definition & classification of diabetes & pre-diabetes...

Definition & classification of

diabetes & pre-diabetes abnormalities

Dan Gaita

CV Mortality & Events in Persons with/ without DM

1991 1998

'diabetes mellitus' derives from:

Greek: 'diabetes' – “siphon” or “to pass through”

Latin: 'mellitus' – “honeyed” or “sweet”**

* Diagnosis and Classification of Diabetes Mellitus. ADA 2009.** http://science.jrank.org/pages/2044/Diabetes-Mellitus.html

Topics

• History

• Guidelines

• A1c

• Gestational

History

1979 - National Diabetes Data Group (NDDG) :

Glycaemic values

Diagnostic criteria

Symptoms

FG ≥ 140 mg/dl , or

G2h OGTT – 75 g glucose ≥ 200 mg/dl

NDDG. Diabetes 1979;28:1039–1057W.H.O. 1980

Non-DM DM

FG ≥ 140 mg/dl

National Diabetes Data Group (NDDG) :

IGT – high risk of progression to DM

IFG < 140 mg/dl

G 2h OGTT = 140 - 200 mg/dl

Non-DM IGT DM

FG < 140 mg/dl

G2h OGTT = 140-200 mg/dl

1979

Expert Committee on theDiagnosis and Classification of DM

In 1997

G2h-OGTT is not “golden-standard” for DM !!!

FG – test for diagnostic ≥ 126 mg/dl

Practical

Low-cost

Reproducible

Re-focus on the relation

glycaemia–chronic complication

Diabetes Care 1997;20:1183–1197

1997 IFG = 110 – 125 mg/dl

IGT = G 2h OGTT = 140 - 200 mg/dl

2003

IFG = 100 – 125 mg/dl

Non-DM IGT DM

IFG = 110100

mg/dl BG ≥ 126 mg/dl

G-2h OGTT=140-200mg/dl

Glycaemic abnormalities:

- DM

- intermediate hyper-glycaemia:

• IFG

• IGT

- normo-glycaemia

&2006

FG (a jeun)

≥ 126 mg/dl or

Glycaemia 2–h post OGTT

≥ 200 mg/dl or

Symptoms & glycaemia ≥200 mg/dl

Non-DM HG DM

IFG < 110100 mg/dl

FG ≥ 126 mg/dl

&2006

G-2h OGTT = 140-200 mg/dl

IFG IGT

DM

Dg. !?

Topics

• History

• Guidelines

• A1c

• Gestational

Metabolic disorder of multiple aetiology characterized by

chronic hyperglycaemia

with disturbances of

carbohydrate, fat & protein metabolism

resulting from defects of

insulin secretion, insulin action, or a combination of both

Definition

DeFronzo RA. International Textbook of Diabetes Mellitus. 3rd ed. Chichester, West Sussex, Hoboken, NJ: John Wiley; 2004.

Criteria used for gluco-metabolic classification according to the WHO (1999), ADA (1997) & (2003)

Lars Ryden et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases. EHJ (2007)

Other specific types of diabetes


Disorders of glycaemia: aetiological types and clinical stages


Aetiological classification of glycaemic disorders


Conversion factors between plasma and other vehicles for glucose values


* Postprandial measurements should be made 1-2 h after the beginning of the meal, generally peak levels in patients with diabetes.

Glycemic goals• HbA1c < 7.0%

• Preprandial capillary plasma glucose 70-130 mg/dl (3.9-7.2 mmol/l)

• Peak postprandial capillary plasma glucose < 180 mg/dl (< 10.0 mmol/l)*

• Key concepts in setting glycemic goals

• HbA1c is the primary target for glycemic control

• Goals should be individualized based on:

– duration of diabetes

– age/life expectancy

– comorbid conditions

– known CVD or advanced microvascular complications

– hypoglycemia unawareness

– individual patient considerations

• More or less stringent glycemic goals may be appropriate for individual patients

• Postprandial glucose may be targeted if HbA1c goals are not met despite reaching preprandial glucose goals

2010 ADA

DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010

NEWS!!

Topics

• History

• Guidelines

• A1c

• Gestational

Glycemia – Chronic DM complications

Glycemic continuum

A1c: 4% - 5% - 5,5% - 6% - 6,5% - 7% - > 7% ......

Risk continuum

Role of the A1C assay in the diagnosis of DM

International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes. DIABETES CARE (2009)

• The A1C assay is an accurate, precise measure of chronicglycemic levels and correlates well with the risk of diabetescomplications.

• Diabetes should be diagnosed when A1C is 6.5%.

• Diagnosis should be confirmed with a repeat A1C test.Confirmation is not required in symptomatic subjects withplasma glucose levels 200 mg/dl (11.1 mmol/l).

• A1C testing is indicated in children in whom diabetes issuspected but the classic symptoms and a casual plasmaglucose 200 mg/dl (11.1 mmol/l) are not found.

Role of the A1C assay in the diagnosis of DM

International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes. DIABETES CARE (2009)

For the identification of those at high risk for diabetes:

• The risk for diabetes based on levels of glycemia is acontinuum; therefore, there is no lower glycemic thresholdat which risk clearly begins.

• The categorical clinical states pre-diabetes, IFG, and IGTfail to capture the continuum of risk

• Individuals with A1C levels below the threshold fordiabetes but 6.0% should receive preventive interventions.

• Individuals with A1C below this range may still be at riskand may also benefit from prevention efforts.

V high risk

DM - 10 x

DM

Retinopathy risk

A1c – “Risk classes”

Low risk

A1c: 4% - 5% - 5,5% - 6% - 6,5% - 7%

High risk

12-25%-5 y

+

HTG, HBP, Ob,

DM fam his

DM risk

HbA1c Level

Multivariate-

Adjusted Hazard

Ratio for

diagnosed

diabetes

< 5% 0.52 (0.40-0.69)

5% to < 5.5% 1.00 (reference)

5.5% to < 6% 1.86 (1.67-2.08)

6% to < 6.5% 4.48 (3.92-5.13)

≥ 6.5% 16.47 (14.22-19.08)

The Atherosclerosis Risk in Communities (ARIC) study

CAD risk Stroke risk

“HbA1c values significantly predicted CVD or death“

CAD Mortality Risk

A1c 6.5% + Confirmation

Without confirmation – symptoms ( 200 mg/dl).

A1c = 6% - 6.5% - Very high risk

Prevention +++

A1c < 6% - risk related to other RF for DM

Prevention ++

2010

Topics

• History

• Guidelines

• A1c

• Gestational

Gestational diabetes mellitus (GDM) - “any degree of glucose

intolerance with onset or first recognition during pregnancy”:

> week 24

symptoms

Gestational Diabetes Mellitus: an Opportunity to

Prevent Type 2 Diabetes and Cardiovascular Disease

in Young WomenGraziano Di Cianni et al. Women's Health. 2010;6(1):97-105

Cumulative incidence

in the first 5 years

HR CV ev = 1,71

- HBP, DLP, microalbuminuria,

- enhanced CVR profile,

- increased vessel stiffness,

- early abnormalities in diastolic function

- impaired cardiac autonomic function

Non-DM DM

Non-DM IGT DM

FG < 140 mg/dl G2h OGTT = 140-200 mg/dl

FG < 140 mg/dl

Non-DZ IGT DM

IFG = 110100

mg/dlFG ≥ 126 mg/dl G-2h OGTT = 140-200 mg/dl

A1c: 4% - 5% - 5,5% - 6% - 6,5% - 7% - > 7% ......

Investigational algorithm for CAD & DM


definition & classification of diabetes & pre-diabetes...

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