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DiabetesBoardReview
March5,2016JonMcKrell,MD
HeritageValleyFMResidencyProgram
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ObjecFves
Bytheendofthis30minuteboardreview,youwillbeableto:1. AnswercommonlyaskedboardquesFons
aboutdiabetes2. ApplythisknowledgetobePercareforyour
diabeFcpaFents
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Agenda
• Screening• Pre-diabetes• Diagnosis• Treatments• HealthMaintenance• SpecialConsideraFons
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#1WhyDoWeScreenforDM2?
• Verycommondisease• Causesalotofmorbidityandmortality• Wehavereliabletests• TreatmentiseffecFve– Decreasetheprogressionofthedisease– Decreaseadversesequelae
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Whoshouldbescreened?TheUSPSTF:NewRecommendaFons!
Individualsbetweenages40—70OverweightorObese(BMI≥25orBMI≥30)Basedonrandomizedtrials
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WhatDoestheADARecommend?InasymptomaFcpaFents,tesFngbeginsatage45…Unless…• Theyareoverweightorobese(BMI≥25)andhave1ormoreaddiFonalriskfactors:– PhysicalinacFvity– FirstdegreerelaFvewithDM– High-riskrace/ethnicity– Womendeliveringababy>9lborwithhxofGDM– HTN– HDL<35ortrig>250– PCOS– A1C≥5.7,IGT,orIFGonprevioustests– Clinicalinsulinresistance(severeobesity,acanthosisnigrans)
– HistoryofCVD
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UpdateFromtheADAin2015
• ScreenAsianAmericanswithaBMI≥23kg/m²• AtriskforDM2atlowerBMIlevelscomparedtothegeneralpopulaFon
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ScreeningforDM2inCanada
• UseriskcalculaFontools
• FINDRISC– Validated– ProspecFve– Improvedpt.outcomes
• CANRISC– Lessevidence– Longer
• Assess:– Age– Obesity– h/o↑glucose– h/oHTN– FMHofDM2– LowacFvitylevel– Poordiet
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ScreeningQuesFon
1.WhichofthefollowingdoestheUSPSTFrecognizeasthemostimportantriskfactorinscreeningfordiabetes?A.ObesityB.HypertensionC.HyperlipidemiaD.AcFvitylevelE.Ethnicity
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ScreeningQuesFon
2.Ofthefollowing,whoshouldbescreenedfordiabetes?A. 37y/oBMwithhyperlipidemiaandnofamily
history,BP130/75B. 42y/oobeseWFwithnohealthissuesC. 23y/othinBMwithastrongfamilyhistoryof
diabeteswithaBPof127/65D. 12y/overyobeseHFwithacanthosisnigricans
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#2Pre-diabetes
Currentcriteria:• A1C5.7-6.4%• FasFngplasmaglucose100to125• 2hourplasmaglucose140to199PIniFatedietandexercisePScreenmorefrequentlyforDMPConsidermeqormininhighriskpts.
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Pre-diabetesQuesFon3.A42-year-oldfemalebringsyoutheresultsofacomprehensivemetabolicprofileobtainedthroughhealthscreeningprogramofferedbyheremployer.Shefastedfor8hourspriortothetest,andherbloodglucoselevelwasreportedat110.Herlipidvaluesandherbloodpressurewerenormal,butherBMIis30.5.ShecurrentlyviewsherselfasrelaFvelyhealthyandreportsnosymptomsconsistentwithdiabetes.AddiFonaltesFngrevealsahemoglobinA1cof6.3%.Basedonthisdata,whichoneofthefollowingismostappropriateatthisFme?a. OrderaC-pepFdelevelb. OrderanisletcellanFbodylevelc. RecommendlifestylemodificaFonsonlyd. Startlow-doseempagliflozin(Jardiance)dailye. Startlow-doseinsulinglargine(Lantus)daily
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#3DiagnosingDiabetesMellitus
• SpectrumofDisorders• Type1DM• Type2DM• GestaFonalDM• PreDM• MaturityOnsetdiabetesofyouth• Latentautoimmunediabetesinadults
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DiagnosingDiabetes
Type1• <10%ofDM• Onsetusuallyinchildhood
