1 / 54

Diabetes Management in the Outpatient Setting

Diabetes Management in the Outpatient Setting. Diagnostic Criteria (before 2010). FPG≥126 mg/dl. Prediabetes (IFG)≥100 mg/dl. 75 gram OGTT 2 hour-value≥200 mg/dl. Prediabetes (IGT)≥140 mg/dl. Random blood glucose≥200 mg/dl + symptoms (polyuria, polydipsia, unexplained weight loss).

beall
Download Presentation

Diabetes Management in the Outpatient Setting

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Diabetes Management in the Outpatient Setting

  2. Diagnostic Criteria (before 2010) • FPG≥126 mg/dl. • Prediabetes (IFG)≥100 mg/dl. • 75 gram OGTT 2 hour-value≥200 mg/dl. • Prediabetes (IGT)≥140 mg/dl. • Random blood glucose≥200 mg/dl + symptoms (polyuria, polydipsia, unexplained weight loss).

  3. International Expert Committee Report on the Role of A1C in the Diagnosis of Diabetes 6.5% THE INTERNATIONAL EXPERT COMMITTEE. Diabetes Care 2009;32:1327

  4. 2010 Diagnosis of Diabetes and Categories of Increased Risk for Diabetes ADA, Diabetes Care 33: Suppl. 1, S11-S61, 2010

  5. Main factors in support of using HbA1C as a screening and diagnostic test • A1c does not require patients to be fasting. • HbA1c reflects longer-term glycemia than does plasma glucose. • Relatively unaffected by acute (e.g., stress or illness related) perturbations in glucose levels. • Currently used to guide management and adjust therapy. • HbA1c laboratory methods are now well standardized and reliable. J Clin Endocrinol Metab 93: 2447–2453, 2008 Diabetes Care 32 (7):1327-1334, 2009

  6. Limitations of the Use of A1C for the Diagnosis of Diabetes • Greater cost • Limited availability of A1C testing in certain regions of the developing world • Incomplete correlation between A1C and average glucose • Misleading in patients with anemia and hemoglobinopathies.

  7. Factors influencing A1c

  8. Recommendation of the International Expert Committee for the diagnosis of diabetes • Diabetes should be diagnosed when A1C is ≥6.5% • Diagnosis should be confirmed with a repeat A1C test • Confirmation is not required in symptomatic subjects with plasma glucose levels >200 mg/dl • If A1C testing is not possible, previously recommended diagnostic methods (e.g., FPG or2HPG, with confirmation) are acceptable. DIABETES CARE, VOLUME 32, NUMBER 7, JULY 2009

  9. Who To Screen • No major risk factors, FPG every 3 years beginning at 45 y.o. • Any risk factors, screen earlier and more often: • Overweight (BMI>25 kg/m2). • First degree relative with T2DM. • High risk ethnic group. • Hypertension (≥140/90 mmHg). • HDL≤35 mg/dl and/or triglycerides≥250 mg/dl. • History of gestational diabetes or delivered baby ≥9lb. • Polycystic ovary syndrome. • History of vascular disease. • Habitual physical inactivity.

  10. Treatment Goals for Type 2 Diabetes

  11. Guidelines for Glycemic, BP, & Lipid Control HDL = high-density lipoprotein; LDL = low-density lipoprotein; PG = plasma glucose; TG = triglycerides. ADA. Diabetes Care. 2012;35:S11-63

  12. Standard of Care-Multifactorial Therapy • DCCT (1993) and UKPDS (1998) established role for better glycemic control on prevention of microvascular complications. • Studies that improved BP or lipids generally showed lower CAD in type 2 diabetes. • Steno 2 trial (2003) showed a marked lowering of both micro and macrovascular events when all 3 utilized.

  13. Standard of Care-Multifactorial Therapy • DCCT (1993) and UKPDS (1998) established role for better glycemic control on prevention of microvascular complications. • Studies that improved BP or lipids generally showed lower CAD in type 2 diabetes. • Steno 2 trial (2003) showed a marked lowering of both micro and macrovascular events when all 3 utilized. • Memory effect-longterm micro and macrovascular • protection years after stopping the trial-in DCCT, UKPDS, and Steno 2 trials.

