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131_1323.ppt
Transcript of 131_1323.ppt
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Management of the Patient with Type 2 Diabetes
Gretchen M. Ray, Pharm.D.Cardiovascular Pharmacotherapy Resident
University of New Mexico College of Pharmacy
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Objectives
• Provide diabetes screening criteria for adults
• Describe available pharmacologic treatment options for type 2 diabetes including advantages/disadvantages of therapy and contraindications
• Given a patient case recommend appropriate lifestyle modifications and pharmacotherapy to achieve glycemic goals
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Objectives
• Distinguish between microvascular and macrovascular complications
• Provide screening criteria for nephropathy, neuropathy, and retinopathy
• Provide treatment strategies for the prevention and treatment of micro and macrovascular complications
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Epidemiology of Type 2 DM
• In 2005 20.8 million people (7% of the US population) had diabetes– 14.6 million diagnosed– 6.2 million undiagnosed
• Type 2 diabetes accounts for 90-95% of patients with diabetes
• In 2002 total indirect and direct medical costs for diabetes = $132 billion
CDC. National diabetes fact sheet. 2005 available at www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf
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Risk factors for type 2 diabetes• Physically inactive
• 1st degree relative with diabetes
• Minority ethnic groups
• Gestational diabetes or delivering a baby >9 lbs
• Hypertension
• HDL <35 mg/dL and/or triglycerides >250 mg/dL
• Polycystic ovary syndrome
• Previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)
• History of vascular disease
• Psychiatric illness
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Diagnosis of diabetes
• Symptoms of diabetes + casual plasma glucose ≥ 200 mg/dl
• FPG ≥ 126 mg/dl
• Oral glucose tolerance test (OGTT): 2-h postload glucose ≥ 200 mg/dl
OR
OR
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Definition of “pre-diabetes”
• Impaired fasting glucose (IFG) = FPG 100-125 mg/dl
• Impaired glucose tolerance (IGT) = 2-h post load glucose 140-199 mg/dl
• IFG and IGT indicate a risk factor for diabetes and cardiovascular disease
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Diabetes Screening
• Screening identifies asymptomatic patients who might have diabetes
• Consider in patients ≥ 45 years especially if their BMI ≥ 25 kg/m2
• Screen patients < 45 years old if they are overweight + an additional risk factor
• FPG should be done initially
• Repeat screening every 3 years
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Oral Therapies
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Metformin
hepatic glucose production, intestinal glucose absorption, insulin sensitivity
• Efficacy: A1C 1.5%
• Adverse effects– Primarily GI (up to 50%)
• Diarrhea, abdominal bloating, nausea• Titrate dose at weekly intervals to minimize AEs• Give with meals
– Lactic acidosis- rare• Monitor SCr
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Contraindications to Metformin
• Renal impairment SCr >1.5 for men, >1.4 for women
• Radiocontrast studies
• Age >80 unless normal GFR
• Hypoxia
• Liver dysfunction
• Alcoholism
• Heart Failure requiring pharmacologic therapy– According to package insert
• Should heart failure be a contraindication to metformin?Should heart failure be a contraindication to metformin?
