diabetes: the 2007 guidelines

Diabetes:Diabetes:The 2007 GuidelinesThe 2007 Guidelines

Kevin E. Moore, M.D.Kevin E. Moore, M.D.LTC, MCLTC, MC

Residency DirectorResidency DirectorNCC-DACH Family Medicine ResidencyNCC-DACH Family Medicine Residency

ADA 2007 Clinical Practice ADA 2007 Clinical Practice RecommendationsRecommendations

● Why is this important?Why is this important?● Current screening guidelinesCurrent screening guidelines● 6 cornerstones of diabetes6 cornerstones of diabetes● New developmentsNew developments● Questions!!Questions!!

Why is this important?Why is this important?● Type 2 DM is most prevalent formType 2 DM is most prevalent form● 7.9% of adults have diagnosed/undiagnosed7.9% of adults have diagnosed/undiagnosed

diabetes diabetes ● 4-fold more likely to have a MI.4-fold more likely to have a MI.● 8-fold more likely to die from first MI.8-fold more likely to die from first MI.● Leading cause of blindness ages 20-74.Leading cause of blindness ages 20-74.● 1/3 of all cases of legal blindness.1/3 of all cases of legal blindness.● Most common cause of ESRDMost common cause of ESRD● 1/3 of all dialysis patients.1/3 of all dialysis patients.● #2 cause of amputations.#2 cause of amputations.

● Leading Healthcare Expenditure in U.SLeading Healthcare Expenditure in U.S

Medical Management Can Change All of the Above

ScreeningScreening

● 2025, 9% of U.S. population will be diabetic2025, 9% of U.S. population will be diabetic● 5.2 million undiagnosed diabetics in U.S5.2 million undiagnosed diabetics in U.S● Diagnosis latency for Type 2 DM is 4.2 Diagnosis latency for Type 2 DM is 4.2

yearsyears● Polyuria, polyphagia, and polydypsia are Polyuria, polyphagia, and polydypsia are

very unreliable screening indicators.very unreliable screening indicators.

Risk FactorsRisk Factors

● Family HistoryFamily History● Obesity (BMI > 25)Obesity (BMI > 25)● Race/Ethnicity (African-Race/Ethnicity (African-

American, Hispanic-American, Hispanic-American, Native American, Native Americans, Asian Americans, Asian Americans, Pacific Americans, Pacific Islanders)Islanders)

● Age > 45Age > 45● Hypertension (> 140/90)Hypertension (> 140/90)

● HDL Cholesterol < 35HDL Cholesterol < 35● Triglycerides > 250Triglycerides > 250● History of GDMHistory of GDM● History of MacrosomiaHistory of Macrosomia● Polycystic Ovarian Polycystic Ovarian

DiseaseDisease● Previous Abnormal Previous Abnormal

ScreeningScreening● Physically InactivePhysically Inactive● Vascular DiseaseVascular Disease

Screening RecommendationsScreening Recommendations

● Patients at high-risk for diabetes (2-3 risk factors) Patients at high-risk for diabetes (2-3 risk factors) screened every 3 yearsscreened every 3 years

● IGT/IFG – Screen every 1-2 yearsIGT/IFG – Screen every 1-2 years● Screening TestsScreening Tests

● Fasting Plasma Glucose - Preferred - accuracy, ease, Fasting Plasma Glucose - Preferred - accuracy, ease, low-cost.low-cost.

● 2 hour OGTT (75 gm glucose load) 2 hour OGTT (75 gm glucose load) ● Random Plasma Glucose - very inaccurate, Random Plasma Glucose - very inaccurate,

discourage use.discourage use.● HgA1C - NOT a screening test.HgA1C - NOT a screening test.

Repeat and Confirm all Screening Tests in 24 Hours!

Screening TestsScreening Tests

Random > 200

2hPG > 2002hPG 140-1992hPG < 139

FPG > 126FPG 110-125FPG < 109

DiabetesIFG or IGTNormal

Cornerstones of Diabetes Cornerstones of Diabetes Management?Management?

