DM ABCs essential of management ; 2015 update

1. DIABETES MELLITUS
Standards Of Care- 2015
The ABCs
Dr. Mohammad Daoud
Consultant Endocrinologist
KAMC/ NGHA
Jeddah –Saudi Arabia

2. Type 2 diabetes is NOT a mild disease
Diabetic
Retinopathy
Leading cause
of blindness
in working age
adults1
Diabetic
Nephropathy
Leading cause of
end-stage renal disease2
Cardiovascular
Disease
Stroke
2 to 4 fold increase in
cardiovascular
mortality and stroke3
Diabetic
Neuropathy
Leading cause of
non-traumatic lower
extremity amputations5
8/10 diabetic patients
die from CV events4
1 Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–
S98.
3 Kannel WB, et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997.
5Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
Mild Type 2 Diabetes ?

3. Aims of Mx of DM
Improve quality of life
Reduce acute symptoms
Achieve euglycemia safely
Avoid Acute &
Chronic
Complications

4. ADA 2015
A patient-centered communication style that incorporates
patient preferences, assesses literacy and numeracy, and
addresses cultural barriers to care should be used. B
Treatment decisions should be timely and founded on
evidence-based guidelines that are tailored to individual
patient preferences, prognoses, and co-morbidities. B

5. Criteria for the Diagnosis of Diabetes
A1C ≥6.5% Adults
OR
Fasting plasma glucose (FPG)
≥126 mg/dL (7.0 mmol/L)
OR
2-h plasma glucose ≥200 mg/dL
(11.1 mmol/L) during an OGTT
OR
A random plasma glucose ≥200 mg/dL (11.1
mmol/L)
ADA. I. Classification and Diagnosis. Diabetes Care 2014;37(suppl 1):S15; Table 2

6. Testing for Diabetes in Asymptomatic
Adult Patients
• Adults of any age who are overweight / obese (BMI ≥25
kg/m2 or ≥23 kg/m2 in Asian Americans) and who have
one or more additional risk factors for diabetes.
• For all patients, particularly those who are overweight
or obese, testing should begin at age 45 years. B
• To test for pre-diabetes, the A1C, FPG, or 2-h 75-g
OGTT are appropriate B
• In those with pre-diabetes, identify and, if appropriate,
treat other CVD risk factors E
ADA. II. Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2015

7. Testing for Diabetes in Asymptomatic
Adult Individuals
• Physical inactivity
• First-degree relative with
diabetes
• High-risk race/ethnicity (e.g.,
African American, Latino, Native
American, Asian American,
Pacific Islander)
• Women who delivered a baby
weighing >9 lb or were diagnosed
with GDM
• Hypertension (≥140/90 mmHg or
on therapy for hypertension)
• HDL cholesterol level
<35 mg/dL (0.90 mmol/L) and/or a
triglyceride level >250 mg/dL (2.82
mmol/L)
• Women with polycystic ovarian
syndrome (PCOS)
• A1C ≥5.7%, IGT, or IFG on
previous testing
• Other clinical conditions associated
with insulin resistance (e.g., severe
obesity, acanthosis nigricans)
• History of CVD
*At-risk BMI may be lower in some ethnic groups.
1. Testing should be considered in all adults who are overweight
(BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and have additional risk
factors:
ADA. Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2015

8. 2. If tests are normal, repeat testing at least at 3-year
intervals is reasonable C
Consider more frequent testing depending on initial
results and risk status (e.g., those with prediabetes should
be tested yearly)
ADA. Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2015
Testing for Diabetes in Asymptomatic
Adult Individuals

9. Recommendations:
Detection and Diagnosis of GDM (1)
• Screen for undiagnosed type 2 DM at the first prenatal visit in
those with risk factors, using standard diagnostic criteria
B
• Screen for GDM at 24–28 weeks of gestation in pregnant women not
previously known to have DM A
• Screen women with GDM for persistent DM at 6–12 weeks
postpartum, using OGTT, nonpregnancy diagnostic criteria
E
• Women with a +ve history of GDM should have lifelong screening for
the development of DM or pre-DM at least every 3 years B
• Women with a history of GDM found to have pre-DM should
receive TLC or Metformin to prevent DM
A
Detection and Diagnosis of GDM. Diabetes Care 2015

