131_1323.ppt

Management of the Patient with Type 2 Diabetes

Gretchen M. Ray, Pharm.D.Cardiovascular Pharmacotherapy Resident

University of New Mexico College of Pharmacy

Objectives

• Provide diabetes screening criteria for adults

• Describe available pharmacologic treatment options for type 2 diabetes including advantages/disadvantages of therapy and contraindications

• Given a patient case recommend appropriate lifestyle modifications and pharmacotherapy to achieve glycemic goals

Objectives

• Distinguish between microvascular and macrovascular complications

• Provide screening criteria for nephropathy, neuropathy, and retinopathy

• Provide treatment strategies for the prevention and treatment of micro and macrovascular complications

Epidemiology of Type 2 DM

• In 2005 20.8 million people (7% of the US population) had diabetes– 14.6 million diagnosed– 6.2 million undiagnosed

• Type 2 diabetes accounts for 90-95% of patients with diabetes

• In 2002 total indirect and direct medical costs for diabetes = $132 billion

CDC. National diabetes fact sheet. 2005 available at www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf

Risk factors for type 2 diabetes• Physically inactive

• 1st degree relative with diabetes

• Minority ethnic groups

• Gestational diabetes or delivering a baby >9 lbs

• Hypertension

• HDL <35 mg/dL and/or triglycerides >250 mg/dL

• Polycystic ovary syndrome

• Previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

• History of vascular disease

• Psychiatric illness

Diagnosis of diabetes

• Symptoms of diabetes + casual plasma glucose ≥ 200 mg/dl

• FPG ≥ 126 mg/dl

• Oral glucose tolerance test (OGTT): 2-h postload glucose ≥ 200 mg/dl

OR

OR

Definition of “pre-diabetes”

• Impaired fasting glucose (IFG) = FPG 100-125 mg/dl

• Impaired glucose tolerance (IGT) = 2-h post load glucose 140-199 mg/dl

• IFG and IGT indicate a risk factor for diabetes and cardiovascular disease

Diabetes Screening

• Screening identifies asymptomatic patients who might have diabetes

• Consider in patients ≥ 45 years especially if their BMI ≥ 25 kg/m2

• Screen patients < 45 years old if they are overweight + an additional risk factor

• FPG should be done initially

• Repeat screening every 3 years

Oral Therapies

Metformin

hepatic glucose production, intestinal glucose absorption, insulin sensitivity

• Efficacy: A1C 1.5%

• Adverse effects– Primarily GI (up to 50%)

• Diarrhea, abdominal bloating, nausea• Titrate dose at weekly intervals to minimize AEs• Give with meals

– Lactic acidosis- rare• Monitor SCr

Contraindications to Metformin

• Renal impairment SCr >1.5 for men, >1.4 for women

• Radiocontrast studies

• Age >80 unless normal GFR

• Hypoxia

• Liver dysfunction

• Alcoholism

• Heart Failure requiring pharmacologic therapy– According to package insert

• Should heart failure be a contraindication to metformin?Should heart failure be a contraindication to metformin?

Improved Clinical Outcomes Associated with Metformin in Patients with Diabetes and Heart Failure

• Investigate the association between metformin and clinical outcomes in patients with HF and diabetes

• Retrospective study

• Primary outcome: all-cause mortality at 1 year and end of follow-up

• Secondary outcome: all-cause hospitalizations at 1 year and end of follow-up

Eurich DT, et al. Diabetes Care. 2005;28:2345-51


Sulfonylurea monotherapy

(n=773)

Metformin monotherapy

(n=208)

Combination therapy

(n=852)

Adjusted all-cause mortality, HR (95% CI)

1.0 0.70 (0.54-0.91) 0.61(0.52-0.72)

Adjusted all-cause hospitalization, HR (95% CI)

1.0 0.87 (0.73-1.05) 0.93 (0.83-1.05)

Combined endpoint

1.0 0.83 (0.70-0.99) 0.86 (0.77-0.96)



