Philippine Clinical Practice Guidelines for the Diagnosis and Management of Type 2 Diabetes Mellitus

1. Philippine Practice Guidelines for the Diagnosis & Management of Type 2 Diabetes Mellitus Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM Chief, Medical Informatics Unit Associate Professor IV, UP College of Medicine Adapted from the presentation of Dr. Cecilia Jimeno Tuesday, April 23, 13

2. UNITE FOR DIABETES PHILIPPINES Diabetes Philippines Institute for Studies on Diabetes Foundation, Inc. Philippine Society of Endocrinology & Metabolism Philippine Center for Diabetes Education Foundation, Inc. Tuesday, April 23, 13

3. Goals & Areas of Collaboration Establishment of a national diabetes database Encourage best diabetes practices - development of a uniﬁed CPG Spearhead the ﬁght for patients’ rights & safety - vigilance on false claims UNITE FOR DIABETES PHILIPPINES Tuesday, April 23, 13

4. Objectives for the Clinical Practice Guideline UNITE FOR DIABETES PHILIPPINES To develop clinical practice guidelines on the screening, diagnosis and management of diabetes which reﬂect the current best evidence and which incorporate local data into the recommendations, in view of aiding clinical decision making for the beneﬁt of the Filipino patient GUIDELINES THAT ARE SUITED FOR LOCAL REALITIES Tuesday, April 23, 13

5. Organizations in the Consensus Panel Diabetes Philippines Institute for Studies on Diabetes Foundation, Inc. Philippine Society of Endocrinology & Metabolism Philippine Center for Diabetes Education Foundation, Inc. 23 other specialty, subspecialty organizations lay representatives of persons with diabetes UNITE FOR DIABETES PHILIPPINES Tuesday, April 23, 13

6. Scope of the Philippine CPG development Outpatient setting Screening and diagnosis Screening for complications Prevention and treatment Special groups: GDM, elderly Tuesday, April 23, 13

7. Philippine Clinical Practice Guideline for Diabetes Mellitus Part 1: SCREENING & DIAGNOSIS Tuesday, April 23, 13

8. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Statement 2.1 All individuals being seen at any physician’s clinic or by any healthcare provider should be evaluated annually for risk factors for type 2 diabetes. (Table 1) [Grade D, Level 5] Tuesday, April 23, 13

9. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Statement 2.2 Universal screening using laboratory tests is NOT recommended as it would identify very few individuals who are at risk. [Grade D, Level 5] Tuesday, April 23, 13

10. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Table 1. Demographic and Clinical Risk Factors for Type 2 Diabetes Testing should be considered in all adults >40 years old. Tuesday, April 23, 13

11. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Consider earlier testing if with at least one other risk factor as follows: •history of IGT or IFG •history of GDM or delivery of a baby weighing 8 lbs or above •polycystic ovary syndrome (PCOS) •overweight (BMI >23 kg/m2 ) or obese (BMI >25 kg/m2 ) •waist circumference >80 cm (♀) and >90 cm (♂) or waist-hip ratio (WHR) >1 (♂) and >0.85 (♀) Tuesday, April 23, 13

12. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Consider earlier testing if with at least one other risk factor as follows (con’t): •ﬁrst-degree relative with type 2 diabetes •sedentary lifestyle •hypertension (BP >140/90 mm Hg) •diagnosis or history of any vascular diseases including stroke, peripheral arterial occlusive disease, coronary artery disease Tuesday, April 23, 13

13. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Consider earlier testing if with at least one other risk factor as follows (con’t): •acanthosis nigricans •schizophrenia •serum HDL <35 mg/dL (0.9 mmol/L) and/or •serum triglycerides >250 mg/dL (2.82 mmol/L) Tuesday, April 23, 13

14. Which of the following will you NOT screen for diabetes? a.42/F on follow-up for hypertension b.35/M consulting for cough c.45/M with tuberculosis d.28/F diagnosed with PCOS Tuesday, April 23, 13

