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
  • Diabetes Guidelines

    1. 1. Diabetes Guidelines Kevin H McKinney MD University of Texas Medical Branch at Galveston Division of Endocrinology/Stark Diabetes Center
    2. 2. DIABETES MELLITUS <ul><li>Inability of the body to metabolize blood sugar </li></ul><ul><li>A disease of inadequate insulin secretion and action </li></ul><ul><li>Hyperglycemia is the main manifestation </li></ul>
    3. 3. COMPLICATIONS <ul><li>Chronic hyperglycemia may cause: </li></ul><ul><ul><li>retinal damage </li></ul></ul><ul><ul><li>chronic kidney disease </li></ul></ul><ul><ul><li>nerve damage </li></ul></ul><ul><ul><li>vascular disease </li></ul></ul>
    4. 4. COMPLICATIONS (cont.) <ul><li>Blindness </li></ul><ul><li>Dialysis </li></ul><ul><li>Lower Limb Amputation </li></ul><ul><li>Stroke </li></ul><ul><li>Myocardial infarction </li></ul><ul><li>Claudication </li></ul>
    5. 5. PRIMARY CLASSES OF DIABETES MELLITUS <ul><li>Type 1 </li></ul><ul><ul><li>Autoimmune destruction of islets </li></ul></ul><ul><ul><li>No insulin secretion </li></ul></ul><ul><li>Type 2 Diabetes </li></ul><ul><ul><li>Insulin resistance with progressive insulin secretory defect </li></ul></ul><ul><ul><li>90% are obese </li></ul></ul>
    6. 6. PREVALENCE OF TYPE 1 DIABETES IN THE US <ul><li>1 million people </li></ul><ul><li>Caucasians constitute the majority of </li></ul><ul><li>type 1 diabetics </li></ul><ul><li>Most prominent during childhood </li></ul>
    7. 7. PREVALENCE OF TYPE 2 DIABETES IN THE US <ul><li>Most common type of diabetes among </li></ul><ul><li>all ethnic groups </li></ul><ul><li>17 million patients with known diabetes </li></ul><ul><li>45% of children and teens with new </li></ul><ul><li>diagnoses </li></ul>
    8. 8. PREVALENCE OF TYPE 2 DIABETES IN THE US <ul><li>Caucasian women experience higher </li></ul><ul><li>prevalence rates than men (57% vs. 26%) </li></ul><ul><li>By age 70, African American prevalence </li></ul><ul><li>rates increase to 42% of the population </li></ul>
    9. 9. METABOLIC SYNDROME <ul><li>Insulin resistance (type 2 diabetes) </li></ul><ul><li>Hypertension </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Polycystic ovary syndrome </li></ul><ul><li>Hyperuricemia </li></ul><ul><li>Hypercoagulability </li></ul>
    10. 10. PREVALENCE OF METABOLIC SYNDROME IN THE US <ul><li>Third NHANES Study (Prevalence Rates) </li></ul><ul><ul><li>21.6% African American Adults </li></ul></ul><ul><ul><li>31.9% Mexican American Adults </li></ul></ul><ul><ul><li>23.8% Caucasian Adults </li></ul></ul>
    11. 11. OBESITY—A PUBLIC HEALTH PROBLEM <ul><li>Rise in metabolic syndrome is related to increasing prevalence of obesity </li></ul><ul><li>Multifactorial causes for obesity including </li></ul><ul><ul><li>A sedentary lifestyle </li></ul></ul><ul><ul><li>Decline in exercise </li></ul></ul><ul><ul><li>Increased access to unhealthy foods </li></ul></ul><ul><ul><li>Greater food portions </li></ul></ul>
    12. 12. GESTATIONAL DIABETES <ul><li>Occurs after the onset of pregnancy </li></ul><ul><li>Is secondary to the production of human </li></ul><ul><li>placental lactogen and other hormones </li></ul><ul><li>needed to sustain pregnancy </li></ul><ul><li>Most common in people of color </li></ul>
    13. 13. GESTATIONAL DIABETES <ul><li>If untreated, may result in fetal macrosomia </li></ul><ul><li>Fetal macrosomia may lead to </li></ul><ul><ul><li>Cesarean section </li></ul></ul><ul><ul><li>Shoulder dystocia </li></ul></ul><ul><ul><li>Fetal hypoglycemia </li></ul></ul><ul><li>High risk women should be screened at first prenatal visit </li></ul><ul><li>Low-risk women should be screened from 24 to 28 weeks of gestation </li></ul>
    14. 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. <ul><li>Total costs 12 billion US $ </li></ul><ul><li>CVD accounts for 64% of total costs </li></ul>Others Ophthalmic disease Cardiovascular disease Renal disease Neurologic disease Peripheral vascular disease
