It is my pleasure to share with you Pennsylvania’s first-ever Diabetes Action Plan. to thank those who served on the Diabetes Stakeholder Group and have …
Diabetes Update Diabetes Update
Belinda Vail, MD University of Kansas School of Medicine Department of Family Medicine Kansas City, Kansas
Scope of the Problem Scope of the Problem
19 million diabetics in the US; 177 million worldwide; numbers will double in the next 25 years More than 30 of newly diagnosed diabetics who are younger than 20 years of age have type 2 diabetes 7th leading cause of death; major cause of blindness, renal failure and amputations in the US 100 billion/year; 63 spent on inpatient costs
Pathogenesis Pathogenesis
Types 1 and 2: Genetic component Environmental component body weight insulin resistance Beta cells initial response is to increase output but this response decreases over time Latent autoimmune diabetes of adulthood LADA: Tcell destruction of pancreatic islet cells Patients are thin Short response to oral medications Type 3: link between Alzheimers and lack of insulin production in the brain
Clinical Focus Clinical Focus
Cardiovascular risk reduction HgbA1C improvement goal: 7 Aggressive blood pressure control Patient support Consistent screening for complications
Metabolic Syndrome Metabolic Syndrome
No single
definition
Glucose intolerance 100-110 mg/dL / hyperinsulinemia Abdominal obesity men: waist 40 in / women: waist 35 in Elevated triglycerides 150 mg/dL Low HDL men: 40 mg/dL / women: 50 mg/dL Blood pressure 130/85 mm Hg Microalbuminuria World Health Organization
Increased risk of cardiovascular disease, stroke, impaired vascular relaxation 25 of Americans who are 20-79 years of age have metabolic syndrome
Audience Response Question: Audience Response Question:
Which of the following patients would not be recommended for diabetes screening?
1 12 y/o F BMI 39 whose mother has diabetes 2 38 y/o M triglycerides 320 mg/dL, HDL 35 mg/dL 3 42 y/o F BMI 28, normal blood pressure/lipids, no family history of diabetes 4 57 y/o M blood pressure of 180/100 mm Hg 5 17 y/o F BMI 32, blood pressure of 140/90 mm Hg
Audience Response: Audience Response:
5 0
1 12 y/o F BMI 39 whose mother has diabetes
2 38 y/o M triglycerides 320 mg/dL, HDL 35 mg/dL
Correct answer: 42 y/o BMI 28, normal blood pressure / lipids, no family history of diabetes
91
4 57 y/o blood pressure of 180/100 mm Hg
2 1
5 17 y/o F BMI 32, blood pressure of 140/90 mm Hg
Screening Recommendations
Screening Recommendations
US Preventive Services Task Force USPSTF: patients who have hypertension and/or hyperlipidemia American Diabetes Association ADA: every 3 years, starting at age 45 More frequent or earlier screening if:
Diabetes in 1st degree relative Blood pressure 140/90 mm Hg Obesity High-risk ethnic population History of impaired glucose tolerance Undesirable lipid levels Previous gestational diabetes or baby 9 lbs
Screening Recommendations in Children Screening Recommendations in Children
American Diabetes Association ADA: Screen every 2 years, starting at age 10 or puberty if: BMI 85th percentile for age and sex, or if weight 120 of ideal for height Two of the following risk factors are present: Family history 1st or 2nd degree relative Maternal history of diabetes or gestational diabetes GDM Ethnicity/race Signs or symptoms of insulin resistance acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome
Audience Response Question: Audience Response Question:
Which of the following patients has met the criteria for diagnosis of diabetes?