• Lower all-cause mortality with metformin

• No increase in hospitalizations associated with metformin

• Observational study– Cannot prove that metformin is efficacious in this

population


Sulfonylureas

• ↑ insulin secretion from pancreatic β-cells

• Efficacy: ↓ A1C 1.5%

• Glyburide– Not recommended if CrCl < 50 ml/min (use a different sulfonylurea)

• Glipizide– Not recommended if CrCl < 10 ml/min

• Glimepiride– Not recommended if CrCl < 22 ml/min

• Response of sulfonylureas plateaus after half the max dose

• Reduced GI absorption if blood glucose > 250 mg/dL

Sulfonylureas Adverse Effects

• Hypoglycemia– Elderly patients– Hepatic/renal impairment– Combination therapy

• Weight gain

Thiazolidenediones (TZDs) Insulin Sensitizers

• TZDs are PPAR- gamma receptor activators

• ↑ insulin sensitivity – Primarily in the peripheral tissue

• Efficacy: A1C 0.5-1.4%

• Effect may not be seen for 4 weeks

• Rosiglitazone (Avandia®)– Initial dose 4 mg/day, Max dose 8 mg/day

• Pioglitazone (Actos®)– Initial dose 15-30 mg/day, Max dose 45 mg/day

Adverse Effects/Contraindications of TZDs

AE’s

• Fluid retention and peripheral edema

• Weight gain– Fluid retention is a major

contributor– Redistribution of adipose tissue

• New-onset heart failure– < 1%– 2-3% when combined with

insulin

CI’s

• ALT > 2.5 x upper limit of normal

• Hepatic disease

• Alcohol Abuse

• HF NYHA class III or IV (see following slides)

Granberry MC, et al. Am J Health-Syst Pharm. 2007;64:931-6

TZD Use In Heart Failure

• Use of TZDs in patients with NYHA class I or II HF– May be used with initiation of treatment at the lowest

dosage (rosiglitazone 2 mg daily or pioglitazone 15 mg daily)

– Observe for weight gain, edema, or exacerbation of HF

• Do not use TZDs in patients with NYHA class III or IV HF

Nesto RW, et al. Diabetes Care. 2004;27:256-63

Meta-analysis of MI Risk With Rosiglitazone

• 42 trials comparing rosiglitazone with placebo–15,560 patients received rosiglitazone–12,283 patients assigned to comparator groups–24-52 week duration of trials–Mean baseline A1C 8.2% for both groups

Nissen SE, et al. N Engl J Med. 2007;356:1-15

Meta-analysis of MI Risk With Rosiglitazone

Rosiglitazone

n= 14,371

Control

n= 11,634

Odds Ratio (95% CI)

P value

Myocardial Infarction

# events

86 72 1.43 (1.03-1.98) 0.03

Death from CV causes

# events

39 22 1.64 (0.98-1.74) 0.06

Nissen SE, et al. N Engl J Med. 2007;356:1-15

PROactive Trial

• Primary objective: Determine if pioglitazone reduces CV morbidity and mortality in patients with diabetes

• Pioglitazone vs. placebo– ↓ Triglycerides 11% vs. 1.8% ↑– ↑ LDL 7.2% vs. 4.9%– ↓ LDL/HDL 9.5% vs. 4.2%

• Non-significant reduction in the primary endpoint

Dormandy JA, et al. Lancet. 2005;366:1279-89

PROactive Sub-analysis

• Evaluated same endpoints in patients with prior MI

• Significant ↓ in fatal/nonfatal MI excluding silent MI with pioglitazone– 5.3% pioglitazone vs. 7.2% placebo p=0.0453

• Results for rosiglitazone and pioglitazone recently confirmed with two new meta-analyses

