maj gen farooq ahmad khan hi(m) mbbs, mcps, dip endocrinol (lond), fcps, frcp (ireland), frc path...
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Maj Gen Farooq Ahmad Khan HI(M)MBBS, MCPS, Dip Endocrinol (Lond), FCPS, FRCP
(Ireland),
FRC Path (UK), PhD (Lond)
Professor of Pathology
Armed Forces Institute of Pathology
Rawalpindi
Diabetes mellitus - Updates
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What is diabetes mellitus?
Diabetes mellitus is a chronic
metabolic disorder characterized by
persistent hyperglycemia, disturbances of
carbohydrate, fat and protein
metabolism due to deficiency of insulin
secretion or insulin effect in the body.
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Why Diabetes?
Huge public health problem
serious common
costly
Controllable
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DCCT: Results Summary
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Characteristics ofVulnerable and Stable Plaques
Platelets
Lumen
Thrombus
Lipid rich core
Smoothmuscle cell
Endothelium
Thickfibrous capMacrophage
Large lipid core with thin fibrous cap, macrophages interacting with thrombus
Reduced lipid core with thick fibrous cap reinforced with
increased smooth muscle cells
Vulnerable Plaque Stable Plaque
Thinfibrous cap
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Vascular Risk Factors and Events
0
2
4
6
Vascular risk factors
Colwell JA. Semin Thromb Hemost. 1991; 17: 439-444.
Major vascular events
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1995 (millions) 2025 (millions)
Rank1 India 19.4 India 57.22 China 16.0 China 37.63 U.S. 13.9 U.S. 21.94 Russian Fed. 8.9 Pakistan 14.55 Japan 6.3 Indonesia 12.46 Brazil 4.9 Russian Fed. 12.27 Indonesia 4.5 Mexico 11.78 Pakistan 4.3 Brazil 11.69 Mexico 3.8 Egypt 8.810 Ukraine 3.6 Japan 8.5
All other countries 49.7 103.6
Total 135.3 300.0
Top ten countries for estimated number of adults with diabetes, 1995 and 2025
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Lifestyle Changes that Promote Sedentary Behavior
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Change in lifestyle & Obesity?
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Classification of diabetes Type 1 diabetes
β-cell destruction
Type 2 diabetes
Progressive insulin secretary defect
Other specific types of diabetes
Genetic defects in β-cell function, insulin action
Disease of the exocrine pancreas
Drug or chemical-induced
Gestational diabetes mellitusADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S12.
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Criteria for the diagnosis of diabetesFasting plasma glucose > 7.0 mmol/l (no caloric intake
for 8 h)
Repeat at interval of at least one week
OR
Two-hour plasma glucose > 11.1 mmol/l on OGTT
The test should be performed as described by the
WHO, using a glucose load containing the equivalent
of 75 g anhydrous glucose dissolved in water
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Criteria for the diagnosis of diabetes
In a patient with classic symptoms of hyperglycemia,
a random plasma glucose > 11.1 mmol/L
OR
A1C > 6.5%
The test should be performed in a laboratory using an
NGSP-certified method standardized to the DCCT
assay
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. .
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Criteria for the diagnosis of Pre-diabetes
Pre-diabetes: Categories of increased risk for
diabetes
IFG : FPG 5.6-6.9 mmol/l
Or
IGT : 2-h plasma glucose in the OGTT 7.8-11.0 mmol/l
Or
A1C : 5.7-6.4 %
ADA. I. Classification and Diagnosis. Diabetes Care 2011;34(suppl 1):S13. .
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Criteria for Testing for diabetes in asymptomatic adult individuals
Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors:
• A1C ≥5.7%, IGT or IGF on previous
testing
• HDL cholesterol level 0.90 mmol/l
and /or a triglyceride level ≥ 2.82
mmol/l
• First degree relative with diabetes
• Hypertension (≥140/90 mmHg or on
therapy for hypertension)
• CVD history
• Physical inactivity
• Women who delivered a baby
weighing > 9lb or were diagnosed
with GDM
• Women with polycystic ovarian
syndrome(PCOS)
• Other clinical conditions
associated with insulin resistance
(e.g. severe obesity, acanthosis
nigricans)
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Criteria for Testing for diabetes in asymptomatic adult individuals
In the absence of risk factors testing for diabetes
should begin at age of 45 years
If results are normal, testing should be repeated
at least at 3 years intervals, with consideration
of more frequent testing depending on initials
results and risk status
ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.
