Type II Diabetes

JacobiAmbulatory Care Service

Type II Diabetes

Matthew Love, M.D.


Case 1

Fred Banting, a 52 year-old man, complains of polyuria and polydypsia for three weeks. On questioning, he also admits to dizziness on standing.

On exam, his BP is 135/80, Pulse 95. He is 5’8” tall, weighs 220# and has acanthosis nigricans.

Urine dipstick is ++ for glucose. Fingerstick glucose is 188. Point of Care Hemoglobin A1c is 8.3%.

Does this patient have Diabetes?


Diagnosis

Method Threshold Value Advantages Disadvantages

Fasting Plasma Glucose

> 126 mg/dl •Time since last meal easy to define•ADA preferred•Cheap

•Inconvenient•Unstable

Random glucose >200 + symptoms •Convenient •Less reproducible

HbA1c ≥ 6.5% •Correlates with disease process•Stable

•Cost

OGGT >200 @ 2 hours •Pregnancy •Cumbersome


Prediabetes

• Impaired fasting glucose: 100 < FPG < 126• Impaired glucose tolerance: OGTT result at 2h

between 140-199. • Hemoglobin A1c of 6.0% – 6.4%


Remember the Pathogenesis


Remember the Pathophysiology


Case 2

Dulce Diente is a 37 year-old female with a family history of diabetes. She wants to be checked for diabetes because she has gained a lot of weight, she keeps getting yeast infections and her urine tastes sweet.

Physical exam is normal except for a BMI of 29.

FPG checked by fingerstick on her father’s glucometer has been 110-120. Point of Care HbA1c comes back at 6.8%

Should she be started on medicine? Is there anything that can be done to prevent the progression of her diabetes?


Diabetes Prevention ProgramResults


Diabetes Prevention ProgramChange in weight & Physical Activity


PREVENTION TRIALS


Case 3

Isabel Fadiman is a 41 year-old African-American female who presents for a check-up. She has no complaints. Past medical history includes gestational diabetes during her last pregnancy five years ago. Family history is positive for two brothers and both parents with Type 2 DM. She does not smoke.

On exam, her BP is 120/80 and her BMI is 27. There is no acanthosis nigracans or any other abnormality.

Should she be screened for diabetes?


Diabetes Screening RecommendationsOrganization Recommendation

US Preventive Services Task Force

• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower.• The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.

American Diabetes Association

• For adults who do not have diabetes risk factors, consider screening every 3 y starting at age 45 y, particularly if body mass index >25 kg/m2• Screen adults < 45 y of age if they are overweight and have another diabetes riskFactor

Canadian Diabetes Association

• Evaluate all patients for type 2 diabetes risk annually• Screen patients without diabetes risk factors every 3 y starting at age 40 y• Consider earlier, more frequent screening for patients with diabetes risk factors


Risk Factors for Type 2 Diabetes

• Age > 45 y

• First-degree relative with type 2 Diabetes

• African-American, Hispanic, Asian, Pacific Islander, or Native American ethnicity

• History of gestational diabetes or delivery of infant weighing ≥9 lbs

• Polycystic ovary syndrome

• Overweight, especially abdominal obesity

• Cardiovascular disease,hypertension, dyslipidemia, or other metabolic syndrome features


Initial Evaluation

• Symptoms

• Exam – BP, BMI, Feet

• Labs – HbA1c

– Ualb/cr

– Chemistry (Cr, LFTs)

– EKG

• Referrals– Dietician

– Glucometer Teaching

– Ophthalmology

– Podiatry


Blood Glucose Monitoring


Glucometer Operation


Case 4

Matt Forman is a 54 year-old man with newly diagnosed Type II Diabetes. His FPG is 148 and his HbA1c is 7.8% . Physical is normal except for BMI of 28. Except for the glucose values, his laboratory exams are normal.

How should he be treated?


