TYPE 2 DIABETES MELLITUS Asma Jafri, MD

1. TYPE 2 DIABETES MELLITUSAsma Jafri, MD July 22, 2004

2. GOALS: • Recognize the changing face of Type 2 Diabetes Mellitus regarding demographics and epidemiology. • Demonstrate understanding of the “Standards of Medical Care for Patients with Type 2 Diabetes Mellitus.” • Understand multidisciplinary therapeutic approaches to the management of Type 2 Diabetes Mellitus. • Recognize metabolic syndrome as a clinical condition and risk factor for Diabetes.

3. Table 1. CRITERIA FOR THE DIAGNOSIS OF DIABETES MELLITUS IN NON-PREGNANT ADULTS • Symptoms of diabetes plus casual plasma glucose concentration ≥ 200 mg/dl (11.1 mmol/L).* Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsea and unexplained weight loss. or • FPG ≥ 126 mg/dl (7.0 mml/L).* Fasting is defined as no caloric intake for at least eight hours. or 3. 2hPG ≥200 mg/dl (11.1 mmol/L) during an OGTT.* The test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

4. *In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. The third measure (OGTT) is not recommended for routine clinical use. From the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus Care 20:1183-1197, 1997; with permission.

5. Table 2. CRITERIA FOR THE DIAGNOSIS OF IMPAIRED GLUCOSE TOLERANCE IN NON-PREGNANT ADULTS (PRE DIABETES) • Fasting plasma glucose of ≥ 110 mg/dl or < 125 mg/dl • 2-hour post-prandial plasma glucose of > 140 and < 200 mg/do

6. CLINICAL FEATURES: • Insulin resistance and progressive insulin secretory defect. • Most patients are obese. • If not obese, they have increased percentage of body fat distributed predominately in the abdominal region. • Ketoacidosis seldom occurs spontaneously. When seen, it usually arises in association with the stress of another illness such as infection. • Risk increases with age, obesity and lack of physical activity. • Strong genetic predisposition.

7. METABOLIC SYNDROME • Insulin resistance • Hyperinsulinemia • Obesity (central), waist circumference is > 35” in females and > 40” in males • Dislipidemia of ↑ TG and or low HDL • Hypertension

8. PREVALENCE: • Prevalence was 7.4% in 1995. This is expected to rise to above 9% in 2025. It is estimated that there are 16 million people with Type 2 Diabetes Mellitus and over 10 million Americans have impaired glucose tolerance. Costs $120 billion annually; approximately 15% of the U.S. healthcare expenditure. The number of individuals with Type 2 DM diagnosed between 30-39 years of age has increased 76% in the past ten years. The increase in prevalence of diabetes in younger individuals seems to parallel the equally alarming rate of obesity in America. Reports suggest that Type 2 DM now represents 8% - 46% of all diabetes cases among children. The average AIC of people with diabetes in the U.S. is 9%. The latest study of American adults with diabetes revealed that 37% had AIC > 8% and 14% had AIC> 10%.

9. Presently about half of the adults with diabetes in the U.S. are undiagnosed (8 million). • At the time of diagnosis of Type 2 Diabetes: - 2-9% of patients have retinopathy - 8-18% have nephropathy - 5-13% have neuropathy - 8% have cardiovascular disease

10. GENERAL RECOMMENDATIONS FOR SCREENING BY PHYSICIANS: • Screening should be considered at three (3) year intervals for: 1. All individuals at age 45 years and above. 2. Test at a younger age and more frequently in individuals who: a. Are obese with BMI ≥ 27 kg/m². b. Have a first degree relative with diabetes. c. Are members of a high-risk ethnic population (i.e., African American, Hispanic, Native American, Asian American, Pacific Islander). d. Have delivered a baby weighing > 9 lbs. or have been diagnosed with GDM. e. Are hypertensive (BP ≥ 140/90). f. Have an HDL cholesterol level ≤ 35 mg/dl and/or TG level > 250 mg/dl. g. On previous testing had IGT or IPG. h. Habitual physical inactivity.

11. SCREENING TEST: • Fasting plasma glucose (FPG). • Oral glucose tolerance test (75 gm glucose). The fasting plasma glucose test is strongly preferred because it is easier and faster to perform, more convenient and less expensive. • A random plasma glucose level ≥ 160 mg/dl is considered a positive screening test result and needs further testing. • Glycated hemoglobin is currently not recommended for the screening or diagnosis of diabetes. • The OGTT is more sensitive for the diagnosis of diabetes and pre-diabetes, but is impractical and expensive as a screening procedure.

12. TABLE 3 GLYCEMIC CONTROL FOR PEOPLE WITH DIABETES Recommendations for Glycemic Control* Biochemical Action Index Normal Goal Suggested _______________________________________________________________________ Fasting/Preprandial glucose <110 mg/dl 80 to 120 mg/dl < 80 or > 140 mg/dl Bedtime glucose <120 mg/dl 100 to 140 mg/dl <100 or > 160 mg/dl Glycosylated hemoglobin < 6% < 7% > 8% _______________________________________________________________________ *These values are for non-pregnant adults. Goals and “Action Suggested” depend on individual patient circumstances. Such actions may include enhanced diabetes self-management education, co-management with a diabetes team, referral to an endocrinologist, change in pharmacological therapy, initiation or increased SMBG, or more frequent contact with the patient. HbA1c is referenced to a non-diabetic range of 4.0 – 6.0% (mean 5.0%, SD ∀ 0.5%).

