Diabetes:Diabetes:The 2007 GuidelinesThe 2007 Guidelines

Kevin E. Moore, M.D.Kevin E. Moore, M.D.

LTC, MCLTC, MC

Residency DirectorResidency Director

NCC-DACH Family Medicine ResidencyNCC-DACH Family Medicine Residency

Medical ppt http://hastaneciyiz.blogspot.com

ADA 2007 Clinical ADA 2007 Clinical Practice Practice

RecommendationsRecommendations Why is this important?Why is this important? Current screening guidelinesCurrent screening guidelines 6 cornerstones of diabetes6 cornerstones of diabetes New developmentsNew developments Questions!!Questions!!

Why is this important?Why is this important? Type 2 DM is most prevalent formType 2 DM is most prevalent form 7.9% of adults have 7.9% of adults have

diagnosed/undiagnoseddiagnosed/undiagnosed diabetes diabetes 4-fold more likely to have a MI.4-fold more likely to have a MI. 8-fold more likely to die from first MI.8-fold more likely to die from first MI. Leading cause of blindness ages 20-74.Leading cause of blindness ages 20-74. 1/3 of all cases of legal blindness.1/3 of all cases of legal blindness. Most common cause of ESRDMost common cause of ESRD 1/3 of all dialysis patients.1/3 of all dialysis patients. #2 cause of amputations.#2 cause of amputations.

Leading Healthcare Expenditure in U.SLeading Healthcare Expenditure in U.S

Medical Management Can Change All of the Above

ScreeningScreening

2025, 9% of U.S. population will be 2025, 9% of U.S. population will be diabeticdiabetic

5.2 million undiagnosed diabetics in U.S5.2 million undiagnosed diabetics in U.S Diagnosis latency for Type 2 DM is 4.2 Diagnosis latency for Type 2 DM is 4.2

yearsyears Polyuria, polyphagia, and polydypsia are Polyuria, polyphagia, and polydypsia are

very unreliable screening indicators.very unreliable screening indicators.

Risk FactorsRisk Factors

Family HistoryFamily History Obesity (BMI > 25)Obesity (BMI > 25) Race/Ethnicity Race/Ethnicity

(African-American, (African-American, Hispanic-American, Hispanic-American, Native Americans, Native Americans, Asian Americans, Asian Americans, Pacific Islanders)Pacific Islanders)

Age > 45Age > 45 Hypertension (> Hypertension (>

140/90)140/90)

HDL Cholesterol < 35HDL Cholesterol < 35 Triglycerides > 250Triglycerides > 250 History of GDMHistory of GDM History of MacrosomiaHistory of Macrosomia Polycystic Ovarian Polycystic Ovarian

DiseaseDisease Previous Abnormal Previous Abnormal

ScreeningScreening Physically InactivePhysically Inactive Vascular DiseaseVascular Disease

Screening Screening RecommendationsRecommendations

Patients at high-risk for diabetes (2-3 risk Patients at high-risk for diabetes (2-3 risk factors) screened every 3 yearsfactors) screened every 3 years

IGT/IFG – Screen every 1-2 yearsIGT/IFG – Screen every 1-2 years Screening TestsScreening Tests

Fasting Plasma Glucose - Preferred - Fasting Plasma Glucose - Preferred - accuracy, ease, low-cost.accuracy, ease, low-cost.

2 hour OGTT (75 gm glucose load) 2 hour OGTT (75 gm glucose load) Random Plasma Glucose - very inaccurate, Random Plasma Glucose - very inaccurate,

discourage use.discourage use. HgA1C - NOT a screening test.HgA1C - NOT a screening test.

Repeat and Confirm all Screening Tests in 24 Hours!

Screening TestsScreening Tests

NormalNormal IFG or IGTIFG or IGT DiabetesDiabetes

FPG < 109FPG < 109 FPG 110-125FPG 110-125 FPG FPG >> 126 126

2hPG < 2hPG < 139139

2hPG 140-2hPG 140-199199 2hPG 2hPG >> 200 200

Random Random >> 200 200

Cornerstones of Cornerstones of Diabetes Management?Diabetes Management? Glycemic ControlGlycemic Control HypertensionHypertension HyperlipidemiaHyperlipidemia NephropathyNephropathy RetinopathyRetinopathy Foot CareFoot Care

Glycemic ControlGlycemic Control

HgA1C is the gold standardHgA1C is the gold standard SMBG is an integral component of SMBG is an integral component of

diabetes management – Expert diabetes management – Expert ConsensusConsensus

All treatment decisions for Type 2 All treatment decisions for Type 2 Diabetics should be based on A1C levelsDiabetics should be based on A1C levels

Check A1c twice each year in all patientsCheck A1c twice each year in all patients

