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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

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


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?


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.


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


DIABETES MELLITUS Diagnostic Criteria for Type 2 DM

Glucose levels (mmol/L) for diagnosis:


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?


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


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


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)


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


  • 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?


    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)


    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 ?


    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


    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


    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


    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


    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


    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!!)


    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


  • 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)


    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


    DIABETES MELLITUS

    UHN AIMGP CLINIC

    SUMMER SERIES 2007

    Next week - Therapy of Type 2 DM

    Non-pharmacologic and

    pharmacologic


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