Transcript Diabetes Health Maintenance

Duke Internal Medicine Residency Curriculum
Diabetes Health Maintenance
Author: Laura Leigh Fitzpatrick, MD, MPH
Editor: Amy Shaheen, MD, Assistant Professor
of Clinical Medicine
Duke University Medical Center
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Duke Internal Medicine Residency Curriculum
Cardiovascular Considerations: Hypertension
• Diabetes increases the risk of coronary events
(2x in men; 4x in women).1
• Associated CV risk factors such as HTN,
dyslipidemia are partly responsible for the
increase in risk.
• Measure BP at every routine diabetes visit.1
• The ADA recommends a target BP goal of
<130/80 in pts with diabetes; This is consistent
with JNC VII recommendations, and supported
by K/DOQI and HOT trial. 1, 2, 3
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Cardiovascular Considerations: Hypertension (2)
• There is evidence to suggest moderate Na
dietary restriction, physical activity and weight
reduction improves BP control. 1
• Patients with sbp of 130-139 mm Hg and dbp
80-89 mm Hg can have lifestyle/ behavioral
therapy alone for up to 3 months, then
pharmacologic therapy if targets are not
achieved. 1
• Patients with DM and HTN should be treated with
an agent shown to decrease CVD events. (ACEI’s, ARB’s, beta-blockers, diuretics, CCB’s)1
• ACE-I’s/ ARB’s should be considered in patients
with evidence of proteinuria.
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Cardiovascular Considerations: Dyslipidemia
• The most common pattern of lipid elevation in patients
with diabetes is low HDL and high TG. LDL among pts
with DM is not markedly different than among patients
without diabetes. 4
• Primary therapy should be directed at LDL-c lowering.
• The ADA recommends “testing for lipid disorders at least
annually and more often if needed to achieve goals.” If
lipid values are low-risk, can test every 2 years. 4
• Goal LDL-c for pts with diabetes as recommended by
current ATP-III guidelines is 100. 5
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Cardiovascular Considerations: Dyslipidemia (2)
• -Several studies have suggested benefits to
further lowering among high-risk individuals:
– PROVE IT (2004) – randomized 4000 pts with ACS in
the prior 10 days to pravastatin 40 mg vs. atorvastatin
80 mg. LDL’s achieved were 95 (pravastatin group),
and 62 (atorvastatin group). Primary endpoints of
death, MI, revascularization were significantly reduced
at 2 years. 6
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Cardiovascular Considerations: Dyslipidemia (3)
– Heart Protection Study (2002)- Randomized about
20,000 pts with CAD, other arterial disease, and/or
diabetes to simvastatin 40 mg vs. placebo.
Simvastatin group had significant reductions in allcause mortality, MI, CVA and revascularization. Similar
reductions in relative risk occurred in groups
regardless of baseline LDL-c level. Those with LDL-c
>135, <116 or <100 achieved the similar benefits.
Those subgroups with combined CVD and diabetes had
the greatest risk reduction in outcomes. 7
• Until further data, controlling LDL-c to <100 in pts with
diabetes is firmly recommended. Strong consideration
should be given to placing pts on a statin to achieve LDL-c
to < 70.
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Cardiovascular Considerations: Smoking
Click here for an
enlarged .pdf
file of this table
Table from “Smoking and Diabetes 8
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Cardiovascular Considerations: Aspirin
• Primary Prevention –
– Subset of patients with diabetes from the Physicians’
Health Study showed a reduction in MI from 10% to
4% with low-dose aspirin therapy. 9
– The Early Treatment Diabetic Retinopathy Study
(ETDRS) included pts with diabetes (both with and
without CVD) randomized to ASA vs. placebo. Those
receiving aspirin had a significantly lower relative risk
of MI in 5 years of 0.72. 10
– The Hypertension Outcomes Treatment trial (HOT)
randomized patients with HTN to aspirin 75 mg vs.
placebo and found a 15% decrease in CV events and a
36% decrease in MI among those tx with aspirin. 7
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Cardiovascular Considerations: Aspirin (2)
• Secondary Prevention –
– The Antiplatelet Trial was a meta-analysis examining
patients with prior CVD, CVA/TIA or other vascular
disease (both diabetics and nondiabetics). There were
about 25% fewer incidents among those treated with
aspirin. 11
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Nephropathy
• Diabetes is the single most common cause of ESRD in
the U.S.
• 20-30% of patients with type 1 or type 2 diabetes
develop nephropathy
• a smaller proportion of those with type 2 progress to
ESRD.
• Native Americans, Hispanics and African Americans at
increased risk.
