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GO! Diabetes Program. Goals For Today. Review evidence based guidelines and equip you to deliver state of the art care to your diabetic patients Understand tools that support practice performance and improvement Review oral and injectable medicines hypoglycemics

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goals for today
Goals For Today
  • Review evidence based guidelines and equip you to deliver state of the art care to your diabetic patients
  • Understand tools that support practice performance and improvement
  • Review oral and injectable medicines hypoglycemics
  • Review multifaceted approach to cardiovascular disease protection
united kingdom prospective diabetes study
United Kingdom Prospective Diabetes Study
  • Study summary – 10 years
    • Type 2 diabetics – convention vs. intense control
      • Glycemic control – 7.0 vs. 7.9
      • Hypertension control – 144/82 vs. 154/87
    • Glycemic control
      • metformin, sulfonylureas, and insulin
    • Hypertension
      • captopril, atenolol
ukpds blood pressure study tight vs less tight control
UKPDS Blood Pressure Study:Tight vs. Less Tight Control
  • 1148 type 2 patients
  • BP lowered to avg. 144/82 (controls-154/87); 9 yr follow-up

Endpoint Risk Reduction(%) P Value______

Any diabetes related endpoint 24 0.0046

Diabetes related deaths 32 0.019

Heart failure 56 0.0043

Stroke 44 0.013

Myocardial infarction 21 NS

Microvascular disease 37 0.0092

UKPDS. BMJ. 317: 703-713. 1998.

glycemic control reduces complications
Glycemic Control Reduces Complications

Diabetes Control and Complications Trial (DCCT) Research Group. N Engl J Med 1893:329:977-988

UK Prospective Diabetes Study (UKPDS) Group. Lancet 1993; 352:837-853.

abcs of diabetes management
ABCs Of Diabetes Management

Diabetes Care 2009;32:S6-12

control of cv risk factors in diabetic hypertensive patients in academic medical centers
Control of CV Risk Factors in Diabetic Hypertensive Patients in Academic Medical Centers
  • A1C <7%
  • 27%
  • LDL <100
  • 36%
  • BP <130/85 mmHg
  • 27%
  • Daily Aspirin (ASA) Use
  • 46%
  • BP, Lipids and A1C
  • 3%
  • BP, Lipids, A1C + ASA
  • 2%

McFarlane SI. DiabetesCare 2002;25:718

metabolic syndrome
Metabolic Syndrome
  • Requires 3 or more:
    • Triglycerides > 150
    • HDL < 40
    • Waist size >40” men, >35” women
    • BP > 130/85
    • Fasting glucose > 100
  • Caveat: Treatment counts for requirements…

(Grundy, Circulation, 2005)

pre diabetes definition
Pre-Diabetes Definition

If FBG >100 there is a 10-15% risk of DM within 7 years…

or

Fasting

GTT

who and when to screen
Who and When to Screen?
  • Family history
  • Overweight (BMI 25)
  • Dyslipidemia
  • HTN
  • High risk ethnicity
  • Vascular disease
  • Prior glucose elevation
  • Hx or exam findings
  • Starting at age 45, a fasting blood glucose every three years
  • More frequent screening if:
role of obesity in diabetes
Role of Obesity in Diabetes
  • Obesity (specifically abdominal) has one of the highest associations with insulin resistance and glucose intolerance
  • Numerous studies have tied weight loss to diabetes prevention
  • A 5-10% weight loss yields a 58% reduction in the incidence of diabetes!
    • At the end of four years
  • Diet and exercise regimens average a 4kg loss after two years
  • Advice alone results in a 1kg gain