    15. 15. DISPARITIES IN DIABETES COMPLICATIONS IN AFRICAN AMERICANS <ul><li>Contributing factors </li></ul><ul><ul><li>Average delay in diagnosis of 4-7 years </li></ul></ul><ul><ul><li>Longer duration of poorly controlled type 2 </li></ul></ul><ul><ul><li>diabetes </li></ul></ul><ul><ul><li>Development of equally devastating </li></ul></ul><ul><ul><li>complications </li></ul></ul>
    16. 16. MICROVASCULAR COMPLICATIONS OF DIABETES <ul><li>Diabetic retinopathy </li></ul><ul><ul><li>46% higher in African Americans and 86% higher in Mexican Americans than in Caucasians </li></ul></ul><ul><li>Diabetic Nephropathy </li></ul><ul><ul><li>African Americans, Latinos, and Native Americans have 3-4 times higher rates of renal failure than Caucasians </li></ul></ul>
    17. 17. <ul><li>DIABETIC NEUROPATHY </li></ul><ul><li>Primary contributor to the loss of limb protection through the diminution or absence of pain and sensory perception. </li></ul><ul><li>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. </li></ul><ul><li>Lower extremity limb amputation is 2-3 times higher in African Americans and Mexican Americans than in Caucasians. </li></ul>
    18. 18. MACROVASCULAR RISKS OF DIABETES <ul><li>Risk of stroke, coronary artery disease, and peripheral vascular disease is increased 2-4 times in all patients with diabetes. </li></ul><ul><li>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. </li></ul>
    19. 19. MACROVASCULAR RISKS OF DIABETES <ul><li>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. </li></ul><ul><li>Cardiovascular disease (CVD) remains the leading cause of death in individuals with diabetes, up to 70% of type 2 diabetes patients. </li></ul>
    20. 20. <ul><li>RISK REDUCTION OF MACROVASCULAR COMPLICATIONS </li></ul><ul><ul><li>Glycemic Control </li></ul></ul><ul><ul><li>Smoking Cessation </li></ul></ul><ul><ul><li>Blood Pressure Control </li></ul></ul><ul><ul><li>Lipoprotein Management </li></ul></ul><ul><ul><li>Prothrombotic State Improvement </li></ul></ul>
    21. 21. SCREENING GUIDELINES <ul><li>Adults 45 years of age and older esp with BMI > 25 </li></ul><ul><ul><li>Fasting Plasma Glucose at 3 year intervals </li></ul></ul><ul><li>Overweight or obese individuals with risk factors for diabetes, African Americans, Latinos </li></ul><ul><ul><li>Fasting Plasma Glucose screened at an earlier age and more frequently </li></ul></ul><ul><li>Children with BMI > 85 th percentile </li></ul><ul><ul><li>Screened at age 10 and every 2 years thereafter </li></ul></ul>
    22. 22. DIAGNOSTIC CRITERIA <ul><li>Fasting Plasma Glucose > 126 mg/dL </li></ul><ul><li>Casual Blood Sugar > 200 mg/dL or greater as with diabetic symptoms </li></ul><ul><li>2-hour postprandial serum glucose of 200 mg/dL as stimulated by a glucose tolerance test </li></ul><ul><li>Test reconfirmation required </li></ul>
    23. 23. PRE-DIABETIC STATES <ul><li>Impaired glucose tolerance (IGT) </li></ul><ul><ul><li>2-hour glucose between 140 and 199 </li></ul></ul><ul><li>Impaired fasting glucose (IFG) </li></ul><ul><ul><li>Fasting glucose beteween 100 and 125 </li></ul></ul><ul><li>Above are risk factors for future diabetes and cardiovascular disease </li></ul>
    24. 25. TREATMENT GOALS FOR DIABETES MELLITUS <ul><li>Maintaining: </li></ul><ul><li>Pre-meal blood glucose in the range of 90 mg/dL to 130 mg/dL </li></ul><ul><li>Bedtime blood glucose in the range of 100 mg/dL to 140 mg/dL </li></ul><ul><li>A hemoglobin A 1c value from 6.5% to 7% over 3 months </li></ul>
    25. 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
    26. 27. <ul><li>Position in Model Variable P Value* </li></ul><ul><li>First Low-density lipoprotein cholesterol <.0001 </li></ul><ul><li>Second High-density lipoprotein cholesterol .0001 </li></ul><ul><li>Third Hemoglobin A 1c .0022 </li></ul><ul><li>Fourth Systolic blood pressure .0065 </li></ul><ul><li>Fifth Smoking .056 </li></ul>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.
