Transcript Glucose, insulin and HbA1C Levels

Glucose, insulin and HbA1C Levels
Normal Plasma Glucose (PG) Levels
Normal Fasting PG (non-pregnant)
Normal Casual PG (non-pregnant)
Normal Fasting PG (pregnant)
Normal Casual PG (pregnant)
Impaired Glucose Homeostasis Levels
Impaired Fasting Glucose (IFG)
Impaired Fasting Glucose (IFG)
Diagnostic Criteria for Diabetes (non-pregnant*)
Fasting Plasma Glucose
Casual Plasma Glucose
2 hour Oral Glucose Tolerance Test (OGTT)
Plasma Insulin Levels
Fasting Insulin Level <60 years of age
Fasting Insulin Level >60 years of age
Casual Insulin Level
70-110 mg/dL
<140 mg/dL
60-80 mg/dL
<120 mg/dL
3.9-6.0 mmol/L
<7.8 mmol/L
3.3-4.4 mmol/L
<6.7 mmol/L
110-125 mg/dL
140-199 mg/dL
6.1-6.9 mmol/L
7.8-11.0 mmol/L
>126 mg/dL
>200 mg/dL
>200 mg/dL
>7.0 mmol/L
>11.1 mmol/L
>11.1 mmol/L
U/mlg
6-24
6-35
U/ml .mg
15-200
U/ml
6-24 mU/L
6-35 mU/L
15-200 mU/L
* See Detection & Treatment Quick Guide for gestational diabetes mellitus (GDM) diagnostic criteria
If HbA1c is:
1 percentage point above normal
2 percentage point above normal
3 percentage point above normal
4 percentage point above normal
5 percentage point above normal
6 percentage point above normal
7 percentage point above normal
8 percentage point above normal
HbA1c *
7%
8%
9%
10%
11%
12%
13%
14%
* assumes normal range of 4-6%
Nathan, DM, et al: N Engl J Med 1984; 310: 341-346.
iv
Average SMBG is:
~ 150 mg/dL (8.3 mmol/L)
~ 180 mg/dL (10.0 mmol/L)
~ 210 mg/dL (11.7 mmol/L)
~ 245 mg/dL (13.6 mmol/L)
~ 280 mg/dL (15.6 mmol/L)
~ 310 mg/dL (17.2 mmol/L)
~ 345 mg/dL (19.2 mmol/L)
~ 380 mg/dL (21.1 mmol/L)
Chronic Complications Master DecisionPath
Patient with type 1 or
type 2 diabetes
Suspected or diagnosed vascular
complication?
YES
See Hypertension and Dyslipidemia Section,
1-1 to 1-10
YES
See Nephropathy Section,1-11 to 1-15
YES
See Retinopathy Section, 1-16 to 1-19
NO
Suspected or diagnosed renal
complication?
NO
Suspected or diagnosed retinal
complication?
NO
Suspected or diagnosed vascular
complication?
YES
See Neuropathy Section,1-20 to 1-28
NO
Suspected or diagnosed vascular
complication?
YES
See Foot Complications Section, 1-29 to 1-33
YES
See Nephropathy Section,1-11 to 1-15
NO
Suspected or diagnosed vascular
complication?
NO
For acute complications and surgery, see
Hospitalization Section, 1-37 to 1-46
Continue preventive measures
vi
Annual Diabetes Complications Review
Complication
Patient Complaints
Clinical Evidence
Action
Hypertension
and
Dyslipidemia
Often none; may be
blurred vision,
fatigue
Hypertension
BP >130/85 mm Hg
Dyslipidemia
Without CVD:
Cholesterol >200 mg/dL
HDL <35 mg/dL (men)
<45 mg/dL (women)
LDL >130 mg/dL
Tringlyerides >200 mg/dL
With CVD:
Cholesterol >180 mg/dL
HDL <35 mg/dL (men)
<45 mg/dL (women)
LDL >130 mg/dL
Tringlyerides >200 mg/dL
See Hypertension
and Dyslipidemia
Practice
Guidelines, 1-2
Nephropathy
Usually no
symptoms
Retinopathy
Blurred vision in
undiagnosed and
poorly controlled
patients; often no
symptoms with early
nonproliferative diabetic retinopathy;
dramatic changes in
the field of vision
(spots, cobwebs,
flashing lights); sudden loss of vision
with more severe diabetic retinopathy
Microalbuminuria:
30-300 mg Alb/g creatinine
30-300 mg Alb/24 hours
20-200  g. Alb/min (AER)
Microalbuminuria:
30-300 mg Alb/g creatinine
30-300 mg Alb/24 hours
20-200 g Alb/min (AER)
Early Nonproliferative
Diabetic Retinopathy:
Microaneurysms, dot hemorrhages, hard (lipid) exudates
Moderate or Severe
Nonproliferative Diabetic
Retinopathy: Cotton wool
spots, venous and intraretinal
microvascular abnormalities,
severe dot and blot hemorrhages
Proliferative Diabetic
Retinopathy:
Neovascularization, vitreous
hemorrhage, retinal detachment
See Nephropathy
Practice
Guidelines, 1-12
Kidney Disease
Assessment, 1-14 and
Microalbuminuria
Screening, Diagnosis,
and
15 Treatment, 1See Diabetic
Retinopathy
Screening and
Diagnosis, 1-19
Annual Diabetes Complications Review, con’t.
Complication
Patient Complaints
Clinical Evidence
Action
Neuropathy
Diffuse burning pain
in feet and legs;
unsteady walking;
loss of sensitivity to
hot and cold; “pins
and needles” sensations in hands and
feet; early satiety,
nausea, vomiting;
erectile impotence;
vaginal dryness; pain
while moving wrist
or hands; isolated
pain behind eye
Distal Symmetrical
sensorimotor
Polyneuropathy: Paresthesia
and dysethesia, diminished
thermal discrimination, ataxic
gait
Autonomic Neuropathy:
Persistent tachycardia, orthostatic hypotension, gastroparesis, recurring bladder infections, penile impotence and
retrograde ejaculation marked
by infertility
Focal Neuropathies: Sudden
diplopia and pain behind eye,
Bell’s palsy, carpal tunnel
syndrome, foot drop
See Distal
Symmetrical
Sensorimotor
Polyneuropathy, 1-25,
Gastroparesis, 1-26,
Diabetic
Diarrhea, 1-27,
and Genitourinary
Autonomic
Neuropathy, 1-28
Foot
Complications
Hot or burning sensation; sore(s) that
won’t heal or is
infected; feet look
different; localized
reddening at pressure
points; no feeling in
feet, tingling feeling
in feet
Dermatological
and/or Oral
Complications
Patches Of discolored
and/or thickened
skin; athletes foot;
lumps at injection
sites; restricted
movement in joints,
small lumps or pits in
palm; bad breath; dry
mouth; infection in
mouth
Low Risk Normal Foot: No
ulcers or deformities; sensate
to 10 g, 5.07 monofilament
High Risk Abnormal Foot:
Insensate to 10 g, 5.07
monofilament; foot deformities present
High Risk Simple Ulcer:
Ulcer <2 cm wide and <0.5
cm deep; no infection
High Risk Complex Ulcer:
ulcer>2 cm wide and/or >0.5
cm deep; infection present
Dermatological: Necrobiosis;
scleredema on back and
shoulders; sclerosis of skin on
hands; diabetic shin spots;
onychomycosis; lipohypertrophy; eruptive xanthoma
Oral: Periodontal disease;
delayed healing; xerostomia;
oral fungal infection
See 10 g, 5.07
Monofilament
Testing, 1-29,
Diabetic Foot
Management
Practice
Guidelines, 1-30,
Foot Assessment and
Treatment, 1-32 and
Foot Ulcer
Treatment, 1-33
See Dermatological
Complications, 135
and Medications for
Oral Fungal
Infections, 1-36
Hypertension and Dyslipidemia Practice Guidelines………………….. 1-2
Changes in Diabetes Therapy for Hypertension and Dyslipidemia….. 1-3
Hypertension/Diagnosis…………………………………………………. 1-4
Hypertension/Start Treatment…………………………………………. 1-5
Hypertension Drug Therapy/Start……………………………………... 1-6
Hypertension Drug Therapy/Adjust…………………………………... 1-7
Dyslipidemia/Diagnosis and Start Treatment…………………………. 1-8
Dyslipidemia Treatment/Adjust………………………………………... 1-9
Lifestyle Modifications………………………………………………….. 1-10
Hypertension and Dyslipidemia Practice Guidelines
Diagnosis
Hypertension
Dyslipidemia
Symptoms
Risk Factors
Treatment Options
Hypertension
Dyslipidemia
Systolic >130 mm Hg on 2 occasions or diastolic >85 mm Hg on 2 occasions
Without
mg/dL CVD: Cholesterol >200 mg/dL; HDL <35 mg/dL (men) or <45
With CVD: Cholesterol >180 mg/dL; HDL <35 mg/dL (men) or <45 mg/dL
(women); LDL >100 mg/dL; triglycerides >150 mg/dL
Common (classic): None
Occasional (subtle): Blurred vision, fatigue
• Overweight BMI >25 kg/m2
(particularly increased
waist-to-hip ratio)
• Duration of diabetes
• Positive family history
• Nephropathy
• Smoking
• American Indian or Alaska Native; African
American; Asian; Native Hawaiian or other
Pacific Islander; Hispanic
(HbA1c <1.5 percentage points above upper limit of normal)
Medical nutrition therapy alone or in combination with pharmacologic agents (ACE
inhibitors, angiotensin II receptor blockers,
Medical nutrition therapy alone or in combination with pharmacologic agents (HMG