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Improved Clinical Outcomes Associated with Metformin in Patients with Diabetes and Heart Failure
• Investigate the association between metformin and clinical outcomes in patients with HF and diabetes
• Retrospective study
• Primary outcome: all-cause mortality at 1 year and end of follow-up
• Secondary outcome: all-cause hospitalizations at 1 year and end of follow-up
Eurich DT, et al. Diabetes Care. 2005;28:2345-51
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Improved Clinical Outcomes Associated with Metformin in Patients with Diabetes and Heart Failure
Sulfonylurea monotherapy
(n=773)
Metformin monotherapy
(n=208)
Combination therapy
(n=852)
Adjusted all-cause mortality, HR (95% CI)
1.0 0.70 (0.54-0.91) 0.61(0.52-0.72)
Adjusted all-cause hospitalization, HR (95% CI)
1.0 0.87 (0.73-1.05) 0.93 (0.83-1.05)
Combined endpoint
1.0 0.83 (0.70-0.99) 0.86 (0.77-0.96)
Eurich DT, et al. Diabetes Care. 2005;28:2345-51
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Improved Clinical Outcomes Associated with Metformin in Patients with Diabetes and Heart Failure
• Lower all-cause mortality with metformin
• No increase in hospitalizations associated with metformin
• Observational study– Cannot prove that metformin is efficacious in this
population
Eurich DT, et al. Diabetes Care. 2005;28:2345-51
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Sulfonylureas
• ↑ insulin secretion from pancreatic β-cells
• Efficacy: ↓ A1C 1.5%
• Glyburide– Not recommended if CrCl < 50 ml/min (use a different sulfonylurea)
• Glipizide– Not recommended if CrCl < 10 ml/min
• Glimepiride– Not recommended if CrCl < 22 ml/min
• Response of sulfonylureas plateaus after half the max dose
• Reduced GI absorption if blood glucose > 250 mg/dL
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Sulfonylureas Adverse Effects
• Hypoglycemia– Elderly patients– Hepatic/renal impairment– Combination therapy
• Weight gain
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Thiazolidenediones (TZDs) Insulin Sensitizers
• TZDs are PPAR- gamma receptor activators
• ↑ insulin sensitivity – Primarily in the peripheral tissue
• Efficacy: A1C 0.5-1.4%
• Effect may not be seen for 4 weeks
• Rosiglitazone (Avandia®)– Initial dose 4 mg/day, Max dose 8 mg/day
• Pioglitazone (Actos®)– Initial dose 15-30 mg/day, Max dose 45 mg/day
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Adverse Effects/Contraindications of TZDs
AE’s
• Fluid retention and peripheral edema
• Weight gain– Fluid retention is a major
contributor– Redistribution of adipose tissue
• New-onset heart failure– < 1%– 2-3% when combined with
insulin
CI’s
• ALT > 2.5 x upper limit of normal
• Hepatic disease
• Alcohol Abuse
• HF NYHA class III or IV (see following slides)
Granberry MC, et al. Am J Health-Syst Pharm. 2007;64:931-6
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TZD Use In Heart Failure
• Use of TZDs in patients with NYHA class I or II HF– May be used with initiation of treatment at the lowest
dosage (rosiglitazone 2 mg daily or pioglitazone 15 mg daily)
– Observe for weight gain, edema, or exacerbation of HF
• Do not use TZDs in patients with NYHA class III or IV HF
Nesto RW, et al. Diabetes Care. 2004;27:256-63
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Meta-analysis of MI Risk With Rosiglitazone
• 42 trials comparing rosiglitazone with placebo–15,560 patients received rosiglitazone–12,283 patients assigned to comparator groups–24-52 week duration of trials–Mean baseline A1C 8.2% for both groups
Nissen SE, et al. N Engl J Med. 2007;356:1-15
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Meta-analysis of MI Risk With Rosiglitazone
Rosiglitazone
n= 14,371
Control
n= 11,634
Odds Ratio (95% CI)
P value
Myocardial Infarction
# events
86 72 1.43 (1.03-1.98) 0.03
Death from CV causes
# events
39 22 1.64 (0.98-1.74) 0.06
Nissen SE, et al. N Engl J Med. 2007;356:1-15
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PROactive Trial
• Primary objective: Determine if pioglitazone reduces CV morbidity and mortality in patients with diabetes
• Pioglitazone vs. placebo– ↓ Triglycerides 11% vs. 1.8% ↑– ↑ LDL 7.2% vs. 4.9%– ↓ LDL/HDL 9.5% vs. 4.2%
• Non-significant reduction in the primary endpoint
Dormandy JA, et al. Lancet. 2005;366:1279-89
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PROactive Sub-analysis
• Evaluated same endpoints in patients with prior MI
• Significant ↓ in fatal/nonfatal MI excluding silent MI with pioglitazone– 5.3% pioglitazone vs. 7.2% placebo p=0.0453
• Results for rosiglitazone and pioglitazone recently confirmed with two new meta-analyses
Erdmann E, et al. J Am Coll Cardiol. 2007;49:1772-80
