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Management of the Patient with Type 2 Diabetes. Gretchen M. Ray, Pharm.D. Cardiovascular Pharmacotherapy Resident University of New Mexico College of Pharmacy. Objectives. Provide diabetes screening criteria for adults

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Management of the patient with type 2 diabetes l.jpg

Management of the Patient with Type 2 Diabetes

Gretchen M. Ray, Pharm.D.

Cardiovascular Pharmacotherapy Resident

University of New Mexico College of Pharmacy


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Objectives

  • Provide diabetes screening criteria for adults

  • Describe available pharmacologic treatment options for type 2 diabetes including advantages/disadvantages of therapy and contraindications

  • Given a patient case recommend appropriate lifestyle modifications and pharmacotherapy to achieve glycemic goals


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Objectives

  • Distinguish between microvascular and macrovascular complications

  • Provide screening criteria for nephropathy, neuropathy, and retinopathy

  • Provide treatment strategies for the prevention and treatment of micro and macrovascular complications


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Epidemiology of Type 2 DM

  • In 2005 20.8 million people (7% of the US population) had diabetes

    • 14.6 million diagnosed

    • 6.2 million undiagnosed

  • Type 2 diabetes accounts for 90-95% of patients with diabetes

  • In 2002 total indirect and direct medical costs for diabetes = $132 billion

CDC. National diabetes fact sheet. 2005 available at www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf


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Risk factors for type 2 diabetes

  • Physically inactive

  • 1st degree relative with diabetes

  • Minority ethnic groups

  • Gestational diabetes or delivering a baby >9 lbs

  • Hypertension

  • HDL <35 mg/dL and/or triglycerides >250 mg/dL

  • Polycystic ovary syndrome

  • Previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

  • History of vascular disease

  • Psychiatric illness


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Diagnosis of diabetes

  • Symptoms of diabetes + casual plasma glucose ≥ 200 mg/dl

  • FPG ≥ 126 mg/dl

  • Oral glucose tolerance test (OGTT): 2-h postload glucose ≥ 200 mg/dl

OR

OR


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Definition of “pre-diabetes”

  • Impaired fasting glucose (IFG) = FPG 100-125 mg/dl

  • Impaired glucose tolerance (IGT) = 2-h post load glucose 140-199 mg/dl

  • IFG and IGT indicate a risk factor for diabetes and cardiovascular disease


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Diabetes Screening

  • Screening identifies asymptomatic patients who might have diabetes

  • Consider in patients ≥ 45 years especially if their BMI ≥ 25 kg/m2

  • Screen patients < 45 years old if they are overweight + an additional risk factor

  • FPG should be done initially

  • Repeat screening every 3 years



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Metformin

  •  hepatic glucose production,  intestinal glucose absorption,  insulin sensitivity

  • Efficacy:  A1C 1.5%

  • Adverse effects

    • Primarily GI (up to 50%)

      • Diarrhea, abdominal bloating, nausea

      • Titrate dose at weekly intervals to minimize AEs

      • Give with meals

    • Lactic acidosis- rare

      • Monitor SCr


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Contraindications to Metformin

  • Renal impairment SCr >1.5 for men, >1.4 for women

  • Radiocontrast studies

  • Age >80 unless normal GFR

  • Hypoxia

  • Liver dysfunction

  • Alcoholism

  • Heart Failure requiring pharmacologic therapy

    • According to package insert

  • Should heart failure be a contraindication to metformin?