Co-A reductase inhibitors, fibric acid, bile acid sequestrants, nicotinic acid)
12
Targets
Hypertension
Dyslipidemia
Monitoring
BP <130/85 mm Hg
Without history of CVD: Cholesterol <200 mg/dL, LDL <130 mg/dL, HDL >35
mg/dL (men) or >45 mg/dL (women), triglycerides <200 mg/dL
With history of CVD: Cholesterol <200 mg/dL, LDL <100 mg/dL, HDL >35
mg/dL (men) or >45 mg/dL (women), triglycerides <150 mg/dL
Self-BP and SMBG daily while in Adjust Phase
Follow-up
Hypertension
Dyslipidemia
Yearly
(in addition to
3-4 month visit)
Office visit during Adjust Phase (weekly phone contact may be necessary)
Evaluate hypoglycemia; weight or BMI (kg/m2 = weight/height2); medications;
blood pressure; fasting lipid profile; urinalysis; SMBG data (clean and check meter);
food plan; exercise; foot care; HbA1c ; smoking cessation counseling; aspirin therapy
History and physical; annual screening for albuminuria; neurologic examination;
eye examination with dilation; dental examination; diabetes and nutrition continuing
continuing education; complete foot examination (pulses, nerves, and inspection)
Changes in Diabetes Therapy for Hypertension and Dyslipidemia
1-3
If the HbA1c is >1.5 percentage points above the upper limit of normal, change in diabetes therapy is indicated
Severity of
Hypertension
Mild Hypertension
130/85-159/94 mm Hg
Current Diabetes Therapy
Medical Nutrition
Therapy
Oral Agent
Modify food plan to
reduce salt intake
increase exercise, consider oral agent therapy
Start combination oral
agent therapy, modify
salt intake
Mild
Start oral agent therapy,
Hypertension
reduce salt intake
160/95-180/105 mm Hg
Severe Hypertension
> 180/105 mm Hg
Consider insulin
therapy
Insulin (Type 1 and
Type2)
Intensify insulin
therapy, modify salt
intake
Start insulin therapy,
modify salt intake
Intensify insulin
therapy, modify salt
intake
Start intensive insulin
therapy
Intensify insulin
therapy, modify salt
intake; consider referral
to specialist if available
If the HbA1c is >1.5 percentage points above the upper limit of normal, change in diabetes therapy is indicated
Severity of
Dyslipidemia
Medical Nutrition
Therapy
Current Diabetes Therapy
Insulin (Type 1 and
Oral Agent
Type2)
Intensify insulin regiStart combination therapy, modify food plan
men, modify food plan
to <30% of total caloto <25% of total calories from fat, increase
ries from fat, increase
exercise
exercise
Mild
Total Cholesterol
180-200
mg/dL
Modify food plan to
<30% of total calories
from fat, increase
exercise
Moderate
Total Cholesterol
201-239 mg/dL
Start oral agent therapy,
modify food plan to
<25% of total calories
from fat, increase
exercise
Start insulin therapy,
modify food plan to
< 25% of total calories
from fat, increase
exercise
Intensify insulin regimen, modify food plan
to <20% of total calories from fat, increase
exercise
Severe
Total Cholesterol
>239 mg/dL
Consider insulin thera
py, modify food plan to
<20% of total calories
from fat, increase
exercise
Start intensive insulin
therapy, modify food
plan to <20% of total
calories from fat,
increase exercise
Intensify insulinregimen; modify food plan
to <20% of total calories from fat, increase
exercise, consider
referral to specialist if
available
If suing nicotinic acid monitor BG closely
Hypertension/Diagnosis
BP Measurement Guidelines
• Seated with arm at heart level
• No smoking or caffeine within 30 minutes
• Begin measurement after 5 minutes of rest
• Use cuff so bladder encircles arm 80%
• Use calibrated mercury sphygmomanometer
• Record systolic and diastolic BP
• Take 2 or more readings separated by at
least 2 minutes if BP >130/85 mm Hg
• Record cuff size
Patient with type 1 or
type 2 diabetes
Measure BP; review previous
BP values
Is systolic BP >130 mm Hg
and/or diastolic BP >85 mm Hg?
YES
14
NO
Continue to monitor BP at every visit
Is systolic BP >180 mm Hg and/or
diastolic BP >100 mm Hg?
YES
Diagnosis of severe hypertension;
start pharmacologic therapy
immediately
Move to Hypertension Drug
Therapy/Start
Consider referral to specialist if available
NO
Continue to monitor BP at every visit
NO
Measure BP at least 2 times within
1-2 weeks
Is systolic BP >130 mm Hg and/or
diastolic BP >85 mm Hg?
YES
Diagnosis of hypertension
Move to Hypertension /Start
Treatment
Hypertension/Start Treatment
Patient with confirmed hypertension
(BP >130/85 mm Hg in 2 separate
measurements)
Proteinuria detected using
standard dipstick method?
YES
NO
Are at least 2 of 3 tests (timed or
Albumin/Creatinine ratio) positive
for microalbuminuria?
See Microalbuminuria Screening,
Diagnosis, and Treatment, 1-15
NO
YES
1-5
Rule out sources of false positives (UTI,
fever, blood in urine, congestive heart failure,
extreme hypertension, vaginal fluid)
Repeat dipstick test; if second positive, suspect
overt nephropathy and consider referral
to Nephrologist, Endocrinologist, or
Diabetologist if available
Start ACE inhibitor
Move to Hypertension Drug
Therapy/Start
Is systolic BP >140 mm Hg and/or
diastolic BP >90 mm Hg?
YES
Consider drug treatment; start
lifestyle modifications
Move to Lifestyle Modifications and
Hypertension Drug Therapy/Start
NO
Start lifestyle modifications
Move to Lifestyle Modifications
Note: Although some patients with hypertension may respond adequately to single-agent therapy, it is often
necessary to add a second or third agent after a short interval if control is not achieved. The intervals
between regimen changes may be decreased, and the maximum dose of some drugs may be increased. In
some patients it may be necessary to start treatment with more than one agent. Patients with diastolic BP
>120 mm Hg require more immediate therapy and may require hospitalization and consultation.
Hypertension Drug Therapy/Start
Patient with systolic BP>140 mm Hg
and/or diastolic BP >90 mm Hg
Start Antihypertensive Therapy
• Start ACE inhibitor (benazepril, captopril,
enalapril, fosinopril, lisinopril, moexipril,
quinapril, ramipril) because of renal protective effects unless baseline hyperkalemia;
impaired renal function, especially bilateral
renal artery stenosis; drug interactions; previous drug reactions; specific indication for
another agent; likelihood of short-term
fol-low-up is low; pregnancy and lactation
• If ACE inhibitor not tolerated due to cough,
consider starting angiotensin II receptor
blocker (irbesartan, losartan, valsartan)
• If on diuretic therapy, reduce dose or stop for
3 days prior to initiating ACE inhibitor
Begin or continue lifestyle modifications
See Lifestyle Modifications, 1-10
Therapy Targets
• Systolic BP <130 mm Hg
• Diastolic BP <85 mm Hg
• Weight: Individualized
Adjust targets if frail elderly decreased life
expectancy, cognitive disorders, autonomic
neuropathy, other medical concerns
Educate Patient
• Hypertension is a chronic disease
• Importance of taking medications as
prescribed
• May feel tired initially
• Do not stop medications without consulting
your provider
• Medication side effects
Refer to Registered Dietitian and Diabetes
Educator as necessary
1-6
Reevaluate ACE inhibitor therapy if:
• Hyperkalemia: Potassium >5.7 mEq/L
Move to Hypertension Drug
• Acute worsening of serum creatinine:
Therapy/Adjust
0.3-0.5 mg/dL
• Persistent dry cough
Follow-up
• Other side effects (hypotension, rash,
Medical: Monitor BP weekly for 2-3
leukopenia)
weeks; repeat serum creatinine
Beware if NSAIDs are needed (may
and potassium within 2 weeks
decrease renal function)
Treatment options when adding an additional antihypertensive medication, or when ACE inhibitors
and/or angiotensin II receptor blockers are contraindicated or unavailable
Drug class Thiazide Diuretics
Calcium channel
-blockers
.
