Lunch CME Lecture: DiabetesChris Pitsch, DO

ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary.

Name of CME Activity: ACOFP Intensive Update and Board Review in Osteopathic Family Medicine Dates and Location of CME Activity: August 20-23, 2015, Loews Chicago O’Hare Hotel, Rosemont, IL

Topic(s): Diabetes Lunch Lecture Friday, 8/21/15 11:45-12:45pm

Table Trainer -Breakout 1 - OMT for the Thoracic and Cervical Spine

Friday, 8/21/15 2:45-4:15pm & 4:30-6:00pm Saturday, 8/22/15 8:30-10:00am & 10:15-11:45 am

Table Trainer- Workshop: Examination Techniques for Office Orthopedics-Primary Orthopedics: What You Need to Know

Friday, 8/21/15 7:30-9:30pm

Proctor- Test-Taking Skills Workshop: Review of Clinical Scenarios Utilizing a Hands-On Approach in Preparation for Your Board Examination Saturday, 8/22/15 6:30-9:30pm

Name of Faculty/Moderator: Chris Pitsch, DO

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X A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

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Signature: Chris Pitsch, DO Date: 8-6-15

Chris Pitsch, DO

Please fax this form to ACOFP at 866-328-1835 or email to joank@acofp.org as soon as possible Deadline: August 7, 2015

8/6/2015

1

Diabetes Mellitus

Chris Pitsch, DO

Age-adjusted Prevalence of Obesity and Diagnosed Diabetes

Among US Adults

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%

No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at

http://www.cdc.gov/diabetes/statistics

2013

2013

• Prevalence:

• In 1990 the prevalence of self-reported diabetes was 2.9% in

the United States, increasing to almost 8% in the first decade of

the 21st century.

• In men and women, the prevalence of diabetes increases with

age, the rate now is almost 1 in 4 in those older than 60.

• In those over 20, American Indians and Alaskan Natives have

high prevalence (16.5%), Blacks (11.8%), Hispanics/Latinos

(10.4%), and whites (6.6%)

• Education is inversely proportional with the highest prevalence

among those not finishing high school.

• The Southeast has a much higher prevalence than other parts

of the U.S.

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CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics

0

5

10

15

20

25

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2

3

4

5

6

7

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1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 09 11

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Percentage with Diabetes

Number with Diabetes

Number and Percentage of U.S. Population with Diagnosed Diabetes,

1958-2013

Objectives

I. Screening for Diabetes Mellitus

II. Diagnosis of Diabetes Mellitus

III. Complications of Diabetes Mellitus

IV. Treatment of Diabetes Mellitus

I. Screening

Question #1 The USPSTF Screening recommendation for

diabetes is based on using which of the following risk factors as an important predictor of cardiovascular complications in people with type 2 diabetes mellitus?

A) Activity Level

B) Blood Pressure

C) Coronary Artery Disease

D) Dyslipidemia

E) Ethnicity

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I. Screening

http://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/diabetes-mellitus-type-2-in-adults-screening#Copyright

This document is a summary of the 2008 recommendation of the U.S. Preventive Services Task Force (USPSTF) on screening for type 2 diabetes mellitus in adults. This summary is intended for use by primary care clinicians.

Clinical Summary of U.S. Preventive Services Task Force Recommendation

Population Asymptomatic Adults with Sustained Blood Pressure

greater than 135/80 mm Hg

Asymptomatic Adults with Sustained Blood Pressure

135/80 mm Hg or lower

Recs Screen for Type 2 Diabetes Mellitus

Grade: B

No Recommendation

Grade: I (Insufficient Evidence)

Risk Assessment These recommendations apply to adults with no symptoms of type 2 diabetes mellitus or evidence of

possible complications of diabetes.

Blood pressure measurement is an important predictor of cardiovascular complications in people with type

2 diabetes mellitus.

The first step in applying this recommendation should be measurement of blood pressure (BP).

Adults with treated or untreated BP >135/80 mm Hg should be screened for diabetes.

Screening Tests •Three tests have been used to screen for diabetes:

Fasting plasma glucose (FPG).

•2-hour postload plasma.