Erdmann E, et al. J Am Coll Cardiol. 2007;49:1772-80

HF in PROactive

Pioglitazone

n = 2605

Placebo

n = 2633P value

# Events

# Patients

(%)# Events

# Patients (%)

Any report of HF

417 281 (11%) 302 198 (8%) <0.0001

HF w/o hospital admission

160 132 (5%) 117 90 (3%) 0.003

HF with hospital admission

209 149 (6%) 153 108 (4%) 0.007

Fatal HF 25 25 (1%) 22 22 (1%) 0.634

Dormandy JA, et al. Lancet. 2005;366:1279-89

FDA Updates- August 14, 2007

• Rosiglitazone and pioglitazone received a “boxed warning” regarding CHF

www.fda.gov

Actos prescribing information. August 2007

http://www.fda.gov/

FDA Updates: November 19, 2007

• MI risk added to rosiglitazone boxed warning

Avandia prescribing information. November 2007

Sitagliptin (Januvia®)

• DPP-4 inhibitor– Prevents the degradation of endogenous GLP-1– Results in a rise in postprandial endogenous GLP-1 levels

Lauster CD et al. Am J Health Syst Pharm. 2007;64:1265-73

Sitagliptin

Sitagliptin (Januvia®)

• Efficacy: A1C 0.5-0.7%

• 100 mg PO once daily– CrCl 30-50 ml/min 50 mg/day– CrCl <30 ml/min 25 mg/day

• Approved for monotherapy or combination therapy

• Weight neutral

• Side effects similar to placebo

• No contraindications identified yet

Non-Oral Therapies

Glucagon-like peptide 1 (GLP-1) agonists

• Exenatide (Byetta®)

• Glucagon-like-peptide-1 (GLP-1) analog– Incretin mimetic– Resistant to degradation by dipeptidyl peptidase-4 (DPP-4)– Suppresses high glucagon levels– Delays gastric emptying (can affect absorption of other medications)

• Efficacy: ↓ A1C 0.5-1%

• Dosing:– 5 mcg SC twice daily within 60 min of meals– Increase to 10 mcg bid after 4 weeks

• FDA approved for type 2 diabetes in patients on metformin, sulfonylurea, TZD, or a combination who are not at goal– Not yet approved for use with basal insulin

GLP-1 Physiology

GLP-1 secreted upon the ingestion of food

Exenatide adverse effects/contraindications

• AE’s– N/V, diarrhea (30-45%)– Modest weight loss (a good

side effect)– Hypoglycemia especially in

combination with sulfonylureas

– Anti-exenatide antibodies

• Monitoring– Renal function– A1C in 3 months

• CI’s– Type 1 diabetes

• Precautions– CrCl < 30 ml/min– Gastroparesis– Hypoglycemia

Pramlintide (Symlin®)

• Synthetic analog of human amylin– Suppresses glucagon secretion

• Suppression of endogenous glucose from liver– Slows gastric emptying

• Less rapid glucose appearance in the circulation– Regulates food intake due to central modulation of

appetite• Weight loss


• FDA approved for Type 1 or 2 diabetes in patients on optimal insulin therapy who are still not at goal– With or without metformin and/or sulfonylurea therapy

• Efficacy: A1C ~0.1-0.4% in type1 and 0.3-0.7% in type 2

• 60 mcg (10 units) SC titrate to 120 mcg (20 units) before major meals (Type 2 dosing)– Dosed in mcg but drawn up in an insulin syringe– www.symlin.com/7522-Type-2-Dosing.aspx

• Administered in conjunction with mealtime insulin


Adverse Effects

• Insulin-Induced Severe Hypoglycemia:

• Hypoglycemia will occur within 3 hours of injection

• Must reduce pre-meal insulin by 50% at initiation to prevent serious reactions

• Further reduction in insulin may be needed as dosage of pramlintide is adjusted

Contraindications

• Diagnosis of gastroparesis

• Hypoglycemia unawareness

• A1C > 9.0%

• Recurrent severe hypoglycemia requiring assistance during past 6 months

• Using other medications that stimulate gastrointestinal motility

• Pediatrics

Glycemic Goals

Glycemic Control

ADA Guidelines

• A1C < 7.0%– <6.5 may further reduce

complications

• Fasting glucose 90-130 mg/dl

• Peak postprandial glucose <180 mg/dl– 1-2 hours after the start of the

meal

AACE Guidelines

• A1C < 6.5%

• Fasting glucose < 110 mg/dl

• 2-h postprandial glucose <140 mg/dl

A1C and Meal Plasma Glucose Levels

• A1C should be as close to normal for the individual patient

• Use less intensive goals for patients with risk for hypoglycemia

• Target postprandial glucose if A1C goals not met after reaching preprandial goals– Target fasting glucose first!