10. One-step strategy (IADPSG Consensus)
• Perform a 75-g OGTT, with plasma glucose measurement
when patient is fasting and at 1 and 2 h, at 24–28 weeks of
gestation in women not previously diagnosed with overt
diabetes.
• The OGTT should be performed in the morning after an
overnight fast of at least 8 h
The diagnosis of GDM is made when any of the following
plasma glucose values are met or exceeded:
• Fasting: ≥ 92 mg/dL (5.1 mmol/L)
• 1 h: ≥ 180 mg/dL (10.0 mmol/L)
• 2 h: ≥ 153 mg/dL (8.5 mmol/L)
Detection and Diagnosis of GDM. Diabetes Care 2015
Table 2.5—Screening for and diagnosis of GDM

11. Table 2.5—Screening for and diagnosis of GDM
Two-step strategy (2013 -NIH Consensus)
• Step 1: Perform a 50-g GLT (non-fasting), with plasma glucose
measurement at 1 h, at 24–28 weeks of gestation in women not
previously diagnosed with overt diabetes.
• If the plasma glucose level measured 1 h after the load is ≥140 mg/dL*
(7.8 mmol/L), proceed to a 100-g OGTT
NDDG, National Diabetes Data Group.
*The ACOG recommends a lower threshold of 135 mg/dL (7.5 mmol/L) in high-risk ethnic
populations with higher prevalence of GDM;
Some experts also recommend 130 mg/dL (7.2 mmol/L).
Detection and Diagnosis of GDM. Diabetes Care 2015

12. Two-step strategy…
• Step 2: The 100-g OGTT should be performed when the patient is fasting.
• The diagnosis of GDM is made if at least two of the following four plasma
glucose levels
• (measured fasting and 1 h, 2 h, 3 h after the OGTT) are met or exceeded:
• Carpenter/Coustan or NDDG
Fasting 95 mg/dL (5.3 mmol/L) 105 mg/dL (5.8 mmol/L)
1 h 180 mg/dL (10.0 mmol/L) 190 mg/dL (10.6 mmol/L)
2 h 155 mg/dL (8.6 mmol/L) 165 mg/dL (9.2 mmol/L)
3 h 140 mg/dL (7.8 mmol/L) 145 mg/dL (8.0 mmol/L)
Table 2.5—Screening for and diagnosis of GDM
Detection and Diagnosis of GDM. Diabetes Care 2015

13. PREVENTION / DELAY OF
TYPE 2 DIABETES

14. FPG 100–125 mg/dL (5.6–6.9 mmol/L): IFG
OR
2-h plasma glucose in the 75-g OGTT
140–199 mg/dL (7.8–11.0 mmol/L): IGT
OR
A1C 5.7–6.4%
For all three tests, risk is continuous, extending below the lower
limit of the range and becoming disproportionately greater at
higher ends of the range.
Pre-Diabetes
ADA. I. Classification and Diagnosis. Diabetes Care 2015

15. Prevention /Delay of Type 2 DM
Patients with IGT (A), IFG (E), or
an A1C of 5.7–6.4% (E)
Weight loss of 7% of body weight
Physical activity ; at least 150 min/ week
 Follow-up counseling for success. (B)
Diabetes prevention is cost-effective (B)

16. ADA 2015
All patients should limit the amount of time
sitting to less than 90 minutes a stretch
(Avoid Sedentary Life )

17. Prevention /Delay of Type 2 DM
Metformin therapy may be considered in:
IGT (A), IFG(E), or an A1Cof 5.7–6.4% (E)
Especially for those with: (A)
-BMI >35 kg/m2
-Age <60 years,
-Prior GDM.
At least annual monitoring for the development
of DM in those with pre-diabetes is suggested. (E)

19. ADA 2015
Micronutrients and Supplements
 Evidence does not support recommending omega-3
supplements for people with diabetes for the prevention or
treatment of cardiovascular events.
There is no clear evidence of benefit from vitamin or
mineral supplementation in people with diabetes who do not
have underlying deficiencies. C
 Routine supplementation with antioxidants, such as
vitamins E and C and carotene, is not advised due to
insufficient evidence of efficacy and concerns related to long-
term safety. C
.

