Diabetes 2011
Jonathan Ploudré, MD     North Cascade Family Physicians
What’s Bigger?                                        Diabetes or War on Terror?In 2007 it’s a trick question: About the S...
Is Diabetes Destiny?Samoa?                                USA?New Zealand
Ploudré Diabetes Index                             USA                 NZ   Samoa          BMI       Fasting       Glucose...
Diabetes            • Diagnosing            • Managing            • ComplicationLet’s narrow this down to a third of endoc...
Diagnosis  ?
Screening/Diagnosis• Two fasting glucose > 126 mg/dl• Random > 200
Who to screen?• USPTF: Assymptomatic Adults with HTN  (B). All Adults (Insufficient).• ADA: 18-45, Obese with Risk Factor. ...
Should we use the A1c?Population Screening in 2010:1/3 Elevated Fasting Glucose1/3 Elevated A1c (>6.5)1/3 Both Fasting Glu...
Should we use the A1c?Longitudinal Cohort Study,JapanFasting Glucose: 6x Hazard RatioElevated A1c: 6x Hazard RatioBoth: 32...
Screening Problem
Who to listen to?• Metaguideline• Guideline• Review• Study• Preceptor’s Unsourced Opinion• Google
Who to listen to?• Metaguideline• Guideline            Putting evidence into practice requires• Review                    ...
Diabetes• Diagnosing• Managing• Complication
What works   ?
• Exercise (1600s?)• Diet change (1700s)• Weight loss (Rationing, 1870s)• Insulin (1921)• Medications (Sulfonylurea, 1942,...
Lifestyle Management• Why does a chocolate chip cookie, with its  warm, sumptuous mounds of chocolate, have  such power ov...
Guilt• We probably react like rats here. Oral  glucose has measurable affects on  dopaminergic responses in the Amygdala  ...
Lifestyle Management• Patient-centered: Motivational counseling• Systems-approach: Reminders• Support Group• Group Visits
3 month intervention, SMSMessagesPatients with SMS messages had 1.16%drop in A1c compared to controls.                    ...
Medications            • Metformin (Even ER, $4/month)            • Glyburide ( $4/month)            • Contrast: Januvia (...
Insulin• “The most dangerous drug I prescribe”• Key to management: Matching patients  glucose patterns.• Glargine, NPH, 70...
Glucose Monitoring• Somewhere between continuously and  never.• Test Strips are typically $1 each• Testing in stable diabe...
Continuous Glucose
A1c?
A1c in a tweet• Your A1c is like a candy coating on your  blood cells. It gives an average of the sugar  in your blood ove...
A1c Goal < 7.0That’s right, um, isn’t it?
Diabetes• Diagnosing• Managing• Complication
Hospital DM• DKA (Type 1)• Hyperosmolar Hyperglycemia (Type 2)• Contrast-induced Kidney Failure• Secondary Healing Issues•...
Grouping       Complications• Microvascular: Retinopathy, Nephropathy,  Neuropathy• Macrovascular: MI/CAD, Stroke
Diabetes• Diagnosing• Managing• Complication
Secondary Prevention• Retinopathy Exam• Routine Foot Exam• Screening Microalbuminuria• Screening for CVD
Reducing CVD• Aspirin• BP Control (Especially ACEi)• Dyslipidemia• Smoking Cessation
UKPDS, 1998
UKPDS, 1998
Metabolic Syndrome• With Diabetes, the risk of CVD doubles.
35,000 patients (mean age, 62) receivedeither intensive orstandard glucose-lowering treatment.After a mean follow-up of 5 ...
Statins effective in CVDprevention20-30% reduction in major coronaryevents, strokes, revascularizations withsimvastatin.  ...
Medication Cage Match      in   rm fo etM           Vs.                          in                       at              ...
UKPDS, 1998
Intensive BP Therapy: Non-significantChange in Major CV Risk.                                       ACCORD BP,             ...
