TYPE 2 DIABETES MELLITUSTYPE 2 DIABETES MELLITUSAsma Jafri, MDAsma Jafri, MD

July 22, 2004July 22, 2004

GOALS:GOALS:

Recognize the changing face of Type 2 Diabetes Mellitus regarding Recognize the changing face of Type 2 Diabetes Mellitus regarding demographics and epidemiology.demographics and epidemiology.

Demonstrate understanding of the “Standards of Medical Care for Demonstrate understanding of the “Standards of Medical Care for Patients with Type 2 Diabetes Mellitus.”Patients with Type 2 Diabetes Mellitus.”

Understand multidisciplinary therapeutic approaches to the Understand multidisciplinary therapeutic approaches to the management of Type 2 Diabetes Mellitus.management of Type 2 Diabetes Mellitus.

Recognize metabolic syndrome as a clinical condition and risk Recognize metabolic syndrome as a clinical condition and risk factor for Diabetes.factor for Diabetes.

Table 1. CRITERIA FOR THE DIAGNOSIS OF DIABETES Table 1. CRITERIA FOR THE DIAGNOSIS OF DIABETES MELLITUS IN NON-PREGNANT ADULTS MELLITUS IN NON-PREGNANT ADULTS

1.1. Symptoms of diabetes plus casual plasma glucose concentration Symptoms of diabetes plus casual plasma glucose concentration ≥ 200 mg/dl (11.1 mmol/L).* Casual is defined as any time of ≥ 200 mg/dl (11.1 mmol/L).* Casual is defined as any time of day without regard to time since last meal. The classic day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsea and symptoms of diabetes include polyuria, polydipsea and unexplained weight loss.unexplained weight loss.

oror

2.2. FPG ≥ 126 mg/dl (7.0 mml/L).* Fasting is defined as no caloric FPG ≥ 126 mg/dl (7.0 mml/L).* Fasting is defined as no caloric intake for at least eight hours.intake for at least eight hours.

oror

3.3. 2hPG ≥200 mg/dl (11.1 mmol/L) during an OGTT.* The test 2hPG ≥200 mg/dl (11.1 mmol/L) during an OGTT.* The test should be performed using a glucose load containing the should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.equivalent of 75 g anhydrous glucose dissolved in water.

*In the absence of unequivocal hyperglycemia with acute *In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. The third measure (OGTT) is not repeat testing on a different day. The third measure (OGTT) is not recommended for routine clinical use.recommended for routine clinical use.

FromFrom the Expert Committee on the Diagnosis and Classification of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus Care 20:1183-Diagnosis and Classification of Diabetes Mellitus Care 20:1183-1197, 1997; with permission.1197, 1997; with permission.

Table 2. CRITERIA FOR THE DIAGNOSIS OF IMPAIRED Table 2. CRITERIA FOR THE DIAGNOSIS OF IMPAIRED GLUCOSE GLUCOSE TOLERANCE IN NON-PREGNANT ADULTS TOLERANCE IN NON-PREGNANT ADULTS (PRE (PRE DIABETES) DIABETES)

Fasting plasma glucose of Fasting plasma glucose of ≥ 110 mg/dl or < 125 mg/dl≥ 110 mg/dl or < 125 mg/dl

2-hour post-prandial plasma glucose of 2-hour post-prandial plasma glucose of >> 140 and < 200 mg/do 140 and < 200 mg/do

CLINICAL FEATURES:CLINICAL FEATURES:

Insulin resistance and progressive insulin secretory defect.Insulin resistance and progressive insulin secretory defect.

Most patients are obese.Most patients are obese.

If not obese, they have increased percentage of body fat If not obese, they have increased percentage of body fat distributed predominately in the abdominal region.distributed predominately in the abdominal region.

Ketoacidosis seldom occurs spontaneously. When seen, it usually Ketoacidosis seldom occurs spontaneously. When seen, it usually arises in association with the stress of another illness such as arises in association with the stress of another illness such as infection.infection.

Risk increases with age, obesity and lack of physical activity.Risk increases with age, obesity and lack of physical activity.

Strong genetic predisposition.Strong genetic predisposition.