20. ADA 2015
Micronutrients and herbal supplements
There is insufficient evidence to support the routine use of
micronutrients such as chromium, magnesium, and vitamin D
to improve glycemic control in people with diabetes C
There is insufficient evidence to support the use of
cinnamon or other herbs/supplements for the treatment of
diabetes. E

21. Routine screening for CAD is
Not recommended
In asymptomatic patients
(It does not improve outcomes as long as CVD risk
factors are treated)
(A)
Coronary Heart Disease Screening
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S42

22. • To reduce risk of cardiovascular events in
patients with known CVD, use
– ACE inhibitor* (C)
– Aspirin* (A)
– Statin therapy* (A)
• In patients with a prior MI
– Beta-blockers should be continued for at least 2
years after the event (B)
Coronary Heart Disease Treatment
*If not contraindicated.
ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S42

24. GLYCEMIC CONTROL
1. Assessment of Glycemic control
Two primary techniques:
A : Patient self-monitoring of blood glucose
(SMBG) or Interstitial Glucose (CGM)
B : HbA1C
2. Glycemic goals in adults
ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21–S22

25. ADA-2015

26. Glycemic Control
SMBG
Tight Glycemic control : SMBG is an integral part of
the management strategy. (A)
Do SMBG ≥ 3 times a day for patients using Insulin
pump or multiple insulin injections. (B)
Patients using less frequent insulin injections or oral
agents or MNT alone, SMBG is useful (E)
 PP SMBG may be appropriate. (E)
Especially when getting closer to target; Lower A1c

27. Glycemic Control
Recommendations
EMPOWER
Patient should be able to use data
to adjust therapy. (E)
ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21–S22

28. Correlation of A1C with estimated Average Glucose
The correlation factor is (r 0.92)
A1C (%) Mean plasma glucose mg/dl
mmol/l
6 126 ( ̴120)
7 154 ( ̴150)
8 183 ( ̴180)
9 212 ( ̴210)
10 240 ( ̴240)
11 269 ( ̴270)
12 298 ( ̴300)
ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S23; Table 8

29. ADA – EASD Consensus:
(June 2012)

33. ADA-2015
Inpatients Glycemia Mx

34. ADA-2015
Inpatients Glycemia Mx

35. Diabetes in Elderly
Pharmacotherapy
Assess for hypoglycemia regularly
Hypoglycemia risk is linked more to treatment strategies
than to achieved lower A1C
Consider changing therapy and/or targets
Diabetes in older adults-ADA Consensus –
Diabetes Care published ahead of print October 25, 2012, doi:10.2337/dc12-1801

36. Diabetes in Elderly
Pharmacotherapy
Consider poly-pharmacy
Avoid Glyburide / Glibenclamide
Metformin: Safely and is the preferred initial therapy
Assess renal function using e-GFR ;
Not Serum Creatinine alone
Diabetes in older adults-ADA Consensus –
Diabetes Care published ahead of print October 25, 2012, doi:10.2337/dc12-1801

37. Diabetes in Elderly
Pharmacotherapy
Assess the burden of treatment on older adult patients
(caregivers)
Consider patient/caregiver preferences,
and attempt to reduce treatment complexity
Diabetes in older adults-ADA Consensus –
Diabetes Care published ahead of print October 25, 2012, doi:10.2337/dc12-1801

38. Diabetes in Elderly

39. Glycemic Control
Key Concepts
A1C is the primary target
SMBG
Goals to be individualized
Evidence –Based / Individualized Rx