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Improved Clinical Outcomes Associated with Metformin in Patients with Diabetes and Heart Failure

  • Investigate the association between metformin and clinical outcomes in patients with HF and diabetes

  • Retrospective study

  • Primary outcome: all-cause mortality at 1 year and end of follow-up

  • Secondary outcome: all-cause hospitalizations at 1 year and end of follow-up

Eurich DT, et al. Diabetes Care. 2005;28:2345-51


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Improved Clinical Outcomes Associated with Metformin in Patients with Diabetes and Heart Failure

Eurich DT, et al. Diabetes Care. 2005;28:2345-51


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Improved Clinical Outcomes Associated with Metformin in Patients with Diabetes and Heart Failure

  • Lower all-cause mortality with metformin

  • No increase in hospitalizations associated with metformin

  • Observational study

    • Cannot prove that metformin is efficacious in this population

Eurich DT, et al. Diabetes Care. 2005;28:2345-51


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Sulfonylureas Patients with Diabetes and Heart Failure

  • ↑ insulin secretion from pancreatic β-cells

  • Efficacy: ↓ A1C 1.5%

  • Glyburide

    • Not recommended if CrCl < 50 ml/min (use a different sulfonylurea)

  • Glipizide

    • Not recommended if CrCl < 10 ml/min

  • Glimepiride

    • Not recommended if CrCl < 22 ml/min

  • Response of sulfonylureas plateaus after half the max dose

  • Reduced GI absorption if blood glucose > 250 mg/dL


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Sulfonylureas Adverse Effects Patients with Diabetes and Heart Failure

  • Hypoglycemia

    • Elderly patients

    • Hepatic/renal impairment

    • Combination therapy

  • Weight gain


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Thiazolidenediones (TZDs) Insulin Sensitizers Patients with Diabetes and Heart Failure

  • TZDs are PPAR- gamma receptor activators

  • ↑ insulin sensitivity

    • Primarily in the peripheral tissue

  • Efficacy:  A1C 0.5-1.4%

  • Effect may not be seen for 4 weeks

  • Rosiglitazone (Avandia®)

    • Initial dose 4 mg/day, Max dose 8 mg/day

  • Pioglitazone (Actos®)

    • Initial dose 15-30 mg/day, Max dose 45 mg/day


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AE’s Patients with Diabetes and Heart Failure

Fluid retention and peripheral edema

Weight gain

Fluid retention is a major contributor

Redistribution of adipose tissue

New-onset heart failure

< 1%

2-3% when combined with insulin

CI’s

ALT > 2.5 x upper limit of normal

Hepatic disease

Alcohol Abuse

HF NYHA class III or IV (see following slides)

Adverse Effects/Contraindications of TZDs

Granberry MC, et al. Am J Health-Syst Pharm. 2007;64:931-6


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TZD Use In Heart Failure Patients with Diabetes and Heart Failure

  • Use of TZDs in patients with NYHA class I or II HF

    • May be used with initiation of treatment at the lowest dosage (rosiglitazone 2 mg daily or pioglitazone 15 mg daily)

    • Observe for weight gain, edema, or exacerbation of HF

  • Do not use TZDs in patients with NYHA class III or IV HF

Nesto RW, et al. Diabetes Care. 2004;27:256-63


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Meta-analysis of MI Risk With Rosiglitazone Patients with Diabetes and Heart Failure

  • 42 trials comparing rosiglitazone with placebo

    • 15,560 patients received rosiglitazone

    • 12,283 patients assigned to comparator groups

    • 24-52 week duration of trials

    • Mean baseline A1C 8.2% for both groups

Nissen SE, et al. N Engl J Med. 2007;356:1-15


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Meta-analysis of MI Risk With Rosiglitazone Patients with Diabetes and Heart Failure

Nissen SE, et al. N Engl J Med. 2007;356:1-15


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PROactive Trial Patients with Diabetes and Heart Failure

  • Primary objective: Determine if pioglitazone reduces CV morbidity and mortality in patients with diabetes

  • Pioglitazone vs. placebo

    • ↓ Triglycerides 11% vs. 1.8% ↑

    • ↑ LDL 7.2% vs. 4.9%

    • ↓ LDL/HDL 9.5% vs. 4.2%

  • Non-significant reduction in the primary endpoint

Dormandy JA, et al. Lancet. 2005;366:1279-89


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PROactive Sub-analysis Patients with Diabetes and Heart Failure

