventional treatment Time during study (y) DCCT Research Group. Diabetes . 1995;44:968-983. 9 8 7 6 5 4 3 2 1 0
  • United Kingdom Prospective Diabetes Study
    • 5102 newly diagnosed type 2 diabetes
    • Conventional policy: diet
    • Intensive policy: sulfonylurea, metformin (in overweight patients), or insulin
    • Mean 10-year follow-up
    • Published 1998, designed 1970s
  • Cross-sectional and 10-Year Cohort Data: Intensive vs Conventional Policy UKPDS Group . Lancet. 1998;352:837-853. Time from randomization (y)
      • 6
      • 0
      • 3
      • 9
      • 12
      • 15
    Time from randomization (y)
      • 6
      • 0
      • 3
      • 9
      • 12
      • 15
      • 0
      • 100
      • FPG
    Median FPG (mg/dL)
      • HbA 1c
      • 7
      • 8
      • 9
      • 6
    Median HbA 1c (%)
      • 200
      • 180
      • 160
      • 140
      • 120
    All patients assigned to regimen Intensive Conventional Patients followed for 10 years Intensive Conventional
  • UKPDS Results of Intensive Policy: Sulfonylurea/Insulin
    • Microvascular complications 25%
    • Retinopathy progression 21%
    • Nephropathy 34%
    UKPDS Group. Lancet. 1998;352:837-853.
  • ADA Recommendations for Glycemic Control Goal Take Action Preprandial glucose mg/dl 80-120 <80 >140 Bedtime glucose mg/dl 100-140 <100 >160 HbA1c % <7 >8 ADA Diabetes Care 2000
  • Prevention of Macrovascular Disease
    • Control of hypertension
    • Control of lipids
    • Cessation of smoking
    • Aspirin use
  • Prevention of Macrovascular Disease: Control of Hypertension
    • UKPDS substudy proved effectiveness of BP control
      • Intensive control (mean 144/82 vs 154/87) reduced strokes 44%, diabetes related deaths 32% and heart failure 56%
    • Goal <130/85 mmHg
    • ACE inhibitor currently preferred due to renal protective effect
    ADA Diabetes Care 2000
  • Prevention of Macrovascular Disease: Control of Lipids
    • Primary goal is LDL cholesterol < 100 mg/dl
      • same as NCEP guidelines for secondary prevention
      • due to very high risk of CAD in diabetes
    • Secondary goal is HDL cholesterol > 45 mg/dl for men and > 55 mg/dl in women
    ADA Diabetes Care 2000
  • Prevention of Macrovascular Disease: Cessation of Smoking
    • Cigarette smoking and diabetes
      • increases risk of morbidity and mortality of CVD
    • Counsel to quit smoking
    ADA Diabetes Care 2000
  • Prevention of Macrovascular Disease: Aspirin Use
    • Low dose aspirin
      • 81-325 mg/day if >21 YO
    • Secondary prevention
      • MI, stroke, TIA, PVD, angina, claudication
    • Primary prevention if high risk
      • family history CVD, cigarette smoking, hypertension, obese, albuminuria, dyslipidemia
    ADA Diabetes Care 2000
  • Attainment of Normal Quality of Life
    • Patient at center of team of health care providers
    • Psychosocial issues extremely important
  • Diabetes Team PATIENT Primary care provider Endocrinologist Diabetes educator Nutritionist Podiatrist Social worker Psychologist Exercise physiologist
  • Patient Education: Diabetes Self-Management
    • Understand diabetes disease process
      • emphasis on benefit of good control
    • Learn appropriate diet
      • individualized diet plans
    • Learn self-monitoring of blood glucose
      • use of meter
      • what to do with the results
  • Patient Education: Diabetes Self-Management cont.
    • Learn how to use prescribed medications
      • how it works
      • when to take it
      • side effects
    • Learn how to balance diet, exercise and medications as well as stress
    • Learn sick day rules
  • Psychosocial Issues: Impact of the Disease
    • May be devastating due to fear of complications
    • May be overwhelming due to complexity of caring for the disease
      • must watch what they eat, when they eat, take medications on time, juggle activity with food intake and medications, go to the doctor regularly
      • can not just think about it occasionally
  • Psychosocial Issues: Other
    • Many psychosocial issues may impact the ability of the patient to care for themselves
      • lack of money, access to healthcare providers
      • turmoil in family such as caring for a dying parent, spouse with Alzheimer’s disease, child involved with drugs
      • psychiatric illness such as depression greatly impairs the patient’s ability to care for diabetes
  • Summary of Goals of Diabetes Management
    • HbA1c <7%
    • BP <130/85
    • LDL cholesterol <100 mg/dl
    • Smoking cessation
    • 1 aspirin/day
    • Normal quality of life
  • Follow Up Visit for Diabetes
    • Chief complaint
    • History since last visit
    • Physical exam
    • Laboratory
  • Follow Up Visit for Diabetes: Chief Complaint
    • Usually routine visit
    • May have additional complaint(s)
      • evaluate as usual in addition to routine visit if possible
  • Follow Up Visit for Diabetes: Basic History
    • Can be from chart and/or obtain from the patient
      • type of diabetes
      • duration of diabetes
      • complications of diabetes
      • medications for treatment of diabetes (always confirm)
      • all other medications (always confirm)
  • Follow Up Visit for Diabetes: History Since Last Visit
    • Problems with management plan
      • medication, diet, exercise
    • Results of self-monitoring of blood glucose
      • review log book of results and comments
    • Specifically question about hypoglycemia
      • do not assume they will tell you or that it is marked in their log book
  • Follow Up Visit for Diabetes: History Since Last Visit cont.
    • Question about any changes
      • health
      • social issues
      • family history that effects patient’s CVD risk
    • Review need for referral for yearly dilated eye exam (screening for retinopathy)
  • Follow Up Visit for Diabetes: Laboratory
    • Review HbA1c results and goals
    • Review lipid results and goals
    • Review need for yearly lab
      • microalbuminuria (screening for early nephropathy)
  • Follow Up Visit for Diabetes: Physical Exam
    • BP, weight, height (yearly for adults)
    • Previous abnormalities on exam
      • Focus is commonly cardiovascular as well as funduscopic exam and insulin injection sites
    • Foot exam in high risk patients
      • peripheral neuropathy
      • prior foot ulcer or amputation
  •