Diabetes Guidelines

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Diabetes Guidelines

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

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DIABETES MELLITUS

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

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COMPLICATIONS

• Chronic hyperglycemia may cause
• retinal damage
• chronic kidney disease
• nerve damage
• vascular disease

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COMPLICATIONS (cont.)

• Blindness
• Dialysis
• Lower Limb Amputation
• Stroke
• Myocardial infarction
• Claudication

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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

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PREVALENCE OF TYPE 1 DIABETES IN THE US

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

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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

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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

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METABOLIC SYNDROME

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

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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

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OBESITYA 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

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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

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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

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

• Total costs 12 billion US
• CVD accounts for 64 of total costs

Peripheral vascular disease
Renal disease
Cardiovasculardisease
American Diabetes Association. Economic
Consequences of Diabetes Mellitusin the US in
1997. Alexandria, VA American Diabetes
Association, 19981-14.
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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

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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

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• 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.

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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.
  

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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.

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

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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

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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

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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

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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

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Increased A1c Raises Vascular Event Risk
MicrovascularComplications
Adjusted Incidence per1000 Patient-Years ()
MyocardialInfarction
0
5
6
7
8
9
10
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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. 2000321405-412.

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Established Modifiable Cardiovascular Risk
Factors In Type 2 Diabetes
UKPDS 23

• Positionin Model Variable
  P Value
• First Low-density lipoprotein cholesterol
• Second High-density lipoprotein cholesterol .0001
• Third Hemoglobin A1c .0022
• Fourth Systolic blood pressure .0065
• Fifth Smoking .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.
1998316823-828.
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TREATMENT GOALS FOR DIABETES MELLITUS (Cont.)

• Maintaining
• Blood pressure
• LDL Cholesterol mg/dL, and HDL cholesterol 40 mg/dL in men (
  50 mg/dL in women)
• High risk cardiovascular patients should aim for
  LDL cholesterol

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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

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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

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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

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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

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ORAL MEDICAL THERAPY

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

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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) basal-bolus
• Transitional type 2 insulin regimens oral
  agents with bedtime NPH or glargine

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ADJUNCTS

• Cardiovascular
• Aspirin
• Renal
• ACE inhibitor/Angiotensin receptor blocker
• Hypertension
• Diuretics
• Cholesterol
• Statins

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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

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Reference

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