Diabetes Guidelines by malj

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									Diabetes Guidelines
Kevin H McKinney MD University of Texas Medical Branch at Galveston Division of Endocrinology/Stark Diabetes Center

DIABETES MELLITUS
•Inability of the body to metabolize blood sugar •A disease of inadequate insulin secretion and action •Hyperglycemia is the main manifestation

COMPLICATIONS
Chronic hyperglycemia may cause: –retinal damage –chronic kidney disease –nerve damage –vascular disease

COMPLICATIONS (cont.)
•Blindness •Dialysis •Lower Limb Amputation •Stroke •Myocardial infarction •Claudication

PRIMARY CLASSES OF DIABETES MELLITUS
•Type 1
–Autoimmune destruction of islets –No insulin secretion

•Type 2 Diabetes
–Insulin resistance with progressive insulin secretory defect –90% are obese

PREVALENCE OF TYPE 1 DIABETES IN THE US
• 1 million people

• Caucasians constitute the majority of type 1 diabetics • Most prominent during childhood

PREVALENCE OF TYPE 2 DIABETES IN THE US
• Most common type of diabetes among all ethnic groups • 17 million patients with known diabetes • 45% of children and teens with new diagnoses

PREVALENCE OF TYPE 2 DIABETES IN THE US
• Caucasian women experience higher prevalence rates than men (57% vs. 26%) • By age 70, African American prevalence rates increase to 42% of the population

METABOLIC SYNDROME
• • • • • • Insulin resistance (type 2 diabetes) Hypertension Dyslipidemia Polycystic ovary syndrome Hyperuricemia Hypercoagulability

PREVALENCE OF METABOLIC SYNDROME IN THE US
•Third NHANES Study (Prevalence Rates)
–21.6% African American Adults –31.9% Mexican American Adults –23.8% Caucasian Adults

OBESITY—A PUBLIC HEALTH PROBLEM
Rise in metabolic syndrome is related to increasing prevalence of obesity Multifactorial causes for obesity including – A sedentary lifestyle – Decline in exercise – Increased access to unhealthy foods – Greater food portions

GESTATIONAL DIABETES
• Occurs after the onset of pregnancy • Is secondary to the production of human placental lactogen and other hormones needed to sustain pregnancy

• Most common in people of color

GESTATIONAL DIABETES
•If untreated, may result in fetal macrosomia •Fetal macrosomia may lead to –Cesarean section –Shoulder dystocia –Fetal hypoglycemia •High risk women should be screened at first prenatal visit •Low-risk women should be screened from 24 to 28 weeks of gestation

Hospitalization Costs for Chronic Complications of Diabetes in the US
Ophthalmic Others disease

Renal disease

Neurologic disease  Total costs Peripheral 12 billion vascular US $ disease

Cardiovascular disease

 CVD accounts for 64% of total costs

American Diabetes Association. Economic Consequences of Diabetes Mellitus in the US in 1997. Alexandria, VA: American Diabetes Association, 1998:1-14.

DISPARITIES IN DIABETES COMPLICATIONS IN AFRICAN AMERICANS
• Contributing factors –Average delay in diagnosis of 4-7 years –Longer duration of poorly controlled type 2 diabetes –Development of equally devastating complications

MICROVASCULAR COMPLICATIONS OF DIABETES
•Diabetic retinopathy
–46% higher in African Americans and 86% higher in Mexican Americans than in Caucasians

•Diabetic Nephropathy
–African Americans, Latinos, and Native Americans have 3-4 times higher rates of renal failure than Caucasians

DIABETIC NEUROPATHY
•Primary contributor to the loss of limb protection through the diminution or absence of pain and sensory perception. •Diminution or absence of pain and sensory perception leads to limb trauma, open ulcers and polymicrobial foot infections often culminating in gangrene that is treated by limb amputation. •Lower extremity limb amputation is 2-3 times higher in African Americans and Mexican Americans than in Caucasians.

MACROVASCULAR RISKS OF DIABETES
• Risk of stroke, coronary artery disease, and peripheral vascular disease is increased 2-4 times in all patients with diabetes. • The presence of diabetes is viewed as an independent risk factor for first acute myocardial infarction compared to those with recurrent myocardial infarction without diabetes.

MACROVASCULAR RISKS OF DIABETES
• The rates for myocardial infarction and stroke among African Americans, Asian Americans and Hispanic Americans are the same or lower than in Caucasians; however, the mortality from CAD is disproportionately high in minorities.
• Cardiovascular disease (CVD) remains the leading cause of death in individuals with diabetes, up to 70% of type 2 diabetes patients.

RISK REDUCTION OF MACROVASCULAR COMPLICATIONS
–Glycemic Control –Smoking Cessation –Blood Pressure Control –Lipoprotein Management –Prothrombotic State Improvement

SCREENING GUIDELINES
• Adults 45 years of age and older esp with BMI > 25 – Fasting Plasma Glucose at 3 year intervals • Overweight or obese individuals with risk factors for diabetes, African Americans, Latinos – Fasting Plasma Glucose screened at an earlier age and more frequently • Children with BMI > 85th percentile – Screened at age 10 and every 2 years thereafter

DIAGNOSTIC CRITERIA
• Fasting Plasma Glucose > 126 mg/dL • Casual Blood Sugar > 200 mg/dL or greater as with diabetic symptoms • 2-hour postprandial serum glucose of 200 mg/dL as stimulated by a glucose tolerance test • Test reconfirmation required

PRE-DIABETIC STATES
• Impaired glucose tolerance (IGT)
– 2-hour glucose between 140 and 199

• Impaired fasting glucose (IFG)
– Fasting glucose beteween 100 and 125

• Above are risk factors for future diabetes and cardiovascular disease

Diabetes Prevention Program
Screened 158,177 OGTT, then randomize 3819 randomized

Lifestyle 1079

Metformin 1073 3% Wt loss 31% Risk Reduction

Placebo 1082

Thiazolidinedione 585 ~10 month followup

5% Wt loss 58 % Risk Reduction

Diabetes Rate 11 % per year

23 % Risk Reduction

Diabetes Prevention Program Research Gp, NEJM 346(6): 393 -403, 2002.