• The earliest evidence of nephropathy is
microalbuminuria. This progresses into clinical
albuminuria and overt nephropathy. ESRD develops in
50% of those with type 1 DM with overt nephropathy
over 10 yrs. The rate of this progression among type 2
DM is slower, with only 20% having overt nephropathy
progressing to ESRD over 20 yrs. 13
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Nephropathy (2)
• Recommendations:
– Optimize glucose control (both the DCCT and UKPDS
support this in reduction of microvascular
complications) 13, 14, 15
– Optimize blood pressure control. 13
– Perform an annual test for microalbuminuria in
patients with type 1 DM with disease >5 yrs, and in
type 2 DM patients starting at diagnosis. 13
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Nephropathy (3)
• Consider an ACE-I/ ARB among those with
microalbuminuria:
– 1.) Lewis et al. (1993) randomized pts with type 1 DM and
urinary protein excretion >500 mg/ day to captopril vs.
placebo. The rate of doubling of serum Cr was significantly
lower in the captopril group. Captopril treatment was also
associated with reduction in combined death, dialysis and
transplantation. 16
– 2.) Lewis et al. (2001) randomized 1715 pts with
hypertension and nephropathy (defined as urinary protein
excretion > 900 mg/ 24 hours and serum Cr between 1-3)
to amlodipine 10 mg vs. irbesartan 300 mg vs. placebo.
Composite end-point was doubling of baseline Cr,
development or ESRD or death from any cause. Risk of this
endpoint was lowest among those on irbesartan. This effect
was independent of BP reduction. 17
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Nephropathy (4)
• With the onset of overt nephropathy, initiate
protein restriction to:
– 0.8 g · kg-1 body wt · day-1 (10% of daily calories).
– Consider referral to a nephrologist when:
13
• either the GFR has fallen to <60 ml · min-1 · 1.73 m-2 or
difficulties have occurred in the management of
hypertension or hyperkalemia.13
• If ACE-I’s or ARB’s used, monitor for development of
hyperkalemia.
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Retinopathy
• Diabetic retinopathy is the most common cause of new
blindness among adults between 20-74 years. 18
• Laser photocoagulation surgery can reduce severe visual loss
from PDR. 19
• Progression of diabetic retinopathy from non-proliferative
(NPDR) to proliferative diabetic retinopathy (PDR) to progressive
visual loss and ultimately, blindness.
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Retinopathy (2)
• Recommendations
18:
– Refer for comprehensive dilated eye exam among type 1
patients within 3-5 yrs after onset of diabetes. Refer type 2
pts at diagnosis of DM.
– Following initial exam, repeat exam annually, less frequently
(q 2-3 yrs) with advice from eye professional in the setting
of normal exams. More frequent exams may be required if
retinopathy is progressing.
– Follow pregnant women with diabetes (not gestational)
closely with regard to eye examination. Have comprehensive
exam in 1st trimester and closely follow throughout
remainder of pregnancy.
– As always, tightly control blood pressure and glucose.
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Foot care
• Foot ulcers and amputations are a major cause of
morbidity and disability in patients with diabetes.
• Risk factors for amputation include 20:
–
–
–
–
–
–
–
–
peripheral neuropathy with loss of protective sensation
altered biomechanics (in the presence of neuropathy)
evidence of increased pressure (erythema, bleeding)
bony deformity
peripheral vascular disease
history of ulcers or amputation
severe nail pathology
additional risk factors include presence of diabetes>10 yrs,
male gender, poor glucose control, existing CV/ retinal/renal
complications.
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Foot care (2)
• Recommendations
20:
– annual foot exam, including assessment of sensation,
foot structure, pulses and skin integrity.
– Evaluate those with >=1 high-risk foot conditions
more frequently
– People with neuropathy should have a visual inspection
of their feet at each visit.
– Evaluation of sensation should be performed with the
Semmes-Weinstein 10-g monofilament.
– Patient education about risk factors and foot
management.
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Foot care (3)
• Here are some things to suggest to patients:
– check your feet every night for lesions (use a hand
mirror if necessary)
– consider moisturizing lotion for dry skin
– do not go barefoot/ sockfoot
– appropriate foot wear (avoid sandals without socks)
– do not trim calluses/ be careful with toenail cutting
– alert your doctor should you develop a lesion
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Immunizations
• Annually provide an influenza vaccine. 21
• Provide at least one lifetime pneumococcal
vaccine. A one-time revaccination is
recommended for individuals >64 years of age
previously immunized when they were <65
years of age if the vaccine was administered >5
years ago. Other indications for repeat
vaccination include nephrotic syndrome, chronic
renal disease, and other immunocompromised
states. 21
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Clinical Vignette
A 54 y.o. white female with history of GERD, fibromyalgia and
hypertension presents to your clinic complaining of fatigue,
malaise for 3 months. She denies myalgias or arthralgias. She
does not smoke or drink alcohol. Her medications include
amitryptiline 50 mg qhs, HCTZ 25 mg qd, amlodipine 10 mg qd,
and pantoprazole 40 mg qd. She reports unusual thirst and
blurred vision. She denies family history of diabetes, and states
her mother had an MI at age 43. BP- 154/ 92, P- 80, regular,
calculated BMI- 34. On exam, she is well-appearing and anxious.
