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Diabetes Guidelines An Approach to Diagnosis and Treatment A Case Based Approach

Diabetes Guidelines An Approach to Diagnosis and Treatment A Case Based Approach. Barbara Keber MD, FAAFP, member ACCE Associate Program Director Glen Cove Family Medicine Residency Program Assistant Professor Family Medicine Hofstra University School Of Medicine 1/28/2012.

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Diabetes Guidelines An Approach to Diagnosis and Treatment A Case Based Approach

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  1. Diabetes GuidelinesAn Approach to Diagnosis and TreatmentA Case Based Approach Barbara Keber MD, FAAFP, member ACCE Associate Program Director Glen Cove Family Medicine Residency Program Assistant Professor Family Medicine Hofstra University School Of Medicine 1/28/2012

  2. Objectives of Presentation/Discussion • Learn the importance that diabetes plays in our healthcare system/cost of diabetes to all of us • Learn which patients to screen and how to screen them • Become knowledgeable about diagnostic criteria for diabetes and pre-diabetes • Enhance knowledge about the various guidelines for measuring outcomes of diabetes care • Become knowledgeable about the various options for certification in diabetes care and what that means for a practice

  3. Diabetes EpidemiologyWhy Is It Important? • 26 million Americans with Diabetes -11.3% of adults over age 20, 26.9% of those >65yo • 7 million unaware • Pre-diabetes 35% of adults >20 yo, 50% over age 65 for total 79 million Americans • Seventh leading cause of death in 2007 and rising-twice that of general population

  4. Cost of Diabetes • Total cost $174 billion • $116 billion direct medical costs • $58 billion indirect costs-disability/work loss/premature mortality • Medical costs twice that of general population

  5. Complications • Macrovascular-heart disease and stroke-both are 2-4X risk of general population • Microvascular- leading cause of blindness; over 200,000 with end stage renal disease on dialysis/transplant with almost 50,000 new cases annually • 60-70% have neuropathy • 60% of non-traumatic amputations • Severe periodontal disease- 1/3 of diabetics

  6. Diabetes and Pregnancy • 18% of pregnancies using new diagnostic criteria • 35-60% chance of developing Type 2 DM in the 10-20 years following delivery • 5-10% are found to have Type 2 DM post-partum (i.e. Were undiagnosed diabetics before pregnancy) • Complications due to macrosomia, ( Type 1-15-20% spontaneous abortions, 5-10% major birth defects)

  7. Diagnosis of Gestational Diabetes The diagnosis of GDM is made when any of the following plasma glucose values are exceeded: Fasting ≥92 mg/dL (5.1mmol/L) 1 h ≥180 mg/dL (10.0 mmol/L) 2 h ≥153 mg/dL (8.5 mmol/L)

  8. What We Should Know About Caring for Our Diabetic Patients • Guidelines ADA, AACE, NCQA, HEDIS • Classification of diabetes • Who and how to screen for pre-diabetes/diabetes • Who, when and how to treat patients with pre-diabetes to prevent conversion of pre-diabetes to diabetes • When and how to treat type 2 diabetes

  9. Classification of Diabetes • Type 2 DM- most common- 90% -insulin resistance • Gestational DM –diabetes in pregnancy • Type 1DM- absolute deficiency of insulin-+autoantibodies (GAD, Islet cell, insulin) • Monogenic DM-(maturity onset of the young-formerly) history of 3 generations of diabetes, negative antibodies, autosomal dominant

  10. Screening for Pre-diabetesWho to screen • Patients overweight/obese/morbidly obese (BMI>25, >30, >40) • Hypertension • Gestational diabetes in the past (or infant >9 lbs) • Sedentary life style • Abnormal cholesterol (especially TG>250 mg/dl, HDL<35 mg/dl) • Age >45, • Race-African-American, Hispanic, Asian-American, Native American, Pacific Islanders • Family history of diabetes • PCOS syndrome • Early age at menarche# • Antipsychotic medications (those for severe schizophrenia/bipolar disorder)

  11. Screening Options • HbA1C • Fasting glucose • Oral Glucose Tolerance test

  12. Diagnostic levels for various screening tests ADA Diabetes.org diabetes basics

  13. A Typical Patient • NL is a 50 year old female with a longstanding history of hypertension and obesity. She has recently gained back much of the weight she lost by following a diet from weight watchers when she returned to her old dietary habits. Recent lab includes a fasting glucose of 105 mg/dl and a HbA1C of 5.8%.

