Transcript Diabetes: Guideline

A 42-year-old asymptomatic man
with hypertension presents for his
annual physical examination.
His medications include atenolol
combined with chlorthalidone (at
doses of 50 mg and 25 mg per day
Both parents had type 2 diabetes
mellitus later in life
.
He does not smoke cigarettes. His
body-mass index (BMI, the weight in
kilograms divided by the square of
the height in meters) is 32.3, and his
blood pressure is 130/80 mm Hg
. Would you screen the patient for
diabetes, and if so, how?
American Diabetes Association
Recommendations for the Screening of
Asymptomatic Persons for Diabetes.*
Screen beginning at 45 yr of age, at
least every 3 yr
Screen at any age and more frequently
if the body-mass index is 25 or more
and if the person has at least one
additional risk factor
Family history of diabetes (firstdegree relative)
High-risk race (e.g., black, Native
American, Asian, and Pacific Islander)
or ethnic group (Hispanic
Glycated hemoglobin level of 5.7% or
more or impaired fasting glucose or
impaired glucose tolerance on previous
testing
History of gestational diabetes or
delivery of a baby weighing more
than 9 lb (4.1 kg)
The polycystic ovary syndrome
Hypertension (blood pressure
≥140/90 mm Hg; or therapy for
hypertension
History of cardiovascular disease
HDL cholesterol level of less than 35
mg per deciliter, triglyceride level of
more than 250 mg per deciliter or both
Physical inactivity
Other clinical conditions associated
with insulin resistance (e.g., severe
obesity and acanthosis nigricans
Summary: Risk Factors for Type 2 Diabetes
•
•
•
•
•
•
•
•
•
Age ↑
• Dietary Factors
– Carbohydratess ↓
Family History / genetics ↑
– Fats ↑↓
Gestational Diabetes ↑
– Glycemic load ↑
Obesity / fat distribution ↑
– Cereal fiber / whole grain
Physical Activity / fitness ↓
↓
– Dairy products ↓
Smoking ↑
– High fructose corn syrup
Very low birth weight ↑
↑
Depression ↑
– Sugar-sweetened
bevarages ↑
Antipsychotic medications
– Alcohol ↓
↑
– Coffee ↓
• Anti-Retrovial therapy ↑
: AACE Diagnostic Criteria
Glucose Testing and Interpretation
Criteria for the Diagnosis of Diabetes
A1C ≥6.5%
OR
Fasting plasma glucose (FPG)
≥126 mg/dL (7.0 mmol/L)
OR
2-h plasma glucose ≥200 mg/dL
(11.12 mmol/L) during an OGTT
OR
A random plasma glucose ≥200 mg/dL (11.1
mmol/L)
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.
Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG)
≥126 mg/dL (7.0 mmol/L)
Fasting is defined as no caloric
intake
for at least 8 h*
*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.
Criteria for the Diagnosis of Diabetes
2-h plasma glucose ≥200 mg/dL
(11.1 mmol/L) during an OGTT
The test should be performed as described
by the WHO, using a
glucose load containing the equivalent
of 75 g anhydrous glucose
dissolved in water*
*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.
Criteria for the Diagnosis of Diabetes
In a patient with classic symptoms of
hyperglycemia or hyperglycemic crisis,
a random plasma glucose ≥200 mg/dL)
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.
Criteria for the Diagnosis of Diabetes
A1C ≥6.5%
The test should be performed in a
laboratory using a method that is
NGSP certified and standardized
to the DCCT assay*
*In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.
The diagnosis requires confirmation by
the same or the other test.
Prediabetes: IFG, IGT, Increased A1C
Categories of increased risk for diabetes
(prediabetes)*
FPG 100–125 mg/dL (5.6–6.9 mmol/L): IFG
OR
2-h plasma glucose in the 75-g OGTT
140–199 mg/dL (7.8–11.0 mmol/L): IGT
OR
A1C 5.7–6.4%
*For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately
greater at higher ends of the range.
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 3.