40. HYPERTENSION
BP CONTROL
Goals
*People with diabetes and hypertension should be
treated to a (SBP) goal of <140 mmHg. A
Lower systolic targets, such as <130 mmHg, may be appropriate for
certain individuals, such as younger patients, if they can be achieved
without undue treatment burden. C
*Individuals with diabetes should be treated to a
(DBP) <90 mmHg. A
Lower (DBP) targets, such as <80 mmHg, may be appropriate for certain
individuals, such as younger patients, if they can be achieved without
undue treatment burden. B

41. • Patients with confirmed office-based BP
>140/90 mm Hg
=
Prompt initiation of pharmacological therapy to
achieve blood pressure goals. A
HYPERTENSION
BP CONTROL

42. • Lifestyle therapy for elevated BP B
– Weight loss if overweight/ obese
– DASH (Dietary Approaches to Stop Hypertension) -
style dietary pattern including reducing sodium,
increasing potassium intake
– Moderation of alcohol intake
– Increased physical activity
HYPERTENSION
BP CONTROL
ADA. VI. Prevention, Management of Complications. Diabetes Care
2014;37(suppl 1):S36

43. Hypertension Mx
Recommendations
ACE (-) or ARBs (Don’t combine)
or Diuretics
Monitor serum creatinine / (e GFR)
and serum potassium levels.
(E)

44. Hypertension Mx
Recommendations
Multiple Drug Therapy (≥ 2 agents) is
generally required (B)
Including a thiazide diuretic and ACE inhibitor/ARB, at maximal doses)
is generally required to achieve blood pressure targets
Administer one or more antihypertensive
medications at bedtime. (A)

45. DM / Hypertension Mx
< 130 c / 80 B mmHg
Minimal Goal is
< 140 A / 90 A mmHg
ADA-2015
Evidence –Based / Individualized Rx

46. DYSLIPIDEMIA
Intensity Vs Targets
DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012

47. Screening
• At the time of first diagnosis
• Initial medical evaluation
• and/or at age 40 years and
Re-assessments may be repeated
periodically every 1-2 years (E)
Recommendations:
Dyslipidemia/Lipid Management
DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012.

48. Lipids
Rx Recommendations and Goals
Lifestyle modification (TLC) has been
shown to Improve the lipid profile in
patients with diabetes. (A)
This include:
- Reduction of saturated fat, trans fat, and cholesterol intake
-Increase of n-3 fatty acids, viscous fiber and plant stanols / sterols
-Weight loss (if indicated); and increased physical activity

49. Lipids
ADA 2014… was
 To get specified LDL target
Statin therapy should be added, regardless of
baseline lipid levels, for DM patients:
- With overt CVD.
-Without CVD who is > 40 years old and have ≥ 1 other
CVD risk factors. (A)
 A reduction in LDL cholesterol of 30–40% from
baseline is an alternative therapeutic goal. (A)

50. Statins use is based on desired
LDL-C Intensity lowering
rather than LDL target number
Adjustment of intensity of statin therapy
may be needed based on individual patient response to
medication
(e.g., side effects, tolerability, LDL cholesterol levels). E
Lipids
ADA 2015

52. NICE Guidelines -Dyslipidemia and (CVD)
Do not use a risk assessment tool for people
1-With type 1 DM
2-With pre-existing CVD
3-Familial hyper-cholesterolemia
4-With CKD ; e GFR < 60 ml/min/1.73 m2 and/or
albuminuria

53. Statins intensity categories of lowering LDL –C
NICE vs ACC/AHA
NICE
low intensity
20% to 30%
medium intensity
31% to 40%
high intensity > 40%
ACC/AHA
low intensity
<30%
medium intensity
30% to <50%
high intensity ≥ 50%

54. Statins intensity categories of lowering LDL –C
ACC/AHA

55. Again…
Adjustment of intensity of statin therapy
may be needed based on individual patient
response to medication
(e.g., side effects, tolerability, LDL cholesterol levels). E
Lipids
ADA 2015

