Transcript - Pakistan Society Of Chemical Pathology

Diabetes mellitus - Updates
Maj Gen Farooq Ahmad Khan HI(M)
MBBS, MCPS, Dip Endocrinol (Lond), FCPS, FRCP
(Ireland),
FRC Path (UK), PhD (Lond)
Professor of Pathology
Armed Forces Institute of Pathology
Rawalpindi
What is diabetes mellitus?
Diabetes mellitus is a chronic metabolic
disorder
characterized
hyperglycemia,
by
disturbances
persistent
of
carbohydrate, fat and protein metabolism
due to deficiency of insulin secretion or
insulin effect in the body.
Why Diabetes?
common
serious
Huge public health problem
costly
Controllable
DCCT: Results Summary
Characteristics of
Vulnerable and Stable Plaques
Large lipid core with thin
fibrous cap, macrophages
interacting with thrombus
Reduced lipid core with thick
fibrous cap reinforced with
increased smooth muscle cells
Thrombus
Lumen
Endothelium
Smooth
muscle cell
Lipid rich core
Thin
fibrous cap
Thick
fibrous cap
Platelets
Vulnerable Plaque
Macrophage
Stable Plaque
Vascular Risk Factors and Events
6
Major
vascular
events
4
2
0
Vascular risk factors
Colwell JA. Semin Thromb Hemost. 1991; 17: 439-444.
Top ten countries for estimated number of adults
with diabetes, 1995 and 2025
1995 (millions)
2025 (millions)
Rank
1
India
2
China
3
U.S.
4
Russian Fed.
5
Japan
6
Brazil
7
Indonesia
8
Pakistan
9
Mexico
10
Ukraine
All other countries
19.4
16.0
13.9
8.9
6.3
4.9
4.5
4.3
3.8
3.6
49.7
Total
135.3
India
China
U.S.
Pakistan
Indonesia
Russian Fed.
Mexico
Brazil
Egypt
Japan
57.2
37.6
21.9
14.5
12.4
12.2
11.7
11.6
8.8
8.5
103.6
300.0
Lifestyle Changes that
Promote Sedentary Behavior
Change in lifestyle & Obesity?
Classification of diabetes
 Type 1 diabetes
 β-cell destruction
 Type 2 diabetes
 Progressive insulin secretary defect
 Other specific types of diabetes
 Genetic defects in β-cell function, insulin action
 Disease of the exocrine pancreas
 Drug or chemical-induced
 Gestational diabetes mellitus
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S12.
Criteria for the diagnosis of
diabetes
 Fasting plasma glucose > 7.0 mmol/l (no caloric
intake for 8 h)
Repeat at interval of at least one week
OR
 Two-hour plasma glucose > 11.1 mmol/l on 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
Criteria for the diagnosis of
diabetes
 In a patient with classic symptoms of hyperglycemia,
a random plasma glucose > 11.1 mmol/L
OR
 A1C > 6.5%
The test should be performed in a laboratory using an
NGSP-certified method standardized to the DCCT
assay
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. .
Criteria for the diagnosis of Prediabetes
 Pre-diabetes: Categories of increased risk for
diabetes
 IFG :
FPG 5.6-6.9 mmol/l
Or
 IGT :
2-h plasma glucose in the OGTT 7.8-11.0 mmol/l
Or
 A1C :
5.7-6.4 %
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. .
Criteria for Testing for diabetes in
asymptomatic adult individuals
Testing should be considered in all adults who are overweight (BMI ≥25
kg/m2*) and have additional risk factors:
•
•
A1C ≥5.7%, IGT or IGF on previous •
Women who delivered a baby
testing
weighing > 9lb or were diagnosed
HDL cholesterol level 0.90 mmol/l
with GDM
and /or a triglyceride level ≥ 2.82
•
mmol/l
•
First degree relative with diabetes
•
Hypertension (≥140/90 mmHg or on
Women with polycystic ovarian
syndrome(PCOS)
•
Other
clinical
conditions
therapy for hypertension)
associated with insulin resistance
•
CVD history
(e.g. severe obesity, acanthosis
•
Physical inactivity
nigricans)
Criteria for Testing for diabetes in
asymptomatic adult individuals
 In the absence of risk factors testing for diabetes
should begin at age of 45 years
 If results are normal, testing should be repeated
at least at 3 years intervals, with consideration
of more frequent testing depending on initials
results and risk status
ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.
