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Diabetes: Guideline-Based Management

Diabetes: Guideline-Based Management. Eric L. Johnson, M.D. Assistant Medical Director Altru Diabetes Center Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences. Objectives. Overview of diabetes

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Diabetes: Guideline-Based Management

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  1. Diabetes: Guideline-Based Management Eric L. Johnson, M.D. Assistant Medical Director Altru Diabetes Center Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences

  2. Objectives • Overview of diabetes • Discuss guideline based management for diabetes • Apply Diabetes guideline based management in clinical practice

  3. What We’ll Do Today • Overview of Diabetes • Introduce Guidelines • Screening for Diabetes • Treating to Targets • Screening for Complications • Delivering Guideline Based Treatment in Clinical Settings • Case Studies

  4. U.S. Prevalence of Diabetes 2010 Diagnosed: 26 million people—8.3% of population (90%+ have Type 2) Undiagnosed:7 million people 79 million people have pre-diabetes CDC 2011

  5. Diabetes In The U.S. 2010 • 8.3% of all Americans • 11.3% of adults age 20 and older • 27% of adults age 65 and older • 1.9 million diagnosed in 2010 • Could be 33% by 2050 • Prediabetes 35% of adults age 20 and older 50% of Americans 65 and older CDC 2011

  6. Diabetes Disparities • Native American 16.1% • Black 12.6% • Hispanic 11.8%

  7. Diabetes Mellitus • Type 1: autoimmune betacell destruction, absolute insulin deficiency • Type 2: insulin resistance, other mechanisms, eventual betacell failure over time.

  8. The Ominous Octet-Type 2 Impaired Insulin Secretion Islet a-cell Increased Glucagon Secretion Islet b-cell Neurotransmitter Dysfunction DecreasedIncretin Effect Increased Lipolysis Increased Glucose Reabsorption Increased HGP Decreased Glucose Uptake

  9. Diabetes Mellitus • Type 1: Usually younger, insulin at diagnosis • Type 2: Usually older, often oral agents at diagnosis • Type “1.5” (Latent Autoimmune) mixed features ~10% of type 2 • Gestational: Diabetes of Pregnancy

  10. Diabetes Risk and Prevention Risk: • Type 1- mostly unknown, some familial • Type 2- obesity, smoking, sedentary lifestyle, familial Prevention: • Type 1- none known • Type 2- lifestyle management

  11. Diabetes Guideline Management • 2 main sets of guidelines utilized in U.S. • American Diabetes Association (ADA) • American Association of Clinical Endocrinology (AACE) • Lots of overlap, AACE considered “more intense”

  12. Diabetes Guideline Management • Evidence based • Well accepted • Clinically relevant • Can be incorporated into clinical practice • Emphasize comprehensive risk management

  13. Diabetes Guideline Management • ADA publishes guideline update every January (Diabetes Care) • Clinical Practice Recommendations • http://professional.diabetes.org/

  14. Diabetes Guideline Management • AACE updates periodically (2011) • https://www.aace.com/publications/guidelines • AACE Medical Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan • Includes discussion of treatment of risk factors, role of team members, complication screening and management, age groups

  15. Screening For Diabetes

  16. Screening For Diabetes • A1C or FPG or 75 g oral GTT • Testing should be considered in all adults who are overweight (BMI >25 kg/m2) And • Have the following additional risk factors…….

