Approach to Newly Diagnosed T2DM - Looking at ADA Statement 2014

1. Approach to Newly Diagnosed T2DM - Looking at ADA Statement 2014 DR SITI AISYAH ABD MAJID FAMILY MEDICINE TRAINEE, PPUKM

2. T2DM: Global Burden • 347 million people worldwide have diabetes. • In 2004, an estimated 3.4 million people died from consequences of high fasting blood sugar. • More than 80% of diabetes deaths occur in low- and middle-income countries. • WHO projects that diabetes will be the 7th leading cause of death in 2030. • Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of type 2 diabetes. WHO (2013)

16. Risk Factors

18. American Diabetes Association (ADA) 2014: Clinical Practice Recommendations 2014

19. Case Discussion • AH is a 43-year-old Malay man, was recently diagnosed to have T2DM after presented with typical osmotic symptoms of polydipsia and polyuria for 6 months duration. He has comorbid conditions of hypertension, morbid obesity and tobacco use as well as strong family history of DM.

20. Current measurements include: BP 132/80, PR 78 bpm BMI 42.8 HbA1C - 7.4% Total cholesterol - 6.2 mmol/L LDL Cholesterol – 2.8 mmol/L HDL – 1.1 mmol/L TG – 1.6 mmol/L GFR>73 Urine albumin 1+ Medications are: Perindopril 8mg daily Metformin 1g bd HCTZ 12.5 mg daily Aspirin 75mg daily

21. He has failed to lose weight & stop smoking, but does take her medications, check her blood sugars & see the ophthalmologist. He presents for follow up diabetes care.

22. Diagnosis • The diagnosis of diabetes requires one of the following: • A fasting glucose ≥ 126 mg/dL(> 7 mmol/L) • A hemoglobin A1c level ≥ 6.5% •A 75-gram 2-hour glucose level ≥ 200 mg/dL, or •A random glucose level > 200 mg/dL (> 11.1 mmol/L) in a markedly symptomatic patient

23. Goals for Type 2 DiabeticsHbA1C • <7% (ADA) for prevention of microvascular disease –level A • <6.5 % (ACCE) level D- but must be formulated in context of individual patient’s life expectancy, comorbid conditions, presence or absence of micro and macrovascular complications, overall cardiovascular risk factors and risk for severe hypoglycemia. • Goal of A1C 7-8% for those with severe hypoglycemia, limited life expectancy, advanced micro or macrovascular disease, extensive comorbid conditions, long-standing disease uncontrolled despite extensive effort –Level A

26. Glucose Monitoring • Continuous glucose monitoring was added on top of SMBG as a part of glucose monitoring. • supplemental tool to SMBG in pts with hypoglycaemia unawareness and/or frequent hypoglycaemic episodes. • CGM use is associated with HbA1c lowering by ~0.26%. • ASPIRE trial – CGM reduced nocturnal hypoglycaemia without increasing HbA1c level and reduced severe hypoglycaemia for those with h/o nocturnal hypoglycaemia.

27. Blood Pressure Control • BP <140/80 with use of DASH diet-low sodium, counseling by nutritionist, level A for DASH diet, use of ACE/ARB as primary agents for reduction of BP. • For reduction in cardiovascular events, use of ACEi, ARB, ARBs, beta blockers, diuretics & CCB is beneficial.

28. Goals for Lipids • LDL < 2.6 mmol/L (without overt CVD), < 1.8 mmol/L (with overt CVD). • TG < 1.7 mmol/L • HDL < 1.0 mmol/L (men), < 1.3 mmol/L (women) • Lifestyle modification – reduced saturated fat, trans fat & cholesterol intake; increase n-3 fatty acids, visciousfibre& plant sterols; wt loss, increased physical activity. Level A • Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for DM pts: • With overt CVD • Without CVD + 40 y/o + >1 CVD risk factors

29. Pharmacological Therapy • Pharmacological Therapy for Hyperglycemia in Type 2 Diabetes was changed from 3–6 months to 3 months for a trial with non-insulin monotherapy.