 -blockers
.
blockers
Acebutolol,
Diltiazen, veraDoxazosin,
praChlorthalidone,
Drug
atenolol, betaxolol,
pamil (Non-dihyzosin, terazosin
names
hydrochlorothiazide
bisoprolol, metodropyridines pre(low
dose
thiazides,
<25
prolol, nadolol,
ferred)
penbutolol, timolol
mg/day recommended)
Comments
No negative effects on
BG or lipids with low
dose therapy, effective
in elderly, less effective with renal insufficiency
Effective in combination therapy,
neutral lipid effect,
use with caution if
orthostatic
hypotension
Intensify insulinregimen; modify food plan
to <20% of total calories from fat, increase
exercise, consider
referral to specialist if
available
Not recommended as a monotherapy, dihydropyridimes may have
less CV benefit
Hypertension Drug Therapy/Adjust
BP Targets
• Systolic BP <130 mm Hg
• Diastolic BP <85 mm Hg
• Weight: Individualized
Adjust targets if frail elderly decreased life
expectancy, cognitive disorders, autonomic
neuropathy, other medical concerns
Patient treated with
antihypertensive medication
History, physical exam, and laboratory
evaluation by clinician; rule out secondary
causes of hypertension
BP <130/85 mm Hg?
YES
Patient in Hypertension Drug
Therapy/Maintain
Use this DecisionPath for follow-up
Follow-up
Medical: Every 4 months
NO
Investigate suspected adherence issues and
assess psychological and social well being
Step Down
If BP has been controlled for >6 months and
at least 4 visits, antihypertensive drug therapy
may be decreased in a slow, progressive
manner; most successful in patients who also
are following lifestyle modifications; albuminuria may dictate continued use of ACE
inhibitor
1-7
Patient on ACE inhibitor?
NO
YES
Patient on maximum dose?
YES
Patient remains in Hypertension Drug
Therapy/Adjust
Add second drug from different class; consider diuretic as adjunct therapy if expanded
blood volumes (edema); see Hypertension
Drug Therapy/Start, 1-6; monitor BP; use
this DecisionPath for follow-up
Follow-up
Medical: Within 2-6 weeks
NO
Patient in Hypertension Drug
Therapy/Maintain
Adjust current drug to maximum clinical
effectiveness; consider adding a second drug
from different class; see Hypertension
Drug Therapy/Start, 1-6; use this
DecisionPath for follow-up
Follow-up
Medical: Within 2-6 weeks
Patient in Hypertension Drug
Therapy/Maintain
Increase dose without exceeding maximum;
use this DecisionPath for follow-up
Follow-up
Medical: Within 2-6 weeks
Dyslipidemia/Diagnosis and Start Treatment
Diagnosis
Patient with type 1 or type 2 diabetes
NO
YES
Triglycerides >1000 mg/dL?
NO
MEASUREMENT
NO CVD
CVD PRESENT
HDL
mg/dL
HDL
mg/dL
>200 mg/dL >35
Total
mg/dLCholesterol >200 mg/dL >180
LDL
>200 mg/dL >100
mg/dL
Complete fractionated lipid profile; assess
risk factors (tobacco use, hypertension,
obesity)
Diagnosis of dyslipidemia?
1-8
YES
>200 mg/dL >45
Triglycerides
>200 mg/dL >150
mg/dL
Repeat screening in 1 year
Start fibric acid; modify food plan and
lifestyle
Move to Dyslipidemia
Treatment/Adjust
Follow-up
Medical: Phone contact in one week,
then office visit in 1-2 months
Nutrition: 1-2 weeks
See Lifestyle Modifications, 1-10
Triglycerides >1000 mg/dL?
NO
YES
Start HMG- CoA reductive inhibitor if no
liver dysfunction; modify food plan; move to
Dyslipidemia Treatment/Adjust
Follow-up
Medical: Weekly contact for one month;
monitor serum transaminase
level at 8-12 weeks
Nutrition: 1-2 weeks
Starting Therapies
Food Plan Modifications
• Fat: <30% of total calories
• Saturated fat: <10% of total calories
• Meat: <6 oz/day
• Eggs: maximum 2-3/week
• Low-fat dairy products
• Whole-grain breads
• Avoid alcohol
Modify food plan and lifestyle
Move to Dyslipidemia Treatment/Adjust
Follow-up
Medical: 1-2 months
Nutrition: 1-2 weeks
See Lifestyle Modifications, 1-10
HMG-CoA Reductase Inhibitors
Atorvastatin:
10 mg/day
Cerivastatin:
0.3 mg/day
Fluvastatin:
20 mg/day
Lovastatin:
10-20 mg/day
Pravastatin:
10-20 mg/day
Simvastatin:
5-10 mg/day
Aspirin:
162-325
mg/day
Fibrc Acid
Clofibrate: 2 g/day
Fenofibrate: 67 mg/day
Gemfibrozil: 1.2 g/day
Note: Monitor serum transaminase (AST/ALT) levels before
and 8-12 weeks after starting a
statin or fibric acid; monitor
periodically thereafter
Dyslipidemia Treatment/Adjust
Targets
Patient treated for dyslipidemia
MEASUREMENT
Perform complete fractionated lipid profile
Have lipid targets been met?
NO
Patient remains in Dyslipidemia
Treatment/Adjust
See table for adjunct therapies based on current treatment and lipid abnormality
Follow-up
Medical: Lipid profile in 3-4 months;
consider co-management with
lipid specialist if available
YES
1-9
NO CVD
CVD PRESENT
Total
mg/dLCholesterol >200 mg/dL >180
LDL
>130 mg/dL >100
mg/dL
HDL
>35 mg/dL >35
mg/dL(Men)
HDL
mg/dL(Women) >45 mg/dL >45
Triglycerides
>200 mg/dL >150
mg/dL
Patient enters Dyslipidemia
Treatment/Maintain
Use this DecisionPath for follow-up
Follow-up
Medical: Lipid profile in 3-4 months
Current Treatment
Food plan and Lifestyle
Modifications
HMG-CoA Reductase
Inhibitor (Station)
Fibric Acid
Statin
Atorvastatin:
Cerivastatin:
Fluvastatin:
Lovastatin:
Pravastatin:
Simvastatin:
Fibric Acid
Clofibrate
Fenofibrate
Gemfibrozil
Nicotinic Acid
Bile Acid Sequestrants
Cholestyramine
colestipol
Changes in Diabetes Therapy for Dyslipidemia
Only LDL Above Target Only Triglycerides Above Both LDL and
Target
Triglycerides Above Target
Start HMG-CoA reductase Start fibric acid
If triglycerides >1000
inhibitor
mg/dL start fibric aced;
Adjust dose; if at maxiAdd fibric acid
Adjust dose; if at maximum and triglycerides
mum, add bile acid
400 mg/dL, add bile acid sequestrant;
otherwise
sequestrant
refer to lipid specialist
Start HMG-CoA reductase If LDL >100 mg/dL add
Consider adding
inhibitor
Atorvastatin or
Atorvastatin or
Simvastatin; otherwise add Simvastatin
Nicotinic Acid
START
10 mg/day
0.3 mg/day
20 mg/day
10-20 mg/day
10-20 mg/day
5-10 mg/day
CLINICALLY
EFFECTIVE
10-80 mg/day
0.3-0.4 mg/day
20-40 mg/day
20-80 mg/day
10-40 mg/day
5-40 mg/day
1-2 g/day
67 mg/day
1.2 g/day
1.5 g/day
2 g/day
201 mg/day
1.2 g/day
3-4.5 g/day
8 g/day
10 g/day
16-24 glday
20-30 g/day
Comments
Monitor serum transaminase (AST/ALT) levels before and 8-12 weeks
after starting a statin or fibric acid; monitor periodically thereafrter
When using a statin and fibric acid in combination therapy, monitor
for myopathy (especially rhabdomolysis); ask about muscle weakness
or tenderness; monitor creatine phosphokinase (CPK) levels
Lifestyle Modifications
Goals
• BP <130/85 mm Hg
• Total cholesterol <200 mg/dL; <180 mg/dL with
CVD
• LDL <130 mg/dL; <100 mg/dL with CVD
• HDL >35 mg/dL (men); >45 mg/dL (women)
• Triglycerides <200 mg/dL; <150 mg/dL with
CVD
Patient with diagnosed HTN and/or dyslipidemia; ask all questions at each visit
Doses patient smoke?
YES
NO
Does patient drink alcohol?
NO
1-10
YES
• Educate patient about relationship between
smoking and hypertension
• Discuss with patient methods of smoking
cessation: Smoking/smokeless tobacco cessation
program; counseling; nicotine patch/gun
• Educate patient about alcohol and hypertension
• Set goals with patient based on detailed
alcohol hoistory
• Limit daily intake to 1 oz alcohol (2 ox distilled
beverages, 8 oz wine, or 24 oz beer)
• Consider referral for chemical dependency
Does patient eat a high-fat
and/or high-sodium diet?
YES
NO
Is patient overweight?
YES
NO
Is patient sedentary or only mildly active?
NO
Re-assess at each visit
YES
• Reduce dietary fats: Choose lean cuts of
meat and low-fat dairy products; prepare
food without added fats; limit use of highfat snacks, desserts, and fast food
• Reducedietary sodium: <2400 mg/day
• Develop individualized, monitored weight
loss program
• Determine intermediate and long-term goal
weight goals
• Determine weight loss rate; suggest 5 lb
per month
• Reinforce positive achievemeht
• Reduce caloric intake
• Increase physical activity
• Educate patient about benefits of regular
exercise
• Consider stress test if known CVD or other
serious health problem
• Consider submaximal measurement; step
test, mile walk, etc.