AACE Recommendations for
A1C Testing
• A1C may be misleading in some clinical
settings
–
–
–
–
–
–
Hemoglobinopathies
Iron deficiency
Hemolytic anemias
Thalassemias
Spherocytosis
Severe hepatic or renal disease
• AACE/ACE endorse the use of only
standardized, validated assays for A1C
testing
27
AACE. Endocrine Pract. 2010;16:155-156.
AACE Recommendations for
A1C Testing
• A1C should be considered an additional optional
diagnostic criterion, not the primary criterion for
diagnosis of diabetes
• When feasible, AACE/ACE suggest using
traditional glucose criteria for diagnosis of diabetes
• A1C is not recommended for diagnosing type 1
diabetes
• A1C is not recommended for diagnosing
gestational diabetes
28
AACE. Endocrine Pract. 2010;16:155-156.
, for every 25-32mg/dL in increase
blood glucose levels, there is a 1%
increase in HbA1c in patients But
without any hematologic variants. 3 with
patients who do have any hematologic
disorders, this corresponding increase
in HbA1c does not occur.
low values may occur in patients with
certain hemoglobinopathies e.g., sickle
cell disease and thalassemia) or who
have increased red-cell turnover
hemolytic anemiaand spherocytosis) or
stage 4 or 5 chronic kidney disease,
especially if the patient is receiving
erythropoietin
In contrast, falsely high glycated
hemoglobin levels have been reported
in association with iron deficiency and
other states of decreased red-cell
turnover
Glycated hemoglobin
Fasting not required, low biologic variability,
marker of long-term glycemia, stable during
acute illness, sample stability in vial global,
standardization, close association of results
with complications
A1C ~ “Average Glucose”
A1C
%
6
6.5
7
7.5
8
8.5
9
9.5
10
eAG
mg/dL
126
140
154
169
183
197
212
226
240
mmol/L
7.0
7.8
8.6
9.4
10.1
10.9
11.8
12.6
13.4
Formula: 28.7 x A1C - 46.7 - eAG
American Diabetes Association
A fasting glucose level of 100 to 125
mg is consistent with prediabetes; the
range of glycated hemoglobin levels
that are diagnostic of prediabetes is
controversial, but the ADA
recommends a range of 5.7 to 6.4%
Oral glucose-tolerance test
Most sensitive test, earliest marker
of glucose dysregulation
Fasting required, substantial biologic
variability, poor reproducibility from day to
day , lack of association of results with
complications over time, sample instability
in vial more time required, inconvenience,,
higher cost, lack of global standardization
of plasma glucose measurements
Advantage of GTT
• Test allowed established whether has
an n GTTor unkown type 2 diabetes
It disclosed wheathera subject has
prediabetes
Approximately40%of subjects who will
develo diabetes with the NGT
OGTT detectsdiabetes more efficiently
thanFBS
• Sbject withFBS >100in GTT(60%)had
2hpg <140
• Subject withFBS <100 (14%)had
2hpg>.140
• Testing of glycated hemoglobin or
fasting plasma glucose appears to
identify different groups of patients with
diabetes and prediabetes, yet both
tests identify patients at similar risk for
adverse sequelae.
Longitudinal investigations have shown that
persons categorized as being “impaired” by
any of these definitions have approximately
a 5 to 10% annualized risk of diabetes, a
risk that is greater by a factor of
approximately 5 to 10 than that normal
glucose tolerance or normal fasting glucose
.
Risks appear to be similar among
persons with isolated impaired fasting
glucose (i.e., without impaired glucose
tolerance) and isolated impaired
glucose tolerance (without impaired
fasting glucose). However, the
proportion of patients with impaired
glucose tolerance tends to be greater
than that with impaired fasting glucose
in most populations
Persons with both impaired fasting
glucose and impaired glucose tolerance
have a higher risk of diabetes
(approximately 10 to 15% per year)
than those with only one abnormality.
Whereas both prediabetic states are
associated with increased total and
cardiovascular mortality, impaired
glucose tolerance tends to be a better
predictor than impaired fasting glucose.
