10th Annual Diabetes

1. 10th Annual Diabetes/Heart Disease and Stroke Prevention Winter Symposium. Introducing: South Carolina Guidelines for Diabetes Care Gerald Wilson, MD & Kathie Hermayer, MD, MS, FACE March 10, 2012

2. Why do we need Diabetes Guidelines for South Carolina ? High complications, disability, and burden, especially in minority populations Inconsistent adherence to guidelines High variability among practitioners on following guidelinesHigh variability among practitioners on following guidelines

3. Diabetes Advisory Council established in 2010 DAC Mission: to provide community input and statewide leadership to prevent and control diabetes, eliminate disparities, and reduce the impact of diabetes on South Carolinians. Diabetes Guidelines Sub-committee established by DAC By-laws and charged to develop evidence-based guidelines for diabetes care in SC Worked in collaboration with the Diabetes Initiative of SC (DSC) Guidelines released September 15, 2012 by MUSC www.musc.edu/diabetes Guidelines document will be reviewed annually and updated as indicated. Guidelines were approved by full Diabetes Advisory Council. Guidelines were reviewed by DSC Medical Oversight Committee. Guidelines adopted by DSC. Now, Dr. Kathie Hermayer, Co-chair of the DAC Diabetes Guidelines Subcommittee, will review the Guidelines and discuss recommended patient treatment goals for use in primary care. Guidelines document will be reviewed annually and updated as indicated. Guidelines were approved by full Diabetes Advisory Council. Guidelines were reviewed by DSC Medical Oversight Committee. Guidelines adopted by DSC. Now, Dr. Kathie Hermayer, Co-chair of the DAC Diabetes Guidelines Subcommittee, will review the Guidelines and discuss recommended patient treatment goals for use in primary care.

4. Disclosure Verification for: Name: Kathie L. Hermayer, MD, MS, FACE The presenter listed above: ___ Does not have any significant financial relationships to disclose _x_ Has disclosed the following relationship with : Sanofi-aventis, Eli Lilly, Novo Nordisk, Amylin, Boehringer Ingelheim _x_ Research Grants _x_ Speaker�s Bureau __ Ownership __ Consultant for fee __Stock/Bond Holding __ Employment __Partnership Other:_________ Was this activity Supported by an educational grant or received in-kind support? x Yes _ _ No

5. Facts on Diabetes Of 311 million Americans, 26 million Americans have diabetes An estimated 79 million American adults have pre diabetes A condition that increases their risk of type 2 diabetes, heart disease and stroke Diabetes more likely to affect older Americans Almost 27% of people age 65 years and older had diabetes in 2010 Diabetes affects 8.3% of all Americans and 11.3% of adults age 20 and older Some 27% of people with diabetes � 7 million Americans do not know they have the disease

6. Diabetes in South Carolina S.C. ranks 8th highest in the nation in the percent of population with diabetes Approximately 1 in 8 African-Americans in S.C. has diabetes The 21st highest rate of diabetes among African-Americans in the nation Diabetes is the seventh leading cause of death in S.C. after heart disease, cancer, accidents, stroke, chronic lower respiratory disease, and Alzheimer�s

9. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA: Categories of Increased Risk for Diabetes (Prediabetes) The American Diabetes Association cites the following as categories of increased risk for development of diabetes (prediabetes): A1C 5.7%�6.4% or Fasting plasma glucose 100�125 mg/dL (impaired fasting glucose [IFG]) or 2-hour plasma glucose on 75-g oral glucose tolerance test 140�199 mg/dL (impaired glucose tolerance [IGT]) For each test, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range. Both IFG and IGT should be viewed as risk factors for both diabetes and cardiovascular disease, as opposed to clinical entities in their own right. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA: Categories of Increased Risk for Diabetes (Prediabetes) The American Diabetes Association cites the following as categories of increased risk for development of diabetes (prediabetes): A1C 5.7%�6.4% or Fasting plasma glucose 100�125 mg/dL (impaired fasting glucose [IFG]) or 2-hour plasma glucose on 75-g oral glucose tolerance test 140�199 mg/dL (impaired glucose tolerance [IGT]) For each test, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range. Both IFG and IGT should be viewed as risk factors for both diabetes and cardiovascular disease, as opposed to clinical entities in their own right.