Diabetic Nephropathy Practice Guidelines……………………………… 1Changes in Diabetes Therapy for Nephropathy…………………………12
Kidney Disease Assessment………………………………………………. 1Microalbuminuria Screening, Diagnosis, and Treatment………………13
114
115
Diabetic Nephropathy Practice Guidelines
Diagnosis
Incipient Diabetic
Nephropathy
Overt Diabetic
Nephtopaty
Hypertension
Glomerular
Desease
Risk Factors
Persistent microalbuminuria (on at least 2 out of 3 occasions)
Random urine collection 30-300 mg albumin/g creatinine
24-hour urine collection 30-300 mg albumin/24 hours
Timed urine collection 20-200  g.albumin/minute
Macroalbuminuria (proteinuria indicated by a positive dipstick test)
Random urine collection >300 mg albumin/g creatinine
24-hour urine collection >300 .g albumin/24 hr
.
Timed urine collection >200  g albumin/minute
Note: Albumin/creatinine ratio not sensitive when urine protein >2-3 g/24 hours
Systolic >130 mm Hg on 2 occasions or diastolic >85 mm Hg on occasions
Evidece includes mesangial cell matrix expansion, increased basement
membrane thickness, and loss of glomerular capillary surface area
• HbA1c >2 percentage points
above upper limit of normal
• Sibling with nephropathy
• Smoking
• Duration of diabetes >5 years
• Family history of hypertension
and/or dyslipidemia
• American Indian or Alaska Native;
African American; Asian; Native Hawaiian
or other Pacific Islander; Hispanic
112
Treatment Options
Hypertension
Dyslipidemia
Targets
Monitoring
Follow-up
Monthly
Every 3 Months
Yearly
(In addition to
3-4 month visit)
If hyperglycemia, intensify metabolic control
Medical nutrition therapy; ACE inhibitors; angiotensin II receptor blockers
diuretics; calcium channel blockers
 -blockers;
.
-blockers;
.
Medical nutrition therapy; HMG Co-A reductase inhibitors, bile acid sequestrants; fibric acid; nicotinic acid
Near euglycemia; BP <130/85 mm Hg; glomerular filtration rate (GFR)
decrease <0.2 ml/minute/month acceptable
Self-BP and SMBG daily while adjusting treatment
Albuminuria screening should be performed annually in all adults and in all
postpubertal patients with at least 5 years duration of diabetes; if nephropathy
present, see below
Office visit during Adjust Phase (weekly phone contact may be necessary)
Urinalysis with dipstick test for proteinuria; determine HbA1c
Serum creatinine and blood urea nitrogen (BUN) annually in patients with
albuminuria; if macroalbuminuria present, consider consult with Endocrinologist,
Diabetologist, or Nephrologist.
Changes in Diabetes Therapy for Nephropathy
1If the HbA1c is >1.5 percentage points above the upper limit of normal, change in diabetes therapy is indicated
13
Severity of
Hypertension
Normal
(No Nephropathy)
Incipient Diabetic
Nephropathy
(Microalbuminuria)
Overt Diabetic
Nephropathy
(Microalbuminuria)
*Type 2 diabetes
Current Diabetes Therapy
Medical Nutrition
Therapy*
Consider oral agent
therapy, modify salt
intake
Start oral agent therapy,
reduce salt intake to
<2400 mg/day
Start insulin therapy,
modify protein intake,
restrict salt intake to
<2400 mg/day
Oral Agent*
Insulin (Type 1 and
Type2)
Start combination oral Intensify insulin
agent therapy, modify therapy, modify salt
salt intake
intake
Start insulin therapy, Intensify insulin
modify salt intake
therapy, reduce salt
intake to <2400 mg/day
Start intensive insulin Intensify insulin
therapy, modify protein therapy, modify protein
intake, restrict salt
intade, restrict salt
intake to <2000
mg/day, consider
referral to specialist
Microalbuminuria Screening, Diagnosis, and Treatment
1-15
Semi-quantitative test strips may be used for
microalbuminuria screening; verify all positive
tests with standard lab test
Patient with type 1 or
type 2 diabetes
OR
OR
Obtain random urine sample
(first morning urine preferred)
Obtain random urine sample
(first morning urine preferred)
Obtain random urine sample
(first morning urine preferred)
Normal: <30 mg/g creatinine
Microalbuminuria: 30-300 mg/g
Macroalbuminuria: >300 mg/g
(urine albumin is normalized to
urine creatinine)
Normal: <30 mg/24 hour
Microalbuminuria: 30-300 mg/24 hr
Macroalbuminuria: >300 mg/24 hr
(total albumin excreted/24 hr period)
Normal: <20 g/min
.
Microalbuminuria:
20-200 mg/g
Macroalbuminuria: >200 mg/g
(albumin excretion rate, AER, in
micrograms albumin excreted/
minute)
Microalbuminuria?
NO
Repeat screen annually
Repeat microalbuminuria screen twice more
within 60 days
At least 2 of 3 tests positive
for microalbuminuria?
NO
Repeat screen annually
NO
Consider ACE inhibitor
Move to Hypertension Drug
Therapy/Start
YES
Diagnosis of microalbuminuria
Is patient hypertensive
(BP >130/85 mm Hg)?
NO
Start ACE inhibitor and treatment for kidney
disease; repeat testing 1-2 times/year
Move to Hypertension Drug
Therapy/Start and Lifestyle
Modifications
Treatment for Kidney Disease
• HbA1c within 1.5 percentage points of upper
limit of laboratory normal range
• Antihypertensive therapy (ACE inhibitor) to
reduce BP <130/85 mm Hg
• Low-protein diet: 0.8 g/kg/day or ~10% of
total calories (for macroalbuminuria only)
• Reduce salt intake to <2000 mg/day
Increase activity and exercise
Diabetic Retinopathy Practice Guidelines……………………………..… 1Clinical Presentation of Diabetic Retinopathy………………………...…17
Diabetic Retinopathy Screening and Diagnosis………………….……… 118
119
Diabetic Retinopathy Practice Guidelines
Diagnosis
Early Nonproliferative
Diabetic Retinopathy
(NPDR)
Moderate to Severe
NPDR (preproliferative)
Proliferative Diabetic
Retinopathy (PDR)
Risk Factors
Treatment Options
Microaneurysms; dot hemorrhages; sparse blot hemorrhages;
hard (lipid) exudates
Macular edema; cotton wool spots; venous abnormalities;
intraretinal microvascular abnormalities (IRMA); venous dilation
New vessels on the disc (NVD); new vessels elsewhere (NMVE);
retinal detachment
• Persistent hyperglycemia
• Age (>40 years)
• Duration of Diabetes
(>5 years)
• Albuminuria
• Hypertension
• American Indian or Alaska Native; African
American; Asian; Native Hawaiian or other
Pacific Islander; Hispanic
Note: Refer to retinal specialist experienced in diabetic retinopathy
NPDR Enforce tight metabolic control
Hyperglycemia: Medical nutrition therapy, pharmacologic agents;
adjustments in insulin therapy or oral agents; increase SMBG frequency
117
PDR
Severe PDR
Macular Edema
Targets
Monitoring
Follow-up
Yearly
Panretinal photocoagulation, small laser burns (~500  ) .outside venous arcades in
mid-periphery of retina to prevent further neovascularization
Vitrectomy to remove vitreous humor, cot fibrous traction bands, and repair retinal
detachment
Focal photocoagulation, very small laser burns (~50-100  ) to. leaking
microaneurysms and areas of ischemia in the macular region
Near euglycemia (HbA1c <1.5 percentage points above upper limit of normal)
Improved vision; prevention or slowing progression of retinopathy; BP <130/85 mm Hg
Encourage patient to report diminished visual acuity; blurred vision; other
eye-related problems
For patients without retinopathy
Type 1: Annual dilated opthalmoscope examinations beginning 5 years after
diagnosis (usually not before puberty)
Type 2: If never screened, screen now and annual screening thereafter; consider
screening patients in poor control and/or with albuminuria every 6 months
During pregnancy: Dilated eye exam during first trimester and monthly thereafter
for all women with diabetes (not GDM)
Clinical Presentation of Diabetes Retinopathy
118
Stage
Lesion
Clinical Presentation
Early Nonproliferative
Diabetic Retinopathy (NPDR)
Microaneurysms
Small red dots, often in a
punctate pattern
Red round or blot shaped in the
inner nuclear layer, or flame
shaped in the nerve fiber layer
Yellowish specks or patches of
lipid-serum protein mixture
White spots or patches of swelling
axoplasm and organelles of nerve
fibers indicative of localized retinal
ischemia with infarction
Beads and loops of retinal veins
Dilation of fine vessels in areas
of ischemia
Dot and blot hemorrhages
Hard (lipid) exudates
Moderate to Severe NPDR
Cotton wool spots (soft
exudates)
Venous abnormalities
Intraretinal microvascular
abnormalities (IRMA)
Proliferative Diabetic
Retinopathy (PDR)
Neovascularization of the disc
(NVD)
Neovascularization elsewhere
(NVD)
Vitreous hemorrhage
Tractional retinal detachment
Macular Edema
Retinal swelling around macula
Large bundles of new vessels on optic
nerve head
Large bundles of new vessels on the
periphery of the retina
Vitreous is cloudy or opaque and often
with a reddish hue
Loss of vision if the macula is detached
Difficult to diagnosis with ophthalmoscpe,
but a ring of hard exudate around the macular
region is common
Diabetic Retinopathy Screening and Diagnosis
Risk Factors
• Persistent hyperglycemia
• Age and duration of diabetes
• Hypertension and albuminuria
• American Indian or Alaska Native; African
American; Asian; Native Hawaiian or other
Pacific Islander; Hispanic
Patient with type 1 or type 2 diabetes
Assess risk factors
Visualization of retina is improved with
dialation of pupils; to dialate pupils, one drop
each of 2.5% phenylephrine hydrochloride
and 1% tropicamide
Examine eye with monocular ophthalmoscope
(dilation required)
Evidence of retinal lesions?
