Approach to Newly Diagnosed T2DM -

Looking at ADA Statement 2014

DR SITI AISYAH ABD MAJIDFAMILY MEDICINE TRAINEE, PPUKM

T2DM: Global Burden• 347 million people worldwide have diabetes.

• In 2004, an estimated 3.4 million people died from consequences of high fasting blood sugar.

• More than 80% of diabetes deaths occur in low- and middle-income countries.

• WHO projects that diabetes will be the 7th leading cause of death in 2030.

• Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of type 2 diabetes.

WHO (2013)

Risk Factors

American Diabetes Association (ADA) 2014: Clinical Practice Recommendations 2014

Case Discussion

• AH is a 43-year-old Malay man, was recently diagnosed to have T2DM after presented with typical osmotic symptoms of polydipsia and polyuria for 6 months duration. He has comorbid conditions of hypertension, morbid obesity and tobacco use as well as strong family history of DM.

Current measurements include:

BP 132/80, PR 78 bpm

BMI 42.8

HbA1C - 7.4%

Total cholesterol - 6.2 mmol/L

LDL Cholesterol – 2.8 mmol/L

HDL – 1.1 mmol/L

TG – 1.6 mmol/L

GFR>73

Urine albumin 1+

Medications are:

Perindopril 8mg daily

Metformin 1g bd

HCTZ 12.5 mg daily

Aspirin 75mg daily

• He has failed to lose weight & stop smoking, but does take her medications, check her blood sugars & see the ophthalmologist. He presents for follow up diabetes care.

Diagnosis

• The diagnosis of diabetes requires one of the following:

• A fasting glucose ≥ 126 mg/dL (> 7 mmol/L)

• A hemoglobin A1c level ≥ 6.5%

• A 75-gram 2-hour glucose level ≥ 200 mg/dL, or

• A random glucose level > 200 mg/dL (> 11.1

mmol/L) in a markedly symptomatic patient

<7% (ADA) for prevention of microvascular disease –level A

<6.5 % (ACCE) level D- but must be formulated in context of individual patient’s life expectancy, comorbid conditions, presence or absence of micro and macrovascular complications, overall cardiovascular risk factors and risk for severe hypoglycemia.

Goal of A1C 7-8% for those with severe hypoglycemia, limited life expectancy, advanced micro or macrovascular disease, extensive comorbid conditions, long-standing disease uncontrolled despite extensive effort –Level A

Goals for Type 2 DiabeticsHbA1C

Glucose Monitoring

• Continuous glucose monitoring was added on top of SMBG as a part of glucose monitoring.

• supplemental tool to SMBG in pts with hypoglycaemia unawareness and/or frequent hypoglycaemic episodes.

• CGM use is associated with HbA1c lowering by ~0.26%.

• ASPIRE trial – CGM reduced nocturnal hypoglycaemia without increasing HbA1c level and reduced severe hypoglycaemia for those with h/o nocturnal hypoglycaemia.

• BP <140/80 with use of DASH diet-low sodium, counseling by nutritionist, level A for DASH diet, use of ACE/ARB as primary agents for reduction of BP.

• For reduction in cardiovascular events, use of ACEi, ARB, ARBs, beta blockers, diuretics & CCB is beneficial.

Blood Pressure Control

LDL < 2.6 mmol/L (without overt CVD), < 1.8 mmol/L (with overt CVD).

TG < 1.7 mmol/L

HDL < 1.0 mmol/L (men), < 1.3 mmol/L (women)

Lifestyle modification – reduced saturated fat, trans fat & cholesterol intake; increase n-3 fatty acids, viscious fibre & plant sterols; wt loss, increased physical activity. Level A

Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for DM pts:

With overt CVD

Without CVD + 40 y/o + >1 CVD risk factors

Goals for Lipids

Pharmacological Therapy

• Pharmacological Therapy for Hyperglycemia in Type 2 Diabetes was changed from 3–6 months to 3 months for a trial with non-insulin monotherapy.

Medical Nutrition Therapy

• Medical Nutrition Therapy was revised to reflect the updated position statement on nutrition therapy for adults with diabetes.

• Comprehensive group diabetes education programmes including nutrition therapy have reported HbA1c decrease by 0.5-2.0% in T2DM.

• Weight loss of 2-8kg in T2DM pt:

• Increase HDL-C

• Decrease TG

• Decrease BP

• Some eating pattern have been shown to be effective in managing DM eg Mediterranean style, DASH- style (Dietary Approaches to Stop HPT), vegetarian and lower-carbohydrates pattern.

• Cochrane review – decreasing Na intake reduces BP in those with DM. DM pt needs further reduction in Na intake compared to general population. Recommendation for general population <2,300mg/day.

Smoking cessation

• Addition of pharmacological therapy to counselling is more effective than treatment alone.

• Recent research demonstrated that initial wt gain following smoking cessation does not diminish the substantial CVD risk benefit realized from smoking cessation.