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HF in PROactive
Pioglitazone
n = 2605
Placebo
n = 2633P value
# Events
# Patients
(%)# Events
# Patients (%)
Any report of HF
417 281 (11%) 302 198 (8%) <0.0001
HF w/o hospital admission
160 132 (5%) 117 90 (3%) 0.003
HF with hospital admission
209 149 (6%) 153 108 (4%) 0.007
Fatal HF 25 25 (1%) 22 22 (1%) 0.634
Dormandy JA, et al. Lancet. 2005;366:1279-89
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FDA Updates- August 14, 2007
• Rosiglitazone and pioglitazone received a “boxed warning” regarding CHF
www.fda.gov
Actos prescribing information. August 2007
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FDA Updates: November 19, 2007
• MI risk added to rosiglitazone boxed warning
Avandia prescribing information. November 2007
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Sitagliptin (Januvia®)
• DPP-4 inhibitor– Prevents the degradation of endogenous GLP-1– Results in a rise in postprandial endogenous GLP-1 levels
Lauster CD et al. Am J Health Syst Pharm. 2007;64:1265-73
Sitagliptin
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Sitagliptin (Januvia®)
• Efficacy: A1C 0.5-0.7%
• 100 mg PO once daily– CrCl 30-50 ml/min 50 mg/day– CrCl <30 ml/min 25 mg/day
• Approved for monotherapy or combination therapy
• Weight neutral
• Side effects similar to placebo
• No contraindications identified yet
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Non-Oral Therapies
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Glucagon-like peptide 1 (GLP-1) agonists
• Exenatide (Byetta®)
• Glucagon-like-peptide-1 (GLP-1) analog– Incretin mimetic– Resistant to degradation by dipeptidyl peptidase-4 (DPP-4)– Suppresses high glucagon levels– Delays gastric emptying (can affect absorption of other medications)
• Efficacy: ↓ A1C 0.5-1%
• Dosing:– 5 mcg SC twice daily within 60 min of meals– Increase to 10 mcg bid after 4 weeks
• FDA approved for type 2 diabetes in patients on metformin, sulfonylurea, TZD, or a combination who are not at goal– Not yet approved for use with basal insulin
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GLP-1 Physiology
GLP-1 secreted upon the ingestion of food
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Exenatide adverse effects/contraindications
• AE’s– N/V, diarrhea (30-45%)– Modest weight loss (a good
side effect)– Hypoglycemia especially in
combination with sulfonylureas
– Anti-exenatide antibodies
• Monitoring– Renal function– A1C in 3 months
• CI’s– Type 1 diabetes
• Precautions– CrCl < 30 ml/min– Gastroparesis– Hypoglycemia
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Pramlintide (Symlin®)
• Synthetic analog of human amylin– Suppresses glucagon secretion
• Suppression of endogenous glucose from liver– Slows gastric emptying
• Less rapid glucose appearance in the circulation– Regulates food intake due to central modulation of
appetite• Weight loss
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Pramlintide (Symlin®)
• FDA approved for Type 1 or 2 diabetes in patients on optimal insulin therapy who are still not at goal– With or without metformin and/or sulfonylurea therapy
• Efficacy: A1C ~0.1-0.4% in type1 and 0.3-0.7% in type 2
• 60 mcg (10 units) SC titrate to 120 mcg (20 units) before major meals (Type 2 dosing)– Dosed in mcg but drawn up in an insulin syringe– www.symlin.com/7522-Type-2-Dosing.aspx
• Administered in conjunction with mealtime insulin
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Pramlintide (Symlin®)
Adverse Effects
• Insulin-Induced Severe Hypoglycemia:
• Hypoglycemia will occur within 3 hours of injection
• Must reduce pre-meal insulin by 50% at initiation to prevent serious reactions
• Further reduction in insulin may be needed as dosage of pramlintide is adjusted
Contraindications
• Diagnosis of gastroparesis
• Hypoglycemia unawareness
• A1C > 9.0%
• Recurrent severe hypoglycemia requiring assistance during past 6 months
• Using other medications that stimulate gastrointestinal motility
• Pediatrics
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Glycemic Goals
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Glycemic Control
ADA Guidelines
• A1C < 7.0%– <6.5 may further reduce
complications
• Fasting glucose 90-130 mg/dl
• Peak postprandial glucose <180 mg/dl– 1-2 hours after the start of the
meal
AACE Guidelines
• A1C < 6.5%
• Fasting glucose < 110 mg/dl
• 2-h postprandial glucose <140 mg/dl
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A1C and Meal Plasma Glucose Levels
• A1C should be as close to normal for the individual patient
• Use less intensive goals for patients with risk for hypoglycemia
• Target postprandial glucose if A1C goals not met after reaching preprandial goals– Target fasting glucose first!