SMBG is extremely valuable in tailoring SMBG is extremely valuable in tailoring therapy to a specific patienttherapy to a specific patient

Glycemic ControlGlycemic ControlA1C%A1C% Mean Plasma Glucose Mean Plasma Glucose

(mg/dl)(mg/dl)

66 135135

77 170170

88 205205

99 240240

1010 275275

1111 310310

1212 345345

Glycemic ControlGlycemic Control

HgA1C < 6% - normal.HgA1C < 6% - normal. HgA1C < 7% - goal.HgA1C < 7% - goal. HgA1C 7.0 - 7.5% - good control.HgA1C 7.0 - 7.5% - good control. HgA1C > 7.5% - additional therapyHgA1C > 7.5% - additional therapy Pre-prandial glucose 90-130 mg/dlPre-prandial glucose 90-130 mg/dl Peak postprandial glucose < 180 mg/dlPeak postprandial glucose < 180 mg/dl

HgA1C every 3 months unless at HgA1C every 3 months unless at goal then every 6 months.goal then every 6 months.

HypertensionHypertension

Goal B/P < 130/80Goal B/P < 130/80 Treat all patients > 130/80Treat all patients > 130/80

MNT for 130-139/80-89 MNT for 130-139/80-89 Drug treatment - > 140/90Drug treatment - > 140/90

ACEI/ARB’s are drugs of choiceACEI/ARB’s are drugs of choice Beta-blockers may improve myocardial Beta-blockers may improve myocardial

outcome - do not mask hypoglycemia.outcome - do not mask hypoglycemia. Calcium Channel Blockers – ALLHAT Calcium Channel Blockers – ALLHAT

StudyStudy

HypertensionHypertension

UKPDS - 21% reduction in CAD events UKPDS - 21% reduction in CAD events and morbidity (B/P < 144/82)and morbidity (B/P < 144/82)

Atenolol vs. captoprilAtenolol vs. captopril

HOT – CAD events decreased from 9% to HOT – CAD events decreased from 9% to 4% over 3.8 years when the diastolic was 4% over 3.8 years when the diastolic was lowered from 90 to 80 mm Hglowered from 90 to 80 mm Hg

Felodipine/ACE InhibitorFelodipine/ACE Inhibitor

Syst-Eur – CAD events decreased from Syst-Eur – CAD events decreased from 12% to 5% over 2 years when the 12% to 5% over 2 years when the systolic was lowered 20 mm Hgsystolic was lowered 20 mm Hg

Enalapril/HCTZEnalapril/HCTZ

HypertensionHypertension

ALLHAT – Largest Anti-Hypertensive StudyALLHAT – Largest Anti-Hypertensive Study 42,000 patients followed over 6 years42,000 patients followed over 6 years Diuretic vs. lisinopril vs. amlodipineDiuretic vs. lisinopril vs. amlodipine Alpha-blocker arm d/c’d early due to CHFAlpha-blocker arm d/c’d early due to CHF Cardiovascular events were the same in all Cardiovascular events were the same in all

three study armsthree study arms ADA Recommends:ADA Recommends:

ACE/ARB as first-lineACE/ARB as first-line Consider diuretic as first additionConsider diuretic as first addition CCB or beta-blocker third lineCCB or beta-blocker third line

HyperlipidemiaHyperlipidemia

Most common lipid abnormality: Most common lipid abnormality: elevated triglycerides followed by elevated triglycerides followed by reduced HDL.reduced HDL.

LDL levels are usually not elevated LDL levels are usually not elevated compared to non-diabetic compared to non-diabetic population.population.

LDL particles are more atherogenic LDL particles are more atherogenic in diabetic patients.in diabetic patients.

HyperlipidemiaHyperlipidemia Primary PreventionPrimary Prevention

– AFCAPS/TexCAPS – 37% reduction in CAD events AFCAPS/TexCAPS – 37% reduction in CAD events (lovastatin)(lovastatin)

– SENDCAP – reduction in induced ischemia (bezafibrate)SENDCAP – reduction in induced ischemia (bezafibrate)– Helsinki Heart Study – 7% reduction in CAD events Helsinki Heart Study – 7% reduction in CAD events

(gemfibrizol)(gemfibrizol)– Heart Protection Study – 25% reduction in first CAD when Heart Protection Study – 25% reduction in first CAD when

LDL lowered by 30% (simvastatin)LDL lowered by 30% (simvastatin)– CARDS – 40% reduction in first CAD/stroke (atorvastatin)CARDS – 40% reduction in first CAD/stroke (atorvastatin)

Secondary PreventionSecondary Prevention– CARE - 27% reduction CAD events (pravastatin)CARE - 27% reduction CAD events (pravastatin)– 4S – 55% reduction CAD events (simvastatin)4S – 55% reduction CAD events (simvastatin)– VA-HIT - 24% reduction CAD events (gemfibrozilVA-HIT - 24% reduction CAD events (gemfibrozil))

Priorities of Lipid Priorities of Lipid ManagementManagement

First, lower LDL cholesterol.First, lower LDL cholesterol. Second, raise HDL cholesterol.Second, raise HDL cholesterol. Third, lower Triglyceride levels.Third, lower Triglyceride levels.