  14. Our Patient • Additional information- • BP-140/82 • BMI-46.9 • Cholesterol-160 LDL-86 HDL-43 TG-156 • LFT-AST-17 ALT-28 • EKG-normal with no cardiac symptoms • Treatment??- discussion

  15. Treatment of Prediabetes • DPP results indicate • Dietary modification-level B evidence • Exercise-150 min of moderate activity/wk.-level B evidence • Proper sleep (6 hrs/night may reduce insulin resistance) • Medications • Check for progression to diabetes at least annually-evidence level E • Life style modification with weight loss of 5-10% can reduce risk/delay onset of diabetes and delay complications related to prediabetes/diabetes

  16. MedicationsWho, What, When • Cardiovascular disease, fatty liver disease, PCOS, history of gestational diabetes • impaired glucose tolerance-evidence level A • BMI>35, and <60 yo • Metformin-primarily evidence level B for above • Acarbose-may be considered- evidence level E • When life style changes are not having the desired effects for an individual patient • Evaluation of barriers to treatments including life style changes

  17. Barriers to Care

  18. Medications and Others

  19. Diagnosis and Goals for Type 2 DiabetesAmbulatory Care • ADA • ACCE • NCQA (National Committee on Quality Assurance) • HEDIS (Health Effectiveness Data & Information Set)

  20. Diagnostic Criteria of ADA/ACCE • HbA1C>6.4% • Fasting glucose >125 mg/dl (no calories for 8 hrs.) • 2 hr. glucose of >199 mg/dl following 75 Gm oral glucose load (dextrose in water) • Random glucose >199 mg/dl in patient with classical symptoms of diabetes • If levels equivocal then repeat test should be used to confirm • Screening repeated in 3 years if testing normal • Level B evidence

  21. Screening in Pregnancy • At first prenatal visit for those with risk factors previously described • For all pregnant patients at 24-28 weeks gestation • Postpartum 6-12 weeks using either fasting glucose or 2 hr. 75 gm oral glucose testing • (HbA1C may not be sufficient in pregnancy due to rapid turnover of red cells-false lows) • Strict control during pregnancy recommended-fasting glucose <95 mg/dl, postprandial – 1 hour-<140 mg/dl and 2 hour-<120mg/dl

  22. Patient with Type 2 DM • MR is a 51 yo Caucasian female who was diagnosed with type 2 DM 7 years ago. She has comorbid conditions of hypertension, morbid obesity and tobacco use as well as family history of CAD in her father who died due to complications from his diabetes including MI, chronic kidney disease. She has failed to lose weight, stop smoking, but does take her medications, check her blood sugars, see the eye specialist and podiatrist and is up to date with flu and pneumonia vaccines. She presents for follow up diabetes care.

  23. Discussion Current measurements include: BP 132/80 BMI 42.8 HbA1C-7.4 LDL Cholesterol-89 HDL-54 TG-132 Microalbumin/Creatinine random- 4mcg/mg GFR>73 Medications are: Lisinopril 20 mg daily Nataglenide 60 mg at breakfast/120 mg at dinner Metformin 1Gm bid HCTZ 12.5 mg daily Sitagliptin 100 mg daily Aspirin 81 mg daily

  24. Barriers to Improved Control • Patient barriers • Physician inertia • Discussion

  25. Goals for Type 2 DiabeticsHbA1C • <7% (ADA) for prevention of microvascular disease –level A • <6.5 % (ACCE) level D- but must be formulated in context of individual patient’s life expectancy, comorbid conditions, presence or absence of micro and macrovascular complications, overall cardiovascular risk factors and risk for severe hypoglycemia. • Consideration for psychological, social and economic status • Level A evidence for associated factors

  26. Goals Continued • Goal of A1C 7-8% for those with severe hypoglycemia, limited life expectancy, advanced micro or macrovascular disease, extensive comorbid conditions, long-standing disease uncontrolled despite extensive effort –Level A

  27. Blood Pressure Control • BP <130/80 (ADA/ACCE) with use of DASH diet-low sodium, counseling by nutritionist, level A for DASH diet, use of ACE/ARB as primary agents for reduction of BP- level D • Multiple medications for control of BP as needed • For cardiovascular prevention addition of calcium channel blocker, thiazide diuretic, beta-blocker-level A • Other agents as needed

