Transcript diabetes 1 - Jacobi Medical Center

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Type II Diabetes
Matthew Love, M.D.
Case 1
Fred Banting, a 52 year-old man, complains of polyuria
and polydypsia for three weeks. On questioning, he
also admits to dizziness on standing.
On exam, his BP is 135/80, Pulse 95. He is 5’8” tall,
weighs 220# and has acanthosis nigricans.
Urine dipstick is ++ for glucose. Fingerstick glucose is
188. Point of Care Hemoglobin A1c is 8.3%.
Does this patient have Diabetes?
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Diagnosis
Method
Threshold Value Advantages
Fasting Plasma
Glucose
> 126 mg/dl
•Time since last
meal easy to
define
•ADA preferred
•Cheap
•Inconvenient
•Unstable
Random glucose
>200 + symptoms
•Convenient
•Less
reproducible
HbA1c
≥ 6.5%
•Correlates with
disease process
•Stable
•Cost
OGGT
>200 @ 2 hours
•Pregnancy
•Cumbersome
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Disadvantages
Prediabetes
• Impaired fasting glucose: 100 < FPG < 126
• Impaired glucose tolerance: OGTT result at 2h
between 140-199.
• Hemoglobin A1c of 6.0% – 6.4%
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Remember the Pathogenesis
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Remember the Pathophysiology
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Case 2
Dulce Diente is a 37 year-old female with a family history of diabetes.
She wants to be checked for diabetes because she has gained a lot of
weight, she keeps getting yeast infections and her urine tastes sweet.
Physical exam is normal except for a BMI of 29.
FPG checked by fingerstick on her father’s glucometer has been 110-120.
Point of Care HbA1c comes back at 6.8%
Should she be started on medicine? Is there anything that can
be done to prevent the progression of her diabetes?
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Diabetes Prevention Program
Results
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Diabetes Prevention Program
Change in weight & Physical Activity
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PREVENTION TRIALS
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Case 3
Isabel Fadiman is a 41 year-old African-American female who presents
for a check-up. She has no complaints. Past medical history includes
gestational diabetes during her last pregnancy five years ago. Family
history is positive for two brothers and both parents with Type 2 DM.
She does not smoke.
On exam, her BP is 120/80 and her BMI is 27. There is no acanthosis
nigracans or any other abnormality.
Should she be screened for diabetes?
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Diabetes Screening Recommendations
Organization
Recommendation
US Preventive Services
Task Force
• The USPSTF concludes that the current evidence is
insufficient to assess the balance of benefits and harms of
screening for type 2 diabetes in asymptomatic adults with
blood pressure of 135/80 mm Hg or lower.
• The USPSTF recommends screening for type 2 diabetes in
asymptomatic adults with sustained blood pressure (either
treated or untreated) greater than 135/80 mm Hg.
American Diabetes
Association
• For adults who do not have diabetes risk factors, consider
screening every 3 y starting at age 45 y, particularly if body
mass index >25 kg/m2
• Screen adults < 45 y of age if they are overweight and have
another diabetes risk
Factor
Canadian Diabetes
Association
• Evaluate all patients for type 2 diabetes risk annually
• Screen patients without diabetes risk factors every 3 y
starting at age 40 y
• Consider earlier, more frequent screening for patients with
diabetes risk factors
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Risk Factors for Type 2 Diabetes
• Age > 45 y
• First-degree relative with type 2 Diabetes
• African-American, Hispanic, Asian, Pacific Islander, or Native
American ethnicity
• History of gestational diabetes or delivery of infant weighing ≥9 lbs
• Polycystic ovary syndrome
• Overweight, especially abdominal obesity
• Cardiovascular disease,hypertension, dyslipidemia, or other
metabolic syndrome features
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Initial Evaluation
• Symptoms
• Exam – BP, BMI, Feet
• Labs
–
–
–
–
HbA1c
Ualb/cr
Chemistry (Cr, LFTs)
EKG
• Referrals
–
–
–
–
Dietician
Glucometer Teaching
Ophthalmology
Podiatry
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Blood Glucose Monitoring
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Glucometer Operation
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Case 4
Matt Forman is a 54 year-old man with newly diagnosed Type II
Diabetes. His FPG is 148 and his HbA1c is 7.8% . Physical is normal
except for BMI of 28. Except for the glucose values, his laboratory
exams are normal.
How should he be treated?