Lipid Lowering Lipid Lowering MedicationsMedications

Drug of Choice: HMG CoA Drug of Choice: HMG CoA Reductase Inhibitors (the Statins).Reductase Inhibitors (the Statins).

Second Line: Fibric Acid Second Line: Fibric Acid Derivatives.Derivatives.

Third Line: Bile Acid ResinsThird Line: Bile Acid Resins Relatively Contraindicated: NiacinRelatively Contraindicated: Niacin

Maximal Medical Nutrition Therapy has been Maximal Medical Nutrition Therapy has been shown to lower LDL by no more than 20mg/dlshown to lower LDL by no more than 20mg/dl

Testing for Testing for HyperlipidemiaHyperlipidemia

All diabetics should have a full lipid All diabetics should have a full lipid profile done annually profile done annually

Any diabetic being treated should Any diabetic being treated should have lipid profiles done every 3-6 have lipid profiles done every 3-6 months until goal is reached.months until goal is reached.

Once goal is reached, lipid profiles Once goal is reached, lipid profiles should be done every 6 - 12 should be done every 6 - 12 months.months.

Treatment Goals for Treatment Goals for HyperlipidemiaHyperlipidemia

Nutrition Nutrition TherapyTherapy Drug TherapyDrug Therapy

StartStart GoalGoal StartStart GoalGoal

CADCAD >> 100 100 < 100< 100 >> 100 100 < 100< 100

No No CADCAD >> 100 100 < 100< 100 >> 130 130 < 100< 100

NephropathyNephropathy

Incipient Nephropathy - characterized Incipient Nephropathy - characterized by microalbuminuria.by microalbuminuria.

Overt Nephropathy - characterized by Overt Nephropathy - characterized by clinical albuminuria.clinical albuminuria.

End Stage Renal Disease - characterized End Stage Renal Disease - characterized by a declining GFR.by a declining GFR.

ANNUAL SCREENING REQUIREDANNUAL SCREENING REQUIRED MicroalbuminuriaMicroalbuminuria Serum creatinineSerum creatinine

Screening Tests for Screening Tests for AlbuminuriaAlbuminuria

Albumin-to-creatinine ratio in Albumin-to-creatinine ratio in random spot urine collection.random spot urine collection.

24 hour urine albumin and 24 hour urine albumin and creatinine collection.creatinine collection.

Timed (4 hour) urine albumin and Timed (4 hour) urine albumin and creatinine collection.creatinine collection.

Screening Tests for Screening Tests for Albuminuria Albuminuria

Albumin-to-creatinine ratio in Albumin-to-creatinine ratio in random spot collection preferred.random spot collection preferred.

Falsely elevated - hyperglycemia, Falsely elevated - hyperglycemia, UTI, exercise, marked UTI, exercise, marked hypertension, CHF, and feverhypertension, CHF, and fever

Day-to-day variation in Day-to-day variation in albuminuria.albuminuria.Microalbuminuria must be confirmed with Microalbuminuria must be confirmed with

2-3 collections over 6 months to diagnose 2-3 collections over 6 months to diagnose incipient nephropathyincipient nephropathy

Screening Test ResultsScreening Test Results

Collection MethodCollection Method

SpotSpot

(ug/mg(ug/mg CreatinineCreatinine

))

24-Hour24-Hour

(mg/24h)(mg/24h)

TimedTimed

(ug/(ug/min)min)

NormalNormal < 30< 30 < 30< 30 < 20< 20

Micro-Micro-albuminuriaalbuminuria 30-29930-299 30-29930-299 20-19920-199

Clinical Clinical AlbuminuriaAlbuminuria >> 300 300 >> 300 300 >> 200 200

Treatment of Treatment of NephropathyNephropathy

Optimize Glycemic Control.Optimize Glycemic Control. Optimize Hypertension Management.Optimize Hypertension Management. ACE Inhibitors - even if normotensive.ACE Inhibitors - even if normotensive. If intolerant of ACE Inhibitors - ARB’s If intolerant of ACE Inhibitors - ARB’s

have similar supporting datahave similar supporting data Protein Restriction to 0.8mg/kg/day - Protein Restriction to 0.8mg/kg/day -

once CKD develops.once CKD develops.