Exam is otherwise unremarkable. A fasting blood sugar is 278,
and you regretfully inform her she has a diagnosis of diabetes.
Chem7 panel and CBC is WNL, U/A shows 1+ protein with a SG of
1.012 but is otherwise negative. A1c is pending.
What is the patient’s goal blood pressure?
(see next slide for answer)
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Clinical Vignette (2)
• Answer:
– 130/80 mmHg according to JNC VII
guidelines
– 125/75 if her proteinuria totals over 1g per
day
Vignette continued on the next slide
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Clinical Vignette (3)
You correctly decide she needs better
blood pressure control.
Should you start another medicine or ask her to try lifestyle modification
(diet and exercise)?
(see next slide for answer)
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Clinical Vignette (4)
•
Answer:
– With her bp of 154/ 92, you should start another
medicine, or increase the dose of an existing
medication (although this pt is on essentially maximal
doses of her bp meds. With a blood pressures
between 130-139/ 80-89, it is appropriate to
recommend lifestyle changes up to 3 months, then if
not successful add a bp agent.
What class of antihypertensives should you strongly consider using
in this pt? (see next slide for answer)
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Clinical Vignette (5)
• Answer:
– Given proteinuria, start an ACE-I.
What other medication would you strongly consider in this patient to reduce
her risk of CV events and why? (see next slide for answer)
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Clinical Vignette (5)
•
Answer:
– ASA 75mg – 162 mg daily, because she has other risk
factors for CV disease.
What other labwork do you need to more definitely outline her CV risk?
(see next slide for answer)
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Clinical Vignette (5)
• Answer:
– A fasting lipid panel, with strong consideration of
placing her on a statin if LDL > 70.
What other medication would you strongly consider in this patient to reduce
her risk of CV events and why? (see next slide for answer)
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References
1 “Hypertension management in adults with diabetes”. Position Statements, American Diabetes Association. Diabetes
Care 2004; 27 S65-S67.
2 Chobanian et al. “Seventh report of the joint national committee on prevention, detection, and treatment of high blood
pressure”. Hypertension 2003; 42: 1206-1252.
3 Hansson et al. “Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension:
principal results of the Hypertension Optimal Treatment (HOT) randomized trial”. Lancet 1998 Jun
13;351(9118):1755-62
4 “Dyslipidemia management in adults with diabetes”. Position Statements, American Diabetes Association. Diabetes
Care 2004; 27 S68-71.
5 Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and
treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143.
6 Cannon et al. N Engl J Med 2004 Apr 8;350(15):1495-504.
7 Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebocontrolled trial. Lancet 2002 Jul 6;360(9326):7-22.
8 “Smoking and diabetes”. Position Statements, American Diabetes Association. Diabetes Care 2004; 27 S74-75.
9 Final report on the aspirin component of the ongoing Physicians’ Health Study Research Group. N Engl J Med
321:129–135, 1989.
10 The ETDRS Investigators: Aspirin effects on mortality and morbidity in patients with diabetes mellitus: Early
Treatment Diabetic Retinopathy Study report 14, JAMA 268:1292–1300, 1992.
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References (2)
11 “Collaborative overview of randomized trials of antiplatelet therapy-I: prevention of death, myocardial infarction, and
stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration.” BMJ
308:81–106, 1994.
12 “Aspirin therapy and diabetes”. Position Statements, American Diabetes Association. Diabetes Care 2004; 27 S7273.
13 “Nephropathy in diabetes”. Position Statements, American Diabetes Association. Diabetes Care 2004; 27 S79-83.
14 DCCT
15 UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular
complications in type 2 diabetes: UKPDS 38. BMJ 317: 708–713, 1998
16 Lewis EJ, Hunsicker LG, Bain RP, and Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic
nephropathy. The Collaborative Study Group. N Engl J Med 329:1456–1462, 1993.
17 Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, Ritz E, Atkins RC, Rohde BS, Raz I: Renoprotective
effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Eng
J Med 345:851–860, 2001.
18 Fong et al. “Nephropathy in diabetes”. Position Statements, American Diabetes Association. Diabetes Care 2004; 27
S84-87.
19 Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study
(DRS) findings, DRS Report Number 8. The Diabetic Retinopathy Study Research Group. Ophthalmology 1981
Jul;88(7):583-600.
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References (3)
20 “Preventive foot care in diabetes”. Position Statements, American Diabetes Association. Diabetes Care 2004; 27 S63-64.
21 “Influenza and pneumococcal immunization in diabetes”. Position Statements, American Diabetes Association. Diabetes Care
2004; 27 S111-113.
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