(Franz, Journal Amer. Diabetes Assoc, 2007)

quantifying obesity
Quantifying Obesity
  • Easiest is by waist circumferences.
  • 40” males, 35” females
  • Some variation by ethnicity (35” and 31” for Asians)
  • Measured across iliac crest in the back and the umbilicus in the front
healthcare maintenance
Healthcare Maintenance
  • Latest ADA guidelines (2009)
  • Lab surveillance
  • Diabetic education
  • Vaccinations/routine healthcare
  • Smoking cessation
  • Foot exams
  • Eye exams
reasons to look at feet
Reasons to Look at Feet
  • Up to 70% of diabetics eventually develop a neuropathy
  • Up to 25% develop foot ulcers
  • Diabetes doubles your risk of LE disease (vascular, neuro, skin)
  • More than half of the foot ulcers become infected at some point
foot surveillance
Foot Surveillance
  • Examine the feet at every visit
  • Annual comprehensive evaluation
    • Sensation
    • Pulses
    • Skin condition (ulcers, hair, nails)
    • Anatomic deformities
    • Shoe evaluation
sensory exam
Sensory Exam
  • 10-gram monofilament
    • Patient should not watch
    • Five sites per foot
    • Apply filament perpendicular to skin
    • Allow slight buckle of filament in one motion
    • Each site should take 1-2 sec
    • Do not apply to ulcers or calluses
eye care
Eye Care
  • Diabetic retinopathy is the leading preventable cause of blindness
  • Prevalence of DR increases with duration of diabetes (100% Type 1, 60% Type 2 after 20 years)
  • Of all recommendations, eye screening is the least likely to get done
pathogenesis
Pathogenesis
  • Increased circulating glucose leads to weakness of capillary walls
  • Microaneurysms and leakage occurs causing eventual infarction of the nerve fiber layers (cotton wool spots)
  • The localized hypoxia then leads to vasoproliferation
  • Extension into the vitrea (+/- hemorrhage) leads to fibrosis and vision loss
diabetic retinopathy
Diabetic Retinopathy

Normal Retina (left) contrasted with Proliferative Diabetic Retinopathy (right)

Refer patients for ophthalmologist evaluation

general rules hypoglycemic therapy
General RulesHypoglycemic Therapy
  • Normalize fasting glucose levels first (90-130 mg/dl)
    • Many patients will achieve A1C < 7%
  • When to target postprandial glucose levels?
    • Fasting and preprandial values are at goal
    • A1C levels are not met
  • Measure 1-2 hours after beginning of the meal
    • Glucose are generally at their peak
glycemic goals of therapy
Glycemic Goals of Therapy

Verbal Target

~100

<<200

As low as

possible w/o unacceptable adverse effects

Goal

Premeal plasma glucose (mg/dL)

2-h postprandial plasma glucose

A1C

ADA

90-130

<180*

<7%**

* Evaluation and treatment of postprandial glucose may be useful in the setting of suspected postprandial hyperglycemia, with the use of agents targeting postprandial hyperglycemia and for suspected hypoglycemia

** More stringent glycemic goals (i.e. a normal A1C, <6%) may further reduce complications at the cost of increased risk of hypoglycemia

Diabetes Care 2009;32:S6-12

biguanides metformin
Biguanides: Metformin

Mechanism of action

  • Reduces hepatic glucose production
  • Depends upon presence of insulin

Safety and efficacy

  • Decreases A1C 1-2%
  • Adverse effects: diarrhea and nausea; main risk: lactic acidosis
  • Discontinuation rate 5%
  • Contraindications: renal, cardiac, hepatic insufficiency; IV contrast
  • No direct effect on kidney

Dosing

  • Initial dose: 500 mg once a day; dosing: usually BID
  • Maximum effective dose: 2,000 mg per day
  • Titration frequency: week(s) to months
  • Alternate formulations: “XR” and combinations
insulin secretagogues sulfonylureas sfu and glinides
Insulin Secretagogues: Sulfonylureas (SFU) and “Glinides”

Mechanism of action

  • Stimulate basal and postprandial insulin secretion
  • Require functioning beta cells (no effect on beta cell dysfunction)
  • Work quickly

Safety and efficacy

  • Decrease A1Capproximately1-2%
  • Lower fasting glucose 20%
  • Adverse events: weight gain, allergy (rare); main risk, hypoglycemia

