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Diabetes: Guideline-Based Management. Eric L. Johnson, M.D. Assistant Medical Director Altru Diabetes Center Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences. Objectives. Overview of diabetes

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diabetes guideline based management

Diabetes: Guideline-Based Management

Eric L. Johnson, M.D.

Assistant Medical Director

Altru Diabetes Center

Assistant Professor

Department of Family and Community Medicine

University of North Dakota

School of Medicine and Health Sciences

objectives
Objectives
  • Overview of diabetes
  • Discuss guideline based management for diabetes
  • Apply Diabetes guideline based management in clinical practice
what we ll do today
What We’ll Do Today
  • Overview of Diabetes
  • Introduce Guidelines
  • Screening for Diabetes
  • Treating to Targets
  • Screening for Complications
  • Delivering Guideline Based Treatment in Clinical Settings
  • Case Studies
u s prevalence of diabetes 2010
U.S. Prevalence of Diabetes 2010

Diagnosed: 26 million people—8.3% of population (90%+ have Type 2)

Undiagnosed:7 million people

79 million people have pre-diabetes

CDC 2011

diabetes in the u s 2010
Diabetes In The U.S. 2010
  • 8.3% of all Americans
  • 11.3% of adults age 20 and older
  • 27% of adults age 65 and older
  • 1.9 million diagnosed in 2010
  • Could be 33% by 2050
  • Prediabetes

35% of adults age 20 and older

50% of Americans 65 and older

CDC 2011

diabetes disparities
Diabetes Disparities
  • Native American 16.1%
  • Black 12.6%
  • Hispanic 11.8%
diabetes mellitus
Diabetes Mellitus
  • Type 1: autoimmune betacell destruction, absolute insulin deficiency
  • Type 2: insulin resistance, other mechanisms, eventual betacell failure over time.
the ominous octet type 2
The Ominous Octet-Type 2

Impaired

Insulin Secretion

Islet a-cell

Increased

Glucagon Secretion

Islet b-cell

Neurotransmitter

Dysfunction

DecreasedIncretin Effect

Increased

Lipolysis

Increased Glucose

Reabsorption

Increased

HGP

Decreased Glucose

Uptake

diabetes mellitus1
Diabetes Mellitus
  • Type 1: Usually younger, insulin at diagnosis
  • Type 2: Usually older, often oral agents at diagnosis
  • Type “1.5” (Latent Autoimmune) mixed features ~10% of type 2
  • Gestational: Diabetes of Pregnancy
diabetes risk and prevention
Diabetes Risk and Prevention

Risk:

  • Type 1- mostly unknown, some familial
  • Type 2- obesity, smoking, sedentary lifestyle, familial

Prevention:

  • Type 1- none known
  • Type 2- lifestyle management
diabetes guideline management
Diabetes Guideline Management
  • 2 main sets of guidelines utilized in U.S.
  • American Diabetes Association (ADA)
  • American Association of Clinical Endocrinology (AACE)
  • Lots of overlap, AACE considered

“more intense”

diabetes guideline management1
Diabetes Guideline Management
  • Evidence based
  • Well accepted
  • Clinically relevant
  • Can be incorporated into clinical practice
  • Emphasize comprehensive risk management
diabetes guideline management2
Diabetes Guideline Management
  • ADA publishes guideline update every January (Diabetes Care)
  • Clinical Practice Recommendations
  • http://professional.diabetes.org/
diabetes guideline management3
Diabetes Guideline Management
  • AACE updates periodically (2011)
  • https://www.aace.com/publications/guidelines
  • AACE Medical Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan
  • Includes discussion of treatment of risk factors, role of team members, complication screening and management, age groups
screening for diabetes1
Screening For Diabetes
  • A1C or FPG or 75 g oral GTT
  • Testing should be considered in all adults who are overweight (BMI >25 kg/m2)

And

  • Have the following additional risk factors…….
risk factors for screening
Risk Factors for Screening
  • Physical inactivity
  • First-degree relative with diabetes
  • High-risk race/ethnicity
  • African American
  • Latino
  • Asian American
  • Native American, Pacific Islander
  • Women who delivered a baby weighing

9 lb or were diagnosed with GDM

Diabetes Care 34:Supplement 1, 2011

risk factors for screening1
Risk Factors for Screening
  • Hypertension

(>140/>90 mmHg or on therapy for hypertension)

