Transcript RECIPES FOR SUCCESS

2003 CDA Clinical Practice Guidelines
Diabetes Office Mgmt
Toronto
May 6 2004
J. Robin Conway M.D.
Diabetes Clinic - Smiths Falls, ON
www.diabetesclinic.ca
www.diabetesclinic.ca
Worldwide rates of diabetes
mellitus: predictions
80
70
60
50
Prevalence
(millions)
40
30
20
Year
1995
2000
2025
10
0
North
America
Europe
Southeast
Asia
World Health Organization. 1997.
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Canadian Diabetes
Association, 1998 website.
2 Million Canadians
Have Diabetes Mellitus
Frequency of diagnosed and undiagnosed diabetes
and IGT, by age (U.S. data - Harris)
40
35
30
% of
population
IGT
Undiagnosed diabetes
Diagnosed diabetes
25
20
15
10
5
0
20-34
35-44
45-54
Harris. Diabetes Carewww.diabetesclinic.ca
1993;16:642-52.
55-64
65-74
Cardiovascular Disease Risk
is Increased 2 to 4 Times
Framingham study: diabetes and CAD mortality
at 20-year follow-up
20
18
16
14
Annual CAD
12
Deaths per 1,000
10
Persons
8
6
4
2
0
Diabetics
Nondiabetics
17.4
17.0
8.5
3.6
Men
Haffner Am J Cardiolwww.diabetesclinic.ca
1999;84:11J-4J.
Women
What proportion of your office
visits involve Diabetics?
1.
2.
3.
4.
5.
<10%
10-20%
20-30%
30-50%
>50%
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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
Leiter et al. Diabetes Care 2000
• Quebec screening >2 Risk Factors 79% tested
7% Diabetes
13% IGT or IFG
74% No Treatment Advice
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
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84% of patients had A1c in past year
Average A1c 7.9%
(goal<7%)
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
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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 pt’s choice
• All patients had access to any necessary medications,
including statins
• Included lifestyle modifications (diet and exercise) as well
as lipid-lowering medications
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Αthyros VG et al. Curr Med Res Opin. 2002;18:220-228.
Reduction in Relative Risk of
Primary Endpoints
Total Mortality
Coronary
Mortality
Nonfatal MI
Unstable
Angina
PTCA/CABG
CHF
-51
-50
Stroke
0
-10
-20
-30
-40
-50
-43
-47
-52
-60
-47
-59
P=0.0021 P=0.0017 P=0.0001 P=0.0032
Αthyros VG et al. Curr Med Reswww.diabetesclinic.ca
Opin. 2002;18:220-228.
P=0.0011 P=0.021 P=0.034
Type 2 Diabetes
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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?
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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
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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
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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 >40 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).
Risk Factors
Age  40 years
Vascular disease
Abdominal obesity
1st degree relative with diabetes Previous GDM
Overweight
High risk population
Delivery of macrosomic infant
Polycystic ovary disease
Previous IGT or IFG
Hypertension
Acanthosis nigricans
Complications present
Dyslipidemia
Schizophrenia
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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 < 40 years of age with risk factors
FPG
< 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
Normal
Rescreen as clinically
indicated
Isolated IFG, Isolated IGT OR IFG & IGT
Strategies for prevention and rescreen at
appropriate intervals
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IFG
Diabetes
Treatment
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
Type
Recommendation
Aerobic – especially type 2
Brisk walking
 150 minutes of moderate-intensity
Biking
exercise each week
Raking leaves
 spread out over at least 3 nonContinuous swimming
consecutive days
 gradually increase to 4 hours or more a Dancing
Water aerobics
week
 sessions should be at least 10 minutes
at a time
Weight lifting
 3 times a week
Exercise with weight
 start with 1 set of 10-15 repetitions
machines
 progress to 2 sets of 10-15
 then 3 sets of 8
Resistance – all persons with
diabetes, including elderly
Example
• 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
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and for many
hours after exercise.
Nutrition Therapy
People with diabetes should:
• Receive nutrition counseling by a
registered dietitian
• Receive individualized meal planning
• Follow Canada’s 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
Normal range
(considered for patients
in whom it can be
achieved safely)
6.0
4.0-6.0
5.0-8.0
*Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factors.
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.
†Glycemic
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%)
Non-overweight
(BMI 25 kg/m2)
Overweight
(BMI 25 kg/m2)
Biguanide alone or in
combination with 1 of:
• insulin sensitizer*
• insulin secretagogue
• insulin
• alpha-glucosidase
inhibitor
1 or 2† antihyperglycemic
agents from different
classes
2 antihyperglycemic agents
from different classes †
Basal and/or
preprandial insulin
• biguanide
• insulin sensitizer*
• insulin secretagogue
• insulin
• alpha-glucosidase
inhibitor
• biguanide
• insulin sensitizer*
• insulin secretagogue
• insulin
• alpha-glucosidase
inhibitor
I
F
E
S
T
Y
L
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Mild to moderate hyperglycemia (A1C <9.0%)
If not at target
If not at target
If not at target
L
If not at target
Add a drug from a different class
or
Use insulin alone or in combination with:
• biguanide
• insulin secretagogue
• insulin sensitizer*
• alpha-glucosidase inhibitor
Add an oral
antihyperglycemic agent
from a different
class of insulin*
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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Intensify insulin
regimen or add
• biguanide
• insulin
secretagogue**
• insulin sensitizer*
• alpha-glucosidase
inhibitor
Economics
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Gen Ass
Int Ass
Counselling
Insulin Rx
Type 2 Flow
Glucose
Urine
Venipuncture
A003
A007
K013
K029
K030
G002
G009
G489
$54.10
$28.50
$50.45 4x/yr
$50.45 6x/yr
$30.00 3x/yr
$ 1.97
$ 4.20
$ 2.27
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Economics
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A003 G002, G009, G489
G030 G002 G009 G489 x3
K013 G00s G009 G489 x4
A007
x4
TOTAL
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$ 62.54
$105.32
$235.76
$114.00
$517.62
FLOWSHEETS
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ABC of Diabetes
• A1c <7
• Blood Pressure <130/80
• Chol/HDL <4, LDL <2.5, Trig <1.5
• ACR <2 men, <2.5 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?
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