•Hemoglobin A1c.

The American Diabetes Association (ADA) recommends screening with FPG, defines diabetes as FPG ≥ 126

mg/dL, and recommends confirmation with a repeated screening test on a separate day.

Screening

Intervals

The optimal screening interval is not known. The ADA, on the basis of expert opinion, recommends an

interval of every 3 years.

Suggestions for

practice

regarding

insufficient

evidence

When BP is ≤ 135/80 mm Hg, screening may be considered on an individual basis when knowledge of

diabetes status would help inform decisions about coronary heart disease (CHD) preventive strategies,

including consideration of lipid-lowering agents or aspirin.

To determine whether screening would be helpful on an individual basis, information about 10-year CHD

risk must be considered. For example, if CHD risk without diabetes was 17% and risk with diabetes was

>20%, screening for diabetes would be helpful because diabetes status would determine lipid treatment. In

contrast, if risk without diabetes was 10% and risk with diabetes was 15%, screening would not affect the

decision to use lipid-lowering treatment.

I. Screening

USPSTF RecommendationsGrade Definition Suggestions for Practice

A The USPSTF recommends the service. There is high

certainty that the net benefit is substantial.

Offer or provide this service.

B The USPSTF recommends the service. There is high

certainty that the net benefit is moderate or there is

moderate certainty that the net benefit is moderate to

substantial.

Offer or provide this service.

C The USPSTF recommends selectively offering or

providing this service to individual patients based on

professional judgment and patient preferences. There is

at least moderate certainty that the net benefit is small.

Offer or provide this service for selected patients

depending on individual circumstances.

D The USPSTF recommends against the service. There is

moderate or high certainty that the service has no net

benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I

StatementThe USPSTF concludes that the current evidence is

insufficient to assess the balance of benefits and harms

of the service. Evidence is lacking, of poor quality, or

conflicting, and the balance of benefits and harms

cannot be determined.

Read the clinical considerations section of USPSTF

Recommendation Statement. If the service is offered,

patients should understand the uncertainty about the

balance of benefits and harms.

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I. Screening

USPSTF: Recommends screening for

diabetes in adults with HTN

ADA: Recommends screening every 3

years beginning at age 45 especially if BMI

≥ 25 kg/m2

I. Screening

HOWEVER…

Based on…Screening for Abnormal Glucose and Type 2 Diabetes Mellitus: A Systematic Review to Update the 2008 U.S. Preventative Services Task Force Recommendation

This article was published online first at www.annals.org on April 14, 2015

Shelley Selph, MD, MPH; Tracy Dana, MLS; Ian Blazina, MPH; Christina Bougatsos, MPH; Hetal Patel, MD; and Roger Chou, MD;

http://www.uspreventiveservicestaskforce.org/Page/Document/evidence-summary25/screening-for-abnormal-glucose-and-type-2-diabetes-mellitus

I. Screening Screening for Abnormal Glucose and Type 2 Diabetes Mellitus: A Systematic Review to Update the 2008

U.S. Preventative Services Task Force Recommendation

Background: Screening for type 2 diabetes mellitus could lead to earlier identification and treatment of

asymptomatic diabetes, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT), potentially resulting

in improved outcomes.

Purpose: To update the 2008 U.S. Preventive Services Task Force review on diabetes screening in adults.

Data Sources: Cochrane databases and MEDLINE (2007 through October 2014) and relevant studies from

previous Task Force reviews.

Study Selection: Randomized, controlled trials; controlled, observational studies; and systematic reviews.

Data Synthesis: In 2 trials, screening for diabetes was associated with no 10-year mortality benefit versus no

screening (hazard ratio, 1.06 [95% CI, 0.90 to 1.25]). Sixteen trials consistently found that treatment of IFG or

IGT was associated with delayed progression to diabetes. Most trials of treatment of IFG or IGT found no

effects on all-cause or cardiovascular mortality, although lifestyle modification was associated with decreased

risk for both outcomes after 23 years in 1 trial. For screen-detected diabetes, 1 trial found no effect of an

intensive multifactorial intervention on risk for all-cause or cardiovascular mortality versus standard control. In

diabetes that was not specifically screen-detected, 9 systematic reviews found that intensive glucose control did

not reduce risk for all-cause or cardiovascular mortality and results for intensive blood pressure control were

inconsistent.