Diagnosis of GDM

Screen for undiagnosed type 2 diabetes at
the first prenatal visit in those with risk
factors, using standard diagnostic criteria
In pregnant women not previously known to
have diabetes, screen for GDM at 24-28
weeks gestation, using 75-g OGTT.
Diagnosis of GDM
 Perform a 75-g OGTT at 24-48 weeks gestation in
the morning and collect three samples after an
overnight fast of at least 8 h
 GDM diagnosis: when any of the following plasma
glucose values are exceeded
 Fasting 5.1 mmol/l
 1 h 10.0 mmol/l
 2 h 8.5 mmol/l
Screening & Diagnosis of
Diabetes
 Screen women with GDM for persistent
diabetes 6-12 weeks postpartum
 Women with a history of GDM should have
lifelong screening for the development of
diabetes or prediabetes at least every three
years
DIABETES CARE
Diabetes care: Initial Evaluation
 A
complete
medical
evaluation
should
be
performed to
 Classify the diabetes
 Detect presence of diabetes complications
 Review previous treatment, glycemic control in
patients with established diabetes
 Perform laboratory tests necessary to evaluate
each patient’s medical condition
Diabetes care: Initial Evaluation
 Medication history
 Age and characteristics of onset of diabetes
(e.g., DKA, asymptomatic laboratory finding)
 Eating
patterns, physical activity habits,
nutritional status and weight history; growth and
development in children and adolescents
 Diabetes education history
 Review of previous treatment regimens and
response to therapy (HbA1c records)
Diabetes care: Initial Evaluation
 Current
treatment
if
diabetes,
including
medications, meal plan, physical activity patterns
and results of glucose monitoring and patients
used of data
 DKA frequency, severity and cause
 Hypoglycemic episodes
 Hypoglycemia awareness
 Any severe hypoglycemia: frequency and cause
Diabetes care: Initial Evaluation
 History of diabetes-related complications
 Microvascular: retinopathy, nephropathy, neuropathy
 Sensory neuropathy, including history of foot lesions
autonomic neuropathy, including sexual dysfunction and
gastroparesis
 Macrovascular: CHD, cerebrovascular disease, PAD
 Other: psychosocial problems, dental disease
Diabetes care: Initial Evaluation
 Physical examination
 Height, weight, MBI
 Blood pressure determination
 Fundoscopic examination
 Thyroid palpation
 Skin examination (for acanthosis nigricans and
insulin injection sites)
Diabetes care: Initial Evaluation
 Physical examination (2)
 Comprehensive foot examination
 Inspection
 Palpation of dorsalis pedis and posterior tibial pulses
 Presence/ absence of patellar and achilles reflexes
 Determination
of
proprioception,
monofilament sensation
vibration
and
Comprehensive diabetes evaluation
 Laboratory evaluation
 Blood glucose fasting
 A1C, if results not available with in past 2-3 months
 Fasting
lipid profile, including total, LDL-and HDL-
cholesterol and triglycerides
 Liver function tests
 Spot urine albumin/ creatinine ratio
 Serum creatinine and calculated GFR
 TSH in type 1 diabetes, dyslipidemia or women > 50 years
of age
Glucose monitoring
 Self-monitoring of blood glucose should be carried
out 3+ times daily for patients using multiple insulin
injections or insulin pump therapy
 For patients using less frequent insulin injections,
noninsulin therapy, or medical nutrition therapy alone
 SMBG may be useful as a guide to success of therapy
“The past is a foreign country;
they do things differently there.”