YES
NO
Repeat eye examination in one year
1-19
Early Nonproliferative
Diabetic Retinopathy
(NPDR)
• Microaneurysms
• Dot hemorrhages
• Hard (lipid) exudates
Moderate or Severe
Nonproliferative Diabetic
Retinopathy (NPDR)
• Intraretinal microvascular
abnormalities
• Severe dot and blot
hemorrhages
• Cotton wool spots
• Venous dilation
Early Nonproliferative
Diabetic Retinopathy
(NPDR)
• Microaneurysms
• Dot henorrhages
• Hard (lipid) exudates
Establish and maintain
HbA1c <1.5 percentage
points above upper limit of
normal to slow progression;
treat hypertension if present
(ACE inhibitor)
Establish and maintain
HbA1c <1.5 percentage
points above upper limit of
normal to slow progression;
treat hypertension if present
(ACE inhibitor)
Immediately refer to
Ophthalmologist
specializing in retinal
disease (within 48 hours)
Refer to Ophthalmologist
specializing in retinal disease
within 1-3 months
Diabetic Neuropathy Practice Guidelines………………….…………... 1Diabetic Neuropathy Assessment and Diagnosis……………….…..…..21
Medications for Managing Painful Diabetic Neuropathy……..…....…. 1Distal Symmetrical Sensorimotor Polyneuropathy...……….………….23
Gastroparesis……………………...……………………………………... 124
Diabetic Diarrhea……………………….………………………………...
1Genitourinary Autonomic Neuropathy……...………………………….25
126
127
128
Diabetic Neuropathy Practice Guidelines
Diagnosis
Diffuse
Neuropathies
Distal Symmetrical
Sensorimotor
Polyneuropathy
Autonomic
Neuropathy
121
Type 1 (at time of diagnosis): Paresthesia and burning pains in legs and feet; symptoms
disappear with insulin therapy
Type 1 and type 2 (long-term): Paresthesia and dysesthesia(“needles and pins”) in distal
extremities, diminished thermal discrimination; numbness; loss of motor control resulting
in ataxic gait; unsteadiness
Cardiovascular: Persistent tachycardia; reduced beat-to-beat variation on deep respiration;
orthostatic hypotension; predisposition to painless myocardial infarction
Gastrointestinal: Delayed gastric emptying (gastroparesis) causing early satiety/nausea/
anorexia/vomiting; esophageal dysmotility; diabetic diarrhea; diabetic constipation
Genitourinary: Atonic bladder paresis resulting in bladder infection/erectile impotence/
retrograde ejaculation causing infertility/vaginal dryness
Sudomotor: Gustatory sweating; decreased sweating in lower extremities
Adrenal: Reduced hypoglycemia awareness
Iris: Poor night vision; pinpoint pupils (no dilation with change in light)
Focal Neuropathies
Cranial Neuropathy
Diabetic Radiculopathy
Femoral Neuropathy
Nerve Entrapment
Risk Factors
Treatment Options
Diffuse
Neuropathies
Distal Symmetrical
Sensorimotor
Polyneuropathy
3rd and 6th cranial nerve palsies causing sudden diplopia (double vision), strabismus,
isolated pain behind eye; Bell’s palsy
Abdominal and/or thoracic pain due to nerve root lesions
Often seen in older type 2 patients; pain followed by gradual weakening and atrophy
of muscles in thigh and buttocks (diabetic amyotrophy)
Carpal tunnel syndrome involving median nerve in wrist; foot drop from entrapment
of normal; hypertension; hypercholesterolemia; duration of diabetes
Persistent hyperglycemia; HbA1c >2 percentage points above upper limit of normal;
hypertension; hypercholesterolemia; duration of diabetes
Good metabolic control; drug therapy when indicated; routine screening and patient
education are critical
Treat pain with standard analgesics, avoid narcotics; treat localized pain with topical
capsaicin; antidepressants (Amitripthyline, Imipramine, Desipramine, Venlafaxine),
anticonvulsants (Carbamazepine, Gabapentin, phenytoin), antiarrhythmic drug
Mexilitene (Oral Lidocaine) may also be effective
Diabetic Neuropathy Practice Guidelines, con’t.
Autonomic Neuropathy Orthostatic hypotension: Consider reducing or discontinuing anti-hypertensive medication
for symptomatic orthostatic hypotension; use Fludrocortisone with caution, may precipitate
CHF; may use elastic stockings/abdominal binders; increase salt intake; elevate head at night
Painless myocardial ischemia: Consider imaging stress test
Gastroparesis: Encourage frequent small feedings; Cisapride, Erythromycin, or dopamine
antagonists (Metoclopramide) may be effective
Diabetic diarrhea: Treat with broad spectrum antibiotics (Tetracycline) and bile salt sequestrants
(Cholestryramine)
Episodic diabetic constipation: Treat with stool softeners and laxatives; severe cases may
require prokinetic agents (Metoclopramide and Cisapride)
Genitourinary: Encourage regular bladder emptying; treat UTI as required; treat vaginal dryness
with estrogen cream
Psychogenic erectile impotence (normal nocturnal erections): Refer to psychologist
Organic impotence/retrograde djaculations: Sildenafil Citrate; vacuum devices with elastic
constrictors to maintain erection; injection of vasoactive drugs (Prostaglandin, Alprostadel) into
the corpus cavernsum; surgical implantation of penile prosthetics; referral to a urologist is advised
122
Focal Neuropathies Symptomatic palliation until symptoms disappear, usually 1-2 months
Targets
Near euglycemia (GbA1c <1.5 percentage points above upper limit of normal)
Prevent onset of clinical neuropathy and/or slow progression
Monitoring
Encourage patients to record pain and to note intensity, duration, and time of day
Follow-up
With or without neuropathy
Monthly Office visit during Adjust Phase (more frequently if changing medication)
Every 3-4 Months Office visit during Maintain Phase (re-assess symptoms)
Yearly Clinical evidence of diabetic neuropathy rarely is present in type 1 patients within 5
years of diagnosis (except paresthesia and burning sensations at time of diagnosis)
Annual neurological screening with neurological history and neurological exam
including sensory, motor, reflex, and autonomic responses; complete foot examination
(pulses, nerves, and inspection)
Diabetic Neuropathy Assessment and Diagnosis
Patient with type 1 or
type 2 diabetes
Risk Factors
• Persistent hyperglycemia (HbA1c >1.5
percentage points above upper limit of normal)
• History of hypertension
• Duration of diabetes (>10 years)
Neurological Tests
• Sensory test with 10g, 5.07 monofilament,
and/or tuning fork
• Motor and reflex tests
• Autonomic tests; Harris Mat
Assess risk factors
Obtain medical and neurological history
Perform neurological exam
Evidence of distal symmetrical
sensorimotor polyneuropathy (paresthesia
and dysesthesia in the distal extremities,
loss of thermal discrimination, deep
gnawing or tearing pain)?
NO
1-23
YES
See Distal Symmetrical Sensorimotor
Polyneuropathy, 1-25
Evidence of autonomic neuropathy
(nausea and vomiting, early satiety,
anorexia, food compaction, atonic bladder
paresis, bladder infection, sexual
dysfunction)?
YES
See Gastroparesis, 1-26, Diabetic Diarrhea,
1-27 or Genitourinary Autonomic
Neuropathy, 1-28
YES
See Distal Symmetrical Sensorimotor
Polyneuropathy, 1-25
NO
Evidence of focal neuropathy (cranial,
radiculopathy, amyotrophy, nerve
entrapment)?
NO
Repeat assessment annually
Medications for Managing Painful Diabetic Neuropathy
124
Drug
Class
Start
Effective
Comment
Amitriptyline,
Desipramine,
Imipramine
Tricyclic
antidepressant
10-25 mg hs
10-25 mg hs
Venlafaxine
Antidepressant
37.5 mg bid
37.5-75 mg
bid
Fluphenazine
Phenothiazine
derivative
1 mg tid
1 mg tid
Mexiletine
Antiarrythmic
150-200 mg
tid
Block uptake of
norepinephrine
and/or serotonin
Block uptake of
Serotonin and norepinephrine; do not
use in combination
with MAOI
Smetimes used
in combination
with tricyclics
Blocks sodium
channels; must
monitor for
arrhythmia
150-200 mg
tid
Drug
Class
Start
Effective
Comment
Carbamazepine
Anticonvulsant
200 mg bid
200 mg bid to
qid
Unknown action;
associated with
aplastic anemia and
agranulocytosis
Gabapentin
Anticonvulsant
300-6000 mg
tid
300-600 mg
tid
Unknown action
Phenytoin
Anticonvulsant
100 mg tid
100 mg tid to
tid
Promotes sodium
efflux from neurons
Distal Symmetrical Sensorimotor Polyneuropathy
Patient with evidence of distal symmetrical
sensorimotor polyneuropathy (DSSP)
Evidence of DSSP
• Paresthesia and dysesthesia in
distal extremities
• Loss of thermal discrimination
• Deep gnawing or tearing pain
Initial Treatment
• Maintain HbA1c <1.5 percentage points above
normal and SMBG 80-160 mg/dL
• Mild pain: Analgesics and comfort measures
• Localized pain: Topical application of capsaicin
cream 3-4 times/day
Have lipid targets been met?