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Treatment non-pharmacologic Diet
• Carbohydrates




Should comprise 45%-65% of total calories
No concentrated sweets (soda, juice, desserts)
No white starches (especially rice and pasta)
Fresh vegetables and fruits rather than canned
• Fats
 Should comprise < 30% of total calories
 Saturated fats should be < 7%
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Treatment non-pharmacologic Exercise
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Treatment pharmacologic Oral Agents
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Metformin
• No weight gain
• No hypoglycemia
• Cheap, generic, old
• GI side effects frequent
• Rare but serious lactic
acidosis
• Start at 500 bid with meals
• Titrate up quickly to 1000 bid
or 850 tid
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Sulfonylurea
• Cheap, generic, old
• Equally effective
• May cause
hypoglycemia
• Weight gain
• Start at low dose,
increase gradually
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Thiazolidinediones TZD
• Increase glucose uptake
and decrease glucose
production
• Equally effective
• May preserve beta-cell
function
• Newer, more expensive
• Fluid retention
• May cause xs MIs
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Incretin mimetics
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Incretin-based therapies
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Alpha-glucosidase Inhibitors
• Lower postprandial
glucose and A1c
• Less potent
• No weight gain
• Cause flatulence
• Contraindicated in
cirrhosis
• Take with first bite of
meal
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Case 4
Matt Forman is a 54 year-old man with newly diagnosed Type II
Diabetes. His FPG is 148 and his HbA1c is 7.8% . Physical is normal
except for BMI of 28. Except for the glucose values, his laboratory
exams are normal.
After 6 months of a diabetic diet and increased exercise, his HbA1c is 8.1%
How should he be treated?
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Case 4
Matt Forman is a 54 year-old man with newly diagnosed Type II
Diabetes. His FPG is 148 and his HbA1c is 7.8% . Physical is normal
except for BMI of 28. Except for the glucose values, his laboratory
exams are normal.
After 6 months of a diabetic diet and increased exercise, his HbA1c is 8.1%
After 6 months of Metformin at a dose of 1000 mg bid, his HbA1c is 7.1%
How should he be treated?
What is the glycemic control target?
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Glycemic Control Target:
Good Control Reduces Microvascular Complications
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Glycemic Control Target:
The UKDPS – the largest and longest study in Type II DM
• Microvascular complications were reduced 25% in the intensivetherapy group
• Epidemiologic analysis showed that for every 1% reduction of
HbA1c:
↓
↓
↓
↓
35% reduction in microvascular complications
25% reduction in diabetes related deaths
7% reduction in all cause mortality
18% reduction in myocardial infarction
• No lower threshold
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Glycemic Control Target:
Macrovascular Complications
ACCORD trial – Action to Control Cardiovascular Risk in Diabetes
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Glycemic Control Target:
Current Recommendations from the ADA:
• The Benefits of Intensive Glycemic Control on Macrovascular
Complications vary based on the population being treated
– Those most likely to benefit from intensive control are those with
shorter duration of DM, no known vascular disease, and without
severe hypoglycemia
– The risk of intensive glycemic control may outweigh the benefits in
those with a long duration of DM, known vascular disease, or
symptomatic severe hypoglycemia
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Case 4
Matt Forman is a 54 year-old man with newly diagnosed Type II
Diabetes. His FPG is 148 and his HbA1c is 7.8% . Physical is normal
except for BMI of 28. Except for the glucose values, his laboratory
exams are normal.
After 6 months of a diabetic diet and increased exercise, his HbA1c is 8.1%
After 6 months of Metformin at a dose of 1000 mg bid, his HbA1c is 7.1%
How should he be treated?
A second agent should be added
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Case 4 – Algorithm
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Case 5
Norman P. Hagedorn is a 64 year-old man with Type II Diabetes for
12 years. He also has CAD, s/p MI and CABG, HTN, gout, and BPH.
Medications include metformin, glyburide, pioglitazone, and sitagliptin
at maximal doses. Previously, his HbA1c were always in the 7.0-7.9%
range, however his last two HbA1cs, three months apart, are 9.8% and
10.9%. Previous attempts to introduce insulin injections have met with
adamant refusals.
What might have happened to his glycemic control?
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Case 5
Norman P. Hagedorn is a 64 year-old man with Type II Diabetes for
12 years. He also has CAD, s/p MI and CABG, HTN, gout, and BPH.
Medications include metformin, glyburide, pioglitazone, and sitagliptin
at maximal doses. Previously, his HbA1c were always in the 7.0-7.9%
range, however his last two HbA1cs, three months apart, are 9.8% and
10.9%.
Bedtime NPH 10 Units is added to his metformin. Glyburide , pioglitazone,
and sitagliptin are discontinued. After following the titration schedule
for six weeks, he is on 25 units NPH and morning fingersticks are 95125.
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Case 5
Norman P. Hagedorn is a 64 year-old man with Type II Diabetes for 12 years. He
also has CAD, s/p MI and CABG, HTN, gout, and BPH. Medications include metformin,
glyburide, pioglitazone, and sitagliptin at maximal doses. Previously, his HbA1c were
always in the 7.0-7.9% range, however his last two HbA1cs, three months apart, are 9.8%
and 10.9%.
