TYPE 2 DIABETES MELLITUS Asma Jafri, MD

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TYPE 2 DIABETES MELLITUSAsma Jafri, MD

• July 22, 2004

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GOALS

• Recognize the changing face of Type 2 Diabetes
  Mellitus regarding demographics and epidemiology.
• Demonstrate understanding of the Standards of
  Medical Care for Patients with Type 2 Diabetes
  Mellitus.
• Understand multidisciplinary therapeutic
  approaches to the management of Type 2 Diabetes
  Mellitus.
• Recognize metabolic syndrome as a clinical
  condition and risk factor for Diabetes.

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Table 1. CRITERIA FOR THE DIAGNOSIS OF DIABETES
MELLITUS IN NON-PREGNANT ADULTS

• Symptoms of diabetes plus casual plasma glucose
  concentration 200 mg/dl (11.1 mmol/L). Casual
  is defined as any time of day without regard to
  time since last meal. The classic symptoms of
  diabetes include polyuria, polydipsea and
  unexplained weight loss.
• or
• FPG 126 mg/dl (7.0 mml/L). Fasting is defined
  as no caloric intake for at least eight hours.
• or
• 3. 2hPG 200 mg/dl (11.1 mmol/L) during an OGTT.
  The test should be performed using a glucose
  load containing the equivalent of 75 g anhydrous
  glucose dissolved in water.

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• In the absence of unequivocal hyperglycemia
  with acute metabolic decompensation, these
  criteria should be confirmed by repeat testing on
  a different day. The third measure (OGTT) is not
  recommended for routine clinical use.
• From the Expert Committee on the Diagnosis and
  Classification of Diabetes Mellitus Report of
  the Expert Committee on the Diagnosis and
  Classification of Diabetes Mellitus Care
  201183-1197, 1997 with permission.

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Table 2. CRITERIA FOR THE DIAGNOSIS OF IMPAIRED
GLUCOSE TOLERANCE IN NON-PREGNANT ADULTS (PRE
DIABETES)

• Fasting plasma glucose of 110 mg/dl or lt 125
  mg/dl
• 2-hour post-prandial plasma glucose of gt 140 and
  lt 200 mg/do

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CLINICAL FEATURES

• Insulin resistance and progressive insulin
  secretory defect.
• Most patients are obese.
• If not obese, they have increased percentage of
  body fat distributed predominately in the
  abdominal region.
• Ketoacidosis seldom occurs spontaneously. When
  seen, it usually arises in association with the
  stress of another illness such as infection.
• Risk increases with age, obesity and lack of
  physical activity.
• Strong genetic predisposition.

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METABOLIC SYNDROME

• Insulin resistance
• Hyperinsulinemia
• Obesity (central), waist circumference is gt 35
  in females and gt 40 in males
• Dislipidemia of ? TG and or low HDL
• Hypertension

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PREVALENCE

• Prevalence was 7.4 in 1995. This is expected to
  rise to above 9 in 2025. It is estimated that
  there are 16 million people with Type 2 Diabetes
  Mellitus and over 10 million Americans have
  impaired glucose tolerance. Costs 120 billion
  annually approximately 15 of the U.S.
  healthcare expenditure. The number of
  individuals with Type 2 DM diagnosed between
  30-39 years of age has increased 76 in the past
  ten years. The increase in prevalence of
  diabetes in younger individuals seems to parallel
  the equally alarming rate of obesity in America.
  Reports suggest that Type 2 DM now represents 8
  - 46 of all diabetes cases among children. The
  average AIC of people with diabetes in the U.S.
  is 9. The latest study of American adults with
  diabetes revealed that 37 had AIC gt 8 and 14
  had AICgt 10.

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• Presently about half of the adults with diabetes
  in the U.S. are undiagnosed (8 million).
• At the time of diagnosis of Type 2 Diabetes
• - 2-9 of patients have retinopathy
• - 8-18 have nephropathy
• - 5-13 have neuropathy
• - 8 have cardiovascular disease

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GENERAL RECOMMENDATIONS FOR SCREENING BY
PHYSICIANS

• Screening should be considered at three (3) year
  intervals for
• 1. All individuals at age 45 years and above.
• 2. Test at a younger age and more frequently in
  individuals who
• a. Are obese with BMI 27 kg/m².
• b. Have a first degree relative with diabetes.
• c. Are members of a high-risk ethnic
  population (i.e., African American,
  Hispanic, Native American, Asian American,
  Pacific Islander).
• d. Have delivered a baby weighing gt 9 lbs. or
  have been diagnosed with GDM.
• e. Are hypertensive (BP 140/90).
• f. Have an HDL cholesterol level 35 mg/dl
  and/or TG level gt 250 mg/dl.
• g. On previous testing had IGT or IPG.
• h. Habitual physical inactivity.

