DIABETES GUIDELINES AND TREATMENT

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DIABETES GUIDELINESAND TREATMENT

• PCOMMEDNET FAMILY MEDICINE RESIDENCY
• INTENSIVE BOARD REVIEW

RICHARD P. FREY,DO,MPH,FACOFP DME AND FP
RESIDENCY PROGRAM DIRECTOR HEART OF LANCASTER
REGIONAL MEDICAL CENTER
FEBRUARY 8,2009
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TODAYS MISSION

• CLASSIFICATION
• DIAGNOSIS/SCREENING
• PREVENTION/DELAY OF TYPE II DM
• GESTATIONAL DIABETES
• INITIAL EVALUATION
• MEDICAL MANAGEMENT
• OTHER MANAGEMENT

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CLASSIFICATION

• Type I Diabetes
• Type II Diabetes
• Prediabetes
• Gestational Diabetes
• Others-genetic defects,cystic fibrosis,drug
  induced or chemical induced

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Diagnosis

• Fasting plasma glucose is the gold standard
• The use of HgbA1C is not yet recommended for
  diagnosis of diabetes
• Oral glucose tolerance test(75 gram)is more
  sensitive but clearly not as practical

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Specific Criteria

• FPG ? 126 on two separate occasions
• Symptoms of hyperglycemia and a casual plasma
  glucose ? 200
• 2hr plasma glucose ? 200 during OGTT

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Screening

• Who should you screen?
• Adults who are overweight (BMIgt25) or obese(BMI
  gt30) and have 1 or more additional risk factors
• Routine testing for others not meeting criteria
  should begin at age 45
• If normal repeat every 3 years or more frequently
  if risk status changes

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Risk Factors

• Physical inactivity
• 1st degree relative with diabetes
• High risk ethnic groups(African-Amer,Latino,Asian-
  Amer,Pacific Islanders)
• Women who delivered a baby gt9lbs GDM
• Hypertension
• HDLlt35 or Trigs gt250
• Women with PCOS
• IGT or IFG on previous testing
• Hx CVD
• Severe obesity or acanthosis nigricans

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Children

• No current guidelines for screening for Type I DM
  in children
• Why? No standard guidelines/cutoffs for immune
  marker assays. No consensus on follow up of
  abnormals. Low incidence. No effective
  intervention even if detected early.

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Children-Type II Screening

• Overweight(BMIgt85 for age and sex, weight for
  heightgt85, or weight gt 120 of ideal for height)
• Plus any 2 -Fam Hx DMII 1st or 2nd deg relative,
  Nat Amer, Latino,Asian/Amer,Pacific
  Islander,Signs of Insulin Resistance
  (HPT,Acanthosis Nigricans ,dyslipidemia or PCOS),
  Maternal Hx of DM or GestDM
• Initiate at age 10 or onset of puberty, q2yrs,FPG

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GESTATIONAL DIABETES

• Risk assessment at first PN visit
• Screen those at very high risk immediately
• Otherwise check at 24-28 weeks
• Initial check after 50g oral glucose
  load-threshold of 130 or 140 THEN 100gm OGTT on
  separate day in those who fail

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or

• 100 gm OGTT in am after 8hr overnight fast.
• Dx of Gest DM req at least 2 of the values
• Fast?95
• 1 hr?180
• 2 hr?155
• 3 hr?140

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PREDIABETES

• Those patients with impaired fasting
  glucose(100-125) or impaired glucose
  tolerance(2hr between 140-199)
• Both are risk factors for future DM and
  cardiovascular disease.
• Diet and Exercise..how much?
• Follow up counseling important for success
• Metformin may be considered

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Initial EvaluationMedical History

• DKA frequency
• Hypoglycemic frequency
• Hx of complications microvascular-retinopathy,
  nephropathy, neuropathy. Macrovascular- CHD,PAD,
  cerebrovascular disease

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Physical Exam

• Height,weight,BMI
• Blood pressure
• Fundoscopic exam
• Thyroid exam
• Skin-acanthosis nigricans
• Foot exam-inspection, pulses, reflexes, sensory
• Labs-HgbA1C, liver, urine microalbumin,
  creatinine and GFR, TSH(DMI, inc lipids and women
  ? 50)

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ManagementGlycemic Control

• Self monitoring of serum glucose
• 3-4x/day DMI, less frequently in DMII or once
  daily insulin or oral meds
• Continuous glucose monitoring option
• Goal-HgbA1C lt 7 ADA, lt6.5 ACE
• Pre-prandial 70-130mg/dl
• Peak Postprandial lt180 gm/dl

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Medications-goals

• Control sugar
• Control hypertension- goal lt130/80
• Prevent/delay diabetic nephropathy-ACEsARBs
• -albumin normal lt 30
• -microalbuminuria 30-299
• -macroalbuminuria gt300