Treatment non-pharmacologic Diet

• Carbohydrates Should comprise 45%-65% of total calories No concentrated sweets (soda, juice, desserts) No white starches (especially rice and pasta) Fresh vegetables and fruits rather than canned

• Fats Should comprise < 30% of total calories Saturated fats should be < 7%


Treatment non-pharmacologic Exercise


Treatment pharmacologic Oral Agents


Metformin

• No weight gain• No hypoglycemia• Cheap, generic, old

• GI side effects frequent• Rare but serious lactic

acidosis

• Start at 500 bid with meals• Titrate up quickly to 1000 bid

or 850 tid


Sulfonylurea

• Cheap, generic, old• Equally effective

• May cause hypoglycemia

• Weight gain

• Start at low dose, increase gradually


Thiazolidinediones TZD

• Increase glucose uptake and decrease glucose production

• Equally effective• May preserve beta-cell

function

• Newer, more expensive• Fluid retention• May cause xs MIs


Incretin mimetics


Incretin-based therapies


Alpha-glucosidase Inhibitors

• Lower postprandial glucose and A1c

• Less potent• No weight gain

• Cause flatulence• Contraindicated in

cirrhosis

• Take with first bite of meal


Case 4


After 6 months of a diabetic diet and increased exercise, his HbA1c is 8.1%



Case 4



After 6 months of Metformin at a dose of 1000 mg bid, his HbA1c is 7.1%


What is the glycemic control target?


Glycemic Control Target: Good Control Reduces Microvascular Complications


Glycemic Control Target: The UKDPS – the largest and longest study in Type II DM

• Microvascular complications were reduced 25% in the intensive- therapy group

• Epidemiologic analysis showed that for every 1% reduction of HbA1c:↓ 35% reduction in microvascular complications

↓ 25% reduction in diabetes related deaths

↓ 7% reduction in all cause mortality

↓ 18% reduction in myocardial infarction

• No lower threshold


Glycemic Control Target: Macrovascular Complications

ACCORD trial – Action to Control Cardiovascular Risk in Diabetes


Glycemic Control Target:

Current Recommendations from the ADA:

• The Benefits of Intensive Glycemic Control on Macrovascular Complications vary based on the population being treated– Those most likely to benefit from intensive control are those with

shorter duration of DM, no known vascular disease, and without severe hypoglycemia

– The risk of intensive glycemic control may outweigh the benefits in those with a long duration of DM, known vascular disease, or symptomatic severe hypoglycemia


Case 4



After 6 months of Metformin at a dose of 1000 mg bid, his HbA1c is 7.1%


A second agent should be added


Case 4 – Algorithm


Case 5

Norman P. Hagedorn is a 64 year-old man with Type II Diabetes for 12 years. He also has CAD, s/p MI and CABG, HTN, gout, and BPH. Medications include metformin, glyburide, pioglitazone, and sitagliptin at maximal doses. Previously, his HbA1c were always in the 7.0-7.9% range, however his last two HbA1cs, three months apart, are 9.8% and 10.9%. Previous attempts to introduce insulin injections have met with adamant refusals.

What might have happened to his glycemic control?


Case 5

Norman P. Hagedorn is a 64 year-old man with Type II Diabetes for 12 years. He also has CAD, s/p MI and CABG, HTN, gout, and BPH. Medications include metformin, glyburide, pioglitazone, and sitagliptin at maximal doses. Previously, his HbA1c were always in the 7.0-7.9% range, however his last two HbA1cs, three months apart, are 9.8% and 10.9%.

Bedtime NPH 10 Units is added to his metformin. Glyburide , pioglitazone, and sitagliptin are discontinued. After following the titration schedule for six weeks, he is on 25 units NPH and morning fingersticks are 95-125.


Case 5

Norman P. Hagedorn is a 64 year-old man with Type II Diabetes for 12 years. He also has CAD, s/p MI and CABG, HTN, gout, and BPH. Medications include metformin, glyburide, pioglitazone, and sitagliptin at maximal doses. Previously, his HbA1c were always in the 7.0-7.9% range, however his last two HbA1cs, three months apart, are 9.8% and 10.9%.

Bedtime NPH 10 Units is added to his metformin. Glyburide , pioglitazone, and sitagliptin are discontinued. After following the titration schedule for six weeks, he is on 25 units NPH and morning fingersticks are 95-125.

