Type 2 diabetes mellitus review of clinical practice guidelines
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TYPE 2 DIABETES MELLITUS Review of Clinical Practice Guidelines. WEEK 1: Diagnosis and Evaluation UHN AIMGP CLINIC SEMINAR SERIES 2007 Updated by Dr. K. Tzanetos. TYPE 2 DIABETES MELLITUS Review of Clinical Practice Guidelines.

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TYPE 2 DIABETES MELLITUS Review of Clinical Practice Guidelines

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Type 2 diabetes mellitus review of clinical practice guidelines

TYPE 2 DIABETES MELLITUSReview of Clinical Practice Guidelines

WEEK 1: Diagnosis and Evaluation

UHN AIMGP CLINIC

SEMINAR SERIES 2007

Updated by Dr. K. Tzanetos


Type 2 diabetes mellitus review of clinical practice guidelines1

TYPE 2 DIABETES MELLITUSReview of Clinical Practice Guidelines

Canadian Diabetes Association (CDA): 2003 Clinical Practice Guidelines for the Prevention and Management of diabetes in Canada.

  • Can J Diabetes 2003; 27 (Suppl 2).

  • http://www.diabetes.ca/cpg2003

    American Diabetes Association (ADA): Clinical Practice Recommendations 2004.

  • Diabetes Care 2004; 27 (Suppl 1).


Type 2 diabetes mellitus

TYPE 2 DIABETES MELLITUS

Objectives:

1) Examine diagnostic criteria for type 2 diabetes

2) Discuss screening recommendations for type 2 diabetes

3) Explore the suggested evaluation for first visit

4) Appreciate the importance of follow-up

5) Identify specific disease complications

- retinopathy/nephropathy/foot ulcerations


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS Take a minute to discuss…

CASE:

Mrs. X is a 58 year old woman referred to the AIMGP clinic by her GP with a random glucose of 12.0 mmol/L. She feels well with no complaints and this testing was done as a part of her routine blood work.

  • Does she have diabetes ?

  • What further testing could help you to decide?


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS Diagnostic Criteria for Type 2 DM

CASE: Mrs. X.

  • Does she have diabetes?

    • Likely! BUT you must do further tests.

    • Further testing needed…2 confirmatory laboratory glucose tests (FBG, random PG or 2hr 75g OGTT) on separate days in the absence of unequivocal hyperglycemia accompanied by an acute metabolic decompensation.


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS Diagnostic Criteria for Type 2 DM

Random PG ≥ 11.1mmol/L* and symptoms of diabetes

OR

Fasting plasma glucose (FPG) ≥ 7.0 mmol/L†

OR

2h PG in a 75-g oral glucose tolerance test (OGTT) ≥ 11.1 mmol/L

* Symptoms include fatigue, polyuria, polydipsia and weight loss

† Fasting is defined as no caloric intake for at least 8 h


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS Diagnostic Criteria for Type 2 DM

Glucose levels (mmol/L) for diagnosis:


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS Take a minute to discuss…

BACK TO THE CASE: Mrs. X is a Caucasian female who has no other PMHx. Her family history is negative.

  • Should Mrs. X. have been screened before now for type 2 diabetes?

    • By what method?

  • What high risk groups should undergo more frequent or earlier screening?


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS 3) Screening for Type 2 DM

  • All individuals should be evaluated annually for DM2 risk (demographic/clinical criteria)

  • In persons 40 yrs of age screening for DM2 using a FPG should be performed every 3 yrs

  • More frequent and/or earlier screening should be considered in ‘high risk’ groups


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS 3) Screening for Type 2 DM

  • Risk factors for Type 2 DM (CDA)

    • First-degree relative with diabetes

    • Member of high-risk population (e.g. persons of Aboriginal, Hispanic, S. African, Asian or S. Asian descent)

    • History of IGT or IFG

    • Presence of complications of DM

    • Vascular disease (**assoc. with the metabolic synD)

    • History of GDM


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS 3) Screening for Type 2 DM

  • Risk factors for Type 2 DM (CDA) cont’

    • History of macrosomal infant

    • HTN (**)

    • Dyslipidemia (**)

    • Overweight (**)

    • PCOS (**)

    • Acanthosis nigricans (**)

    • Schizophrenia (incidence 3X higher than the gen. population)


Type 2 diabetes mellitus review of clinical practice guidelines

DIABETES MELLITUS 3) Screening for Type 2 DM

  • CDA guidelines mandate yearly screening in patients with:

    • Hx of IFG or IGT

    • Presence of complications associated with diabetes

    • Hx of gestational diabetes or macrosomic infant (>4kg)

    • Presence of HTN or CAD

  • Screening Method

    • FPG (universal recommendation)

    • 2 h PG OGTT if FPG not diagnostic

    • Lack of standardization of the HBA1C test precludes its use for diagnosis


  • Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Take a minute to discuss…

    CASE:

    • Assume that you have taken a thorough medical history from Mrs. X that has included symptoms of hyperglycemia, symptoms of macrovascular and microvascular complications, nutritional details, and medical co-morbidities.

    • What would you now like to emphasize on Mrs. X.’s physical examination during her initial visit?