oradolescence• Lossofbetacellsinthe
pancreas:insulinrequiring• Weightlossisprevalent• Suddenonset• ScreeningforcomplicaFons
begins5yearsauerdiagnosis
Type2• >90%ofDM• Onsetadulthoodbutnow
commoninadolescence• Insulinresistancesohigh
insulinlevels• Obesityisprevalent• Insidiousonset• ScreeningforcomplicaFons
beginsatdiagnosis
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DiagnosingDiabetes
Currentcriteria:• A1C≥6.5%• FasFngplasmaglucose≥126• 2hourOGTTplasmaglucose≥200• Randomplasmaglucose≥200withsymptomsofDM
PIntheabsenceofunequivocalhyperglycemia,shouldbeconfirmedbyrepeattesFng
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DiagnosisQuesFon4.WhichofthefollowingwouldbeconsidereddiagnosFcoftype2diabetes?A. AhemoglobinA1c≥6.0%ontwoseparate
occasionsB. Anoralglucosetolerancetestwith75-gloadanda
2-hourglucoselevel≥150mg/dLC. AfasFngglucoselevel≥126mg/dLon2separate
occasionsD. Arandomglucoselevelof212mg/dLinan
asymptomaFcperson
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#4Treatment:Goals
• PreventcomplicaFons&improveoutcomes• Pre-prandialglucose:80—130mg/dl• Peakpostprandialglucose<180mg/dl• A1C<7%– Lower(<6.5%)fornewdiagnosis,longlifeexpectancy– Higher(<8%)forlongstanding(>12yrs),advancedcomplicaFons,limitedlifeexpectancy
– ACCORDtrialfoundexcessivelyrapidoraggressivecontrolassociatedwithincreasedrisk
– Monitorevery3months(every6ifstableandatgoal)
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Treatment
• Lifestylechange– NutriFon
• Intensivecounseling– AcFvity
• CombinaFonofaerobic&resistanceexercise• Don’tsitlongerthan90mins
– Weightloss• Goalof5%• PharmacologicandSurgicalopFonsnowlistedaswell
• MedicaFon
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Treatment:Meqormin• InsulinsensiFzer,DecreasesglucoseproducFonintheliver,Lowersinsulinandlipidlevels
• Nohypoglycemiaorweightgain• Improvescardiovascularoutcomesintype2decreasesmortality**
• CancorrectfaPyliver• UsewithcauFonintheelderly(>65),renaldysfuncFon,cardiopulmonarydisorders(OKwithstableCHF),andhepaFcdisease
• StoppriortoIVcontrast**• RarecasesoflacFcacidosis*
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Treatment:ThiazolidinedionePioglitazone(Actos)• Decreasesinsulinresistance*,↓gluconeogenesis• UsewithcauFonintheelderlyduetodecliningventricularfuncFon,andincardiopulmonarydisordersduetovolumeoverload*• MustmonitorLFTs,avoidinhepaFcdysfuncFonincludingnonalcoholicfaPyliverdisease*• ↓riskofMI,stroke,anddeath,↓triglycerides,↑HDL,↑seriousheartfailureRosiglitazone(Avandia)• 42%increaseriskofMI;restricted
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Treatment:Sulfonylureas
Glipizide(Glucotrol),glyburide(Micronase),Glimepiride(Amaryl)• SFmulatepancreaFcbetacellstoreleaseinsulin• Weightgainandhypoglycemia*• Canbeusedinlowdosesintheelderly• OKinmildrenaldysfuncFonandcardiopulmonaryco-morbidiFes(sleepapnea,CHF)
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Treatment:MegliFnides
• Repaglinide(Prandin),Nateglinide(Starlix)• RapidacFnginsulinsecretagogues• Halflife<1hour• Maybeusedintheelderly,renalfailure,andcardiopulmonarydisorders
• VeryhelpfulforerraFceaFngschedules
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Treatment:AlphaGlucosidaseInhibitors
Acarbose(Precose)andMiglitol(Glyset)• DelaycarbohydrateabsorpFoningut—decreasespeakglucoselevels,nohypoglycemia*
• Acarbosemaydelayonsetoftype2diabetes• Reducetheriskofcardiovascularevents*• MonitorLFTs;avoidincirrhosis• NotforuseinrenaldysfuncFon(creaFnine>2)• AvoidinGIdisease—significantGIside-effects
