type 2 diabetes mellitus review of clinical practice guidelines

TYPE 2 DIABETES MELLITUS

Review of Clinical Practice Guidelines

TYPE 2 DIABETES MELLITUS

Review of Clinical Practice Guidelines

WEEK 1: Diagnosis and EvaluationWEEK 1: Diagnosis and Evaluation

UHN AIMGP CLINIC UHN AIMGP CLINIC SEMINAR SERIES 2007SEMINAR SERIES 2007

Updated by Dr. K. TzanetosUpdated by Dr. K. Tzanetos

WEEK 1: Diagnosis and EvaluationWEEK 1: Diagnosis and Evaluation

UHN AIMGP CLINIC UHN AIMGP CLINIC SEMINAR SERIES 2007SEMINAR SERIES 2007

Updated by Dr. K. TzanetosUpdated by Dr. K. Tzanetos

TYPE 2 DIABETES MELLITUSReview of Clinical Practice Guidelines

TYPE 2 DIABETES MELLITUSReview of Clinical Practice GuidelinesCanadian Diabetes Association (CDA): 2003 Canadian Diabetes Association (CDA): 2003

Clinical Practice Guidelines for the Prevention Clinical Practice Guidelines for the Prevention and Management of diabetes in Canada.and Management of diabetes in Canada.

Can J Diabetes 2003; 27 (Suppl 2).Can J Diabetes 2003; 27 (Suppl 2). http://www.diabetes.ca/cpg2003http://www.diabetes.ca/cpg2003

American Diabetes Association (ADA): Clinical American Diabetes Association (ADA): Clinical Practice Recommendations 2004.Practice Recommendations 2004.

Diabetes Care 2004; 27 (Suppl 1).Diabetes Care 2004; 27 (Suppl 1).

Canadian Diabetes Association (CDA): 2003 Canadian Diabetes Association (CDA): 2003 Clinical Practice Guidelines for the Prevention Clinical Practice Guidelines for the Prevention and Management of diabetes in Canada.and Management of diabetes in Canada.

Can J Diabetes 2003; 27 (Suppl 2).Can J Diabetes 2003; 27 (Suppl 2). http://www.diabetes.ca/cpg2003http://www.diabetes.ca/cpg2003

American Diabetes Association (ADA): Clinical American Diabetes Association (ADA): Clinical Practice Recommendations 2004.Practice Recommendations 2004.

Diabetes Care 2004; 27 (Suppl 1).Diabetes Care 2004; 27 (Suppl 1).

TYPE 2 DIABETES MELLITUSTYPE 2 DIABETES MELLITUS

Objectives:Objectives:

1) Examine diagnostic criteria for type 2 diabetes1) Examine diagnostic criteria for type 2 diabetes2) Discuss screening recommendations for type 2) Discuss screening recommendations for type

2 2 diabetesdiabetes3) Explore the suggested evaluation for first visit3) Explore the suggested evaluation for first visit4) Appreciate the importance of follow-up4) Appreciate the importance of follow-up5) Identify specific disease complications5) Identify specific disease complications

- retinopathy/nephropathy/foot - retinopathy/nephropathy/foot ulcerationsulcerations

Objectives:Objectives:

1) Examine diagnostic criteria for type 2 diabetes1) Examine diagnostic criteria for type 2 diabetes2) Discuss screening recommendations for type 2) Discuss screening recommendations for type

2 2 diabetesdiabetes3) Explore the suggested evaluation for first visit3) Explore the suggested evaluation for first visit4) Appreciate the importance of follow-up4) Appreciate the importance of follow-up5) Identify specific disease complications5) Identify specific disease complications

- retinopathy/nephropathy/foot - retinopathy/nephropathy/foot ulcerationsulcerations

CASE:CASE:Mrs. X is a 58 year old woman referred to Mrs. X is a 58 year old woman referred to

the AIMGP clinic by her GP with a the AIMGP clinic by her GP with a random glucose of 12.0 mmol/L. She random glucose of 12.0 mmol/L. She feels well with no complaints and this feels well with no complaints and this testing was done as a part of her testing was done as a part of her routine blood work.routine blood work.

