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

• Overview of diabetes
• Discuss guideline based management for diabetes
• Apply Diabetes guideline based management in clinical practice

• 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
• Diagnosed: 26 million people —8.3% of population ( 90%+ have Type 2 )
• Undiagnosed: 7 million people
• 79 million people have pre-diabetes
CDC 2011

• 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

• Native American 16.1%
• Black 12.6%
• Hispanic 11.8%

• Type 1: autoimmune betacell destruction, absolute insulin deficiency
• Type 2: insulin resistance, other mechanisms, eventual betacell failure over time.

Islet b
-cell
Decreased
Incretin Effect
Increased
Lipolysis Impaired
Insulin Secretion
Islet a
-cell
Increased
Glucagon Secretion
Increased Glucose
Reabsorption
Increased
HGP
Decreased Glucose
Uptake
Neurotransmitter
Dysfunction

• 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

Risk:
• Type 1- mostly unknown, some familial
• Type 2- obesity, smoking, sedentary lifestyle, familial
Prevention:
• Type 1- none known
• Type 2- lifestyle 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”

• Evidence based
• Well accepted
• Clinically relevant
• Can be incorporated into clinical practice
• Emphasize comprehensive risk management

• ADA publishes guideline update every
January (Diabetes Care)
• Clinical Practice Recommendations
• http://professional.diabetes.org/

• 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

• 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…….

• 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

• 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

• 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

• Overweight
-BMI >85th percentile
-weight for height >85 th percentile
-weight >120% of ideal for height
• Plus any two of the following risk factors….

• 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

• 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

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

• >45 years old
• Risk factors
• Ethnicity
• Obese
• Smoking
• CVD
• Any Prediabetes syndrome

Risks for Complications in Diabetes
• Abnormal blood sugar/A1C
• Abnormal lipids
• Abnormal blood pressure
• Sedentary lifestyle
• Smoking

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

• 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 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
A1c (%)
ADA
<7*
AACE
≤6.5
Fasting (preprandial) plasma glucose
Postprandial (after meal) plasma glucose
70-130 mg/dL <110 mg/dL
<180 mg/dL <140 mg/dL
• American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
*<6 for certain individuals
• 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.

7
7.5
8
8.5
9
9.5
10
A1C
%
6
6.5
mg/dL
126
140
154
169
183
197
212
226
240 eAG 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
Goalsbedtime/ overnight
Toddlers/ preschool
(0
–6)
School age
(6 –12)
Adolescent/yo ung adults
(13
–19)
7.5-8.5
<8
<7.5
100-180
90-180
90-130
110-200
100-180
90-150
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)
Diabetes Care 2005;28:186 –212

• 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
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
At diagnosis: Lifestyle and MET
+ basal insulin
Lifestyle and MET
+ intensive insulin
Lifestyle
+
MET
Lifestyle and MET+ SU a
Step 1 Step 2
Tier 2: Less well-validated studies
Step 3
Lifestyle and MET
+ pioglitazone
No hypgglycemia edema/CHF
Bone loss
Lifestyle and MET
+ pioglitazone
+ SU a
Lifestyle and MET
+ GLP-1 agonist b
Lifestyle and MET
+ basal insulin
Weight loss
Nausea/vomiting a SU other than glyburide or chlorpropamide. b Insufficient 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*
Treatment FPG

Sulfonylureas 50-60 mg/dl
Metformin 50-60 mg/dl a
-Glucosidase Inhibitors (Precose) 15-30 mg/dl
Repaglinade (Prandin)
Thiazolidinediones
Gliptins (Januvia,Onglyza)
60mg/dl
40-60 mg/dl targets ppd
HbA1C

1-2%
1-2%
0.5-1%
1.7%
1-2%
0.5 - 0.8%
*based on package insert data as monotherapy

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 hypoglycemia
1.5-3.5%
*based on package insert data as monotherapy

• Dr. Clarens overview of non-injectable medications
• More on injectable medications later

• 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

• 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)

• Done at every visit
• Target is <130/<80
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

• 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)

• Lipids: start screening in childhood if strong FH, or at age 10
• Hypertension: BP >90 th percentile for height and weight or >130/>80
• Consider medications (statins, ACE) if necessary
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

BP:
• ACEI usually first line, ARB alternate
• Other meds as necessary (often 2 or 3)
Lipids:
• Statins usually first line
• Fibrates, Fish Oil, Niacin

• Men >50 years of age
• Women >60 years of age
• Younger if higher risk
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

• 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)

• 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)

• 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)

• A1C < 7
• Laser photocoagulation by ophthalmologist or retinologist

• 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)

• 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
• Capsazin creme

• 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
• Small bowel biopsy to confirm
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

• Type 1 screen at diagnosis and every
1 to 2 years, and if pregnant
• At diagnosis, thyroid peroxidase and thyroglobulin antibodies
• TSH thereafter

• NAFLD, NASH
• ~30% of adults with DM
• LFT’s periodic
• Imaging (CT, Ultrasound, MRI) if persistent abnormal LFT’s
• May need biopsy and referral

• 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,
3 rd party payer, etc.
• Medication(if appropriate)
• Other routine screens (i.e.,cancer)

Delivering Guideline Based Care

• Physical Exam-Diabetes Directed
• Labs
• Team management
• Systematic clinical encounterskeep everything organized
• See patient 2 to 4 times a year, prn

HPI-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

Review 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

Review 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
• 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)
• Filament and vibratory testing (feet)
• Reflexes
• General foot exam
(skin, nails, lesions, color, pulses)
• General skin/injection sites
• Other complaint directed
• Growth parameters-children

• 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

• Other:
Age appropriate recommendations
(cancer screening, etc)
Vaccinations

• 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

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

• Diabetes Nurse Educator or Certified
Diabetes Educator (CDE)
• Registered Dietician
• The patient !

• 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

• Medical Nutrition Therapy (MNT)
• Exercise/Activity Prescriptionsalmost everybody can do something
• Indicated for all patients with Diabetes

• 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

• 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

• 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

• 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

• 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
• 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”

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