15. Why 40? Recommendation from other guidelines ADA 2010 CDA 2008 AACE 2007 IDF 2005 All >45 y (B) Earlier if BMI >25 kg/m2 and with >1 risk factor(s) (B) All > 40 y Earlier if with risk factors >30 y with risk factor (B) Target high risk people by risk factor assessment Tuesday, April 23, 13

16. Why 40? NNHeS 2008 Age (y) Prevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes Mellitus Age (y) Based on FBSa Based on 2h postprandial glucose Based on DM questionnaire True Diabetes 20-29 0.4 0.4 0.5 0.9 30-39 3.2 1.1 1.4 3.8 40-49 5.7 3.9 4.2 8.2 50-59 9.0 5.0 8.1 13.0 60-69 9.1 5.9 9.5 15.9 >70 4.4 5.5 7.1 11.8 Overall 4.8 3.0 4.0 7.2 a Based on FBS >125 mg/dL b Based on 2h-PPG > 200 mg/dL c Based on DM questionnaire (previous diagnosis by nurse or physician or on medication) d True diabetes (positive in any of the three assessment methods Tuesday, April 23, 13

17. You screen the 42 y.o. hypertensive. FBS is 5.2 mmol/L. What next? a.Reassure patient she is not diabetic. There is no need to repeat the test. b.Repeat FBS after 1 year. c.Order an OGTT after 6 months. d.Ask for an HbA1c after 3 months. Tuesday, April 23, 13

18. If initial test(s) are negative, when should repeat testing be done? Repeat testing should ideally be done annually for Filipinos with risk factors owing to the signiﬁcant prevalence and burden of diabetes in our country. (Level 5, Grade D) Tuesday, April 23, 13

19. CANDI Manila Fojas MC, Lantion-Ang FL, Jimeno CA, Santiago D, Arroyo M, Laurel A, Sy H, See J. Complications and cardiovascular risk factors among newly-diagnosed type 2 diabetics in Manila. Phil. J. Internal Medicine, 47: 99-105, May-June, 2009 Local study: newly-diagnosed diabetics in Manila 20% peripheral neuropathy 42% proteinuria 2% diabetic retinopathy COMPLICATIONS FOUND AT DIAGNOSIS! Tuesday, April 23, 13

20. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Recommended tests for diagnosing diabetes: •Fasting plasma glucose (FPG) - 8-14 hours •Random plasma glucose (RPG) •2-h plasma glucose in 75-g OGTT Tuesday, April 23, 13

21. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Criteria for diagnosis of diabetes (Level 2, Grade B) •FPG >126 mg/dL (7.0 mmol/L) •Random plasma glucose >200 mg/dL (11.1 mmol/L) in a patient with classic symptoms of hyperglycemia (weight loss, polyuria, polyphagia, polydipsia) or with signs and symptoms of hyperglycemic crisis •2-h plasma glucose in 75-g OGTT >200 mg/dL (11.1 mmol/L) Tuesday, April 23, 13

22. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Fasting plasma glucose (FPG) is the preferred test due to its wide availability, lower cost and better reproducibility (Level 3, Grade B) •If the FPG falls within the impaired fasting glucose range (5.6-6.9 mmol/L) then a 75-g OGTT is recommended (Level 3, Grade B) •Symptomatic patients - random or FPG Tuesday, April 23, 13

23. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Among asymptomatic individuals with positive results, any of the three tests should be repeated within two weeks for conﬁrmation (Level 4, Grade C). Tuesday, April 23, 13

24. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Diabetes can be diagnosed when any of the three tests are positive in a symptomatic patient (weight loss, polyuria, polyphagia, polydipsia). Tuesday, April 23, 13

25. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS A 75-g OGTT is preferred as the ﬁrst test for the following (Level 3, Grade B): •Previous FBS showing IFG 100-125 mg/dL (5.6-6.9 mmol/L) •Previous diagnosis of CVD (CAD, stroke, peripheral arteriovascular disease) or who are at high risk of CVD •A diagnosis of Metabolic Syndrome Tuesday, April 23, 13

26. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS At the present time, we cannot recommend the routine use of the following tests in the diagnosis of diabetes (Level 3, Grade C): •HbA1c •Capillary blood glucose •Fructosamine •Urinalysis (Level 3, Grade B) • Plasma insulin (Level 3, Grade B) Tuesday, April 23, 13

27. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS •HbA1c •Capillary blood glucose •Fructosamine •Urinalysis Interpret an available result with caution and conﬁrm with any of the three standard tests (Level 2, Grade B). Tuesday, April 23, 13

28. Why NOT Hba1C? Until standardization has been done in the Philippines, use HbA1c only as a tool for monitoring control among those with established DM. •HbA1c not readily available in some areas •NGSP certiﬁcation not easily veriﬁed in laboratories •Studies needed to determine effect of ethnicity Tuesday, April 23, 13

29. You screen the 42 y.o. hypertensive. FBS is 5.2 mmol/L. What next? a.Reassure patient she is not diabetic. There is no need to repeat the test. b.Repeat FBS after 1 year. c.Order an OGTT after 6 months. d.Ask for an HbA1c after 3 months. Tuesday, April 23, 13

30. Screen for risk factors for DM, prediabetes and MetS Algorithm for Screening Diabetes Among Asymptomatic Individuals Tuesday, April 23, 13

31. Screen for risk factors for DM, prediabetes and MetS Algorithm for Screening Diabetes Among Asymptomatic Individuals Risk factors (Table 1) YES Tuesday, April 23, 13

32. Screen for risk factors for DM, prediabetes and MetS Algorithm for Screening Diabetes Among Asymptomatic Individuals Risk factors (Table 1) YES Lab testing using FBS, RBS, OGTT (Fig 3) YES Tuesday, April 23, 13

33. Screen for risk factors for DM, prediabetes and MetS Algorithm for Screening Diabetes Among Asymptomatic Individuals Risk factors (Table 1) YES Lab testing using FBS, RBS, OGTT (Fig 3) YES Age >40 y NO YES Tuesday, April 23, 13

34. Screen for risk factors for DM, prediabetes and MetS Algorithm for Screening Diabetes Among Asymptomatic Individuals Risk factors (Table 1) YES Lab testing using FBS, RBS, OGTT (Fig 3) YES Age >40 y NO YES No further testing; re-evaluate annually for risk factors NO Tuesday, April 23, 13

35. Age >40 y Age <40 y with risk factors for DM No 3 P’s or weight loss (asymptomatic) No known CAD, PAD, CVD, No MetS Diagnosed CAD, PAD, CVD or with MetS Symptomatic (polyuria, polydipsia, polyphagia, weight loss) Tuesday, April 23, 13

36. Age >40 y Age <40 y with risk factors for DM No 3 P’s or weight loss (asymptomatic) No known CAD, PAD, CVD, No MetS Diagnosed CAD, PAD, CVD or with MetS Symptomatic (polyuria, polydipsia, polyphagia, weight loss) Fasting plasma glucose <100 mg/dL 100-125 mg/dL >126 mg/dL No diabetes Repeat testing after 1 y 75-g OGTT Diabetes Tuesday, April 23, 13

37. Age >40 y Age <40 y with risk factors for DM No 3 P’s or weight loss (asymptomatic) No known CAD, PAD, CVD, No MetS Diagnosed CAD, PAD, CVD or with MetS Symptomatic (polyuria, polydipsia, polyphagia, weight loss) Fasting plasma glucose <100 mg/dL 100-125 mg/dL >126 mg/dL No diabetes Repeat testing after 1 y 75-g OGTT Diabetes 75-g oral glucose tolerance test (OGTT) FBS <100 & 2h <140 mg/dL FBS 100-125 or 2h 140-199 mg/dL FBS >126 mg/dL or 2h >200 No diabetes Repeat testing after 1 y IFG or IGT Repeat after 6 mos Diabetes Tuesday, April 23, 13