Conclusion: Screening for diabetes did not improve mortality rates after 10 years of follow-up. More evidence

is needed to determine the effectiveness of treatments for screen-detected diabetes. Treatment of IFG or IGT

was associated with delayed progression to diabetes.

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I. Screening

Risk factors for Type 2 Diabetes Family history

HTN

Dyslipidemia (high triglycerides and low HDL)

Obesity

High risk ethnic or racial groups (African-American, Hispanic, Native American)

Previous history of impaired glucose tolerance

Gestational diabetes, or birth of a child > 9 lbs

Habitually physically inactive

Cardiovascular disease

Polycystic ovarian disease

II. Diagnosis

Question #2 All of the following are considered

criteria for the diagnosis of diabetes mellitus in adults except.

A) Random plasma glucose ≥ 200 mg/dLwith polydipsia, polyuria, polyphagia, and/or weight loss

B) Fasting plasma glucose ≥ 126 mg/dL

C) Two-hour oral glucose tolerance test ≥ 200 mg/dL after a 75 gram glucose load

D) A1C ≥ 6.0

II. Diagnosis

Diagnostic Criteria for Diabetes Fasting plasma glucose ≥ 126 mg/dL on

more than one occasion. Fasting is at least 8 hours.

Random venous plasma glucose ≥ 200 mg/dL in a patient with classic symptoms of hyperglycemia.

Plasma glucose ≥ 200 mg/dL measured 2 hour after a glucose load of 1.75 g/kg (maximum dose of 75 g) OGTT.

Glycated hemoglobin A1C ≥ 6.5 percent.

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II. Diagnosis

Diabetes Type 1 Up to 10% of cases of diabetes

Polyuria, polydipsia, nocturia, weight loss

Etiology: complex interaction of genetic and environmental factors. Destruction of pancreatic β cells and loss of body’s ability to produce insulin.

Type 1A: approx. 85%, autoimmune destruction of pancreatic beta cells

Type 1B: approx. 15%, no evidence of autoimmune destruction of pancreatic beta cells

II. Diagnosis

Diabetes Type 1 Bimodal distribution: one peak at 4 to 6

years of age and a second at early puberty,

10 to 14 years of age

45% of children present before age 10

Most common in non-Hispanic white

II. Diagnosis

Diabetes Type 1 Signs/Symptoms:

Fatigue, malaise, nausea and vomiting,

irritability and weight loss

Hyperglycemia without acidosis is the

most common presentation of childhood

Type 1 Diabetes

DKA is the second most common form

of presentation for T1DM in most

populations

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II. Diagnosis

Diabetes Type 2 Up to 90% of cases of diabetes

Etiology: increasing cellular resistance to

insulin, accelerated by obesity and

inactivity. Some patients have latent

autoimmune diabetes with onset similar

to type 2 but with destruction of the βcells, and a more rapid progression to

insulin dependence.

II. Diagnosis

Diabetes Type 2 Signs/Symptoms:

Fatigue, irritability, drowsiness, blurred

vision, numbness or tingling in extremities,

slow wound healing, frequent infections of

the skin, gums, or urinary tract including

candidal infections

III. Complications

Question # 3 The most common cause of end-stage

renal disease in the United States is:

A) NSAID overuse

B) IV drug abuse

C) Diabetic nephropathy

D) Autoimmune disease

E) HTN

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III. Complications

Ketoacidosis: insufficient insulin to meet body’s needs resulting in increased gluconeogenesis, fatty acid oxidation, and ketogenesis

Infections: community-acquired pneumonia, influenza, cholecystitis, UTI, pyelonephritis, fungal infections, skin infections, eye infections, foot infections

Retinopathy

Neuropathy

Cardiovascular Disease

Hyperlipidemia

Diabetic Feet: 15% of diabetics will have a foot ulcer and 20% of these will lead to amputation.