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Treatment:IncreFnMimeFcsExenaFde(ByePa),LiragluFde(Victoza):GLP-1agonists;PramlinFde(Symlin):SyntheFcanalogueofhumanamylin• AllgivenbysubcutaneousinjecFon• MechanismofacFon– PotenFatesinsulinsecreFon– SuppressespostprandialglucagonsecreFon– Slowsgastricemptying– PromotessaFety(noweightgain)
• Sideeffects– Nausea,vomiFng,diarrhea,weightloss*– Mayworsengastroparesis**– PancreaFFs*– Hypoglycemia(withsulfonylurea)
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Treatment:DPP-4Inhibitors
SitaglipFn(Januvia),SaxaglipFn(Onglyza),LinaglipFn(Tradjenta)• BlockdipepFdylpepFdase4(theenzymethatbreaksdownnaturalincreFns)
• BePerinsulinreleaseandbloodsugarcontrolparFcularlypostprandial
• Sideeffectsminimal:URI,sorethroat,diarrhea,pancreaFFs
• Weightneutral
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SGLT2Inhibitors• Sodium-glucose
cotransporter2inhibitors• MechanismofacFon
– ↓renalthresholdforglucose
– ↓reabsorpFonoffilteredglucosefromthetubules
– ↑urinaryglucoseexcreFon
• Sideeffects– UTI– YeastinfecFons– ↑urinaFon
• Dapagliflozin(Farxiga)• Canagliflozin(Invokana)• Empagliflozin(Jardiance)
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Treatment:Insulin• Weightgainoutweighedbyglucosecontrol• Averagedose0.6-0.8units/kgbodyweight/day– ~40-50unitsfora70kgman– Halfforbasalneedsandhalfwithmeals
• BioavailabilitychangeswithsiteofinjecFon*– Fasterinabdomen,Slowerinthigh– ExerciseacceleratesabsorpFoninthigh*– Armreducesexerciseinducedhypoglycemiaby60%– Abdomenreducesexerciseinducedhypoglycemiaby90%
• BestcombinaFon:long-acFngbasalandrapidacFngsyntheFc—mostcloselymimicsnormal*
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Treatment:RapidacFnginsulin
Lispro(Humalog),Aspart(Novolog),Glulisine(Apidra)• Analogsofhumaninsulin;allsimilar• Onset15min,peak1-3hr,duraFon2-5hr• MayneedtoadjustlongacFngregimen• ParFcularlywell-likedbytype1diabeFcs• (~1/3ofdailyinsulinrequirement)• Availablein75/25mixwithlongeracFngprotamineform
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Treatment:LongacFnginsulin
NPHduraFon16-24hr(2/3inAM,1/3inPM)Glargine(Lantus)24hr(humananalog)– Maybeusedintype1and2– IniFatedoseat80%ofpriortotalinsulindose– BestapproachforgeriatricpaFentsinlong-termcarefaciliFes(predictablecontrol)*
Detemir(Levemir)similartoglargine– Notsupposedtoincreaseweight– LengthofacFvityincreasesasdoseincreases
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Treatment:TherapybasedonA1C• <9.0%:monotherapy(usuallymeqormin)• ≥9.0%:dualtherapy:meqorminplus
– Sulfonylureaor– TZD:Pioglitazoneor– Glinide:Repaglinide/nataglinideor– DPP4:SitaglipFn/saxaglipFn/linaglipFnor– GLP-1agonist:ExenaFde/pramlinFde/liragluFde– SGLT2
• ≥10.0%:Insulinortripletherapy:– Meqorminplus– DPP4orGLP-1orSGLT2plus/or– Sulfonylureaorglinideplus/or– TZD
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TreatmentQuesFon5.A56-year-oldmalewithtype2diabetesmellitushasnormalcardiacandrenalfuncFonbuthasfailedtoachieveadequatecontrolofhisdiabeteswithdietandmulFpleoralagents.HisBMIis30.1kg/m2andhishemoglobinA1clevelis9.1%WhichoneofthefollowingismostlikelytobebeneficialincombinaFonwithinsulinanddiettherapyinthispaFent?A.Acarbose(Precose)B. Glimepiride(Amaryl)C. Meqormin(Glucophage)D. Pioglitazone(Actos)E. Repaglinide(Prandin)
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TreatmentQuesFon6.YouareconsideringaddingsitaglipFn(Januvia)totheregimenofapaFentwithtype2diabetesmellitus.WhichoneofthefollowingbestdescribesthemechanismofacFonofthisdrug?A.ItincreasesglucagonlevelsB. ItslowsinacFvaFonofincreFnhormonesC. ItreducestheabsorpFonofglucoseinthe