A1CMean Plasma

glucose mg/dl

6 135

7 170

8 205

9 240

10 275

11 310

12 345

Self-Monitoring of Blood Glucose (SMBG)

• At least 3 times/day if on insulin injections

• If on orals, just use SMBG to help them achieve their glycemic goals

• Use the data to make decisions on what therapy to add

Diabetes Care 2007;30(Suppl 1)

Lifestyle + Metformin- Step 1

• Titrate metformin to max dose over 1-2 months

• TZDs and sitagliptin are also approved for monotherapy

• Consider adding other oral medications if there is persistent hyperglycemia

Lifestyle Modifications

Diet

• Weight loss will reduce insulin resistance

• Saturated fat < 7 % of total daily calories

• Carbohydrates should be from fruits, vegetables, whole grains, legumes, low fat milk– Low carb diets < 130 g/day not recommended for weight loss

• Recommend sugar alcohols and nonnutritive sweeteners

• Limit alcohol to 1 drink/day for women 2 drinks/day for men– If on insulin or a secretagogue drink alcohol with food to avoid

hypoglycemia

Exercise

• 150 min/week of moderate-intensity aerobic activity (50-70% of max heart rate)

• 90 min/week of vigorous aerobic exercise (>70% of max heart rate)

• Resistance exercise 3 times a week

• Improves glycemia

OR

Diabetes Self-Management Education (DSME)

• All patients with diabetes should receive DSME after diagnosis

• Teaches patients about the disease and how to improve self care

• Should be conducted by either a CDE or health care professional with recent experience in diabetes management

Additional Medications - Step 2

• Add within 2-3 months of initiation of therapy

• Sulfonylurea– Cheapest option

• TZDs– More expensive– Cardiac risk with rosiglitazone

• Insulin– Most effective option– Consider in patients with A1C >8.5% or symptoms of hyperglycemia– Initiate with basal insulin

Step-2 Alternatives

• Sitagliptin

• Glinides

• Exenatide

Step-3 Initiate or intensify insulin therapy

• Start or intensify insulin if lifestyle + metformin + a 2nd medication have not attained goal A1C

• Third oral medication can be considered if A1C is close to goal <8.0%– Expensive, not as effective as insulin– Exenatide could be used at this step

• D/C insulin secretagogues (sulfonylurea or glinides) when pre-prandial rapid insulin is started

Long Acting Insulin 10 units or 0.2 units/kg

Increase dose 2 units q 3 days until fasting levels 70-130 mg/dl

A1C ≥ 7% after 2-3 months?

No

Continue regimen Check A1C q 3 months

Check pre-meal BG & add 2nd injection ~4 units before meal

Yes

Pre-Lunch BG high: Add rapid acting at

breakfast

Pre-Dinner high: Add rapid acting at lunch

Pre-Bed high: Add rapid acting at

dinner


Nathan DM, et al. Diabetes Care 2006;29


YesRecheck pre-meal BG and add another injection.

Check 2-h postprandial BG and adjust pre-prandial insulin dose

No

Continue regimen and check A1C q 3 months

Nathan DM, et al. Diabetes Care 2006;29

Pramlintide

Exenatide

SitagliptinTZD

Exenatide

CASE 1

• JK is a 59 year old male presenting for a follow-up visit to the diabetes clinic.

• Past Medical History– Type 2 diabetes– Hypertension– Coronary artery disease– Chronic renal insufficiency

CASE 1

• Medications

• Metformin 1000 mg BID

• Glyburide 10 mg BID

• Pioglitazone 45 mg once daily

• Metoprolol XL 50 mg once daily

• Fosinopril 20 mg once daily

• Aspirin 81 mg once daily

• Labs (fasting)

• Glucose 170 mg/dL

• A1C 9.0%

• SCr 1.7 mg/dL

• CrCl 70 ml/min

CASE 1

• Which diabetes medication on his profile is contraindicated and should be discontinued?

