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Diabetes: Guideline-Based Management
Eric L. Johnson, M.D.
Assistant Medical Director
Altru Diabetes Center
Assistant Professor
Department of Family and Community Medicine
University of North Dakota
School of Medicine and Health Sciences
Objectives
• Overview of diabetes
• Discuss guideline based management for diabetes
• Apply Diabetes guideline based management in clinical practice
What We’ll Do Today• Overview of Diabetes • Introduce Guidelines• Screening for Diabetes• Treating to Targets• Screening for Complications• Delivering Guideline Based Treatment in Clinical
Settings• Case Studies
U.S. Prevalence of Diabetes 2010
• Diagnosed: 26 million people—8.3% of population (90%+ have Type 2)
• Undiagnosed: 7 million people
• 79 million people have pre-diabetes
CDC 2011
Diabetes In The U.S. 2010• 8.3% of all Americans• 11.3% of adults age 20 and older• 27% of adults age 65 and older• 1.9 million diagnosed in 2010• Could be 33% by 2050• Prediabetes
35% of adults age 20 and older
50% of Americans 65 and older
CDC 2011
Diabetes Disparities
• Native American 16.1%
• Black 12.6%
• Hispanic 11.8%
Diabetes Mellitus
• Type 1: autoimmune betacell destruction, absolute insulin deficiency
• Type 2: insulin resistance, other mechanisms, eventual betacell failure over time.
The Ominous Octet-Type 2
Islet -cell
ImpairedImpairedInsulin SecretionInsulin SecretionImpairedImpairedInsulin SecretionInsulin Secretion
NeurotransmitterNeurotransmitterDysfunctionDysfunction
Decreased GlucoseDecreased GlucoseUptakeUptakeDecreased GlucoseDecreased GlucoseUptakeUptake
Islet -cell
IncreasedIncreasedGlucagon SecretionGlucagon SecretionIncreasedIncreasedGlucagon SecretionGlucagon Secretion
IncreasedIncreasedLipolysisLipolysisIncreasedIncreasedLipolysisLipolysis
Increased GlucoseIncreased GlucoseReabsorptionReabsorptionIncreased GlucoseIncreased GlucoseReabsorptionReabsorption
IncreasedIncreasedHGPHGPIncreasedIncreasedHGPHGP
DecreasedDecreasedIncretin EffectIncretin Effect
DecreasedDecreasedIncretin EffectIncretin Effect
Diabetes Mellitus
• Type 1: Usually younger, insulin at diagnosis
• Type 2: Usually older, often oral agents at diagnosis
• Type “1.5” (Latent Autoimmune) mixed features ~10% of type 2
• Gestational: Diabetes of Pregnancy
Diabetes Risk and Prevention
Risk:•Type 1- mostly unknown, some familial•Type 2- obesity, smoking, sedentary lifestyle, familial
Prevention:•Type 1- none known•Type 2- lifestyle management
Diabetes Guideline Management
• 2 main sets of guidelines utilized in U.S.
• American Diabetes Association (ADA)
• American Association of Clinical Endocrinology (AACE)
• Lots of overlap, AACE considered
“more intense”
Diabetes Guideline Management
• Evidence based
• Well accepted
• Clinically relevant
• Can be incorporated into clinical practice
• Emphasize comprehensive risk management
Diabetes Guideline Management
• ADA publishes guideline update every January (Diabetes Care)
• Clinical Practice Recommendations
• http://professional.diabetes.org/
Diabetes Guideline Management
• AACE updates periodically (2011)• https://www.aace.com/publications/guidelines• AACE Medical Guidelines for Developing a
Diabetes Mellitus Comprehensive Care Plan • Includes discussion of treatment of risk factors,
role of team members, complication screening and management, age groups
Screening For Diabetes
Screening For Diabetes
• A1C or FPG or 75 g oral GTT
• Testing should be considered in all adults who are overweight (BMI >25 kg/m2)
And
• Have the following additional risk factors…….