  • Evaluated same endpoints in patients with prior MI

  • Significant ↓ in fatal/nonfatal MI excluding silent MI with pioglitazone

    • 5.3% pioglitazone vs. 7.2% placebo p=0.0453

  • Results for rosiglitazone and pioglitazone recently confirmed with two new meta-analyses

Erdmann E, et al. J Am Coll Cardiol. 2007;49:1772-80


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HF in PROactive Patients with Diabetes and Heart Failure

Dormandy JA, et al. Lancet. 2005;366:1279-89


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FDA Updates- August 14, 2007 Patients with Diabetes and Heart Failure

  • Rosiglitazone and pioglitazone received a “boxed warning” regarding CHF

www.fda.gov

Actos prescribing information. August 2007


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FDA Updates: November 19, 2007 Patients with Diabetes and Heart Failure

  • MI risk added to rosiglitazone boxed warning

Avandia prescribing information. November 2007


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Sitagliptin (Januvia Patients with Diabetes and Heart Failure®)

  • DPP-4 inhibitor

    • Prevents the degradation of endogenous GLP-1

    • Results in a rise in postprandial endogenous GLP-1 levels

Sitagliptin

Lauster CD et al. Am J Health Syst Pharm. 2007;64:1265-73


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Sitagliptin (Januvia Patients with Diabetes and Heart Failure®)

  • Efficacy: A1C 0.5-0.7%

  • 100 mg PO once daily

    • CrCl 30-50 ml/min 50 mg/day

    • CrCl <30 ml/min 25 mg/day

  • Approved for monotherapy or combination therapy

  • Weight neutral

  • Side effects similar to placebo

  • No contraindications identified yet


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Non-Oral Therapies Patients with Diabetes and Heart Failure


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Glucagon-like peptide 1 (GLP-1) agonists Patients with Diabetes and Heart Failure

  • Exenatide (Byetta®)

  • Glucagon-like-peptide-1 (GLP-1) analog

    • Incretin mimetic

    • Resistant to degradation by dipeptidyl peptidase-4 (DPP-4)

    • Suppresses high glucagon levels

    • Delays gastric emptying (can affect absorption of other medications)

  • Efficacy: ↓ A1C 0.5-1%

  • Dosing:

    • 5 mcg SC twice daily within 60 min of meals

    • Increase to 10 mcg bid after 4 weeks

  • FDA approved for type 2 diabetes in patients on metformin, sulfonylurea, TZD, or a combination who are not at goal

    • Not yet approved for use with basal insulin


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GLP-1 Physiology Patients with Diabetes and Heart Failure


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AE’s Patients with Diabetes and Heart Failure

N/V, diarrhea (30-45%)

Modest weight loss (a good side effect)

Hypoglycemia especially in combination with sulfonylureas

Anti-exenatide antibodies

Monitoring

Renal function

A1C in 3 months

CI’s

Type 1 diabetes

Precautions

CrCl < 30 ml/min

Gastroparesis

Hypoglycemia

Exenatide adverse effects/contraindications


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Pramlintide (Symlin Patients with Diabetes and Heart Failure®)

  • Synthetic analog of human amylin

    • Suppresses glucagon secretion

      • Suppression of endogenous glucose from liver

    • Slows gastric emptying

      • Less rapid glucose appearance in the circulation

    • Regulates food intake due to central modulation of appetite

      • Weight loss


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Pramlintide (Symlin Patients with Diabetes and Heart Failure®)

  • FDA approved for Type 1 or 2 diabetes in patients on optimal insulin therapy who are still not at goal

    • With or without metformin and/or sulfonylurea therapy

  • Efficacy: A1C ~0.1-0.4% in type1 and 0.3-0.7% in type 2

  • 60 mcg (10 units) SC titrate to 120 mcg (20 units) before major meals (Type 2 dosing)