  17. Risk Factors for Screening • Physical inactivity • First-degree relative with diabetes • High-risk race/ethnicity • African American • Latino • Asian American • Native American, Pacific Islander • Women who delivered a baby weighing 9 lb or were diagnosed with GDM Diabetes Care 34:Supplement 1, 2011

  18. Risk Factors for Screening • Hypertension (>140/>90 mmHg or on therapy for hypertension) • HDL <35 mg/dl and/or a triglycerides >250mg/dl • Women with polycystic ovarian syndrome (PCOS) • A1C >5.7%, IGT, or IFG on previous testing • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) • History of CVD Diabetes Care 34:Supplement 1, 2011

  19. Risk Factors for Screening • In the absence of the previous criteria, testing begins at age 45 • Normal results, repeat at least at 3-year intervals • Consider more frequent testing depending results and risk status • At-risk BMI may be lower in some ethnic groups (i.e., Native American) Diabetes Care 34:Supplement 1, 2011

  20. Type 2 Diabetes Screening in Children/Adolescents • Overweight -BMI >85th percentile -weight for height >85th percentile -weight >120% of ideal for height • Plus any two of the following risk factors….

  21. Type 2 Diabetes Screening in Children/Adolescents • FH of type 2 diabetes in 1st or 2nd-degree relative • Race/ethnicity (Native American, African American, Latino, Asian American,Pacific Islander) • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for -gestational-age (SGA) birth weight) • Maternal history of diabetes or GDM during gestation Diabetes Care 34:Supplement 1, 2011

  22. Type 2 Diabetes Screening for Children/Adolescents • Age of initiation: at-risk age 10 years or if younger onset puberty • Screen every 3 years • No screening recommended for Type 1 Diabetes in asymptomatic individuals outside of research protocols Diabetes Care 34:Supplement 1, 2011

  23. Diabetes Diagnosis Category FPG (mg/dL) 2h 75gOGTT A1C Normal <100 <140 <5.7 Prediabetes 100-125 140-199 5.7-6.4 Diabetes >126** >200 >6.5 Or patients with classic hyperglycemic symptoms with plasma glucose >200 ** On 2 separate occasions Diabetes Care 34:Supplement 1, 2011 https://www.aace.com/publications/guidelines 2011

  24. Screening Review • >45 years old • Risk factors • Ethnicity • Obese • Smoking • CVD • Any Prediabetes syndrome

  25. Risks for Complications in Diabetes Abnormal blood sugar/A1C Abnormal lipids Abnormal blood pressure Sedentary lifestyle Smoking

  26. Avoiding Diabetes Complications • Blood glucose control A1C <7% • Treat cholesterol profiles to targets • Total cholesterol <200 • Triglycerides <150 • HDL (“good”) >40 men, >50 women • LDL (“bad”) <100, <70 high risk • Treat blood pressure to target <130/<80 For most non-pregnant adults

  27. Treating To Targets • A1C <7%: Fewer microvascular complications (eye, nerve, kidney) • Less glucose variability: Fewer macrovascular complications (CVD, PAD) • BP <130/<80: reduced kidney disease reduced CVD • Lipids to target: reduced CVD

  28. Treating to Targets • Treating patients to target early in the course of diabetes most likely to give benefit • Tight control late in course of disease with a history of poor control, less likely to benefit

  29. Glycemic Control

  30. Targets for Glycemic (blood sugar) Control In Most Non-Pregnant Adults *<6 for certain individuals • American Diabetes Association. Diabetes Care. 2011;34(suppl 1) • Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement at http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January 6, 2006. • AACE Diabetes Guidelines – 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.

  31. A1C ~ “Average Glucose” A1C eAG % mg/dL mmol/L 6 126 7.0 6.5 140 7.8 7 154 8.6 7.5 169 9.4 8 183 10.1 8.5 197 10.9 9 212 11.8 9.5 226 12.6 10 240 13.4 Formula: 28.7 x A1C - 46.7 - eAG American Diabetes Association

  32. ADA Guidelines for Glucose Management Children and Adolescents American Diabetes Association. Diabetes Care. 2011;34(suppl 1) Diabetes Care 2005;28:186–212

  33. Diabetes MedicationsGlycemic Control • Type 1: Always insulin, maybe symlin in combo • Type 2: Many oral med choices, insulin, non-insulin injectable • Complete discussion in Slide Deck/Podcast