Dosing

  • Initial dose: 1/8 to 1/4 maximum dose; dosing: 1-2 times/day (SFU), 3 times/day (glinides)
  • Maximum effective dose: 1/2 maximum(full dose with nateglinide)
  • Titration frequency: day(s) to weeks
preferred sulfonylureas
Preferred Sulfonylureas
  • All available as generic agents

Glipizide ER 5-20 mg once per day

      • Once daily, flat profile, low plasma levels resulting in a low risk of weight gain and hypoglycemia

Glipizide 2.5 to 20 mg twice a day

      • Twice daily. Half-life 2-4 hours, peaks in 2-3 hours. By taking it once a day at low dose it stimulates insulin secretion for 6-12 hours

Glimepiride 1-8 mg per day

      • Once daily. Half-life 9 hours, peak action for 4 hours. Special utility like with glipizide but with longer half-life

Buse J. Personal Opinion

Melander A. Diabetes 2004;53 Suppl 3:S151

thiazolidinediones tzd s or glitazones pioglitazone and rosiglitazone
Thiazolidinediones (TZD’s or Glitazones): Pioglitazone and Rosiglitazone

Mechanism of action

  • Enhance insulin sensitivity in muscle, adipose tissue
  • Inhibit hepatic gluconeogenesis
  • Reduced rate of beta cell dysfunction

Safety and efficacy

  • Decrease A1C1-2%
  • Adverse events: edema, weight gain, anemia; rare serious risk: liver failure

Dosing

  • Initial dose (monotherapy): 1/2 to 2/3 maximum; dosing,1-2 x/day
  • Maximum effective dose: maximum dose
  • Titration frequency: weeks to month(s)
oral hypoglycemics tzd lipid effects
Oral Hypoglycemics TZD Lipid Effects
  • Rosiglitazone(Avandia)
    • +LDL
    • +HDL
    • +Triglycerides
  • Pioglitazone (Actos)
    • +LDL
    • +HDL
    • -Triglycerides
  • Rosiglitazone – Black box warning for CHF and ischemic heart disease; warnings about increased fracture risk in women
  • Pioglitzaone – Black box warning for CHF and warning about increase fracture risk. No evidence to suggest increased ischemic heart disease.
aha ada consensus statement for tzds
AHA/ADA Consensus Statement for TZDs
  • Not recommended for patients with NY Heart Association class III or IV heart failure
  • TZDs alone, or particularly in combination with insulin, may cause fluid retention which can lead to heart failure
    • Incidence of CHF <1% with TZD monotherapy
    • Increased to 2%-3% in combination with insulin
  • Patients should be observed for signs and symptoms of heart failure
  • TZDs should be discontinued if any deterioration in cardiac status occurs

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

alpha glucosidase inhibitors acarbose and miglitol
Alpha-Glucosidase Inhibitors: Acarbose And Miglitol

Mechanism of action

  • Delay absorption of carbohydrates
  • Depend upon postprandial hyperglycemia

Safety and efficacy

  • Decrease A1C0.5-1%
  • Adverse events: flatulence; main risk: rare liver enzyme elevation

Dosing

  • Initial dose: 1/4 maximum once daily; dosing: 3 times daily
  • Maximum effective dose: 1/2 maximum dose
  • Titration frequency: week(s) to months
  • Used infrequently by most clinicians
incretin drugs
Incretin Drugs

Exenatide (Byetta) – GLP-1 analog

  • Injection twice daily
    • 5mcg bid AC x 1 month, then 10mcg bid AC
  • Beneficial effects described previously
  • Expensive
  • Weight loss
  • Reduction in HgBA1C

Sitagliptin (Januvia)– DPP4 inhibitor

  • Technically not an incretin but similar effects
  • Oral administration
    • 100mg daily
  • Weight neutral
key points to consider for therapy
Key Points to Consider for Therapy

Maximal benefits of metformin are observed at the recommended daily dose of 2000 mg (1 g BID)1

Thiazolidinediones should be started at low doses and slowly increased to minimize side effects2