NO
Start antidepressive therapy; add
Fluphenazine 1 mg tid if needed
DRUG
START
Amitriptyline
Desipramine
Imipramine
Venlafaxine
10-25 mg hs 50-150 mg hs
130 mg hs
50-150 mg hs
35 mg hs
50-150 mg hs
45 mg hs
37.5-75 mg bid
CLINICALLY
EFFECTIVE
YES
Maintain therapy as required
1-25
Effective pain relief within 4 weeks?
YES
Maintain therapy as required
YES
Maintain therapy as required
NO
Start anticonvulsive therapy
DRUG
START
CLINICALLY
EFFECTIVE
Carbamazepin 200 mg bid 200 mg bid to qid
Gabapentin 300 mg hs 300-600 mg tid
Phenytoin
100 mg bid 100 mg bid to tid
Effective pain relief within 2-4 weeks?
NO
Start antiarrythmic therapy; Mexiltene
150-200 mg itd; monitor for arrhythmia
Gastroparesis
1-26
Evidence of Gastroparesis
• Nausea and vomiting
• Early satiety
• Anorexia
• Food compaction (bezoar)
Patient with evidence of gastroparesis
Initial Treatment
• Establish and maintain HbA1c ,1.5 percentage
points above upper limit of normal
• Encourage frequent and smaller meals (6-8
small meals per day)
• Avoid high-fat foods and carbonated beverages
• Encourage liquids, soft foods low in fiber
Effective gastrointestinal relief
within 2 weeks?
NO
YES
Maintain therapy as required
Start cisapride 10 mg before meals and at
bedtime; may increase to 20 mg if required
Note: Use of Cisapride and Erythromycin in
Combination is contraindicated
Effective gastrointestinal relief
within 2 weeks?
YES
Maintain therapy as required
YES
Maintain therapy as required
NO
Start Erythromycin 250 mg tid
Effective gastrointestinal relief
within 2 weeks?
NO
Start Metoclopramide 10 mg before meals
and at bedtime; may increase to 15 mg if
required
Diabetic Diarrhea
Patient with evidence of diabetic diarrhea
Evidence of Gastroparesis
• Uncontrolled diabetes
• Distal polyneuropathy and other autonomic
neuropathies
• Brown, voluminous, episodic stools; often at
night
• Fecal incontinence
• Rule out other GI disorders (ulcer, irritable
bowel, diverticulitus, etc.)
Initial Treatment
• Establish and maintain HbA1c <1.5 percentage
points above upper limit of normal
• Over-the-counter antidiarrheal medications
(Loperamide and Dephenoxylate)
Effective relief of diarrhea within
1 weeks?
NO
1-27
YES
Maintain therapy as required
Start broad-spectrum antibiotics (Tetracycline
or cephalosporin) to stop bacterial colonization
in bowel
Effective relief of diarrhea within
10 days?
YES
Maintain therapy as required
YES
Maintain therapy as required
NO
Start Clonidine, 0.1-0.3 mg bid; may cause
orthostatic hypotension
Effective relief of diarrhea within
1 weeks?
NO
Start somatostatin analogue Octreotide
50-75 .g subcutaneously 2 times/day
Genitourinary Autonomic Neuropathy
Patient with evidence of
genitourinary
autonomic neuropathy
Atonic bladder
paresis or recurrent
bladder infection?
YES
1-28
Evidence of Genitourinary
Autonomic Neuropathy
• Atonic bladder paresis
• Recurrent UTI
• Erectile impotence
ON
Erectile impotence?
YES
NO
Retrograde ejaculation
(very rare in diabetes)?
YES
Encourage regular bladder
emptying; explain abdominal
compression techniques
Treat occasional urinary
tract infections as required
If recurring bladder
infections, consider
referral to Urologist
Determine if impotence
is psychogenic and/or
organic in nature
Psychogenic
• Nocturnal erections
present
• Sudden loss of erection
Refer to Psychologist
experienced in treating
diabetes-related impotence
Consider referral to
Urologist?
Organic (due to diabetes)
• Nocturnal erections not
present
• Normal libido
• Gradual loss of erection
Refer to Urologist experienced in treating diabetes-related impotence
Treatment options:
Sidenafil Citrate, vacuum
devies, vasoactive drugs
(Prostaglandin, Alprostadel)
penile implants (increasingrare)
10 g, 5.07 Monofilament Testing
1. Show the monofilament to patient,
touch to their hand so they know it does
not hurt.
2. Shield testing from patient’s view and
ask them to respond when the
monofilament is felt.
3. Apply 10 g, 5.07 monofilament
perpendicular to the skin’s surface for
1-2 seconds.
4. Apply enough force on monofilament to
make it bend slingthy, do not drag
monofilament across skin.
5. Randomly check all sites on the plantar
and dorsal areas as shown on the right.
Document exam on SDM Foot Risk
Assessment/Exam Form.
6. Apply monofilament to perimeter of
calloues, scars or ulcers.
1-29
Diabetic Foot Management Practice Guidelines……………………….. 1Diabetic Foot Master DecisionPath……………………………………… 30
Foot Assessment and Treatment…………………………………………. 1Foot Ulcer Treatment………………………………………………...…… 31
132
133
Diabetic Foot Management Practice Guidelines
Diagnosis
Low Risk Normal Foot
High Risk Abnormal Foot
High Risk Simple Ulcer
High Risk Complex Ulcer
Risk Factors
Normal Foot, no ulcer; sensate to 10 g, 5.07 monofilament; no deformities; no
history of ulcer or amputation
Abnormal foot, no active ulcer; insensate to 10 g, 5.07 monofilament; deformities;
history of ulcer; amputation
Active ulcer, superficial involvement; ulcer <2 cm wide and <0.5 cm deep; no
infection; vascular status intact; no systemic symptoms
Active ulcer, extensive involvement; ulcer >2 cm wide and/or >0.5 cm deep; infection; hyperglycemia; vascular disease; systemic symptoms present
•
•
•
•
Previous amputation
Previous ulcers
Foot deformities
Age (>40 years)
•
•
•
•
Persistent hyperglycemia
Elevated HbA1c
Duration of diabetes (>5 years)
Males
Treatment Options
Low Risk Normal Foot Patient preventative care; educate and refer for risk reduction such as intensified
diabetes management, smoking cessation, and other behavioral changes
130
High Risk Abnormal Foot
High Risk Simple Ulcer
High Risk Complex Ulcer
Targets
Monitoring
Follow-up
Daily
2-3 Times Per Week
Monthly
Every 3-4 months
Yearly
Patient education; protective footwear; non-invasive vascular evaluation; (vascular
lab); treatment if required
Outpatient wound care 2-3 times/week until ulcer healed; frequent follow-up to
prevent recurrence; patient education; protective footwear; appropriate referral
In-patient wound care; revascularization or minor amputation if needed; appropriate
referral
HbA1c <1.5 percentage points above upper limit of normal, with frequent
SMBG; prevention of foot of foot disease; complete healing of ulcer and prevention
of recurrence
Self care: Daily foot inspection; record all foot-related symptoms
Inpatient: Daily foot inspection by provider
Patients with foot complications
For inpatient management of complex ulcer, monitor BG
For outpatient management of simple ulcer, measure BG at each visit
Once stabilized, re-inspect foot each visit (up to 6 months) to prevent recurrence;
HbA1c each visit
Patients with no foot complications
Complete foot examination; HbA1c each visit
For low risk feet, complete foot examination (pulses, nerves, and inspection)
Diabetic Foot Master DecisionPath
1-31
Upon Assessment
Normal Foot
Sensate to 10 g,
5.07 monofilament; no ulcer
Abnormal Foot
Previous ulcer; insensate to 10 g,
5.07 monofilament;
deformities present
Low Risk Normal Foot
Ulcer prevention
Patient self-care
If any change in status, reclassify
foot
See Foot Assessment and
Treatment, 1-32
High Risk Abnormal Foot
Ulcer prevention
Protective footwear
If any change in status, reclassify
foot
See Foot Assessment and
Treatment, 1-32
Healed
Healed
Active Ulcer
Superficial involvement; <2 cm
diameter and <0.5 cm deep
High Risk Simple Ulcer
Treat simple ulcer
Consider referral to specialist or
obtain consultation if failure to
improve in 2 weeks
See Foot Ulcer Treatment, 1-33
Improved
Active Ulcer
Extensive involvement; >2 cm
diameter and/or >0.5 cm deep
High Risk Complex ulcer
Treat complex ulcer
Consider referral to specialist or
obtain consultation
See Foot Ulcer Treatment, 1-33
Foot Assessment and Treatment
Patient with type 1 or type 2 diabetes
Foot Classifications
• Low Risk Normal Foot
• High Risk Abnormal Foot
• High Risk Simple Ulcer
• High Risk Complex Ulcer
Assess Condition of Feet
• Deformities (nail deformities; hallux valgus
or varus; claw or hammertoes; bony prominence;
charcot feet)
• Ulcers, redness, trauma
• Test sensation with 10 g, 5.07 monofilament
• Poor circulation
• Ischemic symptoms
• Amputation
Ulcer present?