Risk Factors for Screening• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity • African American
• Latino
• Asian American
• Native American, Pacific Islander
• Women who delivered a baby weighing
9 lb or were diagnosed with GDM
Diabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011
Risk Factors for Screening
• Hypertension
(>140/>90 mmHg or on therapy for hypertension)• HDL <35 mg/dl and/or a triglycerides >250mg/dl• 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
Diabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011
Risk Factors for Screening
• In the absence of the previous criteria, testing begins at age 45
• Normal results, repeat at least at 3-year intervals • Consider more frequent testing depending results
and risk status• At-risk BMI may be lower in some ethnic groups
(i.e., Native American)
Diabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011
Type 2 Diabetes Screening in Children/Adolescents
• Overweight
-BMI >85th percentile
-weight for height >85th percentile
-weight >120% of ideal for height
• Plus any two of the following risk factors….
Type 2 Diabetes Screening in Children/Adolescents
• FH of type 2 diabetes in 1st or 2nd-degree relative• Race/ethnicity (Native American, African American,
Latino, Asian American,Pacific Islander)• Signs of insulin resistance or conditions associated with
insulin resistance
(acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for -gestational-age (SGA) birth weight)
• Maternal history of diabetes or GDM during gestation
Diabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011
Type 2 Diabetes Screening for Children/Adolescents
• Age of initiation: at-risk age 10 years or if younger onset puberty
• Screen every 3 years
• No screening recommended for Type 1 Diabetes in asymptomatic individuals outside of research protocols
Diabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011
Diabetes DiagnosisCategory FPG (mg/dL) 2h 75gOGTT A1C
Normal <100 <140 <5.7
Prediabetes 100-125 140-199 5.7-6.4
Diabetes >126** >200 >6.5Or patients with classic hyperglycemic symptoms with plasma glucose >200
** On 2 separate occasionsDiabetes Care 34:Supplement 1, 2011Diabetes Care 34:Supplement 1, 2011https://www.aace.com/publications/guidelines 2011 2011
Screening Review• >45 years old• Risk factors• Ethnicity• Obese• Smoking• CVD• Any Prediabetes syndrome
Risks for Complications in Diabetes
• Abnormal blood sugar/A1C
• Abnormal lipids
• Abnormal blood pressure
• Sedentary lifestyle
• Smoking
Avoiding Diabetes Complications
• Blood glucose control A1C <7%
• Treat cholesterol profiles to targets– Total cholesterol <200– Triglycerides <150– HDL (“good”) >40 men, >50 women– LDL (“bad”) <100, <70 high risk
• Treat blood pressure to target <130/<80For most non-pregnant adults
Treating To Targets
• A1C <7%: Fewer microvascular complications (eye, nerve, kidney)
• Less glucose variability: Fewer macrovascular complications (CVD, PAD)
• BP <130/<80: reduced kidney disease reduced CVD
• Lipids to target: reduced CVD
Treating to Targets
• Treating patients to target early in the course of diabetes most likely to give benefit
• Tight control late in course of disease with a history of poor control, less likely to benefit
Glycemic Control
Targets for Glycemic (blood sugar) Control In Most Non-Pregnant Adults
ADA AACE
A1c (%) <7* ≤6.5Fasting (preprandial) plasma glucose 70-130 mg/dL <110 mg/dL
Postprandial (after meal) plasma glucose <180 mg/dL <140 mg/dL
• American Diabetes Association. Diabetes Care. 2011;34(suppl 1) • Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement
at http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January 6, 2006. • AACE Diabetes Guidelines – 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.