Glucose-lowering effects of a sulfonylurea plateau at half the maximum recommended dose3

Garber AJ et al. Am J Med 1997;103:491

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

Stenman S et al. Ann Intern Med 1993;118:169

63 of patients with diabetes are not at ada a1c goal 7

12.4%

37.2%

>8%

7.8%

63%

7%

17.0%

25.8%

37.0%

63% Of Patients with DiabetesAre Not at ADA A1CGoal <7%

Adults aged 20-74 years with previously diagnosed diabetes who participated in the interview and examination components of the National Health And Nutrition Examination Survey (NHANES), 1999-2000

A1C

% of Subjects

n=404

Saydah SH et al. JAMA 2004;291:335

difficulties in achieving target a1c values
Difficulties In AchievingTarget A1C Values
  • Challenges
    • Late diagnosis and initiation of therapy
    • Therapeutic inertia
    • Lack of effective lifestyle intervention
    • Secondary failure
    • Adverse events associated with antihyperglycemic therapies
    • Complexity of care
    • Role of postprandial glucose in failure
common concerns when transitioning to insulin
Common Concerns When Transitioning To Insulin
  • Fear of needles or pain from injections
  • Fear of hypoglycemia
  • Weight gain

Funnel M. Self-management Support for Insulin Therapy in Type 2 Diabetes.

The Diabetes Educator 2004;30:274

common concerns when transitioning to insulin1
Common Concerns When Transitioning To Insulin
  • Adverse impact on lifestyle; inconvenient; loss of personal freedom and independence
  • Belief that insulin means diabetes is worse or more serious disease
  • Insulin as a personal failure
  • Insulin causes complications
  • Treated differently by family members

Funnel M. Self-management support for insulin therapy in type 2 diabetes. The Diabetes Educator 2004;30:274

potential insulin regimens
Potential Insulin Regimens
  • Insulin pump Physiologic/COMPLEX/Flexible
  • Multiple daily injections
  • Free mixing - twice daily
  • Pre-mixed - twice daily
  • Basal only SIMPLE/Inflexible

How do we balance simplicity and flexibility to achieve glycemic control?

indications for insulin
Indications for Insulin
  • Not contraindicated at anytime
  • Consider as initial therapy
    • HgbA1C > 10%
    • Fasting glucose > 250mg/dl
    • Random glucose > 300
  • Recommended as initial therapy
    • Polyuria, polydipsia, weight loss, ketones
insulin initiation answers to provider concerns
Insulin InitiationAnswers to Provider Concerns
  • Normalize the fasting glucose
    • Fasting FSBS 70-130
    • Once Daily Options
      • Start 10 units or 0.2 u/kg
        • Basal Insulin (glargine or detemir)
        • NPH (bedtime)
        • Premixed before dinner
      • Increase 2-3 units every 3 days prn to reach target of 70-130 fasting
      • Decrease 3 units for fasting < 70
insulin action effect of various formulations

Rapid (Glulisine,Lispro, Aspart,)

Long (Glargine)

Insulin ActionEffect Of Various Formulations

140

120

100

Short (Regular)

Insulin

Level

(U/ml)

80

Intermediate (NPH)

