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Diabetes Type 2 Update

Diabetes Type 2 Update. SFM Didactics January 8 , 2013 Carol Cordy, MD . Screening for Type 2 Diabetes. Why Screen – Burden of Disease. A) Which of the following statements are true regarding type 2 diabetes in Americans

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Diabetes Type 2 Update

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  1. Diabetes Type 2 Update SFM Didactics January 8, 2013 Carol Cordy, MD

  2. Screening for Type 2 Diabetes

  3. Why Screen – Burden of Disease A) Which of the following statements are true regarding type 2 diabetes in Americans • Over 35% of the population over age 20 has either prediabetesor type 2 diabetes • Over 25% percent of the population over 65 has type 2 diabetes • The risk of death in diabetic patients with diabetes is four times that of non diabetics • Diabetes is twice as common in non-hispanic black and Mexican Americans as in non-hispanicwhite Americans

  4. Why Screen – Burden of Disease A) Which of the following is not true regarding type 2 diabetes in Americans • Over 35% of the population over age 20 has either prediabetes or type 2 diabetes – true – 0ver 9% has diabetes and 26% has prediabetes • Over 25% of the US population over 65 has diabetes – true – over 75% has prediabetes or diabetes • The risk of death in diabetic patients with diabetes is twice that of non diabetics – true • Diabetes is twice as common in non-hispanic black and Mexican Americans as in non-hispanic white Americans - true

  5. Why Diagnose Early? • At the present time, 50% of patients already have chronic complications of diabetes when they are diagnosed • There is a 30 – 35% reduction in microvascular complications for every 1% reduction in A1c • There is a 14% reduction in macrovascular complications for every 1% reduction in A1c • Weight loss and increased physical activity can reduce the rate of progression of pre-diabetes to type 2 diabetes

  6. Diagnosis of Diabetes • Fasting plasma glucose > 125 • Random A1c ≥ 6.5 (new recommendation by ADA) • A random plasma glucose of ≥200 and symptoms of diabetes (polyuria, polydipsia or unexplained weight loss) • A 2-hour OTT (75 g anhydrous glucose dissolved in water) plasma glucose ≥200

  7. Prediabetes(add this to your problem lists) • Not-so-new category of diabetes • Fasting plasma glucose 100 to 125 • Weight loss and exercise are effective in slowing progression to type 2 diabetes • Medications (metformin, acarbose, orlistat) are shown to slow progression to type 2 diabetes but not routinely used

  8. USPSTF 2008 Screening Recommendations B) According to the USPSTF, which of the following groups should not be screened for diabetes • Patients with polydypsia, polyuria, or polyphagia • Patients with BMI ≥25 • Patients with blood pressure >135/80 • Patients with CAD, stroke, PAD

  9. USPSTF 2008 Screening Recommendations B) According to the USPSTF, which of the following groups should not be screened for diabetes • Patients with polydypsia, polyuria, or polyphagia - screen • Patients with BMI ≥25 – don’t screen per USPSTF • Patients with blood pressure >135/80 – screen • Patients with CAD, stroke, PAD - screen

  10. ADA Screening Recommendations C) Which is true regarding testing to detect type 2 diabetes and assess risk for future diabetes in asymptomatic patients ? • All adults age ≥40 should be screened for type 2 diabetes • Adults of any age who are overweight or obese (BMI ≥25 kg/m2) should be screened for type 2 diabetes • In adults of any age who are overweight or obese and who have one or more additional risk factors for diabetes should be screened for type 2 diabetes

  11. ADA Screening Recommendations C) Which is true regarding testing to detect type 2 diabetes and assess risk for future diabetes in asymptomatic patients ? • All adults age ≥40 should be screened for type 2 diabetes – false – screen if ≥45 • Adults of any age who are overweight or obese (BMI ≥25 kg/m2) should be screened for type 2 diabetes - false • In adults of any age who are overweight or obese and who have one or more additional risk factors for diabetes should be screened for type 2 diabetes – true

  12. ADA Risk Factors for Diabetes Testing • Physical inactivity • First-degree relative with diabetes • Members of a high-risk ethnic population (e.g., African American, Latino, Native American, Asian American, Pacific Islander) • Women who delivered a baby weighing >9 lb or were diagnosed with GDM • Hypertension (≥140/90 mmHg or on therapy for hypertension) ** • HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l) • Women with polycystic ovary syndrome • A1c ≥ 5.7, IGT, or IFG on previous testing (pre-diabetes 5.7-6.4) • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosisnigricans) • History of CVD

