Diabetes Office Mgmt

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2003 CDA Clinical Practice Guidelines

• Diabetes Office Mgmt

J. Robin Conway M.D. Diabetes Clinic - Smiths
Falls, ON
Toronto May 6 2004
www.diabetesclinic.ca
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Worldwide rates of diabetes mellitus predictions
80 70 60 50 40 30 20 10 0
Prevalence (millions)
Year 1995 2000 2025
North America
Europe
Southeast Asia
World Health Organization. 1997. Canadian
Diabetes Association, 1998 website.
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2 Million Canadians Have Diabetes Mellitus
Frequency of diagnosed and undiagnosed diabetes
and IGT, by age (U.S. data - Harris)
Harris. Diabetes Care 199316642-52.
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Cardiovascular Disease Risk is Increased 2 to 4
Times
Framingham study diabetes and CAD mortalityat
20-year follow-up
Haffner Am J Cardiol 19998411J-4J.
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What proportion of your office visits involve
Diabetics?

1. lt10
2. 10-20
3. 20-30
4. 30-50
5. gt50

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The burden of Diabetes

• 87 of Type 2 Diabetes is managed in Primary
  Care
• Diascan Study 23.5 of patients in our office
  have diabetes
• Quebec screening gt2 Risk Factors 79 tested
  7 Diabetes
  13 IGT or IFG
  74 No
  Treatment Advice

Leiter et al. Diabetes Care 2000
Strychar I et al. Cdn J Diab 2003(abs)
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Glucose Monitoring

• Do you do A1c to follow glycemic control
• 1 YES
• 2 NO

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Microvascular Complications

• Do you order urine microalbumen test
• 1 YES
• 2 NO

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Microvascular Complications

• Do you use a 10 gm filament for testing sensation
  in the feet?
• 1 YES
• 2 NO

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T2DM in Family Practice

• 84 of patients had A1c in past year
• Average A1c 7.9 (goallt7)
• 88 had BP check
• 48 had lipid profiles
• 28 tested for microalbuminuria
• 15 had foot exams

Harris S et al. Cdn Fam Phys 2003
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Organization and Delivery of Care

• Diabetes should be organized using a DHC
  (Diabetes Healthcare) team approach
• People with diabetes should be offered initial
  and ongoing needs-based diabetes education
• The role of diabetes nurse educators and other
  DHC team members should be enhanced in
  cooperation with the physician

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Structured care

• ACLS
• ATLS
• Seattle Defibrillator Experience
• GREACE Study

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Structured Care VS Usual Care

• Patients received atorvastatin 10 mg/d (titrated
  up to 80 mg/d) to reach the NCEP LDL-C goal
• Specialist care unit with a strict protocol to
  achieve NCEP LDL-C target
• Treatment from a physician of pts choice
• All patients had access to any necessary
  medications, including statins
• Included lifestyle modifications (diet and
  exercise) as well as lipid-lowering medications

Structured Care
Usual Care
?thyros VG et al. Curr Med Res Opin.
200218220-228.
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Reduction in Relative Risk of Primary Endpoints
Reduction
P0.034
P0.0021
P0.0017
P0.0011
P0.0001
P0.0032
P0.021
?thyros VG et al. Curr Med Res Opin.
200218220-228.
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Type 2 Diabetes

• Increasing Prevalence
• Primary Care Based
• Forms a large part of a practice
• Needs structured care approach
• Team Approach
• Multiple comorbidities
• Limited Time Funding

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How can we deal with this?

• Refer all Diabetic Patients?
• Community Education Programs?
• Guidelines Based Structured Care?
• Identify the Diabetics in the practice?
• Diabetes Day in Office?
• Get some Diabetes CME?
• Team Approach in Office?
• Office Tools?

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Diabetes Day in the Office

• Book Diabetic Patients for one day
• Get office support staff to follow formula
• Office staff do Wt, BMI, BP, Glucose, lab
• Have educational material, consider 1 room
• Follow Guideline Algorithms
• Use Tools Flowsheet
• Extra Staff?
• Follow up Appt Lab

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Educational Material

• Canadian Diabetes Assoc www.diabetes.ca
• Pharma Companies Lilly, Novo, Bayer
• Web Site list www.diabetesclinic.ca
• Hospital Diabetes Education Program
• Community Diabetes Education Program

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Screening and Prevention - Type 2 Diabetes

• Screen all persons gt40 years for type 2 diabetes,
  with a fasting blood glucose (FPG), every 3
  years.
• For people with risk factors, screen earlier and
  /or more frequently, with either FPG or Oral
  Glucose Tolerance test (OGTT).
• If the FPG is 5.7 6.9mmol/L and suspicion of
  diabetes or IGT is high, recommend a 2hPG in a
  75-g OGTT.