Leslie Poles Hartley
Glucose Monitoring
Ancient method
Modern method
Glucose monitoring
• Home blood glucose meters measure the
glucose in whole blood, while most lab
tests measure the glucose in plasma
• Plasma glucose levels are generally 10%–
15% higher than glucose measurements in
whole blood
• Most of the modern meters on the market
give results as "plasma equivalent," even
though they are measuring whole blood
glucose
• Sample sizes vary from 30 to 0.3 μl
• Test times vary from 5 seconds to 2
minutes
CGMS
Continuous Glucose Monitoring System
• Test glucose in the IF
• Every few minutes for up
to 7 days alarm system
warns if glucose rapidly
changes real time results
Glucose monitoring - CGMS
• By analyzing the trends, the patient or
the physician can adjust insulin
• Leads to better glycemic control
Benefits of CGMS
• Increased
security
from
alarms & alerts Immediate
feedback - look and learn
• BG
trend
information
provides
more
than
static
readings
• Control + safety
Limitations of CGMS*
 Interference with glucose readings by sensor can
occur with certain substances

i.e.gluthatione, ascorbic acid, uric acid, salicylates – can cause cooxidation, which will lead to overestimation of glucose levels
 Lag-time for up to 15 minutes when glucose
changes rapidly
 Overall percentage of error – near 15%
• Guardian REAL-Time –
• DexCom • Navigator
17%
11-16%
12-14%
* E. Cenzic, MD and William tamboriane, MD. A Tale of Two Compartments: Interstitial Versus Blood Glucose Monitoring. DIABETES
TECHNOLOGY & THERAPEUTICS. Volume 11, September 2009.
Glucose Monitoring - CGMS
Abbott FreeStyle
Navigator®
Medtronic MiniMed
Paradigm® REAL-Time
DexCom™
SEVEN® PLUS
Insulin Delivery Modes
Insulin Pens/Devices
•Ease of handling
•More discrete use
Insulin Delivery Modes
Jet Injectors
• sends insulin through the skin , using high pressure mechanism
• an option for people with severe needle phobia
Insulin Delivery Modes
Insulin Pumps
•provide continues insulin delivery
•infusion site needs to be changed
only every 2-3 days
Pump Advantages
 More reliable, precise insulin action
 Fewer missed doses
 Less insulin stacking
 Fewer lows, especially at night
 Easier to exercise
 Less glucose exposure and variability
 Less insulin
 Matches variable basal insulin need
 Fewer social limitations
 Better data access for providers and patients
Future
“Prediction is very difficult,
especially about the future”.
Niels Bohr
 Pump technology continues to advance
 On the horizon:
 Pumping and monitoring by cell phone
 Cooler styles
 Smaller sizes
 Improved human interface
 More helpful data analysis
 Gradual progress toward a closed loop
Non-invasive Continuous Blood
Glucose Monitor
OrSense’s NBM-200G
 A highly sensitive optical system, using an array of calibrated
light sources, measures light absorption and scattering. The
desktop monitor calculates the glucose level and displays the
results.
 Exhibits comparable accuracy to invasive solutions, while
providing superior ease of use and safety
 Tested on over 450 subjects
 At this stage, the NBM 200G glucose monitor is utilized for
investigation and market awareness purpose only.
Glycemic Recommendations for Adults
with Diabetes
 Goals should be individualized based on
 Duration of diabetes
 Age/life expectancy
 Co-morbid conditions
 Known CVD or advanced micro-vascular complications
 Hypoglycemic unawareness
 Individual patient consideration
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
A1C Recommendation
 Perform A1C test at least twice yearly in patients
meeting treatment goals
 Perform A1C test quarterly in patients whose
therapy has changed or who are not meeting
glycemic goals
 Lowering
A1C
to
below
or
around
7%
is
recommended: shown to reduce macrovascular and
neuropathic complications of diabetes
Correlation
of
A1C
with
estimated average glucose (eAG)
A1C (%)
Mean plasma glucose
mmol/l
6
7.0
7
8.6
8
10.2
9
11.8
10
13.4
11
14.9
12
16.5
The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results
into
estimated
average
glucose
(eAG),
in
mmol/l,
is
available
at
http://professional.diabetes.org/GlucoseCalculator.aspx.
