SCREENING IN DIABETES

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SCREENING IN DIABETES

• TONY ROBINSON
• 12th September 2007

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What to Screen

• Macrovascular Risk
• Microvaascular Risk
• Other Endocrine risk

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MACROVASCULAR RISK

• Cholesterol
• Blood Pressure
• Aspirin

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Loss of life expectancy due to diabetes
Years of life lost
Females
8
Males
7
6
5
4
3
2
1
0
2529
3034
3539
4044
4549
5054
5559
6064
6569
7074
7579
8084
8589
90
lt25
Age at diagnosis
Hopkinson et al (1999)
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4S
LIPS
HPS
GREACE
LIPID
CARDS
LRC-CPPT
?
CARE
Post-CABG
ASCOT
WOSCOPS
AFCAPS/TexCAPS
1.6 2.1 2.6 3.1 3.6
4.2 4.7 5.2
(mmol/l)
HPS Lancet July 2002. LIPS Lescol
Intervention Prevention Study JAMA July 2002
GREACE 2002. AngloScandinavian Cardiac
Outcome Trial ACC, Chicago 2nd April 2003
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Cholesterol

• Target all type 2
• Cholesterol lt 4.0mmol/l
• HDL gt1 (male), 1.2 (female)
• TG lt1.7
• LDL lt 2
• Or 30-40 risk reduction
• Statin first (if low HDL, high TGs fibrate)

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Type 1 Patients

• Target risk patients i.e. smokers, microvascular
  complications, DM gt 10 years or gt40
• Remember 30 reduction in life expectancy is
  mainly macrovascular disease

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Relationship Between Hypertension and Diabetic
Nephropathy
Incidence Rate of Proteinuria per 1,000 Type 1
Diabetics per year
Noth RH, Krolewski AS, Kaysen GA, et al. Ann
Intern Med 1989110795-813
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Blood Pressure

• BP130/80 or lower if younger and female
• Remember risk benefit in elderly
• Presence of micro albuminuria requires ACE or
  AT2 blocker
• Evidence in type 2 AT2 but cost
• Type 1 ACE

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ASPIRIN

• Secondary prevention
• Primary preventionType 2 gt 40 or with FH or
  documented other increased risks i.e. smoking
• Type 1 gt 40 esp. with microvascular disease or
  other cardiovascular risk factors
• 30-40 with increased risk
• Not below 21

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Retinal Screening

• Yearly 100 offered with 80 uptake
• Opt out
• DNA repeated opt out (17 of appointments)
• All day clinics
• Awaiting funding agreements (STILL)

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Feet (wrong session !)

• Annual check pedal pulses and sensation in two
  modalities
• Usually at GP practice, Specialist care if
  problems or being seen frequently gt1(2?)/year
• Patients with neuropathy ulcer
• Patients with neuropathy and poor blood supply
  amputation

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Treatment Principles
Diagnose early patients at risk
Treat early
Improve clinical outcome and more Cost-effective
Prevention of Costly Complications
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Other Endocrine Conditions

• VIRTUALLY ALLTYPE 1
• Autoimmune thyroid disease
• 20 lifetime risk with 30 prevalence of thyroid
  antibodies
• Suggested screening every 3 years and in females
  gt18 to 40 annually

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Other Endocrine Conditions 2

• Coeliac disease
• Asymptomatic to extremes
• Prevalence 1-6 in type 1
• Children screened annually
• Adults for symptoms and 3-5 yearly

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Other Endocrine Conditions 3

• Addisons
• Rare lt1 of type 1 diabetes
• Polyglandular autoimmunity
• No indication for regular screening
• Weight loss, increasing hypos and pigmentation