gastrointesFnaltractD. ItreducesinsulinresistanceinskeletalmuscleE. Itreducesinsulinresistancetotheliver
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TreatmentQuesFon7.An81yearoldmalewithtype2diabetesmellitushashemoglobinA1Cof10.9%.Heisalreadyonthemaximumdosageofglipizide(Glucotrol).Hisothermedicalproblemsincludemildrenalinsufficiencyandmoderateischemiccardiomyopathy.WhichoneofthefollowingwouldbethemostappropriatechangeinthepaFent’sdiabetesregimen?A. Addmeqormin(Glucophage)B. AddsitaglipFn(Januvia)C. Addpioglitazone(Actos)D. IniFateinsulintherapy
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TreatmentQuesFon8.A66yearoldmalewithtype2diabetesmellitusisseenforafollowupvisitandhasahemoglobinA1Cof6.7%.Heiscurrentlytakingmeqormin(Glucophage),1000mgtwicedaily.Hehasnohistoryofcoronaryarterydiseaseorheartfailure.Whichoneofthefollowingwouldbemostappropriate?A. ConFnuinghiscurrentregimenB. IncreasingthemeqormindosageC. AddingasulfonylureaD. AddingthiazolidinedioneE. AddingdailylongacFnginsulin
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#5HealthMaintenanceGoals• Bloodpressure<140/90andprevenFonofnephropathy– ACEI(angiotensinconverFngenzymeinhibitor)slowsprogression
– UseARBswhenACEinhibitorsarenottoleratedorcontraindicated
• Lipids– TreatmentandiniFalstaFndosearedrivenbyriskstatus
– NolongerbasedonLDLnumbers
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HealthMaintenanceGoals
• Lipids– OvertCVDalwaysmeanshighintensitystaFn– Age<40:
• Noriskfactors—notreatment• CVDriskfactors—moderateintensitystaFn
– Age40–75:• Noriskfactors—moderateintensitystaFn• CVDriskfactors—HighintensitystaFn
– Age>75:• Sameasage40–75butmaynottoleratehighintensity
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HealthMaintenance• Yearlyeyeexam• YearlyurinemicroalbuminandcreaFnine• Yearlycomprehensivefootexam:– EvaluaFonofpulses– VisualinspecFonoffeet– TesFngforlossofprotecFvesensaFon(LOPS)
• Bloodpressureateveryvisit• Lipidsyearly• Screenfortobaccouse• Screenfordepression
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HealthMaintenance
• Lowdoseaspirinisreasonableinadultswithdiabetesandnohistoryofvasculardiseasewhose10-yearriskofCHDeventsis>10%andnotatincreasedriskofbleeding– Males>50andFemales>60with1addiFonalriskfactor
– Smoking,hypertension,dyslipidemia,albuminuria,familyhistoryofprematuredeath
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HealthMaintenanceQuesFon9.AccordingtothemostrecentAmericanDiabetesAssociaFonguidelines,whichoneofthefollowinggroupsofpaFentswithdiabetesmellitusshouldtakeaspirinforprimaryprevenFonofcardiovascularevents?A. AllpaFentsB. AllpaFentsovertheageof55C. Onlythosewhoseriskforcardiovasculardisease
eventsis>10%D. Onlythosewhoseriskforcardiovasculardisease
eventsis>20%
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#6SpecialConsideraFons• SteroidInjecFons– Intra-arFcular– SouFssue
• ClassiccomplicaFons– Contrastinducednephropathy(meqormin)– Delayedwoundhealing– Dupuytren’sdisease– ErecFledysfuncFon– Charcotfoot
• CDLrestricFon– Insulinrequiringoruncontrolled
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SpecialConsideraFonsQuesFon
10.WhichoneofthefollowingfindingsonexaminaFonshouldpromptimmediatespecialtyreferral?A. ParoFdenlargementB. Dupuytren’sdiseaseC. CharcotfootD. PosturalhypotensionE. Periodontalbleeding
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Summary
TheABFMandAOBFPexamsfrequentlyhavequesFonsrelatedtodiabetesscreening,diagnosisandtreatmentincludingcomplicaFonsandhealthmaintenancerecommendaFons.BesuretoreviewthekeypointsintheseslidesandintheADAguidelinestobewellprepared.ThankYouandGoodLuck!