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Diabetes

Diabetes. Rachel Hindin, MD Washington University School of Medicine Department of Medical Education Grace Hill Murphy O’Fallon Clinic March 5, 2008. In the clinic….

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Diabetes

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  1. Diabetes Rachel Hindin, MD Washington University School of Medicine Department of Medical Education Grace Hill Murphy O’Fallon Clinic March 5, 2008

  2. In the clinic… • 56 yo man with DM, HTN, hyperlipidemia, and CAD presents for his routine 3 month follow-up. He reports AM fasting sugars of 120-140. He reports taking his medications regularly, including insulin glargine, metformin, lisinopril, atorvastatin, and aspirin. He has no complaints. His labwork reveals: HgbA1c 8.5, LDL 115, microalbumin 22. What is the next step in the management of this patient?

  3. In the clinic… • 42 yo woman presents to the clinic complaining of general fatigue over the past 8 mths. On review of systems, she endorses polyuria, polydipsia, and weight loss over the same time period. She has a sister, a brother, and two aunts who carry the diagnosis of diabetes. Her random glucose at the time of her visit is 250. What is the next step in evaluating and managing this patient?

  4. In the clinic… • 52 yo man with HTN and dyslipidemia presents for his routine follow up. He has no complaints. His blood pressure is 120/80. His medications include amlodipine, hydrochlorothiazide, and aspirin. His last LDL a year ago was 118. A fasting glucose done at his visit is 120. What is this patient’s diagnosis? How should he be managed?

  5. Epidemiology • Prevalence – 20.8 million children/adults = 7% of US • 14.6 million dx’ed • 6.2 million undx’ed (1/3) • Healthcare encounters • Outpatient – 27 million visits • Inpatient – 599,000 hospital discharge diagnoses (avg length of stay 4.7d) • Mortality • 224, 092 – DM related deaths • Cost – total: $174 billion • Medical - $116 billion • DM care - $27 billion • Chronic DM-related complications - $58 billion • Excess general medical costs - $31 billion • Non-medical (disability/lost productivity) - $58 billion

  6. Epidemiology

  7. Glucose homeostasis

  8. Insulin release

  9. Insulin-mediated glucose uptake

  10. Definition • Type 1 diabetes/insulin dependent diabetes (IDDM) • Absolute insulin deficiency due to pancreatic beta-cell destruction • Type 2 diabetes/non-insulin dependent diabetes (NIDDM) • Underlying insulin resistance with subsequent progressive insulin secretory defect • Gestational diabetes (GDM) • Diagnosed during pregnancy • Other • Secondary to genetic or other disease processes

  11. Diagnosis - Diabetes

  12. Diagnosis – Pre-diabetes • Impaired fasting glucose • Fasting glucose: 100-125 mg/dl • Impaired glucose tolerance • Glucose (2hrs post-oral glucose tolerance test): 140-199 mg/dl

  13. Screening • Asymptomatic adults • >45 yo, especially w/BMI>25; q3yrs if normal • <45 yo if BMI>25 addnl RFs • Family hx, high-risk ethnic population, dyslipidemia, HTN, hx of vascular disease, hx of IFG • Pregnant women • High-risk- screen at beginning of pregnancy • Average-risk- screen between wk 24-28 • Low-risk- no screening • Post-partum- screen GDM pts at 6-12 wks PPM

  14. Evaluation • History • Physical • Laboratory

  15. Evaluation: history • Age of onset • Laboratory: home glucose monitoring, prior HgbA1c • Lifestyle: weight pattern, nutrition, exercise • Medications: current and past, oral vs insulin • Symptoms • Hyperglycemia: polydipsia, polyuria, polyphagia • Hypoglycemia: diaphoresis, palpitations, weak, anxious • Disease related complications • Microvascular: eye, kidney, nerve • Macrovascular: cardiac, cerebrovascular, peripheral arterial • Other: sexual dysfunction, gastroparesis

  16. Evaluation: physical examination • Blood pressure • Fundoscopic exam • Skin exam • Foot exam • Neurologic • Vascular

  17. Laboratory evaluation • Fasting glucose • Hemoglobin A1c • Lipid profile • Renal function • Creatinine • Microalbumin

  18. Management • Glycemic control • Lipid control • Blood pressure control

  19. Glycemic control • Measurements of glycemic control • HgbA1c < 7.0% • Fasting glucose: 90-130 mg/dl • Postprandial glucose <180 mg/dl • Frequency of HgbA1c testing • q3mths when not controlled • at least q6mths when controlled

  20. Diabetes medications • Biguanides (metformin) • Decrease hepatic gluconeogenesis, increase insulin sensitivity • Sulfonylureas (glipizide, glyburide) • Stimulate pancreatic insulin release • Glitazones (pioglitazone, rosiglitazone) • Increase insulin sensitivity • Glucosidase inhibitors (acarbose) • Inhibit intestinal alpha-glucosidase hydrolase, delaying glucose absorption • Insulin • Long acting (glargine, NPH) • Short acting (regular, lispro) • Combination (70/30)

  21. DM meds- site of action

  22. Approach to therapy

  23. Lipid control • Measurements of lipid control • LDL <100 • TGs <150 • HDL >40 • Medications • Statins • Fibrates • Zetia • Frequency of testing • Annually (more often if not at goal)

  24. Blood pressure control • Goal: 130/80 • Medication of choice – ACE inhibitor/ARB

  25. Screening: nephropathy • Measurement of renal function • Microalbumin • Creatinine • Definition : microalbuminuria • Normal < 30 μg/mg • Microalbuminuria: 30-299 μg/mg • Macroalbuminuria >300 μg/mg • Definition: chronic kidney disease (based on creatinine) • Glomerular filtration rate <90 • Medications • ACEI • ARB

  26. Screening: retinopathy • Annual exam

  27. Additional recommendations • Lifestyle modifications • Nutrition • Exercise • Smoking cessation • Medications • Antiplatelet therapy (aspirin)

  28. In the clinic… • 56 yo man with DM, HTN, hyperlipidemia, and CAD presents for his routine 3 month follow-up. He reports AM fasting sugars of 120-140. He reports taking his medications regularly, including insulin glargine, metformin, lisinopril, atorvastatin, and aspirin. He has no complaints. His labwork reveals: HgbA1c 8.5, LDL 115, microalbumin 22. What is the next step in the management of this patient?

  29. In the clinic… • 42 yo woman presents to the clinic complaining of general fatigue over the past 8 mths. On review of systems, she endorses polyuria, polydipsia, and weight loss over the same time period. She has a sister, a brother, and two aunts who carry the diagnosis of diabetes. Her random glucose at the time of her visit is 250. What is the next step in evaluating and managing this patient?

  30. In the clinic… • 52 yo man with HTN and dyslipidemia presents for his routine follow up. He has no complaints. His blood pressure is 120/80. His medications include amlodipine, hydrochlorothiazide, and aspirin. His last LDL a year ago was 118. A fasting glucose done at his visit is 120. What is this patient’s diagnosis? How should he be managed?

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