  • HDL <35 mg/dl and/or a triglycerides >250mg/dl
  • Women with polycystic ovarian syndrome (PCOS)
  • A1C >5.7%, IGT, or IFG on previous testing
  • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
  • History of CVD

Diabetes Care 34:Supplement 1, 2011

risk factors for screening2
Risk Factors for Screening
  • In the absence of the previous criteria, testing begins at age 45
  • Normal results, repeat at least at 3-year intervals
  • Consider more frequent testing depending results and risk status
  • At-risk BMI may be lower in some ethnic groups (i.e., Native American)

Diabetes Care 34:Supplement 1, 2011

type 2 diabetes screening in children adolescents
Type 2 Diabetes Screening in Children/Adolescents
  • Overweight

-BMI >85th percentile

-weight for height >85th percentile

-weight >120% of ideal for height

  • Plus any two of the following risk factors….
type 2 diabetes screening in children adolescents1
Type 2 Diabetes Screening in Children/Adolescents
  • FH of type 2 diabetes in 1st or 2nd-degree relative
  • Race/ethnicity (Native American, African American, Latino, Asian American,Pacific Islander)
  • Signs of insulin resistance or conditions associated with insulin resistance

(acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for -gestational-age (SGA) birth weight)

  • Maternal history of diabetes or GDM during gestation

Diabetes Care 34:Supplement 1, 2011

type 2 diabetes screening for children adolescents
Type 2 Diabetes Screening for Children/Adolescents
  • Age of initiation: at-risk age 10 years or if younger onset puberty
  • Screen every 3 years
  • No screening recommended for Type 1 Diabetes in asymptomatic individuals outside of research protocols

Diabetes Care 34:Supplement 1, 2011

diabetes diagnosis
Diabetes Diagnosis

Category FPG (mg/dL) 2h 75gOGTT A1C

Normal <100 <140 <5.7

Prediabetes 100-125 140-199 5.7-6.4

Diabetes >126** >200 >6.5

Or patients with classic hyperglycemic symptoms with plasma glucose >200

** On 2 separate occasions

Diabetes Care 34:Supplement 1, 2011

https://www.aace.com/publications/guidelines 2011

screening review
Screening Review
  • >45 years old
  • Risk factors
  • Ethnicity
  • Obese
  • Smoking
  • CVD
  • Any Prediabetes syndrome
risks for complications in diabetes
Risks for Complications in Diabetes

Abnormal blood sugar/A1C

Abnormal lipids

Abnormal blood pressure

Sedentary lifestyle

Smoking

avoiding diabetes complications
Avoiding Diabetes Complications
  • Blood glucose control A1C <7%
  • Treat cholesterol profiles to targets
    • Total cholesterol <200
    • Triglycerides <150
    • HDL (“good”) >40 men, >50 women
    • LDL (“bad”) <100, <70 high risk
  • Treat blood pressure to target <130/<80

For most non-pregnant adults

treating to targets
Treating To Targets
  • A1C <7%: Fewer microvascular complications (eye, nerve, kidney)
  • Less glucose variability: Fewer macrovascular complications (CVD, PAD)
  • BP <130/<80: reduced kidney disease reduced CVD
  • Lipids to target: reduced CVD
treating to targets1
Treating to Targets
  • Treating patients to target early in the course of diabetes most likely to give benefit
  • Tight control late in course of disease with a history of poor control, less likely to benefit
targets for glycemic blood sugar control in most non pregnant adults
Targets for Glycemic (blood sugar) Control In Most Non-Pregnant Adults

*<6 for certain individuals

  • American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
  • Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement at http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January 6, 2006.
  • AACE Diabetes Guidelines – 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.
a1c average glucose
A1C ~ “Average Glucose”

A1C eAG

% mg/dL mmol/L

6 126 7.0

6.5 140 7.8

7 154 8.6

7.5 169 9.4

8 183 10.1

8.5 197 10.9

9 212 11.8

9.5 226 12.6

10 240 13.4

Formula: 28.7 x A1C - 46.7 - eAG

American Diabetes Association

slide32

ADA Guidelines for Glucose Management

Children and Adolescents

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Diabetes Care 2005;28:186–212

diabetes medications glycemic control
Diabetes MedicationsGlycemic Control
  • Type 1: Always insulin, maybe symlin in combo
  • Type 2: Many oral med choices, insulin, non-insulin injectable
  • Complete discussion in

Slide Deck/Podcast

ada easd consensus algorithm to manage type 2
ADA/EASD consensus algorithmto manage type 2

Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months. The interventions should be changed if A1C is ≥7%.