  28. Goals for Lipids • LDL-C<100 mg/dl/Non-HDL-C <130 mg/dl in those with no additional CVD or risk factors • LDL-C <70 mg/dl/non-HDL-C<100 mg/dl for those with established CVD, 2 additional risk factors • Statins are treatment of choice for those not reaching goal with lifestyle modifications • Level A evidence • Measured annually for those at goal and more frequently for those not at goal

  29. Evaluation for Complications Macrovascular • Cardiovascular disease-coronary, peripheral, carotid, cerebrovascular Microvascular • Nephropathy • Retinopathy • Neuropathy Depression Sleep Apnea

  30. Macrovascular Complications • Screening for coronary artery disease in asymptomatic patients does not improve outcomes or mortality • VADT (Vet. Affairs Diab. Trial) –improvement of 90% of future cardiovascular events with intensive glycemic control those with coronary calcium scores<100 at initiation of intensive control-level A • Use of aspirin (men >65 yo) reduction in all cause and CV mortality-level B (effects of ASA are reduced in environment of elevated glucose) • Aggressive BP control improves rate CV events in diabetics (ALLHAT/HOPE)

  31. Microvascular ComplicationsNephropathy • Microalbuminuria 30-299 mg/gm albumin to creatinine ratio • Random urine • Measured annually • Abnormal should be confirmed by second test • GFR should also be used in screening (NKF-Classifications)-calculated annually • Prevention & Treatment includes intensive glycemic control (A1C<7), use of ACE/ARB, BP control (<130/80) and control of other risk factors (lipids/tobacco) level A • Limitation of protein intake to 10% of daily caloric intake for persistent decline in renal function • Aliskerin (direct renin inhibitor) for persistent albuminuria as an additional agent-Level A

  32. Retinopathy • Dilated retinal examination recommended annually for those without retinal disease • Initially at the time of diagnosis for all with Type 2 DM (after 5 years for type 1 DM) • More frequent examinations during and after pregnancy

  33. Diagnosis and Treatment of Neuropathy • Diagnosis is clinical • Strict glycemic control • Lipid lowering agents • Control of BP-level A • Tricyclics, anticonvulsants, serotonin/ norepinephrine reuptake inhibitors-level A • Large fiber-strength/balance and gait training-level A • Small fiber-foot protection/supportive shoes/diabetic socks/regular foot inspection/protection from heat injury/ emollient creams/ medications for pain-level A

  34. Depression • All adults with DM should be screened for depression-level A • Depression has serious implications for treatment of DM

  35. Immunizations • Influenza annually • Pneumococcal at diagnosis and one additional dose at the appropriate time according to ACIP recommendations

  36. Immunizations • Hepatitis B- 12/2011-ACIP-newly recommended due to possible cross contamination via shared glucose meters (in hospital settings or other facilities) • Td or Tdap per usual recommendations

  37. Self Management • Diabetes education and self management skills- key to glycemic control and reduction of complications- level A • Referral for CDE, nutrition counseling at time of onset and as indicated • Key components- self glucose testing, adjustment of medications for illness, identification of hypoglycemia and treatment, foot care, use of insulin and disposal of needles/syringes, complications

  38. Comprehensive Care Plan • Level A evidence –ACCE unanimous support for a comprehensive, team based approach to diabetes care • Use of CDE, nutritionists, specialists in endocrinology, cardiology, vascular surgery, nephrology, ophthalmology

  39. Use of Registry • Critical to track patients and results and reports • Used for reminders to patients who have not complied with visits, labs, consultations

  40. Guidelines for Goals NCQA

  41. HEDIS Measurements • Measures used by third party payers to evaluate physician participants. • Chosen by the payer • For Diabetes similar to those for NCQA • Measures are however, obtained from payment coding rather than submitted by the practice or physician • Important to respond to letters which are received and show incorrect data • Physician report cards developed in part from these measures

  42. Diabetes Specific Measures • HbA1C >9% • HbA1C <8% • HbA1C <7% • Eye exam • LDL screening • LDL control <100 mg/dl • Medical attention for nephropathy • Assessment of tobacco use • Assistance with tobacco cessation • Influenza vaccine • Pneumococcal vaccine

  43. Inpatient Diabetes Management • Practice Guidelines – consensus of Endocrine Society, ADA, AHA, AADE, European Society of Endocrinology, Society of Hospital Medicine based on quality and strength of evidence

  44. Hospitalized Patients • Elderly, multiple co-morbidities, physiologic stressors (steroid, TPN, surgery etc)

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