DiabetesBoardReview

March5,2016JonMcKrell,MD

HeritageValleyFMResidencyProgram

ObjecFves

Bytheendofthis30minuteboardreview,youwillbeableto:1.  AnswercommonlyaskedboardquesFons

aboutdiabetes2.  ApplythisknowledgetobePercareforyour

diabeFcpaFents

Agenda

•  Screening•  Pre-diabetes•  Diagnosis•  Treatments•  HealthMaintenance•  SpecialConsideraFons

#1WhyDoWeScreenforDM2?

•  Verycommondisease•  Causesalotofmorbidityandmortality•  Wehavereliabletests•  TreatmentiseffecFve– Decreasetheprogressionofthedisease– Decreaseadversesequelae

Whoshouldbescreened?TheUSPSTF:NewRecommendaFons!

Individualsbetweenages40—70OverweightorObese(BMI≥25orBMI≥30)Basedonrandomizedtrials

WhatDoestheADARecommend?InasymptomaFcpaFents,tesFngbeginsatage45…Unless…• Theyareoverweightorobese(BMI≥25)andhave1ormoreaddiFonalriskfactors:–  PhysicalinacFvity–  FirstdegreerelaFvewithDM–  High-riskrace/ethnicity– Womendeliveringababy>9lborwithhxofGDM–  HTN–  HDL<35ortrig>250–  PCOS–  A1C≥5.7,IGT,orIFGonprevioustests–  Clinicalinsulinresistance(severeobesity,acanthosisnigrans)

–  HistoryofCVD

UpdateFromtheADAin2015

•  ScreenAsianAmericanswithaBMI≥23kg/m²•  AtriskforDM2atlowerBMIlevelscomparedtothegeneralpopulaFon

ScreeningforDM2inCanada

•  UseriskcalculaFontools

•  FINDRISC–  Validated–  ProspecFve–  Improvedpt.outcomes

•  CANRISC–  Lessevidence–  Longer

•  Assess:–  Age–  Obesity–  h/o↑glucose–  h/oHTN–  FMHofDM2–  LowacFvitylevel–  Poordiet

ScreeningQuesFon

1.WhichofthefollowingdoestheUSPSTFrecognizeasthemostimportantriskfactorinscreeningfordiabetes?A.ObesityB.HypertensionC.HyperlipidemiaD.AcFvitylevelE.Ethnicity

ScreeningQuesFon

2.Ofthefollowing,whoshouldbescreenedfordiabetes?A.  37y/oBMwithhyperlipidemiaandnofamily

history,BP130/75B.  42y/oobeseWFwithnohealthissuesC.  23y/othinBMwithastrongfamilyhistoryof

diabeteswithaBPof127/65D.  12y/overyobeseHFwithacanthosisnigricans

#2Pre-diabetes

Currentcriteria:•  A1C5.7-6.4%•  FasFngplasmaglucose100to125•  2hourplasmaglucose140to199PIniFatedietandexercisePScreenmorefrequentlyforDMPConsidermeqormininhighriskpts.

Pre-diabetesQuesFon3.A42-year-oldfemalebringsyoutheresultsofacomprehensivemetabolicprofileobtainedthroughhealthscreeningprogramofferedbyheremployer.Shefastedfor8hourspriortothetest,andherbloodglucoselevelwasreportedat110.Herlipidvaluesandherbloodpressurewerenormal,butherBMIis30.5.ShecurrentlyviewsherselfasrelaFvelyhealthyandreportsnosymptomsconsistentwithdiabetes.AddiFonaltesFngrevealsahemoglobinA1cof6.3%.Basedonthisdata,whichoneofthefollowingismostappropriateatthisFme?a.  OrderaC-pepFdelevelb.  OrderanisletcellanFbodylevelc.  RecommendlifestylemodificaFonsonlyd.  Startlow-doseempagliflozin(Jardiance)dailye.  Startlow-doseinsulinglargine(Lantus)daily

#3DiagnosingDiabetesMellitus

•  SpectrumofDisorders•  Type1DM•  Type2DM•  GestaFonalDM•  PreDM•  MaturityOnsetdiabetesofyouth•  Latentautoimmunediabetesinadults