*<6 for certain individuals
A1C ~ “Average Glucose”
American Diabetes Association
A1C eAG
% mg/dL mmol/L
6 126 7.0
6.5 140 7.8
7 154 8.6
7.5 169 9.4
8 183 10.1
8.5 197 10.9
9 212 11.8
9.5 226 12.6
10 240 13.4
Formula: 28.7 x A1C - 46.7 - eAG
Age A1C Blood Sugar Goals-fasting/ before meals
Blood Sugar Goals-bedtime/overnight
Toddlers/ preschool (0–6)
7.5-8.5 100-180 110-200
School age (6–12)
<8 90-180 100-180
Adolescent/young adults (13–19)
<7.5 90-130 90-150
ADA Guidelines for Glucose Management Children and Adolescents
American Diabetes Association. Diabetes Care. 2011;34(suppl 1) Diabetes Care 2005;28:186–212
Diabetes MedicationsGlycemic Control
• Type 1: Always insulin, maybe symlin in combo
• Type 2: Many oral med choices, insulin, non-insulin injectable
• Complete discussion in
Slide Deck/Podcast
ADA/EASD consensus algorithmto manage type 2
MET: metformin; SU: sulfonylurea. Nathan et al. Diabetes Care 2009;32(1): 193-203
aSU other than glyburide or chlorpropamide. bInsufficient clinical use to be confident regarding safety.
No No hypoglycemiaWeight loss
Nausea/vomiting
Lifestyle and MET + intensive insulin
Lifestyle and MET+ basal insulin
Lifestyle and MET+ SUa
At diagnosis:
Lifestyle +
MET
Step 1 Step 2 Step 3
Lifestyle and MET + pioglitazone
No No hypgglycemiaedema/CHF
Bone loss
Lifestyle and MET + GLP-1 agonistb
Lifestyle and MET + pioglitazone
+ SUa
Lifestyle and MET+ basal insulin
Tier 2: Less well-validated studies
Tier 1: Well-validated core therapies
Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months. The interventions should be changed if A1C is ≥7%.
Glucose-lowering Potential of Diabetes Therapies*
Treatment FPG HbA1C
Sulfonylureas 50-60 mg/dl 1-2%
Metformin 50-60 mg/dl 1-2%
-Glucosidase Inhibitors (Precose) 15-30 mg/dl 0.5-1% Repaglinade (Prandin) 60mg/dl 1.7%
Thiazolidinediones 40-60 mg/dl 1-2%
Gliptins (Januvia,Onglyza) targets ppd 0.5 - 0.8%
*based on package insert data as monotherapy
Glucose-lowering Potential of Injection Diabetes Therapies*
Treatment FPG HbA1C
Exenatide (Byetta) targets ppd 1-1.5%
Liraglutide (Victoza) targets ppd 1-1.5%
Pramlintide (Symlin) targets ppd 1-2%
Insulin Limited by 1.5-3.5%
hypoglycemia
*based on package insert data as monotherapy
Diabetes Medications
• Dr. Clarens overview of non-injectable medications
• More on injectable medications later
Key Points of Medication Selection in Type
2• Metformin at diagnosis unless a
contraindication
• Second line agents- basal insulin or many other meds
• A1C >9 at diagnosis-may need more than one medication
Goals For Older Adults
• Age and functional status dependent• Less than 3 year life expectancy, long- term
care, A1C ~8.0%• BP goals likewise individualized• HTN treatment-”big bang for the buck”• Statin?• Aspirin? Johnson EL Brosseau J et al Clinical Diabetes 2008 (26) 4; 152-156
American Medical Directors Association,2002American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Blood Pressureand
Lipids
Blood Pressure
• Done at every visit
• Target is <130/<80
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Lipids (Cholesterol)
• Fasting lipid panel at least annually
• Goals:
Total cholesterol <200
Triglycerides <150
HDL >40 men, >50 womenLDL <100 (<70, CVD or high risk)
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Children with DMHypertension and Lipids
• Lipids: start screening in childhood if strong FH, or at age 10
• Hypertension: BP >90th percentile for height and weight or >130/>80
• Consider medications (statins, ACE) if necessary
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Blood Pressure and LipidsTreatment
BP:
•ACEI usually first line, ARB alternate
•Other meds as necessary (often 2 or 3)
Lipids:
•Statins usually first line
•Fibrates, Fish Oil, Niacin