Anti-hypertensive?              ACCOMPLISH     ALLHAT                            SANDSADVANCE                    UKPDS
Do DM Goals Help?• A1c < 7.0• LDL < 70• SBP < 130, DBP < 85• Microalbumin < 30• Monofilament > ....
Let’s not get too     Doctor-centered• Medication adherence probably matters  more for reducing CVD. Apparently, the  stat...
The future of Diabetes            Low Agency        High Agency            Diabetes is our   Map for treatingCertain      ...
Thanks Flickr, Creative     Commons.•   McDiabetes: http://www.flickr.com/photos/hertzen/5594880296/sizes/l/in/    photostr...
Want the slides?unchart.com/2011/diabetes/
Diabetes for MS3s
Diabetes for MS3s
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Diabetes for MS3s

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A ~ 50 slide overview of diabetes for 3rd year medical students.

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Diabetes for MS3s

  1. 1. Diabetes 2011
  2. 2. Jonathan Ploudré, MD North Cascade Family Physicians
  3. 3. What’s Bigger? Diabetes or War on Terror?In 2007 it’s a trick question: About the Same. $174 Billion/year.
  4. 4. Is Diabetes Destiny?Samoa? USA?New Zealand
  5. 5. Ploudré Diabetes Index USA NZ Samoa BMI Fasting GlucoseWHO Noncommunicable Diseases Data. 1980 - 2010
  6. 6. Diabetes • Diagnosing • Managing • ComplicationLet’s narrow this down to a third of endocrinology
  7. 7. Diagnosis ?
  8. 8. Screening/Diagnosis• Two fasting glucose > 126 mg/dl• Random > 200
  9. 9. Who to screen?• USPTF: Assymptomatic Adults with HTN (B). All Adults (Insufficient).• ADA: 18-45, Obese with Risk Factor. All over 45.
  10. 10. Should we use the A1c?Population Screening in 2010:1/3 Elevated Fasting Glucose1/3 Elevated A1c (>6.5)1/3 Both Fasting Glucose & A1c J Clin Endocrinol Metab 2010 Dec. 95:5289
  11. 11. Should we use the A1c?Longitudinal Cohort Study,JapanFasting Glucose: 6x Hazard RatioElevated A1c: 6x Hazard RatioBoth: 32x Hazard Ratio Heianza Y et al. Lancet, 2011
  12. 12. Screening Problem
  13. 13. Who to listen to?• Metaguideline• Guideline• Review• Study• Preceptor’s Unsourced Opinion• Google
  14. 14. Who to listen to?• Metaguideline• Guideline Putting evidence into practice requires• Review more guesswork and judgement than you might think as a 3rd year. Less about facts, more about hunches.• Study• Preceptor’s Unsourced Opinion• Google
  15. 15. Diabetes• Diagnosing• Managing• Complication
  16. 16. What works ?
  17. 17. • Exercise (1600s?)• Diet change (1700s)• Weight loss (Rationing, 1870s)• Insulin (1921)• Medications (Sulfonylurea, 1942, Oral in 1956)• Glucose monitoring (1969)• Secondary Screening (A1c, 1979)
  18. 18. Lifestyle Management• Why does a chocolate chip cookie, with its warm, sumptuous mounds of chocolate, have such power over us? — David Kessler
  19. 19. Guilt• We probably react like rats here. Oral glucose has measurable affects on dopaminergic responses in the Amygdala for 7 days. Gastric infusion doesn’t.• Changing Diet is harder than giving the advice.
  20. 20. Lifestyle Management• Patient-centered: Motivational counseling• Systems-approach: Reminders• Support Group• Group Visits
  21. 21. 3 month intervention, SMSMessagesPatients with SMS messages had 1.16%drop in A1c compared to controls. Diabetes Res Clin Pract. 2011 Aug
  22. 22. Medications • Metformin (Even ER, $4/month) • Glyburide ( $4/month) • Contrast: Januvia ($200/month), Actos ($300/month) Since I include the prices, here, I’m guessing you have a hunch about my opinion.Only oral meds on WHOs Model List of Essential Meds: Metformin, Glyburide.
