New Guidelines streamline Diabetes Diagnosis

1
New GuidelinesstreamlineDiabetes Diagnosis

• Clev Clin J Med 19986510-12

2
Guideline Development

• 1979 National Diabetes Data Group
• 1997 American Diabetes Association

Diabetes 1979281039-1057Diabetes Care
1997201183-1197
3
National Diabetes Data Group

• Issued in 1979
• fasting plasma glucose gt 140 mg/dl
• 2 hr glucose tolerance test gt 200 mg/dl
• tests not equivalent only 1/4 of patients with
  abnormal GTT have abnormal FBS
• GTT is expensive, time-consuming, inconvenient
• FBS is more reliable and consistent

Diabetes 1979281039-1057
4
American Diabetes Association

• Report of the Expert Committee on the
  Diagnosis and Classification of Diabetes
  Mellitus
• Diabetes Care 1997201183-1197

5
American Diabetes Association

• Issued in 1997
• fasting plasma glucose gt126 mg/dl
• glucose tolerance test not used
• simplify the diagnostic process
• identify more patients with previously
  unidentified diabetes

Diabetes Care 1997201183-1197
6
ADA criteria for the diagnosis of diabetes
mellitus

• Symptoms of diabetes (polyuria, polydipsia,
  unexplained weight loss) plus a casual plasma
  glucose concentration ? 200 mg/dl
• A fasting plasma glucose concentration ? 126
  mg/dl (measured after at least 8 hours of no
  caloric intake)
• An abnormal oral glucose tolerance test result (a
  plasma glucose concentration ? 200 mg/dl two
  hours after a glucose load of 75 grams of
  anhydrous glucose dissolved in water)

Diabetes Care 1997201183-1197
7
Usefulness of Hemoglobin A1cfor follow-up but
not for screening

• HbA1c level reflect long-term glucose level
  useful in the follow-up of diabetics
• Problems
• methods not standardized for all labs
• abnormal low values in patients with abnormal
  hemoglobins or those with reduced red blood cell
  life span

8
Who should be screened?

• Prevalence of diabetes (ages 40-74)
• 12.27 using the 1979 criteria
• 14.26 using the 1997 criteria
• Currently, only 50 of diabetics are identified
• Earlier identification and treatment may lead to
  fewer complications

The 3rd National Health and Nutrition Survey
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Who should be screened?

• Consider testing all persons age 45 and older (if
  normal, repeat every 3 years)
• Consider testing at a younger age, or more
  frequently, for higher risk individuals

Diabetes Care 1997201183-1197
10
Who should be screened?high risk patients

• Obese persons (? 120 desired body wt or body
  mass index ? 27 kg/m2)
• first-degree relatives with diabetes
• high-risk ethnic groups (African Americans,
  Hispanic, American Indians)
• mothers of babies weighing ? 9 lb at birth
• women with a history of gestational diabetes

Diabetes Care 1997201183-1197
11
Who should be screened?high risk patients

• hypertensive patients (? 140/90)
• dyslipidemic patients (HDL ? 35 mg/dl or
  triglyceride ? 250 mg/dl or both)
• patients with previous finding of impaired
  glucose tolerance (140-199 mg/dl on 2-hr test) or
  impaired fasting glucose (110-125 mg/dl)

Diabetes Care 1997201183-1197
12
Old Nomenclatureclassification by disease
treatment

• Discard the use of IDDM (insulin-dependent
  DM)NIDDM (non-insulin-dependent DM)
• classification based on treatment
• not all patients fit into either category

Diabetes Care 1997201183-1197
13
New Nomenclatureclassification by disease process

• Type 1 diabetes
• due to beta cell destruction, usually leading to
  absolute insulin deficiency
• Type 2 diabetes
• range from predominantly insulin resistance with
  relative insulin deficiency to predominantly
  secretory defect with insulin resistance

Diabetes Care 1997201183-1197
14
New Nomenclatureclassification by disease process

• Other types of diabetes
• specific genetic defects, diseases of the
  exocrine pancreas, endocrinopathies, drugs or
  chemicals, infections, immune-mediated diseases
• Gestational diabetes
• screen women at high risk (age gt25, obesity,
  family history, ethnic groups)

Diabetes Care 1997201183-1197
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Oral Hypoglycemic Agents

• Sulfonylreas
• increase insulin secretion by the pancreas
• Acarbose
• delay carbohydrate absorption by inhibiting
  enzymes that break down starches in the small
  intestine

16
Oral Hypoglycemic Agents

• Metformin
• decrease hepatic glucose production
• increase insulin sensitivity in muscle cells
• Troglitazone
• increase insulin sensitivity
• isolated reports of severe hepatotoxicity

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Toward rational use of Oral Hypoglycemic Agents

• One approach is to choose the drug appropriate
  for the stage of the disease based on the natural
  history of type 2 diabetes

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Natural history of Type 2 diabetes

• Early phase
• ? insulin sensitivity
• gradual rise in blood glucose
• ? insulin secretion to compensate
• Late phase
• ? insulin levels as beta cell wears out
• sharp rise in blood sugar level

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Natural history of Type 2 diabetes Clue to
disease progression

• Weight gain
• Is the patient is still gaining weight at the
  time of diagnosis ?
• weight gain, in the absence of therapy, indicates
  that the patient still has adequate insulin
  secretion

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Toward rational use of Oral Hypoglycemic Agents

• General guidelines
• monitor FBS and HbA1c at regular intervals (2 - 4
  times / yr) and adjust treatment as needed
• Treatment guided by disease stage
• early phase acarbose, metformin, troglitazone
• late phase sulfonylureas and insulin

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Toward rational use of Oral Hypoglycemic Agents

• A M T S
• Postprandial ? sugar
• Liver disease -- --
• Obese patients
• Kidney disease --
• Elderly patients
• FBS gt 200 mg/dl

A acarbose, M metformin, T troglitazone, S
sulfonylureas favored or indicated,
low-dose, -- avoid
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References

• Expert Committee on the Diagnosis and
  Classification of Diabetes Mellitus. Diabetes
  Care 1997201183-1197.
• National Diabetes Data Group. Classification and
  diagnosis of diabetes and other categories of
  glucose intolerance.Diabetes 1979281039-1057.
• Comparison of fasting and 2-hour glucose and
  HBA1c levels for diagnosing diabetes diagnostic
  criteria and performance revisited.Engelgau MM,
  Thompson TJ, et al. Diabetes Care
  199720785-791.
• New guidelines streamline diabetes diagnosis.
  Reddy S.Clev Clinic j Med 199865(1)10-12.