DiagnosingDiabetes

Type1•  <10%ofDM•  Onsetusuallyinchildhood

oradolescence•  Lossofbetacellsinthe

pancreas:insulinrequiring•  Weightlossisprevalent•  Suddenonset•  ScreeningforcomplicaFons

begins5yearsauerdiagnosis

Type2•  >90%ofDM•  Onsetadulthoodbutnow

commoninadolescence•  Insulinresistancesohigh

insulinlevels•  Obesityisprevalent•  Insidiousonset•  ScreeningforcomplicaFons

beginsatdiagnosis

DiagnosingDiabetes

Currentcriteria:•  A1C≥6.5%•  FasFngplasmaglucose≥126•  2hourOGTTplasmaglucose≥200•  Randomplasmaglucose≥200withsymptomsofDM

PIntheabsenceofunequivocalhyperglycemia,shouldbeconfirmedbyrepeattesFng

DiagnosisQuesFon4.WhichofthefollowingwouldbeconsidereddiagnosFcoftype2diabetes?A.  AhemoglobinA1c≥6.0%ontwoseparate

occasionsB.  Anoralglucosetolerancetestwith75-gloadanda

2-hourglucoselevel≥150mg/dLC.  AfasFngglucoselevel≥126mg/dLon2separate

occasionsD.  Arandomglucoselevelof212mg/dLinan

asymptomaFcperson

#4Treatment:Goals

•  PreventcomplicaFons&improveoutcomes•  Pre-prandialglucose:80—130mg/dl•  Peakpostprandialglucose<180mg/dl•  A1C<7%–  Lower(<6.5%)fornewdiagnosis,longlifeexpectancy– Higher(<8%)forlongstanding(>12yrs),advancedcomplicaFons,limitedlifeexpectancy

– ACCORDtrialfoundexcessivelyrapidoraggressivecontrolassociatedwithincreasedrisk

– Monitorevery3months(every6ifstableandatgoal)

Treatment

•  Lifestylechange– NutriFon

•  Intensivecounseling– AcFvity

•  CombinaFonofaerobic&resistanceexercise•  Don’tsitlongerthan90mins

– Weightloss•  Goalof5%•  PharmacologicandSurgicalopFonsnowlistedaswell

•  MedicaFon

Treatment:Meqormin•  InsulinsensiFzer,DecreasesglucoseproducFonintheliver,Lowersinsulinandlipidlevels

•  Nohypoglycemiaorweightgain•  Improvescardiovascularoutcomesintype2decreasesmortality**

•  CancorrectfaPyliver•  UsewithcauFonintheelderly(>65),renaldysfuncFon,cardiopulmonarydisorders(OKwithstableCHF),andhepaFcdisease

•  StoppriortoIVcontrast**•  RarecasesoflacFcacidosis*

Treatment:ThiazolidinedionePioglitazone(Actos)• Decreasesinsulinresistance*,↓gluconeogenesis• UsewithcauFonintheelderlyduetodecliningventricularfuncFon,andincardiopulmonarydisordersduetovolumeoverload*• MustmonitorLFTs,avoidinhepaFcdysfuncFonincludingnonalcoholicfaPyliverdisease*• ↓riskofMI,stroke,anddeath,↓triglycerides,↑HDL,↑seriousheartfailureRosiglitazone(Avandia)• 42%increaseriskofMI;restricted

Treatment:Sulfonylureas

Glipizide(Glucotrol),glyburide(Micronase),Glimepiride(Amaryl)• SFmulatepancreaFcbetacellstoreleaseinsulin• Weightgainandhypoglycemia*• Canbeusedinlowdosesintheelderly• OKinmildrenaldysfuncFonandcardiopulmonaryco-morbidiFes(sleepapnea,CHF)

Treatment:MegliFnides

•  Repaglinide(Prandin),Nateglinide(Starlix)•  RapidacFnginsulinsecretagogues•  Halflife<1hour•  Maybeusedintheelderly,renalfailure,andcardiopulmonarydisorders

•  VeryhelpfulforerraFceaFngschedules

Treatment:AlphaGlucosidaseInhibitors

Acarbose(Precose)andMiglitol(Glyset)•  DelaycarbohydrateabsorpFoningut—decreasespeakglucoselevels,nohypoglycemia*

•  Acarbosemaydelayonsetoftype2diabetes•  Reducetheriskofcardiovascularevents*•  MonitorLFTs;avoidincirrhosis•  NotforuseinrenaldysfuncFon(creaFnine>2)•  AvoidinGIdisease—significantGIside-effects

Treatment:IncreFnMimeFcsExenaFde(ByePa),LiragluFde(Victoza):GLP-1agonists;PramlinFde(Symlin):SyntheFcanalogueofhumanamylin• AllgivenbysubcutaneousinjecFon• MechanismofacFon–  PotenFatesinsulinsecreFon–  SuppressespostprandialglucagonsecreFon–  Slowsgastricemptying–  PromotessaFety(noweightgain)

