Transcript TYPE 2 DIABETES MELLITUS Asma Jafri, MD

TYPE 2 DIABETES MELLITUS
Asma Jafri, MD
July 22, 2004
GOALS:
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Recognize the changing face of Type 2 Diabetes Mellitus regarding
demographics and epidemiology.
Demonstrate understanding of the “Standards of Medical Care for Patients
with Type 2 Diabetes Mellitus.”
Understand multidisciplinary therapeutic approaches to the management of
Type 2 Diabetes Mellitus.
Recognize metabolic syndrome as a clinical condition and risk factor for
Diabetes.
Table 1. CRITERIA FOR THE DIAGNOSIS OF DIABETES
MELLITUS IN NON-PREGNANT ADULTS
1.
2.
3.
Symptoms of diabetes plus casual plasma glucose concentration ≥ 200
mg/dl (11.1 mmol/L).* Casual is defined as any time of day without
regard to time since last meal. The classic symptoms of diabetes include
polyuria, polydipsea and unexplained weight loss.
or
FPG ≥ 126 mg/dl (7.0 mml/L).* Fasting is defined as no caloric intake
for at least eight hours.
or
2hPG ≥200 mg/dl (11.1 mmol/L) during an OGTT.* The test should be
performed using a glucose load containing the equivalent of 75 g
anhydrous glucose dissolved in water.
*In the absence of unequivocal hyperglycemia with acute metabolic
decompensation, these criteria should be confirmed by repeat testing on a
different day. The third measure (OGTT) is not recommended for routine
clinical use.
From the Expert Committee on the Diagnosis and Classification of Diabetes
Mellitus:
Report of the Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus Care 20:1183-1197, 1997; with
permission.
Table 2. CRITERIA FOR THE DIAGNOSIS OF IMPAIRED
GLUCOSE
TOLERANCE IN NON-PREGNANT ADULTS (PRE
DIABETES)
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Fasting plasma glucose of ≥ 110 mg/dl or < 125 mg/dl
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2-hour post-prandial plasma glucose of > 140 and < 200 mg/do
CLINICAL FEATURES:
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Insulin resistance and progressive insulin secretory defect.
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Most patients are obese.
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If not obese, they have increased percentage of body fat distributed
predominately in the abdominal region.
Ketoacidosis seldom occurs spontaneously. When seen, it usually arises in
association with the stress of another illness such as infection.
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Risk increases with age, obesity and lack of physical activity.
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Strong genetic predisposition.
METABOLIC SYNDROME
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Insulin resistance
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Hyperinsulinemia
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Obesity (central), waist circumference is > 35” in females and > 40” in
males
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Dislipidemia of ↑ TG and or low HDL
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Hypertension
PREVALENCE:
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Prevalence was 7.4% in 1995. This is expected to rise to above 9% in
2025. It is estimated that there are 16 million people with Type 2 Diabetes
Mellitus and over 10 million Americans have impaired glucose tolerance.
Costs $120 billion annually; approximately 15% of the U.S. healthcare
expenditure. The number of individuals with Type 2 DM diagnosed
between 30-39 years of age has increased 76% in the past ten years. The
increase in prevalence of diabetes in younger individuals seems to parallel
the equally alarming rate of obesity in America. Reports suggest that Type
2 DM now represents 8% - 46% of all diabetes cases among children. The
average AIC of people with diabetes in the U.S. is 9%. The latest study of
American adults with diabetes revealed that 37% had AIC > 8% and 14%
had AIC> 10%.
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Presently about half of the adults with diabetes in the U.S. are undiagnosed
(8 million).
At the time of diagnosis of Type 2 Diabetes:
- 2-9% of patients have retinopathy
- 8-18% have nephropathy
- 5-13% have neuropathy
- 8% have cardiovascular disease
GENERAL RECOMMENDATIONS FOR SCREENING BY
PHYSICIANS:
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Screening should be considered at three (3) year intervals for:
1.
All individuals at age 45 years and above.
2.
