© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (3): ITC3-1. * For Best Viewing:...

© Copyright Annals of Internal Medicine, 2015Ann Int Med. 162 (3): ITC3-1.

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in the clinic

Type 2 Diabetes


Should we screen for type 2 diabetes?

Many people with diabetes are unaware of it

Unclear if screening improves outcomes

Consensus lacking

Who should be screened? How often?

Magnitude of benefit (if any)?

Some groups recommend:

Screen every third year if >45 or if ≤45 + risk factors


Risk Factors for Type 2 Diabetes

Age >45 years

First-degree relative with type 2 diabetes

African American, Hispanic, Asian, Pacific Islander, or Native-American ethnicity

History of gestational diabetes or delivery of infant weighing ≥9 lb

The polycystic ovary syndrome

Overweight, especially abdominal obesity

Cardiovascular disease, hypertension, dyslipidemia, other features of the metabolic syndrome


Which patients are likely to benefit from screening?

Patients with hypertension

Blood pressure treatment goals should be the same for those with and without diabetes

Patients with risk factors for cardiovascular disease

Diabetes screening most likely to improve outcomes in these patients

Knowledge of diabetes status alters likelihood of treatment

When managing lipids: use a risk calculator that includes diabetes as risk factor


Can type 2 diabetes be prevented?

Diet and exercise

Substantially reduce incidence in those with prediabetes

Prediabetes = impaired fasting glucose / glucose tolerance

Modest weight loss (5%–7% body weight) can be effective

Medications

Prevent diabetes onset in prediabetes

Metformin

Acarbose

Rosiglitazone


CLINICAL BOTTOM LINE: Screening and Prevention... Evidence doesn’t support broad-based screening programs

Diabetes can be prevented in persons with prediabetes

Diet and exercise universally beneficial

Medications for those who can’t achieve lifestyle goals

Loss of 7% of body weight + 150 minutes of exercise per week substantially reduces diabetes risk


What are the diagnostic criteria for type 2 diabetes in nonpregnant adults? Pre-diabetes

HbA1c level 5.7–6.4%

Fasting plasma glucose 5.55-6.94 mmol/L (100-125 mg/dL) on 2 occasions ≥1 day apart

Diabetes

HbA1c level ≥6.5%

Fasting plasma glucose ≥7.0 mmol/L (≥126 mg/dL)

Classic symptoms

Polyuria, polydipsia, polyphagia, weight loss

Evidence of diabetes complications

Retinopathy, nephropathy, neuropathy, impotence, acanthosis nigricans, or frequent infections


What should the initial evaluation of patients with newly diagnosed type 2 diabetes include? Detailed history and physical

Review of diet and physical activity

Assessment of cardiovascular, cerebrovascular, ED

Blood pressure measurement

Inspect for possible diabetes complications via cardiovascular, neurologic, skin, and foot examinations

Lab tests to assess levels of glucose control, cholesterol levels, nephropathy, liver function

Ophthalmologic assessment to evaluate for retinopathy


CLINICAL BOTTOM LINE: Diagnosis and Evaluation... Consider type 2 diabetes when patients present with

Suggestive symptoms or signs

Complications of disease

Confirm diagnosis

HbA1c ≥6.5% or fasting plasma glucose levels >7.0 mmol/L (126 mg/dL) on 2 occasions ≥1 day apart

Examine newly diagnosed patients for hypertension and neurologic, ophthalmologic, and podiatric complications

Lab evaluation should include assessment of glucose control, lipid profile, and urine microalbumin-creatinine ratio


What are the components of nondrug therapy for patients with type 2 diabetes?

Lifestyle changes are cornerstones of management

Diet and exercise

First-line therapy unless severe hyperglycemia requires immediate medication treatment

ADA nutrition guidelines: http://care.diabetesjournals.org/content/37/Supplement_1/S120.full

Individualize assessment to develop feasible strategy

No one diet or exercise regimen applies to all patients


What is the role of home glucose monitoring?

Allows longitudinal monitoring of glucose control

Real-time feedback on effect of treatments

Standard of care for persons receiving insulin therapy

Allows sensible dose adjustments

Shows if symptoms are from hyper- or hypoglycemia

Frequency left to discretion of patient and provider

Monitor fasting and premeal glucose levels

Postprandial measurement may be helpful if HbA1c levels elevated despite normal fasting levels

Role to guide oral therapy is less clear


What is the target HbA1c level?

