Diabetes Guidelines

Kevin H McKinney MDUniversity of Texas Medical Branch at GalvestonDivision of Endocrinology/Stark Diabetes Center

DIABETES MELLITUS

•Inability of the body to metabolize blood sugar

•A disease of inadequate insulin secretion and action

•Hyperglycemia is the main manifestation

COMPLICATIONS

Chronic hyperglycemia may cause:–retinal damage–chronic kidney disease–nerve damage–vascular disease

COMPLICATIONS (cont.)

•Blindness•Dialysis•Lower Limb Amputation•Stroke•Myocardial infarction•Claudication

PRIMARY CLASSES OF DIABETES MELLITUS

•Type 1–Autoimmune destruction of islets–No insulin secretion

•Type 2 Diabetes–Insulin resistance with progressive insulin secretory defect–90% are obese

PREVALENCE OF TYPE 1 DIABETES IN THE US

• 1 million people

• Caucasians constitute the majority of

type 1 diabetics

• Most prominent during childhood

PREVALENCE OF TYPE 2 DIABETES IN THE US

• Most common type of diabetes among

all ethnic groups

• 17 million patients with known diabetes

• 45% of children and teens with new

diagnoses

PREVALENCE OF TYPE 2 DIABETES IN THE US

• Caucasian women experience higher

prevalence rates than men (57% vs. 26%)

• By age 70, African American prevalence

rates increase to 42% of the population

METABOLIC SYNDROME

• Insulin resistance (type 2 diabetes)

• Hypertension

• Dyslipidemia

• Polycystic ovary syndrome

• Hyperuricemia

• Hypercoagulability

PREVALENCE OF METABOLIC SYNDROME IN THE US

•Third NHANES Study (Prevalence Rates)

–21.6% African American Adults

–31.9% Mexican American Adults

–23.8% Caucasian Adults

OBESITY—A PUBLIC HEALTH PROBLEM

Rise in metabolic syndrome is related to increasing prevalence of obesity

Multifactorial causes for obesity including– A sedentary lifestyle – Decline in exercise– Increased access to unhealthy foods– Greater food portions

GESTATIONAL DIABETES

• Occurs after the onset of pregnancy

• Is secondary to the production of human

placental lactogen and other hormones

needed to sustain pregnancy

• Most common in people of color

GESTATIONAL DIABETES

•If untreated, may result in fetal macrosomia•Fetal macrosomia may lead to

–Cesarean section–Shoulder dystocia–Fetal hypoglycemia

•High risk women should be screened at first prenatal visit•Low-risk women should be screened from 24 to 28 weeks of gestation

Hospitalization Costs for Chronic Complications of Diabetes in the US

American Diabetes Association. Economic Consequences of Diabetes Mellitusin the US in 1997. Alexandria, VA: American Diabetes Association, 1998:1-14.

Total costs 12 billion US $

CVD accounts for 64% of total costs

OthersOphthalmic

disease

Cardiovasculardisease

Renal disease

Neurologic disease

Peripheral vascular disease

DISPARITIES IN DIABETES COMPLICATIONS IN AFRICAN AMERICANS

• Contributing factors–Average delay in diagnosis of 4-7 years–Longer duration of poorly controlled type 2

diabetes–Development of equally devastating

complications

MICROVASCULAR COMPLICATIONS OF DIABETES

•Diabetic retinopathy–46% higher in African Americans and 86% higher in Mexican Americans than in Caucasians

•Diabetic Nephropathy–African Americans, Latinos, and Native Americans have 3-4 times higher rates of renal failure than Caucasians

•

DIABETIC NEUROPATHY

•Primary contributor to the loss of limb protection through the diminution or absence of pain and sensory perception.

•Diminution or absence of pain and sensory perception leads to limb trauma, open ulcers and polymicrobial foot infections often culminating in gangrene that is treated by limb amputation.

•Lower extremity limb amputation is 2-3 times higher in African Americans and Mexican Americans than in Caucasians.

MACROVASCULAR RISKS OF DIABETES

• Risk of stroke, coronary artery disease, and peripheral vascular disease is increased 2-4 times in all patients with diabetes.

• The presence of diabetes is viewed as an independent risk factor for first acute myocardial infarction compared to those with recurrent myocardial infarction without diabetes.

MACROVASCULAR RISKS OF DIABETES

• The rates for myocardial infarction and stroke among African Americans, Asian Americans and Hispanic Americans are the same or lower than in Caucasians; however, the mortality from CAD is disproportionately high in minorities.

• Cardiovascular disease (CVD) remains the leading cause of death in individuals with diabetes, up to 70% of type 2 diabetes patients.

•

RISK REDUCTION OF MACROVASCULAR COMPLICATIONS

–Glycemic Control

–Smoking Cessation

–Blood Pressure Control

–Lipoprotein Management

–Prothrombotic State Improvement

SCREENING GUIDELINES

• Adults 45 years of age and older esp with BMI > 25

– Fasting Plasma Glucose at 3 year intervals

• Overweight or obese individuals with risk factors for diabetes, African Americans, Latinos– Fasting Plasma Glucose screened at an earlier age

and more frequently

• Children with BMI > 85th percentile

– Screened at age 10 and every 2 years thereafter

DIAGNOSTIC CRITERIA

• Fasting Plasma Glucose > 126 mg/dL

• Casual Blood Sugar > 200 mg/dL or greater as with diabetic symptoms

• 2-hour postprandial serum glucose of 200 mg/dL as stimulated by a glucose tolerance test

• Test reconfirmation required

PRE-DIABETIC STATES

• Impaired glucose tolerance (IGT)– 2-hour glucose between 140 and 199

• Impaired fasting glucose (IFG)– Fasting glucose beteween 100 and 125

• Above are risk factors for future diabetes and cardiovascular disease

Diabetes Prevention ProgramScreened 158,177

OGTT, then randomize

Metformin1073

Lifestyle1079

3819 randomized

Placebo1082

Thiazolidinedione585

3% Wt loss5% Wt loss ~10 month followup

31% Risk Reduction

58 %Risk Reduction

Diabetes Rate11 % per year

23 %Risk Reduction

Diabetes Prevention Program Research Diabetes Prevention Program Research GpGp, , NEJM NEJM 346(6): 393346(6): 393--403, 2002.403, 2002.

