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
• Discuss guideline based management
for diabetes
• Apply Diabetes guideline based
management in clinical practice
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
•
•
•
•
•
•
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
• Native American 16.1%
• Black 12.6%
• Hispanic 11.8%
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
• 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
• 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
Management
•
•
•
•
Evidence based
Well accepted
Clinically relevant
Can be easily incorporated into clinical
practice
• Emphasize comprehensive risk
management
Diabetes Guideline
Management
• ADA publishes guideline update every
January (Diabetes Care)
• Clinical Practice Recommendations
• http://professional.diabetes.org/
Diabetes Guideline
Management
• AACE updates periodically (2011)
• http://www.aace.com/pub/guidelines/
• AACE Medical Guidelines for Clinical
Practice for the Management of Diabetes
Mellitus
Screening For Diabetes
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
• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity (e.g., African
• American, Latino, Native American,
Asian 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 Screening
(cont’d)
• 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 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
• 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/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
• 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 Diagnosis
Category
FPG (mg/dL)
2h 75gOGTT
A1C
Normal
<100
<140
<5.7
140-199
5.7-6.4
>200
>6.5
Prediabetes 100-125
Diabetes
>126**
Or patients with classic hyperglycemic symptoms with plasma glucose >200
** On 2 separate occasions
Diabetes Care 34:Supplement 1, 2011
Gestational Diabetes (GDM)
• Screen for type 2 diabetes first prenatal visit if risk
factors
• Not known to have diabetes, screen for GDM at 24 –28
weeks of gestation
• Screen women with GDM for persistent diabetes 6–12
weeks postpartum
• Women with a history of GDM lifelong screening for
diabetes or prediabetes at least every 3 years (up to 7x
higher risk than non-GDM)
Diabetes Care 34:Supplement 1, 2011
Lancet, 2009, 373(9677): 1773-9
Diabetes Care 21(2):B161–B167, 1998
Diabetes Care 2010; 33: 676–682
Gestational Diabetes (GDM)
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•
•
•
Overnight fast, 75g OGTT
Fasting >92 mg/dl
1h
>180 mg/dl
2h
>153 mg/dl
Diabetes Care 34:Supplement 1, 2011
Diabetes Care 2010; 33: 676–682
Targets for Glycemic (blood sugar) Control
In Most Non-Pregnant Adults
A1c (%)
Fasting (preprandial) plasma
glucose
Postprandial (after meal)
plasma glucose
ADA
AACE
<7*
≤6.5
70-130 mg/dL <110 mg/dL
<180 mg/dL
<140 mg/dL
*<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
%
6
6.5
7
7.5
8
8.5
9
9.5
10
eAG
mg/dL
126
140
154
169
183
197
212
226
240
mmol/L
7.0
7.8
8.6
9.4
10.1
10.9
11.8
12.6
13.4
Formula: 28.7 x A1C - 46.7 - eAG
American Diabetes Association
ADA Guidelines for Glucose Management
Children and Adolescents
Age
A1C
Blood Sugar
Goals-fasting/
before meals
Blood Sugar
Goals-bedtime/
overnight
Toddlers/
preschool
(0–6)
7.5-8.5
100-180
110-200
School age
(6–12)
<8
90-180
100-180
Adolescent/yo
ung adults
(13–19)
<7.5
90-130
90-150
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Diabetes Care 2005;28:186–212
Goals For Older Adults
• Age and functional status dependent
• Less than 3 year life expectancy, longterm 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
• Done at every visit
• Target is <130/<80
• ACE inhibitors typically first line
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
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
• 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)
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
• 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)
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)
Neuropathy Screening
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•
•
•
Screen at diagnosis and annual thereafter
Filament testing
Vibratory testing
Reflexes
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
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-endomysial antibiodies with serum IgA
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Thyroid Screening
• Type 1 screen at diagnosis and every
1 to 2 years, pregnant
• At diagnosis, thyroid peroxidase and
thyroglobulin antibodies
• TSH thereafter
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
• Physical Exam-Diabetes Directed
• Labs
• Team management
• More on this later
(“Diabetes Complications” 2/24/11)
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 Team
• Diabetes Nurse Educator or Certified
Diabetes Educator (CDE)
• Registered Dietician
• The patient !
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
• Medical Nutrition Therapy (MNT)
• Exercise/Activity Prescriptionsalmost everybody can do something
• Indicated for all patients with Diabetes
Lifestyle Management
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
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
• Implementation of evidenced based
guidelines improves diabetes outcomes
• Guidelines are easily available
• Getting patients to goals is important
Acknowledgements
• North Dakota Department of Health, Karalee Harper
• 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
• Disclosure: Novo Nordisk Speaker’s Bureau
Contact Info/Slide Decks/Media
e-mail
ejohnson@medicine.nodak.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 Medcast
(updated soon)
WebMD Page: (under construction)
http://www.webmd.com/eric-l-johnson
Diabetes e-columns (archived):
http://www.ndhealth.gov/diabetescoalition/DrJohnson/DrJohnson.htm