diabetes guidelines
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Diabetes Guidelines
Kevin H McKinney MDUniversity of Texas Medical Branch at GalvestonDivision of Endocrinology/Stark Diabetes Center
DIABETES MELLITUS
•Inability of the body to metabolize blood sugar
•A disease of inadequate insulin secretion and action
•Hyperglycemia is the main manifestation
COMPLICATIONS
Chronic hyperglycemia may cause:–retinal damage–chronic kidney disease–nerve damage–vascular disease
COMPLICATIONS (cont.)
•Blindness•Dialysis•Lower Limb Amputation•Stroke•Myocardial infarction•Claudication
PRIMARY CLASSES OF DIABETES MELLITUS
•Type 1–Autoimmune destruction of islets–No insulin secretion
•Type 2 Diabetes–Insulin resistance with progressive insulin secretory defect–90% are obese
PREVALENCE OF TYPE 1 DIABETES IN THE US
• 1 million people
• Caucasians constitute the majority of
type 1 diabetics
• Most prominent during childhood
PREVALENCE OF TYPE 2 DIABETES IN THE US
• Most common type of diabetes among
all ethnic groups
• 17 million patients with known diabetes
• 45% of children and teens with new
diagnoses
PREVALENCE OF TYPE 2 DIABETES IN THE US
• Caucasian women experience higher
prevalence rates than men (57% vs. 26%)
• By age 70, African American prevalence
rates increase to 42% of the population
METABOLIC SYNDROME
• Insulin resistance (type 2 diabetes)
• Hypertension
• Dyslipidemia
• Polycystic ovary syndrome
• Hyperuricemia
• Hypercoagulability
PREVALENCE OF METABOLIC SYNDROME IN THE US
•Third NHANES Study (Prevalence Rates)
–21.6% African American Adults
–31.9% Mexican American Adults
–23.8% Caucasian Adults
OBESITY—A PUBLIC HEALTH PROBLEM
Rise in metabolic syndrome is related to increasing prevalence of obesity
Multifactorial causes for obesity including– A sedentary lifestyle – Decline in exercise– Increased access to unhealthy foods– Greater food portions
GESTATIONAL DIABETES
• Occurs after the onset of pregnancy
• Is secondary to the production of human
placental lactogen and other hormones
needed to sustain pregnancy
• Most common in people of color
GESTATIONAL DIABETES
•If untreated, may result in fetal macrosomia•Fetal macrosomia may lead to
–Cesarean section–Shoulder dystocia–Fetal hypoglycemia
•High risk women should be screened at first prenatal visit•Low-risk women should be screened from 24 to 28 weeks of gestation
Hospitalization Costs for Chronic Complications of Diabetes in the US
American Diabetes Association. Economic Consequences of Diabetes Mellitusin the US in 1997. Alexandria, VA: American Diabetes Association, 1998:1-14.
Total costs 12 billion US $
CVD accounts for 64% of total costs
OthersOphthalmic
disease
Cardiovasculardisease
Renal disease
Neurologic disease
Peripheral vascular disease
DISPARITIES IN DIABETES COMPLICATIONS IN AFRICAN AMERICANS
• Contributing factors–Average delay in diagnosis of 4-7 years–Longer duration of poorly controlled type 2
diabetes–Development of equally devastating
complications
MICROVASCULAR COMPLICATIONS OF DIABETES
•Diabetic retinopathy–46% higher in African Americans and 86% higher in Mexican Americans than in Caucasians
•Diabetic Nephropathy–African Americans, Latinos, and Native Americans have 3-4 times higher rates of renal failure than Caucasians
•
DIABETIC NEUROPATHY
•Primary contributor to the loss of limb protection through the diminution or absence of pain and sensory perception.
•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.
•Lower extremity limb amputation is 2-3 times higher in African Americans and Mexican Americans than in Caucasians.
MACROVASCULAR RISKS OF DIABETES
• Risk of stroke, coronary artery disease, and peripheral vascular disease is increased 2-4 times in all patients with diabetes.
• 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.
MACROVASCULAR RISKS OF DIABETES
• 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.
• Cardiovascular disease (CVD) remains the leading cause of death in individuals with diabetes, up to 70% of type 2 diabetes patients.
•
RISK REDUCTION OF MACROVASCULAR COMPLICATIONS
–Glycemic Control
–Smoking Cessation
–Blood Pressure Control
–Lipoprotein Management
–Prothrombotic State Improvement
SCREENING GUIDELINES
• Adults 45 years of age and older esp with BMI > 25
– Fasting Plasma Glucose at 3 year intervals
• Overweight or obese individuals with risk factors for diabetes, African Americans, Latinos– Fasting Plasma Glucose screened at an earlier age
and more frequently
• Children with BMI > 85th percentile
– Screened at age 10 and every 2 years thereafter
DIAGNOSTIC CRITERIA
• Fasting Plasma Glucose > 126 mg/dL
• Casual Blood Sugar > 200 mg/dL or greater as with diabetic symptoms
• 2-hour postprandial serum glucose of 200 mg/dL as stimulated by a glucose tolerance test
• Test reconfirmation required
PRE-DIABETIC STATES
• Impaired glucose tolerance (IGT)– 2-hour glucose between 140 and 199
• Impaired fasting glucose (IFG)– Fasting glucose beteween 100 and 125
• Above are risk factors for future diabetes and cardiovascular disease
Diabetes Prevention ProgramScreened 158,177
OGTT, then randomize
Metformin1073
Lifestyle1079
3819 randomized
Placebo1082
Thiazolidinedione585
3% Wt loss5% Wt loss ~10 month followup
31% Risk Reduction
58 %Risk Reduction
Diabetes Rate11 % per year
23 %Risk Reduction
Diabetes Prevention Program Research Diabetes Prevention Program Research GpGp, , NEJM NEJM 346(6): 393346(6): 393--403, 2002.403, 2002.