  13. Frequency of Screening for DM2 D) How often should asymptomatic patients with BP >135/80 (USPSTF) or BMI ≥25 (plus one other risk factor) (ADA) or age ≥45 (ADA) be screened for diabetes? • Yearly • Every two years • Every three years

  14. Frequency of Screening for DM2 D) How often should asymptomatic patients with BP >135/80 (USPSTF) or BMI ≥25 (plus one other risk factor) (ADA) or age ≥45 (ADA) be screened for diabetes? • Yearly • Every two years • Every three years

  15. Review • Who will you screen for diabetes? USPSTF? ADA? • When will you screen your adult patients who are of normal weight and have normal blood pressure? USPSTF? ADA? • How often will you screen asymptomatic patients for diabetes? USPSTF? ADA?

  16. Review • Who will you screen for diabetes? • USPSTF? Adults with BP > 135/80 • ADA? Adults with BMI ≥ 25 and over and one other risk factor • When will you screen your adult patients who are of normal weight and have normal blood pressure? • USPSTF? Never • ADA? At 45 • How often will you screen asymptomatic patients for diabetes? • USPSTF? No recommendations • ADA? Every three years

  17. Treatment Goals for Type 2 Diabetes

  18. Treatment Goals for Diabetes • Prevent acute complications (hyperglycemia and hypoglycemia requiring hospitalization) • Prevent chronic complications (microvascular – retinopathy, neuropathy, nephropathy and macrovascular – cardiovascular disease and MI) • Reduce A1c to <7% • Lower blood pressure to <130/80 • Lower LDL cholesterol to <100, increase HDL cholesterol to >40 for men and 50 for women, and lower triglycerides to <150

  19. Guidelines from AACE - FYIAmerican Association of Clinical Endocrinologists - 2007 • Lower A1c to less than 6.5 (5.6 or less is normal in non-diabetics) • Lower fasting and pre-prandial plasma glucose to 110 or less (ADA 90 – 130) • Lower two hour post-prandial plasma glucose to 140 or less (ADA below 180) • Lower screening of high risk patients to age 30 (previous recommendation was age 45)

  20. Medications for Type 2 Diabetes

  21. Review of Medications for Type 2 Diabetes • How does type 2 diabetes effect different organs and how does this effect change over the course of the illness? • How does each class of oral diabetes medications work? • Using the above knowledge, how can you pick the best medication or combination of medications for your patients with type 2 diabetes and explain to them how their medications work.

  22. Classes of Oral Diabetes Medications • Drugs that help the body use insulin (sensitizers) and lower the production of glucose by the liver • biguanides (reduce A1c by 1-2%) – metformin • thiazolidinediones – rosiglitizone, pioglitazone • DDP-IV -sitagliptin, saxagliptin (increases insulin availablilty) • Drugs that stimulate the pancreas to release more insulin (secretagogues) • sulfonyureas (reduce A1c by 1-2%) – glipizide, glyburide, glymepiride; • meglitinides - repaglinide, nateglinide (less likely to cause hypoglycemia than sulfonyureas) • Drugs that block the breakdown of starches and sugars (a-glucosidase inhibitors) • acarbose, miglitol (reduce A1c by 0.5-1%)

  23. Other Type 2 Diabetes Medications • Combination therapy – Glucovance (glyburide and metformin), Metaglip (glipizide and metformin), Avandamet (metformin and rosiglitazone) • Both metformin and acarbose have been shown to reduce a person's risk of developing type 2 diabetes, particularly when combined with lifestyle changes such as a proper diet and regular exercise program • Injectables – pramlintide acetate (amylin analog) and exenatide (mimics incretin and slows digestion)

  24. Summary • Type 2 diabetes affects many organs • Type 2 diabetes changes over time • Diabetes treatment changes over time • Medications can now be selected to work where the problem is • Combinations of medications, because they work at different sites in the body usually work better than monotherapy

  25. Indications For Starting Insulin in Type 2 Diabetics Absolute • Ketoacidosis or severe hyperglycemia (blood sugars over 500) • Presence of serious infection (pneumonia) • Concurrent illness (heart attack) • During and after major surgery • During pregnancy • Failure to achieve ideal glycemic control with two or three oral agents • A1c over 10% - can change back to oral meds when controlled • A1c over 7.5% plus fasting glucose over 250

  26. Indications For Starting Insulin in Type 2 Diabetics • Relative • Patients who are underweight or losing weight without dieting • Patients who have symptoms from blood sugars over 200 • Any patient who is hospitalized • Patients requiring steroids (such as prednisone) for other disorders • Onset of diabetes prior to age thirty, or a duration over fifteen years • Complications such as painful diabetic neuropathy

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