NO
1-32
YES
Move to Foot Ulcer Treatment
Any of the following present:
Deformity; foot insensate to 10 g, 5.07
monofilament in any plantar areas (except
heel); previous amputation; ischemic index
calculated from doppler <0.8?
NO
Classification: Low Risk Normal Foot
Educate Patient
Daily foot inspection; report any injury or
abnormality; wear appropriate footwear;
skin, nail and callus care; avoid foot soaks;
tight glycemic control
Follow-up
Medical: Assess feet at each visit
YES
Classification: High Risk Abnormal Foot
• If deformity present, refer to Podiatrist for
extra-depth shoes with molded inserts
• If nail deformities or calluses, palliative
foot care
• If neuropathies/no deformities, change
footwear to commercially acceptable type
• If vascular disease (history of amputation,
ischemic symptoms, poor circulation), refer
for complete evaluation
Foot Ulcer Treatment
Patient with foot ulcer
Assess Condition of Feet
• Measure width and depth of ulcer
• Temperature, white blood count
• Deep space infection: Abscess,
osteomyelitis, gangrene
• Pulses; ankle/arm index
• Ischemic symptoms
Any of the following present:
Ulcer >2 cm diameter and/or >0.5 cm
deep; cellulitis with 2 cm margin or o
ascending
infection; temperature >100.5 F
(38 oC); white blood count >12,000; deep
space infection; pulses absent; or
ankle /arm index <0.8 with
ischemic symptoms?
NO
YES
1-33
Classifications: High Risk Complex Ulcer
(active ulcer with extensive involvement)
• Hospitalize patient for wide surgical
debridement; culture for infections; sterile
dressing changes; no weight bearing on
foot
• If deep space infection, start parenteral
antibiotic for staphylococcus and streptococcus
• Complete vascular evaluation if ischemia
present
Classification: High Risk Simple Ulcer
(small superficial ulcer with no complications)
• Weekly debridement; sterile dressing changes;
limit weight bearing to foot
• If exudate or limited cellulitis, start oral
antibiotic for staphylococcus and streptococcus
• Arrange home care follow-up
Follow-up
Medical: Weekly until ulcer is resolved,
then 2 month complete examination; assess foot at every visit
Education: Daily foot inspection; report any
injury or abnormality; wear appropriate footwear; skin, nail, callus
care; avoid foot soaks; tight
glycemic control
If no improvement within two week,
reclassify to High Risk Complex Ulcer;
consider hospitalization
Follow-up
Medical: Daily until ulcer improves, then
2 month complete examination;
arrange home care follow-up
If improved reclassify to High
Risk Simple Ulcer
Education: Daily foot inspection; report any
injury or abnormality; wear
appropriate footwear; skin,
nail, callus care; avoid foot
soaks; tight glycemic control
If no improvement within 2 weeks for simple ulcer or 1 week for complex ulcer, refer
to specialist; consider amputation
Dermatological Complications…………...……………………………... . 1Medications for Oral Fungal Infections……...………………………….17
118
Hospitalization Master DecisionPath
1-38
Hospitalized patient with type 1 or
type 2 diabetes
Patent admitted for acute
complication of diabetes?
NO
YES
See Hypoglycemia Treatment/Inpatient, 1-39,
Poor Control Treatment/Inpatient, 1-40, or
DKA and HONK Treatment/Inpatient, 1-41
Patient admitted for illness?
YES
See Illness/Inpatient, 1-43
YES
See Inpatient Surgery, 1-45
NO
Patient admitted for surgery?
NO
If patient admitted for other reasons, see
DecisionPath for specific therapy to manage
patient’s diabetes while hospitalized
Hypoglycemia Treatment/Inpatient
Hospitalized patient with BG <70 mg/dL
Start Treatment
• If patient able to eat or drink, provide 30 g of
carbohydrate (use glucose tablets or milk for
patients on alpha-glucosidase inhibitor)
• If patient unconscious, unable to eat, unwilling
to eat, or unresponsive to oral treatment, start IV
glucose (if available) or administer glucagon
IV Glucose Dose: 10-20 ml bolus of 50%
dextrose then 5 or 10% dextrose at 100 ml/hour
until stabilized
Glucagon Dose: Adolescents and adults 1.0 mg
(1 ml); children 0.5 mg (1/2 ml) or 15 g .
Monitor BG every 30 minutes until
BG>100 mg/dL
Symptoms
Sweating, palpitations, blurred vision,
confusion, slurred speech, weakness,
drowsiness, tired, headache, hunger,
irritability, coma
Carbohydrate Sources (15 grams)
• 3 glucose tablets
• 15 g glucose gel
• 1/2 cup fruit juice
• 1 cup milk
• 3/4 cup regular soda pop
• 3 tsp honey or corn syrup
• 6 saltine crackers
• 1 slice bread
1-39
When BG >100 mg/dL and stable, re-evaluate
treatment and consider alternate therapy
Determine cause of hypoglycemia; educate
patient about self treatment and prevention
Follow-up
Education: Within 1 month
Poor Control Treatment/Inpatient
1-40
Patient in danger of severe hypoglycemia
or hyperglycemia
Is blood glucose <70 mg/dL with
symptoms (sweating, palpitations, blurred
vision, confusion, irritability, coma?
YES
See Hypoglycemia Treatment/Inpatient, 1-39
YES
See DKA and HONK Treatment/Inpatient, 1-41
NO
Type 1 diabetes: BG>250 mg/dL, or
positibe ketones, serum pH <7.3, and
bicarbonate <15 mEq/L?
Type 2 diabetes: Low BP, and plasma
osmolality 300-400 mOsm/L, BG >400
mg/dL and sodium often below normal
due to suppression by elevated glucose?
Start Treatment
• Monitor BG every 60 minutes to determine
direction
• If treated with insulin: Start Insulin Stage 4A
• If treated with oral agent: Consider starting
Insulin Stage 4A to stabilize BG
See SDM Detection and Treatment Quick Guide
When BG stable, re-evaluate treatment and
consider alternate therapy
Determine cause of poor control; teach diabetes self-management skills, including
SMBG
Follow-up
Education: Within 1 month
Nutrition: Within 1 month
DKA and HONK Treatment/Inpatient
Patient with type 1 or type 2 diabetes and
probable DKA or GONK
Initiate Fluid Replacement
• One liter normal saline first hour, then 1
liter over next 2 hours
• Continue fluid replacement at approx.
250 ml/hour with 0.45% saline
• Maximum fouid usually will not exceed
7000-7500 ml during first 24 hours
Start IV Insulin Therapy
• Give 0.1 U/kg bolus regular insulin (sometimes not used in young children)
• Start 0.1 U/kg/hour constant drep infusion
• When BG ~ 250 mg/dL, add 5 or 10% dextrose to replacement fluids
Adjust insulin infusion rate to maintain BG
of 150-200 mg/dL; avoid BG <150 mg/dL
Monitor BG, electrolytes, and acidosis
1-41
Diabetic Ketoacidosis (DKA) Symptoms
and Laboratory Findings
• Abdominal pain, vomiting, deep Kussmaul
breathing, confused or comatose, fruity
breath (acetone), dehydration
• Serum glucose >250 mg/dL, positive serum
ketones, serum pH <7.3, bicarbonate
<15 mEq/L, anion gap >12
Hyperosmolar Nonketotic Coma (HONK)
Symptoms and Laboratory Findings
• Elderly type 2 patients with infection or illness, weight loss, dehydration, polyuria,
polydipsia
• Serum glucose>400 mg/dL, 300-400
mOsm , lactic acidosis, small to moderate
ketones
Monitoring
• BG: Check every 30-60 minutes
• Electrolytes: Check every 1-2 hours during
first 8 hors of therapy, every 4 hours
thereafter
• Acidosis: Consider checking venous blood
gases every 2-4 hours until serum pH>7.0
Initiate Potassium Replacement
• Normal potassium level: Start 20 mEq/L
KCl with IV replacement fluids
• Hypokalemia: Start 40 mEq/L KCl with IV
replacement fluids
• No potassium replacement is indecated with
Chronic renal disease, no urine output, or
initial potassium >60 mEq/L
Additional lectrolyte Replacement
• Phosphate: Required only if phosphate
<1.5 mg/dL, replace with potassium
phosphate
• Magnesium: For mild hypomagnesemia
(1-1.5) give 16-24 mEq magnesium sulfate
over 8 hours in IV fluids; for severe hypomagnesemia (<1.0) give 32-48 mEq magenesium sulfate over 24 hours in IV fluids
• Bicarbonate: Rarely required, consider for
severe acidosis (serum pH <7.0)
When bicarbonate level is normal and patient
is capable of eating, resume diabetes regimen
YES
Determine cause of DKA:
• Infection (UTI, sinus or gum infections, etc.)