60

40

Detimir

20

0

0

2

4

8

10

12

14

16

6

Hours

fasting glucose at target hgba1c not at goal
Fasting Glucose at TargetHgbA1C Not at Goal
  • Must Normalize Post Prandial Glucose
  • Options
    • Change HS NPH to BID NPH
    • Change Pre-mixed Insulin from QD to BID
    • Add Mealtime Insulin to Basal Insulins
monomeric insulin analogs
Monomeric Insulin Analogs
  • How to switch or start
    • Insulin immediately before the meal (or after)
    • Review signs, symptoms and management of hypoglycemia
  • Safety
    • Arguably, glulisine, aspart, lispro and are safer than regular human insulin
  • Patient preference
    • Significant patient preference for monomeric analog versus regular human insulin
  • Duration of action
    • Covers postprandial glucose surge well
    • In type 1 diabetes, will need an additional injection of basal or NPH
carbohydrate counting
Carbohydrate Counting
  • Technique based on the concept that most meal-related glucose increase is due to the carbohydrate content
  • Patients count either
    • Carbohydrate choices (milk, fruit, breads, sweets, starchy vegetables)
    • Grams of “total carbohydrates” on food label
  • Providers prescribe insulin-to-carbohydrate ratio
    • Start with 1 unit per choice or 1 unit per 15 grams
    • Typical dose is 2-4 units per choice in type 2 diabetes
  • Titrate based on postprandial glucose monitoring
  • Generally, start with glulisine/lispro/aspart administered just after meals
mixed analog insulin bid
Mixed-Analog Insulin BID
  • Starting dose in most
    • Pre-breakfast 10 units
    • Pre-supper 10 units
  • Titration, once or twice a week (self-adjusted or with supervision)
  • Alternatively, could just increase at both breakfast and supper in parallel

Buse JB et al. Clinical Diabetes 2005;23:78

pre mixed insulin bid compared to basal alone initiate study
Pre-Mixed Insulin BID Compared to Basal Alone – INITIATE Study

Aspart 70/30 bid Glargine qhs

  • Minor hypoglycemia 43% 16%
  • Median rate per pt per mo 0.30.2
  • Severe hypoglycemia None 1 episode
  • Weight gain (Kg) 5.4 4.8 3.5 4.5
  • Total daily insulin (u/Kg) 0.82 0.40 0.55 0.27

Raskin P et al. Diabetes Care 2005;28:260

oral meds what to do when insulin started general rules
Oral Meds – What to Do When Insulin Started (General Rules)
  • Metformin
    • Continue unless contraindicated
  • Sulfonylureas
    • Continue with basals generally
    • Stop if using large doses of insulin
    • Stop if using premixed insulin
  • TZDs
    • Proceed with caution
    • Exacerbates weight gain and edema
slide55

General Prescribing ConsiderationsDosing

Stable Dose

10 mcg BID

Stable Dose

5 mcg BID

1 Mo

Initiation

Indicated for use in patients failing metformin or sulfonylurea

Generally reduce SFU dose to smallest tablet to minimize risk of hypoglycemia

No dosage adjustments based on meal size or physical activity

No additional glucose monitoring required

Exenatide Prescribing Information. 2005

glargine vs exenatide in patients failing oral therapies

A1C (%)

Body Weight (lbs)

*

*

*

*

*

*

Glargine Vs Exenatidein Patients Failing Oral Therapies

ITT patient sample

Mean ± SE shown

* p<0.0001, exenatide vs insulin glargine at same time point

Heine RJ et al. Ann Intern Med 2005;143(8):559

slide57

Quarterly to semi-annual follow-up

Monthly to quarterly follow-up

Lifestyle intervention

MNT, physical activity, education

Yes

No

Are A1C/FPG targets achieved?

FPG >200 mg/dL

FPG <130 mg/dL

*

Target Insulin Deficiency

Target Insulin Resistance

Target PPG

* Keep adding agents until target reached. Self-titration at home when possible

Metformin, glitazone

Exenatide, nateglinide, α-glucosidase inhibitors, rapid-acting insulin, pramlintide

SFUs/glinide, insulin, exenatide

Treatment Algorithm - Glucose

Diagnosis

by screening or with symptoms

causes of hypoglycemia
Causes of Hypoglycemia
  • Incorrect amount of insulin/oral agents
  • Skipped or delayed meal/snack
  • Carbohydrate intake less than normal
  • Alcohol intake without food
  • Exercise without insulin/food adjustment
  • Not re-testing 1 to 2 hours after hypoglycemia treatment if meal or snack is not eaten
treatment of hypoglycemia
Treatment of Hypoglycemia
  • Definition of hypoglycemia: Plasma glucose <70 mg/dL
  • Symptoms may or may not be present
    • Sweaty, cold, unable to concentrate, dizzy
  • Treatment
    • Treat with 15 g carbohydrate; wait 15 minutes; test BG, if BG not >70 mg/dL, treat again
    • All carbohydrates raise blood glucose
    • On average, 15 g of glucose can increase BG from 60 to ~110 mg/dL (50mg/dL) over ~40 minutes
    • BG starts to fall at 60 minutes and reaches previous treatment level at 2 hours