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Diagnosis of GDM
Screen for undiagnosed type 2 diabetes at
the first prenatal visit in those with risk
factors, using standard diagnostic criteria
In pregnant women not previously known to
have diabetes, screen for GDM at 24-28
weeks gestation, using 75-g OGTT.
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Diagnosis of GDMPerform a 75-g OGTT at 24-48 weeks gestation in
the morning and collect three samples after an
overnight fast of at least 8 h
GDM diagnosis: when any of the following plasma
glucose values are exceeded
Fasting 5.1 mmol/l
1 h 10.0 mmol/l
2 h 8.5 mmol/l
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Screening & Diagnosis of Diabetes
Screen women with GDM for persistent
diabetes 6-12 weeks postpartum
Women with a history of GDM should have
lifelong screening for the development of
diabetes or prediabetes at least every three
years
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DIABETES CARE
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Diabetes care: Initial Evaluation
A complete medical evaluation should be
performed to
Classify the diabetes
Detect presence of diabetes complications
Review previous treatment, glycemic control in
patients with established diabetes
Perform laboratory tests necessary to evaluate
each patient’s medical condition
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Diabetes care: Initial Evaluation
Medication history
Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding)
Eating patterns, physical activity habits, nutritional status and weight history; growth and development in children and adolescents
Diabetes education history
Review of previous treatment regimens and response to therapy (HbA1c records)
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Diabetes care: Initial Evaluation
Current treatment if diabetes, including
medications, meal plan, physical activity patterns
and results of glucose monitoring and patients
used of data
DKA frequency, severity and cause
Hypoglycemic episodes
Hypoglycemia awareness
Any severe hypoglycemia: frequency and cause
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Diabetes care: Initial Evaluation
History of diabetes-related complications
Microvascular: retinopathy, nephropathy, neuropathy
Sensory neuropathy, including history of foot lesions
autonomic neuropathy, including sexual dysfunction and
gastroparesis
Macrovascular: CHD, cerebrovascular disease, PAD
Other: psychosocial problems, dental disease
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Diabetes care: Initial Evaluation
Physical examination
Height, weight, MBI
Blood pressure determination
Fundoscopic examination
Thyroid palpation
Skin examination (for acanthosis nigricans and
insulin injection sites)
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Diabetes care: Initial Evaluation
Physical examination (2)
Comprehensive foot examination
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/ absence of patellar and achilles reflexes
Determination of proprioception, vibration and
monofilament sensation
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Comprehensive diabetes evaluation
Laboratory evaluation
Blood glucose fasting
A1C, if results not available with in past 2-3 months
Fasting lipid profile, including total, LDL-and HDL-
cholesterol and triglycerides
Liver function tests
Spot urine albumin/ creatinine ratio
Serum creatinine and calculated GFR
TSH in type 1 diabetes, dyslipidemia or women > 50 years
of age
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Glucose monitoring
Self-monitoring of blood glucose should be carried
out 3+ times daily for patients using multiple insulin
injections or insulin pump therapy
For patients using less frequent insulin injections,
noninsulin therapy, or medical nutrition therapy aloneSMBG may be useful as a guide to success of therapy
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Glucose Monitoring
Ancient method Modern method
“The past is a foreign country; they do things differently there.” Leslie Poles Hartley
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• Home blood glucose meters measure the glucose in whole blood, while most lab tests measure the glucose in plasma
• Plasma glucose levels are generally 10%–15% higher than glucose measurements in whole blood
• Most of the modern meters on the market give results as "plasma equivalent," even though they are measuring whole blood glucose
• Sample sizes vary from 30 to 0.3 μl
• Test times vary from 5 seconds to 2 minutes
Glucose monitoring
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CGMSContinuous Glucose Monitoring System
• Test glucose in the IF
• Every few minutes for up
to 7 days alarm system
warns if glucose rapidly
changes real time results
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Glucose monitoring - CGMS
• By analyzing the trends, the patient or the physician can adjust insulin
• Leads to better glycemic control
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Benefits of CGMS
• Increased security from
alarms & alerts Immediate
feedback - look and learn
• BG trend provides more
information than static
readings
• Control + safety
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Limitations of CGMS* Interference with glucose readings by sensor can
occur with certain substances i.e.gluthatione, ascorbic acid, uric acid, salicylates – can cause co-
oxidation, which will lead to overestimation of glucose levels
Lag-time for up to 15 minutes when glucose changes rapidly
Overall percentage of error – near 15%• Guardian REAL-Time – 17%• DexCom - 11-16%• Navigator 12-14%
* E. Cenzic, MD and William tamboriane, MD. A Tale of Two Compartments: Interstitial Versus Blood Glucose Monitoring. DIABETES TECHNOLOGY & THERAPEUTICS. Volume 11, September 2009.