A1CMean Plasma
glucose mg/dl
6 135
7 170
8 205
9 240
10 275
11 310
12 345
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Self-Monitoring of Blood Glucose (SMBG)
• At least 3 times/day if on insulin injections
• If on orals, just use SMBG to help them achieve their glycemic goals
• Use the data to make decisions on what therapy to add
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Diabetes Care 2007;30(Suppl 1)
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Lifestyle + Metformin- Step 1
• Titrate metformin to max dose over 1-2 months
• TZDs and sitagliptin are also approved for monotherapy
• Consider adding other oral medications if there is persistent hyperglycemia
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Lifestyle Modifications
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Diet
• Weight loss will reduce insulin resistance
• Saturated fat < 7 % of total daily calories
• Carbohydrates should be from fruits, vegetables, whole grains, legumes, low fat milk– Low carb diets < 130 g/day not recommended for weight loss
• Recommend sugar alcohols and nonnutritive sweeteners
• Limit alcohol to 1 drink/day for women 2 drinks/day for men– If on insulin or a secretagogue drink alcohol with food to avoid
hypoglycemia
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Exercise
• 150 min/week of moderate-intensity aerobic activity (50-70% of max heart rate)
• 90 min/week of vigorous aerobic exercise (>70% of max heart rate)
• Resistance exercise 3 times a week
• Improves glycemia
OR
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Diabetes Self-Management Education (DSME)
• All patients with diabetes should receive DSME after diagnosis
• Teaches patients about the disease and how to improve self care
• Should be conducted by either a CDE or health care professional with recent experience in diabetes management
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Additional Medications - Step 2
• Add within 2-3 months of initiation of therapy
• Sulfonylurea– Cheapest option
• TZDs– More expensive– Cardiac risk with rosiglitazone
• Insulin– Most effective option– Consider in patients with A1C >8.5% or symptoms of hyperglycemia– Initiate with basal insulin
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Step-2 Alternatives
• Sitagliptin
• Glinides
• Exenatide
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Step-3 Initiate or intensify insulin therapy
• Start or intensify insulin if lifestyle + metformin + a 2nd medication have not attained goal A1C
• Third oral medication can be considered if A1C is close to goal <8.0%– Expensive, not as effective as insulin– Exenatide could be used at this step
• D/C insulin secretagogues (sulfonylurea or glinides) when pre-prandial rapid insulin is started
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Long Acting Insulin 10 units or 0.2 units/kg
Increase dose 2 units q 3 days until fasting levels 70-130 mg/dl
A1C ≥ 7% after 2-3 months?
No
Continue regimen Check A1C q 3 months
Check pre-meal BG & add 2nd injection ~4 units before meal
Yes
Pre-Lunch BG high: Add rapid acting at
breakfast
Pre-Dinner high: Add rapid acting at lunch
Pre-Bed high: Add rapid acting at
dinner
A1C ≥ 7% after 2-3 months?
Nathan DM, et al. Diabetes Care 2006;29
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A1C ≥ 7% after 2-3 months?
YesRecheck pre-meal BG and add another injection.
Check 2-h postprandial BG and adjust pre-prandial insulin dose
No
Continue regimen and check A1C q 3 months
Nathan DM, et al. Diabetes Care 2006;29
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Pramlintide
Exenatide
SitagliptinTZD
Exenatide
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CASE 1
• JK is a 59 year old male presenting for a follow-up visit to the diabetes clinic.
• Past Medical History– Type 2 diabetes– Hypertension– Coronary artery disease– Chronic renal insufficiency
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CASE 1
• Medications
• Metformin 1000 mg BID
• Glyburide 10 mg BID
• Pioglitazone 45 mg once daily
• Metoprolol XL 50 mg once daily
• Fosinopril 20 mg once daily
• Aspirin 81 mg once daily
• Labs (fasting)
• Glucose 170 mg/dL
• A1C 9.0%
• SCr 1.7 mg/dL
• CrCl 70 ml/min
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CASE 1
• Which diabetes medication on his profile is contraindicated and should be discontinued?