13. ESSENTIAL COMPONENTS OF MANAGEMENT – INITIAL VISIT: • Medical History 1. Symptoms, results of laboratory tests and special examination results related to diagnosis of diabetes. 2. Prior G Hb results. 3. Eating patterns, nutritional status, weight history. 4. Details of previous treatment programs including nutrition and diabetes self-management education. 5. Current treatment of diabetes including medications, meals, results of glucose monitoring. 6. Exercise history. 7. Acute complications such as DKA, hypoglycemia. 8. Prior or current infections. 9. Symptoms and treatment of eye, kidney, nerve, gu, bladder and GI function, heart, peripheral vascular, foot, CVA, etc.

14. 10. Other medications that may affect blood glucose levels. 11. Risk factors for atherosclerosis: smoking, HTN, obesity, dislipidemia and family history. 12. Family history of diabetes and other endocrine disorders. 13. Gestational history. 14. Life style, cultural, psychosocial, educational and economic factors that might influence the management of diabetes. 15. Tobacco and alcohol use.

15. Physical Examination • Height and weight. • Sexual maturation staging (peripubertal). • Blood pressure with orthostatic measurements when indicated. • Ophthalmoscopic examination (dilation). • Oral examination. • Thyroid palpitation. • Cardiac examination. • Abdominal examination. • Evaluation of pulses. • Hand/finger examination. • Foot examination. • Skin examination. • Neurological examination.

16. Laboratory Evaluation • Fasting or random plasma glucose. • GHb • Fasting lipid profile. • Serum creatinine in adults. • Urine analysis, glucose, ketones, protein, sediment. • Test for microalbuminuria. • Urine culture if sediment is abnormal or symptoms are present. • TSH in all Type 1 patients. • EKG in adults.

17. DIABETES SELF-MANAGEMENT EDUCATION: National standards for Diabetes Self-Management Education have been developed. Ten content areas have been identified as the core topics needed to provide comprehensive education to the person with diabetes: • Diabetes disease process and treatment options. • Nutritional management. • Incorporating physical activity in lifestyle. • Using medication effectively. • Monitoring blood glucose and using the results. • Preventing, detecting and treating acute complications.

18. Goal setting to promote health and problem solving for daily living. • Integrating psychosocial adjustment into daily life. • Promoting preconception care and managing diabetes during pregnancy when applicable. A major emphasis in diabetes education is patient empowerment in making decisions regarding diabetes management.

19. CONTINUING CARE (FREQUENCY): • Individualized regimen and frequency of visits. • If target goals met, frequency every six months. • If target goals not met, frequency every three months.

20. ROUTINE FOLLOW-UP VISIT: • History of goals, activity, diet, MBG, medications, symptoms of CAD, personal concerns, stresses, evaluate smoking status. • Exam: weight, BP (goal < 138/80; lower BP may be even better). Epidemiologic analyses show that blood pressure > 115/75 are associated with increased CV event rates and mortality in persons with diabetes. A. Pulses - annually B. Annual Foot exam including Semmes-Weinstein monofilament, tuning fork, palpation and visual exam (skin, nails). (B) Perform a visual inspection of patients’ feet at each visit. (E) C. Dilated eye exam annually (B).

21. Laboratory studies • GHg every three months if treatment changes or not meeting goals, otherwise every six months. • Annual fasting lipid panel or biannual if goals met. Repeat lipid profiles as dictated by therapy. Goal is LDL<100, HDL >45 in males and >55 in females, and TG < 150 mg/dl. • Annual serum creatinine. • Urine analysis for microalbumin annually until confirmed positive.

22. Other • Aspirin 80 mg/day for patients over age 40 for primary prevention. May use over age 30 in patients with additional risk factors (A). Aspirin does not prevent retinopathy or increase risk of hemorrhage (A). • Influenza and pneumococcal vaccination (C). • Advise all patients not to smoke (A). • In patients > 55 years of age with or without HTN but with another CV risk factor, an ACE inhibitor should be considered to reduce the risk of CV events (A).

23. Table 4. DEFINITIONS OF ABNORMALITIES IN ALBUMIN EXCRETION _______________________________________________________________ 24-h Timed Spot Category Collection Collection Collection _______________________________________________________________ Normal < 30 mg/24 h < 20 µ < 30 µg/mg creatinine Microalbuminaria 30-300 mg/24 h 20-200 µg/min 30-300 µg/mg creatinine Clinical albuminuria > 300 mg/24 h > 200 µg/min < 300 µg/mg creatinine _______________________________________________________________________ Because of variability in urinary albumin excretion, two of three specimens collected within a three to six month period should be abnormal before considering a patient to have crossed one of these diagnostic thresholds. Exercise within 24 h, infection, fever, congestive heart failure, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline values. From the American Diabetes Association Clinical Practice Recommendations 1999. Diabetes Care 22(suppl1);S67, 1999; with permission.

24. Table 5. OPHTHALMOLOGIC EXAMINATION SCHEDULE ____________________________________________________________________ Recommended First Minimum Routine Patient Group_______________Examination_________________Follow-Up*_____ 29 Years or Within 3-5 years after diagnosis of Yearly younger+ diabetes once patient is age 10 years or older 30 years or older+ At time of diagnosis of diabetes Yearly Pregnancy in Before conception and during trimester Physician discretion pending Pre-existing results of 1st trimester Diabetes exam ______________________________________________________________ *Abnormal findings necessitate more frequent follow-up +As indicated in WESDR, these are operational definitions of Type 1 and Type 2 diabetes based on age (age <30 years at diagnosis, Type 1; age ≥ 30 years at diagnosis, Type 2) and not pathogenetic classification. From the American Diabetes Association Clinical Practice Recommendations 1999. Diabetes Care 22(suppl1):S72, 1999; with permission.