32. Medical Nutrition Therapy • Medical Nutrition Therapy was revised to reflect the updated position statement on nutrition therapy for adults with diabetes. • Comprehensive group diabetes education programmes including nutrition therapy have reported HbA1c decrease by 0.5-2.0% in T2DM. • Weight loss of 2-8kg in T2DM pt: • Increase HDL-C • Decrease TG • Decrease BP

33. Some eating pattern have been shown to be effective in managing DM eg Mediterranean style, DASH- style (Dietary Approaches to Stop HPT), vegetarian and lower-carbohydrates pattern. • Cochrane review – decreasing Na intake reduces BP in those with DM. DM pt needs further reduction in Na intake compared to general population. Recommendation for general population <2,300mg/day.

34. Smoking cessation • Addition of pharmacological therapy to counselling is more effective than treatment alone. • Recent research demonstrated that initial wt gain following smoking cessation does not diminish the substantial CVD risk benefit realized from smoking cessation.

35. Evaluation for Complications Macrovascular • Cardiovascular disease-coronary, peripheral, carotid, cerebrovascular Microvascular • Nephropathy • Retinopathy • Neuropathy Depression Sleep Apnea

36. CVD & Antiplatelet agents • Antiplatelet Agents was revised to recommend more general therapy . • Use aspirin therapy as a secondary prevention strategy in those with a h/o CVD. • If allergy to aspirin, clopidogrel should be used. • Dual antiplatlet therapy is reasonable for up to a year after an ACS. • Benefit of using aspirin in primary prevention among pts with no previous CV events is more controversial, both for pts with and without a history of DM.

37. Nephropathy • Nephropathy was revised to remove terms “microalbuminuria” and “macroalbuminuria,” which were replaced with: • “albuminuria 30–299 mg/24 h” (previously microalbuminuria), and; • “albuminuria ≥300 mg/24 h” (previously macroalbuminuria).

38. Optimize glucose & BP control to reduce risk or slow the progression of nephropathy. • Annual test to quantify urine albumin excretion in T2DM should be performed starting at Dx. • Measurement of eGFR from serum creatinine.

41. Retinopathy • Retinopathy was revised to recommend exams every 2 years versus 2–3 years, if no retinopathy is present. • If retinopathy is present, subsequent examination should be repeated annually by ophthalmologist or optometrist. • Optimize glucose & BP control to reduce risk or slow the progression of nephropathy.

43. Neuropathy • Neuropathy was revised to provide more descriptive treatment options for neuropathic pain. • May present as distal symmetric polyneuropathy (DSN), diabetic autonomic neuropathy (DAN), cardiovascular autonomic neuropathy (CAN), GI neuropathy & genitourinary tract neuropathy.

44. Glycemic control – tight & stable. • An intensive CV risk intervention (glucose, BP, lipids, smoking, lifestyle) has been shown to reduce the progression & development of CAN among pt with T2DM. • Use of metoclopramide (Maxolon®) in presence of gastroparesisSx to be reserved to only severe cases that are unresponsive to other therapies. Extrapyramidal effects should be monitored. • ED – PDE type 5 inhibitors, intracorporeal or intraurethral prostaglandin, vacuum devices or penile prostheses. However, they do not change natural history of disease process, but improve pt’s QOL.

46. Hospital Care • Diabetes Care in the Hospital was updated to discourage the sole use of sliding scale insulin in non-critically ill patient.

48. Foot Care

49. Increased risk of foot ulcers & amputation is seen in: • Previuos h/o amputation • Past foot ulcer hx • Peripheral neuropathy • Foot deformity eg hammertoes, prominent metatarsal head, bunions, Charcot joint • Peripheral vascular disease • Diabetic nephropathy esp on dialysis • Poor glycemic control • Cigarette smoking