38. Age >40 y Age <40 y with risk factors for DM No 3 P’s or weight loss (asymptomatic) No known CAD, PAD, CVD, No MetS Diagnosed CAD, PAD, CVD or with MetS Symptomatic (polyuria, polydipsia, polyphagia, weight loss) Fasting plasma glucose <100 mg/dL 100-125 mg/dL >126 mg/dL No diabetes Repeat testing after 1 y 75-g OGTT Diabetes 75-g oral glucose tolerance test (OGTT) FBS <100 & 2h <140 mg/dL FBS 100-125 or 2h 140-199 mg/dL FBS >126 mg/dL or 2h >200 No diabetes Repeat testing after 1 y IFG or IGT Repeat after 6 mos Diabetes Random plasma glucose <140 mg/dL 140-199 mg/dL >200 mg/dL No diabetes Repeat testing after 1 y 75-g OGTT Diabetes Tuesday, April 23, 13

39. Philippine Clinical Practice Guideline for Diabetes Mellitus Part 2: MANAGEMENT & MONITORING Tuesday, April 23, 13

40. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Initial evaluation - comprehensive medical history and PE •Coronary heart disease risk assessment •Foot evaluation: assess risk for foot ulcer (identify high-risk feet) •Eye exam: fundoscopy on diagnosis •Dental history or oral health history Tuesday, April 23, 13

41. RED FLAGS of dental disease tooth ache pain when chewing sensitivity to cold/hot drinks badly broken teeth swelling of gums bad breath Tuesday, April 23, 13

42. Prevalence among T2DM 68% (SLMC, n =192) Bitong et al PJIM 2010 PERIODONTITIS gum bleeding on brushing swelling and redness of gums looseness or mobility of teeth teeth that fall off in adults Tuesday, April 23, 13

43. Which of the following will you NOT request as initial tests for a person with diabetes? a.Fasting blood glucose, HbA1c b.Complete lipid proﬁle c.Blood uric acid, 12-lead ECG d.ALT, AST, serum creatinine Tuesday, April 23, 13

44. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Minimal initial tests to be requested • Fasting blood glucose, complete lipid proﬁle • HbA1c • Liver function tests • Urinalysis; spot urine albumin-to-creatinine ratio • Serum creatinine and calculated GFR Tuesday, April 23, 13

45. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Optional tests • ECG and TET • TSH in type 1 diabetes, dyslipidemia or women over age 50 y Tuesday, April 23, 13

46. Which of the following will you NOT request as initial tests for a person with diabetes? a.Fasting blood glucose, HbA1c b.Complete lipid proﬁle c.Blood uric acid, 12-lead ECG d.ALT, AST, serum creatinine Tuesday, April 23, 13

47. Which of the following statements is true about monitoring diabetes? a. Monitor Hba1c ideally twice a year. b. Check FBS and postprandial blood sugar every 2-4 weeks. c. Estimate trends in blood sugar control by checking CBGs once a week. d. Achieve glycemic goals within three months. Tuesday, April 23, 13

48. Glycemic targets Individualize targets. FBS <4-7 mmol/L (72-126 mg/dL) 2h PPG <5-10 mmol/L (90-180 mg/dL) Capillary (ADA) fasting 90-130 mg/dL PPBG <180 mg/dL HbA1c <7% Tuesday, April 23, 13

49. Glycemic targets Individualize targets. FBS <6 mmol/L 2h PPG <8 mmol/L Newly diagnosed Relatively young (age <60 y) No complications No risk factors for hypoglycemia HbA1c <6.5% Tuesday, April 23, 13

50. Ideally, HbA1c every 3-6 months; 2x a year if controlled on stable therapy FBS, postprandial sugar every 2-4 weeks Capillary blood glucose 2x a week to estimate trends Tuesday, April 23, 13

51. Glycemic targets should be achieved within 6 months of diagnosis or ﬁrst prescription. Tuesday, April 23, 13

52. Which of the following statements is true about monitoring diabetes? a. Monitor Hba1c ideally twice a year. b.Check FBS and postprandial blood sugar every 2-4 weeks. c. Estimate trends in blood sugar control by checking CBGs once a week. d. Achieve glycemic goals within three months. Tuesday, April 23, 13