METABOLIC SYNDROMEMETABOLIC SYNDROME

Insulin resistanceInsulin resistance

HyperinsulinemiaHyperinsulinemia

Obesity (central), waist circumference is > 35” in females and > Obesity (central), waist circumference is > 35” in females and > 40” in males40” in males

Dislipidemia of Dislipidemia of ↑ TG and or low HDL↑ TG and or low HDL

HypertensionHypertension

PREVALENCE:PREVALENCE:

Prevalence was 7.4% in 1995. This is expected to rise to above Prevalence was 7.4% in 1995. This is expected to rise to above 9% in 2025. It is estimated that there are 16 million people with 9% in 2025. It is estimated that there are 16 million people with Type 2 Diabetes Mellitus and over 10 million Americans have Type 2 Diabetes Mellitus and over 10 million Americans have impaired glucose tolerance. Costs $120 billion annually; impaired glucose tolerance. Costs $120 billion annually; approximately 15% of the U.S. healthcare expenditure. The approximately 15% of the U.S. healthcare expenditure. The number of individuals with Type 2 DM diagnosed between 30-39 number of individuals with Type 2 DM diagnosed between 30-39 years of age has increased 76% in the past ten years. The years of age has increased 76% in the past ten years. The increase in prevalence of diabetes in younger individuals seems to increase in prevalence of diabetes in younger individuals seems to parallel the equally alarming rate of obesity in America. Reports parallel the equally alarming rate of obesity in America. Reports suggest that Type 2 DM now represents 8% - 46% of all diabetes suggest that Type 2 DM now represents 8% - 46% of all diabetes cases among children. The average AIC of people with diabetes in cases among children. The average AIC of people with diabetes in the U.S. is 9%. The latest study of American adults with diabetes the U.S. is 9%. The latest study of American adults with diabetes revealed that 37% had AIC > 8% and 14% had AIC> 10%. revealed that 37% had AIC > 8% and 14% had AIC> 10%.

Presently about half of the adults with diabetes in the U.S. are Presently about half of the adults with diabetes in the U.S. are undiagnosed (8 million).undiagnosed (8 million).

At the time of diagnosis of Type 2 Diabetes:At the time of diagnosis of Type 2 Diabetes:

- 2-9% of patients have retinopathy- 2-9% of patients have retinopathy

- 8-18% have nephropathy- 8-18% have nephropathy

- 5-13% have neuropathy- 5-13% have neuropathy

- 8% have cardiovascular disease- 8% have cardiovascular disease

GENERAL RECOMMENDATIONS FOR SCREENING BY GENERAL RECOMMENDATIONS FOR SCREENING BY PHYSICIANS:PHYSICIANS: Screening should be considered at three (3) year intervals for:Screening should be considered at three (3) year intervals for:

1.1. All individuals at age 45 years and above.All individuals at age 45 years and above.

2.2. Test at a younger age and more frequently in individuals Test at a younger age and more frequently in individuals who:who:

a. Are obese with BMI a. Are obese with BMI ≥ 27 kg/m².≥ 27 kg/m².b. Have a first degree relative with diabetes.b. Have a first degree relative with diabetes.c. Are members of a high-risk ethnic population (i.e., c. Are members of a high-risk ethnic population (i.e.,

African African American, Hispanic, Native American, Asian American, Hispanic, Native American, Asian American, Pacific American, Pacific Islander). Islander).

d. Have delivered a baby weighing > 9 lbs. or have been d. Have delivered a baby weighing > 9 lbs. or have been diagnosed diagnosed with GDM. with GDM.

e. Are hypertensive (BP ≥e. Are hypertensive (BP ≥ 140/90).140/90).f. Have an HDL cholesterol level f. Have an HDL cholesterol level ≤ 35 mg/dl and/or TG ≤ 35 mg/dl and/or TG

level > 250 level > 250 mg/dl. mg/dl.g. On previous testing had IGT or IPG.g. On previous testing had IGT or IPG.h. Habitual physical inactivity.h. Habitual physical inactivity.

SCREENING TEST:SCREENING TEST:

Fasting plasma glucose (FPG).Fasting plasma glucose (FPG).

Oral glucose tolerance test (75 gm glucose). The fasting plasma Oral glucose tolerance test (75 gm glucose). The fasting plasma glucose test is strongly preferred because it is easier and faster to glucose test is strongly preferred because it is easier and faster to perform, more convenient and less expensive.perform, more convenient and less expensive.

A random plasma glucose level A random plasma glucose level ≥ 160 mg/dl is considered a ≥ 160 mg/dl is considered a positive screening test result and needs further testing.positive screening test result and needs further testing.

Glycated hemoglobin is currently Glycated hemoglobin is currently not recommendednot recommended for the for the screening or diagnosis of diabetes.screening or diagnosis of diabetes.

The OGTT is more sensitive for the diagnosis of diabetes and pre-The OGTT is more sensitive for the diagnosis of diabetes and pre-diabetes, but is impractical and expensive as a screening diabetes, but is impractical and expensive as a screening procedure.procedure.