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SCREENING TEST

• Fasting plasma glucose (FPG).
• Oral glucose tolerance test (75 gm glucose). The
  fasting plasma glucose test is strongly preferred
  because it is easier and faster to perform, more
  convenient and less expensive.
• A random plasma glucose level 160 mg/dl is
  considered a positive screening test result and
  needs further testing.
• Glycated hemoglobin is currently not recommended
  for the screening or diagnosis of diabetes.
• The OGTT is more sensitive for the diagnosis of
  diabetes and pre-diabetes, but is impractical and
  expensive as a screening procedure.

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TABLE 3 GLYCEMIC CONTROL FOR PEOPLE WITH DIABETES

• Recommendations for Glycemic Control
• Biochemical Action
• Index Normal Goal Suggested
• __________________________________________________
  _____________________
• Fasting/Preprandial glucose lt110 mg/dl 80
  to 120 mg/dl lt 80 or gt 140 mg/dl
• Bedtime glucose lt120 mg/dl 100 to 140
  mg/dl lt100 or gt 160 mg/dl
• Glycosylated hemoglobin lt 6
  lt 7 gt 8
• __________________________________________________
  _____________________
• These values are for non-pregnant adults.
  Goals and Action Suggested depend on individual
  patient circumstances. Such actions may include
  enhanced diabetes self-management education,
  co-management with a diabetes team, referral to
  an endocrinologist, change in pharmacological
  therapy, initiation or increased SMBG, or more
  frequent contact with the patient. HbA1c is
  referenced to a non-diabetic range of 4.0 6.0
  (mean 5.0, SD ? 0.5).

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ESSENTIAL COMPONENTS OF MANAGEMENT INITIAL
VISIT

• Medical History
• 1. Symptoms, results of laboratory tests and
  special examination results related to diagnosis
  of diabetes.
• 2. Prior G Hb results.
• 3. Eating patterns, nutritional status, weight
  history.
• 4. Details of previous treatment programs
  including nutrition and diabetes self-management
  education.
• 5. Current treatment of diabetes including
  medications, meals, results of glucose
  monitoring.
• 6. Exercise history.
• 7. Acute complications such as DKA,
  hypoglycemia.
• 8. Prior or current infections.
• 9. Symptoms and treatment of eye, kidney, nerve,
  gu, bladder and GI function, heart, peripheral
  vascular, foot, CVA, etc.

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• 10. Other medications that may affect blood
  glucose levels.
• 11. Risk factors for atherosclerosis smoking,
  HTN, obesity, dislipidemia and family history.
• 12. Family history of diabetes and other
  endocrine disorders.
• 13. Gestational history.
• 14. Life style, cultural, psychosocial,
  educational and economic factors that might
  influence the management of diabetes.
• 15. Tobacco and alcohol use.

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Physical Examination

1. Height and weight.
2. Sexual maturation staging (peripubertal).
3. Blood pressure with orthostatic measurements when
   indicated.
4. Ophthalmoscopic examination (dilation).
5. Oral examination.
6. Thyroid palpitation.
7. Cardiac examination.
8. Abdominal examination.
9. Evaluation of pulses.
10. Hand/finger examination.
11. Foot examination.
12. Skin examination.
13. Neurological examination.

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Laboratory Evaluation

1. Fasting or random plasma glucose.
2. GHb
3. Fasting lipid profile.
4. Serum creatinine in adults.
5. Urine analysis, glucose, ketones, protein,
   sediment.
6. Test for microalbuminuria.
7. Urine culture if sediment is abnormal or symptoms
   are present.
8. TSH in all Type 1 patients.
9. EKG in adults.

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DIABETES SELF-MANAGEMENT EDUCATION

• National standards for Diabetes Self-Management
  Education have been developed. Ten content areas
  have been identified as the core topics needed to
  provide comprehensive education to the person
  with diabetes
• Diabetes disease process and treatment options.
• Nutritional management.
• Incorporating physical activity in lifestyle.
• Using medication effectively.
• Monitoring blood glucose and using the results.
• Preventing, detecting and treating acute
  complications.