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Glucose Monitoring - CGMS
Abbott FreeStyle Navigator®
DexCom™ SEVEN® PLUS
Medtronic MiniMed Paradigm® REAL-Time
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Insulin Delivery Modes Insulin Pens/Devices
•Ease of handling•More discrete use
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Insulin Delivery Modes Jet Injectors
• sends insulin through the skin , using high pressure mechanism• an option for people with severe needle phobia
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Insulin Delivery Modes Insulin Pumps
•provide continues insulin delivery
•infusion site needs to be changed only every 2-3 days
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Pump AdvantagesMore reliable, precise insulin action
Fewer missed doses
Less insulin stacking
Fewer lows, especially at night
Easier to exercise
Less glucose exposure and variability
Less insulin
Matches variable basal insulin need
Fewer social limitations
Better data access for providers and patients
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“Prediction is very difficult, especially about the future”.
Niels BohrFuture
Pump technology continues to advance
On the horizon:
Pumping and monitoring by cell phone
Cooler styles
Smaller sizes
Improved human interface
More helpful data analysis
Gradual progress toward a closed loop
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Non-invasive Continuous Blood Glucose MonitorOrSense’s NBM-200GA highly sensitive optical system, using an array of calibrated
light sources, measures light absorption and scattering. The desktop monitor calculates the glucose level and displays the results.Exhibits comparable accuracy to invasive solutions, while
providing superior ease of use and safetyTested on over 450 subjectsAt this stage, the NBM 200G glucose monitor is utilized for
investigation and market awareness purpose only.
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Glycemic Recommendations for Adults with DiabetesGoals should be individualized based on
Duration of diabetes
Age/life expectancy
Co-morbid conditions
Known CVD or advanced micro-vascular complications
Hypoglycemic unawareness
Individual patient consideration
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
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A1C Recommendation
Perform A1C test at least twice yearly in patients
meeting treatment goals
Perform A1C test quarterly in patients whose
therapy has changed or who are not meeting
glycemic goals
Lowering A1C to below or around 7% is
recommended: shown to reduce macrovascular and
neuropathic complications of diabetes
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Correlation of A1C with estimated average glucose (eAG)
The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results into estimated average glucose (eAG), in mmol/l, is available at http://professional.diabetes.org/GlucoseCalculator.aspx.
A1C (%)Mean plasma glucose
mmol/l
6 7.0
7 8.6
8 10.2
9 11.8
10 13.4
11 14.9
12 16.5
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Recommendations: Glycemic , blood, pressure, lipid control in adultsA1C < 7.0%
Blood pressure < 130/80 mmHg*
LDL cholesterol < 2.6 mmol*
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S31. Table 12.
*More or less stringent glycemic goals may be appropriate for individual patients. Goals should be individualized based on: duration of diabetes, age/life expectancy, comorbid conditions, known CVD or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.†Based on patient characteristics and response to therapy, higher or lower systolic blood pressure targets may be appropriate.‡In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dl (1.8 mmol/l), using a high dose of statin, is an option.