    • Dosed in mcg but drawn up in an insulin syringe

    • www.symlin.com/7522-Type-2-Dosing.aspx

  • Administered in conjunction with mealtime insulin


Pramlintide symlin37 l.jpg

Adverse Effects Patients with Diabetes and Heart Failure

Insulin-Induced Severe Hypoglycemia:

Hypoglycemia will occur within 3 hours of injection

Must reduce pre-meal insulin by 50% at initiation to prevent serious reactions

Further reduction in insulin may be needed as dosage of pramlintide is adjusted

Contraindications

Diagnosis of gastroparesis

Hypoglycemia unawareness

A1C > 9.0%

Recurrent severe hypoglycemia requiring assistance during past 6 months

Using other medications that stimulate gastrointestinal motility

Pediatrics

Pramlintide (Symlin®)


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Glycemic Goals Patients with Diabetes and Heart Failure


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ADA Guidelines Patients with Diabetes and Heart Failure

A1C < 7.0%

<6.5 may further reduce complications

Fasting glucose 90-130 mg/dl

Peak postprandial glucose <180 mg/dl

1-2 hours after the start of the meal

AACE Guidelines

A1C < 6.5%

Fasting glucose < 110 mg/dl

2-h postprandial glucose <140 mg/dl

Glycemic Control


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A1C and Meal Plasma Glucose Levels Patients with Diabetes and Heart Failure

  • A1C should be as close to normal for the individual patient

  • Use less intensive goals for patients with risk for hypoglycemia

  • Target postprandial glucose if A1C goals not met after reaching preprandial goals

    • Target fasting glucose first!


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Self-Monitoring of Blood Glucose (SMBG) Patients with Diabetes and Heart Failure

  • At least 3 times/day if on insulin injections

  • If on orals, just use SMBG to help them achieve their glycemic goals

  • Use the data to make decisions on what therapy to add


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Lifestyle + Metformin- Step 1 Patients with Diabetes and Heart Failure

  • Titrate metformin to max dose over 1-2 months

  • TZDs and sitagliptin are also approved for monotherapy

  • Consider adding other oral medications if there is persistent hyperglycemia


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Lifestyle Modifications Patients with Diabetes and Heart Failure


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Diet Patients with Diabetes and Heart Failure

  • Weight loss will reduce insulin resistance

  • Saturated fat < 7 % of total daily calories

  • Carbohydrates should be from fruits, vegetables, whole grains, legumes, low fat milk

    • Low carb diets < 130 g/day not recommended for weight loss

  • Recommend sugar alcohols and nonnutritive sweeteners

  • Limit alcohol to 1 drink/day for women 2 drinks/day for men

    • If on insulin or a secretagogue drink alcohol with food to avoid hypoglycemia


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Exercise Patients with Diabetes and Heart Failure

  • 150 min/week of moderate-intensity aerobic activity (50-70% of max heart rate)

  • 90 min/week of vigorous aerobic exercise (>70% of max heart rate)

  • Resistance exercise 3 times a week

  • Improves glycemia

OR


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Diabetes Self-Management Education (DSME) Patients with Diabetes and Heart Failure

  • All patients with diabetes should receive DSME after diagnosis

  • Teaches patients about the disease and how to improve self care

  • Should be conducted by either a CDE or health care professional with recent experience in diabetes management


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Additional Medications - Step 2 Patients with Diabetes and Heart Failure

  • Add within 2-3 months of initiation of therapy

  • Sulfonylurea

    • Cheapest option

  • TZDs

    • More expensive

    • Cardiac risk with rosiglitazone

  • Insulin

    • Most effective option

    • Consider in patients with A1C >8.5% or symptoms of hyperglycemia

    • Initiate with basal insulin


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Step-2 Alternatives Patients with Diabetes and Heart Failure

  • Sitagliptin

  • Glinides

  • Exenatide


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Step-3 Initiate or intensify insulin therapy Patients with Diabetes and Heart Failure

  • Start or intensify insulin if lifestyle + metformin + a 2nd medication have not attained goal A1C

  • Third oral medication can be considered if A1C is close to goal <8.0%

    • Expensive, not as effective as insulin

    • Exenatide could be used at this step

  • D/C insulin secretagogues (sulfonylurea or glinides) when pre-prandial rapid insulin is started


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Long Acting Insulin 10 units or 0.2 units/kg Patients with Diabetes and Heart Failure

Increase dose 2 units q 3 days until fasting levels 70-130 mg/dl

A1C ≥ 7% after 2-3 months?