• A. Metformin

• B. Glyburide

• C. Pioglitazone

CASE 1

• Why?

• A. Coronary artery disease

• B. Renal insufficiency

• C. Drug Interaction

• D. Non-adherence

CASE 1

• Which one of the following would be most appropriate to replace the discontinued medication?

A. Glipizide XL 20 mg PO once daily

B. Insulin aspart 4 units SC before breakfast

C. Insulin glargine 10 units SC at bedtime

D. Pramlintide 60 mcg SC before meals

Complications of Diabetes

Complications of Uncontrolled DiabetesHyperglycemia

Spike Continuous

Chronic ToxicityAcute Toxicity

Tissue Lesions

Diabetic Complications

Microvascular Macrovascular

Nephropathy Neuropathy Retinopathy PVD MI Stroke

Hanefeld M, et al. Diabet Med. 1997;14(suppl 3):S6

HbA1CPPG

Relative Risk of Progression of Diabetic Complications Relative Risk of Progression of Diabetic Complications by Mean HbAby Mean HbA1c1c

**

Updated Mean HbA1c (%)

Stratton IM, et al. BMJ. 2000;321:405-12.

Adjusted Incidenceper 1000 person years

6 7 8 9 10 11*Based on UKPDS 35 data

Macrovascular Complications

Macrovascular Complication Statistics

• CVD and Stroke– Adults with DM have heart disease death rates 2-4x

higher than non-diabetics– Risk for stroke is 2 to 4x higher and risk of death from

stroke is 2.8x higher than in non-diabetics

U.S. Department of Health and Human Services, National Institute of Health, 2005.

Macrovascular Complications• ~ 80% of all diabetic mortality

–75% from coronary atherosclerosis–25% from cerebral or peripheral vascular disease

• > 75% of all hospitalizations for diabetic complications

• > 50% of patients with newly diagnosed type 2 diabetes have CHD

National Diabetes Data Group. Diabetes in America. 2nd. Ed. NIH; 1995.

Accelerated atherosclerosis

Clinical diabetes

Hyperinsulinemia Impairedglucose

tolerance

HypertriglyceridemiaDecreased HDL-C

Essentialhypertension

Insulin resistance

Insulin Resistance and Atherosclerosis

Heart Disease and Diabetes

• Intensive treatment of hyperglycemia

• Therapy for insulin resistance

• Appropriate lipid management

• Aggressive blood pressure control

Treatment of CVD in diabetes is similar to therapy for non-diabetic individuals, the risk of CVD is much higher and the benefits of

therapy are greater

Hypertension

• Defined as BP ≥ 140/90 mmHg– GOAL BP: < 130/80 mmHg

• 20 – 60% of Diabetics have HTN

• Epidemiologic evidence from the UKPDS indicate that each 10 mmHg decrease in mean SBP results in: 12% any DM complication 15% any DM-related death 11% MI 13% microvascular complications

American Diabetes Association. Diabetes Care. 2007;30:S4-S41.

Hypertension

• Weight loss 1 kg results in of MAP ~ 1 mmHg

• Sodium restriction– In non-diabetic patients reduces SBP ~ 5 mmHg and DBP ~2 - 3

mmHg

• Drug Therapy (If SBP ≥ 140 mmHg or DBP ≥ 90 mmHg or lifestyle modification failure)– 1st choice: ACE-I or ARB– 2nd choice: Thiazide, β-Blocker, or Non-DCCB

JNC 7 report. JAMA 2003;289:2560-72.

Cholesterol Management• Screening:

– Fasting lipid panel at least annually – More often if needed to achieve goals– In adults with low-risk lipid values, may obtain fasting lipid

panel every 2 years

• Goals:– LDL < 100 mg/dL

• Optional: LDL <70 mg/dL– TG < 150 mg/dL– HDL:

• > 40 mg/dL for males• > 50 mg/dL for females

American Diabetes Association. Diabetes Care .2007;30:S4-S41.