Test at a younger age and more frequently in individuals who:
a. Are obese with BMI ≥ 27 kg/m².
b. Have a first degree relative with diabetes.
c. Are members of a high-risk ethnic population (i.e., African
American, Hispanic, Native American, Asian American, Pacific
Islander).
d. Have delivered a baby weighing > 9 lbs. or have been diagnosed
with GDM.
e. Are hypertensive (BP ≥ 140/90).
f. Have an HDL cholesterol level ≤ 35 mg/dl and/or TG level > 250
mg/dl.
g. On previous testing had IGT or IPG.
h. Habitual physical inactivity.
SCREENING TEST:
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Fasting plasma glucose (FPG).
Oral glucose tolerance test (75 gm glucose). The fasting plasma glucose
test is strongly preferred because it is easier and faster to perform, more
convenient and less expensive.
A random plasma glucose level ≥ 160 mg/dl is considered a positive
screening test result and needs further testing.
Glycated hemoglobin is currently not recommended for the screening or
diagnosis of diabetes.
The OGTT is more sensitive for the diagnosis of diabetes and pre-diabetes,
but is impractical and expensive as a screening procedure.
TABLE 3 GLYCEMIC CONTROL FOR PEOPLE WITH DIABETES
Recommendations for Glycemic Control*
Biochemical
Action
Index
Normal
Goal
Suggested
_____________________________________________________________
__________
Fasting/Preprandial glucose <110 mg/dl
80 to 120 mg/dl
< 80 or > 140
mg/dl
Bedtime glucose
mg/dl
<120 mg/dl
100 to 140 mg/dl
<100 or > 160
Glycosylated hemoglobin
< 6%
< 7%
> 8%
_______________________________________________________________________
*These values are for non-pregnant adults. Goals and “Action Suggested” depend on
individual patient circumstances. Such actions may include enhanced diabetes selfmanagement education, co-management with a diabetes team, referral to an
endocrinologist, change in pharmacological therapy, initiation or increased SMBG, or
more frequent contact with the patient. HbA1c is referenced to a non-diabetic range
of 4.0 – 6.0% (mean 5.0%, SD ∀ 0.5%).
ESSENTIAL COMPONENTS OF MANAGEMENT – INITIAL VISIT:
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Medical History
1.
Symptoms, results of laboratory tests and special examination results
related to diagnosis of diabetes.
2.
Prior G Hb results.
3.
Eating patterns, nutritional status, weight history.
4.
Details of previous treatment programs including nutrition and
diabetes self-management education.
5.
Current treatment of diabetes including medications, meals, results of
glucose monitoring.
6.
Exercise history.
7.
Acute complications such as DKA, hypoglycemia.
8.
Prior or current infections.
9.
Symptoms and treatment of eye, kidney, nerve, gu, bladder and
GI function, heart, peripheral vascular, foot, CVA, etc.
10.
11.
12.
13.
14.
15.
Other medications that may affect blood glucose levels.
Risk factors for atherosclerosis: smoking, HTN, obesity, dislipidemia
and family history.
Family history of diabetes and other endocrine disorders.
Gestational history.
Life style, cultural, psychosocial, educational and economic factors
that might influence the management of diabetes.
Tobacco and alcohol use.
• Physical Examination
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Height and weight.
Sexual maturation staging (peripubertal).
Blood pressure with orthostatic measurements when indicated.
Ophthalmoscopic examination (dilation).
Oral examination.
Thyroid palpitation.
Cardiac examination.
Abdominal examination.
Evaluation of pulses.
Hand/finger examination.
Foot examination.
Skin examination.
Neurological examination.
• Laboratory Evaluation
1.
2.
3.
4.
5.
6.
7.
8.
9.
Fasting or random plasma glucose.
GHb
Fasting lipid profile.
Serum creatinine in adults.
Urine analysis, glucose, ketones, protein, sediment.
Test for microalbuminuria.
Urine culture if sediment is abnormal or symptoms are present.
TSH in all Type 1 patients.
EKG in adults.
DIABETES SELF-MANAGEMENT EDUCATION:
National standards for Diabetes Self-Management Education have been
developed. Ten content areas have been identified as the core topics
needed to provide comprehensive education to the person with diabetes:
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Diabetes disease process and treatment options.