Recommendations:
Glycemic , blood, pressure, lipid
control in adults
A1C
< 7.0%
Blood pressure
< 130/80 mmHg*
LDL cholesterol
< 2.6 mmol*
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should
be individualized based on: duration of diabetes, age/life expectancy, comorbid conditions,
known CVD or advanced microvascular complications, hypoglycemia unawareness, and
individual patient considerations.
†Based on patient characteristics and response to therapy, higher or lower systolic blood
pressure targets may be appropriate.
‡In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a
high dose of statin, is an option.
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31. Table
12.
Diagnosing Metabolic Syndrome
According to the National Cholesterol Education Program (NCEP), the presence of
three or more of the following traits indicates metabolic syndrome:
 Waist Circumference
 Greater than 35 inches in women and 40 inches in men (abdominal obesity)
 Triglyceride
 Levels of 150 milligrams per deciliter (mg/dl) or higher
 Blood Pressure
 130/85 millimeters of mercury or higher
 Fasting blood glucose
 Level of 110 mg/dl or higher
 High-density lipoprotein cholesterol (HDL)
 Lower than 50 mg/dl in women and 40 mg/dl for men
Gelfand EV et al, 2006; Vasudevan AR et al, 2005
Treatment
PREVENTION AND MANAGEMENT
OF DIABETES COMPLICATION
Progression of diabetes
Diagnosis of
diabetes
•Genetic susceptibility
•Environmental factors
•Nutrition
•Obesity
•inactivity
•Insulin resistance
•HDL C
•Triglycerides
•Atherosclerosis
•Hypertension
Appearance of complications
Disability
IGT
Ongoing hyperglycaemia
- Hyperglycaemia
- PPG levels
-Retinopathy
-Nephropathy
Death
-Blindness
-ESRD/dialysis/transplantation
-CHD
-Stroke
-Amputation
Cardiovascular disease (CVD) in
individuals with diabetes
 CVD is a major cause of morbidity, mortality for
those with diabetes
 Common conditions coexisting with type 2 diabetes
(e.g., hypertension, dyslipidemia) are clear risk
factors for CVD
 Diabetes itself confers independent risk
 Benefits observed when individual cardiovascular
risk factors are controlled to prevent/slow CVD in
people with diabetes
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Hypertension
/ Blood pressure control
 Screening and diagnosis
 Measure blood pressure at every routine diabetes
visit
 If patients have systolic blood pressure
≥130 mmHg or diastolic blood pressure ≥80
mmHg
 Confirm blood pressure on a separate day
 Repeat systolic blood pressure ≥130 mmHg or diastolic
blood pressure ≥80 confirms a diagnosis of hypertension
(C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Hypertension
/ Blood pressure control
 Goals
 A goal systolic blood pressure <130 mmHg is appropriate
for most patients with diabetes ©
 Based on patient characteristics and response to therapy,
higher or lower systolic blood pressure targets may be
appropriate (B)
 Patients with diabetes should be treated to a diastolic blood
pressure <80 mmHg (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Hypertension
/ Blood pressure control
 Treatment (1)
 Patients with a systolic blood pressure 130–139
mmHg or a diastolic blood pressure 80–89 mmHg
 May be given lifestyle therapy alone for a maximum of 3
months
 If targets are not achieved, patients should be treated
with the addition of pharmacological agents
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Hypertension
/ Blood pressure control
 Treatment (2)
 Patients with more severe hypertension (systolic
blood pressure ≥140 mmHg or diastolic blood
pressure ≥90 mmHg) at diagnosis or follow-up
 Should receive pharmacologic therapy in addition to
lifestyle therapy (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Hypertension
/ Blood pressure control
 Treatment (3)