  14. But…then the role of intensive glucose control management came under active debate.

  15. Conclusions • Intensive treatment of glycemia in the ACCORD cohort did not reduce the risk of composite measures of advanced microvascular outcomes • renal failure: initiation of dialysis or ESRD, or renal transplant, or a rise of serum creatinine above 3.3 mg/dL • retinal photocoagulation or vitrectomy to treat diabetic retinopathy, • or development of neuropathy • Intensive therapy delayed the onset of albuminuria and some measures of eye complications and neuropathy • Microvascular benefits of intensive therapy should be weighed against increase in total and CVD-related mortality, increased weight gain, and high risk for severe hypoglycemia

  16. Figure 1 Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print] (Adapted with permission from: Ismail-Beigi F, et al. Ann Intern Med 2011;154:554)

  17. Main Pathophysiological Defects in T2DM pancreatic insulin secretion incretin effect pancreatic glucagon secretion ? - gut carbohydrate delivery & absorption HYPERGLYCEMIA - + peripheral glucose uptake hepatic glucose production Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011

  18. Antihyperglycemic Agents Major Sites of Action Plasma glucose Glucosidase Inhibitors (-) Glucose Uptake Glucose Production Carbohydrate Absorption Muscle/Fat GI tract (-) Injected Insulin Liver (+) Metformin Glitazones Insulin Secretion Sulfonylureas Meglitinides Insulin Secretion (+) Pancreas 1. Hines SE. Intensive management of type 2 diabetes. Patient Care.April 30, 2000:91-107. 2. Kelley DB, ed. Medical Management of Type 2 Diabetes. 4th ed. Alexandria, Va: American Diabetes Association; 1998:56-72.

  19. Natural History of Type 2 DM Plasma Glucose Postmeal glucose Fasting glucose 126mg/dL Insulin resistance Relative -Cell Function Insulin secretion -30 -20 -10 0 10 20 30 Years of Diabetes DeFronzo RA. Pathogenesis of type 2 diabetes: Implications for metformin. Drugs. 1999;58 (suppl 1):29-30.

  20. Management of Hyperglycemia in T2DM • ANTI-HYPERGLYCEMIC THERAPY • Therapeutic options: Lifestyle • Weight optimization • Healthy diet • Increased activity level Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  21. Management of Hyperglycemia in T2DM • ANTI-HYPERGLYCEMIC THERAPY • Therapeutic options: • Oral agents & non-insulin injectables • Metformin • Sulfonylureas • Thiazolidinediones • DPP-4 inhibitors • GLP-1 receptor agonists • Meglitinides • a-glucosidase inhibitors • Bile acid sequestrants • Dopamine-2 agonists • Amylin mimetics Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  22. Table 1. Properties of anti-hyperglycemic agents Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  23. Table 1. Properties of anti-hyperglycemic agents Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  24. Table 1. Properties of anti-hyperglycemic agents Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  25. Management of Hyperglycemia in T2DM • ANTI-HYPERGLYCEMIC THERAPY • Implementation strategies: • Initial therapy • Advancing to dual combination therapy • Advancing to triple combination therapy • Transitions to & titrations of insulin Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  26. Management of Hyperglycemia in T2DM • ANTI-HYPERGLYCEMIC THERAPY • Implementation strategies: • If A1c >9% start with 2 meds. • Consider insulin if BS>300 or A1c>10% • Adding a second agent drops A1c on average 1%. • A1c>8.5% and on 2 drugs=insulin.