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Waist Circumference Greater than 35 inches in women and 40 inches in men (abdominal obesity)
Triglyceride Levels of 150 milligrams per deciliter (mg/dl) or higher
Blood Pressure 130/85 millimeters of mercury or higher
Fasting blood glucose Level of 110 mg/dl or higher
High-density lipoprotein cholesterol (HDL) Lower than 50 mg/dl in women and 40 mg/dl for men
Diagnosing Metabolic SyndromeAccording to the National Cholesterol Education Program (NCEP), the presence of three or more of the following traits indicates metabolic syndrome:
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Cardiometabolic risk*
Gelfand EV et al, 2006; Vasudevan AR et al, 2005
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Treatment
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PREVENTION AND MANAGEMENT OF DIABETES COMPLICATION
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Progression of diabetesDiagnosis of
diabetes
Appearance of complications
Disability
•Genetic susceptibility•Environmental factors
• Nutrition• Obesity• inactivity
Death•Insulin resistance IGT Ongoing hyperglycaemia•HDL C •Triglycerides - Hyperglycaemia -Retinopathy -Blindness•Atherosclerosis -Nephropathy -ESRD/dialysis/transplantation•Hypertension -CHD
-Stroke- PPG levels -Amputation
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Cardiovascular disease (CVD) in individuals with diabetesCVD is a major cause of morbidity, mortality for
those with diabetes
Common conditions coexisting with type 2 diabetes (e.g., hypertension, dyslipidemia) are clear risk factors for CVD
Diabetes itself confers independent risk
Benefits observed when individual cardiovascular risk factors are controlled to prevent/slow CVD in people with diabetes
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
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Recommendations: Hypertension / Blood pressure controlScreening and diagnosis
Measure blood pressure at every routine diabetes visit
If patients have systolic blood pressure≥130 mmHg or diastolic blood pressure ≥80 mmHgConfirm blood pressure on a separate dayRepeat systolic blood pressure ≥130 mmHg or diastolic
blood pressure ≥80 confirms a diagnosis of hypertension (C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
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Recommendations: Hypertension / Blood pressure control
Goals
A goal systolic blood pressure <130 mmHg is appropriate
for most patients with diabetes ©
Based on patient characteristics and response to therapy,
higher or lower systolic blood pressure targets may be
appropriate (B)
Patients with diabetes should be treated to a diastolic
blood pressure <80 mmHg (B)ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
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Recommendations: Hypertension / Blood pressure control
Treatment (1)
Patients with a systolic blood pressure 130–139
mmHg or a diastolic blood pressure 80–89 mmHg
May be given lifestyle therapy alone for a maximum of 3
months
If targets are not achieved, patients should be treated
with the addition of pharmacological agents
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
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Recommendations: Hypertension / Blood pressure control
Treatment (2)
Patients with more severe hypertension (systolic
blood pressure ≥140 mmHg or diastolic blood
pressure ≥90 mmHg) at diagnosis or follow-upShould receive pharmacologic therapy in addition to
lifestyle therapy (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
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Recommendations: Hypertension / Blood pressure control
Treatment (3)Pharmacologic therapy for patients with diabetes and
hypertensionPair with a regimen that includes either an ACE inhibitor or
angiotensin II receptor blocker
If one class is not tolerated, the other should be substituted
If needed to achieve blood pressure targetsThiazide diuretic should be added to those with estimated GFR
≥30 ml x min/1.73 m2
Loop diuretic for those with an estimated GFR <30 ml x min/1.73 m2
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S27.
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Recommendations: Dyslipidemia/ lipid management
Screening
In most adult patients
Measure fasting lipid profile at least annually
In adults with low-risk lipid values (LDL
cholesterol <100 mg/dl, HDL cholesterol >50
mg/dl, and triglycerides <150 mg/dl)
Lipid assessments may be repeated every 2 years
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
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Recommendations: Dyslipidemia/ lipid management Treatment recommendations and goals (1)
To improve lipid profile in patients with diabetes, recommend lifestyle modification (A), focusing onReduction of saturated fat, trans fat, cholesterol intake
Increased n-3 fatty acids, viscous fiber
Weight loss (if indicated)
Increased physical activity
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
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Recommendations: Dyslipidemia/ lipid management
Treatment recommendations and goals (2)
Statin therapy should be added to lifestyle
therapy, regardless of baseline lipid levels, for
diabetic patients:
with overt CVD (A)
without CVD who are >40 years of age and have one
or more other CVD risk factors (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
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Recommendations: Dyslipidemia/ lipid management
Treatment recommendations and goals (3)
For patients at lower risk (e.g., without overt CVD
and <40 years of age) (E)
Statin therapy should be considered in addition
to lifestyle therapy if LDL cholesterol remains
>100 mg/dl
In those with multiple CVD risk factorsADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
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Recommendations: Dyslipidemia/ lipid management
Treatment recommendations and goals (4)
In individuals without overt CVD
Primary goal is an LDL cholesterol
<100 mg/dl (2.6 mmol/l) (A)
In individuals with overt CVD
Lower LDL cholesterol goal of <70 mg/dl
(1.8 mmol/l), using a high dose of a statin, is an option
(B)ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
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Recommendations: Dyslipidemia/ lipid management Treatment recommendations and goals (5)
If targets not reached on maximal tolerated statin therapyAlternative therapeutic goal: reduce LDL cholesterol
~30–40% from baseline (A)Triglyceride levels <150 mg/dl (1.7 mmol/l), HDL
cholesterol >40 mg/dl (1.0 mmol/l) in men and >50 mg/dl (1.3 mmol/l) in women, are desirableHowever, LDL cholesterol–targeted statin therapy
remains the preferred strategy (C)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
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Recommendations: Dyslipidemia/ lipid management If targets are not reached on maximally tolerated
doses of statins
Combination therapy using statins and other lipid lowering agents may be considered to achieve lipid targets
Has not been evaluated in outcome studies for either CVD outcomes or safety
Statin therapy is contraindicated in pregnancy
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Recommendations: Coronary heart disease screening
In asymptomatic patients, routine screening
for CAD is not recommended, as it does not
improve outcomes as long as CVD risk
factors are treated (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S32.