Does she have diabetes ?Does she have diabetes ? What further testing could help you to What further testing could help you to

decide?decide?

CASE:CASE:Mrs. X is a 58 year old woman referred to Mrs. X is a 58 year old woman referred to

the AIMGP clinic by her GP with a the AIMGP clinic by her GP with a random glucose of 12.0 mmol/L. She random glucose of 12.0 mmol/L. She feels well with no complaints and this feels well with no complaints and this testing was done as a part of her testing was done as a part of her routine blood work.routine blood work.

Does she have diabetes ?Does she have diabetes ? What further testing could help you to What further testing could help you to

decide?decide?

DIABETES MELLITUS Take a minute to discuss…DIABETES MELLITUS Take a minute to discuss…

CASE: Mrs. X.CASE: Mrs. X. Does she have diabetes?Does she have diabetes?

Likely! BUT you must do further tests.Likely! BUT you must do further tests.

Further testing needed…2 confirmatory Further testing needed…2 confirmatory laboratory glucose tests (FBG, random laboratory glucose tests (FBG, random PG or 2hr 75g OGTT) on separate days PG or 2hr 75g OGTT) on separate days in the absence of unequivocal in the absence of unequivocal hyperglycemia accompanied by an hyperglycemia accompanied by an acute metabolic decompensation.acute metabolic decompensation.

CASE: Mrs. X.CASE: Mrs. X. Does she have diabetes?Does she have diabetes?

Likely! BUT you must do further tests.Likely! BUT you must do further tests.

Further testing needed…2 confirmatory Further testing needed…2 confirmatory laboratory glucose tests (FBG, random laboratory glucose tests (FBG, random PG or 2hr 75g OGTT) on separate days PG or 2hr 75g OGTT) on separate days in the absence of unequivocal in the absence of unequivocal hyperglycemia accompanied by an hyperglycemia accompanied by an acute metabolic decompensation.acute metabolic decompensation.

DIABETES MELLITUS Diagnostic Criteria for Type 2 DMDIABETES MELLITUS Diagnostic Criteria for Type 2 DM

Random PG ≥ 11.1mmol/L* Random PG ≥ 11.1mmol/L* andand symptoms of symptoms of diabetesdiabetes

ORORFasting plasma glucose (FPG) ≥ 7.0 mmol/LFasting plasma glucose (FPG) ≥ 7.0 mmol/L††

OROR2h PG in a 75-g oral glucose tolerance test (OGTT) 2h PG in a 75-g oral glucose tolerance test (OGTT)

≥ 11.1 mmol/L≥ 11.1 mmol/L

* Symptoms include fatigue, polyuria, polydipsia * Symptoms include fatigue, polyuria, polydipsia and weight lossand weight loss

†† Fasting is defined as no caloric intake for at least 8 Fasting is defined as no caloric intake for at least 8 hh

Random PG ≥ 11.1mmol/L* Random PG ≥ 11.1mmol/L* andand symptoms of symptoms of diabetesdiabetes

ORORFasting plasma glucose (FPG) ≥ 7.0 mmol/LFasting plasma glucose (FPG) ≥ 7.0 mmol/L††

OROR2h PG in a 75-g oral glucose tolerance test (OGTT) 2h PG in a 75-g oral glucose tolerance test (OGTT)

≥ 11.1 mmol/L≥ 11.1 mmol/L

* Symptoms include fatigue, polyuria, polydipsia * Symptoms include fatigue, polyuria, polydipsia and weight lossand weight loss

†† Fasting is defined as no caloric intake for at least 8 Fasting is defined as no caloric intake for at least 8 hh


Glucose levels (mmol/L) for diagnosis:Glucose levels (mmol/L) for diagnosis:Glucose levels (mmol/L) for diagnosis:Glucose levels (mmol/L) for diagnosis:


FPGFPG 2 h PG in a 2 h PG in a 75-g OGTT75-g OGTT

IFGIFG 6.1 - 6.96.1 - 6.9 NANA

IFG IFG (isolated)(isolated)