 Pharmacologic therapy for patients with diabetes and
hypertension
 Pair with a regimen that includes either an ACE inhibitor or
angiotensin II receptor blocker
 If one class is not tolerated, the other should be substituted
 If needed to achieve blood pressure targets
 Thiazide diuretic should be added to those with estimated GFR
≥30 ml x min/1.73 m2
 Loop diuretic for those with an estimated GFR <30 ml x min/1.73
m2
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
Recommendations: Dyslipidemia/
lipid management
 Screening
 In most adult patients
 Measure fasting lipid profile at least annually
 In adults with low-risk lipid values (LDL
cholesterol <100 mg/dl, HDL cholesterol >50
mg/dl, and triglycerides <150 mg/dl)
 Lipid assessments may be repeated every 2 years
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Dyslipidemia/
lipid management
 Treatment recommendations and goals (1)
 To improve lipid profile in patients with diabetes,
recommend lifestyle modification (A), focusing
on
 Reduction of saturated fat, trans fat, cholesterol intake
 Increased n-3 fatty acids, viscous fiber
 Weight loss (if indicated)
 Increased physical activity
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Dyslipidemia/
lipid management
 Treatment recommendations and goals (2)
 Statin therapy should be added to lifestyle
therapy, regardless of baseline lipid levels, for
diabetic patients:
 with overt CVD (A)
 without CVD who are >40 years of age and have one
or more other CVD risk factors (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Dyslipidemia/
lipid management
Treatment recommendations and goals (3)
 For patients at lower risk (e.g., without overt CVD
and <40 years of age) (E)
 Statin therapy should be considered in addition
to lifestyle therapy if LDL cholesterol remains
>100 mg/dl
 In those with multiple CVD risk factors
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Dyslipidemia/
lipid management
 Treatment recommendations and goals (4)
 In individuals without overt CVD
 Primary
goal
is
an
LDL
cholesterol
<100 mg/dl (2.6 mmol/l) (A)
 In individuals with overt CVD
 Lower
LDL
cholesterol
goal
of
<70
mg/dl
(1.8 mmol/l), using a high dose of a statin, is an option
(B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Dyslipidemia/
lipid management
 Treatment recommendations and goals (5)
 If targets not reached on maximal tolerated statin
therapy
 Alternative therapeutic goal: reduce LDL cholesterol
~30–40% from baseline (A)
 Triglyceride levels <150 mg/dl (1.7 mmol/l), HDL
cholesterol >40 mg/dl (1.0 mmol/l) in men and
>50 mg/dl (1.3 mmol/l) in women, are desirable
 However,
LDL cholesterol–targeted
remains the preferred strategy (C)
statin
therapy
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Dyslipidemia/
lipid management
 If targets are not reached on maximally tolerated
doses of statins
 Combination therapy using statins and other lipid
lowering agents may be considered to achieve
lipid targets
 Has not been evaluated in outcome studies for
either CVD outcomes or safety
 Statin therapy is contraindicated in pregnancy
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Recommendations: Coronary
heart disease screening
 In asymptomatic patients, routine screening
for CAD is not recommended, as it does not
improve outcomes as long as CVD risk
factors are treated (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S32.
Recommendations: Coronary
heart disease treatment (1)
 To reduce risk of cardiovascular events in patients
with known CVD, use
 ACE inhibitor*
 Aspirin*
 Statin therapy*
 In patients with a prior MI
 Beta-blockers should be continued for at least 2
years after the event
* If not contraindicated
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S32.