• Patient not taking insulin (enpecially common in adolescent patients with adherence
issuec)
• Insulin pump malfunction or improper use
• Degraded insulin from improper storage or
insulin past expiration date
• Acute illness or events
Determine cause of HONK
• Patient not taking medication
• Intercurrent event (MI)
• Infection (foot ulcer)
• Degraded insulin from inproper storage or
insulin past expiration date
• New treatment started recently that may
elevate glucose (steroids, tube feeding)
Changes in Diabetes Therapy for Poor Control Treatment/Inpatient
Reason for Admission
Hypoglycemia
BG <50 mg/dL
Poor Control
BG >400 mg/dL
Hyperosmolar
Nonketotic Coma
(HONK)
142
Type 2 Diabetes
Changes to Current Therapy When Admitted for Poor Control
Medical Nutrition
Oral Agent
Insulin
Therapy
Rare-modify food plan Consider lowering dose, Consider lowering dose,
changing to non-hypoincreasing number injection
to spread insulin out,
glycemic agent (Metor switching to nonformin, Thiazolidinedione, Alpha-glucosidase hypoglycemic oral agent
inhibitor) or switching to
medical nutrition therapy
Consider changing to
Start insulin therapy,
Intensify insulin
consider combination
oral agent
therapy
oral agents or insulin
at discharge
Address Cause of
Address cause of
Address cause of
HONK; consider oral
HONK; consider intenHONK; consider
agent or insulin therapy insulin therapy
sifying insulin therapy
Reason for Admission
Changes to Current Therapy When Admitted for Poor Control
Medical Nutrition Therapy
Insulin
Hypoglycemia
BG <50 mg/dL
Re-adjust and synchronize medical
nutrition therapy with insulin regimen
Adjust insulin therapy if not at
target, see SDM Detection and
Treatment Quick Guide
Poor Control
BG >400 mg/dL
Re-adjust and synchronize medical
nutrition therapy with insulin regimen
Intensify insulin therapy, see SDM
Detection and Treatment Quick Guide
DKA
Address Cause of DKA; re-adjust
and synchronize medical nutrition
therapy with insulin regimen
Address cause of DKA; intensify
insulin therapy, see SDM
Detection and Treatment
Quick Guide
IIIness Treatment/Inpatient
Patient hospitalized for non-surgical reasons
Is the patient NPO (nothing by mouth)?
NO
YES
• Start IV Regular insulin at 1.0 U/hour
0.5 U/hour for small or thin type 1 patients;
2.0 U/hour for type 2 patients taking more
than 100 U/day)
• Start IV glucose at 100 ml/hour of 5 or 10%
dextrose, 20 mEq/L KCl in 0.45% saline
• Monitor BG hourly
• Monitor ketones every 24 hours
• Set BG target range or 120-200 mg/dL
BG in target range of 120-200 mg/dL?
NO
YES
Patient too ill to self manage:
• Adjust BG targets to 120-200 mg/dL to
avoid hypoglycemia
• May add insulin if needed
Patient able to self manage:
• Maintain current therapy and BG targets
• SMBG at least 4 times/day (pre-meal, 2
hours post-meal, and bedtime)
• Consider 3 AM SMBG
• May add insulin if needed
Maintain current therapy
Monitor BG hourly
1-43
BG <120 mg/dL?
YES
NO
Has BG dropped >100 mg/dL
in past hour?
NO
• If BG 200-250 mg/dL, increase insulin by
0.2 U/hour
• If BG >250 mg/dL, increase insulin by
0.6 U/hour
• Monitor BG hourly until target of 120-200
mg/dL achieved
When food tolerated, stop IV insulin and glucose; retrun to regular diabetes management
regimen (for patients restarting an insulin regimen; administer subcutaneous insulin while
maintaining IV insulin and dextrose for 30 minutes before stopping infusions); resume SMBG
as soon as possible
YES
Decrease insulin infusion rate based on BG:
100-120 mg/dL ฏ 0.6 U/hour; recheck BG
in 30 minutes
80-99
ฏ 1.0 U/hour; recheck BG
in 30 minutes
<80 mg/dL
Stop infusion, give amp
(25 ml) 50% Dextrose;
recheck BG in 30 minutes;
start infusion at reduced rate
Continue to monitor BG hourly
Continue current infusion rate
Changes in Diabetes Therapy for Illness/Inpatient
144
Changes in Diabetes Therapy for Illness in Patients Treated with Insulin
Medical Nutrition Therapy
Insulin
Type 1 Diabetes
Modify food plan to adjust for
changes in insulin regimen
Intensify insulin therapy if not at
target
Type 2 Diabetes
Modify food plan to synchronize
with changes in insulin regimen
Intensify insulin therapy if not at
target
Changes in Diabetes Therapy for Illness in Type 2 Diabetes (Non-insulin Treated)
Oral Agent
Medical Nutrition Therapy
Type 1 Diabetes
Consider changing to insulin
temporarily if entry fasting
BG >120 mg/dL or casual
BG >160 mg/dL
Start insulin therapy
Inpatient Surgery
Patient with type 1 or type 2 diabetes
admitted for surgery
Is the patient treated with insulin?
Patient Assessment
• Stop oral diabetes medications
Second generation sulfonylureas, stop on
the day of surgery
Chlorpropamide, stop 36-48 hours before
surgery
Metformin, stop before surgery
• If BG >250 mg/dL, start subcutaneous Regular
insulin (4-6 U)
• If BG >350 mg/dL, start IV insulin and IV
dextrose
• Obtain ECG
• Screen for albuminuria and serum creatinine
See Kidney Disease Assessment, 1-14
NO
YES
Is surgery planned?
YES
NO
Preoperative Assessment
• Determine insulin regimen; calculate current
insulin dose/day
• Obtain ECG
• Serum creatinine
• Screen for neuropathy (warn surgeon and
anesthesiologist if autonomic neuropathy present)
1-45
Emergency Surgery
• Assess urine ketones, plasma glucose, and pH
• Initiate IV saline
• Treat DKA before starting surgery if possible
• For major surgery, initiate IV insulin and IV
dextrose
• Monitor BG every 30-60 minutes; maintain at
120-200 mg/dL
See DKA and HONK Treatment, 1-41
Day of Surgery (Initiate insulin infusion or subcutaneous insulin therapy*)
• In surgery in morning, don’t give AM injection of intermediate or long-acting insulin
• Start IV glucose: 100 ml/hour of 10% dextrose, 20 mEq/L KCl in 0.45% saline
• Prepare IV insulin: 10U Regular insulin/100 ml saline
• Calculate starting insulin infusion rate based on current insulin dose/day:
If <20 U/day, start IV at 0.5 U/hour
If 20-50 U/day, start IV at 1.0 U/hour
If >50 U/day, start IV at 1.5 U/hour
• Monitor BG every 30-60 minutes; maintain at 120-200 mg/dL
Maintain current therapy
Monitor BG hourly during surgery
• If BG <120 mg/dL, decrease insulin infusion
rate
by 0.2-0.3 U/hour
• If BG 201-250 mg/dL, increase insulin infusion
rate by 0.3 U/hour
• If BG >250 mg/dL, increase insulin infusion
rate
by 0.6 U/hour
• Monitor BG hourly until target of 120-200
mg/dL
achieved
Post surgery
Monitor BG every 1-2 hours; adjust insulin infusion rate as required. When food tolerated, stop IV
insulin and dextrose; return to regular diabetes
management regimen
Resume SMBG as soon as possible
*Subcutaneous Insulin Therapy
• Administer1/2 daily dose of NPH or UL insulin
and 2-4 U of R insulin
• Initiate 5% dextroxe infusion, 100 ml/hour
• Monitor BG hourly; adjust dextrose infusion up
or down to maintain 120-200 mg/dL BG target
BG in target range of 120-200 mg/dL?
YES
NO
Changes in Diabetes Therapy in Preparation for Surgery
Planned Surgery
Emergency Surgery
146
Changes in Diabetes Therapy for Surgery in Type 2 Diabetes
Medical Nutrition
Oral Agent
Insulin
Therapy
Adjust to optimize conModify food plan
Intensify insulin
therapy if not at target
trol, may have to withaccording to
dose prior to surpreparation for surgery hold
(i.e. only clear liquids) gery
Closely monitor BG;
use insulin as required
Closely monitor BG;
use insulin as required
Closely monitor BG;
adjust insulin therapy if
not at target; consider
IV insulin and IV
glucose
Changes in Diabetes Therapy for Surgery in Type 1 Diabetes
Medical Nutrition Therapy
Insulin
Planned Surgery
Modify food plan according to
preparation for surgery (i.e.
only clear liquids)
Intensify insulin therapy if not at
target
Emergency Surgery
Modify food plan as required
Closely monitor BG; adjust insulin
therapy if not at target; consider IV
insulin and IV glucose