● Glycemic ControlGlycemic Control● HypertensionHypertension● HyperlipidemiaHyperlipidemia● NephropathyNephropathy● RetinopathyRetinopathy● Foot CareFoot Care

Glycemic ControlGlycemic Control

● HgA1C is the gold standardHgA1C is the gold standard● SMBG is an integral component of diabetes SMBG is an integral component of diabetes

management – Expert Consensusmanagement – Expert Consensus● All treatment decisions for Type 2 Diabetics All treatment decisions for Type 2 Diabetics

should be based on A1C levelsshould be based on A1C levels● Check A1c twice each year in all patientsCheck A1c twice each year in all patients

● SMBG is extremely valuable in tailoring SMBG is extremely valuable in tailoring therapy to a specific patienttherapy to a specific patient


3451231011275102409205817071356

Mean Plasma Glucose (mg/dl)A1C%


● HgA1C < 6% - normal.HgA1C < 6% - normal.● HgA1C < 7% - goal.HgA1C < 7% - goal.● HgA1C 7.0 - 7.5% - good control.HgA1C 7.0 - 7.5% - good control.● HgA1C > 7.5% - additional therapyHgA1C > 7.5% - additional therapy● Pre-prandial glucose 90-130 mg/dlPre-prandial glucose 90-130 mg/dl● Peak postprandial glucose < 180 mg/dlPeak postprandial glucose < 180 mg/dl

● HgA1C every 3 months unless at goal then HgA1C every 3 months unless at goal then every 6 months.every 6 months.

HypertensionHypertension

● Goal B/P < 130/80Goal B/P < 130/80● Treat all patients > 130/80Treat all patients > 130/80

● MNT for 130-139/80-89 MNT for 130-139/80-89 ● Drug treatment - > 140/90Drug treatment - > 140/90

● ACEI/ARB’s are drugs of choiceACEI/ARB’s are drugs of choice● Beta-blockers may improve myocardial Beta-blockers may improve myocardial

outcome - do not mask hypoglycemia.outcome - do not mask hypoglycemia.● Calcium Channel Blockers – ALLHAT StudyCalcium Channel Blockers – ALLHAT Study


● UKPDS - 21% reduction in CAD events and UKPDS - 21% reduction in CAD events and morbidity (B/P < 144/82)morbidity (B/P < 144/82)

● Atenolol vs. captoprilAtenolol vs. captopril

● HOT – CAD events decreased from 9% to 4% HOT – CAD events decreased from 9% to 4% over 3.8 years when the diastolic was lowered over 3.8 years when the diastolic was lowered from 90 to 80 mm Hgfrom 90 to 80 mm Hg

● Felodipine/ACE InhibitorFelodipine/ACE Inhibitor

● Syst-Eur – CAD events decreased from 12% Syst-Eur – CAD events decreased from 12% to 5% over 2 years when the systolic was to 5% over 2 years when the systolic was lowered 20 mm Hglowered 20 mm Hg

● Enalapril/HCTZEnalapril/HCTZ


● ALLHAT – Largest Anti-Hypertensive StudyALLHAT – Largest Anti-Hypertensive Study● 42,000 patients followed over 6 years42,000 patients followed over 6 years● Diuretic vs. lisinopril vs. amlodipineDiuretic vs. lisinopril vs. amlodipine● Alpha-blocker arm d/c’d early due to CHFAlpha-blocker arm d/c’d early due to CHF● Cardiovascular events were the same in all Cardiovascular events were the same in all

three study armsthree study arms● ADA Recommends:ADA Recommends:

● ACE/ARB as first-lineACE/ARB as first-line● Consider diuretic as first additionConsider diuretic as first addition● CCB or beta-blocker third lineCCB or beta-blocker third line

HyperlipidemiaHyperlipidemia

● Most common lipid abnormality: Most common lipid abnormality: elevated triglycerides followed by elevated triglycerides followed by reduced HDL.reduced HDL.

● LDL levels are usually not elevated LDL levels are usually not elevated compared to non-diabetic population.compared to non-diabetic population.

● LDL particles are more atherogenic in LDL particles are more atherogenic in diabetic patients.diabetic patients.

HyperlipidemiaHyperlipidemia● Primary PreventionPrimary Prevention

– AFCAPS/TexCAPS – 37% reduction in CAD events AFCAPS/TexCAPS – 37% reduction in CAD events (lovastatin)(lovastatin)

– SENDCAP – reduction in induced ischemia (bezafibrate)SENDCAP – reduction in induced ischemia (bezafibrate)– Helsinki Heart Study – 7% reduction in CAD events Helsinki Heart Study – 7% reduction in CAD events

(gemfibrizol)(gemfibrizol)– Heart Protection Study – 25% reduction in first CAD when Heart Protection Study – 25% reduction in first CAD when

LDL lowered by 30% (simvastatin)LDL lowered by 30% (simvastatin)– CARDS – 40% reduction in first CAD/stroke (atorvastatin)CARDS – 40% reduction in first CAD/stroke (atorvastatin)

● Secondary PreventionSecondary Prevention– CARE - 27% reduction CAD events (pravastatin)CARE - 27% reduction CAD events (pravastatin)– 4S – 55% reduction CAD events (simvastatin)4S – 55% reduction CAD events (simvastatin)– VA-HIT - 24% reduction CAD events (gemfibrozilVA-HIT - 24% reduction CAD events (gemfibrozil))

Priorities of Lipid Priorities of Lipid ManagementManagement

● First, lower LDL cholesterol.First, lower LDL cholesterol.● Second, raise HDL cholesterol.Second, raise HDL cholesterol.● Third, lower Triglyceride levels.Third, lower Triglyceride levels.

