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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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
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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
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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
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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
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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 postpartum (i.e. Were undiagnosed diabetics
before pregnancy)
Complications due to macrosomia, ( Type 115-20% spontaneous abortions, 5-10% major
birth defects)
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)
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Guidelines ADA, AACE, NCQA, HEDIS
Classification of diabetes
Who and how to screen for prediabetes/diabetes
Who, when and how to treat patients with
pre-diabetes to prevent conversion of prediabetes to diabetes
When and how to treat type 2 diabetes
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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 youngformerly) history of 3 generations of diabetes,
negative antibodies, autosomal dominant
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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)
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HbA1C
Fasting glucose
Oral Glucose Tolerance test
Diagnostic levels for various screening tests
ADA Diabetes.org diabetes basics
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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%.
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Additional informationBP-140/82
BMI-46.9
Cholesterol-160 LDL-86 HDL-43 TG-156
LFT-AST-17 ALT-28
EKG-normal with no cardiac symptoms
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Treatment??- discussion
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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
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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
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ADA
ACCE
NCQA (National Committee on Quality
Assurance)
HEDIS (Health Effectiveness Data &
Information Set)
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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
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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 recommendedfasting glucose <95 mg/dl, postprandial – 1
hour-<140 mg/dl and 2 hour-<120mg/dl
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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.
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
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Patient barriers
Physician inertia
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Discussion
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<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
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Goal of A1C 7-8% for those with severe
hypoglycemia, limited life expectancy,
advanced micro or macrovascular disease,
extensive comorbid conditions, longstanding disease uncontrolled despite
extensive effort –Level A
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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
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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
Macrovascular
 Cardiovascular disease-coronary, peripheral,
carotid, cerebrovascular
Microvascular
 Nephropathy
 Retinopathy
 Neuropathy
Depression
Sleep Apnea
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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)
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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 (NKFClassifications)-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
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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
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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 traininglevel A
Small fiber-foot protection/supportive
shoes/diabetic socks/regular foot
inspection/protection from heat injury/ emollient
creams/ medications for pain-level A
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All adults with DM should be screened for
depression-level A
Depression has serious implications for
treatment of DM
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Influenza annually
Pneumococcal at diagnosis and one
additional dose at the appropriate time
according to ACIP recommendations
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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
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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
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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
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Critical to track patients and results and
reports
Used for reminders to patients who have not
complied with visits, labs, consultations
HbA1C poor control>9%
<15%
HbA1C control <8 %
60%
HbA1C control <7%
40%
BP control > 140/90 mm Hg
<35%
15 pts
BP control <130/80 mm Hg
25%
10 pts
Eye Exam
60%
10 pts
Smoking Status/ Cessation advice
80%
12 pts
8 pts
5 pts
10 pts
LDL control >130 mg/dl
<37%
10 pts
LDL control <100 mg/dl
36%
10 pts
Nephropathy assessment
80%
5 pts
Foot examination
80%
5 pts
Total pts
Points needed for recognition
100
75
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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
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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
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Practice Guidelines – consensus of Endocrine
Society, ADA, AHA, AADE, European Society
of Endocrinology, Society of Hospital
Medicine based on quality and strength of
evidence
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Elderly, multiple co-morbidities, physiologic
stressors (steroid, TPN, surgery etc)
35%
% of Patients
30%
Mortality
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Complications‡
25%
N = 2471
†
20%
*
15%
10%
*
Non-ICU patients with
community-acquired
pneumonia
5%
0%
<200 mg/dL
*P
‡
†P
>200 mg/dL
Admission BG Level
= .03;
= .01.
Complications include all in-hospital complications except for abnormalities of glucose.
McAlister FA et al. Diabetes Care. 2005;28:810-815.
P < .01
P < .01
In-hospital
Mortality Rate
(%)
Patients
With
Normoglycemia
Patients
With History
of Diabetes
Newly
Discovered
Hyperglycemia
Umpierrez GE, et al. J Clin Endocrinol Metab. 2002; 87:978-982.
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Measured before meals and at bedtime or
every 6 hours for NPO status-level 1 evidence
Use of insulin in hospital setting- basal/bolus
regimenDO NOT USE SLIDING SCALE ONLY-level 1
evidence
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Most patients with diabetes type 2 –
substituted for oral agents
CHF, Sepsis, COPD, CVA, MI, Surgical,
Glycemic Targets- pre-meal<140 mg/dl and
random <180 mg/dl for non-critical patients
Suggestion for consistent carbohydrate rather
than “diabetic diet” in conjunction with
nutritionist -less hypoglycemia and
advantage of consistent pre-meal insulin
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0.2-0.3 Units/kg (age>70, GFR<60ml/min
0.4 Units/kg with glucose 140-200 mg/dl at
admission
0.5 Units/kg 201-400 mg/dl
50% basal and 50% nutritional
Basal –glargine/detemir-daily or NPH BID
Prandial insulin-3 equally divided doses-held
if patient NPO or not able to eat
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Supplemental or correction Insulin- according
to sensitivity
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Absolute insulin requirement
MUST ALWAYS receive insulin even if NPO
Calculation of dose -10-20% decrease in
basal insulin/ uncontrolled patients may
receive their full dose
If using NPH BID- reduction of 25-50%
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<70 mg/dl –nursing strategies for treatment
A marker for more severe illness (rather than
cause of increased mortality)
To be avoided-increased-elderly, greater
severity of illness, change in nutritional
intake, steroid tapering etc.
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Patient-self management skills/support
groups
Staff – ongoing, targeted to adverse events
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www.CDC.gov/diabetes -2011 diabetes fact sheet
www.diabetes.org
www.mayoclinic.com
www.acce.com
J. Clinical Endocrinol Metab 97: 16-38, 2012
Diabetologia-15 December 2011 -Age at menarche is
associated with prediabetes and diabetes in women (aged
32–81 years) from the general population:the KORA F4
Study D. Stöckl & A. Döring & A. Peters & B. Thorand &M.
Heier & C. Huth & H. Stöckl &W. Rathmann &B. Kowall & C.
Meisinger;
Diabetologia (2008) 51:781–786; Association between age
at menarche and risk of diabetes in adults: results from
the EPIC-Norfolk cohort study R. Lakshman & N. Forouhi &
R. Luben & S. Bingham &K. Khaw & N. Wareham & K. K.
Ong