Cryer et al. Diabetes Care 2003;26:1902

treatment of severe hypoglycemia
Treatment of Severe Hypoglycemia
  • Definition: Requires assistance to treat
  • Inject glucagon with loss of consciousness or seizure
  • Administered by another person
    • May be given intramuscular or subcutaneous
  • Standard dose
    • 1.0 mg for adults; 0.5 mg for children under 5 yrs
  • Prescription is required
  • Precautions
    • May cause nausea/vomiting/headache
  • Call 911
cardiovascular disease prevention blood pressure dyslipidemia antiplatelet therapy

Cardiovascular Disease PreventionBlood Pressure, Dyslipidemia, Antiplatelet Therapy

diabetes and hypertension key questions
Diabetes and Hypertension Key Questions
  • Why should we pay so much attention?
  • What parameters?
  • Non Drug Recommendations
  • Which drugs and how many?
  • What do others besides the ADA say?
  • What about resistant cases?
diabetes and hypertension why
Diabetes and HypertensionWhy?
  • Volume Expansion
    • Increased insulin levels
      • Higher sympathetic activity
    • Increased glucose level
      • Increased sodium resorption with hyperglycemia
  • Decreased arterial compliance
  • Obesity
ukpds blood pressure study tight vs less tight control1
UKPDS Blood Pressure Study:Tight vs. Less Tight Control
  • 1148 type 2 patients
  • BP lowered to avg. 144/82 (controls-154/87); 9 yr follow-up

Endpoint Risk Reduction(%) P Value

Any diabetes related endpoint 24 0.0046

Diabetes related deaths 32 0.019

Heart failure 56 0.0043

Stroke 44 0.013

Myocardial infarction 21 NS

Microvascular disease 37 0.0092

UKPDS. BMJ. 317: 703-713. 1998.

diabetes treatment goals for blood pressure
Diabetes Treatment Goalsfor Blood Pressure
  • Control blood pressure
    • 130/80 mmHg for most patients
    • 125/75 mmHg for patients who have proteinuria>1 g/day and renal insufficiency
  • Reduce the risk of end-organ failure
  • Reduce the risk of cardiovascular events
    • Myocardial infarction
    • Cardiovascular death
  • Delay or prevent the progression to heart failure

JNC 7 Report. JAMA 2003;289:2560; Bakris GL et al. Am J Kidney Dis 2000;36:646

ADA. Diabetes Care 2007;30(suppl 1):S15

number of medications to achieve goal bp in 5 trials of dm and or renal disease
Number of Medications to Achieve Goal BP In 5 Trials of DM and/or Renal Disease

UKPDS (<150/85 mmHg)

2.7

ABCD (<75 mmHg DBP)

2.8

MDRD (<92 mmHg MAP)

3.6

HOT (<80 mmHg DBP)

3.3

AASK (<92 mmHg MAP)

3.8

0

1

2

3

4

Number Of BP Meds

Bakris. J Clin Hypertens 1999;1:141

nkf recommendations on treatment of hypertension and diabetes
NKF Recommendations On TreatmentOf Hypertension And Diabetes
  • Blood pressure goal: ≤130/80 mmHg
  • BP-lowering medications should reduce both BP + proteinuria
  • Lower goal has been recommended to reduce renal disease progression and incidence of ischemic heart disease
  • Antihypertensive drug classes shown to reduce proteinuria and cardiovascular events
    • ACE inhibitors
    • --blocker (carvedilol)
    • -blockers
    • CCBs
    • Diuretics

Bakris GL et al. Am J Kidney Dis 2000;36:646

ukpds ace inhibitor vs blocker aggregate clinical endpoints
UKPDS: ACE Inhibitor Vs -Blocker Aggregate Clinical Endpoints