Persons with both impaired fasting
glucose and impaired glucose tolerance
have a higher risk of diabetes
(approximately 10 to 15% per year)
than those with only one abnormality.
Whereas both prediabetic states are
associated with increased total and
cardiovascular mortality, impaired
glucose tolerance tends to be a better
predictor than impaired fasting
glucose.14
Type 2 Diabetes Screening in
Children/Adolescents
• Overweight
-BMI >85th percentile
-weight for height >85th percentile
-weight >120% of ideal for height
• Plus any two of the following risk factors….
Type 2 Diabetes Screening in
Children/Adolescents
• FH of type 2 diabetes in 1st or 2nd-degree relative
• Race/ethnicity (Native American, African American,
Latino, Asian American,Pacific Islander)
• Signs of insulin resistance or conditions associated with
insulin resistance
(acanthosis nigricans, hypertension, dyslipidemia,
PCOS, or small-for -gestational-age (SGA) birth weight)
• Maternal history of diabetes or GDM during gestation
Diabetes Care 34:Supplement 1, 2011
Type 2 Diabetes Screening for
Children/Adolescents
• Age of initiation: at-risk age 10 years or if
younger onset puberty
• Screen every 3 years
• No screening recommended for Type 1
Diabetes in asymptomatic individuals
outside of research protocols
Gestational Diabetes (GDM)
• Screen for type 2 diabetes first prenatal visit if
risk factors
• Not known to have diabetes, screen for GDM at
24 –28 weeks of gestation
• Screen women with GDM for persistent
diabetes 6–12 weeks postpartum
• Women with a history of GDM lifelong
screening for diabetes or prediabetes at least
every 3 years (up to 7x higher
risk
than1,nonDiabetes Care
34:Supplement
2011
Lancet, 2009, 373(9677): 1773-9
Diabetes Care 21(2):B161–B167, 1998
GDM)
Diabetes Care 2010; 33: 676–682
Screening for and Diagnosis of GDM
• Perform a 75-g OGTT, with plasma glucose
measurement fasting and at 1 and 2 h, at
24–28 weeks of gestation in women not
previously diagnosed with overt diabetes
• Perform OGTT in the morning after an
overnight fast of at least 8 h
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2013;36(suppl 1):S15; Table 6.
• GDM diagnosis: when any of the
following plasma glucose values are
exceeded
–Fasting ≥92 mg/dL (5.1 mmol/L)
–1 h ≥180 mg/dL (10.0 mmol/L)
–2 h ≥153 mg/dL (8.5 mmol/L)
Gestational Diabetes (GDM)
•
•
•
•
Overnight fast, 75g OGTT
Fasting >92 mg/dl
1h
>180 mg/dl
2h
>153 mg/dl
Diabetes Care 34:Supplement 1, 2011
Diabetes Care 2010; 33: 676–682
OGTT Levels for Diagnosis of Gestational Diabetes
**Carpenter and Coustan Conversion, some labs use different numbers.
Fasting, before drinking
glucose
95 or above
92 or above
1 hour after drinking
glucose
180 or above
180 or above
2 hours after drinking
glucose
155 or above
153 or above
3 hours after drinking
glucose
140 or above
Not used
Requirements for
Diagnosis
TWO or more of the
ONE or more of the
above levels must be met above levels must be met
Classification of Diabetes
• Type 1 diabetes
– β-cell destruction
• Type 2 diabetes
– Progressive insulin secretory defect
• Other specific types of diabetes
– Genetic defects in β-cell function, insulin action
– Diseases of the exocrine pancreas
– Drug- or chemical-induced
• Gestational diabetes mellitus (GDM)
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11.
Classification of Diabetes
• Type 2 diabetes
– Progressive insulin secretory defect
• Other specific types of diabetes
– Genetic defects in β-cell function, insulin
action
– Diseases of the exocrine pancreas
– Drug- or chemical-induced
• Gestational diabetes mellitus (GDM)
•ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11.