III. Complications

Nephropathy:

Risk factors: poor glycemic control, smoking, HTN, family history, and glomerular hyperinfiltration

All patients should be screened yearly with a microalbumin or microalbumin/creatinine ratio.

Microalbuminuria is defined as 30-300 mg protein in a 24 hour urine collection. More than 300 mg/24 hour constitutes macroalbuminuria or nephropathy.

Risk of microalbuminuria increases by 25% for each 10% rise in A1c

ACE inhibitors are the drug of choice. Ramipril has been showed to reduce ESRD and death by 41% and proteinuria by 20% when compared with amlodipine. ARBs have comparable efficacy and should be used when use of ACE inhibitors is limited.

The most common cause of ESRD is diabetic nephropathy

American Diabetes Association: Diabetic nephropathy (Position Statement). Diabetes Care 2003; 26 (Suppl. 1): S94-S98

III. Complications

Retinopathy:

About 20% of Type 2 diabetic patients show signs of retinopathy at time of diagnosis.

Patients with Type 1 diabetes may begin yearly opthalmologic visits 5 years after diagnosis, type 2 diabetics should begin yearly visits as soon as diagnosis is made.

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III. Complications

Cardiovascular disease: heart disease is the leading cause of death in patients with diabetes

Aspirin therapy at 81 mg/day is indicated for men older than 50 and women older than 60 years with one additional cardiovascular risk factor.

Statins are the drugs of choice in treating hyperlipidemia in diabetic patients.

American Heart Association, American College of Cardiology, and American Diabetic Association. Diabetes Care 2010; 33: 1395 and J Am CollCardiol 2010; 55: 2878

IV. Treatment

Education

Nutrition

Exercise

Home Glucose Monitoring

Pharmacologic Therapy

IV. Treatment

Diabetes Type 1, Treatment Diet

Exercise

Insulin replacement: two-thirds total dose

in the morning (split 2:1, regular:

intermediate) and one-third total dose in

the evening (split 2:1, regular:

intermediate). Also consider basal insulin

plus prandial insulin.

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IV. Treatment

Diabetes Type 2, Treatment Diet

Weight control

Exercise

Oral meds with or without insulin

IV. Treatment

Nutrition:

Weight loss of 10%-15% significantly improves glucose control, insulin sensitivity, and decreases mortality. It can be achieved with a reduction of 300-400 kcal/day

Mediterranean diet with exercise and not smoking

Limit alcohol

Consistent daily caloric intake for those on insulin

Carbs: 55% - 60%

Fats: < 30% (saturated < 7% - 10%)

Protein: 10% - 20%

Sodium: < 2400 mg if hypertensive

IV. Treatment

Home Glucose Monitoring The consensus panel of the American

Diabetes Association has recommended

that all patient with diabetes should

perform home glucose monitoring.

Type 1 diabetics should monitor blood

glucose at least 4 times a day

Type 2 diabetics can monitor once or

twice daily with fasting and postprandial

values being most helpful

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IV. Treatment

Biguanides Biguanides: Metformin (Glucophage)

MOA: Decrease gluconeogenesis in the liver, increase insulin sensitivity

Advantages: No hypoglycemia, lowers insulin levels, possible weight loss, improves lipids and endothelial function, decreases mortality

Side effects/precautions: Nausea, diarrhea, not for use when creatinine ≥ 1.5 mg/dL, hold before and after IV contrast, caution with CHF and hepatic dysfunction

IV. Treatment

Question #4 All of the following are true regarding

sulfonylureas except:

A) They are contraindicated in a patient with sulfa allergy.

B) They tend to cause weight gain.

C) Most are metabolized by the liver to substances that are cleared by the kidney, thus they are generally not used in significant liver or kidney disease.

D) Their efficacy tends to wear out after approximately 5 years of treatment.

E) They help improve insulin sensitivity.

IV. Treatment

Sulfonylureas Sulfonylureas: Glipizide (Glucotrol),

Glyburide (Diabeta, Micronase),

Glimeperide (Amaryl)

MOA: Induce insulin secretion from

pancreatic β cells

Metabolized in the liver and excreted

primarily through urine

Side effects/precautions: Hypoglycemia,

weight gain

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IV. Treatment

Question #5 Which of the following regarding

thiazolidinediones such as pioglitazone (Actos) and rosiglitazone (Avandia) is true?