Relative Risk & 95% CI

RR

P

0.5

1

2

Any diabetes-related endpoint

1.10

0.43

1.27

Diabetes-related deaths

0.28

1.14

All-cause mortality

0.44

1.20

Myocardial infarction

0.35

1.29

Microvascular disease

0.30

1.12

Stroke

0.74

FavorsACE Inhibitor

Favors-Blocker

UKPDS Group. BMJ 1998;317:713

which class of agents should be added second line
Which Class Of Agents Should Be Added Second-Line?
  • Thiazide diuretics
    • Complementary mechanism to ACEs or ARBs
    • ALLHAT showed benefit
    • Particularly effective in African American patients
    • BUT slightly higher deterioration of glucose metabolism
  • Beta blockers
    • Good evidence of benefit particularly for those with coronary heart disease or congestive heart failure
    • BUT mechanism of action may not complement ACEs or ARBs
additional bp recommendations
Additional BP Recommendations
  • Lower blood pressure gradually in the elderly
  • If unable to achieve goal, don’t hesitate to discuss with peers
  • Check for orthostasis in some patients when clinically indicated
  • If angiotensin modifying drugs or diuretics are used, monitor renal function and potassium
  • Use as many medicines as necessary to achieve blood pressure target
    • 130/80 mmHg
    • 125/75 mmHg if proteinuria is found
  • Begin with an angiotensin modifying drug
  • Add a thiazide in African American patients
  • Add a Beta blocker in patients with heart disease

ADA. Diabetes Care 2007;30(Suppl1):16

causes of resistant hypertension
Causes Of Resistant Hypertension
  • Improper blood pressure measurement
  • Excess sodium intake
  • Inadequate diuretic therapy
  • Medication
    • Inadequate doses
    • Drug actions and interactions (e.g. nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
    • Over-the-counter (OTC) drugs and herbal supplements
  • Excess alcohol intake
  • Identifiable causes of hypertension
statins primary and secondary prevention

4S

LIPID

CARE

PROVE-IT

HPS(estimated)

WOSCOPS

CARDS

TNT

TNT

HPS(estimated)

AFCAPS

Statins:Primary And Secondary Prevention

25

20

% With

CVD

Event

15

10

5

0

50

70

90

110

130

150

170

190

210

LDL-C (mg/dL)

Adapted from Illingworth. Med Clin North Am 2000;84:23 and LaRosa. N Engl J Med 2005;352 (e-pub) and Colhoun. Lancet 2004;364:685

ada standards 2009 dyslipidemia
ADA Standards 2009Dyslipidemia
  • Fasting lipid profile annually
  • Without overt CVD
    • LDL<100
    • At age 40 start on statin regardless of LDL to reduce LDL 30-40%
  • With overt CVD
    • Start statin to reduce LDL 30-40%
    • LDL<70 is an option
    • Normalizing triglycerides and raising HDL with fibrates reduces CV events
ada standards 2009 dyslipidemia1
ADA Standards 2009Dyslipidemia
  • High LDL, High triglycerides, Low HDL
    • Consider statin + fibric acid
      • Remember the increased risk of rhabdomyolysis
    • Consider statin + niacin
      • Remember niacin can increase glucose levels
      • moderate doses = mild changes in glycemia
anti platelet therapy ada standards
Anti-platelet TherapyADA Standards
  • Recommendations for Aspirin
    • ASA 75-162 mg/day for 2o prevention
    • ASA 75-162 mg/day for 1o prevention
      • Age > 40
      • Any age with CV risk factors (htn, hyperlipidemia, renal disease, family history, smoking)
    • Not recommended ages < 21 (Reye’s syndrome)
  • Clopidogrel
    • Very high risk diabetics; intolerance to ASA
metric
METRIC
  • Metric stands for Measuring, Evaluating, and Translating Research Into Care.
  • It is an innovative online practice improvement program where you will input records of 10 diabetic patients prior to today and again within 90 days.
  • www.aafp.org/metric