10. Case #1 You perform a physical exam on a pleasant 48 year old female with no prior H/O T2DM, + strong family history of DM. Her FBG 115, A1C 6.2%, height 5�6�, Weight 170 lbs, BMI 27.4, BP 120/70, chol 195, TG 115, HDL 52 and LDL 120, S creat 0.7. What do you advise? Begin metformin 500 mg bid Begin Lantus 10 u sc hs Stress diet and exercise Refer to personal trainer Start glucotrol xL 5 mg qd

11. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Criteria for Testing for Diabetes in Asymptomatic Adults Testing should be considered in all adults who are overweight (body mass index [BMI] =25 kg/m2) and have one or more of the following risk factors (note that at-risk BMI may be lower in some ethnic groups): physical inactivity first-degree relative with diabetes member of a high-risk ethnic group (African American, Latino, Native American, Asian American, and Pacific Islander) women who delivered a baby weighing >9 lb or were diagnosed with gestational diabetes mellitus low HDL-C (<35 mg/dL; <0.90 mmol/L) and/or high TG (>250 mg/dL; >2.82 mmol/L) women with polycystic ovary syndrome hypertension (=140/90 mm Hg) or on therapy for hypertension A1C =5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing other clinical conditions associated with insulin resistance (eg, severe obesity and acanthosis nigricans) history of cardiovascular disease In the absence of the above criteria, testing should begin no later than age 45 years because age is a major risk factor for diabetes. If results are normal, testing should be repeated in at least 3-year intervals or more frequently depending on initial results and risk status. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Criteria for Testing for Diabetes in Asymptomatic Adults Testing should be considered in all adults who are overweight (body mass index [BMI] =25 kg/m2) and have one or more of the following risk factors (note that at-risk BMI may be lower in some ethnic groups): physical inactivity first-degree relative with diabetes member of a high-risk ethnic group (African American, Latino, Native American, Asian American, and Pacific Islander) women who delivered a baby weighing >9 lb or were diagnosed with gestational diabetes mellitus low HDL-C (<35 mg/dL; <0.90 mmol/L) and/or high TG (>250 mg/dL; >2.82 mmol/L) women with polycystic ovary syndrome hypertension (=140/90 mm Hg) or on therapy for hypertension A1C =5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing other clinical conditions associated with insulin resistance (eg, severe obesity and acanthosis nigricans) history of cardiovascular disease In the absence of the above criteria, testing should begin no later than age 45 years because age is a major risk factor for diabetes. If results are normal, testing should be repeated in at least 3-year intervals or more frequently depending on initial results and risk status.

12. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Recommendations for Prevention/Delay of Type 2 Diabetes Refer patients with impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or A1C 5.7%�6.4% to ongoing support program targeting weight loss: 7% of body weight increased physical activity: 150 min/week moderate activity Consider metformin therapy for diabetes prevention among those with IGT, IFG, or A1C 5.7%�6.4% give particular consideration to those with body mass index >35 kg/m2, aged <60 years, and women with prior gestational diabetes mellitus Annually monitor those with prediabetes for diabetes development. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Recommendations for Prevention/Delay of Type 2 Diabetes Refer patients with impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or A1C 5.7%�6.4% to ongoing support program targeting weight loss: 7% of body weight increased physical activity: 150 min/week moderate activity Consider metformin therapy for diabetes prevention among those with IGT, IFG, or A1C 5.7%�6.4% give particular consideration to those with body mass index >35 kg/m2, aged <60 years, and women with prior gestational diabetes mellitus Annually monitor those with prediabetes for diabetes development.

14. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: A1C Recommendations A1C test should be performed at least 2 times/year in patients who are meeting treatment goals and have stable glycemic control quarterly in patients whose therapy has changed or who are not meeting glycemic goals Use of point-of-care (POC) testing for A1C allows for more timely changes in treatment. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: A1C Recommendations A1C test should be performed at least 2 times/year in patients who are meeting treatment goals and have stable glycemic control quarterly in patients whose therapy has changed or who are not meeting glycemic goals Use of point-of-care (POC) testing for A1C allows for more timely changes in treatment.

15. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Correlation of A1C With Average Glucose A strong correlation between A1C and average glucose was demonstrated in the A1C-Derived Average Glucose (ADAG) trial. ADAG utilized frequent self-monitoring of blood glucose and continuous glucose monitoring subjects (N=507) enrolled in ADAG had type 1, type 2, and no diabetes; 83% were Caucasian study results showed a 0.92 correlation between A1C and average glucose The strength of this correlation justifies reporting of both A1C and estimated average glucose when an A1C test is ordered. Subjects studied in ADAG were adults, the majority of whom were Caucasian; therefore, further study is required to determine whether there are significant differences in how A1C relates to average glucose among children or African Americans. Among subjects whose A1C and average glucose do not correlate, the following possibilities should be considered by the healthcare professional: hemoglobinopathy, altered red cell turnover, and more frequent and/or different timing of self-monitoring of blood glucose or use of continuous glucose monitoring. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Correlation of A1C With Average Glucose A strong correlation between A1C and average glucose was demonstrated in the A1C-Derived Average Glucose (ADAG) trial. ADAG utilized frequent self-monitoring of blood glucose and continuous glucose monitoring subjects (N=507) enrolled in ADAG had type 1, type 2, and no diabetes; 83% were Caucasian study results showed a 0.92 correlation between A1C and average glucose The strength of this correlation justifies reporting of both A1C and estimated average glucose when an A1C test is ordered. Subjects studied in ADAG were adults, the majority of whom were Caucasian; therefore, further study is required to determine whether there are significant differences in how A1C relates to average glucose among children or African Americans. Among subjects whose A1C and average glucose do not correlate, the following possibilities should be considered by the healthcare professional: hemoglobinopathy, altered red cell turnover, and more frequent and/or different timing of self-monitoring of blood glucose or use of continuous glucose monitoring.

16. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Glycemic Recommendations for Nonpregnant Adults With Diabetes ADA glycemic recommendations for nonpregnant adults with diabetes: A1C <7.0% Preprandial capillary plasma glucose 70�130 mg/dL Peak postprandial capillary plasma glucose <180 mg/dLa,b Individualize goals based on Age/life expectancy Comorbid conditions Diabetes duration Hypoglycemia unawareness Individual patient considerations (more or less stringent goals may be appropriate) Known CVD/advanced microvascular complications aPostprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. bPostprandial glucose measurements should be made 1�2 h after beginning of meal. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Glycemic Recommendations for Nonpregnant Adults With Diabetes ADA glycemic recommendations for nonpregnant adults with diabetes: A1C <7.0% Preprandial capillary plasma glucose 70�130 mg/dL Peak postprandial capillary plasma glucose <180 mg/dLa,b Individualize goals based on Age/life expectancy Comorbid conditions Diabetes duration Hypoglycemia unawareness Individual patient considerations (more or less stringent goals may be appropriate) Known CVD/advanced microvascular complications aPostprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals. bPostprandial glucose measurements should be made 1�2 h after beginning of meal.

17. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA: Goals for Glycemic, Blood Pressure, and Lipid Control The American Diabetes Association in general recommends an A1C goal for patients with diabetes of <7%. A more or less stringent A1C goal goal may be appropriate for certain patients; goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations. The blood pressure goal for adults with diabetes is <130/<80 mm Hg. Based on individual patient characteristics and response to therapy, higher or lower blood pressure targets may be appropriate. The primary goal of lipid management in adults with diabetes is to lower LDL-C levels to <100 mg/dL (<2.6 mmol/L). In patients with diabetes and overt cardiovascular disease, an LDL-C goal of <70 mg/dL (<1.8 mmol/L), using a high dose of a statin, is an option. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA: Goals for Glycemic, Blood Pressure, and Lipid Control The American Diabetes Association in general recommends an A1C goal for patients with diabetes of <7%. A more or less stringent A1C goal goal may be appropriate for certain patients; goals should be individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations. The blood pressure goal for adults with diabetes is <130/<80 mm Hg. Based on individual patient characteristics and response to therapy, higher or lower blood pressure targets may be appropriate. The primary goal of lipid management in adults with diabetes is to lower LDL-C levels to <100 mg/dL (<2.6 mmol/L). In patients with diabetes and overt cardiovascular disease, an LDL-C goal of <70 mg/dL (<1.8 mmol/L), using a high dose of a statin, is an option.

18. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (1 of 2) This slide reviews the classes, actions, and available noninsulin agents for the treatment of hyperglycemia in type 2 diabetes. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (1 of 2) This slide reviews the classes, actions, and available noninsulin agents for the treatment of hyperglycemia in type 2 diabetes.

19. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (2 of 2) This slide reviews the classes, actions, and available noninsulin agents for the treatment of hyperglycemia in type 2 diabetes. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Noninsulin Therapies for Hyperglycemia in Type 2 Diabetes (2 of 2) This slide reviews the classes, actions, and available noninsulin agents for the treatment of hyperglycemia in type 2 diabetes.

20. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Recommendations for Hypoglycemia Glucose (15�20 g) is preferred treatment for hypoglycemia, although any form of glucose-containing carbohydrate can be used repeat treatment if continued hypoglycemia (per self-monitoring of blood glucose) is present 15 minutes after initial treatment individual should consume meal or snack to prevent hypoglycemia recurrence Prescribe glucagon for all persons at significant risk of hypoglycemia train family members, caregivers in administration Advise those with hypoglycemia or =1 severe hypoglycemic episode(s) to raise glycemic targets. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Recommendations for Hypoglycemia Glucose (15�20 g) is preferred treatment for hypoglycemia, although any form of glucose-containing carbohydrate can be used repeat treatment if continued hypoglycemia (per self-monitoring of blood glucose) is present 15 minutes after initial treatment individual should consume meal or snack to prevent hypoglycemia recurrence Prescribe glucagon for all persons at significant risk of hypoglycemia train family members, caregivers in administration Advise those with hypoglycemia or =1 severe hypoglycemic episode(s) to raise glycemic targets.

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22. Overweight/Obesity

23. Screening: Overweight Measure BMI routinely at each regular check-up. Classifications: BMI 18.5-24.9 = normal BMI 25-29.9 = overweight BMI 30-39.9 = obesity BMI =40 = extreme obesity

24. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Nutrition Strategies for Weight Loss Weight loss is recommended for all overweight or obese individuals at risk for, or with, diabetes. Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years) for weight loss in patients with diabetes. For patients with low-carbohydrate diets, it is recommended that lipid profiles, renal function, and protein intake (in those with nephropathy) should be monitored, and hypoglycemic therapies should be adjusted as needed. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Nutrition Strategies for Weight Loss Weight loss is recommended for all overweight or obese individuals at risk for, or with, diabetes. Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years) for weight loss in patients with diabetes. For patients with low-carbohydrate diets, it is recommended that lipid profiles, renal function, and protein intake (in those with nephropathy) should be monitored, and hypoglycemic therapies should be adjusted as needed.

25. Hypertension

26. Hypertension: Evaluation and Screening Persons without Diabetes BP should be�measured at each regular visit or at least once every 2 years if BP <120/80 mmHg BP measured seated after 5 min rest in office Persons with Diabetes BP should be�measured at each regular visit BP measured seated after 5 min rest in office Patients with =130 or =80 mmHg should have BP confirmed on a separate day

27. Management of Hypertension Non-pharmacologic DASH diet Dietary Approaches to Stop Hypertension High in whole grains, fruits, vegetables, and low-fat dairy Low in saturated and trans fat, cholesterol Physical Activity Weight loss, if applicable

28. Management of Hypertension Pharmacologic Drug therapy indicated if BP =140/ =90 mm Hg Combination therapy often necessary Treatment should include ACE or ARB Thiazide diuretic may be added to reach goals Monitor renal function and serum potassium

29. Complications of Hypertension in Patients with Diabetes Microvascular Renal disease Autonomic neuropathy Eye disease (glaucoma, retinopathy with potential blindness) Macrovascular Cardiac disease Cerebrovascular disease Reduced survival and recovery rates from stroke Peripheral vascular disease

30. Abnormal Lipid Metabolism

31. Screening for Dyslipidemia Persons without Diabetes Test at least every 5 years, starting at age 20, including adults with low-risk values Persons with Diabetes In adults, test at least annually Lipoproteins: measure at after initial blood glucose control is achieved as hyperglycemia may alter results

32. Cholesterol Management

33. Cholesterol Management Improve glucose control if diabetes is present Weight loss if overweight Daily exercise Smoking cessation Dietary modifications including low saturated fat (fat intake less than 30% of total calories and saturated fat less than 7% of total calories), low cholesterol (no more than 200 mg daily) diet Pharmacologic treatment frequently necessary Risk factors include hypertension; HDL < 40; family history of MI before age 55; male > 45 years old; female > 55 years old; smoking.