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Medications-goals

• Control lipids-without CVD lt100 LDL
• -with CVD lt70 LDL
• -triglycerides lt150
• -HDL gt40men gt50women
• -statins, fibrates, niacin

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Antiplatelet therapy

• ASA-75-162mg/day secondary prevention w/ hx of
  CVD
• 75-162mg/day primary prevention w/Type I and II
  w/ ?CV risk, gt40yo, hpt, smoking, dyslipidemia,
  albuminuria or FHx CVD
• Not recommended lt 30 (no evidence to support)
• Combo therapy Plavix(clopidrogel) and ASA in pts
  with severe and progressive CVD

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Vaccinations

• Flu shot annually
• Pneumovax for all adults with diabetes
• One time revaccination for ? 65 years of age if
  previously vaccinated lt 65 and vaccine was
  administered gt 5 yrs ago
• Absolutely no evidence or recommendation for more
  than 2 lifetime vaccinations

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Diabetes MedicationsOral

• Biguanides(Glucophage-metformin) lowers the
  production of glucose made in the liver
• Well accepted as the drug of first choice in Type
  II
• Major side effects are GI
• Lactic acidosis rare but serious side effect

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Sulfonylureas

• Oldest of oral meds
• Until 1995 the only meds available
• 1st gen- Orinase,Tolinase,Diabinese
• 2nd gen-Glucotrol(glipizide), Micronase or
  Diabeta(glyburide)
• 3rd gen- Amaryl(glimeperide)
• Stimulate the pancreas to release more insulin,
  hypoglycemia can be side effect

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Meglitinides

• Prandin(repaglinide)
• Starlix(nateglitinide)
• Stimulate insulin secretion when there is glucose
  present in the blood stream
• Used with meals

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Alpha-Glucosidase Inhibitors

• Precose(acarbose)
• Glyset(miglitol)
• Delay the conversion of carbohydrates into
  glucose during digestion
• Major side effect gas/bloating limits use

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Thiazolidinediones(TZDs)

• Avandia(rosiglitazone)
• Actos(pioglitazone)
• Sensitizes muscle and fat cells to accept insulin
  more easily
• FDA warning in May 2007 that Avandia may be
  associated with possibility of heart attacks or
  other CV events
• Cause or exacerbate CHF, watch closely for edema

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Incretin Mimetics

• Byetta(exenatide)-originally isolated from the
  saliva of Gila monster Lizard
• Shares several of the coregulatory effects of the
  incretin glucagon-like peptide-1(GLP-1)
• Improves glucose dependent insulin secretion
• Restores first phase insulin response
• Suppresses inappropriate glucagon secretion
• Slows rate of gastric emptying
• Increases satiety
• BID injection, main side effect nausea/weight
  loss

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DPP-4 Inhibitor

• Dipepityl Peptidase 4 inhibitor-slows the
  inactivation of GLP-1 and GIP (glucose-dependent
  insulinotropic polypeptide)
• Januvia(sitagliptin)
• Very minimal side effects, weight neutral
• Most effective when used with metformin

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Insulin

• Each type different onset, peak, and duration
• Rapid ActingNovolog(aspart)
• Apidra(glulisine)
• Humalog(lispro)
• Onset-15 min
• Peak- 30-90 min
• Duration- 3-5 hrs
• Take at the beginning of meals

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InsulinShort acting

• Humulin R and Novolin R (regular)
• Onset- 30-60 min
• Peak- 2-4 hrs
• Duration- 5-8 hrs
• Take 30 minutes before meals

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InsulinIntermediate Acting

• Humulin N and Novolin N (NPH)
• Onset- 1-3 hrs
• Peak- 8 hrs
• Duration- 12-16 hrs
• Usually twice a day

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Insulin Long Acting

• Levemir (detemir) and Lantus (glargine)
• Also referred to as basal insulins
• Onset- 1 hr
• Peak- none
• Duration- 20-26hrs
• Usually once a day, may need bid as dose increases

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InsulinPremixed N and R

• Humulin 70/30
• Novolin 70/30
• Humulin 50/50
• Onset 30-60 min
• Peak- variable
• Duration- 10-16 hrs
• Typically bid

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InsulinPre-mix lispro protamine and lispro

• Humalog Mix 75/25 and 50/50
• Intermediate and rapid-acting
• Onset- 15min
• Peak- variable
• Duration- 10-16 hrs
• Typically bid

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InsulinPre-mix aspart protamineand aspart

• Novolog Mix 70/30
• Intermediate and rapid-acting
• Onset- 15min
• Peak- variable
• Duration- 10-16 hrs

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Summary

• Think Diabetes- Who to screen!
• Good History and Physical
• Educate, educate, educate!
• Monitor
• Be aggressive- dont be afraid to use insulin!