1 64 y/o F with a fasting glucose of 125 mg/dL 2 45 y/o M with a random glucose of
180 mg/dL 3 31 y/o G3P2 F with a 1-hour glucose tolerance test GTT of 145 mg/dL 4 55 y/o F with 2 fasting glucoses of 128 mg/dL and 131 mg/dL 5 60 y/o M with a HgbA1C of 7
Audience Response: Audience Response:
2 11
1 64 y/o F with a fasting glucose of 125 mg/dL
2 45 y/o M with a random glucose of 180 mg/dL
3 31 y/o G3P2 F with a 1hour glucose tolerance test GTT of 145 mg/dL
1
Correct answer: 55 y/o F with fasting glucoses of 128 mg/dL and 131 mg/dL
74 11
5 60 y/o M with a HgbA1C of 7
Diagnosis of Diabetes Diagnosis of Diabetes
Fasting glucose 126 mg/dL Random glucose 200 mg/dL with signs No current indication for using HgbA1C for the diagnosis of diabetes Impaired fasting glucose: 100 mg/dL - 125 mg/dL Impaired glucose tolerance: 2-hour GTT 140 mg/dL - 199 mg/dL Gestational diabetes: 3-hour GTT with 100 g load
Assessment and Documentation Assessment and Documentation
History/physical exam weight, height, BMI, blood pressure, eyes, oral, cardiovascular, skin, feet {monofilament}, neurological Laboratory tests glucose, HgbA1C {2 to 4 times/year}, lipids, creatinine, yearly urine microalbumin Electrocardiogram depending on patients individual needs Patient
knowledge base and motivation Education
Treating Prediabetes Treating Prediabetes
Intensive lifestyle changes Cardiovascular risk reduction Follow-up and routine screening Useful medications: Metformin Thiazolidinediones ACE inhibitors Alpha-glucosidase inhibitors
Efficacy of Therapy Efficacy of Therapy
From individual and societal perspective, glycemic control is a cost-effective intervention for decreasing microvascular complications Blood pressure control independently affects progression of microvascular and macrovascular complications ACE inhibitors delay onset and improve microalbuminuria Decreasing cardiovascular risk improves outcomes Risk of cardiovascular event in diabetic patient is equivalent to risk in nondiabetic patient with coronary artery disease Statins may independently improve outcomes 1 reduction in HgbA1C 21 decrease in risk of developing complications Managing glucose, blood pressure and lipids reduces macrovascular and microvascular complications
Audience Response Question: Audience Response Question:
Which of the following is not a primary management goal for all of your diabetic patients?
1 2 3 4 5
Daily aspirin therapy Smoking
cessation HgbA1C 7 Bedtime glucose 120 mg/dL Blood pressure 130/80 mm Hg
Audience Response: Audience Response:
47 7 3 41 3
Correct answer: daily aspirin therapy 2 Smoking cessation
3 HgbA1C 7
4 Bedtime glucose 120 mg/dL 5 Blood pressure 130/80 mm Hg
Management Goals Management Goals
Preprandial glucose 100 mg/dL Bedtime glucose 120 mg/dL HgbA1C 7 Blood pressure 130/80 mm Hg LDL cholesterol 70 mg/dL officially still 100 mg/dL Daily aspirin therapy in patients 40 years of age / coronary artery disease Statin therapy ACE inhibitor for hypertension or microalbuminuria Avoidance of tobacco Goals must be individualized for each patient Education
Treatment Changes Outcomes Treatment Changes Outcomes
In patients with type 2 diabetes, the risk of diabetic complications was strongly associated with previous hyperglycemia Any reduction in HgbA1C is likely to reduce the risk of complications, with the lowest risk being in those with HgbA1C values in the normal range 60
Information taken from: Institute for Clinical Systems Improvement Management of type 2 diabetes mellitus 2005 Retrieved November 21,2006, from the World Wide Web:
http://wwwicsiorg/knowledge/detailasp?catID29itemID182
Nutrition Nutrition
Weight loss cut 500-1000 kcal/day Reasonable expectation: 10-20 lbs In patients with type 2 diabetes, 10 weight loss significantly lowers glucose levels Protein: 20 of total daily energy 08-10 g/kg with microalbuminuria and 08 g/kg with macroalbuminuria Healthy diet: whole grains, fruits, vegetables, low-fat dairy, high fiber Fats: 30 total; saturated fat: 7; cholesterol: 200 mg Limit alcohol intake Some evidence for chromium and magnesium supplementation