RetinopathyRetinopathy

21% of Type 2 diabetics have 21% of Type 2 diabetics have evidence of retinopathy at time of evidence of retinopathy at time of diagnosis.diagnosis.

Treatment available by both Laser Treatment available by both Laser Photocoagulation and Argon Laser Photocoagulation and Argon Laser therapy - best treated by experienced therapy - best treated by experienced ophthalmologist.ophthalmologist.

Screen can be done by qualified Screen can be done by qualified optometrist and/or ophthalmologist.optometrist and/or ophthalmologist.

Natural History of Natural History of RetinopathyRetinopathy

Mild Non-Proliferative Retinopathy- Mild Non-Proliferative Retinopathy- increased vascular permeabilityincreased vascular permeability

Moderate to Severe Non-Proliferative Moderate to Severe Non-Proliferative Retinopathy - vascular closureRetinopathy - vascular closure

Proliferative Retinopathy - regrowth Proliferative Retinopathy - regrowth of new vessels on retina and of new vessels on retina and posterior surface of the vitreous.posterior surface of the vitreous.

Screening Screening Recommendations for Recommendations for

RetinopathyRetinopathyPatient Patient GroupGroup First ExamFirst Exam Follow-Follow-

UpUp

Type 1 Type 1 DiabetesDiabetes

3-5 years after 3-5 years after diagnosisdiagnosis

(age > 10)(age > 10)YearlyYearly

Type 2 Type 2 DiabetesDiabetes When diagnosedWhen diagnosed YearlyYearly

Foot CareFoot Care

Annual Foot Exam Looking for High-Annual Foot Exam Looking for High-Risk Conditions.Risk Conditions.

Foot Exams at Every Visit.Foot Exams at Every Visit. Professional Foot Care for Patients Professional Foot Care for Patients

with One or More Risk Factors.with One or More Risk Factors. Daily Foot Care for All Patients - Daily Foot Care for All Patients -

Patient Instruction on Nail and Skin Patient Instruction on Nail and Skin CareCare

Annual Foot ExamAnnual Foot Exam

Components:Components: Monofilament testing for sensory lossMonofilament testing for sensory loss Skin examSkin exam Examination of foot anatomy/dystrophiesExamination of foot anatomy/dystrophies Vascular examVascular exam

Risk Factors for Foot Risk Factors for Foot DiseaseDisease

Peripheral Peripheral NeuropathyNeuropathy

Altered Altered BiomechanicsBiomechanics

Evidence of Evidence of Increased Pressure Increased Pressure (callus, erythema, (callus, erythema, bruising)bruising)

Decreased Joint Decreased Joint MobilityMobility

Bony DeformityBony Deformity Marked Nail Marked Nail

PathologyPathology Peripheral Vascular Peripheral Vascular

DiseaseDisease History of History of

AmputationAmputation History of Foot UlcerHistory of Foot Ulcer

New Developments - New Developments - Prevention Prevention

Finnish Study: Finnish Study: – Intense MNT vs ControlIntense MNT vs Control– Average Follow-up 3.2 yearsAverage Follow-up 3.2 years– 58% risk reduction for diabetes58% risk reduction for diabetes

Diabetes Prevention Program (DPP):Diabetes Prevention Program (DPP):– Intense MNT vs Metformin vs PlaceboIntense MNT vs Metformin vs Placebo– Average Follow-up 2.8 yearsAverage Follow-up 2.8 years– 58% risk reduction for diabetes for MNT58% risk reduction for diabetes for MNT– 31% risk reduction for diabetes for Metformin31% risk reduction for diabetes for Metformin

New Developments - New Developments - PreventionPrevention

Troglitazone Prevention of Diabetes Troglitazone Prevention of Diabetes (TRIPOD):(TRIPOD):– Troglitazone vs placeboTroglitazone vs placebo– Average follow-up 2.5 yearsAverage follow-up 2.5 years– 58% risk reduction for diabetes58% risk reduction for diabetes

STOP-NIDDM:STOP-NIDDM:– Acarbose vs placeboAcarbose vs placebo– Average follow-up 3.3 yearsAverage follow-up 3.3 years– 36% risk reduction for diabetes36% risk reduction for diabetes

New Developments - New Developments - Children Children

Type 2 Diabetes in ChildrenType 2 Diabetes in Children– Included in 2003 Guidelines – significant Included in 2003 Guidelines – significant

update in 2006 guidelinesupdate in 2006 guidelines– Screening AddressedScreening Addressed– ? Standards for Hypertension and Lipid ? Standards for Hypertension and Lipid

ManagementManagement

More Information to Follow in Upcoming YearsMore Information to Follow in Upcoming Years

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