Lipid Lowering MedicationsLipid Lowering Medications

● Drug of Choice: HMG CoA Reductase Drug of Choice: HMG CoA Reductase Inhibitors (the Statins).Inhibitors (the Statins).

● Second Line: Fibric Acid Derivatives.Second Line: Fibric Acid Derivatives.● Third Line: Bile Acid ResinsThird Line: Bile Acid Resins● Relatively Contraindicated: NiacinRelatively Contraindicated: Niacin

Maximal Medical Nutrition Therapy has been Maximal Medical Nutrition Therapy has been shown to lower LDL by no more than 20mg/dlshown to lower LDL by no more than 20mg/dl

Testing for HyperlipidemiaTesting for Hyperlipidemia

● All diabetics should have a full lipid All diabetics should have a full lipid profile done annually profile done annually

● Any diabetic being treated should have Any diabetic being treated should have lipid profiles done every 3-6 months lipid profiles done every 3-6 months until goal is reached.until goal is reached.

● Once goal is reached, lipid profiles Once goal is reached, lipid profiles should be done every 6 - 12 months.should be done every 6 - 12 months.

Treatment Goals for Treatment Goals for HyperlipidemiaHyperlipidemia

< 100> 130< 100> 100No CAD

< 100> 100< 100> 100CAD

GoalStartGoalStart

Drug TherapyNutrition Therapy

NephropathyNephropathy

● Incipient Nephropathy - characterized by Incipient Nephropathy - characterized by microalbuminuria.microalbuminuria.

● Overt Nephropathy - characterized by clinical Overt Nephropathy - characterized by clinical albuminuria.albuminuria.

● End Stage Renal Disease - characterized by a End Stage Renal Disease - characterized by a declining GFR.declining GFR.

● ANNUAL SCREENING REQUIREDANNUAL SCREENING REQUIRED● MicroalbuminuriaMicroalbuminuria● Serum creatinineSerum creatinine

Screening Tests for Screening Tests for AlbuminuriaAlbuminuria

● Albumin-to-creatinine ratio in random Albumin-to-creatinine ratio in random spot urine collection.spot urine collection.

● 24 hour urine albumin and creatinine 24 hour urine albumin and creatinine collection.collection.

● Timed (4 hour) urine albumin and Timed (4 hour) urine albumin and creatinine collection.creatinine collection.

Screening Tests for Screening Tests for Albuminuria Albuminuria

● Albumin-to-creatinine ratio in random Albumin-to-creatinine ratio in random spot collection preferred.spot collection preferred.

● Falsely elevated - hyperglycemia, UTI, Falsely elevated - hyperglycemia, UTI, exercise, marked hypertension, CHF, exercise, marked hypertension, CHF, and feverand fever

● Day-to-day variation in albuminuria.Day-to-day variation in albuminuria.

Microalbuminuria must be confirmed with Microalbuminuria must be confirmed with 2-3 collections over 6 months to diagnose 2-3 collections over 6 months to diagnose

incipient nephropathyincipient nephropathy

Screening Test ResultsScreening Test Results

> 200> 300> 300Clinical Albuminuria

20-19930-29930-299Micro-albuminuria

< 20< 30< 30Normal

Timed(ug/min)

24-Hour(mg/24h)

Spot(ug/mg

Creatinine)

Collection Method

Treatment of NephropathyTreatment of Nephropathy

● Optimize Glycemic Control.Optimize Glycemic Control.● Optimize Hypertension Management.Optimize Hypertension Management.● ACE Inhibitors - even if normotensive.ACE Inhibitors - even if normotensive.● If intolerant of ACE Inhibitors - ARB’s If intolerant of ACE Inhibitors - ARB’s

have similar supporting datahave similar supporting data● Protein Restriction to 0.8mg/kg/day - Protein Restriction to 0.8mg/kg/day -

once CKD develops.once CKD develops.