34. Healthy Lipid GoalsTargets for Patients Without DM or CVD these are the same for people with diagnosed diabetesthese are the same for people with diagnosed diabetes

35. Risk ManagementAbnormal Lipids Pharmacologic treatment: primary goal is LDL lowering Without overt CVD: If over 40, statin therapy recommended to achieve 30-40% LDL reduction With overt CVD: All patients should receive statin therapy to achieve 30-40% LDL reduction Lowering triglycerides and raising HDL with a fibrate is associated with fewer cardiovascular events in patients with clinical CVD, low HDL, and near-normal LDL

36. Nephropathy

37. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Treatment Recommendations for Nephropathy It is important to optimize glucose and blood pressure control to reduce risk or slow progression of nephropathy. Serum creatinine should be measured annually to estimate glomerular filtration rate (GFR) in all adults with diabetes. The serum creatinine should be used to estimate GFR and level of chronic kidney disease (CKD). Urine albumin testing should also be performed annually in type 1 patients with 5-year diabetes duration and in all type 2 patients starting at diagnosis. Protein intake should be limited to 0.8�1.0 g/kg/day in early-stage CKD and 0.8 g/kg/day in later stages. In patients with micro- or macroalbuminuria, treatment with an ACE inhibitor or ARB is indicated. If one class is not tolerated, substitute the other. Serum creatinine and potassium levels should be monitored in all patients receiving an agent from either class. It is reasonable to continue monitoring urine albumin excretion to assess therapeutic response and disease progression. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Treatment Recommendations for Nephropathy It is important to optimize glucose and blood pressure control to reduce risk or slow progression of nephropathy. Serum creatinine should be measured annually to estimate glomerular filtration rate (GFR) in all adults with diabetes. The serum creatinine should be used to estimate GFR and level of chronic kidney disease (CKD). Urine albumin testing should also be performed annually in type 1 patients with 5-year diabetes duration and in all type 2 patients starting at diagnosis. Protein intake should be limited to 0.8�1.0 g/kg/day in early-stage CKD and 0.8 g/kg/day in later stages. In patients with micro- or macroalbuminuria, treatment with an ACE inhibitor or ARB is indicated. If one class is not tolerated, substitute the other. Serum creatinine and potassium levels should be monitored in all patients receiving an agent from either class. It is reasonable to continue monitoring urine albumin excretion to assess therapeutic response and disease progression.

38. Aspirin

39. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Recommendations for Aspirin Therapy in Diabetes Aspirin 75�162 mg/day is recommended as Primary prevention in type 1 or type 2 diabetes patients at increased cardiovascular disease (CVD) risk (10-year risk >10%) Eg, most men >50 years of age or women >60 years of age who have =1 additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) There is no sufficient evidence to recommend aspirin for primary prevention in lower risk individuals (10-year CVD risk <5%; eg, men <50 years of age or women <60 years of age without other major risk factors) since potential adverse effects from bleeding likely offset potential benefits. Clinical judgment is recommended for treating patients in these age groups with other risk factors (10-year risk 5%�10%) Use aspirin therapy (75�162 mg/day) as a secondary prevention strategy in those with diabetes with history of CVD. Use clopidogrel (75 mg/day) for those with CVD and documented aspirin allergy. Combination therapy with aspirin (75�162 mg/day) and clopidogrel (75 mg/day) is reasonable for =1 year after acute coronary syndrome. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Recommendations for Aspirin Therapy in Diabetes Aspirin 75�162 mg/day is recommended as Primary prevention in type 1 or type 2 diabetes patients at increased cardiovascular disease (CVD) risk (10-year risk >10%) Eg, most men >50 years of age or women >60 years of age who have =1 additional major risk factor (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) There is no sufficient evidence to recommend aspirin for primary prevention in lower risk individuals (10-year CVD risk <5%; eg, men <50 years of age or women <60 years of age without other major risk factors) since potential adverse effects from bleeding likely offset potential benefits. Clinical judgment is recommended for treating patients in these age groups with other risk factors (10-year risk 5%�10%) Use aspirin therapy (75�162 mg/day) as a secondary prevention strategy in those with diabetes with history of CVD. Use clopidogrel (75 mg/day) for those with CVD and documented aspirin allergy. Combination therapy with aspirin (75�162 mg/day) and clopidogrel (75 mg/day) is reasonable for =1 year after acute coronary syndrome.