Check pre-meal BG & add 2nd injection ~4 units before meal

Yes

No

Continue regimen Check A1C q 3 months

Pre-Bed high: Add rapid acting at dinner

Pre-Lunch BG high: Add rapid acting at breakfast

Pre-Dinner high: Add rapid acting at lunch

A1C ≥ 7% after 2-3 months?

Nathan DM, et al. Diabetes Care 2006;29


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A1C Patients with Diabetes and Heart Failure≥ 7% after 2-3 months?

No

Yes

Recheck pre-meal BG and add another injection.

Check 2-h postprandial BG and adjust pre-prandial insulin dose

Continue regimen and check A1C q 3 months

Nathan DM, et al. Diabetes Care 2006;29


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TZD Patients with Diabetes and Heart Failure

Sitagliptin

Exenatide

Exenatide

Pramlintide


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CASE 1 Patients with Diabetes and Heart Failure

  • JK is a 59 year old male presenting for a follow-up visit to the diabetes clinic.

  • Past Medical History

    • Type 2 diabetes

    • Hypertension

    • Coronary artery disease

    • Chronic renal insufficiency


Case 157 l.jpg

Medications Patients with Diabetes and Heart Failure

Metformin 1000 mg BID

Glyburide 10 mg BID

Pioglitazone 45 mg once daily

Metoprolol XL 50 mg once daily

Fosinopril 20 mg once daily

Aspirin 81 mg once daily

Labs (fasting)

Glucose 170 mg/dL

A1C 9.0%

SCr 1.7 mg/dL

CrCl 70 ml/min

CASE 1


Case 158 l.jpg
CASE 1 Patients with Diabetes and Heart Failure

  • Which diabetes medication on his profile is contraindicated and should be discontinued?

  • A. Metformin

  • B. Glyburide

  • C. Pioglitazone


Case 159 l.jpg
CASE 1 Patients with Diabetes and Heart Failure

  • Why?

  • A. Coronary artery disease

  • B. Renal insufficiency

  • C. Drug Interaction

  • D. Non-adherence


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CASE 1 Patients with Diabetes and Heart Failure

  • Which one of the following would be most appropriate to replace the discontinued medication?

    A. Glipizide XL 20 mg PO once daily

    B. Insulin aspart 4 units SC before breakfast

    C. Insulin glargine 10 units SC at bedtime

    D. Pramlintide 60 mcg SC before meals


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Complications of Diabetes Patients with Diabetes and Heart Failure


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Complications of Uncontrolled Diabetes Patients with Diabetes and Heart Failure

Hyperglycemia

Continuous

Spike

Acute Toxicity

Chronic Toxicity

Tissue Lesions

Diabetic Complications

Microvascular

Macrovascular

Nephropathy Neuropathy Retinopathy

PVD MI Stroke

PPG

HbA1C

Hanefeld M, et al. Diabet Med. 1997;14(suppl 3):S6


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Adjusted Incidence Patients with Diabetes and Heart Failure

per 1000 person years

9

10

6

7

8

11

*Based on UKPDS 35 data

Stratton IM, et al. BMJ. 2000;321:405-12.

Relative Risk of Progression of Diabetic Complications by Mean HbA1c*

Updated Mean HbA1c (%)


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Macrovascular Complications Patients with Diabetes and Heart Failure


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Macrovascular Complication Statistics Patients with Diabetes and Heart Failure

  • CVD and Stroke

    • Adults with DM have heart disease death rates 2-4x higher than non-diabetics

    • Risk for stroke is 2 to 4x higher and risk of death from stroke is 2.8x higher than in non-diabetics

U.S. Department of Health and Human Services, National Institute of Health, 2005.