• A. Metformin
• B. Glyburide
• C. Pioglitazone
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CASE 1
• Why?
• A. Coronary artery disease
• B. Renal insufficiency
• C. Drug Interaction
• D. Non-adherence
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CASE 1
• Which one of the following would be most appropriate to replace the discontinued medication?
A. Glipizide XL 20 mg PO once daily
B. Insulin aspart 4 units SC before breakfast
C. Insulin glargine 10 units SC at bedtime
D. Pramlintide 60 mcg SC before meals
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Complications of Diabetes
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Complications of Uncontrolled DiabetesHyperglycemia
Spike Continuous
Chronic ToxicityAcute Toxicity
Tissue Lesions
Diabetic Complications
Microvascular Macrovascular
Nephropathy Neuropathy Retinopathy PVD MI Stroke
Hanefeld M, et al. Diabet Med. 1997;14(suppl 3):S6
HbA1CPPG
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Relative Risk of Progression of Diabetic Complications Relative Risk of Progression of Diabetic Complications by Mean HbAby Mean HbA1c1c
**
Updated Mean HbA1c (%)
Stratton IM, et al. BMJ. 2000;321:405-12.
Adjusted Incidenceper 1000 person years
6 7 8 9 10 11*Based on UKPDS 35 data
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Macrovascular Complications
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Macrovascular Complication Statistics
• CVD and Stroke– Adults with DM have heart disease death rates 2-4x
higher than non-diabetics– Risk for stroke is 2 to 4x higher and risk of death from
stroke is 2.8x higher than in non-diabetics
U.S. Department of Health and Human Services, National Institute of Health, 2005.
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Macrovascular Complications• ~ 80% of all diabetic mortality
–75% from coronary atherosclerosis–25% from cerebral or peripheral vascular disease
• > 75% of all hospitalizations for diabetic complications
• > 50% of patients with newly diagnosed type 2 diabetes have CHD
National Diabetes Data Group. Diabetes in America. 2nd. Ed. NIH; 1995.
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Accelerated atherosclerosis
Clinical diabetes
Hyperinsulinemia Impairedglucose
tolerance
HypertriglyceridemiaDecreased HDL-C
Essentialhypertension
Insulin resistance
Insulin Resistance and Atherosclerosis
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Heart Disease and Diabetes
• Intensive treatment of hyperglycemia
• Therapy for insulin resistance
• Appropriate lipid management
• Aggressive blood pressure control
Treatment of CVD in diabetes is similar to therapy for non-diabetic individuals, the risk of CVD is much higher and the benefits of
therapy are greater
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Hypertension
• Defined as BP ≥ 140/90 mmHg– GOAL BP: < 130/80 mmHg
• 20 – 60% of Diabetics have HTN
• Epidemiologic evidence from the UKPDS indicate that each 10 mmHg decrease in mean SBP results in: 12% any DM complication 15% any DM-related death 11% MI 13% microvascular complications
American Diabetes Association. Diabetes Care. 2007;30:S4-S41.
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Hypertension
• Weight loss 1 kg results in of MAP ~ 1 mmHg
• Sodium restriction– In non-diabetic patients reduces SBP ~ 5 mmHg and DBP ~2 - 3
mmHg
• Drug Therapy (If SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or lifestyle modification failure)– 1st choice: ACE-I or ARB– 2nd choice: Thiazide, β-Blocker, or Non-DCCB
JNC 7 report. JAMA 2003;289:2560-72.
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Cholesterol Management• Screening:
– Fasting lipid panel at least annually – More often if needed to achieve goals– In adults with low-risk lipid values, may obtain fasting lipid
panel every 2 years
• Goals:– LDL < 100 mg/dL
• Optional: LDL <70 mg/dL– TG < 150 mg/dL– HDL:
• > 40 mg/dL for males• > 50 mg/dL for females
American Diabetes Association. Diabetes Care .2007;30:S4-S41.