6.1 - 6.96.1 - 6.9 andand < 7.8< 7.8

IGT IGT (isolated)(isolated)

< 6.1< 6.1 andand 7.8 - 11.07.8 - 11.0

IFG and IGTIFG and IGT 6.1 - 6.96.1 - 6.9 andand 7.8 - 11.07.8 - 11.0

DiabetesDiabetes ≥ ≥ 7.07.0 oror ≥ ≥ 11.111.1

BACK TO THE CASE: Mrs. X is a Caucasian BACK TO THE CASE: Mrs. X is a Caucasian female who has no other PMHx. Her female who has no other PMHx. Her family history is negative.family history is negative.

Should Mrs. X. have been screened before now for type 2 diabetes? By what method?

What high risk groups should undergo more frequent or earlier screening?

BACK TO THE CASE: Mrs. X is a Caucasian BACK TO THE CASE: Mrs. X is a Caucasian female who has no other PMHx. Her female who has no other PMHx. Her family history is negative.family history is negative.

Should Mrs. X. have been screened before now for type 2 diabetes? By what method?

What high risk groups should undergo more frequent or earlier screening?


All individuals should be evaluated All individuals should be evaluated annually for DM2 risk annually for DM2 risk (demographic/clinical criteria)(demographic/clinical criteria)

In persons 40 yrs of age screening for In persons 40 yrs of age screening for DM2 using a FPG should be performed DM2 using a FPG should be performed every 3 yrsevery 3 yrs

More frequent and/or earlier screening More frequent and/or earlier screening should be considered in ‘high risk’ should be considered in ‘high risk’ groupsgroups

All individuals should be evaluated All individuals should be evaluated annually for DM2 risk annually for DM2 risk (demographic/clinical criteria)(demographic/clinical criteria)

In persons 40 yrs of age screening for In persons 40 yrs of age screening for DM2 using a FPG should be performed DM2 using a FPG should be performed every 3 yrsevery 3 yrs

More frequent and/or earlier screening More frequent and/or earlier screening should be considered in ‘high risk’ should be considered in ‘high risk’ groupsgroups

DIABETES MELLITUS 3) Screening for Type 2 DMDIABETES MELLITUS 3) Screening for Type 2 DM

Risk factors for Type 2 DM (CDA)Risk factors for Type 2 DM (CDA) First-degree relative with diabetesFirst-degree relative with diabetes Member of high-risk population (e.g. persons of Member of high-risk population (e.g. persons of

Aboriginal, Hispanic, S. African, Asian or S. Asian Aboriginal, Hispanic, S. African, Asian or S. Asian descent)descent)

History of IGT or IFGHistory of IGT or IFG Presence of complications of DMPresence of complications of DM Vascular disease (**assoc. with the metabolic Vascular disease (**assoc. with the metabolic

synD)synD) History of GDMHistory of GDM

Risk factors for Type 2 DM (CDA)Risk factors for Type 2 DM (CDA) First-degree relative with diabetesFirst-degree relative with diabetes Member of high-risk population (e.g. persons of Member of high-risk population (e.g. persons of

Aboriginal, Hispanic, S. African, Asian or S. Asian Aboriginal, Hispanic, S. African, Asian or S. Asian descent)descent)

History of IGT or IFGHistory of IGT or IFG Presence of complications of DMPresence of complications of DM Vascular disease (**assoc. with the metabolic Vascular disease (**assoc. with the metabolic

synD)synD) History of GDMHistory of GDM


Risk factors for Type 2 DM (CDA) cont’Risk factors for Type 2 DM (CDA) cont’ History of macrosomal infantHistory of macrosomal infant HTN (**)HTN (**) Dyslipidemia (**)Dyslipidemia (**) Overweight (**)Overweight (**) PCOS (**)PCOS (**) Acanthosis nigricans (**)Acanthosis nigricans (**) Schizophrenia (incidence 3X higher than the gen. Schizophrenia (incidence 3X higher than the gen.

population)population)