After 3 months with continued good am fingersticks, HbA1c is 8.5%. What would you do now?

Pre-dinner fsg are 160-180, so NPH is switched to glargine and eventually titrated up to a dose of 35 U daily.

Now am fsg are 80-110 and pre-dinner are 95-120.

3 months later HbA1c is 8.0%. What would you do now?


Diabetes Treatment Algorithm


Diabetes and Hypertension - UKDPS

For each 10 mm decrease in SBP:

• Microvascular complications ↓ 13%

• Death ↓ 15% • MI ↓ 11%


Diabetes & Lipids - Heart Protection Study

Primary prevention with risk factors (hypertension, diabetes, and CVA)

2x2 factorial design simvastatin 40 mg/day, antioxidant cocktail (600 mg vitamin E, 250 mg vitamin C, 20 mg beta carotene)

N = 20,000; subgroups include: Women (n ~ 5,000) Elderly (>65, n ~ 10,000) Diabetics (n ~ 6,000) Stroke (n ~ 3,000) Hypertension (n ~ 8,000) Noncoronary vascular disease (n ~ 7,000) Low to average blood cholesterol (n ~ 8,000)


Heart Protection Study: Vascular Events by Baseline Disease

Baseline featureSimvastatin (n=10,269)

Placebo (n=10,267)

Previous MI 1007 1255

Other CHD (not MI) 914 1234

No prior CHD

CVD 182 215

PVD 332 427

Diabetes 279 369

All patients2042

(19.9%)2606

(25.4%)

Risk ratio and 95% CI

Statin better

Statin worse

24 ± 2.6% (2P <0.00001)

0.4 0.6 0.8 1.0 1.2 1.4


Diabetes/HTN & Lipids – Steno-2

Intervention was intensive lowering of BP, lipids, and A1c

Macrovascular complications reduced 50% in intensive treatment group over 13 years


Diabetes & HTN & Lipids

Clinical Parameter Target

LDL cholesterol < 100

Blood Pressure < 130/80

HbA1c < 7%


The Routine Followup Visit

• Glycemic Control– Fingersticks

• Daily if previously at target and on orals or glargine• More frequently if not at target or more complicated regimen

– Symptoms of hypoglycemia & hyperglycemia

• Adherence to Diet, Exercise, & Medication

• Ongoing Education

• Ongoing Screening for longterm microsvascular complications (at least yearly)– Nephropathy (Ualb/cr), Neuropathy (monofilament) , retinopathy

• Control of other macrovascular risk factors• LDL < 100

• BP < 130/80


Question 1 – What are the symptoms of diabetes?

• Hyperglycemia - Tm of kidney for reabsorption of glucose > 160, sugar pulls

water, leading to polyuria; the dehydration stimulates thirst- Polyphagia and weight loss- Blurry vision – glucose deposits in cornea- Yeast infections

• Volume Depletion

- Orthostatic dizziness

• Nonspecific symptoms– Headaches, weakness


Question 2 – the following patient is taking 25 U of NPH in the morning and 16 Units at bedtime. What adjustments would you make to her regimen?

Day 8 a.m. fasting 6pm pre-dinner 10 pm bedtime

S 140 120

M 174 100

T 144 220

W 155 184

Th 151 84

F 133 65 179

Sa 130 112

S 149 108

M 145 188


Question 3 – this patient is using 45 Units of Lantus at bedtime and has the following fingersticks:


S 90 85

M 82 85

T 99 106

W 83

Th 82 84

F 96 112

Sa 100 88

S 120 123

M 100 88

HBA1c is 7.8 % What could explain this? What would you recommend?


Question 4 – this patient is taking 1000 mg of Metformin bid and has the following fingersticks:


S 90 88 125

M 82 99 123

T 99 101 165

W 82 87 101

Th 82 94 112

F 96 96 140

Sa 100 121 130

S 120 88 115

M 100 99 113

What would you expect the HbA1c to be?


Translating the A1c into Estimated Average Glucose Values

Type II Diabetes

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