TABLE 3 GLYCEMIC CONTROL FOR PEOPLE WITH TABLE 3 GLYCEMIC CONTROL FOR PEOPLE WITH DIABETESDIABETES

Recommendations for Glycemic Control*Recommendations for Glycemic Control*BiochemicalBiochemical Action Action IndexIndex Normal Normal Goal Goal

SuggestedSuggested______________________________________________________________________________________________________________________________________________Fasting/Preprandial glucoseFasting/Preprandial glucose <110 mg/dl 80 to 120 mg/dl < 80 or > <110 mg/dl 80 to 120 mg/dl < 80 or >

140 mg/dl140 mg/dl

Bedtime glucoseBedtime glucose <120 mg/dl 100 to 140 mg/dl <100 or > <120 mg/dl 100 to 140 mg/dl <100 or > 160 mg/dl160 mg/dl

Glycosylated hemoglobinGlycosylated hemoglobin < 6% < 7% < 6% < 7% > 8% > 8%______________________________________________________________________________________________________________________________________________

*These values are for non-pregnant adults. Goals and “Action Suggested” *These values are for non-pregnant adults. Goals and “Action Suggested” depend on individual patient circumstances. Such actions may include depend on individual patient circumstances. Such actions may include enhanced diabetes self-management education, co-management with a enhanced diabetes self-management education, co-management with a diabetes team, referral to an endocrinologist, change in pharmacological diabetes team, referral to an endocrinologist, change in pharmacological therapy, initiation or increased SMBG, or more frequent contact with the therapy, initiation or increased SMBG, or more frequent contact with the patient. HbA1c is referenced to a non-diabetic range of 4.0 – 6.0% (mean patient. HbA1c is referenced to a non-diabetic range of 4.0 – 6.0% (mean 5.0%, SD 5.0%, SD ∀∀ 0.5%). 0.5%).

ESSENTIAL COMPONENTS OF MANAGEMENT – INITIAL ESSENTIAL COMPONENTS OF MANAGEMENT – INITIAL VISIT:VISIT: Medical HistoryMedical History

1.1. Symptoms, results of laboratory tests and special Symptoms, results of laboratory tests and special examination results examination results related to diagnosis of diabetes.related to diagnosis of diabetes.

2.2. Prior G Hb results.Prior G Hb results.

3.3. Eating patterns, nutritional status, weight history.Eating patterns, nutritional status, weight history.

4.4. Details of previous treatment programs including nutrition Details of previous treatment programs including nutrition and and diabetes self-management education.diabetes self-management education.

5.5. Current treatment of diabetes including medications, Current treatment of diabetes including medications, meals, results of meals, results of glucose monitoring.glucose monitoring.

6.6. Exercise history.Exercise history.

7.7. Acute complications such as DKA, hypoglycemia.Acute complications such as DKA, hypoglycemia.

8.8. Prior or current infections.Prior or current infections.

9.9. Symptoms and treatment of eye, kidney, nerve, gu, Symptoms and treatment of eye, kidney, nerve, gu, bladder and bladder and GI function, heart, peripheral vascular, foot, CVA, GI function, heart, peripheral vascular, foot, CVA, etc.etc.

10.10. Other medications that may affect blood glucose levels.Other medications that may affect blood glucose levels.

11.11. Risk factors for atherosclerosis: smoking, HTN, obesity, Risk factors for atherosclerosis: smoking, HTN, obesity, dislipidemia dislipidemia and family history.and family history.

12.12. Family history of diabetes and other endocrine disorders.Family history of diabetes and other endocrine disorders.

13.13. Gestational history.Gestational history.

14.14. Life style, cultural, psychosocial, educational and Life style, cultural, psychosocial, educational and economic factors economic factors that might influence the management of that might influence the management of diabetes.diabetes.

15.15. Tobacco and alcohol use.Tobacco and alcohol use.

• Physical ExaminationPhysical Examination

1.1. Height and weight.Height and weight.

2.2. Sexual maturation staging (peripubertal).Sexual maturation staging (peripubertal).

3.3. Blood pressure with orthostatic measurements when indicated.Blood pressure with orthostatic measurements when indicated.