Risk factors for Type 2 DM (CDA) cont’Risk factors for Type 2 DM (CDA) cont’ History of macrosomal infantHistory of macrosomal infant HTN (**)HTN (**) Dyslipidemia (**)Dyslipidemia (**) Overweight (**)Overweight (**) PCOS (**)PCOS (**) Acanthosis nigricans (**)Acanthosis nigricans (**) Schizophrenia (incidence 3X higher than the gen. Schizophrenia (incidence 3X higher than the gen.

population)population)


CDA guidelines mandate CDA guidelines mandate yearlyyearly screening in screening in patients with:patients with:

Hx of IFG or IGTHx of IFG or IGTPresence of complications associated with Presence of complications associated with

diabetesdiabetesHx of gestational diabetes or macrosomic infant Hx of gestational diabetes or macrosomic infant

(>4kg)(>4kg)Presence of HTN or CADPresence of HTN or CAD

Screening MethodScreening Method FPG (universal recommendation)FPG (universal recommendation) 2 h PG OGTT if FPG not diagnostic2 h PG OGTT if FPG not diagnostic Lack of standardization of the HBA1C test precludes Lack of standardization of the HBA1C test precludes

its use for diagnosisits use for diagnosis

CDA guidelines mandate CDA guidelines mandate yearlyyearly screening in screening in patients with:patients with:

Hx of IFG or IGTHx of IFG or IGTPresence of complications associated with Presence of complications associated with

diabetesdiabetesHx of gestational diabetes or macrosomic infant Hx of gestational diabetes or macrosomic infant

(>4kg)(>4kg)Presence of HTN or CADPresence of HTN or CAD

Screening MethodScreening Method FPG (universal recommendation)FPG (universal recommendation) 2 h PG OGTT if FPG not diagnostic2 h PG OGTT if FPG not diagnostic Lack of standardization of the HBA1C test precludes Lack of standardization of the HBA1C test precludes

its use for diagnosisits use for diagnosis


CASE:CASE:• Assume that you have taken a thorough Assume that you have taken a thorough

medical history from Mrs. X that has medical history from Mrs. X that has included symptoms of hyperglycemia, included symptoms of hyperglycemia, symptoms of macrovascular and symptoms of macrovascular and microvascular complications, nutritional microvascular complications, nutritional details, and medical co-morbidities.details, and medical co-morbidities.

What would you now like to emphasize What would you now like to emphasize on Mrs. X.’s physical examination during on Mrs. X.’s physical examination during her initial visit?her initial visit?

CASE:CASE:• Assume that you have taken a thorough Assume that you have taken a thorough

medical history from Mrs. X that has medical history from Mrs. X that has included symptoms of hyperglycemia, included symptoms of hyperglycemia, symptoms of macrovascular and symptoms of macrovascular and microvascular complications, nutritional microvascular complications, nutritional details, and medical co-morbidities.details, and medical co-morbidities.

What would you now like to emphasize What would you now like to emphasize on Mrs. X.’s physical examination during on Mrs. X.’s physical examination during her initial visit?her initial visit?


PE in a patient with DM:PE in a patient with DM: GeneralGeneral (height, weight, BMI, postural BP, HR) (height, weight, BMI, postural BP, HR) H & NH & N (Pupils, EOMs, Lens opacities, fundi, oral (Pupils, EOMs, Lens opacities, fundi, oral

hygiene and dental caries, thyroid)hygiene and dental caries, thyroid) CVSCVS (signs of HTN, CHF, CAD; pulses, bruits, other (signs of HTN, CHF, CAD; pulses, bruits, other

signs of PVD)signs of PVD) AbdomenAbdomen (hepatomegaly) (hepatomegaly) GUGU (r/o fungal infections, bladder distension) (r/o fungal infections, bladder distension) MSKMSK (foot inspection, colour, temperature, (foot inspection, colour, temperature,

arthropathy)arthropathy) NeuroNeuro (dysesthesiae, change in proprioception, (dysesthesiae, change in proprioception,

vibration, light touch [monofilament], reflexes, vibration, light touch [monofilament], reflexes, autonomic nervous system)autonomic nervous system)