Tier 1:

Well-validated core therapies

Lifestyle and MET + intensive insulin

Lifestyle and MET

+ basal insulin

At diagnosis:

Lifestyle

+

MET

Lifestyle and MET+ SUa

Step 1

Step 2

Step 3

Tier 2: Less well-validated studies

Lifestyle and MET + pioglitazone

Lifestyle and MET + pioglitazone + SUa

No hypgglycemia

No

edema/CHF

Bone loss

Lifestyle and MET + GLP-1 agonistb

Lifestyle and MET

+ basal insulin

No hypoglycemia

No

Weight loss

Nausea/vomiting

aSU other than glyburide or chlorpropamide. bInsufficient clinical use to be confident regarding safety.

MET: metformin; SU: sulfonylurea. Nathan et al.Diabetes Care 2009;32(1): 193-203

glucose lowering potential of diabetes therapies
Glucose-lowering Potential of Diabetes Therapies*

Treatment FPG ¯ HbA1C ¯

Sulfonylureas 50-60 mg/dl 1-2%

Metformin 50-60 mg/dl 1-2%

a-Glucosidase Inhibitors (Precose) 15-30 mg/dl 0.5-1%

Repaglinade (Prandin) 60mg/dl 1.7%

Thiazolidinediones 40-60 mg/dl 1-2%

Gliptins (Januvia,Onglyza) targets ppd 0.5 - 0.8%

*based on package insert data as monotherapy

glucose lowering potential of injection diabetes therapies
Glucose-lowering Potential of Injection Diabetes Therapies*

Treatment FPG ¯ HbA1C ¯

Exenatide (Byetta) targets ppd 1-1.5%

Liraglutide (Victoza) targets ppd 1-1.5%

Pramlintide (Symlin) targets ppd 1-2%

Insulin Limited by 1.5-3.5%

hypoglycemia

*based on package insert data as monotherapy

diabetes medications
Diabetes Medications
  • Dr. Clarens overview of non-injectable medications
  • More on injectable medications later
key points of medication selection in type 2
Key Points of Medication Selection in Type 2
  • Metformin at diagnosis unless a contraindication
  • Second line agents- basal insulin or many other meds
  • A1C >9 at diagnosis-may need more than one medication
goals for older adults
Goals For Older Adults
  • Age and functional status dependent
  • Less than 3 year life expectancy, long- term care, A1C ~8.0%
  • BP goals likewise individualized
  • HTN treatment-”big bang for the buck”
  • Statin?
  • Aspirin?

Johnson EL Brosseau J et al Clinical Diabetes 2008 (26) 4; 152-156

American Medical Directors Association,2002

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

blood pressure
Blood Pressure
  • Done at every visit
  • Target is <130/<80

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

lipids cholesterol
Lipids (Cholesterol)
  • Fasting lipid panel at least annually
  • Goals:

Total cholesterol <200

Triglycerides <150

HDL >40 men, >50 women

LDL <100 (<70, CVD or high risk)

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

children with dm hypertension and lipids
Children with DMHypertension and Lipids
  • Lipids: start screening in childhood if strong FH, or at age 10
  • Hypertension: BP >90th percentile for height and weight or >130/>80
  • Consider medications (statins, ACE) if necessary

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

blood pressure and lipids treatment
Blood Pressure and LipidsTreatment

BP:

  • ACEI usually first line, ARB alternate
  • Other meds as necessary (often 2 or 3)

Lipids:

  • Statins usually first line
  • Fibrates, Fish Oil, Niacin
aspirin
Aspirin
  • Men >50 years of age
  • Women >60 years of age
  • Younger if higher risk

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

nephropathy kidney disease screening
Nephropathy (Kidney Disease)Screening
  • Annual urine testing for micro- or macro- albuminuria
  • Annual creatinine and GFR
  • Start at diagnosis for type 2
  • Start 5 years after diagnosis type 1

Diabetes Care. 2011;34(suppl 1)

kidney disease management
Kidney Disease Management
  • ACEI or ARB for microalbuminuria or proteinuria
  • Serum creatinine and creatinine clearance (or GFR)
  • May need 24 hour urine protein
  • May need nephrology referral
  • Blood pressure to target <130/<80
  • A1C <7