    27. 28. TREATMENT GOALS FOR DIABETES MELLITUS (Cont.) <ul><li>Maintaining: </li></ul><ul><li>Blood pressure < 130/80 mm Hg </li></ul><ul><li>LDL Cholesterol < 100 mg/dL, triglycerides < 150 mg/dL, and HDL cholesterol > 40 mg/dL in men (> 50 mg/dL in women) </li></ul><ul><li>High risk cardiovascular patients should aim for LDL cholesterol < 70 mg/dL </li></ul>
    28. 29. MANAGEMENT PLAN <ul><li>Must be individualized for each individual patient </li></ul><ul><li>Diabetes education: initial and subsequent </li></ul><ul><li>Lifestyle modifications </li></ul><ul><ul><li>Diet (improve your nutrition) </li></ul></ul><ul><ul><li>Exercise (increase your activity) </li></ul></ul><ul><li>Home blood glucose monitoring </li></ul><ul><ul><li>At least once/day for oral medications </li></ul></ul><ul><ul><li>Three times daily for insulin users </li></ul></ul><ul><li>Medications </li></ul>
    29. 30. FOLLOW-UP CARE <ul><li>Annual eye exam </li></ul><ul><li>Physician visits every 3 months, more frequently for poor control </li></ul><ul><ul><li>Fundoscopic exam </li></ul></ul><ul><ul><li>Foot exam </li></ul></ul><ul><li>HbA 1c quarterly for poor control, every biannually for good control </li></ul><ul><li>Lipogram yearly </li></ul><ul><li>Microalbumin yearly </li></ul>
    30. 32. MEDICAL NUTRITIONAL THERAPY <ul><li>Must be individualized for each patient </li></ul><ul><ul><li>Children must be allowed enough calories for growth, development, and activity </li></ul></ul><ul><ul><li>Pregnant women, elderly also deserve special consideration </li></ul></ul><ul><li>Permanent low-carbohydrate diets not recommended </li></ul><ul><ul><li>“ carbohydrate counting” can be done with insulin users </li></ul></ul>
    31. 33. MEDICAL NUTRITIONAL THERAPY (cont) <ul><li>Weight management </li></ul><ul><ul><li>One should aim for 500-1000 Calorie reduction in intake per day </li></ul></ul><ul><ul><li>1000-1200 Calories/day for women, 1200-1600 Calories/day for men for weight reduction </li></ul></ul><ul><ul><li>Bariatrics? </li></ul></ul><ul><li>Activity should consist of 3-5 sessions per week </li></ul><ul><ul><li>30-45 minutes for health </li></ul></ul><ul><ul><li>Weight loss: 1 hour of walking, 30 minutes of vigorous exercise </li></ul></ul>
    32. 34. ORAL MEDICAL THERAPY <ul><li>First line: metformin useful except where contraindicated </li></ul><ul><li>Sulfonylureas or meglitinides also frequently used </li></ul><ul><li>Second line: thiazolidinediones </li></ul><ul><li>Used uncommonly: acarbose </li></ul>
    33. 35. INSULIN <ul><li>Traditional regimens </li></ul><ul><ul><li>Type 1: Basal insulin (NPH, glargine) with bolus regular or short-acting insulin (lispro, aspart, glulisine) by sliding scale; split-mix regimen; insulin pump </li></ul></ul><ul><ul><li>Type 2: split-mix regimen; fixed combination (70/30, 50/50, 75/25); basal-bolus </li></ul></ul><ul><li>Transitional type 2 insulin regimens: oral agents with bedtime NPH or glargine </li></ul>
    34. 36. ADJUNCTS <ul><li>Cardiovascular </li></ul><ul><ul><li>Aspirin </li></ul></ul><ul><li>Renal </li></ul><ul><ul><li>ACE inhibitor/Angiotensin receptor blocker </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>Diuretics </li></ul></ul><ul><li>Cholesterol </li></ul><ul><ul><li>Statins </li></ul></ul>
    35. 37. WHEN TO REFER <ul><li>Poor control for 6 months despite patient adherence and physician manipulation (HbA 1c >10%) </li></ul><ul><li>Multiple episodes of decompensation (DKA, HONK) </li></ul><ul><li>Frequent hypoglycæmic episodes </li></ul>
    36. 38. Reference <ul><li>American Diabetes Association. Diabetes Care 28:S4, 2005 Jan. </li></ul><ul><li>American Association of Clinical Endocrinologists. Endocrine Practice 8:S40, 2002 Jan/Feb. </li></ul>