SkinSkin (infections, dyslipidemias, ulcers, trauma, (infections, dyslipidemias, ulcers, trauma, injection sites)injection sites)

PE in a patient with DM:PE in a patient with DM: GeneralGeneral (height, weight, BMI, postural BP, HR) (height, weight, BMI, postural BP, HR) H & NH & N (Pupils, EOMs, Lens opacities, fundi, oral (Pupils, EOMs, Lens opacities, fundi, oral

hygiene and dental caries, thyroid)hygiene and dental caries, thyroid) CVSCVS (signs of HTN, CHF, CAD; pulses, bruits, other (signs of HTN, CHF, CAD; pulses, bruits, other

signs of PVD)signs of PVD) AbdomenAbdomen (hepatomegaly) (hepatomegaly) GUGU (r/o fungal infections, bladder distension) (r/o fungal infections, bladder distension) MSKMSK (foot inspection, colour, temperature, (foot inspection, colour, temperature,

arthropathy)arthropathy) NeuroNeuro (dysesthesiae, change in proprioception, (dysesthesiae, change in proprioception,

vibration, light touch [monofilament], reflexes, vibration, light touch [monofilament], reflexes, autonomic nervous system)autonomic nervous system)

SkinSkin (infections, dyslipidemias, ulcers, trauma, (infections, dyslipidemias, ulcers, trauma, injection sites)injection sites)

DIABETES MELLITUS Evaluation at first visitDIABETES MELLITUS Evaluation at first visit

CASE:CASE: What laboratory tests would you like to What laboratory tests would you like to

obtain on or shortly after Mrs. X.’s initial obtain on or shortly after Mrs. X.’s initial visit ?visit ?

CASE:CASE: What laboratory tests would you like to What laboratory tests would you like to

obtain on or shortly after Mrs. X.’s initial obtain on or shortly after Mrs. X.’s initial visit ?visit ?


What laboratory tests would you like to obtain on What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit (ADA)?or shortly after Mrs. X.’s initial visit (ADA)? FPG (optional), HbA1cFPG (optional), HbA1c Fasting lipid profileFasting lipid profile Serum creatinine, UrinalysisSerum creatinine, Urinalysis Test for microalbuminuria (type 1 diabetic patients Test for microalbuminuria (type 1 diabetic patients

after at least 5 years and in all patients with type 2 after at least 5 years and in all patients with type 2 diabetes at diagnosis)diabetes at diagnosis)

Urine culture (if indicated)Urine culture (if indicated) Thyroid-stimulating hormone (TSH) in all type 1 Thyroid-stimulating hormone (TSH) in all type 1

diabetic patients; in type 2 if clinically indicateddiabetic patients; in type 2 if clinically indicated ECGECG

What laboratory tests would you like to obtain on What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit (ADA)?or shortly after Mrs. X.’s initial visit (ADA)? FPG (optional), HbA1cFPG (optional), HbA1c Fasting lipid profileFasting lipid profile Serum creatinine, UrinalysisSerum creatinine, Urinalysis Test for microalbuminuria (type 1 diabetic patients Test for microalbuminuria (type 1 diabetic patients

after at least 5 years and in all patients with type 2 after at least 5 years and in all patients with type 2 diabetes at diagnosis)diabetes at diagnosis)

Urine culture (if indicated)Urine culture (if indicated) Thyroid-stimulating hormone (TSH) in all type 1 Thyroid-stimulating hormone (TSH) in all type 1

diabetic patients; in type 2 if clinically indicateddiabetic patients; in type 2 if clinically indicated ECGECG

DIABETES MELLITUS Evaluation at first visitDIABETES MELLITUS Evaluation at first visit

CASE:CASE: How frequently should patients like Mrs. X be How frequently should patients like Mrs. X be

followed after the initial visit?followed after the initial visit?