4.4. Ophthalmoscopic examination (dilation).Ophthalmoscopic examination (dilation).

5.5. Oral examination.Oral examination.

6.6. Thyroid palpitation.Thyroid palpitation.

7.7. Cardiac examination.Cardiac examination.

8.8. Abdominal examination.Abdominal examination.

9.9. Evaluation of pulses.Evaluation of pulses.

10.10. Hand/finger examination.Hand/finger examination.

11.11. Foot examination.Foot examination.

12.12. Skin examination.Skin examination.

13.13. Neurological examination.Neurological examination.

• Laboratory EvaluationLaboratory Evaluation

1.1. Fasting or random plasma glucose.Fasting or random plasma glucose.

2.2. GHbGHb

3.3. Fasting lipid profile.Fasting lipid profile.

4.4. Serum creatinine in adults.Serum creatinine in adults.

5.5. Urine analysis, glucose, ketones, protein, sediment.Urine analysis, glucose, ketones, protein, sediment.

6.6. Test for microalbuminuria.Test for microalbuminuria.

7.7. Urine culture if sediment is abnormal or symptoms are present.Urine culture if sediment is abnormal or symptoms are present.

8.8. TSH in all Type 1 patients.TSH in all Type 1 patients.

9.9. EKG in adults.EKG in adults.

DIABETES SELF-MANAGEMENT EDUCATION:DIABETES SELF-MANAGEMENT EDUCATION:

National standards for Diabetes Self-Management Education have National standards for Diabetes Self-Management Education have been developed. Ten content areas have been identified as the been developed. Ten content areas have been identified as the core topics needed to provide comprehensive education to the core topics needed to provide comprehensive education to the person with diabetes:person with diabetes:

Diabetes disease process and treatment options.Diabetes disease process and treatment options. Nutritional management.Nutritional management. Incorporating physical activity in lifestyle.Incorporating physical activity in lifestyle. Using medication effectively.Using medication effectively. Monitoring blood glucose and using the results.Monitoring blood glucose and using the results. Preventing, detecting and treating acute complications.Preventing, detecting and treating acute complications.

Goal setting to promote health and problem solving for daily Goal setting to promote health and problem solving for daily living.living.

Integrating psychosocial adjustment into daily life.Integrating psychosocial adjustment into daily life. Promoting preconception care and managing diabetes during Promoting preconception care and managing diabetes during

pregnancy when applicable.pregnancy when applicable.

A major emphasis in diabetes education is patient A major emphasis in diabetes education is patient empowerment in making decisions regarding diabetes empowerment in making decisions regarding diabetes management.management.

CONTINUING CARE (FREQUENCY):CONTINUING CARE (FREQUENCY):

Individualized regimen and frequency of visits.Individualized regimen and frequency of visits.

If target goals met, frequency every six months.If target goals met, frequency every six months.

If target goals not met, frequency every three months.If target goals not met, frequency every three months.

ROUTINE FOLLOW-UP VISIT:ROUTINE FOLLOW-UP VISIT:

History of goals, activity, diet, MBG, medications, symptoms of History of goals, activity, diet, MBG, medications, symptoms of CAD, personal concerns, stresses, evaluate smoking status.CAD, personal concerns, stresses, evaluate smoking status.

Exam: weight, BP (goal < 138/80; lower BP may be even better). Exam: weight, BP (goal < 138/80; lower BP may be even better). Epidemiologic analyses show that blood pressure > 115/75 are Epidemiologic analyses show that blood pressure > 115/75 are associated with increased CV event rates and mortality in persons associated with increased CV event rates and mortality in persons with diabetes. with diabetes.

A.A. Pulses - annuallyPulses - annually

B.B. Annual Foot exam including Semmes-Weinstein Annual Foot exam including Semmes-Weinstein monofilament, tuning monofilament, tuning fork, palpation and visual exam (skin, fork, palpation and visual exam (skin, nails). (B) Perform a visual nails). (B) Perform a visual inspection of patients’ feet at each inspection of patients’ feet at each visit. (E)visit. (E)

C.C. Dilated eye exam annually (B). Dilated eye exam annually (B).

• Laboratory studiesLaboratory studies

1.1. GHg every three months if treatment changes or not meeting GHg every three months if treatment changes or not meeting goals, otherwise every six months.goals, otherwise every six months.

2.2. Annual fasting lipid panel or biannual if goals met. Repeat lipid Annual fasting lipid panel or biannual if goals met. Repeat lipid profiles as dictated by therapy. Goal is LDL<100, HDL >45 in profiles as dictated by therapy. Goal is LDL<100, HDL >45 in males and >55 in females, and TG < 150 mg/dl. males and >55 in females, and TG < 150 mg/dl.

3.3. Annual serum creatinine.Annual serum creatinine.

4.4. Urine analysis for microalbumin annually until confirmed Urine analysis for microalbumin annually until confirmed positive. positive.