TREATMENT GOALS FOR DIABETES MELLITUS
Maintaining: • Pre-meal blood glucose in the range of 90 mg/dL to 130 mg/dL • Bedtime blood glucose in the range of 100 mg/dL to 140 mg/dL • A hemoglobin A1c value from 6.5% to 7% over 3 months

Increased A1c Raises Vascular Event Risk
80
Adjusted Incidence per 1000 Patient-Years (%)

60

Microvascular Complications Myocardial Infarction

40

20

0

0

5

6

7

8

9

10

11

Updated Mean A1c (%)*
* Updated mean A1c is adjusted for age, sex, and ethnic group, expressed for white men aged 50-54 years at diagnosis and with mean duration of diabetes of 10 years. Stratton IM et al. BMJ. 2000;321:405-412.

Established Modifiable Cardiovascular Risk Factors In Type 2 Diabetes
UKPDS 23
•Position in Model •First •Second Variable Low-density lipoprotein cholesterol High-density lipoprotein cholesterol P Value* <.0001 .0001

•Third
•Fourth •Fifth

Hemoglobin A1c
Systolic blood pressure Smoking

.0022
.0065 .056

* Significant for CAD (n = 280). P values are significance of risk factors after controlling for all other risk factors in model. Adjusted for age and sex in 2693 white patients with type 2 diabetes with dependent variable as time to first event. Turner RC et al. BMJ. 1998;316:823-828.

TREATMENT GOALS FOR DIABETES MELLITUS (Cont.)
Maintaining: • Blood pressure < 130/80 mm Hg • LDL Cholesterol < 100 mg/dL, triglycerides < 150 mg/dL, and HDL cholesterol > 40 mg/dL in men (> 50 mg/dL in women) • High risk cardiovascular patients should aim for LDL cholesterol < 70 mg/dL

MANAGEMENT PLAN
• Must be individualized for each individual patient • Diabetes education: initial and subsequent • Lifestyle modifications
– Diet (improve your nutrition) – Exercise (increase your activity)

• Home blood glucose monitoring
– At least once/day for oral medications – Three times daily for insulin users

• Medications

FOLLOW-UP CARE
• Annual eye exam • Physician visits every 3 months, more frequently for poor control
– Fundoscopic exam – Foot exam

• HbA1c quarterly for poor control, every biannually for good control • Lipogram yearly • Microalbumin yearly

Natural History of Type 2 Diabetes
Obesity IGT * Diabetes Uncontrolled Hyperglycemia

Plasma Glucose
120 (mg/dL)

Post-Meal Glucose Fasting Glucose

Relative  -Cell Function
100 (%)

Insulin Resistance Insulin Secretion -20 -10 0 10 20 30
*IGT = impaired glucose tolerance.

Years of Diabetes

Adapted from International Diabetes Center (IDC), Minneapolis, M innes ota.

MEDICAL NUTRITIONAL THERAPY
• Must be individualized for each patient
– Children must be allowed enough calories for growth, development, and activity – Pregnant women, elderly also deserve special consideration

• Permanent low-carbohydrate diets not recommended
– “carbohydrate counting” can be done with insulin users

MEDICAL NUTRITIONAL THERAPY (cont)
• Weight management
– One should aim for 500-1000 Calorie reduction in intake per day – 1000-1200 Calories/day for women, 1200-1600 Calories/day for men for weight reduction – Bariatrics?

• Activity should consist of 3-5 sessions per week
– 30-45 minutes for health – Weight loss: 1 hour of walking, 30 minutes of vigorous exercise

ORAL MEDICAL THERAPY
• First line: metformin useful except where contraindicated • Sulfonylureas or meglitinides also frequently used • Second line: thiazolidinediones • Used uncommonly: acarbose

INSULIN
• Traditional regimens
– Type 1: Basal insulin (NPH, glargine) with bolus regular or short-acting insulin (lispro, aspart, glulisine) by sliding scale; split-mix regimen; insulin pump – Type 2: split-mix regimen; fixed combination (70/30, 50/50, 75/25); basalbolus

• Transitional type 2 insulin regimens: oral agents with bedtime NPH or glargine

ADJUNCTS
• Cardiovascular
– Aspirin

• Renal
– ACE inhibitor/Angiotensin receptor blocker

• Hypertension
– Diuretics

• Cholesterol
– Statins

WHEN TO REFER
• Poor control for 6 months despite patient adherence and physician manipulation (HbA1c >10%) • Multiple episodes of decompensation (DKA, HONK) • Frequent hypoglycæmic episodes

Reference
• American Diabetes Association. Diabetes Care 28:S4, 2005 Jan. • American Association of Clinical Endocrinologists. Endocrine Practice 8:S40, 2002 Jan/Feb.


								
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