Aspirin Therapy: 75 – 162 mg/day

• Primary prevention in those with ↑ CVD risk:– Family Hx of CVD– Tobacco use– HTN– Albuminuria– Lipids: TC >200; LDL >100; HDL < 45 (or 55) & TG >200– Age ≥ 40 years

• Secondary prevention in those with DM + CVD

• Not recommended for patients < 30 years-old



• Smoking cessation–Advise all patients not to smoke–Provide smoking cessation counseling and

other forms of treatment if needed


Management Summary for Macrovascular Complications


Goals

Hypertension Dyslipidemia• LDL < 100 mg/dL

• Optimal < 70 mg/dL

• TG < 150 mg/dL• HDL:

• > 40 mg/dL – Male• > 50 mg/dL - Female

Blood Pressure:• < 130/80 mmHg

Treatment

• Weight loss• Sodium restriction• ACE-I / ARB

Everyone needs: • Aspirin • Lifestyle modifications • Smoking Cessation

• Statin


Microvascular Complications

Relative Risk of Progression of Diabetic Complications by Mean HbA1c

*

Skyler JS ,et al. Endocrinol Metab Clin North Am. 1996;25:243-54.

Relative risk

6 7 8 9 10 11 12

15

13

11

9

7

5

3

1

HbA1c (%)

Diabetic retinopathyNephropathyNeuropathyMicroalbuminuria

*Based on DCCT data

Diabetic Nephropathy

• Occurs in 20 to 40% of diabetics

• Most common cause of ESRD

• ESRD develops in 50% of type 1 patients with overt nephropathy within 10 years

• ESRD develops in about 20% of type 2 patients with overt nephropathy within 20 years


Nephropathy: DiagnosisCategory Spot Collection

(albumin-to-creatinine) (mcg/mg)

Normal < 30

Microalbuminuria 30 - 299

Clinical albuminuria > 300

Two of three specimens collected within a 3-6 month period should be abnormal before diagnosing.

Exercise within 24 hr, infection, fever, CHF, marked hyperglycemia or HTN, pyuria, & hematuria may elevate urinary albumin excretion over baseline values


Nephropathy: Screening

• Screening– DM 1: Within 5 years of diagnosis– DM 2: Upon diagnosis– DM 1 and 2: Follow-up exams annually

• If (+) for microalbuminuria, test twice more over next 3 to 6 months – If 2 of 3 tests are positive, they have microalbuminuria and

should have treatment started

• Serum creatinine should be measured at least annually for estimation of GFR

American Diabetes Association. Diabetes Care. 2007;30:S4-S41

Nephropathy: Treatment

• Glycemic control: HbA1c < 7%

• Blood pressure control: BP < 130/80 mmHg– ACE-I / ARBs

• Decrease progression of microalbuminuria and slow rate of decline in GFR in patients with proteinuria

• Non-DCCBs, BB’s, or thiazide acceptable if intolerant to ACEI/ARB

• If ACE-I, ARBs, or thiazide used, monitor K+

• Protein restriction– With presence of nephropathy

• ≤ 0.8 g/kg per day (~ 10% of daily calories)

American Diabetes Association. Diabetes Care. 2007;30:S4-S41

Diabetic NeuropathySensorimotor

• Muscular– Muscle weakeness– Balance difficulties

• Sensory– Pain– Parathesias– Numbness– Cramping– Nighttime falls

Autonomic

• Cardiovascular– Syncope, fatigue, sustained heart rate

• GI– Dysphagia, N/V, constipation, diarrhea

• Genitourinary– ↓ bladder control, UTIs, ED, Dyspareunia

• Sudomotor– Dry skin, calluses, limb hair loss

• Endocrine– Hypoglycemic unawareness

• Other– Depression, anxiety, sleep disorders

Diabetic Neuropathy Screening

• Annual foot exam: –Assessment for protective sensation, foot

structure and biomechanics, vascular status, and skin integrity.• Neurologic status assessed with 5.07 (10-g)

monofilament• Also consider: pin-prick sensation, temperature and

vibration perception (using tuning fork)• Assess for history of claudication, and assess pedal

pulses• Assess skin integrity especially b/w toes and under

metatarsal heads. Look for erythema, warmth, or callus formation (increased plantar pressure)