RetinopathyRetinopathy

● 21% of Type 2 diabetics have evidence 21% of Type 2 diabetics have evidence of retinopathy at time of diagnosis.of retinopathy at time of diagnosis.

● Treatment available by both Laser Treatment available by both Laser Photocoagulation and Argon Laser Photocoagulation and Argon Laser therapy - best treated by experienced therapy - best treated by experienced ophthalmologist.ophthalmologist.

● Screen can be done by qualified Screen can be done by qualified optometrist and/or ophthalmologist.optometrist and/or ophthalmologist.

Natural History of Natural History of RetinopathyRetinopathy

● Mild Non-Proliferative Retinopathy- Mild Non-Proliferative Retinopathy- increased vascular permeabilityincreased vascular permeability

● Moderate to Severe Non-Proliferative Moderate to Severe Non-Proliferative Retinopathy - vascular closureRetinopathy - vascular closure

● Proliferative Retinopathy - regrowth of Proliferative Retinopathy - regrowth of new vessels on retina and posterior new vessels on retina and posterior surface of the vitreous.surface of the vitreous.

Screening Recommendations Screening Recommendations for Retinopathyfor Retinopathy

YearlyWhen diagnosedType 2 Diabetes

Yearly3-5 years after

diagnosis(age > 10)

Type 1 Diabetes

Follow-UpFirst ExamPatient Group

Foot CareFoot Care

● Annual Foot Exam Looking for High-Annual Foot Exam Looking for High-Risk Conditions.Risk Conditions.

● Foot Exams at Every Visit.Foot Exams at Every Visit.● Professional Foot Care for Patients with Professional Foot Care for Patients with

One or More Risk Factors.One or More Risk Factors.● Daily Foot Care for All Patients - Daily Foot Care for All Patients -

Patient Instruction on Nail and Skin Patient Instruction on Nail and Skin CareCare

Annual Foot ExamAnnual Foot Exam

● Components:Components:● Monofilament testing for sensory lossMonofilament testing for sensory loss● Skin examSkin exam● Examination of foot anatomy/dystrophiesExamination of foot anatomy/dystrophies● Vascular examVascular exam

Risk Factors for Foot DiseaseRisk Factors for Foot Disease

● Peripheral NeuropathyPeripheral Neuropathy● Altered BiomechanicsAltered Biomechanics● Evidence of Increased Evidence of Increased

Pressure (callus, Pressure (callus, erythema, bruising)erythema, bruising)

● Decreased Joint Decreased Joint MobilityMobility

● Bony DeformityBony Deformity● Marked Nail PathologyMarked Nail Pathology● Peripheral Vascular Peripheral Vascular

DiseaseDisease● History of AmputationHistory of Amputation● History of Foot UlcerHistory of Foot Ulcer

New Developments - New Developments - Prevention Prevention

● Finnish Study: Finnish Study: – Intense MNT vs ControlIntense MNT vs Control– Average Follow-up 3.2 yearsAverage Follow-up 3.2 years– 58% risk reduction for diabetes58% risk reduction for diabetes

● Diabetes Prevention Program (DPP):Diabetes Prevention Program (DPP):– Intense MNT vs Metformin vs PlaceboIntense MNT vs Metformin vs Placebo– Average Follow-up 2.8 yearsAverage Follow-up 2.8 years– 58% risk reduction for diabetes for MNT58% risk reduction for diabetes for MNT– 31% risk reduction for diabetes for Metformin31% risk reduction for diabetes for Metformin

New Developments - New Developments - PreventionPrevention

● Troglitazone Prevention of Diabetes Troglitazone Prevention of Diabetes (TRIPOD):(TRIPOD):– Troglitazone vs placeboTroglitazone vs placebo– Average follow-up 2.5 yearsAverage follow-up 2.5 years– 58% risk reduction for diabetes58% risk reduction for diabetes

● STOP-NIDDM:STOP-NIDDM:– Acarbose vs placeboAcarbose vs placebo– Average follow-up 3.3 yearsAverage follow-up 3.3 years– 36% risk reduction for diabetes36% risk reduction for diabetes

New Developments - New Developments - Children Children

● Type 2 Diabetes in ChildrenType 2 Diabetes in Children– Included in 2003 Guidelines – significant Included in 2003 Guidelines – significant

update in 2006 guidelinesupdate in 2006 guidelines– Screening AddressedScreening Addressed– ? Standards for Hypertension and Lipid ? Standards for Hypertension and Lipid

ManagementManagement

More Information to Follow in Upcoming YearsMore Information to Follow in Upcoming Years

diabetes: the 2007 guidelines

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