No clear single HbA1c target applies to all patients

Adjust targets to life expectancy + comorbid conditions

Most organizations and quality measurement groups advocate a target ≤7% for most patients

Moderate control (HbA1c 7%-8.5%) probably provides the most benefit for most patients

Patients with long life expectancy (≥20 years) may eventually realize benefit from more intensive control (HbA1c <7%)

But more aggressive control may increase mortality


When should treatment include drugs?

If diet and exercise don’t achieve the goal within ≈6 wks

In all patients except those with only mild HbA1c elevations

Severe hyperglycemia or symptoms may require pharmacologic intervention immediately

Sometimes with insulin


How should physicians select therapies from among the many oral drug options?

Most drugs achieve similar glycemic control

Insufficient data on relative efficacy for clinical end points

Differ in mechanism, tolerability, timing of administration

Metformin is often first-line therapy

If metformin contraindicated or not tolerated, consider patient preferences on potential side effects, efficacy, cost

Worsening glycemic control over time requires >1 agent

If increasing the dose of existing oral agents isn’t enough

Combination formulations may provide advantages in convenience or cost


When should physicians consider insulin therapy?

If patients can’t achieve goals through oral medications

If rapid reduction of blood glucose needed

If HbA1c levels are markedly elevated at diagnosis

Many formulations (biphasic, prandial, basal) available

Separated primarily by their onset of action and duration

Unclear that any particular regimen is superior

Primary risks: hypoglycemia and weight gain


What other options are available if control is inadequate on traditional oral drugs or insulin?

Glucagon-like peptide-1 (GLP-1) agonists

Act through GLP-1, a naturally occurring hormone involved in glucose homeostasis

Dipeptidyl peptidase-IV (DPP-IV) inhibitors

Work through the incretin and GLP-1 pathway

Sodium glucose-linked transporter-2 (SGLT2) inhibitors

Block glucose transport in the kidney

Synthetic forms of pancreatic hormones

Pramlintide: subcutaneously administered synthetic form of amylin


Noninsulin Medications for Type 2 Diabetes Biguanides (metformin, metformin XR)

Sulfonylureas (glimepiride, glipizide, glipizide SR, glyburide, glyburide micronized)

Thiozolidinediones (pioglitazone, rosiglitazone)

Alpha-glucosidase inhibitors (acarbose, miglitol)

Nonsulfonylurea insulin secretagogues (repaglinide, nateglinide)

DPP-IV inhibitors (sitagliptin, saxagliptin, linagliptin, alogliptin)

SGLT2 inhibitors (canaglifozin, empaglifozin, dapagliflozin)

GLP-1 agonists (injectable) (exenatide, exenatide XR, liraglutide, abliglutide, dulaglutide)


What novel therapeutic options are on the horizon?

Additional DPP-IV inhibitors

Vildagliptin approved for use in the EU

Anagliptin and teneligliptin approved for use in Japan

Additional SGLT2 inhibitors

Also in development


Aside from glycemic control, what other clinical interventions reduce complications?

Control of blood pressure

Use of lipid-lowering agents

Aspirin therapy

Retinal examination

Neuropathy screening

Foot care


Therapies to Reduce Neuropathy Symptoms

Tricyclic antidepressants

Duloxetine

Capsaicin cream

Antiepileptic agents


How frequently should physician see patients with type 2 diabetes, and what should be included in follow-up visits?

Quarterly

Based on expert opinion

Recommended frequency of monitoring HbA1c levels

Once disease is stable, reduce to every 6 months


When should specialists be consulted? Certified diabetes educator

To improve key domains in diabetes care (glycemic control)

Endocrinologist

To address questions about diagnosis or when glucose management has become difficult

Refer patients if pregnant or contemplating pregnancy

Ophthalmologist

For examination every 1 to 3 years

Frequency depends on prior exam results + glucose control

Nephrologist

If GFR <30 ml/min/1.73 m2 or renal insufficiency origin unclear

If patients have hyperkalemia, acidemia, trouble controlling BP

Podiatrist

To manage lesions to reduce risk for foot ulcers, amputation


When should patients with type 2 diabetes be hospitalized?

Severe, symptomatic hyperglycemia

Diabetic ketoacidosis or hyperosmolar coma

Diabetes complications

Cellulitis or osteomyelitis may require IV antibiotics or surgery


CLINICAL BOTTOM LINE: Treatment... Achieve glycemic targets on individual basis

Based on life expectancy and patient preference

Aim for at least moderate level of control (HbA1c <8.0%–8.5%)

Minimizes hyperglycemia

Limits microvascular risk

Reserve more aggressive targets (<7.0%) for patients with a long life expectancy

Reductions in advanced diabetes complications take 15 to 20 years to accrue

© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (3): ITC3-1. * For Best Viewing:...

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