53. Targets to Decrease CV Risk BP control Lipid control ASA Tuesday, April 23, 13

54. Which of the following statements is true about reducing CV risk in diabetes? a. Statins should be given regardless of baseline lipid levels. b. There is insufﬁcient evidence to recommend aspirin for primary prevention in men <60 y. c. Give clopidogrel 75 mg/day for those with diabetes and a history of CVD. d. The goal BP for most persons with diabetes is <140/80 mm Hg. Tuesday, April 23, 13

55. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS The goal BP for most persons with diabetes is <140/80 mm Hg. •Lifestyle therapy alone for 3 months if pre-hypertensive (SBP 130-139 mm Hg or DBP 80-89 mm Hg) •Pharmacologic + lifestyle therapy if SBP>140 mm Hg or DBP >90 mm Hg, or pre-hypertensive uncontrolled with lifestyle therapy alone Tuesday, April 23, 13

56. Weight loss if overweight DASH-style dietary pattern (reduce Na, increase K, moderation of alcohol, increased physical activity). Lifestyle therapy Tuesday, April 23, 13

57. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Statement 7.3 ACE inhibitors & ARBs are generally recommended as initial therapy. If one class is not tolerated, the other should be substituted. Multiple drug therapy (>2 agents at maximal doses) is generally required to achieve BP targets. Thiazide-type diuretics, calcium channel blockers and B-blockers may be given as additional agents. Tuesday, April 23, 13

58. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Recommendations are consistent with Philippine Practice Guidelines for the Treatment of Dyslipidemia. •LDL is the primary target for dyslipidemia management in persons with diabetes. Tuesday, April 23, 13

59. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Statement 8.1.1 Statin therapy should be added to lifestyle therapy, regardless of baseline levels for diabetics •with overt CVD (A) •without CVD who are >40 y and have >1more other CVD risk factors (A) Tuesday, April 23, 13

60. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Statement 8.1.2 For patients at lower risk (e.g. without overt CVD and <40 y), statin therapy should be considered in addition to lifestyle therapy if - •LDL-C remains >100 mg/dL •those with multiple risk factors (hypertension, familial hypercholesterolemia, LVH, smoking, family history of premature CAD, male sex, age >55 y, proteinuria, albuminuria, BMI>25) Tuesday, April 23, 13

61. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS The 100-70 rule •Without overt CVD, goal is LDL-C <100 mg/ dL (2.6 mmol/L) [A] •With overt CVD, goal is LDL-C <70 mg/dL (1.8 mmol/L). Use of high dose statin is an option. [B] Tuesday, April 23, 13

62. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Recommendation 9.2 Insufﬁcient evidence to recommend aspirin for primary prevention in lower risk individuals •Men < 50 y •Women <60 y * Clinical judgement if with multiple risk factors Tuesday, April 23, 13

63. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Recommendation 9.3 Use aspirin therapy for secondary prevention strategy in those with DM and a history of CVD [A]. •For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. Tuesday, April 23, 13

64. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Recommendation 9.4 Combination therapy of ASA (75-162 mg/day) and clopidogrel (75 mg/day) is reasonable up to a year after an acute coronary syndrome [B]. Tuesday, April 23, 13

65. Which of the following statements is true about reducing CV risk in diabetes? a. Statins should be given regardless of baseline lipid levels. b. There is insufﬁcient evidence to recommend aspirin for primary prevention in men <60 y. c. Give clopidogrel 75 mg/day for those with diabetes and a history of CVD. d.The goal BP for most persons with diabetes is <140/80 mm Hg. Tuesday, April 23, 13

66. Newly diagnosed T2DM Initiation of Drug Therapy among Newly Diagnosed Type 2 Diabetes Patients Tuesday, April 23, 13

67. Newly diagnosed T2DM Initiation of Drug Therapy among Newly Diagnosed Type 2 Diabetes Patients HbA1c <9% FBS < 250 HbA1c >9% FBS > 250 Tuesday, April 23, 13

68. Newly diagnosed T2DM Initiation of Drug Therapy among Newly Diagnosed Type 2 Diabetes Patients HbA1c <9% FBS < 250 HbA1c >9% FBS > 250 Mono- therapy Option for combination therapy Tuesday, April 23, 13

