Standards of Medical Care in Diabetes - 2008

Standards of Medical Care in Diabetes - 2008

Jeri Jennings Mills, RD/LD, CDE Sami Wood, RD/LD, CDE OSUMC Diabetes Education



Types of Diabetes



• Type 1 diabetes

• IDDM • juvenile onset • type I



• Type 2 diabetes

• NIDDM • adult onset • type II



Gestational diabetes (GDM)

•



Others

– Genetic defects in beta cell function – Genetic defects in insulin action – Diseases of the pancreas (cystic fibrosis) – Drug induced (AIDS Tx/organ transplantation) – MODY



Some patients cannot be clearly classified as type 1 or type 2 • LADA • Type 1.5



How to diagnosis diabetes

• FPG is the preferred diagnostic test • Use of the A1c for diagnosis is not recommended at this time



Three diagnostic criteria:

• FPG > 125 mg/dL*, or



• “Casual” plasma glucose > 200 mg/dL & sx’s of high blood sugar, or • 2-h plasma glucose* > 200 mg/dl (during an 75 gram glucose OGTT)

*needs repeat confirmation on different day



Screening for diabetes

In diabetes, the same tests used to screen for diabetes, also diagnose diabetes

“There is no more „screening‟ for type 2”!



Screening for type 1 diabetes

• Screening asymptomatic individuals for autoantibodies is not currently recommended • Clinical studies are being done to test various methods of preventing type 1



Joe is 30 years old with a BMI of 29. He does not exercise. His father has “borderline” diabetes. Joe has no symptoms of diabetes. Should he be tested? (B)

Ye



1. Yes 2. No



0%

s



0%

N o



Testing for type 2

• About 1/3 of all people with diabetes may be undiagnosed • Average dx is 7-10 years after onset • Type 2 DM is frequently diagnosed after complications appear • So…who should be tested?



All adults with BMI >24 and a risk factor below… • Physical inactivity • 1st degree relative with DM • High-risk ethnic group • Women w/hx GDM and/or PCOS • HTN • HDL 250 • IGT or IFG on previous testing • Acanthosis nigricans • Hx of CVD • Age 45 if none of the above apply & q 3 yrs…



“Type 2 diabetes has a long asymptomatic phase and significant clinical risk markers. Diabetes may be identified anywhere along a spectrum of clinical scenarios”.



Prediabetes is NOT

“borderline diabetes”!

• Fasting: 100-125 – Impaired fasting glucose (IFG) • 2-hr glucose: 140-199 – Impaired glucose tolerance (IGT)



Both IFG and IGT are considered risk factors for future diabetes & CVD and should be treated.



Testing for type 2 diabetes in asymptomatic children

(Table 4 page S14)



BMI >85th percentile for age & sex, weight for height or weight >120% of ideal for height plus 2 of the following risk factors…



• Family hx in 1st or 2nd degree relative • Race/ethnicity (African American, Native American, Latino, Asian, Pacific Islander) • Signs of insulin resistance (Acanthosis nigricans, hypertension, dyslipidemia, or PCOS) • Maternal history of diabetes or GDM



When to test for type 2 diabetes in children (Table 4 page S14)

• Age of initiation: 10 yrs or at onset of puberty • Frequency: every 2 yrs • Test: FPG preferred



Gestational Diabetes

(Table 5 Page S15)



If high risk factors present, screen for diabetes ASAP after pregnancy confirmed. • Marked obesity • Hx of GDM • Previous large-for-gestation-age infant • Glycosuria • PCOS or “insulin resistant” • Fam Hx DM



Low risk factors for GDM

• Age 40 in men • HDL >50 in women • LDL 100)



• LDL 5 yrs,

– in type 2 DM at diagnosis, and – during pregnancy



• Screen annually for serum creatinine & GFR



Complications: Kidneys

• Dietary protein reduction may be needed if CKD present • Diabetic nephropathy is the single leading cause of ESRD

(See Table 12 & 13 pg S30 for specific information)



Fa



A foot exam using a monofilament, tuning fork, palpation & visual exam should be done at least every 3 years. (B)



1. True 2. False



0%

Tr ue



0%

ls e



Diabetes Complications: FEET

• Foot Exam Should Be Done: – at diagnosis of type 2 – 5 yrs after diagnosis of type 1 – at least annually thereafter



Diabetes Complications: FEET

• Includes use of monofilament, tuning fork, palpation and visual inspection • Initial screening for PAD (Doppler Study or ABI – ankle brachial index)



Other Neuropathies:

Autonomic diabetic neuropathy

– Resting tachycardia – Exercise intolerance – Orthostatic hypotension – Constipation – Gastroparesis – Erectile dysfunction – Brittle diabetes – Hypoglycemic unawareness



Immunizations – Page S24

• Flu vaccine annually >6 months of age

w/DM



• At least one lifetime pneumococcal vaccine for adults with diabetes.



Diabetes Care: Inpatient Setting

• Glucose goals for critically ill:

– 110 - <140 (A) • Goals for non-critically ill:

–fasting <126 and –random glucoses <180-200 (E)



Insulin in the Inpatient Setting



• “Sliding scale” or “correction scale” is NOT effective as monotherapy and is NOT recommended

• What is recommended? Meal-time coverage a “correction” scale, and basal insulin



Diabetes Self Management Education (DSME)

• People with diabetes need education from qualified health care providers with professional training (CDE’s) • Should be reimbursed by 3rd party payors • Education should be on-going (yearly)



References

• You have been given an overview of your printed Diabetes Care article. • Over 200 references to access for future lectures if needed • Thank you for your time!