Aspirin
• Men >50 years of age
• Women >60 years of age
• Younger if higher risk
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Complications Screening
Nephropathy
Nephropathy (Kidney Disease)
Screening• Annual urine testing for
micro- or macro- albuminuria
• Annual creatinine and GFR
• Start at diagnosis for type 2
• Start 5 years after diagnosis type 1
Diabetes Care. 2011;34(suppl 1)
Kidney Disease Management
• ACEI or ARB for microalbuminuria or proteinuria• Serum creatinine and creatinine clearance (or
GFR)• May need 24 hour urine protein• May need nephrology referral• Blood pressure to target <130/<80• A1C <7
Diabetes Care. 2011;34(suppl 1)
Retinopathy
Retinopathy Screening
• Type 1 annual starting after age 10 or after 5 years post diagnosis
• Type 2 annual starting shortly after diagnosis
• Consider less frequent if one or more normal exams (not usually done)
Diabetes Care. 2011;34(suppl 1)
Retinopathy Management
• A1C < 7
• Laser photocoagulation by ophthalmologist or retinologist
Neuropathy
Neuropathy Screening
• Screen at diagnosis and annual thereafter
• Be aware of less common presentations
Foot inspection every visit plus annual/prn:
• Filament testing
• Vibratory testing (128 HZ)
• ReflexesAmerican Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Neuropathy: Treatment
• Optimize blood glucose control
• Consider other differentials, i.e. B12 deficiency in metformin users, thyroid
• Anti-seizure meds (gapapentin, pregabelin)
• Tricyclic anti-depressants (amitriptyline)
• Duloxetine-antidepressant with neuropathy indication
• Capsazin creme
Other Screening
Celiac Disease Screening• At diagnosis in Type 1 and periodic (?), pregnant• Rescreen if GI symptoms, failure to thrive, glycemic control
changes• ~10% of type 1?
Test:• Tissue transglutaminase IgA and IgG
Or• Anti-endomysial antibiodies with serum IgA• Small bowel biopsy to confirm
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Thyroid Screening
• Type 1 screen at diagnosis and every
1 to 2 years, and if pregnant
• At diagnosis, thyroid peroxidase and
thyroglobulin antibodies
• TSH thereafter
Liver Disease
• NAFLD, NASH
• ~30% of adults with DM
• LFT’s periodic
• Imaging (CT, Ultrasound, MRI) if persistent abnormal LFT’s
• May need biopsy and referral
Other Screening/Interventions
• Tobacco cessation
• Smoking contributes to poor glucose control and increased CVD risk
• Smokers should be directed to a cessation program, i.e., Quitline, Quitnet, Quitplan, 3rd party payer, etc.
• Medication(if appropriate)
• Other routine screens (i.e.,cancer)
Diabetes Clinical Encounters:
Delivering Guideline Based Care
Routine Diabetes Clinical Encounter
• Physical Exam-Diabetes Directed
• Labs
• Team management
• Systematic clinical encounters- keep everything organized
• See patient 2 to 4 times a year, prn
Diabetes Clinical EncountersHPI-My EHR Template
Patient comes in today for follow up on type (1 or 2) diabetes
•(Other problem list)
•Home Blood glucose monitoring:
•Ambulatory/Home Blood Pressures:
•Current concerns:
•Last educator appointment:
•Last dietician appointment:
•Last eye appointment:
•Last dental:
•Flu vaccine (seasonal):
•Other recent appointments:
•Complete medication review
Diabetes Clinical EncountersReview of Systems-My EHR Template
• General: Fatigue/Energy level, appetite, recent illnesses, polydipsia
• HEENT: Vision change, sore throat, neck pain/masses
• Cardiopulmonary: CP, dyspnea, palpitations
• Abdomen: Diarrhea, constipation, pain
Diabetes Clinical EncountersReview of Systems (cont’d)
• Genitourinary: Polyuria, Dysuria, Urgency, Frequency, Nocturia
• Musculoskeletal: Muscle or Joint Pain, Foot or Leg Pain
• Neurologic: Dizzy, Lightheaded, Parasthesias, Weakness, Pain
• Skin: Rash or other