69. Newly diagnosed T2DM Initiation of Drug Therapy among Newly Diagnosed Type 2 Diabetes Patients HbA1c <9% FBS < 250 HbA1c >9% FBS > 250 Mono- therapy Option for combination therapy Combination therapy Insulin therapy Tuesday, April 23, 13

70. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Statement 10.1 Initiate treatment with metformin for monotherapy unless with contraindications or intolerance of its ADE’s - • diarrhea • severe nausea • abdominal pain Tuesday, April 23, 13

71. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS When optimization of therapy is needed, choose the second drug according to the following - •degree of HbA1c lowering •hypoglycemia risk •weight gain •patient proﬁle (dosing complexity, renal/hepatic problems, other contraindications and age) Tuesday, April 23, 13

72. Adapted from AACE Diabetes Mellitus Guidelines Endocr Pract 2007 Drug Therapy HbA1c reduction (%) MONOTHERAPYMONOTHERAPY Sulfonylureas 0.9 to 2.5 Biguanide (Metformin) 1.1 to 3.0 Thiazolidinedione 1.5 to 1.6 Alpha-glucosidase inhibitors 0.6 to 1.3 DPP-4 inhibitors 0.8 NON-INSULIN INJECTABLENON-INSULIN INJECTABLE Exenatide 0.8 to 0.9 COMBINATION THERAPYCOMBINATION THERAPY SU + Metformin 1.7 SU + Pioglitazone 1.2 SU + Acarbose 1.3 Repaglinide + Metformin 1.4 Pioglitazone + Metformin 0.7 DPP-4 inhibitor + Metformin 0.7 DPP-4 inhibitor + Pioglitazone 0.7 Tuesday, April 23, 13

73. Safety and Tolerability Insulin secretagogues Metformin alpha-glucosidase inhibitors TZDs Insulin Risk of hypoglycemia ✔ ✔ Weight gain ✔ ✔ ✔ GI side effects ✔ ✔ Lactic acidosis ✔ Edema ✔ 1DeFronzo RA. Ann Intern Med 1999; 131:281–303. 2UKPDS. Lancet 1998; 352:837–853. 3Nesto RW, et al. Circulation 2003; 108:2941–2948. Tuesday, April 23, 13

74. Contraindications Sulfonylurea Meglitinide Biguanide AGI TZD Renal insufﬁciency ✔ ✔ ✔ Liver disease ✔ ✔ ✔ ✔ ✔ Inﬂammatory bowel disease ✔ Congestive heart failure ✔ ✔ Known hypersensitivity ✔ ✔ ✔ ✔ ✔ Tuesday, April 23, 13

75. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Since HbA1c reduction is the overriding goal, the precise combination used may not be as important as the glucose level achieved. •There is no evidence that a speciﬁc combination is any more effective in lowering glucose levels or preventing complications than another. SU + Pio = SU + Metformin (Haneﬁeld et al, 2004 & Nagasaka et al, 2004) SU + Met = SU + DPP-IV inhibitors (?) Tuesday, April 23, 13

76. UNITE PHILIPPINE CPG FOR DIABETES MELLITUS Statement 10.4.2 The following patients must be referred to internists or diabetes specialists (endocrinologists or diabetologists) - • Type 1 diabetes • Moderate to severe hyperglycemia • Co-morbid conditions (infections, acute CV events i.e. CHF or acute MI) • Signiﬁcant hepatic and renal impairment • Women with diabetes who are pregnant Tuesday, April 23, 13

77. Clinical practice guidelines aim to help physicians and patients reach the best healthcare decisions. Steinbrook R. NEJM 2007 Tuesday, April 23, 13

78. “If you write it, and it is good, then they will follow.” Keefer JH. Clin Chem 2001 Tuesday, April 23, 13

79. THANK YOU http://www.endocrine-witch.net http://www.facebook.com/EndocrineWitch http://endocrine-witch.tumblr.com @endocrine_witch Tuesday, April 23, 13

Philippine Clinical Practice Guidelines for the Diagnosis and Management of Type 2 Diabetes Mellitus

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Philippine Clinical Practice Guidelines for the Diagnosis and Management of Type 2 Diabetes Mellitus