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Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome

Canadian Diabetes Association 2013 Clinical Practice Guidelines. Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome . Chapter 3 Ronald Goldenberg, Zubin Punthakee. Key Messages. Screen wisely. Diagnose precisely. Diagnosis of diabetes can be made with:

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Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome

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  1. Canadian Diabetes Association 2013 Clinical Practice Guidelines Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome Chapter 3 Ronald Goldenberg, Zubin Punthakee

  2. Key Messages • Screen wisely. Diagnose precisely. • Diagnosis of diabetes can be made with: • Fasting plasma glucose (FPG) level of ≥7.0 mmol/L • 2-hr plasma glucose (2hPG) in 75 g OGTT ≥11.1 mmol/L • A1C ≥6.5% • “Prediabetes”↑risk of developing diabetes • Impaired fasting glucose (FPG 6.1-6.9 mmol/L) • Impaired glucose tolerance (2hPG 75g OGTT 7.8-11.0) • A1C 6.0- 6.4% 2013 2013

  3. Classification of Diabetes

  4. Diagnosis of Diabetes 2013 2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

  5. 2013 Diagnosis of Diabetes Single test in diabetes range No symptoms* Symptoms* Diagnosis made. Repeat not necessary Repeat confirmatory test on different day If FPG, A1C or 2hPG used initially If random PG used initially Use same test as confirmatory test Use FPG, A1C or 2hPG OGTT as confirmatory test If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.

  6. Glycemia and Retinopathy Thresholds FPG 15 2hPG Pima Indians HbA1c 10 Retinopathy (%) 5 0 Threshold levels for the development of retinopathy are similar in all 3 populations: FPG ≥7.0 mmol/L 2hPG ≥11.1 mmol/L A1C ≥6.5% FPG (mg/dl) 70- 89- 93- 97- 100- 105- 109- 116- 136- 226- 2hPG (mg/dl) 38- 94- 106- 116- 126- 138- 156- 185- 244- 364- HbA1c (%) 3.4- 4.8- 5.0- 5.2- 5.3- 5.5- 5.7- 6.0- 6.7- 9.5- FPG 50 2hPG 40 HbA1c Egyptians 30 Retinopathy (%) 20 10 0 FPG (mg/dl) 57- 79- 84- 89- 93- 99- 108- 130- 178- 258- 2hPG (mg/dl) 39- 80- 90- 99- 110- 125- 155- 218- 304- 386- HbA1c (%) 2.2- 4.7- 4.9- 5.1- 5.4- 5.6- 6.0- 6.9- 8.5- 10.3- FPG 15 2hPG HbA1c NHANES III 10 Retinopathy (%) 5 0 FPG (mg/dl) 42- 87- 90- 93- 96- 98- 101- 104- 109- 120- 2hPG (mg/dl) 34- 75- 86- 94- 102- 112- 120- 133- 154- 195- HbA1c (%) 3.3- 4.9- 5.1- 5.2- 5.4- 5.5- 5.6- 5.7- 5.9- 6.2- The International Expert Committee. Diabetes Care 2009; 32:1327-1334.

  7. DETECT-2: A1C ≥6.5% Threshold for Retinopathy 45 40 Any retinopathy 35 ≥ moderate NPDR 30 25 Prevalence (%) 20 15 10 5 0 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5 15.0+ FPG by 0.5 mmol/L intervals 45 40 35 30 25 Prevalence (%) 20 15 10 5 0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0 15.0 16.0 17.0 18.0+ 2hPG by 0.5 mmol/L intervals 45 40 35 30 25 Prevalence (%) 20 15 10 5 0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5 12.0+ 4.0 HbA1c by 0.5% intervals Colagiuri S et al. Diabetes Care 2011; 34:145-150.

  8. Considerations when using A1C for Diagnosis • Need validated standardized assay • Repeat confirmatory test on another day • Recognize conditions leading to misleading A1C • A1C is not used for diagnosis in children, adolescents, pregnancy or suspected type 1 diabetes • Ethnicity and age can affect A1C results

  9. Recognize pitfalls of A1C: conditions that can affect value

  10. Pros and Cons of Diagnostic Tests

  11. Diagnostic Testing With 3 Different Tests • Dealing with Discordance • Many people identified as having diabetes using A1C will not be identified as having diabetes by traditional glucose criteria, and vice versa. FPG 2hPG A1C • When results of more than one test are available (amongst FPG, A1C, 2hPG in a 75-g OGTT) and the results are discordant, the test whose result is above diagnostic cut-point should be repeated, and the diagnosis made on basis of the repeat test.

  12. Diagnosis of Prediabetes* 2013 * Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM

  13. A1C Level and Future Risk of Diabetes: Systematic Review Zhang X et al. Diabetes Care. 2010;33:1665-1673.

  14. Screening for Type 2 Diabetes in Adults 2013 Algorithm presented on next slides

  15. Screening for Type 2 Diabetes in Adults (continued) *If both FPG and A1C are available, but discordant, use the test that appears furthest to the right side of the algorithm.

  16. ‡In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed. ‡ Diabetes: In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.

  17. **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%

  18. **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%

  19. Definition of Metabolic Syndrome

  20. Recommendation 1 2013 • Diabetes should be diagnosed by any of the following criteria: • FPG ≥7.0 mmol/L[Grade B, Level 2] • A1C ≥6.5% (for use in adults in the absence of conditions that affect the accuracy of A1C and not for use in suspected type 1 diabetes) [Grade B, Level 2] • 2hPG in a 75-g OGTT ≥11.1 mmol/L [Grade B, Level 2] • Random PG ≥11.1 mmol/L [Grade D, Consensus]

  21. Recommendation 2 2013 • In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation, but a random PG in the diabetes range in an asymptomatic individual should be confirmed with an alternate test.Grade D, Consensus.

  22. Recommendation 2 (continued) 2013 • In the case of symptomatichyperglycemia, the diagnosis has been made and confirmatory test is not required before treatment is initiated. In individuals in whom type 1 diabetes is likely (younger or lean or symptomatic hyperglycemia, especially with ketonuria or ketonemia), confirmatory testing should not delay initiation of treatment to avoid rapid deterioration. [Grade D, Consensus].

  23. Recommendation 2 (continued) 2013 • If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed. Grade D, Consensus.

  24. Recommendation 3 2013 • Prediabetes, defined as a state which places individuals at high risk of developing diabetes and its complications, is diagnosed by any of the following criteria: • IFG (FPG 6.1 - 6.9 mmol/L) Grade A, Level 1. • IGT (2hPG in a 75-g OGTT 7.8 to 11.0 mmol/L) Grade A, Level 1. • A1C 6.0 - 6.4% (for use in adults in the absence of factors that affect the accuracy of A1C and not for use in suspected type 1 diabetes) Grade B, Level 2 .

  25. CDA Clinical Practice Guidelines http://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca – for patients

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