CURE Conference Diabetes Management October 15, 2003

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CURE ConferenceDiabetes ManagementOctober 15,
2003

• Beth A. Damitz, MD
• Kevin Izard, MD
• Brian Wolter, MD

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Objectives

• Understand the importance of testing and
  aggressive treatment to reach HgA1C goal
• List key reasons for achieving goals for LDL and
  vaccination with diabetic patients
• Develop, evaluate and answer questions to improve
  diabetic patient management
• Discuss strengths and limits of evidence on
  Family Medicine care of diabetic patients.

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Background

• Diabetes is diagnosed in about 5 of adults aged
  20 years or older in the USA
• Diabetes results from deficient insulin
  secretion, decreased insulin action or both.
• Diabetes when uncontrolled has both acute and
  chronic consequences.

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ADA Guideline Recommendations

• HgbA1c checked every 3-6 mo
• Daily aspirin
• Dental visits every 6 months
• Pneumococcal vaccination
• Influenza vaccination annually in the fall
• Annual screening
• Microalbumenuria
• Lipid profile
• Retinal exam
• foot care screening

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Glycemic Control

• Evidence shows that intensive glycemic control
  significantly reduces the development and
  progression of microvascular and neuropathic
  complications.
• HgA1C
• Testing HgA1C should be done every 3-6 months

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Lipid Profile Control

• Diabetes is a major risk factor for
  cardiovascular disease.
• In the USA, 60-75 of people with diabetes die
  from cardiovascular causes.
• LDL goal is
• LDL should be tested yearly.

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Blood Pressure Control

• Hypertension is the single most important
  co-morbid factor which puts diabetics at risk for
  heart attack.
• ADA and NKF recommend BP goal of 130/80.
• Blood pressure should be checked at each visit.

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Vaccinations in the Diabetic

• Since there is an increased susceptibility to
  certain infections in diabetics, they should be
  offered specific vaccinations.
• Pneumococcal vaccine should be offered to all
  diabetic patients regardless of age.

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Conclusion

• Diabetes affects virtually every major organ of
  the body. Microvascular change is the major cause
  of mortality / morbidity
• Be vigilant in treating co-morbid disease
  hyperglycemia, hyperlipidemia, hypertention
• Immunizations are key. Diabetics are more
  susceptible to complicated pneumonia and influenza

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Select Data from Across FP Residency Clinics

• Judy Payne, DFCM
• Sandy Olsen, St Michael FP

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New Level of Evidence Designation
JASTS
Judy And Sandy Think So
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Case Presentation JE
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Case JE, a 59 year old caucasian female

• JE is a new patient with a 10 year h/o type 2
  diabetes. She does not take her own accuchecks
  at home. She states she only a low sugar once
  every 3 months and can feel when she does.
• Her current medications are avandia 4mg po QD,
  glucovance 5/500 2 tabs po BID, zestril 5mg po QD.

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Case JE continued

• JE pays for her medications out of pocked and
  wants to know which of her meds she really needs
  to take
• She thinks she had a HbA1C about a year ago and
  thinks it was 8-9
• She does not know her LDL level or when it was
  last checked
• She had pneumovax about 8 years ago

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Case JE continued

• On physical exam she is a pleasant, slightly
  obese woman. Height 64 inches and weight 180.
• Blood pressure 128/75
• Normal physical exam.

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Your Questions Patient Care or Systems

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Our Questions

• Given her normal blood pressure, would you
  recommend JE spend money on an ACE inhibitor?
• Which is the best class of glycemic agent to
  treat her with? (i.e. sulfonyurea, metformin,
  glitizone, other?)
• Should your clinic begin screening asymptomatic
  adult patients for diabetes?
• Does the use of a diabetic nurse/team result in
  better diabetes management?