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Screening for Type 2 Diabetes, IFG and IGT
Every 3 Years in individuals ? 40 years of age
with no other risk factors Earlier and/or more
frequently in individuals lt 40 years of age with
risk factors
FPG
lt 5.7 mmol/L
5.7 - 6.9 mmol/L plus risk factor(s) for
diabetes/IGT
6.1 - 6.9 mmol/L and not risk factors for
diabetes/IGT
? 7.0 mmol/L
2hPG in 75-g OGTT
Classify patients as normal, IFG (isolated), IGT
(isolated), IFG IGT or Diabetes
Isolated IFG, Isolated IGT OR IFG IGT
IFG
Diabetes
Normal
Strategies for prevention and rescreen at
appropriate intervals
Rescreen as clinically indicated
Treatment
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Diagnostic Criteria
Diagnosis of diabetes
FPG ? 7.0 mmol/L or Casual PG ? 11.1 mmol/L symptoms of diabetes or 2hPG in a 75g OGTT ? 11.1 mmol/L

• FPG fasting plasma glucose, no caloric intake
  for at least 8 hours
• OGTT oral glucose tolerance test
• 2hPG 2-hour plasma glucose
• Casual PG any time of the day, without regard
  to the interval since the last meal
• Classic symptoms of diabetes polyuria,
  polydipsia and unexplained weight loss

• A confirmatory laboratory glucose test must be
  done on another day unless there is unequivocal
  hyperglycemia and acute metabolic decompensation

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Physical Activity and Diabetes

• For people who have not previously exercised
  regularly and are at risk of CVD, an ECG stress
  test should be considered prior to starting an
  exercise program

Testing is particularly important before, during
and for many hours after exercise.
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Nutrition Therapy

• People with diabetes should
• Receive nutrition counseling by a registered
  dietitian
• Receive individualized meal planning
• Follow Canadas Guidelines for Healthy Eating
• People on intensive insulin should also be taught
  to adjust the insulin for the amount of
  carbohydrate consumed

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Recommended targets for glycemic control
A1C ()
FPG/preprandial PG (mmol/L)
2-hour postprandial PG (mmol/L)
Target for most patients
?7.0
4.0-7.0
5.0-10.0
?6.0
4.0-6.0
5.0-8.0
Normal range (considered for patients in whom
it can be achieved safely)
Treatment goals and strategies must be tailored
to the patient, with consideration given to
individual risk factors. Glycemic targets for
children ?12 years of age and pregnant women
differ from these targets. Please refer to
Other Relevant Guidelines for further
details. An A1C of 7.0 corresponds to a
laboratory value of 0.070. Where possible,
Canadian laboratories should standardize
their A1C values to DCCT levels (reference range
0.040 to 0.060). However, as many laboratories
continue to use a different reference range, the
target A1C value should be adjusted based on the
specific reference range used by the laboratory
that performed the test. As a useful guide an
A1C target of 7.0 refers to a threshold that is
approximately 15 above the upper limit of
normal. A1C glycosylated hemoglobin DCCT
Diabetes Control and Complications Trial FPG
fasting plasma glucose PG plasma glucose
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Clinical assessment and initiation of nutrition
and physical activity
Marked hyperglycemia (A1C ?9.0)
Mild to moderate hyperglycemia (A1C lt9.0)

Basal and/or preprandial insulin
Non-overweight (BMI ?25 kg/m2)
Overweight (BMI ?25 kg/m2)
2 antihyperglycemic agents from different classes

• biguanide
• insulin sensitizer
• insulin secretagogue
• insulin
• alpha-glucosidase
• inhibitor

L I F E S T Y L E
Biguanide alone or in combination with 1 of
1 or 2 antihyperglycemic agents from
different classes

• insulin sensitizer
• insulin secretagogue
• insulin
• alpha-glucosidase
• inhibitor

• biguanide
• insulin sensitizer
• insulin secretagogue
• insulin
• alpha-glucosidase
• inhibitor

Add an oral antihyperglycemic agent from a
different class of insulin
Add a drug from a different class or Use
insulin alone or in combination with
Intensify insulin regimen or add

• biguanide
• insulin secretagogue
• insulin sensitizer
• alpha-glucosidase inhibitor

• biguanide
• insulin
• secretagogue
• insulin sensitizer
• alpha-glucosidase
• inhibitor

Timely adjustments to and/or additions of oral
antihyperglycemic agents and/or insulin should be
made to attain target A1C within 6 to 12 months
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Economics

• Gen Ass A003 54.10
• Int Ass A007 28.50
• Counselling K013 50.45 4x/yr
• Insulin Rx K029 50.45 6x/yr
• Type 2 Flow K030 30.00 3x/yr
• Glucose G002 1.97
• Urine G009 4.20
• Venipuncture G489 2.27

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Economics

• A003 G002, G009, G489 62.54
• G030 G002 G009 G489 x3 105.32
• K013 G00s G009 G489 x4 235.76
• A007 x4 114.00
• TOTAL 517.62

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FLOWSHEETS
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ABC of Diabetes

• A1c lt7
• Blood Pressure lt130/80
• Chol/HDL lt4, LDL lt2.5, Trig lt1.5
• ACR lt2 men, lt2.5 women
• ACE
• ASA

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INVOLVE THE PATIENT
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In Conclusion

• Prevalence of type 2 diabetes is increasing
  dramatically
• Majority of patients are diagnosed and treated by
  the family physician
• New paradigm need to be much more aggressive
  early in the treatment of these patients
  utilizing dual therapies
• Hypoglycemia can be managed through proper
  treatment choices and lifestyle management
• Glucose is a continuous progressive risk factor
  for cardiovascular disease

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Questions?