  27. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Age • Weight • Sex / racial / ethnic / genetic differences • Comorbidities • Coronary artery disease • Heart Failure • Chronic kidney disease • Liver dysfunction • Hypoglycemia Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  28. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Age: Older adults • Reduced life expectancy • Higher CVD burden • Reduced GFR • At risk for adverse events from polypharmacy • More likely to be compromised from hypoglycemia • Less ambitious targets • HbA1c <7.5–8.0% if tighter targets not easily achieved • Focus on drug safety Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  29. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Weight • Majority of T2DM patients overweight / obese • Intensive lifestyle program • Metformin • GLP-1 receptor agonists • ? Bariatric surgery • Consider LADA in lean patients Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  30. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Sex/ethnic/racial/genetic differences • Little is known • MODY & other monogenic forms of diabetes • Latinos: more insulin resistance • East Asians: more beta cell dysfunction • Gender may drive concerns about adverse effects (e.g., bone loss from TZDs) Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  31. Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print] T2DM Anti-hyperglycemic Therapy: General Recommendations

  32. Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print] Adapted Recommendations: When Goal is to Avoid Weight Gain

  33. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Comorbidities • Coronary Disease • Heart Failure • Renal disease • Liver dysfunction • Hypoglycemia • Metformin: CVD benefit (UKPDS) • Avoid hypoglycemia • ? SUs & ischemic preconditioning • ? Pioglitazone &  CVD events • ? Effects of incretin-based therapies Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  34. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Comorbidities • Coronary Disease • Heart Failure • Renal disease • Liver dysfunction • Hypoglycemia • Metformin: May use unless condition is unstable or severe • Avoid TZDs • ? Effects of incretin-based therapies Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  35. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Comorbidities • Coronary Disease • Heart Failure • Renal disease • Liver dysfunction • Hypoglycemia • Increased risk of hypoglycemia • Metformin & lactic acidosis • US: stop @SCr ≥ 1.5 (1.4 women) • UK:  dose @GFR <45 & stop @GFR <30 • Caution with SUs (esp. glyburide) • DPP-4-i’s – dose adjust for most • Avoid exenatide if GFR <30 Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  36. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Comorbidities • Coronary Disease • Heart Failure • Renal disease • Liver dysfunction • Hypoglycemia • Most drugs not tested in advanced liver disease • Pioglitazone may help steatosis • Insulin best option if disease severe Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  37. Management of Hyperglycemia in T2DM • CONSIDERATIONS • Comorbidities • Coronary Disease • Heart Failure • Renal disease • Liver dysfunction • Hypoglycemia • Emerging concerns regarding association with increased mortality • Proper drug selection in the hypoglycemia prone Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print]

  38. Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print] T2DM Anti-hyperglycemic Therapy: General Recommendations

  39. Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print] Adapted Recommendations: When Goal is to Avoid Hypoglycemia

  40. Diabetes Care,Diabetologia. 19April 2012 [Epub ahead of print] Adapted Recommendations: When Goal is to Minimize Costs

  41. Physiologic Insulin Secretion :Basal/Bolus Concept Prandial Insulin 50 Insulin (µU/mL) 25 0 Basal Insulin Breakfast Lunch Supper 150 Prandial Glucose • Suppresses Glucose Production Between Meals & Overnight • Basal  50% of Daily Needs 100 Glucose (mg/dL) 50 Basal Glucose 0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 A.M. P.M. Time of Day

  42. Management of Hyperglycemia in T2DM • ANTI-HYPERGLYCEMIC THERAPY • Therapeutic options: Insulin Rapid (Lispro, Aspart, Glulisine) Short (Regular) Insulin level Intermediate (NPH) Long (Detemir) Long (Glargine) Hours 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours after injection

  43. Establishing Basal Requirement for Glargine • Initial calculation of basal dose • BW in kilograms x sensitivity index (0.15 – 0.2 ) • Or • Body Weight in pounds x 0.1 • From BID NPH • Take total NPH dose and decrease by 20% for starting dose

  44. Establishing Basal Requirement for Glargine • Sequential increase • Increase every 2-3 days by • 4 U if FBG>140 mg/dL • 2 U if FBG=120mg/dL to 140 mg/dL • OR • Mean of am BG after five days • Add to initial Glargine by formula • (Average BG-100)/10 • Example: 200 pounds on 20 units glargine q hs, mean am BG is200 on 6th and 7th day • Add (Av BG -100)10 to glargine, (200-100/10) • i.e. increase from 20 to 30 units q hs • 2nd week--average 130 ,increase glargine from 30 to 33

More Related