Diabetes Care. 2011;34(suppl 1)

retinopathy screening
Retinopathy Screening
  • Type 1 annual starting after age 10 or after 5 years post diagnosis
  • Type 2 annual starting shortly after diagnosis
  • Consider less frequent if one or more normal exams (not usually done)

Diabetes Care. 2011;34(suppl 1)

retinopathy management
Retinopathy Management
  • A1C < 7
  • Laser photocoagulation by ophthalmologist or retinologist
neuropathy screening
Neuropathy Screening
  • Screen at diagnosis and annual thereafter
  • Be aware of less common presentations

Foot inspection every visit plus annual/prn:

  • Filament testing
  • Vibratory testing (128 HZ)
  • Reflexes

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

slide56

Neuropathy: Treatment

  • Optimize blood glucose control
  • Consider other differentials, i.e. B12 deficiency in metformin users, thyroid
  • Anti-seizure meds (gapapentin, pregabelin)
  • Tricyclic anti-depressants (amitriptyline)
  • Duloxetine-antidepressant with neuropathy indication
  • Capsazincreme
celiac disease screening
Celiac Disease Screening
  • At diagnosis in Type 1 and periodic (?), pregnant
  • Rescreen if GI symptoms, failure to thrive, glycemic control changes
  • ~10% of type 1?

Test:

  • Tissue transglutaminase IgA and IgG

Or

  • Anti-endomysialantibiodies with serum IgA
  • Small bowel biopsy to confirm

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

thyroid screening
Thyroid Screening
  • Type 1 screen at diagnosis and every

1 to 2 years, and if pregnant

  • At diagnosis, thyroid peroxidase and

thyroglobulin antibodies

  • TSH thereafter
liver disease
Liver Disease
  • NAFLD, NASH
  • ~30% of adults with DM
  • LFT’s periodic
  • Imaging (CT, Ultrasound, MRI) if persistent abnormal LFT’s
  • May need biopsy and referral
other screening interventions
Other Screening/Interventions
  • Tobacco cessation
  • Smoking contributes to poor glucose control and increased CVD risk
  • Smokers should be directed to a cessation program, i.e., Quitline, Quitnet, Quitplan, 3rd party payer, etc.
  • Medication(if appropriate)
  • Other routine screens (i.e.,cancer)
routine diabetes clinical encounter
Routine Diabetes Clinical Encounter
  • Physical Exam-Diabetes Directed
  • Labs
  • Team management
  • Systematic clinical encounters- keep everything organized
  • See patient 2 to 4 times a year, prn
diabetes clinical encounters hpi my ehr template
Diabetes Clinical EncountersHPI-My EHR Template

Patient comes in today for follow up on type (1 or 2) diabetes

  • (Other problem list)
  • Home Blood glucose monitoring:
  • Ambulatory/Home Blood Pressures:
  • Current concerns:
  • Last educator appointment:
  • Last dietician appointment:
  • Last eye appointment:
  • Last dental:
  • Flu vaccine (seasonal):
  • Other recent appointments:
  • Complete medication review
diabetes clinical encounters review of systems my ehr template
Diabetes Clinical EncountersReview of Systems-My EHR Template
  • General: Fatigue/Energy level, appetite, recent illnesses, polydipsia
  • HEENT: Vision change, sore throat, neck pain/masses
  • Cardiopulmonary: CP, dyspnea, palpitations
  • Abdomen: Diarrhea, constipation, pain
diabetes clinical encounters review of systems cont d
Diabetes Clinical EncountersReview of Systems (cont’d)
  • Genitourinary: Polyuria, Dysuria, Urgency, Frequency, Nocturia
  • Musculoskeletal: Muscle or Joint Pain, Foot or Leg Pain
  • Neurologic: Dizzy, Lightheaded, Parasthesias, Weakness, Pain
  • Skin: Rash or other
  • Psych: Depression, Anxiety
diabetes clinical encounters physical exam
Diabetes Clinical EncountersPhysical Exam
  • VS: Height, Weight, BP (x2?),Pulse, Tobacco status
  • Fundus exam
  • Cardiopulmonary
  • Carotids
  • Thyroid
  • Abdomen (enlarged liver-fatty liver)
diabetes clinical encounters physical exam cont d
Diabetes Clinical EncountersPhysical Exam (cont’d)
  • Filament and vibratory testing (feet)
  • Reflexes
  • General foot exam (skin, nails, lesions, color, pulses)
  • General skin/injection sites
  • Other complaint directed
  • Growth parameters-children
diabetes foot exam
Diabetes Foot Exam
  • Every visit: visual inspection of skin, nails, lesions, color, deformity (i.e., hammertoes, charcot joint), edema
  • Annual complete foot exam skin, nails, lesions, color, pulses, deformity, edema, 10gm monofilament sensitivity, 128 vibratory sensation, reflexes
diabetes clinical encounters
Diabetes Clinical Encounters
  • Other:

Age appropriate recommendations (cancer screening, etc)

Vaccinations

diabetes labs
Diabetes Labs
  • A1C 2-4 times yearly
  • Chemistry panel, to include renal and hepatic 1-2 times yearly, prn
  • Urine for microalbumin annually
  • CBC annually, particularly if on aspirin and/or renal disease
  • Celiac screening in type 1 periodically (ever 3 years and prn)
  • Thyroid screening usually annual in type 1

Diabetes Care 34:Supplement 1, 2011

the diabetes team
The Diabetes Team
  • Physician: Primary Care, Diabetologist, Endocrinologist
  • Mid-level provider: Physician Assistant, APRN,or Nurse Practitioner
  • Other appropriate specialists (eye, kidney, heart, psychologist, foot, dentist)
the diabetes team1
The Diabetes Team

Diabetes Nurse Educator or Certified Diabetes Educator (CDE)

Registered Dietician

The patient !

self monitored blood glucose
Self Monitored Blood Glucose
  • On insulin, generally minimum TID, usually more if MDI or pump
  • CGM clinic or home may be useful
  • Type 2 on orals, maybe less if stable
lifestyle management
Lifestyle Management
  • Medical Nutrition Therapy (MNT)
  • Exercise/Activity Prescriptions- almost everybody can do something
  • Indicated for all patients with Diabetes
ada nutrition strategies
ADA Nutrition Strategies
  • Encourage weight loss in overweight/obese
  • Modest weight loss-improve insulin resistance
  • Reduce calories and fat
  • Saturated fat <7%, minimize trans-fat
  • Customize plans for patients
weight loss bariatric surgery
Weight Loss (Bariatric)Surgery
  • BMI >40
  • BMI >35 and one obesity and/or diabetes related issue
  • Usually results in dramatic improvement in type 2 and related issues
  • Effective tool if combined with medical management in appropriate patients
slide78
EHR
  • Electronic health records have great potential to monitor diabetes labs, progress, goals, etc
  • Work with your IT department, many systems have customizable “built in” diabetes systems
summary
Summary
  • Implementation of evidenced based guidelines improves diabetes outcomes
  • Guidelines are easily available
  • Getting patients to goals is important
  • Organized clinical encounters help get patients to goals
acknowledgements
Acknowledgements
  • North Dakota Department of Health, Karalee Harper
  • Dakota Diabetes Coalition, Tera Miller
  • Centers for Disease Control
  • Office of Continuing Medical Education, UNDSMHS, Mary Johnson
  • Department of Family and Community Medicine, UNDSMHS, Melissa Gardner
  • Brandon Thorvilson, UNDSMHS IT
slide decks and itunes podcasts
Slide Decks and iTunes Podcasts
  • Podcasts 5 to 10 minute Diabetes Topics

Google

“Dr. Eric Johnson Diabetes Podcasts”

  • All slide decks downloadable to view

Google

“Dr. Eric Johnson Diabetes Slide Decks”

contact info slide decks media
Contact Info/Slide Decks/Media

e-mail

eric.l.johnson@med.und.edu

ejohnson@altru.org

Phone

701-739-0877 cell

Slide Decks (Diabetes, Tobacco, other)http://www.med.und.edu/familymedicine/slidedecks.html

iTunes Podcasts (Diabetes) (Free downloads)http://www.med.und.edu/podcasts/ or iTunes>> search UND

WebMD Page: (under construction)http://www.webmd.com/eric-l-johnson

Diabetes e-columns (archived):

http://www.diabetesnd.org/?id=73&page=Dr.+Eric+Johnson+Archive