• Sideeffects–  Nausea,vomiFng,diarrhea,weightloss*– Mayworsengastroparesis**–  PancreaFFs*–  Hypoglycemia(withsulfonylurea)

Treatment:DPP-4Inhibitors

SitaglipFn(Januvia),SaxaglipFn(Onglyza),LinaglipFn(Tradjenta)•  BlockdipepFdylpepFdase4(theenzymethatbreaksdownnaturalincreFns)

•  BePerinsulinreleaseandbloodsugarcontrolparFcularlypostprandial

•  Sideeffectsminimal:URI,sorethroat,diarrhea,pancreaFFs

•  Weightneutral

SGLT2Inhibitors•  Sodium-glucose

cotransporter2inhibitors•  MechanismofacFon

–  ↓renalthresholdforglucose

–  ↓reabsorpFonoffilteredglucosefromthetubules

–  ↑urinaryglucoseexcreFon

•  Sideeffects–  UTI–  YeastinfecFons–  ↑urinaFon

•  Dapagliflozin(Farxiga)•  Canagliflozin(Invokana)•  Empagliflozin(Jardiance)

Treatment:Insulin•  Weightgainoutweighedbyglucosecontrol•  Averagedose0.6-0.8units/kgbodyweight/day–  ~40-50unitsfora70kgman–  Halfforbasalneedsandhalfwithmeals

•  BioavailabilitychangeswithsiteofinjecFon*–  Fasterinabdomen,Slowerinthigh–  ExerciseacceleratesabsorpFoninthigh*–  Armreducesexerciseinducedhypoglycemiaby60%–  Abdomenreducesexerciseinducedhypoglycemiaby90%

•  BestcombinaFon:long-acFngbasalandrapidacFngsyntheFc—mostcloselymimicsnormal*

Treatment:RapidacFnginsulin

Lispro(Humalog),Aspart(Novolog),Glulisine(Apidra)•  Analogsofhumaninsulin;allsimilar•  Onset15min,peak1-3hr,duraFon2-5hr•  MayneedtoadjustlongacFngregimen•  ParFcularlywell-likedbytype1diabeFcs•  (~1/3ofdailyinsulinrequirement)•  Availablein75/25mixwithlongeracFngprotamineform

Treatment:LongacFnginsulin

NPHduraFon16-24hr(2/3inAM,1/3inPM)Glargine(Lantus)24hr(humananalog)– Maybeusedintype1and2–  IniFatedoseat80%ofpriortotalinsulindose– BestapproachforgeriatricpaFentsinlong-termcarefaciliFes(predictablecontrol)*

Detemir(Levemir)similartoglargine– Notsupposedtoincreaseweight– LengthofacFvityincreasesasdoseincreases

Treatment:TherapybasedonA1C•  <9.0%:monotherapy(usuallymeqormin)•  ≥9.0%:dualtherapy:meqorminplus

–  Sulfonylureaor–  TZD:Pioglitazoneor–  Glinide:Repaglinide/nataglinideor–  DPP4:SitaglipFn/saxaglipFn/linaglipFnor–  GLP-1agonist:ExenaFde/pramlinFde/liragluFde–  SGLT2

•  ≥10.0%:Insulinortripletherapy:–  Meqorminplus–  DPP4orGLP-1orSGLT2plus/or–  Sulfonylureaorglinideplus/or–  TZD

TreatmentQuesFon5.A56-year-oldmalewithtype2diabetesmellitushasnormalcardiacandrenalfuncFonbuthasfailedtoachieveadequatecontrolofhisdiabeteswithdietandmulFpleoralagents.HisBMIis30.1kg/m2andhishemoglobinA1clevelis9.1%WhichoneofthefollowingismostlikelytobebeneficialincombinaFonwithinsulinanddiettherapyinthispaFent?A.Acarbose(Precose)B.  Glimepiride(Amaryl)C.  Meqormin(Glucophage)D.  Pioglitazone(Actos)E.  Repaglinide(Prandin)

TreatmentQuesFon6.YouareconsideringaddingsitaglipFn(Januvia)totheregimenofapaFentwithtype2diabetesmellitus.WhichoneofthefollowingbestdescribesthemechanismofacFonofthisdrug?A.ItincreasesglucagonlevelsB.  ItslowsinacFvaFonofincreFnhormonesC.  ItreducestheabsorpFonofglucoseinthe

gastrointesFnaltractD.  ItreducesinsulinresistanceinskeletalmuscleE.  Itreducesinsulinresistancetotheliver