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Macrovascular Complications
Aspirin Therapy: 75 – 162 mg/day
• Primary prevention in those with ↑ CVD risk:– Family Hx of CVD– Tobacco use– HTN– Albuminuria– Lipids: TC >200; LDL >100; HDL < 45 (or 55) & TG >200– Age ≥ 40 years
• Secondary prevention in those with DM + CVD
• Not recommended for patients < 30 years-old
American Diabetes Association. Diabetes Care .2007;30:S4-S41.
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Macrovascular Complications
• Smoking cessation–Advise all patients not to smoke–Provide smoking cessation counseling and
other forms of treatment if needed
American Diabetes Association. Diabetes Care .2007;30:S4-S41.
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Management Summary for Macrovascular Complications
Macrovascular Complications
Goals
Hypertension Dyslipidemia• LDL < 100 mg/dL
• Optimal < 70 mg/dL
• TG < 150 mg/dL• HDL:
• > 40 mg/dL – Male• > 50 mg/dL - Female
Blood Pressure:• < 130/80 mmHg
Treatment
• Weight loss• Sodium restriction• ACE-I / ARB
Everyone needs: • Aspirin • Lifestyle modifications • Smoking Cessation
• Statin
American Diabetes Association. Diabetes Care .2007;30:S4-S41.
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Microvascular Complications
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Relative Risk of Progression of Diabetic Complications by Mean HbA1c
*
Skyler JS ,et al. Endocrinol Metab Clin North Am. 1996;25:243-54.
Relative risk
6 7 8 9 10 11 12
15
13
11
9
7
5
3
1
HbA1c (%)
Diabetic retinopathyNephropathyNeuropathyMicroalbuminuria
*Based on DCCT data
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Diabetic Nephropathy
• Occurs in 20 to 40% of diabetics
• Most common cause of ESRD
• ESRD develops in 50% of type 1 patients with overt nephropathy within 10 years
• ESRD develops in about 20% of type 2 patients with overt nephropathy within 20 years
American Diabetes Association. Diabetes Care. 2007;30:S4-S41.
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Nephropathy: DiagnosisCategory Spot Collection
(albumin-to-creatinine) (mcg/mg)
Normal < 30
Microalbuminuria 30 - 299
Clinical albuminuria > 300
Two of three specimens collected within a 3-6 month period should be abnormal before diagnosing.
Exercise within 24 hr, infection, fever, CHF, marked hyperglycemia or HTN, pyuria, & hematuria may elevate urinary albumin excretion over baseline values
American Diabetes Association. Diabetes Care. 2007;30:S4-S41.
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Nephropathy: Screening
• Screening– DM 1: Within 5 years of diagnosis– DM 2: Upon diagnosis– DM 1 and 2: Follow-up exams annually
• If (+) for microalbuminuria, test twice more over next 3 to 6 months – If 2 of 3 tests are positive, they have microalbuminuria and
should have treatment started
• Serum creatinine should be measured at least annually for estimation of GFR
American Diabetes Association. Diabetes Care. 2007;30:S4-S41
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Nephropathy: Treatment
• Glycemic control: HbA1c < 7%
• Blood pressure control: BP < 130/80 mmHg– ACE-I / ARBs
• Decrease progression of microalbuminuria and slow rate of decline in GFR in patients with proteinuria
• Non-DCCBs, BB’s, or thiazide acceptable if intolerant to ACEI/ARB
• If ACE-I, ARBs, or thiazide used, monitor K+
• Protein restriction– With presence of nephropathy
• ≤ 0.8 g/kg per day (~ 10% of daily calories)
American Diabetes Association. Diabetes Care. 2007;30:S4-S41
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Diabetic NeuropathySensorimotor
• Muscular– Muscle weakeness– Balance difficulties
• Sensory– Pain– Parathesias– Numbness– Cramping– Nighttime falls
Autonomic
• Cardiovascular– Syncope, fatigue, sustained heart rate
• GI– Dysphagia, N/V, constipation, diarrhea
• Genitourinary– ↓ bladder control, UTIs, ED, Dyspareunia
• Sudomotor– Dry skin, calluses, limb hair loss
• Endocrine– Hypoglycemic unawareness
• Other– Depression, anxiety, sleep disorders
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Diabetic Neuropathy Screening
• Annual foot exam: –Assessment for protective sensation, foot
structure and biomechanics, vascular status, and skin integrity.• Neurologic status assessed with 5.07 (10-g)
monofilament• Also consider: pin-prick sensation, temperature and
vibration perception (using tuning fork)• Assess for history of claudication, and assess pedal
pulses• Assess skin integrity especially b/w toes and under
metatarsal heads. Look for erythema, warmth, or callus formation (increased plantar pressure)
• Bony deformities, limitation in joint mobility, and gait and balance should be assessed
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Diabetic Neuropathy Treatment
• Glycemic control: HbA1c < 7%
• Foot care– Proper footwear– Daily patient assessment– Moisturizing
• Not between toes
– NO bare feet!