Type 1
Blood Pressure
• Done at every visit
• Target is <130/<80
• ACE inhibitors typically first line
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Children with DM
Hypertension and Lipids
• Lipids: start screening in childhood if
strong FH, or at age 10
• Hypertension: BP >90th percentile for
height and weight or >130/>80
• Consider medications (statins, ACE) if
necessary
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Lipids (Cholesterol)
• Fasting lipid panel at least annually
• Goals:
Total cholesterol <200
Triglycerides
<150
HDL
>40 men, >50 women
LDL
<100 (<70, CVD or high risk)
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Aspirin
• Men >50 years of age
• Women >60 years of age
• Younger if higher risk
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Nephropathy (Kidney Disease)
Screening
• Annual urine testing for
micro- or macro- albuminuria
• Annual creatinine and GFR
• Start at diagnosis for type 2
• Start 5 years after diagnosis type 1
Diabetes Care. 2011;34(suppl 1)
Retinopathy Screening
• Type 1 annual starting after age 10 or after
5 years post diagnosis
• Type 2 annual starting shortly after
diagnosis
• Consider less frequent if one or more
normal exams (not usually done)
Diabetes Care. 2011;34(suppl 1)
Neuropathy Screening
•
•
•
•
Screen at diagnosis and annual thereafter
Filament testing
Vibratory testing
Reflexes
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Celiac Disease Screening
• At diagnosis in Type 1 and periodic (?), pregnant
• Rescreen if GI symptoms, failure to thrive,
glycemic control changes
• ~10% of type 1?
Test:
• Tissue transglutaminase IgA and IgG
Or
• Anti-endomysial antibiodies with serum IgA
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Thyroid Screening
• Type 1 screen at diagnosis and every
1 to 2 years, pregnant
• At diagnosis, thyroid peroxidase and
thyroglobulin antibodies
• TSH thereafter
Other Screening/Interventions
• Tobacco cessation
• Smoking contributes to poor glucose
control and increased CVD risk
• Smokers should be directed to a cessation
program, i.e., Quitline, Quitnet, Quitplan,
3rd party payer, etc.
• Medication(if appropriate)
• Other routine screens (i.e.,cancer)
All diabetes and IGT
2003
2025
Total population (millions)
544.6
839.2
Adult population (millions) (20-79
years)
276.0
493.6
Diabetes prevalence (%) (20-79 years)
7.0
8.0
Diabetes number (millions) (20-79
years)
19.2
39.4
IGT prevalence (%) (20-79 years)
6.8
7.4
IGT number (millions) (20-79 years)
Type 1 diabetes (0-14 years)
18.7
2003
36.5
Child population (millions)
205.8
Type 1 diabetes prevalence (%)
0.02
Type 1 diabetes number (thousands)
46.5
Diabetes Pyramid of Prevention
Adult Prevalence
7.6%
Goal / Intervention Tier
Diabetes
2.6%
Undiagnosed DM
~12-15%
Very High Risk
(A1c > 5.7%; IGT; GDM)
~15-20%
High Risk (FPG > 100);
Central Obesity; HTN, age
Moderate Risk
~57%
Low Risk
Prevent Morbidity
Detect Early
What type of
intervention
for what
level of risk?
Prevalence of Diabetes and its
risk factors in Iran
Methods:
• Conducted in 2007
• 5,287 Iranian citizens included
• Sample size aged 15–64 years
2.5 million Iranian
Results:
• Diabetes
8.7%
• Hypertension
26.6%
• Obesity
22.3%
• Central obesity
53.6%
Esteghamati A, et al. Third national surveillance of risk factors of non-communicable diseases (SuRFNCD-2007) in Iran: methods and
results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health. 2009 May 29;9:167
Epidemiology
Prevalence
2-3 million
Incidence
124000
Blindness
9500
Dialysis
1000
Amputation
5700
MI
20000
CV
25000
Hypertension
62000
Death
40000
Complications
Heart disease and stroke
In 2004, heart disease was noted on 68% of
diabetes-related death certificates among
people aged 65 years or older.
In 2004, stroke was noted on 16% of
diabetes-related death certificates among
people aged 65 years or older.
.