  34. ADA/EASD consensus algorithmto manage type 2 Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months. The interventions should be changed if A1C is ≥7%. Tier 1: Well-validated core therapies Lifestyle and MET + intensive insulin Lifestyle and MET + basal insulin At diagnosis: Lifestyle + MET Lifestyle and MET+ SUa Step 1 Step 2 Step 3 Tier 2: Less well-validated studies Lifestyle and MET + pioglitazone Lifestyle and MET + pioglitazone + SUa No hypgglycemia No edema/CHF Bone loss Lifestyle and MET + GLP-1 agonistb Lifestyle and MET + basal insulin No hypoglycemia No Weight loss Nausea/vomiting aSU other than glyburide or chlorpropamide. bInsufficient clinical use to be confident regarding safety. MET: metformin; SU: sulfonylurea. Nathan et al.Diabetes Care 2009;32(1): 193-203

  35. Glucose-lowering Potential of Diabetes Therapies* Treatment FPG ¯ HbA1C ¯ Sulfonylureas 50-60 mg/dl 1-2% Metformin 50-60 mg/dl 1-2% a-Glucosidase Inhibitors (Precose) 15-30 mg/dl 0.5-1% Repaglinade (Prandin) 60mg/dl 1.7% Thiazolidinediones 40-60 mg/dl 1-2% Gliptins (Januvia,Onglyza) targets ppd 0.5 - 0.8% *based on package insert data as monotherapy

  36. Glucose-lowering Potential of Injection Diabetes Therapies* Treatment FPG ¯ HbA1C ¯ Exenatide (Byetta) targets ppd 1-1.5% Liraglutide (Victoza) targets ppd 1-1.5% Pramlintide (Symlin) targets ppd 1-2% Insulin Limited by 1.5-3.5% hypoglycemia *based on package insert data as monotherapy

  37. Diabetes Medications • Dr. Clarens overview of non-injectable medications • More on injectable medications later

  38. Key Points of Medication Selection in Type 2 • Metformin at diagnosis unless a contraindication • Second line agents- basal insulin or many other meds • A1C >9 at diagnosis-may need more than one medication

  39. Goals For Older Adults • Age and functional status dependent • Less than 3 year life expectancy, long- term care, A1C ~8.0% • BP goals likewise individualized • HTN treatment-”big bang for the buck” • Statin? • Aspirin? Johnson EL Brosseau J et al Clinical Diabetes 2008 (26) 4; 152-156 American Medical Directors Association,2002 American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

  40. Blood PressureandLipids

  41. Blood Pressure • Done at every visit • Target is <130/<80 American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

  42. Lipids (Cholesterol) • Fasting lipid panel at least annually • Goals: Total cholesterol <200 Triglycerides <150 HDL >40 men, >50 women LDL <100 (<70, CVD or high risk) American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

  43. Children with DMHypertension and Lipids • Lipids: start screening in childhood if strong FH, or at age 10 • Hypertension: BP >90th percentile for height and weight or >130/>80 • Consider medications (statins, ACE) if necessary American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

  44. Blood Pressure and LipidsTreatment BP: • ACEI usually first line, ARB alternate • Other meds as necessary (often 2 or 3) Lipids: • Statins usually first line • Fibrates, Fish Oil, Niacin

  45. Aspirin • Men >50 years of age • Women >60 years of age • Younger if higher risk American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

  46. Complications Screening

  47. Nephropathy

  48. Nephropathy (Kidney Disease)Screening • Annual urine testing for micro- or macro- albuminuria • Annual creatinine and GFR • Start at diagnosis for type 2 • Start 5 years after diagnosis type 1 Diabetes Care. 2011;34(suppl 1)

  49. Kidney Disease Management • ACEI or ARB for microalbuminuria or proteinuria • Serum creatinine and creatinine clearance (or GFR) • May need 24 hour urine protein • May need nephrology referral • Blood pressure to target <130/<80 • A1C <7 Diabetes Care. 2011;34(suppl 1)

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