Nutritional management.
Incorporating physical activity in lifestyle.
Using medication effectively.
Monitoring blood glucose and using the results.
Preventing, detecting and treating acute complications.
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Goal setting to promote health and problem solving for daily living.
Integrating psychosocial adjustment into daily life.
Promoting preconception care and managing diabetes during pregnancy
when applicable.
A major emphasis in diabetes education is patient empowerment in
making decisions regarding diabetes management.
CONTINUING CARE (FREQUENCY):
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Individualized regimen and frequency of visits.
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If target goals met, frequency every six months.
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If target goals not met, frequency every three months.
ROUTINE FOLLOW-UP VISIT:
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History of goals, activity, diet, MBG, medications, symptoms of CAD,
personal concerns, stresses, evaluate smoking status.
Exam: weight, BP (goal < 138/80; lower BP may be even better).
Epidemiologic analyses show that blood pressure > 115/75 are associated
with increased CV event rates and mortality in persons with diabetes.
A.
Pulses - annually
B.
Annual Foot exam including Semmes-Weinstein monofilament, tuning
fork, palpation and visual exam (skin, nails). (B) Perform a visual
inspection of patients’ feet at each visit. (E)
C.
Dilated eye exam annually (B).
• Laboratory studies
1.
2.
3.
4.
GHg every three months if treatment changes or not meeting goals,
otherwise every six months.
Annual fasting lipid panel or biannual if goals met. Repeat lipid profiles
as dictated by therapy. Goal is LDL<100, HDL >45 in males and >55 in
females, and TG < 150 mg/dl.
Annual serum creatinine.
Urine analysis for microalbumin annually until confirmed positive.
• Other
1.
Aspirin 80 mg/day for patients over age 40 for primary prevention.
May use over age 30 in patients with additional risk factors (A). Aspirin
does not prevent retinopathy or increase risk of hemorrhage (A).
2.
Influenza and pneumococcal vaccination (C).
3.
Advise all patients not to smoke (A).
4.
In patients > 55 years of age with or without HTN but with another CV
risk factor, an ACE inhibitor should be considered to reduce the risk of CV
events (A).
Table 4. DEFINITIONS OF ABNORMALITIES IN ALBUMIN EXCRETION
_______________________________________________________________
24-h
Timed
Spot
Category
Collection
Collection
Collection
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Normal
< 30 mg/24 h
< 20 µ
< 30 µg/mg
creatinine
Microalbuminaria 30-300 mg/24 h
20-200 µg/min
30-300 µg/mg
creatinine
Clinical albuminuria > 300 mg/24 h
> 200 µg/min
< 300 µg/mg
creatinine
_______________________________________________________________________
Because of variability in urinary albumin excretion, two of three specimens
collected within a three to six month period should be abnormal before
considering a patient to have crossed one of these diagnostic thresholds.
Exercise within 24 h, infection, fever, congestive heart failure, marked
hyperglycemia, and marked hypertension may elevate urinary albumin
excretion over baseline values.
From the American Diabetes Association Clinical Practice Recommendations
1999. Diabetes Care 22(suppl1);S67, 1999; with permission.
Table 5. OPHTHALMOLOGIC EXAMINATION SCHEDULE
____________________________________________________________________
Recommended First
Minimum Routine
Patient Group_______________Examination_________________FollowUp*_____
29 Years or
younger+
Within 3-5 years after diagnosis of
diabetes once patient is age 10 years
or older
Yearly
30 years or older+
At time of diagnosis of diabetes
Yearly
Pregnancy in
Pre-existing
Diabetes
Before conception and during trimester
Physician discretion pending
results of 1st trimester
exam
______________________________________________________________
*Abnormal findings necessitate more frequent follow-up
+As indicated in WESDR, these are operational definitions of Type 1 and Type 2 diabetes based
on age (age <30 years at diagnosis, Type 1; age ≥ 30 years at diagnosis, Type 2) and not
pathogenetic classification.
From the American Diabetes Association Clinical Practice Recommendations 1999. Diabetes Care
22(suppl1):S72, 1999; with permission.