• Bony deformities, limitation in joint mobility, and gait and balance should be assessed

Diabetic Neuropathy Treatment

• Glycemic control: HbA1c < 7%

• Foot care– Proper footwear– Daily patient assessment– Moisturizing

• Not between toes

– NO bare feet!

Peripheral Neuropathy Treatment• Optimal glycemic control: GOAL HbA1c < 7%

Wong M, et al. BMJ. 2007; 335; 1-10.

Diabetic Retinopathy• Leading cause of new cases of blindness among

adults (20 to 74 years of age).

• Prevalence is strongly related to duration of diabetes.

Normal Vision Diabetic Retinopathy

Diabetic Retinopathy Screening

• Comprehensive dilated eye exam:– DM 1: Within 3 to 5 years of diagnosis– DM 2: Upon diagnosis– DM 1 and 2: Follow-up exams annually


Diabetic Retinopathy Management

• Tight glycemic control HbA1C < 7%

• Tight blood pressure control <130/80 mmHg– Both shown to delay or prevent onset of retinopathy

Management Summary for Microvascular Complications

Microvascular Complications

Screening

Nephropathy Neuropathy Retinopathy

Annual Exam:• Dilated Eye• Retinal vessels• Cataract• Intraocular Pressure

Annual Microalbumin:• Screen Albumin:

Creatinine ratio• Repeat to confirm

Comprehensive foot exam:• Inspection• Vascular• Vibratory perception• Monofilament

Treatment

• Glycemic Control• ACE-I / ARB

• Glycemic Control• Foot care/ footwear• Medication Management

• Glycemic Control• BP Control• Photocoagulation

Everyone needs lifestyle modifications

Standards of Care in Diabetes

Diabetes Care. 2007;30(suppl 1):S4-S41

Medical history during the 1st evaluation

• Age and characteristics of onset of diabetes

• Eating patterns

• History of diabetes education

• Previous and current treatments

• Exercise history

• Hypoglycemic episodes

• History of DKA?

• History of diabetes related complications

Physical Exam/Labs

Physical Exam

• BP

• Fundoscopic exam

• Thyroid palpation

• Skin exam

• Peripheral pulses

• Patellar and achilles reflexes

• Peripheral sensation

Labs to order

• A1C

• Fasting lipids

• LFTs

• Microalbuminuria

• SCr and GFR

• TSH

Health Maintenance/Prevention of Complications

• Influenza vaccine annually

• Pneumococcal vaccine for all adults

• Smoking cessation!

• BP at every visit, goal < 130/80 mmHg

• Check lipids annually: Goal LDL <100 mg/dL, TG <150 mg/dL, HDL >40 for men >50 for women

• Annual test for microalbuminuria

• Annual eye exam to screen for retinopathy

• Annual screening for peripheral and autonomic neuropathy

• Foot care

CASE 2

• JT is a 58 year old male newly diagnosed with Type 2 diabetes

• PMH– Dyslipidemia

• SH: Tobacco 1 pack/day x 30 years; Rare ETOH use; denies illicit drug use; diet is high in carbohydrates and sugars and low in vegetables; physical activity “little to none”

CASE 2

• How much exercise should you recommend for JT?

A. 90 minutes/week

B. 60 minutes/week

C. 150 minutes/week

D. 300 minutes/week

CASE 2

• Which of the following should be done at diagnosis?

A. Eye exam

B. Test for microalbuminuria

C. Blood pressure

D. Fasting lipids

E. All of the above

CASE 2

• JT’s blood pressure is 150/90, what would be your recommendation for initial therapy?

A. Fosinopril

B. HCTZ

C. Diltiazem

D. Metoprolol

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