Consider the following patient circumstances:Consider the following patient circumstances: Diabetes is Diet controlledDiabetes is Diet controlled Patient on oral hypoglyemics (at initiation, when Patient on oral hypoglyemics (at initiation, when

titrating, on maintenance dosing)titrating, on maintenance dosing) Patient on insulin (at initiation, when titrating, on Patient on insulin (at initiation, when titrating, on

maintenance dosing)maintenance dosing) For routine visits if they are meeting goalsFor routine visits if they are meeting goals For routine visits if they are not meeting goalsFor routine visits if they are not meeting goals

CASE:CASE: How frequently should patients like Mrs. X be How frequently should patients like Mrs. X be

followed after the initial visit?followed after the initial visit?

Consider the following patient circumstances:Consider the following patient circumstances: Diabetes is Diet controlledDiabetes is Diet controlled Patient on oral hypoglyemics (at initiation, when Patient on oral hypoglyemics (at initiation, when

titrating, on maintenance dosing)titrating, on maintenance dosing) Patient on insulin (at initiation, when titrating, on Patient on insulin (at initiation, when titrating, on

maintenance dosing)maintenance dosing) For routine visits if they are meeting goalsFor routine visits if they are meeting goals For routine visits if they are not meeting goalsFor routine visits if they are not meeting goals


Follow-up Visit Frequency (ADA)?Follow-up Visit Frequency (ADA)? Daily for initiation of insulin or change in Daily for initiation of insulin or change in

regimenregimen Weekly for initiation of oral hypoglycemic Weekly for initiation of oral hypoglycemic

agents or change in regimenagents or change in regimen(Are we meeting, or do we need to meet, (Are we meeting, or do we need to meet, these guidelines in AIMGP?)these guidelines in AIMGP?)

Routine diabetes visits:Routine diabetes visits:Quarterly for patients who are not Quarterly for patients who are not

meeting goalsmeeting goals (Is this frequent enough?)(Is this frequent enough?)Semi-annually for patients with well-Semi-annually for patients with well-

controlled diabetescontrolled diabetes

Follow-up Visit Frequency (ADA)?Follow-up Visit Frequency (ADA)? Daily for initiation of insulin or change in Daily for initiation of insulin or change in

regimenregimen Weekly for initiation of oral hypoglycemic Weekly for initiation of oral hypoglycemic

agents or change in regimenagents or change in regimen(Are we meeting, or do we need to meet, (Are we meeting, or do we need to meet, these guidelines in AIMGP?)these guidelines in AIMGP?)

Routine diabetes visits:Routine diabetes visits:Quarterly for patients who are not Quarterly for patients who are not

meeting goalsmeeting goals (Is this frequent enough?)(Is this frequent enough?)Semi-annually for patients with well-Semi-annually for patients with well-

controlled diabetescontrolled diabetes

DIABETES MELLITUS Evaluation in follow-upDIABETES MELLITUS Evaluation in follow-up

CASE:CASE:

What historical information will you gather on Mrs. X’s What historical information will you gather on Mrs. X’s follow-up visits?follow-up visits?

What would you like to emphasize on Mrs. X.’s physical What would you like to emphasize on Mrs. X.’s physical examination during her follow-up visits?examination during her follow-up visits? Include discussion on appropriate frequency of various maneuversInclude discussion on appropriate frequency of various maneuvers

What laboratory tests would you like to obtain on or What laboratory tests would you like to obtain on or shortly after Mrs. X.’s follow-up visits?shortly after Mrs. X.’s follow-up visits? Include discussion on appropriate frequency of various testsInclude discussion on appropriate frequency of various tests

CASE:CASE:

What historical information will you gather on Mrs. X’s What historical information will you gather on Mrs. X’s follow-up visits?follow-up visits?