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Evaluation at first visit

    • PE in a patient with DM:

      • General (height, weight, BMI, postural BP, HR)

      • H & N (Pupils, EOMs, Lens opacities, fundi, oral hygiene and dental caries, thyroid)

      • CVS (signs of HTN, CHF, CAD; pulses, bruits, other signs of PVD)

      • Abdomen (hepatomegaly)

      • GU (r/o fungal infections, bladder distension)

      • MSK (foot inspection, colour, temperature, arthropathy)

      • Neuro (dysesthesiae, change in proprioception, vibration, light touch [monofilament], reflexes, autonomic nervous system)

      • Skin (infections, dyslipidemias, ulcers, trauma, injection sites)


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Take a minute to discuss…

    CASE:

    • What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit ?


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Evaluation at first visit

    • What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit (ADA)?

      • FPG (optional), HbA1c

      • Fasting lipid profile

      • Serum creatinine, Urinalysis

      • Test for microalbuminuria (type 1 diabetic patients after at least 5 years and in all patients with type 2 diabetes at diagnosis)

      • Urine culture (if indicated)

      • Thyroid-stimulating hormone (TSH) in all type 1 diabetic patients; in type 2 if clinically indicated

      • ECG


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Take a minute to discuss…

    CASE:

    • How frequently should patients like Mrs. X be followed after the initial visit?

    • Consider the following patient circumstances:

      • Diabetes is Diet controlled

      • Patient on oral hypoglyemics (at initiation, when titrating, on maintenance dosing)

      • Patient on insulin (at initiation, when titrating, on maintenance dosing)

      • For routine visits if they are meeting goals

      • For routine visits if they are not meeting goals


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Evaluation in follow-up

    • Follow-up Visit Frequency (ADA)?

      • Daily for initiation of insulin or change in regimen

      • Weekly for initiation of oral hypoglycemic agents or change in regimen

        (Are we meeting, or do we need to meet, these guidelines in AIMGP?)

      • Routine diabetes visits:

        • Quarterly for patients who are not meeting goals

          (Is this frequent enough?)

        • Semi-annually for patients with well-controlled diabetes


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Take a minute to discuss…

    CASE:

    • What historical information will you gather on Mrs. X’s follow-up visits?

    • What would you like to emphasize on Mrs. X.’s physical examination during her follow-up visits?

      • Include discussion on appropriate frequency of various maneuvers

    • What laboratory tests would you like to obtain on or shortly after Mrs. X.’s follow-up visits?

      • Include discussion on appropriate frequency of various tests


    Diabetes mellitus evaluation in follow up

    DIABETES MELLITUS Evaluation in follow-up

    • History taking on follow-up visits:

      • Treatment regimens (frequency of hyper/hypoglycemia, acute symptoms, self-monitoring BG results, pt regimen adjustments, adherence problems)

      • Lifestyle changes

      • Symptoms of chronic complications (including ensuring visits to opthomologist)

      • Changes in co-morbidities

      • Psychosocial issues

      • Immunization status


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS

    A Note on Retinopathy: Opthomology Follow-up

    • Type 2 diabetes:

      • At time of diagnosis

      • 1 year or less if retinopathy present

      • Every 1-2 yrs on advice of eye care professional if no evidence of retinopathy


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Evaluation in follow-up

    • Physical Examination at Follow-up Visits (ADA)?

      • At every regular diabetes visit:

        • Weight

        • BP

        • Previous abnormalities on physical exam

      • Complete physical exam annually

      • Comprehensive foot examination annually and visual inspection at every visit (and shoes!!)


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS A Note on Foot Care

    • Initial visit and annually thereafter IDENTIFY:

      • Peripheral neuropathy (monofilament or vibration)

      • Altered biomechanics (evidence of increased pressure - callus, erythema; limited joint mobility; bony deformity; or severe nail pathology - thick nails)

      • Peripheral vascular disease (hx of claudication, pulse exam, skin exam)

      • History of ulcers or amputation

  • The presence of any of these risk factors requires visualization of the patient’s feet at every subsequent visit


  • Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS Evaluation in follow-up

    • Laboratory tests at follow-up visits (ADA)

      • HbA1c

        • Quarterly if medications change or patient not meeting goals

        • Semi-annually if stable

      • FPG (optional)

      • Fasting lipid profile annually, unless low risk

      • Urinary microalbumin measurement annually (if indicated)


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS A Note on Nephropathy: Screening

    • Annual screening with a random daytime urine albumin: creatinine ratio (ACR)

    • For values ≥ 2.8 for females and 2.0 for males the test should be repeated

      • confirmed in 2 out of 3 measurements over 3 months

    • Uncertainty is clarified by 24h urine for protein

    • Microalbuminuria = 30 - 299 mg of albumin/24hrs

    • NB: If patients are dipstick positive, they will likely have macroalbuminuria


    Type 2 diabetes mellitus review of clinical practice guidelines

    DIABETES MELLITUS

    UHN AIMGP CLINIC

    SUMMER SERIES 2007

    Next week - Therapy of Type 2 DM

    Non-pharmacologic and

    pharmacologic


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