• Psych: Depression, Anxiety
Diabetes Clinical EncountersPhysical Exam
• VS: Height, Weight, BP (x2?),Pulse, Tobacco status
• Fundus exam• Cardiopulmonary• Carotids • Thyroid• Abdomen (enlarged liver-fatty liver)
Diabetes Clinical EncountersPhysical Exam (cont’d)
• Filament and vibratory testing (feet)• Reflexes• General foot exam (skin,
nails, lesions, color, pulses) • General skin/injection sites• Other complaint directed • Growth parameters-children
Diabetes Foot Exam
• Every visit: visual inspection of skin, nails, lesions, color, deformity (i.e., hammertoes, charcot joint), edema
• Annual complete foot exam skin, nails, lesions, color, pulses, deformity, edema, 10gm monofilament sensitivity, 128 vibratory sensation, reflexes
Diabetes Clinical Encounters
• Other:Age appropriate recommendations
(cancer screening, etc)
Vaccinations
Diabetes Labs• A1C 2-4 times yearly• Chemistry panel, to include renal and hepatic 1-2 times
yearly, prn• Urine for microalbumin annually• CBC annually, particularly if on aspirin and/or renal
disease• Celiac screening in type 1 periodically (ever 3 years
and prn)• Thyroid screening usually annual in type 1
Diabetes Care 34:Supplement 1, 2011
The Diabetes Team
• Physician: Primary Care, Diabetologist, Endocrinologist
• Mid-level provider: Physician Assistant, APRN,or Nurse Practitioner
• Other appropriate specialists (eye, kidney, heart, psychologist, foot, dentist)
The Diabetes Team
• Diabetes Nurse Educator or Certified Diabetes Educator (CDE)
• Registered Dietician
• The patient !
Self Monitored Blood Glucose
• On insulin, generally minimum TID, usually more if MDI or pump
• CGM clinic or home may be useful
• Type 2 on orals, maybe less if stable
Lifestyle Management
• Medical Nutrition Therapy (MNT)
• Exercise/Activity Prescriptions- almost everybody can do something
• Indicated for all patients with Diabetes
ADA Nutrition Strategies• Encourage weight loss in overweight/obese• Modest weight loss-improve insulin
resistance• Reduce calories and fat • Saturated fat <7%, minimize trans-fat• Customize plans for patients
Weight Loss (Bariatric)Surgery
• BMI >40
• BMI >35 and one obesity and/or diabetes related issue
• Usually results in dramatic improvement in type 2 and related issues
• Effective tool if combined with medical management in appropriate patients
EHR
• Electronic health records have great potential to monitor diabetes labs, progress, goals, etc
• Work with your IT department, many systems have customizable “built in” diabetes systems
Summary
• Implementation of evidenced based guidelines improves diabetes outcomes
• Guidelines are easily available
• Getting patients to goals is important
• Organized clinical encounters help get patients to goals
Acknowledgements
• North Dakota Department of Health, Karalee Harper• Dakota Diabetes Coalition, Tera Miller• Centers for Disease Control• Office of Continuing Medical Education, UNDSMHS,
Mary Johnson• Department of Family and Community Medicine,
UNDSMHS, Melissa Gardner• Brandon Thorvilson, UNDSMHS IT
Slide Decks and iTunes Podcasts
• Podcasts 5 to 10 minute Diabetes Topics
“Dr. Eric Johnson Diabetes Podcasts”
• All slide decks downloadable to view
“Dr. Eric Johnson Diabetes Slide Decks”
Contact Info/Slide Decks/Media
e-maileric.l.johnson@med.und.eduejohnson@altru.org
Phone701-739-0877 cell
Slide Decks (Diabetes, Tobacco, other)http://www.med.und.edu/familymedicine/slidedecks.html
iTunes Podcasts (Diabetes) (Free downloads)http://www.med.und.edu/podcasts/ or iTunes>> search UND
WebMD Page: (under construction)http://www.webmd.com/eric-l-johnson
Diabetes e-columns (archived):
http://www.diabetesnd.org/?id=73&page=Dr.+Eric+Johnson+Archive
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