A) They lead to weight loss by improving insulin sensitivity.

B) They should not be combined with sulfonylureas to avoid drug interactions.

C) They should be avoided in patients with congestive heart failure because of their tendency toward fluid retention.

D) They are insulin secretagogues.

E) A main advantage is that liver function tests do not have to be monitored.

IV. Treatment

Thiazolodinediones Thiazolodinediones: Pioglitazone (Actos),

Rosiglitazone (Avandia)

MOA: Insulin sensitizers in muscle and

adipose tissue

Side effects/precautions: Cannot use in

Class III or IV heart failure, must monitor

liver function tests

IV. Treatment

Meglitinides Meglitinides: Repaglinide (Prandin),

Neteglinide (Starlix)

MOA: Induce secretion of insulin from

pancreatic β cells

Advantages: Can be used in renal failure,

rapid onset and short half-life

Side effects/precautions: Caution in

hepatic insufficiency

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IV. Treatment

α-Glucosidase inhibitors α-Glucosidase inhibitors: Acarbose

(Precose), Miglitol (Glyset)

MOA: inhibit breakdown of disaccharides

and delay carbohydrate absorption in

brush border of small intestine

Advantages: No hypoglycemia

Side effects/precautions: Flatulence,

cannot use with GI disorders, cirrhosis,

Crt > 2 mg/dL

IV. Treatment

DPP-4 inhibitor DPP-4 inhibitor: Sitagliptin (Januvia),

Saxagliptin (Onglyza)

MOA: Block the breakdown of natural

incretins

Advantages: Do not cause hypoglycemia,

Lowers postprandial glucose

Side effects/precautions: Nausea and

vomiting, must decrease dose in renal

impairment

IV. Treatment

Incretin Mimetics Incretin Mimetics: Exenatide (Byetta),

Pramlintide (Symlin)

MOA: Enhance glucose-dependent insulin

secretion, suppress inappropriate glucagon

secretion and slow gastric emptying

Advantages: Early satiety and weight loss

Side effects/precautions: Nausea and

vomiting, hypoglycemia, Exenatide associated

with hemorrhagic or necrotizing pancreatitis

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Our Role for our Diabetic Patients?

History and physical

Discuss nutrition, physical activity, management of diabetes and cardiovascular risk factors and diabetes related complications

BP and feet checks at every visit

Annual dilated eye exams

A1C every 3 months, every 6 months in stable patients

Fasting lipids and urine albumin-to-creatinine ratio annually

Understand up to date treatment guidelines

Standards of medical care in diabetes-2015: summary of revisions. Diabetes Care 2015; 38 Suppl:S4

References 1. American Diabetes Association: Diabetic nephropathy (Position Statement). Diabetes

Care 2003; 26 (Suppl. 1): S94-S98

2. American Diabetes Association: Standards of medical care in diabetes, 2011. Diabetes Care 2011; 34, Suppl 1:S11

3. American Heart Association, American College of Cardiology, and American Diabetic Association. Diabetes Care 2010; 33: 1395 and J Am Coll Cardiol 2010; 55: 2878

4. http://www.cdc.gov/diabetes/data/center/slides.html

5. Tallia, Alfred, Swanson’s Family Medicine Review, A Problem-Oriented Approach, 6th

Edition, 2005, “Diabetes Mellitus,” Chp 41, pp 205- 223.

6. Rakel, Robert E., Rakel, David P., Textbook of Family Medicine, Eight Edition, 2007, pp 732-733

7.http://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/diabetes-mellitus-type-2-in-adults-screening#Copyright

8.http://www.uspreventiveservicestaskforce.org/Page/Document/evidence-summary25/screening-for-abnormal-glucose-and-type-2-diabetes-mellitus

9. Vail, Belinda, MD, MS, "Diabetes," Chp 35, Current Diagnosis and Medical Treatment, Family Medicine, Third Edition, 2011, pp 389- 398

10. UptoDate, “Diabetes Mellitus,” “Treatment of Diabetes Mellitus”