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Macrovascular Complications Patients with Diabetes and Heart Failure

~ 80% of all diabetic mortality

75% from coronary atherosclerosis

25% from cerebral or peripheral vascular disease

> 75% of all hospitalizations for diabetic complications

> 50% of patients with newly diagnosed type 2 diabetes have CHD

National Diabetes Data Group. Diabetes in America. 2nd. Ed. NIH; 1995.


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Insulin Resistance and Atherosclerosis Patients with Diabetes and Heart Failure

Insulin resistance

Hyperinsulinemia

Impairedglucosetolerance

HypertriglyceridemiaDecreased HDL-C

Essentialhypertension

Clinicaldiabetes

Accelerated atherosclerosis


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Heart Disease and Diabetes Patients with Diabetes and Heart Failure

Intensive treatment of hyperglycemia

Therapy for insulin resistance

Appropriate lipid management

Aggressive blood pressure control

Treatment of CVD in diabetes is similar to therapy for non-diabetic individuals, the risk of CVD is much higher and the benefits of therapy are greater


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Hypertension Patients with Diabetes and Heart Failure

Defined as BP ≥ 140/90 mmHg

GOAL BP: < 130/80 mmHg

20 – 60% of Diabetics have HTN

Epidemiologic evidence from the UKPDS indicate that each 10 mmHg decrease in mean SBP results in:

 12% any DM complication

 15% any DM-related death

 11% MI

 13% microvascular complications

American Diabetes Association. Diabetes Care. 2007;30:S4-S41.


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Hypertension Patients with Diabetes and Heart Failure

Weight loss

 1 kg results in  of MAP ~ 1 mmHg

Sodium restriction

In non-diabetic patients reduces SBP ~ 5 mmHg and DBP ~2 - 3 mmHg

Drug Therapy (If SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or lifestyle modification failure)

1st choice: ACE-I or ARB

2nd choice: Thiazide, β-Blocker, or Non-DCCB

JNC 7 report. JAMA 2003;289:2560-72.


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Cholesterol Management Patients with Diabetes and Heart Failure

Screening:

Fasting lipid panel at least annually

More often if needed to achieve goals

In adults with low-risk lipid values, may obtain fasting lipid panel every 2 years

Goals:

LDL < 100 mg/dL

Optional: LDL <70 mg/dL

TG < 150 mg/dL

HDL:

> 40 mg/dL for males

> 50 mg/dL for females

American Diabetes Association. Diabetes Care .2007;30:S4-S41.


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Macrovascular Complications Patients with Diabetes and Heart Failure

Aspirin Therapy: 75 – 162 mg/day

Primary prevention in those with ↑ CVD risk:

Family Hx of CVD

Tobacco use

HTN

Albuminuria

Lipids: TC >200; LDL >100; HDL < 45 (or 55) & TG >200

Age ≥ 40 years

Secondary prevention in those with DM + CVD

Not recommended for patients < 30 years-old

American Diabetes Association. Diabetes Care .2007;30:S4-S41.


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Macrovascular Complications Patients with Diabetes and Heart Failure

Smoking cessation

Advise all patients not to smoke

Provide smoking cessation counseling and other forms of treatment if needed

American Diabetes Association. Diabetes Care .2007;30:S4-S41.


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Macrovascular Complications Patients with Diabetes and Heart Failure

Goals

Dyslipidemia

Hypertension

  • LDL < 100 mg/dL

    • Optimal < 70 mg/dL

  • TG < 150 mg/dL

  • HDL:

    • > 40 mg/dL – Male

    • > 50 mg/dL - Female

  • Blood Pressure:

  • < 130/80 mmHg

Treatment

  • Weight loss

  • Sodium restriction

  • ACE-I / ARB

  • Statin

  • Everyone needs:

  • Aspirin

  • Lifestyle modifications

  • Smoking Cessation

Management Summary for Macrovascular Complications

American Diabetes Association. Diabetes Care .2007;30:S4-S41.