Exercise Exercise
4-7 times/week, 30 or more minutes Can be in 10- to 15-minute segments Moderate activity Athletes should not participate in strenuous activity if glucose 300 mg/dL or 250 mg/dL with urine ketones
Exercise Exercise
Both vigorous exercise and moderate exercise reduce the risk of type 2 diabetes in women The more exercise taken, the greater the risk reduction
Information taken from: Bandolier Exercise and type 2 diabetes Retrieved November 21, 2006, from the World Wide Web: http://wwwjr2oxacuk/bandolier/booth/hliving/excer2diabhtml
Pharmacological Therapy Pharmacological Therapy
Metformin
Thiazolidinediones rosiglitazone, pioglitazone Sulfonylureas glyburide, glipizide, glimepiride Meglitinides repaglinide, nateglinide Alpha-glucosidase inhibitors acarbose, miglitol Insulin short- and long-acting; human and synthetic New drugs: exenatide, pramlintide acetate
Audience Response Question: Audience Response Question:
A 57-year-old Caucasian female with a BMI of 30 has tried lifestyle changes but fasting glucose is still 135 mg/dL What should initial therapy be? 1 Glargine insulin 2 Metformin 3 Acarbose 4 Glipizide 5 Pioglitazone
Audience Response: Audience Response:
1 92 1 5 1
1 Glargine insulin
Correct answer: metformin
3 Acarbose
4 Glipizide
5 Pioglitazone
Metformin Metformin
Acts on liver cells to decrease glucose production; no hypoglycemia or weight gain Lowers insulin and lipid levels Improves cardiovascular outcomes in overweight and newly diagnosed type 2 diabetics Use with caution in elderly patients, and in patients with renal dysfunction, cardiopulmonary disorders and hepatic disease Creatinine must be checked prior to use Suspend therapy 1 day before administering IV contrast Widely used in obese patients with impaired glucose tolerance;
may delay onset of diabetes Widely used in the treatment of polycystic ovarian syndrome PCOS 25/month generic
Thiazolidinediones Thiazolidinediones
Insulin sensitizers: rosiglitazone Avandia and pioglitazone Actos Lower insulin levels Use with caution in elderly patients due to declining ventricular function, and in anyone with ca 
rdiopulmonary disorders due to volume overload Liver function tests LFTs must be monitored; avoid in patients with hepatic dysfunction Increase ovulation 150/month
Sulfonylureas Sulfonylureas
Glipizide Glucotrol, glyburide Micronase, glimepiride Amaryl Stimulate pancreatic beta cells to increase insulin production May cause weight gain and hypoglycemia Can be used in low doses in elderly patients May be used in patients with mild renal dysfunction and cardiopulmonary comorbidities sleep apnea, congestive heart failure 25-75/month generics available
Meglitinides Meglitinides
Repaglinide Prandin, nateglinide Starlix Rapid-acting insulin secretagogues Half life 1 hour High cost for moderate decrease in glucose; 150/month Very helpful for patients with erratic eating schedules May be used in elderly patients and in patients with
renal failure or cardiopulmonary disorders
Alpha-Glucosidase Inhibitors Alpha-Glucosidase Inhibitors
Acarbose Precose and miglitol Glyset Delay carbohydrate absorption in the gut; decrease peak glucose levels; no hypoglycemia Acarbose may delay onset of type 2 diabetes Monitor liver function tests LFTs Should not be used in patients with renal dysfunction or gastrointestinal disease Significant gastrointestinal side effects Moderate reduction of glucose for cost; 100/month
Exenatide Injection Byetta Exenatide Injection Byetta
GLP-1 agonist incretin mimetic Potentiates insulin secretion Suppresses postprandial glucagon secretion Slows gastric emptying Promotes satiety no weight gain Indicated for type 2 diabetics who are not controlled on oral agents subcutaneous injection Not indicated for use with insulin Not indicated for patients with CrCl 30 mL/min Category C in pregnancy Side effects: hypoglycemia with sulfonylureas, neovascularization of the disc NVD Mean HgbA1C reduction 086 150-200/month