What would you like to emphasize on Mrs. X.’s physical What would you like to emphasize on Mrs. X.’s physical examination during her follow-up visits?examination during her follow-up visits? Include discussion on appropriate frequency of various maneuversInclude discussion on appropriate frequency of various maneuvers

What laboratory tests would you like to obtain on or What laboratory tests would you like to obtain on or shortly after Mrs. X.’s follow-up visits?shortly after Mrs. X.’s follow-up visits? Include discussion on appropriate frequency of various testsInclude discussion on appropriate frequency of various tests



History taking on follow-up visits:History taking on follow-up visits: Treatment regimens (frequency of Treatment regimens (frequency of

hyper/hypoglycemia, acute symptoms, self-hyper/hypoglycemia, acute symptoms, self-monitoring BG results, pt regimen monitoring BG results, pt regimen adjustments, adherence problems)adjustments, adherence problems)

Lifestyle changes Lifestyle changes Symptoms of chronic complications Symptoms of chronic complications

(including ensuring visits to opthomologist)(including ensuring visits to opthomologist) Changes in co-morbiditiesChanges in co-morbidities Psychosocial issuesPsychosocial issues Immunization statusImmunization status

History taking on follow-up visits:History taking on follow-up visits: Treatment regimens (frequency of Treatment regimens (frequency of

hyper/hypoglycemia, acute symptoms, self-hyper/hypoglycemia, acute symptoms, self-monitoring BG results, pt regimen monitoring BG results, pt regimen adjustments, adherence problems)adjustments, adherence problems)

Lifestyle changes Lifestyle changes Symptoms of chronic complications Symptoms of chronic complications

(including ensuring visits to opthomologist)(including ensuring visits to opthomologist) Changes in co-morbiditiesChanges in co-morbidities Psychosocial issuesPsychosocial issues Immunization statusImmunization status

• Type 2 diabetes:Type 2 diabetes:• At time of diagnosisAt time of diagnosis• 1 year or less if retinopathy present1 year or less if retinopathy present• Every 1-2 yrs on advice of eye care Every 1-2 yrs on advice of eye care

professional if no evidence of retinopathyprofessional if no evidence of retinopathy

• Type 2 diabetes:Type 2 diabetes:• At time of diagnosisAt time of diagnosis• 1 year or less if retinopathy present1 year or less if retinopathy present• Every 1-2 yrs on advice of eye care Every 1-2 yrs on advice of eye care

professional if no evidence of retinopathyprofessional if no evidence of retinopathy

DIABETES MELLITUS A Note on Retinopathy: Opthomology Follow-up

DIABETES MELLITUS A Note on Retinopathy: Opthomology Follow-up

Physical Examination at Follow-up Visits Physical Examination at Follow-up Visits (ADA)?(ADA)?

At every regular diabetes visit:At every regular diabetes visit:WeightWeightBPBPPrevious abnormalities on physical examPrevious abnormalities on physical exam

Complete physical exam Complete physical exam annuallyannually Comprehensive foot examination annually Comprehensive foot examination annually

and visual inspection at and visual inspection at every visitevery visit (and (and shoes!!)shoes!!)

Physical Examination at Follow-up Visits Physical Examination at Follow-up Visits (ADA)?(ADA)?

At every regular diabetes visit:At every regular diabetes visit:WeightWeightBPBPPrevious abnormalities on physical examPrevious abnormalities on physical exam

Complete physical exam Complete physical exam annuallyannually Comprehensive foot examination annually Comprehensive foot examination annually

and visual inspection at and visual inspection at every visitevery visit (and (and shoes!!)shoes!!)


Initial visit and annually thereafter IDENTIFY: Initial visit and annually thereafter IDENTIFY: Peripheral neuropathy (monofilament or vibration)Peripheral neuropathy (monofilament or vibration)Altered biomechanics (evidence of increased Altered biomechanics (evidence of increased

pressure - callus, erythema; limited joint mobility; pressure - callus, erythema; limited joint mobility; bony deformity; or severe nail pathology - thick bony deformity; or severe nail pathology - thick nails)nails)

Peripheral vascular disease (hx of claudication, Peripheral vascular disease (hx of claudication, pulse exam, skin exam)pulse exam, skin exam)

History of ulcers or amputationHistory of ulcers or amputation The presence of any of these risk factors The presence of any of these risk factors

requires visualization of the patient’s feet at requires visualization of the patient’s feet at every subsequent visitevery subsequent visit