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Microvascular Complications Patients with Diabetes and Heart Failure


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Relative Risk of Progression of Diabetic Complications by Mean HbA1c*

15

Diabetic retinopathy

Nephropathy

Neuropathy

Microalbuminuria

13

11

Relative

risk

9

7

5

3

1

7

8

9

6

10

11

12

HbA1c (%)

*Based on DCCT data

Skyler JS ,et al. Endocrinol Metab Clin North Am. 1996;25:243-54.


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Diabetic Nephropathy Mean HbA

Occurs in 20 to 40% of diabetics

Most common cause of ESRD

ESRD develops in 50% of type 1 patients with overt nephropathy within 10 years

ESRD develops in about 20% of type 2 patients with overt nephropathy within 20 years

American Diabetes Association. Diabetes Care. 2007;30:S4-S41.


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Nephropathy: Diagnosis Mean HbA

Category Spot Collection

(albumin-to-creatinine)

(mcg/mg)

Normal < 30

Microalbuminuria 30 - 299

Clinical albuminuria > 300

Two of three specimens collected within a 3-6 month period should be abnormal before diagnosing.

Exercise within 24 hr, infection, fever, CHF, marked hyperglycemia or HTN, pyuria, & hematuria may elevate urinary albumin excretion over baseline values

American Diabetes Association. Diabetes Care. 2007;30:S4-S41.


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Nephropathy: Mean HbAScreening

Screening

DM 1: Within 5 years of diagnosis

DM 2: Upon diagnosis

DM 1 and 2: Follow-up exams annually

If (+) for microalbuminuria, test twice more over next 3 to 6 months

If 2 of 3 tests are positive, they have microalbuminuria and should have treatment started

Serum creatinine should be measured at least annually for estimation of GFR

American Diabetes Association. Diabetes Care. 2007;30:S4-S41


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Nephropathy: Treatment Mean HbA

Glycemic control: HbA1c < 7%

Blood pressure control: BP < 130/80 mmHg

ACE-I / ARBs

Decrease progression of microalbuminuria and slow rate of decline in GFR in patients with proteinuria

Non-DCCBs, BB’s, or thiazide acceptable if intolerant to ACEI/ARB

If ACE-I, ARBs, or thiazide used, monitor K+

Protein restriction

With presence of nephropathy

≤ 0.8 g/kg per day (~ 10% of daily calories)

American Diabetes Association. Diabetes Care. 2007;30:S4-S41


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Sensorimotor Mean HbA

Muscular

Muscle weakeness

Balance difficulties

Sensory

Pain

Parathesias

Numbness

Cramping

Nighttime falls

Autonomic

Cardiovascular

Syncope, fatigue, sustained heart rate

GI

Dysphagia, N/V, constipation, diarrhea

Genitourinary

↓ bladder control, UTIs, ED, Dyspareunia

Sudomotor

Dry skin, calluses, limb hair loss

Endocrine

Hypoglycemic unawareness

Other

Depression, anxiety, sleep disorders

Diabetic Neuropathy


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Diabetic Neuropathy Screening Mean HbA

  • Annual foot exam:

    • Assessment for protective sensation, foot structure and biomechanics, vascular status, and skin integrity.

      • Neurologic status assessed with 5.07 (10-g) monofilament

      • Also consider: pin-prick sensation, temperature and vibration perception (using tuning fork)

      • Assess for history of claudication, and assess pedal pulses

      • Assess skin integrity especially b/w toes and under metatarsal heads. Look for erythema, warmth, or callus formation (increased plantar pressure)

      • Bony deformities, limitation in joint mobility, and gait and balance should be assessed


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Diabetic Neuropathy Treatment Mean HbA

  • Glycemic control: HbA1c < 7%

  • Foot care

    • Proper footwear

    • Daily patient assessment

    • Moisturizing

      • Not between toes

    • NO bare feet!