Pramlintide Acetate Symlin Pramlintide Acetate Symlin
Synthetic analogue of human amylin Slows gastric emptying should not be used with other motility agents
Suppresses postprandial glucagon secretion Increases satiety no weight gain For poorly controlled type 1 or 2 diabetics who inject insulin at mealtimes Subcutaneous injection before major meals Cannot be mixed with insulin in the same syringe Side effects: nausea, vomiting, anorexia, headache, hypoglycemia with insulin Mean HgbA1C reduction 062 Expensive approximately 160/month
Insulin Insulin
Weight gain outweighed by glucose control Human insulin or synthetic insulin Average dose 06-08 units/kg body weight/day Bioavailability changes with site of injection faster in abdomen, slower in thigh Inhaled insulin is on the market–question of how precisely it will be absorbed
Rapid-Acting Analogues Rapid-Acting Analogues
Lispro Humalog, aspart NovoLog, glulisine Apidra Analogs of human insulin Particularly well-liked by type 1 diabetics Onset 15 min, peak 1-3 hr, duration 2-5 hr May need to adjust long-acting regimen Available in 75/25 mix with longer-acting protamine form
Audience Response Question: Audience Response Question:
Your patient, who has type 2 diabetes, has been using NPH insulin 30 u bid and sliding scale regular about 40 u/d How much glargine
should you use to replace all of this insulin?
1 2 3 4 5
110 u 100 u 90 u 80 u 70 u
Audience Response: Audience Response:
0 10 5 35 51
1 110 U
2 100 U
3 90 U
Correct answer: 80 U
5 70 U
Long-Acting Insulin Long-Acting Insulin
NPH duration 16-24 hr Glargine Lantus 24 hr human analog
Cannot mix with other types of insulin Solution must remain clear May be used in type 1 and 2 diabetics Initiate dose at 80 of prior total insulin dose
Detemir Levemir similar to glargine
Insulin Pump / Transplant Insulin Pump / Transplant
High patient satisfaction Type 1 diabetics Requires motivated patient to do frequent glucose checks Improved glucose control Uses only short-acting insulin Pancreatic transplant still primarily experimental
Combination Therapy Combination Therapy
Available combinations Metformin and glyburide Glucovance Metformin and glipizide Metaglip Metformin and pioglitazone ActoPlus Met Metformin and rosiglitazone Avandamet Rosiglitazone and glimepiride Avandaryl Best if different mechanisms of action are combined Increases efficacy, but increases cost As beta cell function declines, add insulin
Complications Complications
Ketoacidosis Nephropathy Retinopathy Neuropathy Cardiovascular Diabetic Foot
Audience Response Question: Audience Response Question:
What fluid should you use in a 19year-old Caucasian male with ketoacidosis, K of 68 mEq/L and pH 712? 1 Normal saline until K is 40 mEq/L 2 Half-normal saline until K is 50 mEq/L 3 Normal saline until K is 35 mEq/L 4 Half-normal saline until K is 40 mEq/L 5 Normal saline until K is 55 mEq/L
Audience Response: Audience Response:
36 11 29 5
1 Normal saline until K is 40 mEq/L
2 Half-normal saline until K is 50 mEq/L
3 Normal saline until K is 35 mEq/L
4 Half-normal saline until K is 40 mEq/L
Correct answer: normal saline until K is 55 mEq/L
20
Ketoacidosis Ketoacidosis
Insufficient insulin, increased gluconeogenesis and fatty acid oxidation See Wash Manual Metabolic acidosis Volume replacement 1 L normal saline/hr until dehydration is resolved–then half-normal saline at 150500 mL/hr Replace K as soon as it starts to fall Insulin drip 1-2 units/hr until acidosis is resolved Add D5 when glucose is 250 mg/dL Bicarbonate only for pH 72 or HCO2 10 mEq/L Hourly monitoring of electrolytes, glucose and pH
Audience Response Question:
Audience Response Question:
Which of the following is not part of the treatment for microvascular complications of diabetes?