  23. 23. Insulin• “The most dangerous drug I prescribe”• Key to management: Matching patients glucose patterns.• Glargine, NPH, 70/30, Regular: It depends.
  24. 24. Glucose Monitoring• Somewhere between continuously and never.• Test Strips are typically $1 each• Testing in stable diabetics correlates with depression (Unactionable result?)• 10 years ago, I was taught 2x Daily. My practice now trends toward 0x Daily.
  25. 25. Continuous Glucose
  26. 26. A1c?
  27. 27. A1c in a tweet• Your A1c is like a candy coating on your blood cells. It gives an average of the sugar in your blood over the 3 months blood cells live.• Or just use the estimated glucose instead? ~A1c x 29 As fundamental as A1c is, how many patients don’t grasp it?
  28. 28. A1c Goal < 7.0That’s right, um, isn’t it?
  29. 29. Diabetes• Diagnosing• Managing• Complication
  30. 30. Hospital DM• DKA (Type 1)• Hyperosmolar Hyperglycemia (Type 2)• Contrast-induced Kidney Failure• Secondary Healing Issues• 2 am Calls (Sugar is 500. Sugar is 25)
  31. 31. Grouping Complications• Microvascular: Retinopathy, Nephropathy, Neuropathy• Macrovascular: MI/CAD, Stroke
  32. 32. Diabetes• Diagnosing• Managing• Complication
  33. 33. Secondary Prevention• Retinopathy Exam• Routine Foot Exam• Screening Microalbuminuria• Screening for CVD
  34. 34. Reducing CVD• Aspirin• BP Control (Especially ACEi)• Dyslipidemia• Smoking Cessation
  35. 35. UKPDS, 1998
  36. 36. UKPDS, 1998
  37. 37. Metabolic Syndrome• With Diabetes, the risk of CVD doubles.
  38. 38. 35,000 patients (mean age, 62) receivedeither intensive orstandard glucose-lowering treatment.After a mean follow-up of 5 years,intensive glucose lowering was notassociated with lower risks forall-cause mortality and CV death BMJ 2011 Jul
  39. 39. Statins effective in CVDprevention20-30% reduction in major coronaryevents, strokes, revascularizations withsimvastatin. Lancet 2003.
  40. 40. Medication Cage Match in rm fo etM Vs. in at st va Sim
  41. 41. UKPDS, 1998
  42. 42. Intensive BP Therapy: Non-significantChange in Major CV Risk. ACCORD BP, 2010
  43. 43. Anti-hypertensive? ACCOMPLISH ALLHAT SANDSADVANCE UKPDS
  44. 44. Do DM Goals Help?• A1c < 7.0• LDL < 70• SBP < 130, DBP < 85• Microalbumin < 30• Monofilament > ....
  45. 45. Let’s not get too Doctor-centered• Medication adherence probably matters more for reducing CVD. Apparently, the statin only works if the patient swallows it regularly.• Cost is still a major factor for patients.• Wouldn’t we get more bang from getting at the 1 out of 3 diabetics that isn’t diagnosed?
  46. 46. The future of Diabetes Low Agency High Agency Diabetes is our Map for treatingCertain destiny diabetes Who knows what Let’s build theUncertain we’ll do someday future of diabetes
  47. 47. Thanks Flickr, Creative Commons.• McDiabetes: http://www.flickr.com/photos/hertzen/5594880296/sizes/l/in/ photostream/• Diabetes Syringe: http://www.flickr.com/photos/jill_a_brown/2629206800/ sizes/z/in/photostream/• Iraq: http://www.flickr.com/photos/imcomkorea/3046373113/• Marias World Map: http://www.flickr.com/photos/mrsdkrebs/5967890349/• Breakfast: http://www.flickr.com/photos/k9/46829792/sizes/l/in/photostream/
  48. 48. Want the slides?unchart.com/2011/diabetes/

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