TreatmentQuesFon7.An81yearoldmalewithtype2diabetesmellitushashemoglobinA1Cof10.9%.Heisalreadyonthemaximumdosageofglipizide(Glucotrol).Hisothermedicalproblemsincludemildrenalinsufficiencyandmoderateischemiccardiomyopathy.WhichoneofthefollowingwouldbethemostappropriatechangeinthepaFent’sdiabetesregimen?A.  Addmeqormin(Glucophage)B.  AddsitaglipFn(Januvia)C.  Addpioglitazone(Actos)D.  IniFateinsulintherapy

TreatmentQuesFon8.A66yearoldmalewithtype2diabetesmellitusisseenforafollowupvisitandhasahemoglobinA1Cof6.7%.Heiscurrentlytakingmeqormin(Glucophage),1000mgtwicedaily.Hehasnohistoryofcoronaryarterydiseaseorheartfailure.Whichoneofthefollowingwouldbemostappropriate?A.  ConFnuinghiscurrentregimenB.  IncreasingthemeqormindosageC.  AddingasulfonylureaD.  AddingthiazolidinedioneE.  AddingdailylongacFnginsulin

#5HealthMaintenanceGoals•  Bloodpressure<140/90andprevenFonofnephropathy– ACEI(angiotensinconverFngenzymeinhibitor)slowsprogression

– UseARBswhenACEinhibitorsarenottoleratedorcontraindicated

•  Lipids– TreatmentandiniFalstaFndosearedrivenbyriskstatus

– NolongerbasedonLDLnumbers

HealthMaintenanceGoals

•  Lipids– OvertCVDalwaysmeanshighintensitystaFn– Age<40:

•  Noriskfactors—notreatment•  CVDriskfactors—moderateintensitystaFn

– Age40–75:•  Noriskfactors—moderateintensitystaFn•  CVDriskfactors—HighintensitystaFn

– Age>75:•  Sameasage40–75butmaynottoleratehighintensity

HealthMaintenance•  Yearlyeyeexam•  YearlyurinemicroalbuminandcreaFnine•  Yearlycomprehensivefootexam:–  EvaluaFonofpulses–  VisualinspecFonoffeet–  TesFngforlossofprotecFvesensaFon(LOPS)

•  Bloodpressureateveryvisit•  Lipidsyearly•  Screenfortobaccouse•  Screenfordepression

HealthMaintenance

•  Lowdoseaspirinisreasonableinadultswithdiabetesandnohistoryofvasculardiseasewhose10-yearriskofCHDeventsis>10%andnotatincreasedriskofbleeding– Males>50andFemales>60with1addiFonalriskfactor

– Smoking,hypertension,dyslipidemia,albuminuria,familyhistoryofprematuredeath

HealthMaintenanceQuesFon9.AccordingtothemostrecentAmericanDiabetesAssociaFonguidelines,whichoneofthefollowinggroupsofpaFentswithdiabetesmellitusshouldtakeaspirinforprimaryprevenFonofcardiovascularevents?A.  AllpaFentsB.  AllpaFentsovertheageof55C.  Onlythosewhoseriskforcardiovasculardisease

eventsis>10%D.  Onlythosewhoseriskforcardiovasculardisease

eventsis>20%

#6SpecialConsideraFons•  SteroidInjecFons–  Intra-arFcular–  SouFssue

•  ClassiccomplicaFons–  Contrastinducednephropathy(meqormin)–  Delayedwoundhealing–  Dupuytren’sdisease–  ErecFledysfuncFon–  Charcotfoot

•  CDLrestricFon–  Insulinrequiringoruncontrolled

SpecialConsideraFonsQuesFon

10.WhichoneofthefollowingfindingsonexaminaFonshouldpromptimmediatespecialtyreferral?A.  ParoFdenlargementB.  Dupuytren’sdiseaseC.  CharcotfootD.  PosturalhypotensionE.  Periodontalbleeding

Summary

TheABFMandAOBFPexamsfrequentlyhavequesFonsrelatedtodiabetesscreening,diagnosisandtreatmentincludingcomplicaFonsandhealthmaintenancerecommendaFons.BesuretoreviewthekeypointsintheseslidesandintheADAguidelinestobewellprepared.ThankYouandGoodLuck!