Macrovascular

• Cardiovascular disease-coronary, peripheral, carotid, cerebrovascular

Microvascular

• Nephropathy

• Retinopathy

• Neuropathy

Depression

Sleep Apnea

Evaluation for Complications

CVD & Antiplatelet agents

• Antiplatelet Agents was revised to recommend more general therapy .

• Use aspirin therapy as a secondary prevention strategy in those with a h/o CVD.

• If allergy to aspirin, clopidogrel should be used.

• Dual antiplatlet therapy is reasonable for up to a year after an ACS.

• Benefit of using aspirin in primary prevention among pts with no previous CV events is more controversial, both for pts with and without a history of DM.

Nephropathy

• Nephropathy was revised to remove terms “microalbuminuria” and “macroalbuminuria,” which were replaced with:

• “albuminuria 30–299 mg/24 h” (previously microalbuminuria), and;

• “albuminuria ≥300 mg/24 h” (previously macroalbuminuria).

• Optimize glucose & BP control to reduce risk or slow the progression of nephropathy.

• Annual test to quantify urine albumin excretion in T2DM should be performed starting at Dx.

• Measurement of eGFR from serum creatinine.

Retinopathy

• Retinopathy was revised to recommend exams every 2 years versus 2–3 years, if no retinopathy is present.

• If retinopathy is present, subsequent examination should be repeated annually by ophthalmologist or optometrist.

• Optimize glucose & BP control to reduce risk or slow the progression of nephropathy.

Neuropathy

• Neuropathy was revised to provide more descriptive treatment options for neuropathic pain.

• May present as distal symmetric polyneuropathy (DSN), diabetic autonomic neuropathy (DAN), cardiovascular autonomic neuropathy (CAN), GI neuropathy & genitourinary tract neuropathy.

• Glycemic control – tight & stable.

• An intensive CV risk intervention (glucose, BP, lipids, smoking, lifestyle) has been shown to reduce the progression & development of CAN among pt with T2DM.

• Use of metoclopramide (Maxolon®) in presence of gastroparesis Sx to be reserved to only severe cases that are unresponsive to other therapies. Extrapyramidal effects should be monitored.

• ED – PDE type 5 inhibitors, intracorporeal or intraurethral prostaglandin, vacuum devices or penile prostheses. However, they do not change natural history of disease process, but improve pt’s QOL.

Hospital Care• Diabetes Care in the Hospital was updated to

discourage the sole use of sliding scale insulin in non-critically ill patient.

Foot Care

• Increased risk of foot ulcers & amputation is seen in:

• Previuos h/o amputation

• Past foot ulcer hx

• Peripheral neuropathy

• Foot deformity eg hammertoes, prominent metatarsal head, bunions, Charcot joint

• Peripheral vascular disease

• Diabetic nephropathy esp on dialysis

• Poor glycemic control

• Cigarette smoking

Other Common Comorbid Conditions

COMORBIDITIES NOTES

Depression Highly prevalent in DM and has worse outcome. Assessment is recommended in DM (geriatric depression scale, DASS).

OSA Prevalence DM with OSA is 23%. Rx significantly improves QOL and BP control.

Fatty liver Intervention that improve metabolic abnormalities are beneficial.

COMORBIDITIES NOTES

Cancer T2DM increased risk of cancer (liver, pancreas, endometrium, colon, breast & bladder). Cancer screening and reduction in modifiable cancer risk factors (obesity, smoking, physical inactivity) are encouraged.

Fractures BMD test is recommended. Avoid thiazolidinediones.

Cognitive Impairment Increased risk of dementia.

Periodontal assessment Periodontal disease is more severe in DM pt. Referral to dentist is beneficial.

Hearing impairment NHANES analysis – 2x risk in diabetics compared to non-diabetics.

T2DM: Summary of Revisions to the ADA 2014 Clinical Practice

Recommendations • Diagnosis of Diabetes was clarified to note that A1C is one

of three available methods to diagnose diabetes.

• Glucose Monitoring was revised to add additional continuous glucose monitoring language, reflecting the recent approval of a sensor-augmented low glucose suspend threshold pump for those with frequent nocturnal hypoglycemia and/or hypoglycemia unawareness.

• Pharmacological Therapy for Hyperglycemia in Type 2 Diabetes was changed from 3–6 months to 3 months for a trial with noninsulin monotherapy.

• Medical Nutrition Therapy was revised to reflect the updated position statement on nutrition therapy for adults with diabetes.

• Antiplatelet Agents was revised to recommend more general therapy (i.e., dual antiplatelet therapy versus combination therapy with aspirin and clopidogrel).

• Nephropathy was revised to remove terms “microalbuminuria” and “macroalbuminuria,” which were replaced with albuminuria 30–299 mg/24 h (previously microalbuminuria) and albuminuria ≥300 mg/24 h (previously macroalbuminuria).

• Retinopathy was revised to recommend exams every 2 years versus 2–3 years, if no retinopathy is present.

• Neuropathy was revised to provide more descriptive treatment options for neuropathic pain.

• Diabetes Care in the Hospital was updated to discourage the sole use of sliding scale insulin in the inpatient hospital setting.

THANK YOU