56. Lipids
ADA 2014… was
If targets are not reached;
Use combination therapy
of lipid lowering agents.
(No outcome studies;
CVD outcomes or safety. (E)

57. Combination therapy
(statin/ fibrate and statin/niacin)
has not been shown to provide additional
cardiovascular benefit above statin therapy alone
and is Not generally recommended
A
Lipids
ADA 2015

58. A1C <7.0%
<6.5%
Blood pressure <140/90 mmHg
Lipids: Statins Moderate – High
Intensity
Glycemic, BP, Lipid Control in Adults
Evidence –Based / Individualized Rx
DIABETES CARE , JANUARY 2015

59. NEPHROPATHY

60. Nephropathy-Screen
At least once a year
Assess , quantitatively
Urinary albumin
(e.g., urine albumin /creatinine ratio [UACR])
and
estimated glomerular filtration rate (e GFR)
Type 1 DM ≥ 5 years / All Type 2 DM

61. Nephropathy-Screen

62. Nephropathy-Treatment
ACE inhibitor or (ARB) is
Not recommended
for the primary prevention of diabetic kidney
disease in patients with DM with
Normal BP and normal UACR (< 30 mg/g)
B

63. Nephropathy-Nutrition
Diabetic kidney disease
Reducing the amount of dietary protein below the
recommended 0.8 g/kg/day
Not recommended
(it does not alter glycemic measures, CV risk measures,
or the course of GFR decline)
A

64. Nephropathy
Key Concepts
 Optimize DM & HTN control (A)
 Treatment of Albuminuria
with ACE(-) or ARB based Rx (A)
DIABETES CARE, , JANUARY 2015
Evidence –Based / Individualized Rx

65. Anti-Platelets
& DIABETES

66. Aspirin
Use aspirin therapy (75–162 mg/day) as a
secondary prevention strategy in those
with diabetes with a history of CVD. (A)
* U.S. Physicians' Health Study, Early Treatment Diabetic Retinopathy Study
(ETDRS), Hypertension Optimal Treatment (HOT)
DIABETES CARE, SUPPLEMENT 1, JANUARY 2015

67. Aspirin- Primary prevention
Consider ASA as a primary prevention strategy in those with
type 1 or type 2 DM at increased cardiovascular risk (10-year risk
> 10%)
This includes most men >50 years or women >60 years
With at least one additional major risk factor
(Family Hx. of CVD, Hypertension, Smoking, Dyslipidemia,or Albuminuria)
(C)
-US Preventive Services Task Force (USPSTF): Aspirin for the prevention of cardiovascular disease:
U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;150:396–404
-Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the
evidence for the (USPSTF): . Ann Intern Med 2009;150:405–410 238.
DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012

68. Take Home
Messages

69. Take Home Messages
Guidelines …evolving
Treat patients …Not numbers !
Individualize
Team work

70. Take Home Messages
TLC
(dietary and exercise) modifications are
essential for all patients with DM
EMPOWER
Individualize and get patient involved

71. Take Home Messages
• Treat
Hyperglycemia, HTN & Dyslipidemia
with the same intensity
• Achieve Targets
….Safely

72. Diabetes Mellitus
Targets For Control (ADA-2015)
Parameter Goal Action
Suggested
AC Glucose
Post-P Glucose
80-130
< 180
<80 or >140
>180
HS glucose 100-140 <100 or >160
HbA1c % <7 (6.5) >7
BP (mmHg.) <140/90 >140/90
LDL-Chol
TG
≥ 40-50%
<150
DM patients
HDL-Chol >40 males
>50 females
<40
<50

73. Remember Your ABCs
 A:
A1C
ASA
Albuminuria
 B: Blood Pressure
 C: Cholesterol
 Cardiac
 D: Diabetes education
Diet / Dietician
 E: Eye exam
Exercise
 F: Foot care
 G: Glucose monitoring
 H: Health ;
Vaccination
D/C Smoking
 I: Identify need for
referral