Bedtime NPH 10 Units is added to his metformin. Glyburide , pioglitazone, and sitagliptin are
discontinued. After following the titration schedule for six weeks, he is on 25 units NPH
and morning fingersticks are 95-125.
After 3 months with continued good am fingersticks, HbA1c is 8.5%. What
would you do now?
Pre-dinner fsg are 160-180, so NPH is switched to glargine and eventually
titrated up to a dose of 35 U daily.
Now am fsg are 80-110 and pre-dinner are 95-120.
3 months later HbA1c is 8.0%. What would you do now?
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Diabetes Treatment Algorithm
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Diabetes and Hypertension - UKDPS
For each 10 mm decrease
in SBP:
• Microvascular
complications ↓ 13%
• Death ↓ 15%
• MI ↓ 11%
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Diabetes & Lipids - Heart Protection Study
 Primary prevention with risk factors
(hypertension, diabetes, and CVA)
 2x2 factorial design
simvastatin 40 mg/day, antioxidant cocktail
(600 mg vitamin E, 250 mg vitamin C, 20 mg beta
carotene)
 N = 20,000; subgroups include:
Women (n ~ 5,000)
Elderly (>65, n ~ 10,000)
Diabetics (n ~ 6,000)
Stroke (n ~ 3,000)
Hypertension (n ~ 8,000)
Noncoronary vascular disease (n ~ 7,000)
Low to average blood cholesterol (n ~ 8,000)
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Heart Protection Study: Vascular
Events by Baseline Disease
Risk ratio and 95% CI
Baseline feature
Previous MI
Simvastatin
(n=10,269)
Placebo
(n=10,267)
1007
1255
914
1234
CVD
182
215
PVD
332
427
Diabetes
279
369
All patients
2042
(19.9%)
2606
(25.4%)
Other CHD (not MI)
Statin
better
Statin
worse
No prior CHD
 24 ± 2.6%
(2P <0.00001)
0.4 0.6 0.8 1.0 1.2 1.4
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Diabetes/HTN & Lipids – Steno-2
Intervention was intensive
lowering of BP, lipids,
and A1c
Macrovascular
complications reduced
50% in intensive
treatment group over 13
years
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Diabetes & HTN & Lipids
Clinical Parameter
Target
LDL cholesterol
< 100
Blood Pressure
< 130/80
HbA1c
< 7%
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The Routine Followup Visit
•
Glycemic Control
– Fingersticks
• Daily if previously at target and on orals or glargine
• More frequently if not at target or more complicated regimen
– Symptoms of hypoglycemia & hyperglycemia
• Adherence to Diet, Exercise, & Medication
• Ongoing Education
• Ongoing Screening for longterm microsvascular
complications (at least yearly)
– Nephropathy (Ualb/cr), Neuropathy (monofilament) , retinopathy
• Control of other macrovascular risk factors
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• LDL < 100
• BP < 130/80
Question 1 – What are the symptoms
of diabetes?
• Hyperglycemia
- Tm of kidney for reabsorption of glucose > 160, sugar pulls
water, leading to polyuria; the dehydration stimulates thirst
- Polyphagia and weight loss
- Blurry vision – glucose deposits in cornea
- Yeast infections
• Volume Depletion
- Orthostatic dizziness
• Nonspecific symptoms
– Headaches, weakness
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Question 2 – the following patient is taking 25 U of NPH in the morning and
16 Units at bedtime. What adjustments would you make to her regimen?
Day
8 a.m. fasting
6pm pre-dinner
S
140
120
M
174
100
T
144
220
W
155
184
Th
151
84
F
133
65
Sa
130
112
S
149
108
M
145
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10 pm bedtime
179
188
Question 3 – this patient is using 45 Units of Lantus at bedtime and has the
following fingersticks:
Day
8 a.m. fasting
6pm pre-dinner
S
90
85
M
82
85
T
99
106
W
10 pm bedtime
83
Th
82
84
F
96
112
Sa
100
88
S
120
123
M
100
88
HBA1c is 7.8 % What could explain this? What would you recommend?
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Question 4 – this patient is taking 1000 mg of Metformin bid and has the
following fingersticks:
Day
8 a.m. fasting
6pm pre-dinner
10 pm bedtime
S
90
88
125
M
82
99
123
T
99
101
165
W
82
87
101
Th
82
94
112
F
96
96
140
Sa
100
121
130
S
120
88
115
M
100
99
113
What would you expect the HbA1c to be?
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Translating the A1c into Estimated Average Glucose Values
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