Recommendations: Nephropathy
 To reduce risk or slow the progression of
nephropathy
 Optimize glucose control (A)
 Optimize blood pressure control (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Recommendations: Nephropathy
Screening
 Assess urine albumin excretion annually
 In type 1 diabetic patients with diabetes duration
of 5 years
 In all type 2 diabetic patients at diagnosis
 Measure serum creatinine at least annually
 In all adults with diabetes regardless of degree of
urine albumin excretion
 Serum creatinine should be used to estimate
GFR and stage level of chronic kidney disease, if
present
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Recommendations: Nephropathy
Treatment (1)
 Nonpregnant
patient
with
micro-or
macroalbuminuria
 Either ACE inhibitors or ARBs should be
used
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Recommendations: Nephropathy
Treatment (2)
 In patients with type 1 diabetes, hypertension, and
any degree of albuminuria
 ACE
inhibitors have been shown to delay
progression of nephropathy
 In patients with type 2 diabetes, hypertension, and
microalbuminuria
 Both ACE inhibitors and ARBs have been shown
to delay progression to macroalbuminuria
ADA. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Recommendations: Nephropathy
Treatment (3)
 In
patients with type 2 diabetes, hypertension,
macroalbuminuria, and renal insufficiency (serum
creatinine >1.5 mg/dl)
 ARBs
have been shown to delay progression of
nephropathy
 If one class is not tolerated, the other should be
substituted
ADA. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Recommendations: Nephropathy
Treatment (4)
 Reduction of protein intake may improve measures of
renal function (urine albumin excretion rate, GFR) (B)
 To 0.8 –1.0 g x kg body wt–1 x day–1 in those with
diabetes, earlier stages of CKD
 To 0.8 g x kg body wt–1 x day–1 in later stages of CKD
 When ACE inhibitors, ARBs, or diuretics are used,
monitor
serum
creatinine,
potassium
levels
for
development of acute kidney disease, hyperkalemia
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Recommendations: Nephropathy
Treatment (5)
 Continue monitoring urine albumin excretion to assess
both response to therapy, disease progression (E)
 When eGFR <60 ml/min/1.73 m2, evaluate, manage
potential complications of CKD (E)
 Consider referral to a physician experienced in care of
kidney disease (B)
 Uncertainty about etiology of kidney disease
 Difficult management issues
 Advanced kidney disease
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Definitions of abnormalities in
albumin excretion
Category
Spot collection (µg/mg creatinine)
Normal
< 30
Microalbuminuria
30-299
Macroalbuminuria
≥ 300
(clinical)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
Management of CKD in diabetes (1)
GFR (ml/min/1.73 m2)
Recommended
All patients
Yearly measurement of creatinine, urinary albumin
excretion, potassium
45-60
Referral to nephrology if possibility for nondiabetic
kidney disease exists
Consider dose adjustment of medications
Monitor eGFR every 6 months
Monitor electrolytes, bicarbonate, hemoglobin, calcium,
phosphorus, parathyroid hormone at least yearly
Assure vitamin D sufficiency
Consider bone density testing
Referral for dietary counseling
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35. Table 15; Adapted from
http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.
Management of CKD in diabetes (2)
GFR (ml/min/1.73 m2)
Recommended
30-44
Monitor eGFR every 3 months
Monitor electrolytes, bicarbonate, calcium, phosphorus,
parathyroid hormone, hemoglobin, albumin weight every
3-6 months
Consider need for dose adjustment of medications
Referral for dietary counseling
45-60
Referral to nephrologist
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35. Table 15; Adapted from
http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.
Recommendations: Retinopathy
 To reduce risk or slow progression of retinopathy
 Optimized glycemic control (A)
 Optimize blood pressure control (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35. Table 15; Adapted from
http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.
Recommendations:
screening (1)
Retinopathy
 Initial dilated and comprehensive eye examination
by an ophthalmologist or optometrist
 Adults and children aged 10 years or older with
type 1 diabetes
 Within 5 years after diabetes onset
 Patients with type 2 diabetes
 Shortly after the diagnosis of diabetes
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
Recommendations:
screening (3)
Retinopathy
 High-quality fundus photographs
 Can detect most clinically significant diabetic retinopathy
 Interpretation of the images
 Performed by a trained eye care provider
 While retinal photography may serve as a screening tool
for retinopathy, it is not a substitute for a comprehensive
eye exam
 Perform comprehensive eye exam at least initially and at
intervals thereafter as recommended by an eye care
professional
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
Recommendations:
Neuropathy
screening, treatment (1)
 All patients should be screened for distal symmetric
polyneuropathy (DPN)
 At diagnosis
 At least annually thereafter using simple clinical tests
 Electrophysiological testing rarely needed
 Except in situations where clinical features are typical
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S36.
Recommendations:
Neuropathy
screening, treatment (2)
 Screening for signs and symptoms of cardiovascular
autonomic neuropathy
 Should be instituted at diagnosis of type 2 diabetes and
5 years after the diagnosis of type 1 diabetes
 Special
testing rarely needed;
management or outcomes (E)
may
not
affect
 Medications for relief of specific symptoms related to
DPN, autonomic neuropathy are recommended
 Improve quality of life of the patient (E)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S36.
Recommendations: Foot Care (1)
 For all patients with diabetes, perform an annual
comprehensive foot examination to identify risk
factors predictive of ulcers and amputations
 Inspection
 Assessment of foot pulses
 Test for loss of protective sensation: 10-g
monofilament plus testing any one of
 Vibration using 128-Hz tuning fork
 Pinprick sensation
 Ankle reflexes
 Vibration perception threshold (B)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S37.
Recommendations: Foot Care (2)
 Upper panel
 To
perform
the
10-g
monofilament test, place the
device perpendicular to the skin,
with pressure applied until the
monofilament buckles
 Hold in place for 1 second and
then release
 Lower panel
 The monofilament test should be
performed at the highlighted
sites while the patient’s eyes are
closed
Boulton AJM, et al. Diabetes Care. 2008;31:1679-1685.
Recommendations: Foot Care (3)
 Provide general foot self-care education
 All patients with diabetes
 Use multidisciplinary approach
 Individuals with foot ulcers, high-risk feet; especially prior
ulcer or amputation
 Refer patients to foot care specialists for ongoing
preventive care, life-long surveillance
 Smokers
 Loss of protective sensation or structural abnormalities
 History of prior lower-extremity complications
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S37.
Recommendations: Foot Care (4)
 Initial screening for peripheral arterial disease (PAD)
 Include a history for claudication, assessment of pedal
pulses
 Consider obtaining an ankle-brachial index (ABI); many
patients with PAD are asymptomatic (C)
 Refer patients with significant claudication or a positive
ABI for further vascular assessment
 Consider exercise, medications, surgical options (C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S37.
Recommendations: Diabetes care in
the hospital
 All patients with diabetes admitted to the hospital
should have
 Their diabetes clearly identified in the medical
record
 An order for blood glucose monitoring, with results
available to the health care team
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
Recommendations: Diabetes care in
the hospital (2)
 Goals for blood glucose levels
 Critically
ill
patients:
140-180
mg/dl
(10 mmol/l) (A)
 More stringent goals, such as 110-140 mg/dl (6.1-7.8
mmol/l) may be appropriate for selected patients, if
achievable without significant hypoglycemia (C)
 Non-critically ill patients: base goals on glycemic control,
severe comorbidities (E)
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
Recommendations: Diabetes care in
the hospital (3)
 Scheduled subcutaneous insulin with basal, nutritional,
correction components
 Use correction dose or “supplemental insulin” to correct
premeal
hyperglycemia
in
addition
to
scheduled
prandial and basal insulin
 Initiate glucose monitoring in any patients not known to
be diabetic who receives therapy associated with high
risk for hyperglycemia
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
Recommendations: Diabetes care in
the hospital (4)
 A
hypoglycemia management protocol should be
adopted and implemented by each hospital or hospital
system
 Establish a plan for treating hypoglycemia for each patient;
document episodes of hypoglycemia in medical record and
track
 Obtain A1C for all patients if results within previous 2-3
months unavailable
 Patients with hyperglycemia who do not have a
diagnosis of diabetes should have appropriate plans for
follow-up testing and care documented at discharge
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.