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Recommendations: Coronary heart disease treatment (1) To reduce risk of cardiovascular events in patients
with known CVD, useACE inhibitor* Aspirin* Statin therapy*
In patients with a prior MIBeta-blockers should be continued for at least 2
years after the event
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S32.
* If not contraindicated
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Recommendations: Nephropathy
To reduce risk or slow the progression of
nephropathy
Optimize glucose control (A)
Optimize blood pressure control (A)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
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Recommendations: Nephropathy ScreeningAssess urine albumin excretion annually
In type 1 diabetic patients with diabetes duration of 5 years
In all type 2 diabetic patients at diagnosisMeasure serum creatinine at least annually
In all adults with diabetes regardless of degree of urine albumin excretion
Serum creatinine should be used to estimate GFR and stage level of chronic kidney disease, if present
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
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Recommendations: Nephropathy Treatment (1)
Nonpregnant patient with micro-or
macroalbuminuria
Either ACE inhibitors or ARBs should be
used
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
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Recommendations: Nephropathy Treatment (2)In patients with type 1 diabetes, hypertension, and
any degree of albuminuria
ACE inhibitors have been shown to delay progression of nephropathy
In patients with type 2 diabetes, hypertension, and microalbuminuria
Both ACE inhibitors and ARBs have been shown to delay progression to macroalbuminuria
ADA. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
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Recommendations: Nephropathy Treatment (3)In patients with type 2 diabetes, hypertension,
macroalbuminuria, and renal insufficiency (serum
creatinine >1.5 mg/dl)
ARBs have been shown to delay progression of
nephropathy
If one class is not tolerated, the other should be
substituted
ADA. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
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Recommendations: Nephropathy Treatment (4)Reduction of protein intake may improve measures of
renal function (urine albumin excretion rate, GFR) (B)
To 0.8 –1.0 g x kg body wt–1 x day–1 in those with
diabetes, earlier stages of CKD
To 0.8 g x kg body wt–1 x day–1 in later stages of CKD
When ACE inhibitors, ARBs, or diuretics are used,
monitor serum creatinine, potassium levels for
development of acute kidney disease, hyperkalemia ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S33.
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Recommendations: Nephropathy Treatment (5)Continue monitoring urine albumin excretion to assess
both response to therapy, disease progression (E)
When eGFR <60 ml/min/1.73 m2, evaluate, manage
potential complications of CKD (E)
Consider referral to a physician experienced in care of
kidney disease (B)Uncertainty about etiology of kidney diseaseDifficult management issues Advanced kidney disease
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Definitions of abnormalities in albumin excretionCategory Spot collection (µg/mg
creatinine)
Normal < 30
Microalbuminuria 30-299
Macroalbuminuria ≥ 300
(clinical)
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Management of CKD in diabetes (1)
GFR (ml/min/1.73 m2) Recommended
All patients Yearly measurement of creatinine, urinary albumin excretion, potassium
45-60 Referral to nephrology if possibility for nondiabetic kidney disease existsConsider dose adjustment of medications Monitor eGFR every 6 months Monitor electrolytes, bicarbonate, hemoglobin, calcium, phosphorus, parathyroid hormone at least yearlyAssure vitamin D sufficiency Consider bone density testingReferral for dietary counseling
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35. Table 15; Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.
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Management of CKD in diabetes (2)
GFR (ml/min/1.73 m2) Recommended
30-44 Monitor eGFR every 3 months Monitor electrolytes, bicarbonate, calcium, phosphorus, parathyroid hormone, hemoglobin, albumin weight every 3-6 months Consider need for dose adjustment of medications Referral for dietary counseling
45-60 Referral to nephrologist
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35. Table 15; Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.