TREATMENT GOALS FOR DIABETES MELLITUS

Maintaining: • Pre-meal blood glucose in the range of

90 mg/dL to 130 mg/dL

• Bedtime blood glucose in the range of 100 mg/dL to 140 mg/dL

• A hemoglobin A1c value from 6.5% to 7% over 3 months

* Updated mean A1c is adjusted for age, sex, and ethnic group, expressed for white men aged 50-54 years at diagnosis and with mean duration of diabetes of 10 years.Stratton IM et al. BMJ. 2000;321:405-412.

Increased A1c Raises Vascular Event Risk

MyocardialInfarction

MicrovascularComplications

Updated Mean A1c (%)*

Adj

uste

d In

cide

nce

per

1000

Pat

ient

-Yea

rs (%

)

0

20

40

60

80

0 5 6 7 8 9 10 11

•Positionin Model Variable P Value*

•First Low-density lipoprotein cholesterol <.0001

•Second High-density lipoprotein cholesterol .0001

•Third Hemoglobin A1c .0022

•Fourth Systolic blood pressure .0065

•Fifth Smoking .056

UKPDS 23

* Significant for CAD (n = 280). P values are significance of risk factors after controlling for all other risk factors in model.Adjusted for age and sex in 2693 white patients with type 2 diabetes with dependent variable as time to first event.Turner RC et al. BMJ. 1998;316:823-828.

Established Modifiable Cardiovascular Risk Factors In Type 2 Diabetes

TREATMENT GOALS FOR DIABETES MELLITUS (Cont.)

Maintaining:

• Blood pressure < 130/80 mm Hg

• LDL Cholesterol < 100 mg/dL, triglycerides < 150 mg/dL, and HDL cholesterol > 40 mg/dL in men (> 50 mg/dL in women)

• High risk cardiovascular patients should aim for LDL cholesterol < 70 mg/dL

MANAGEMENT PLAN

• Must be individualized for each individual patient

• Diabetes education: initial and subsequent• Lifestyle modifications

– Diet (improve your nutrition)– Exercise (increase your activity)

• Home blood glucose monitoring– At least once/day for oral medications– Three times daily for insulin users

• Medications

FOLLOW-UP CARE

• Annual eye exam• Physician visits every 3 months, more

frequently for poor control– Fundoscopic exam– Foot exam

• HbA1c quarterly for poor control, every biannually for good control

• Lipogram yearly• Microalbumin yearly

Years of Diabetes * IGT = impaired glucose

tolerance.

Obesity IGT* Diabetes Uncontrolled Hyperglycemia

Relative -Cell Function

100 (%)

-20 -10 0 10 20 30

PlasmaGlucose

Insulin Resistance

Insulin Secretion

120 (mg/dL)

Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

Fasting Glucose

Post-Meal Glucose

Natural History of Type 2 Diabetes

MEDICAL NUTRITIONAL THERAPY

• Must be individualized for each patient– Children must be allowed enough calories

for growth, development, and activity– Pregnant women, elderly also deserve

special consideration

• Permanent low-carbohydrate diets not recommended– “carbohydrate counting” can be done with

insulin users

MEDICAL NUTRITIONAL THERAPY (cont)

• Weight management– One should aim for 500-1000 Calorie reduction in

intake per day– 1000-1200 Calories/day for women, 1200-1600

Calories/day for men for weight reduction– Bariatrics?

• Activity should consist of 3-5 sessions per week– 30-45 minutes for health– Weight loss: 1 hour of walking, 30 minutes of

vigorous exercise

ORAL MEDICAL THERAPY

• First line: metformin useful except where contraindicated

• Sulfonylureas or meglitinides also frequently used

• Second line: thiazolidinediones

• Used uncommonly: acarbose

INSULIN

• Traditional regimens– Type 1: Basal insulin (NPH, glargine) with

bolus regular or short-acting insulin (lispro, aspart, glulisine) by sliding scale; split-mix regimen; insulin pump

– Type 2: split-mix regimen; fixed combination (70/30, 50/50, 75/25); basal-bolus

• Transitional type 2 insulin regimens: oral agents with bedtime NPH or glargine

ADJUNCTS

• Cardiovascular– Aspirin

• Renal– ACE inhibitor/Angiotensin receptor blocker

• Hypertension– Diuretics

• Cholesterol– Statins

WHEN TO REFER

• Poor control for 6 months despite patient adherence and physician manipulation (HbA1c >10%)

• Multiple episodes of decompensation (DKA, HONK)

• Frequent hypoglycæmic episodes

Reference

• American Diabetes Association. Diabetes Care 28:S4, 2005 Jan.

• American Association of Clinical Endocrinologists. Endocrine Practice 8:S40, 2002 Jan/Feb.