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Peripheral Neuropathy Treatment Mean HbA

  • Optimal glycemic control: GOAL HbA1c < 7%

Wong M, et al. BMJ. 2007; 335; 1-10.


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Diabetic Retinopathy Mean HbA

Normal Vision

Diabetic Retinopathy

Leading cause of new cases of blindness among adults (20 to 74 years of age).

Prevalence is strongly related to duration of diabetes.


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Diabetic Retinopathy Screening Mean HbA

  • Comprehensive dilated eye exam:

    • DM 1: Within 3 to 5 years of diagnosis

    • DM 2: Upon diagnosis

    • DM 1 and 2: Follow-up exams annually

American Diabetes Association. Diabetes Care. 2007;30:S4-S41.


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Diabetic Retinopathy Management Mean HbA

  • Tight glycemic control HbA1C < 7%

  • Tight blood pressure control <130/80 mmHg

    • Both shown to delay or prevent onset of retinopathy


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Management Summary for Microvascular Complications Mean HbA

Microvascular Complications

Screening

Retinopathy

Neuropathy

Nephropathy

  • Comprehensive foot exam:

  • Inspection

  • Vascular

  • Vibratory perception

  • Monofilament

  • Annual Exam:

  • Dilated Eye

  • Retinal vessels

  • Cataract

  • Intraocular Pressure

  • Annual Microalbumin:

  • Screen Albumin:

    • Creatinine ratio

    • Repeat to confirm

Treatment

  • Glycemic Control

  • ACE-I / ARB

  • Glycemic Control

  • BP Control

  • Photocoagulation

  • Glycemic Control

  • Foot care/ footwear

  • Medication Management

Everyone needs lifestyle modifications


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Standards of Care in Diabetes Mean HbA

Diabetes Care. 2007;30(suppl 1):S4-S41


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Medical history during the 1 Mean HbAst evaluation

  • Age and characteristics of onset of diabetes

  • Eating patterns

  • History of diabetes education

  • Previous and current treatments

  • Exercise history

  • Hypoglycemic episodes

  • History of DKA?

  • History of diabetes related complications


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Physical Exam Mean HbA

BP

Fundoscopic exam

Thyroid palpation

Skin exam

Peripheral pulses

Patellar and achilles reflexes

Peripheral sensation

Labs to order

A1C

Fasting lipids

LFTs

Microalbuminuria

SCr and GFR

TSH

Physical Exam/Labs


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Health Maintenance/Prevention of Complications Mean HbA

  • Influenza vaccine annually

  • Pneumococcal vaccine for all adults

  • Smoking cessation!

  • BP at every visit, goal < 130/80 mmHg

  • Check lipids annually: Goal LDL <100 mg/dL, TG <150 mg/dL, HDL >40 for men >50 for women

  • Annual test for microalbuminuria

  • Annual eye exam to screen for retinopathy

  • Annual screening for peripheral and autonomic neuropathy

  • Foot care


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CASE 2 Mean HbA

  • JT is a 58 year old male newly diagnosed with Type 2 diabetes

  • PMH

    • Dyslipidemia

  • SH: Tobacco 1 pack/day x 30 years; Rare ETOH use; denies illicit drug use; diet is high in carbohydrates and sugars and low in vegetables; physical activity “little to none”


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CASE 2 Mean HbA

  • How much exercise should you recommend for JT?

    A. 90 minutes/week

    B. 60 minutes/week

    C. 150 minutes/week

    D. 300 minutes/week


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CASE 2 Mean HbA

  • Which of the following should be done at diagnosis?

    A. Eye exam

    B. Test for microalbuminuria

    C. Blood pressure

    D. Fasting lipids

    E. All of the above


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CASE 2 Mean HbA

  • JT’s blood pressure is 150/90, what would be your recommendation for initial therapy?

    A. Fosinopril

    B. HCTZ

    C. Diltiazem

    D. Metoprolol


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