Adults with diabetes have heart disease
death rates about 2 to 4 times higher
than adults without diabetes.
The risk for stroke is 2 to 4 times higher
among people with diabetes
Cardiac Complications
25.00%
21.80%
20.00%
15.00%
15.00%
10.00%
7.90%
5.00%
0.00%
Angina
ECG+ve
H.F-Arryth
High blood pressure
In 2005-2008, of adults aged 20 years
or older with self-reported diabetes,
67% had blood pressure greater than
or equal to 140/90 mmHg or used
prescription medications for
hypertension.
Systolic Blood Pressure
0.50%
2.80%
20.70%
22.30%
130 mm Hg
>200
200
180
150
< 130
53.70%
Diastolic Blood Pressure
0.70%
4.50%
12.10%
18.10%
80 mm Hg
> 120
110
64.60
%
100
90
< 80
Retinopathy (in 1173 patients )
- Free
- Back ground
- Proliferative
68.9 %
22.6 %
9.5 %
Blindness
Diabetes is the leading cause of new
cases of blindness among adults aged
20–74 years.
(28.5%) people with diabetes aged 40
years or older had diabetic retinopathy,
and of these, almost 0.7 million (4.4%
of those with diabetes) had advanced
diabetic retinopathy that could lead to
severe vision loss.
Kidney disease
Diabetes is the leading cause of kidney
failure, accounting for 44% of new
cases in 2008.
.
Nervous system disease
(Neuropathy)
About 60% to 70% of people with
diabetes have mild to severe forms of
nervous system damage.
Amputation
More than 60% of nontraumatic lowerlimb amputations occur in people with
diabetes.
.
Prevalence of foot
complications
1- Fungus infection
2- Foot ulcers
3- Evident Ischaemic changes
4- Amputations
5- Deformities
= 22.0
= 6.8 %
= 9.7 %
= 3.0 %
= 1.0 %
Hospitalization: 3 times
Mortality: 3-4 times
Diabetes care costs: 2.5 times
Cost of Diabetes
Updated March 6, 2013
$245 billion: Total costs of diagnosed
diabetes in the United States in 2012
$176 billion for direct medical costs
$69 billion in reduced productivity
Table: Prevalence, awareness, treatment, and control rate of
hypertension, dyslipidaemia and diabetes: Isfahan Healthy
Heart Programmed study
Condition
treatment %
(% total)
Hypertension
87.7 (35.3)
Dyslipidaemia
49.7 (7.1)
Diabetes mellitus
84.7 (46.2)
Table: Prevalence, awareness, treatment, and control rate of
hypertension, dyslipidaemia and diabetes: Isfahan Healthy
Heart Programmed study
Condition
awareness %
Hypertension
40.3
Dyslipidaemia
14.4
Diabetes mellitus
54.6
Post Prandial Hyperglycemia
- Controlled < 160 mg/dl
- Accepted 161-180 mg/dl
Total
= 13.5 %
= 7.9 %
= 21.4 %
- Uncontrolled ( >180 mg/dl )
= 78.6 %
* Moderate
-220 mg/dl = 17.4 %
* Severe
- 260 mg/dl = 16.0 %
* Very Severe > 260 mg/dl = 45.2 %
Hyperglycemia
Fasting
20.80%
12.50%
> 220
200-220
151-200
31.30%
121-150
-120
15.60%
19.80%
120 mg/dl
How well are diabetic risk factors controlled in
Iran?
Measured in the
previous year
Patients at goal
HbA1c
6.4%
1.1%
Lipids
25.7%
NA
Delaveri A.,Archives of Iranian Med 2009;12:492-495
Lipid Control
Serum Cholesterol
10.40%
33.20%
200 mg
>250
201-250
-200
56.40%
Lipid Control
Serum Triglycerides
7.20%
9.10%
33.30%
150 mg
> 250
201-250
151-200
-150
50.40%
Colum n
1
Costs of Diabetes
Indirect
Direct
~2.3 times more
than medical
costs of people
without diabetes
107
CDC. National diabetes fact sheet, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.