Initial visit and annually thereafter IDENTIFY: Initial visit and annually thereafter IDENTIFY: Peripheral neuropathy (monofilament or vibration)Peripheral neuropathy (monofilament or vibration)Altered biomechanics (evidence of increased Altered biomechanics (evidence of increased

pressure - callus, erythema; limited joint mobility; pressure - callus, erythema; limited joint mobility; bony deformity; or severe nail pathology - thick bony deformity; or severe nail pathology - thick nails)nails)

Peripheral vascular disease (hx of claudication, Peripheral vascular disease (hx of claudication, pulse exam, skin exam)pulse exam, skin exam)

History of ulcers or amputationHistory of ulcers or amputation The presence of any of these risk factors The presence of any of these risk factors

requires visualization of the patient’s feet at requires visualization of the patient’s feet at every subsequent visitevery subsequent visit

DIABETES MELLITUS A Note on Foot CareDIABETES MELLITUS A Note on Foot Care

Laboratory tests at follow-up visits Laboratory tests at follow-up visits (ADA)(ADA) HbA1cHbA1c

Quarterly Quarterly if medications change or if medications change or patient not meeting goalspatient not meeting goals

Semi-annually if stableSemi-annually if stable FPG (optional)FPG (optional) Fasting lipid profile Fasting lipid profile annuallyannually, unless low risk, unless low risk Urinary microalbumin measurement Urinary microalbumin measurement

annuallyannually (if indicated) (if indicated)

Laboratory tests at follow-up visits Laboratory tests at follow-up visits (ADA)(ADA) HbA1cHbA1c

Quarterly Quarterly if medications change or if medications change or patient not meeting goalspatient not meeting goals

Semi-annually if stableSemi-annually if stable FPG (optional)FPG (optional) Fasting lipid profile Fasting lipid profile annuallyannually, unless low risk, unless low risk Urinary microalbumin measurement Urinary microalbumin measurement

annuallyannually (if indicated) (if indicated)


Annual screening with a random daytime urine albumin: Annual screening with a random daytime urine albumin: creatinine ratio (ACR)creatinine ratio (ACR)

For values For values ≥ ≥ 2.8 for females and 2.0 for males the test 2.8 for females and 2.0 for males the test should be repeated should be repeated confirmed in 2 out of 3 measurements over 3 monthsconfirmed in 2 out of 3 measurements over 3 months

Uncertainty is clarified by Uncertainty is clarified by 24h urine for protein24h urine for protein

Microalbuminuria = 30 - 299 mg of albumin/24hrsMicroalbuminuria = 30 - 299 mg of albumin/24hrs

NB: If patients are dipstick positive, they will likely have NB: If patients are dipstick positive, they will likely have macroalbuminuriamacroalbuminuria

Annual screening with a random daytime urine albumin: Annual screening with a random daytime urine albumin: creatinine ratio (ACR)creatinine ratio (ACR)

For values For values ≥ ≥ 2.8 for females and 2.0 for males the test 2.8 for females and 2.0 for males the test should be repeated should be repeated confirmed in 2 out of 3 measurements over 3 monthsconfirmed in 2 out of 3 measurements over 3 months

Uncertainty is clarified by Uncertainty is clarified by 24h urine for protein24h urine for protein

Microalbuminuria = 30 - 299 mg of albumin/24hrsMicroalbuminuria = 30 - 299 mg of albumin/24hrs

NB: If patients are dipstick positive, they will likely have NB: If patients are dipstick positive, they will likely have macroalbuminuriamacroalbuminuria

DIABETES MELLITUS A Note on Nephropathy: ScreeningDIABETES MELLITUS A Note on Nephropathy: Screening

DIABETES MELLITUS UHN AIMGP CLINIC

SUMMER SERIES 2007

Next week - Therapy of Type 2 DM

Non-pharmacologic andpharmacologic

DIABETES MELLITUS UHN AIMGP CLINIC

SUMMER SERIES 2007

Next week - Therapy of Type 2 DM

Non-pharmacologic andpharmacologic

type 2 diabetes mellitus review of clinical practice guidelines

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