TREATMENT GOALS FOR DIABETES MELLITUS
Maintaining: • Pre-meal blood glucose in the range of
90 mg/dL to 130 mg/dL
• Bedtime blood glucose in the range of 100 mg/dL to 140 mg/dL
• A hemoglobin A1c value from 6.5% to 7% over 3 months
* Updated mean A1c 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.
Increased A1c Raises Vascular Event Risk
MyocardialInfarction
MicrovascularComplications
Updated Mean A1c (%)*
Adj
uste
d In
cide
nce
per
1000
Pat
ient
-Yea
rs (%
)
0
20
40
60
80
0 5 6 7 8 9 10 11
•Positionin Model Variable P Value*
•First Low-density lipoprotein cholesterol <.0001
•Second High-density lipoprotein cholesterol .0001
•Third Hemoglobin A1c .0022
•Fourth Systolic blood pressure .0065
•Fifth Smoking .056
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.
Established Modifiable Cardiovascular Risk Factors In Type 2 Diabetes
TREATMENT GOALS FOR DIABETES MELLITUS (Cont.)
Maintaining:
• Blood pressure < 130/80 mm Hg
• LDL Cholesterol < 100 mg/dL, triglycerides < 150 mg/dL, and HDL cholesterol > 40 mg/dL in men (> 50 mg/dL in women)
• High risk cardiovascular patients should aim for LDL cholesterol < 70 mg/dL
MANAGEMENT PLAN
• Must be individualized for each individual patient
• Diabetes education: initial and subsequent• Lifestyle modifications
– Diet (improve your nutrition)– Exercise (increase your activity)
• Home blood glucose monitoring– At least once/day for oral medications– Three times daily for insulin users
• Medications
FOLLOW-UP CARE
• Annual eye exam• Physician visits every 3 months, more
frequently for poor control– Fundoscopic exam– Foot exam
• HbA1c quarterly for poor control, every biannually for good control
• Lipogram yearly• Microalbumin yearly
Years of Diabetes * IGT = impaired glucose
tolerance.
Obesity IGT* Diabetes Uncontrolled Hyperglycemia
Relative -Cell Function
100 (%)
-20 -10 0 10 20 30
PlasmaGlucose
Insulin Resistance
Insulin Secretion
120 (mg/dL)
Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.
Fasting Glucose
Post-Meal Glucose
Natural History of Type 2 Diabetes
MEDICAL NUTRITIONAL THERAPY
• Must be individualized for each patient– Children must be allowed enough calories
for growth, development, and activity– Pregnant women, elderly also deserve
special consideration
• Permanent low-carbohydrate diets not recommended– “carbohydrate counting” can be done with
insulin users
MEDICAL NUTRITIONAL THERAPY (cont)
• Weight management– One should aim for 500-1000 Calorie reduction in
intake per day– 1000-1200 Calories/day for women, 1200-1600
Calories/day for men for weight reduction– Bariatrics?
• Activity should consist of 3-5 sessions per week– 30-45 minutes for health– Weight loss: 1 hour of walking, 30 minutes of
vigorous exercise
ORAL MEDICAL THERAPY
• First line: metformin useful except where contraindicated
• Sulfonylureas or meglitinides also frequently used
• Second line: thiazolidinediones
• Used uncommonly: acarbose
INSULIN
• Traditional regimens– Type 1: Basal insulin (NPH, glargine) with
bolus regular or short-acting insulin (lispro, aspart, glulisine) by sliding scale; split-mix regimen; insulin pump
– Type 2: split-mix regimen; fixed combination (70/30, 50/50, 75/25); basal-bolus
• Transitional type 2 insulin regimens: oral agents with bedtime NPH or glargine
ADJUNCTS
• Cardiovascular– Aspirin
• Renal– ACE inhibitor/Angiotensin receptor blocker
• Hypertension– Diuretics
• Cholesterol– Statins
WHEN TO REFER
• Poor control for 6 months despite patient adherence and physician manipulation (HbA1c >10%)
• Multiple episodes of decompensation (DKA, HONK)
• Frequent hypoglycæmic episodes
Reference
• American Diabetes Association. Diabetes Care 28:S4, 2005 Jan.
• American Association of Clinical Endocrinologists. Endocrine Practice 8:S40, 2002 Jan/Feb.