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Peripheral Neuropathy Treatment• Optimal glycemic control: GOAL HbA1c < 7%
Wong M, et al. BMJ. 2007; 335; 1-10.
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Diabetic Retinopathy• Leading cause of new cases of blindness among
adults (20 to 74 years of age).
• Prevalence is strongly related to duration of diabetes.
Normal Vision Diabetic Retinopathy
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Diabetic Retinopathy Screening
• Comprehensive dilated eye exam:– DM 1: Within 3 to 5 years of diagnosis– DM 2: Upon diagnosis– DM 1 and 2: Follow-up exams annually
American Diabetes Association. Diabetes Care. 2007;30:S4-S41.
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Diabetic Retinopathy Management
• Tight glycemic control HbA1C < 7%
• Tight blood pressure control <130/80 mmHg– Both shown to delay or prevent onset of retinopathy
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Management Summary for Microvascular Complications
Microvascular Complications
Screening
Nephropathy Neuropathy Retinopathy
Annual Exam:• Dilated Eye• Retinal vessels• Cataract• Intraocular Pressure
Annual Microalbumin:• Screen Albumin:
Creatinine ratio• Repeat to confirm
Comprehensive foot exam:• Inspection• Vascular• Vibratory perception• Monofilament
Treatment
• Glycemic Control• ACE-I / ARB
• Glycemic Control• Foot care/ footwear• Medication Management
• Glycemic Control• BP Control• Photocoagulation
Everyone needs lifestyle modifications
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Standards of Care in Diabetes
Diabetes Care. 2007;30(suppl 1):S4-S41
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Medical history during the 1st evaluation
• Age and characteristics of onset of diabetes
• Eating patterns
• History of diabetes education
• Previous and current treatments
• Exercise history
• Hypoglycemic episodes
• History of DKA?
• History of diabetes related complications
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Physical Exam/Labs
Physical Exam
• BP
• Fundoscopic exam
• Thyroid palpation
• Skin exam
• Peripheral pulses
• Patellar and achilles reflexes
• Peripheral sensation
Labs to order
• A1C
• Fasting lipids
• LFTs
• Microalbuminuria
• SCr and GFR
• TSH
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Health Maintenance/Prevention of Complications
• Influenza vaccine annually
• Pneumococcal vaccine for all adults
• Smoking cessation!
• BP at every visit, goal < 130/80 mmHg
• Check lipids annually: Goal LDL <100 mg/dL, TG <150 mg/dL, HDL >40 for men >50 for women
• Annual test for microalbuminuria
• Annual eye exam to screen for retinopathy
• Annual screening for peripheral and autonomic neuropathy
• Foot care
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CASE 2
• JT is a 58 year old male newly diagnosed with Type 2 diabetes
• PMH– Dyslipidemia
• SH: Tobacco 1 pack/day x 30 years; Rare ETOH use; denies illicit drug use; diet is high in carbohydrates and sugars and low in vegetables; physical activity “little to none”
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CASE 2
• How much exercise should you recommend for JT?
A. 90 minutes/week
B. 60 minutes/week
C. 150 minutes/week
D. 300 minutes/week
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CASE 2
• Which of the following should be done at diagnosis?
A. Eye exam
B. Test for microalbuminuria
C. Blood pressure
D. Fasting lipids
E. All of the above
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CASE 2
• JT’s blood pressure is 150/90, what would be your recommendation for initial therapy?
A. Fosinopril
B. HCTZ
C. Diltiazem
D. Metoprolol