• OtherOther1.1. Aspirin 80 mg/day for patients over age 40 for primary Aspirin 80 mg/day for patients over age 40 for primary

prevention.prevention.

May use over age 30 in patients with additional risk factors (A). May use over age 30 in patients with additional risk factors (A). Aspirin does not prevent retinopathy or increase risk of Aspirin does not prevent retinopathy or increase risk of hemorrhage (A).hemorrhage (A).

2.2. Influenza and pneumococcal vaccination (C).Influenza and pneumococcal vaccination (C).

3.3. Advise all patients not to smoke (A).Advise all patients not to smoke (A).

4.4. In patients > 55 years of age with or without HTN but with In patients > 55 years of age with or without HTN but with another CV risk factor, an ACE inhibitor should be considered to another CV risk factor, an ACE inhibitor should be considered to reduce the risk of CV events (A).reduce the risk of CV events (A).

Table 4. DEFINITIONS OF ABNORMALITIES IN ALBUMIN Table 4. DEFINITIONS OF ABNORMALITIES IN ALBUMIN EXCRETIONEXCRETION______________________________________________________________________________________________________________________________

24-h Timed 24-h Timed Spot SpotCategory Collection Collection CollectionCategory Collection Collection Collection______________________________________________________________________________________________________________________________NormalNormal < 30 mg/24 h < 20 < 30 mg/24 h < 20 µ < 30 µg/mg µ < 30 µg/mg

creatininecreatinineMicroalbuminaria 30-300 mg/24 h 20-200 Microalbuminaria 30-300 mg/24 h 20-200 µg/min 30-300 µg/mg µg/min 30-300 µg/mg

creatininecreatinineClinical albuminuria > 300 mg/24 h > 200 µg/min < 300 µg/mg Clinical albuminuria > 300 mg/24 h > 200 µg/min < 300 µg/mg

creatinine creatinine ______________________________________________________________________________________________________________________________________________

Because of variability in urinary albumin excretion, two of three Because of variability in urinary albumin excretion, two of three specimens collected within a three to six month period should be specimens collected within a three to six month period should be abnormal before considering a patient to have crossed one of these abnormal before considering a patient to have crossed one of these diagnostic thresholds. Exercise within 24 h, infection, fever, diagnostic thresholds. Exercise within 24 h, infection, fever, congestive heart failure, marked hyperglycemia, and marked congestive heart failure, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline hypertension may elevate urinary albumin excretion over baseline values.values.

FromFrom the American Diabetes Association Clinical Practice the American Diabetes Association Clinical Practice Recommendations 1999. Diabetes Care 22(suppl1);S67, 1999; with Recommendations 1999. Diabetes Care 22(suppl1);S67, 1999; with permission.permission.

Table 5. OPHTHALMOLOGIC EXAMINATION SCHEDULETable 5. OPHTHALMOLOGIC EXAMINATION SCHEDULE________________________________________________________________________________________________________________________________________ Recommended First Minimum Recommended First Minimum

RoutineRoutinePatient GroupPatient Group______________________________Examination_________________Follow-Up*Examination_________________Follow-Up*__________29 Years or 29 Years or Within 3-5 years after diagnosis ofWithin 3-5 years after diagnosis of Yearly Yearly younger+younger+ diabetes once patient is age 10 yearsdiabetes once patient is age 10 years

or olderor older

30 years or older+30 years or older+ At time of diagnosis of diabetesAt time of diagnosis of diabetes YearlyYearly

Pregnancy inPregnancy in Before conception and during trimesterBefore conception and during trimester Physician discretion pending Physician discretion pendingPre-existingPre-existing results of 1 results of 1stst trimester trimesterDiabetesDiabetes exam exam

____________________________________________________________________________________________________________________________**Abnormal findings necessitate more frequent follow-upAbnormal findings necessitate more frequent follow-up +As indicated in WESDR, these are operational definitions of Type 1 and Type 2 +As indicated in WESDR, these are operational definitions of Type 1 and Type 2 diabetes based on age (age <30 years at diagnosis, Type 1; age diabetes based on age (age <30 years at diagnosis, Type 1; age ≥ 30 years at ≥ 30 years at diagnosis, Type 2) and not pathogenetic classification.diagnosis, Type 2) and not pathogenetic classification.

From From the American Diabetes Association Clinical Practice Recommendations 1999. the American Diabetes Association Clinical Practice Recommendations 1999. Diabetes Care 22(suppl1):S72, 1999; with permission.Diabetes Care 22(suppl1):S72, 1999; with permission.