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• Goal setting to promote health and problem
  solving for daily living.
• Integrating psychosocial adjustment into daily
  life.
• Promoting preconception care and managing
  diabetes during pregnancy when applicable.
• A major emphasis in diabetes education is
  patient empowerment in making decisions regarding
  diabetes management.

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CONTINUING CARE (FREQUENCY)

• Individualized regimen and frequency of visits.
• If target goals met, frequency every six months.
• If target goals not met, frequency every three
  months.

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ROUTINE FOLLOW-UP VISIT

• History of goals, activity, diet, MBG,
  medications, symptoms of CAD, personal concerns,
  stresses, evaluate smoking status.
• Exam weight, BP (goal lt 138/80 lower BP may be
  even better). Epidemiologic analyses show that
  blood pressure gt 115/75 are associated with
  increased CV event rates and mortality in persons
  with diabetes.
• A. Pulses - annually
• B. Annual Foot exam including Semmes-Weinstein
  monofilament, tuning fork, palpation and visual
  exam (skin, nails). (B) Perform a visual
  inspection of patients feet at each visit. (E)
• C. Dilated eye exam annually (B).

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Laboratory studies

1. GHg every three months if treatment changes or
   not meeting goals, otherwise every six months.
2. Annual fasting lipid panel or biannual if goals
   met. Repeat lipid profiles as dictated by
   therapy. Goal is LDLlt100, HDL gt45 in males and
   gt55 in females, and TG lt 150 mg/dl.
3. Annual serum creatinine.
4. Urine analysis for microalbumin annually until
   confirmed positive.

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Other

• Aspirin 80 mg/day for patients over age 40 for
  primary prevention.
• May use over age 30 in patients with additional
  risk factors (A). Aspirin does not prevent
  retinopathy or increase risk of hemorrhage (A).
• Influenza and pneumococcal vaccination (C).
• Advise all patients not to smoke (A).
• In patients gt 55 years of age with or without HTN
  but with another CV risk factor, an ACE inhibitor
  should be considered to reduce the risk of CV
  events (A).

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Table 4. DEFINITIONS OF ABNORMALITIES IN ALBUMIN
EXCRETION

• __________________________________________________
  _____________
• 24-h
  Timed Spot
• Category Collection
  Collection Collection
• __________________________________________________
  _____________
• Normal lt 30 mg/24 h
  lt 20 µ lt 30 µg/mg creatinine
• Microalbuminaria 30-300 mg/24 h 20-200
  µg/min 30-300 µg/mg creatinine
• Clinical albuminuria gt 300 mg/24 h gt
  200 µg/min lt 300 µg/mg creatinine
• __________________________________________________
  _____________________
• Because of variability in urinary albumin
  excretion, two of three specimens collected
  within a three to six month period should be
  abnormal before considering a patient to have
  crossed one of these diagnostic thresholds.
  Exercise within 24 h, infection, fever,
  congestive heart failure, marked hyperglycemia,
  and marked hypertension may elevate urinary
  albumin excretion over baseline values.
• From the American Diabetes Association Clinical
  Practice Recommendations 1999. Diabetes Care
  22(suppl1)S67, 1999 with permission.

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Table 5. OPHTHALMOLOGIC EXAMINATION SCHEDULE

• __________________________________________________
  __________________
• 
  Recommended First Minimum Routine
• Patient Group_______________Examination___________
  ______Follow-Up_____
• 29 Years or Within 3-5 years after diagnosis
  of Yearly
• younger diabetes once patient is age 10
  years
• or older
• 30 years or older At time of diagnosis of
  diabetes Yearly
• Pregnancy in Before conception and during
  trimester Physician discretion pending
• Pre-existing results of 1st trimester
• Diabetes exam
• __________________________________________________
  ____________
• Abnormal findings necessitate more frequent
  follow-up
• As indicated in WESDR, these are operational
  definitions of Type 1 and Type 2 diabetes based
  on age (age lt30 years at diagnosis, Type 1 age
  30 years at diagnosis, Type 2) and not
  pathogenetic classification.
• From the American Diabetes Association Clinical
  Practice Recommendations 1999. Diabetes Care
  22(suppl1)S72, 1999 with permission.