Transcript Diabetes Mellitus 101 for Cardiologists, Part 1

Diabetes Mellitus 101 for
Cardiologists (and Alike): 2015
An Aggressive Pathophysiologic Approach to Therapy of Type 2 Diabetes
in Cardiometabolic Patients:
Looking at Diabetes Medications with a Cardiologist’s Eye
Part 1
Stan Schwartz MD,FACP
Affiliate, Main Line Health System
Emeritus, Clinical Associate Professor of Medicine,
U of Pa.
6105472000
Lecture Based on Evidence-Based PRACTICE
Has Led to Students/MDs who dont ThinkEg: if no evidence, continue doing same old dangerous
therapy (SU);
Specialists are abrogating their responsibility to evaluate and lead
in use of new medications, processes of care
EBM=Evidence
=
Based Medicine
+
EBM=Evidence
Based Medicine
Research Evidence
Randomized, Prospective
Publication Trials
Critical Appraisal
+
Patient-Based
Experience
Clinical expertise
Expert Opinions
Guidelines
= Evidence
Based
Practice
Duggal, Evidence-Based Medicine in Practice,, Int’l j. Clinical Practice,65:639-644,2011
Allan D. Sniderman, MD; Kevin J. LaChapelle, MD; Nikodem A. Rachon, MA;
and Curt D. Furberg, MD, PhDMayo Clin Proc The Necessity for Clinical Reasoning in the
Era of Evidence-Based Medicine October 2013;88(10):1108-1114
Trisha Greenhalgh et al, Evidence based medicine: a movement in crisis? BMJ 2014; 348
Natural History of Type 2 Diabetes
Age
0-15
Genes
15-40+
15-50+
25-70+
Envir.+
Other
Disease
Macrovascular Complications
Insulin
Resistance
Obesity (visceral)
IR phenotype
Poor Diet
Inactivity
Atherosclerosis
obesity
hypertensionHDL,TG,
HYPERINSULINEMIA
MI
CVA
Amp
Endothelial dysfunction
pp>7.8
PCO,ED
 Beta Cell
Secretion
Risk of Dev.
Complications
Disability
IGT
ETOH
BP
Smoking
Eye
Nerve
Kidney
DEATH
Type II DM
Blindness
Amputation
CRF
Disability
Microvascular Complications
Pathogenic, β-CELL-CENTRIC Construct for All Diabetes
Implications for Classification, Diagnosis, Prevention, Therapy, Research
E
P
I
G
E
N
I
T
I
C
S
Environmental Inflam. Triggers
eg: viral,endocrine disruptors, food AGE’s,
BIOME
Resistance (obesity)
inflammatory adipokines
Polygenic-
Gene
E
P
I
G
E
N
I
T
I
C
S
Inflammatory;
Abnormal Immune
Modulation
other
Monogenic (HLA)
Polygenic
Monogenic - MODY
β-Cell PHENOTYPE
secretion/mass
− Mitochondrial
Resistance-(obesity)FFA
Poor diet, inactivity
endocrine disruptors, food AGE’s ,BIOME
Environmental Triggers
Non
Inflammatory
Why Bother to Treat
Agressively?
From: Trends in Prevalence and Control of Diabetes in the United States, 1988–
1994 and 1999–2010 Trends in Prevalence and Control of Diabetes in the United
States
Figure Legend:
Prevalence of total confirmed diabetes and obesity.
Data from U.S. adults aged ≥20 y in NHANES 1988–1994, 1999–2004, and 2005–2010. Total confirmed diabetes was defined as diagnosed diabetes or
undiagnosed diabetes with diagnostic levels of both hemoglobin A1c (≥6.5%) and fasting glucose (7.0 mmol/L [≥126 mg/dL]). Obesity was defined as
body mass index ≥30 kg/m2; 601 persons were missing body mass index data. Prevalence estimates for total confirmed diabetes and obesity were
obtained using only the subsample of participants who attended the morning fasting session (7385 participants for 1988–1994, 5680 participants for
1999–2004, and 6719 participants for 2005–2010). The midpoint for obesity prevalence between 1988–1994 and 1999–2004 was calculated as the
average of the prevalence of the 2 periods. NHANES = National Health and Nutrition Examination Survey.
Ann Intern Med. 2014;160(8):517-525. doi:10.7326/M13-2411
Date of download: 4/17/2014
One third of adults with diabetes are
undiagnosed
 ~10% of US adults have diabetes/~20 million persons in 2005
 Nearly one third dont know they have diabetes
 26% of US adults have impaired fasting glucose (IFG)*
Total: 35% of US adults with diabetes or IFG
~73.3 million persons
*100–125 mg/dL
Cowie CC et al. Diabetes Care. 2006;29:1263-8.
NIDDK. National Diabetes Statistics. www.diabetes.niddk.nih.gov.
RISK OF UNRECOGNIZED HYPERGYCEMIA:
Effect of Hyperglycemia on Mortality, LOS,
ICU admission, D/C Disposition
FBS>126
Ppg>200
New
Hyperglycemia
Known Diabetes
Normo-Glycemia
#495 (26%)
#1168
#223 (12%)
Mortality, total
16
3
Mortality, ICU
31
11
Mortality, non-ICU
10
1.7
0.8
9
5.5
4.5
LOS
ICU Admission
1.7
10
29
14
9
Home
56
74
84
Transition Care
20
15
10
Nursing Home
8
9
4
D/c Dispo.
Umpierrez, JCEM 2002;87:978
Considering the Epidemic of Metabolic Syndrome,
Prediabetes, Prevention Data, Undiagnosed Diabetes-
ER Office and Pre-Admission
IDENTIFICATION IS CRITICAL!
• Family history: whether parents or siblings have had diabetes
• Obesity: especially with an increase in abdominal girth
• High-risk ethnic group: African Americans, Hispanics,
Native Americans, Asians, and Pacific Islanders
• Age: we’re looking at all ages, if patient seems at risk
• Impaired fasting glucose or impaired glucose tolerance
• Hypertension: blood pressure ≥ 140/90 mm Hg in adults
• High density lipoproteins < 35 mg/dL or triglyceride
levels ≥ 250 mg/dL
• Gestational diabetes or given birth to an infant
weighing > 9 pounds
• Pre-adm , pre-cath, pre-op , pre-CABG
FBS >100, ppg >140, POC HgA1c >6.0
Hyperglycemia Leads to Complications: May
Be Present Prior to Diagnosis
Hyperglycemia
Spike
(+variability)
PPG
Argument for Early Discovery
Pre-diabetes, Early Treatment,
Determine on Hospital
Admission
Acute toxicity
Continuous
A1C
Chronic toxicity
Tissue lesion
Diabetic complications
Microvascular
Retinopathy
Nephropathy
Macrovascular
Neuropathy
PVD
MI
Stroke
American Diabetes Association.
10 At: http://www.diabetes.org/diabetes-statistics/complications.jsp.
Brownlee M. Diabetes mellitus: theory and practice. Elsevier Science Publishing Co., Inc; 1990:279-291.
Ceriello A. Diabetes. 2005;54:1-7.