40. Retinopathy

41. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines for Retinopathy Management in Diabetes Optimal glycemic and blood pressure control can reduce the risk or slow progression of diabetic retinopathy. Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20 to 74 years. A comprehensive eye exam by an ophthalmologist or optometrist should be performed shortly after diagnosis (type 2) or within 5 years after onset of diabetes (type 1). Eye exams should be repeated annually. Less frequent exams (every 2�3 years) may be considered at the recommendation of an eye care specialist. High-quality fundus photographs can be used to detect most clinically significant diabetic retinopathy. Pregnant women with preexisting diabetes or those planning a pregnancy should have an eye exam and be counseled on the risk of developing diabetic retinopathy. Exams should occur in the first trimester with close follow-up throughout the pregnancy and for 1 year postpartum. Laser therapy is indicated to reduce risk of vision loss among those with high risk proliferative diabetic retinopathy, clinically significant macular edema, and some cases of severe nonproliferative diabetic retinopathy. Presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines for Retinopathy Management in Diabetes Optimal glycemic and blood pressure control can reduce the risk or slow progression of diabetic retinopathy. Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20 to 74 years. A comprehensive eye exam by an ophthalmologist or optometrist should be performed shortly after diagnosis (type 2) or within 5 years after onset of diabetes (type 1). Eye exams should be repeated annually. Less frequent exams (every 2�3 years) may be considered at the recommendation of an eye care specialist. High-quality fundus photographs can be used to detect most clinically significant diabetic retinopathy. Pregnant women with preexisting diabetes or those planning a pregnancy should have an eye exam and be counseled on the risk of developing diabetic retinopathy. Exams should occur in the first trimester with close follow-up throughout the pregnancy and for 1 year postpartum. Laser therapy is indicated to reduce risk of vision loss among those with high risk proliferative diabetic retinopathy, clinically significant macular edema, and some cases of severe nonproliferative diabetic retinopathy. Presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection.

42. Foot Care

43. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines for Foot Care in Patients With Diabetes Patients with diabetes should receive annual foot examinations to identify high-risk conditions and other risk factors, including peripheral neuropathy, foot deformity, vision impairment, peripheral vascular disease, cigarette smoking, poor glycemic control, diabetic nephropathy, and/or a history of ulcers or amputation. Examinations should include assessment of foot pulses and loss of protective sensation (10-g monofilament plus testing any one of the following: pinprick sensation, vibration using 128-Hz tuning fork, ankle reflexes, or vibration perception threshold). This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines for Foot Care in Patients With Diabetes Patients with diabetes should receive annual foot examinations to identify high-risk conditions and other risk factors, including peripheral neuropathy, foot deformity, vision impairment, peripheral vascular disease, cigarette smoking, poor glycemic control, diabetic nephropathy, and/or a history of ulcers or amputation. Examinations should include assessment of foot pulses and loss of protective sensation (10-g monofilament plus testing any one of the following: pinprick sensation, vibration using 128-Hz tuning fork, ankle reflexes, or vibration perception threshold).

44. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines for Foot Care in Patients With Diabetes (cont) Include a history for claudication and an assessment of pedal pulses in initial screenings for peripheral arterial disease. Refer those with significant claudication, or positive ankle-brachial index, for further vascular assessment and consider exercise, medications, and surgical options. Educate patients with diabetes on the risk factors and self-care management of the diabetic foot, including daily self-inspection. A multidisciplinary approach should be considered for those with high-risk feet, foot ulcers, or a history of prior ulcers or amputation. Refer patients who smoke, have loss of protective sensation and structural abnormalities, or have a history of prior lower-extremity complications to foot care specialists for ongoing preventive care and lifelong monitoring. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines for Foot Care in Patients With Diabetes (cont) Include a history for claudication and an assessment of pedal pulses in initial screenings for peripheral arterial disease. Refer those with significant claudication, or positive ankle-brachial index, for further vascular assessment and consider exercise, medications, and surgical options. Educate patients with diabetes on the risk factors and self-care management of the diabetic foot, including daily self-inspection. A multidisciplinary approach should be considered for those with high-risk feet, foot ulcers, or a history of prior ulcers or amputation. Refer patients who smoke, have loss of protective sensation and structural abnormalities, or have a history of prior lower-extremity complications to foot care specialists for ongoing preventive care and lifelong monitoring.

45. Self-Management Goals

46. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Recommendations for Diabetes Self-Management Education (DSME) At diagnosis and as-needed thereafter, persons with diabetes should receive DSME and support consistent with national standards DSME should address psychosocial issues Measure and monitor effectiveness of self-management and quality of life as part of overall care. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Guidelines: Recommendations for Diabetes Self-Management Education (DSME) At diagnosis and as-needed thereafter, persons with diabetes should receive DSME and support consistent with national standards DSME should address psychosocial issues Measure and monitor effectiveness of self-management and quality of life as part of overall care.

47. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Recommendations for Primary Prevention of Diabetes With Medical Nutrition Therapy Begin a structured program emphasizing lifestyle changes, including moderate weight loss (7% body weight) and regular physical activity (150 min/week) with dietary strategies, including reduced calories and reduced intake of dietary fat Achieve the U.S. Department of Agriculture recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). Limit intake of sugar-sweetened beverages. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Recommendations for Primary Prevention of Diabetes With Medical Nutrition Therapy Begin a structured program emphasizing lifestyle changes, including moderate weight loss (7% body weight) and regular physical activity (150 min/week) with dietary strategies, including reduced calories and reduced intake of dietary fat Achieve the U.S. Department of Agriculture recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). Limit intake of sugar-sweetened beverages.

48. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA: Physical Activity/Exercise Recommendations for Patients With Diabetes Patients with diabetes (absent contraindications) should engage in at least 150 minutes per week of moderate-intensity aerobic activity (50%�70% of maximum heart rate), spread over =3 days/week, with no more than 2 consecutive days without exercise, and resistance training (initiated with a qualified exercise specialist) 2 times per week. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA: Physical Activity/Exercise Recommendations for Patients With Diabetes Patients with diabetes (absent contraindications) should engage in at least 150 minutes per week of moderate-intensity aerobic activity (50%�70% of maximum heart rate), spread over =3 days/week, with no more than 2 consecutive days without exercise, and resistance training (initiated with a qualified exercise specialist) 2 times per week.

49. Case #2 Mr. Jones is a 55 year old male with T2DM X 3 years, on metformin 1000 mg po bid. A1C 6.9%, BP 120/80, + stable CV exam, weight 220 lbs, 5�10� and BMI 31.6. Chol 175, TG 150, HDL 45, LDL 100. Urine microalb neg, S. Creat 0.8. What would you advise next? Add glucotrol XL 5 mg qd. Add Januvia 100 mg qd Diet and exercise to lose 10% total body weight Add actos 15 mg qd No changes. Advise him to keep living his current lifestyle.

50. Immunizations

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52. Smoking

53. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Recommendations for Smoking Cessation in Diabetes All patients with diabetes should be advised not to smoke. Smoking cessation counseling and other forms of treatment should be incorporated as routine components of diabetes care. This slide was created under the auspices of KnowledgePoint360 Group, LLC, and was not associated with funding via an educational grant or a promotional interest. ADA Recommendations for Smoking Cessation in Diabetes All patients with diabetes should be advised not to smoke. Smoking cessation counseling and other forms of treatment should be incorporated as routine components of diabetes care.

54. Neuropathy

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56. What Should We Do?