padmguidelinespa5-25-11

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”


• Evidence based

• Well accepted

• Clinically relevant

• Can be incorporated into clinical practice

• Emphasize comprehensive risk management


• ADA publishes guideline update every January (Diabetes Care)

• Clinical Practice Recommendations

• http://professional.diabetes.org/


• 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

https://www.aace.com/publications/guidelines

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


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)


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


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 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

https://www.aace.com/publications/guidelines

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)


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


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


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


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)


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


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

Google

“Dr. Eric Johnson Diabetes Podcasts”

• All slide decks downloadable to view

Google

“Dr. Eric Johnson Diabetes Slide Decks”

Contact Info/Slide Decks/Media

[email protected]@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

mailto:[email protected]



http://www.med.und.edu/familymedicine/slidedecks.html

http://www.med.und.edu/podcasts/

http://www.webmd.com/eric-l-johnson

padmguidelinespa5-25-11

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