1 2 3 4 5
Tight control of blood pressure Aspirin therapy Tight control of blood sugar Smoking cessation Control of lipids
Audience Response: Audience Response:
4 82 1 4 10
1 Tight control of blood pressure Correct answer: aspirin therapy 3 Tight control of blood sugar
4 Smoking cessation
5 Control of lipids
Nephropathy Prevention Nephropathy Prevention
Patients with microalbuminuria or proteinuria should be considered for angiotensin II antagonist therapy
Information taken from: National Guideline Clearinghouse Retrieved November 21, 2006, from the World Wide Web: http://wwwguidelinegov/summary/summaryaspx?doc_id3078
Microvascular Complications Microvascular Complications
Nephropathy, retinopathy, neuropathy: all treated with glycemic control, blood pressure control, lipid control, smoking cessation Yearly microalbuminuria and ophthalmology exam ACE inhibitors for patients with microalbuminuria Regular monofilament exams Laser photocoagulation for retinopathy Monitor peripheral and autonomic neurological symptoms No evidence that aspirin
therapy is helpful
Cardiovascular Complications Cardiovascular Complications
80 of deaths Increased 2-fold in men; 4-5-fold in women Evaluate for symptoms, microalbuminuria or high index of suspicion Electrocardiogram and stress thallium are the most helpful Control hypertension: all drugs are acceptable Control hyperlipidemia: statins Aspirin therapy, smoking cessation, lifestyle changes
Aspirin Therapy Aspirin Therapy
Patients with type 2 diabetes are at a significantly high risk for development of heart disease For patients with type 2 diabetes mellitus, initiate low-dose aspirin therapy 81-325 mg daily in patients 40 and older unless there is a contraindication to aspirin therapy
Information taken from: Institute for Clinical Systems Improvement Management of type 2 diabetes mellitus 2005 Retrieved November 21, 2006, from the World Wide Web: http://wwwicsiorg/knowledge/detailasp?catID29itemID182
Treatment of Hypertension Treatment of Hypertension
Blood pressure 130/80 mm Hg Drug of choice: ACE inhibitor Angiotensin receptor blocker ARB can be first choice if ACE inhibitor is not tolerated Thiazide diuretics and beta blockers are cardioprotective and can be
used in patients with diabetes Calcium channel blockers and alpha-1-receptor blockers are generally not used alone
Treatment of Hyperlipidemia Treatment of Hyperlipidemia
Diabetic dyslipidemia elevated triglycerides, decreased HDL, increased LDL Aggressive lifestyle changes Drug of choice: statins Fibrates or fish oil may be added to help control triglycerides Goals: Total cholesterol 200 mg per dL Triglycerides 150 mg per dL LDL 100 mg per dL
Audience Response Question: Audience Response Question:
In a 57-year-old Caucasian male patient with a diabetic foot ulcer, what is the best indicator of ability to heal? 1 Size of ulcer 2 Signs of infection 3 Patients pulse 4 Patients blood sugar 5 Patients blood pressure
Audience Response: Audience Response:
2 3 33 57 5
1 Size of ulcer
2 Signs of infection
Correct answer: patients pulse
4 Patients blood sugar
5 Patients blood pressure
Diabetic Foot Diabetic Foot
Leading cause of nontraumatic foot amputation Neuropathy, altered foot structure, vasculopathy Best test for sensation is monofilament Best treatment is aggressive prevention Diabetic foot ulcer treatment:
remove pressure good wound care no
antibiotics if not infected
Best test for osteomyelitis is MRI Best indicator for successful healing is intact vascular supply pulse
Multidisciplinary Approach Multidisciplinary Approach
Diabetes educator Dietitian Exercise physiologist Podiatrist Home health nurse Social worker
Family physician is the team leader Nurse practitioner Medical specialists ophthalmologist, neurologist, renal specialist, endocrinologist
Thank you
Diabetes Update Diabetes Update
The asterisks in the slides throughout this presentation indicate topics of questions that are frequently asked in the In-training or Family Medicine Board Exams