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Recommendations: Retinopathy
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35. Table 15; Adapted from http://www.kidney.org/professionals/KDOQI/guideline_diabetes/.
To reduce risk or slow progression of retinopathy
Optimized glycemic control (A)
Optimize blood pressure control (A)
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Recommendations: Retinopathy screening (1)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
Initial dilated and comprehensive eye examination
by an ophthalmologist or optometrist
Adults and children aged 10 years or older with
type 1 diabetes
Within 5 years after diabetes onset
Patients with type 2 diabetes
Shortly after the diagnosis of diabetes
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Recommendations: Retinopathy screening (3)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S35.
High-quality fundus photographs
Can detect most clinically significant diabetic retinopathy
Interpretation of the images
Performed by a trained eye care provider
While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam
Perform comprehensive eye exam at least initially and at intervals thereafter as recommended by an eye care professional
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Recommendations: Neuropathy screening, treatment (1)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S36.
All patients should be screened for distal symmetric polyneuropathy (DPN)
At diagnosis
At least annually thereafter using simple clinical tests
Electrophysiological testing rarely needed
Except in situations where clinical features are typical
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Recommendations: Neuropathy screening, treatment (2)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S36.
Screening for signs and symptoms of cardiovascular autonomic neuropathy
Should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes
Special testing rarely needed; may not affect management or outcomes (E)
Medications for relief of specific symptoms related to DPN, autonomic neuropathy are recommended
Improve quality of life of the patient (E)
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Recommendations: Foot Care (1)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S37.
For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputationsInspectionAssessment of foot pulsesTest for loss of protective sensation: 10-g
monofilament plus testing any one ofVibration using 128-Hz tuning forkPinprick sensationAnkle reflexesVibration perception threshold (B)
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Recommendations: Foot Care (2)
Boulton AJM, et al. Diabetes Care. 2008;31:1679-1685.
Upper panelTo perform the 10-g
monofilament test, place the device perpendicular to the skin, with pressure applied until the monofilament buckles
Hold in place for 1 second and then release
Lower panelThe monofilament test should be
performed at the highlighted sites while the patient’s eyes are closed
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Recommendations: Foot Care (3)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S37.
Provide general foot self-care education
All patients with diabetes
Use multidisciplinary approach
Individuals with foot ulcers, high-risk feet; especially prior ulcer or amputation
Refer patients to foot care specialists for ongoing preventive care, life-long surveillance
Smokers
Loss of protective sensation or structural abnormalities
History of prior lower-extremity complications
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Recommendations: Foot Care (4)
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S37.
Initial screening for peripheral arterial disease (PAD)
Include a history for claudication, assessment of pedal
pulses
Consider obtaining an ankle-brachial index (ABI); many
patients with PAD are asymptomatic (C)
Refer patients with significant claudication or a positive
ABI for further vascular assessment
Consider exercise, medications, surgical options (C)
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Recommendations: Diabetes care in the hospital
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
All patients with diabetes admitted to the hospital
should have
Their diabetes clearly identified in the medical
record
An order for blood glucose monitoring, with
results available to the health care team
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Recommendations: Diabetes care in the hospital (2)
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
Goals for blood glucose levels
Critically ill patients: 140-180 mg/dl
(10 mmol/l) (A)
More stringent goals, such as 110-140 mg/dl (6.1-7.8
mmol/l) may be appropriate for selected patients, if
achievable without significant hypoglycemia (C)
Non-critically ill patients: base goals on glycemic control,
severe comorbidities (E)
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Recommendations: Diabetes care in the hospital (3)
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
Scheduled subcutaneous insulin with basal, nutritional,
correction components
Use correction dose or “supplemental insulin” to correct
premeal hyperglycemia in addition to scheduled
prandial and basal insulin
Initiate glucose monitoring in any patients not known to
be diabetic who receives therapy associated with high
risk for hyperglycemia
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Recommendations: Diabetes care in the hospital (4)
ADA. VIII. Diabetes Care in Specific Settings. Diabetes Care. 2011;34(suppl 1):S43.
A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital systemEstablish a plan for treating hypoglycemia for each patient;
document episodes of hypoglycemia in medical record and track
Obtain A1C for all patients if results within previous 2-3 months unavailable
Patients with hyperglycemia who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge