diabetes slides 4-21-15

8/20/2019 Diabetes Slides 4-21-15

http://slidepdf.com/reader/full/diabetes-slides-4-21-15 1/72

Copyrig t © 2015 AACE.May not be reprinted in any form without express written permission from

ENDOCRINE PRACTICE Vol 21 No. 4 April 2015

mer can ssoc a on oCinica Endocrinoogists and

American Coege of

Endocrinoogy Cinica!ractice "uideines for#e$eoping a #iabetes

Meitus Comprehensi$e Care!anWriting Committee Cochirper!on!

%ehuda &andesman M#' (AC!' (ACE' ()*A

+achary ,. -oomgarden' M#' MACE

"eorge "runberger' M#' (AC!' (ACE"uiermo mpierre/' M#' (AC!' (ACE

obert . +immerman' M#' (ACE

1




AACE Cinica !ractice "uideines for#iabetes Meitus riting Committee

,as3 (orce

2

Timothy S. Bailey, MD, FACP, FACE, ECNU

Lawrence Blonde MD, FACP, FACE

Geore A. Bray, MD, MACP, MACE

A. !ay Cohen MD, FACE, FAAP

Sam"el Daoo#!ac$, MD, DM, F%CP,

FACE !aime A. Da&id'on, MD, FACP, MACE

Daniel Einhorn, MD, FACP, FACE

(m P. Ganda, MD, FACE

Alan !. Gar)er, MD, PhD, FACE

*. Timothy Gar&ey, MD

%o)ert %. +enry, MDrl B. +ir'ch, MD

Edward S. +orton, MD, FACP, FACE

Daniel L. +"rley, MD, FACE

Pa"l S. !elliner, MD, MACE

Loi' !o&ano&i-, MD, MACE

+arold E. Le)o&it, MD, FACE

Dere$ Le%oith, MD, PhD, FACE

Phili/ Le&y, MD, MACE

!anet B. McGill, MD, MA, FACE

!e0rey . Mechanic$, MD, FACP, FACE,

FACN, ECNU !ore +. Me'tman, MD

Etie S. Mohi''i, MD, FACP, FACE

Eric A. (rec$, MD, FACP, FACE

Pa"l D. %o'en)lit, MD, PhD, FACE, FNLA

Aaron . 1ini$, MD, PhD, FCP, MACP, FACE

2athleen *yne, MD, PhD, FNLA, FACEFarhad 3aneneh, MD, FACP, FACE

Reviewers

Lawrence Blonde MD, FACP, FACE

Alan !. Gar)er, MD, PhD, FACE




AACE #M C!" 4becti$esand tructure

,his C!" aims to pro$ide the foowing6An e$idence7based education resource for the

de$eopment of a diabetes comprehensi$e care

panEasy7to7foow structure 28 diabetes management 9uestions

:; practica recommendations

Concise' practica format that compementsexisting #M textboo3s

A document suitabe for eectronicimpementation to assist with cinica decision7

ma3ing for patients with #M<




AACE #M C!"E$idence atings and "rades

8

E"i#encele"el

E"i#encegr#e

$emntic #e!criptor

1 A Meta7anaysis of randomi/ed controed trias =MC,>

1 A andomi/ed controed trias =C,>

2 -Meta7anaysis of nonrandomi/ed prospecti$e or case7controedtrias =M)C,>

2 - )onrandomi/ed controed tria =)C,>

2 - !rospecti$e cohort study =!C>

2 - etrospecti$e case7contro study =CC>

< C Cross7sectiona study =C>

< C

ur$eiance study =registries' sur$eys' epidemioogic study'

retrospecti$e chart re$iew' mathematica modeing of database>=>

< C Consecuti$e case series =CC>

< C inge case reports =C>

8 #)o e$idence =theory' opinion' consensus' re$iew' or precinicastudy> =)E>




AACE #M C!" ?uestions1. &ow is diabetes screened and

diagnosed@

2. &ow is prediabetes managed@

<. hat are gycemic treatmentgoas of #M@

8. &ow are gycemic targetsachie$ed for ,2#@

5. &ow shoud gycemia in ,1# bemanaged@

:. &ow is hypogycemia managed@

;. &ow is hypertension managed in

patients with diabetes@

. &ow is dysipidemia managed inpatients with diabetes@

B. &ow is nephropathy managed inpatients with diabetes@

10. &ow is retinopathy managed in

patients with diabetes@11. &ow is neuropathy diagnosed and

managed in patients withdiabetes@

12. &ow is C# managed in patientswith diabetes@

1<. &ow is obesity managed inpatients with diabetes@

Contin"ed on ne4t 'lide5




AACE #M C!" ?uestions18. hat is the roe of seep medicine

in the care of the patient withdiabetes@

15. &ow is diabetes managed in thehospita@

1:. &ow is a comprehensi$e diabetescare pan estabished in chidrenand adoescents@

1;. &ow shoud diabetes in pregnancybe managed@

1. hen and how shoud gucose

monitoring be used@1B. hen and how shoud insuin

pump therapy be used@

20. hat is the imperati$e foreducation and team approach in#M management@

21. hat $accinations shoud begi$en to patients with diabetes@

22. &ow shoud depression bemanaged in the context ofdiabetes@

2<. hat is the association betweendiabetes and cancer@

28. hich occupations ha$e speciDc

diabetes managementre9uirements@

Contin"ed 5rom /re&io"' 'lide:




• Age 85 years without other ris3factors

• (amiy history of ,2#• C#• 4$erweight

• -MF <0 3gGm2

• -MF 2572B.B 3gGm2 pus other ris3factorsH

• edentary ifestye• Member of an at7ris3 racia or ethnic

group6 Asian' African American'&ispanic' )ati$e American' and !aciDcFsander

• #ysipidemia• &#*7C I<5 mgGd*• ,rigycerides J250 mgGd*

• F",' F("' andGor metaboic syndrome• !C4' acanthosis nigricans' )A(*#• &ypertension =-! J180GB0 mm &g or

therapy for hypertension>• &istory of gestationa diabetes or

dei$ery of a baby weighing more than8 3g =B b>

• Antipsychotic therapy for schi/ophreniaandGor se$ere bipoar disease

• Chronic gucocorticoid exposure• eep disordersK in the presence of

gucose intoerance

• creen at7ris3 indi$iduas with gucose $aues in the norma range e$ery < years• Consider annua screening for patients with 2 or more ris3 factors

Criteria for creening for ,2# and!rediabetes in Asymptomatic Aduts

;

HAt7ris3 -MF may be ower in some ethnic groupsL consider using waist circumference.K4bstructi$e seep apnea' chronic seep depri$ation' and night shift occupations.-MF body mass indexL -! bood pressureL C#cardio$ascuar diseaseL &#*7C high density ipoproteinchoesteroL F(" impaired fasting gucoseL F", impaired gucose toeranceL )A(*# nonacohoic fatty i$er

diseaseL !C4 poycystic o$ary syndromeL ,2#' type 2 diabetes.

?1. &ow is diabetes screened and diagnosed@




#iagnostic Criteria for !rediabetesand #iabetes in )onpregnant Aduts

Norml %igh Ri!& 'or Di(ete! Di(ete!

(!" I100 mgGd*F("(!" 1007125 mgGd*

(!" 12: mgGd*

27h !" I180 mgGd*

F",

27h !" 18071BB mgGd*

27h !" 200 mgGd*

andom !" 200 mgGd* NsymptomsH

A1C I5.5O5.5 to :.8O(or screening ofprediabetesK

:.5OecondaryP

H!oydipsia =fre9uent thirst>' poyuria =fre9uent urination>' poyphagia =extremehunger>' burred $ision' wea3ness' unexpained weight oss.

KA1C shoud be used ony for screening prediabetes. ,he diagnosis ofprediabetes' which may manifest as either F(" or F",' shoud be conDrmed withgucose testing.

P"ucose criteria are preferred for the diagnosis of #M. Fn a cases' the diagnosisshoud be conDrmed on a separate day by repeating the gucose or A1C testing.hen A1C is used for diagnosis' foow7up gucose testing shoud be done when

possibe to hep manage #M.

(!"' fasting pasma gucoseL F("' impaired fasting gucoseL F",' impaired gucose toeranceL !"' pasma

gucose.





#iagnostic Criteria for"estationa #iabetes

Te!t $creen t 24)2* +ee&! ge!ttion

(!"' mgGd* JB2

17h !"H' mgGd* 10

27h !"H' mgGd* 15<

HMeasured with an 4",, performed 2 hours after ;57g ora gucose oad.

(!"' fasting pasma gucoseL 4",,' ora gucose toerance testL !"' pasma gucose.


B




AACE. Endocrine Pract . 2010;16:155-156.

AACE ecommendations forA1C ,estingA1C shoud be considered an additiona

optiona diagnostic criterion' not the primarycriterion for diagnosis of diabetes

hen feasibe' AACEGACE suggest usingtraditiona gucose criteria for diagnosis ofdiabetes

A1C is not recommended for diagnosing type

1 diabetesA1C is not recommended for diagnosing

gestationa diabetes

10





AACE ecommendations forA1C ,estingA1C e$es may be miseading in se$era ethnic

popuations =for exampe' African Americans>

A1C may be miseading in some cinica settings

&emogobinopathiesFron deDciency

&emoytic anemias

,haassemias

pherocytosise$ere hepatic or rena disease

AACEGACE endorse the use of ony standardi/ed'

$aidated assays for A1C testing

11

AACE. Endocrine Pract . 2010;16:155-156.





#iagnosing ,ype 1 #iabetes=,1#>suay characteri/ed by insuin deDciency and

dependency#ocument e$es of insuin and C7peptide

,est for autoantibodiesHFnsuin

"utamic acid decarboxyase

!ancreatic iset β ces =tyrosine phosphatase FA7

2>+inc transporter =+n,>

May occur in o$erweight or obese as we asean indi$iduas


idence of autoimmunity may be absent in idiopathic ,1#.12




0

2

4

6

8

10

12

4.8

7.8

11

,2# Fncidence in the #!!

1<

Intensive lifestyle

intervention*

(n=1079)

T 2 D M i n

c i d e

n c e

p e r 1 0 0 p e r s o n

- y e a r s

Placeo

(n=10!2)

Metfor"in

!#0 "$ %ID

(n=107&)

#!'

&1'

*Goal: 7% reduction in a!eline od" #ei$t trou$ lo#-calorie& lo#-'at diet and (150 )in#ee+ )oderate inten!it" e,erci!e.

& iaete! re/ention ro$ra); G& i)aired $luco!e tolerance; 2& t"e 2 diaete!.

3e!earc Grou. N Engl J Med . 2002;46:-40.

?2. &ow is prediabetes managed@




Medica and urgica Fnter$entionshown to #eay or !re$ent ,2#

18

2& t"e 2 diaete!.

1. 3e!earc Grou. N Engl J Med . 2002;46:-40. 2. -9 rial 3e!earc Grou. Lancet . 2002;5:2072-2077.

. e'rono 3A& et al. N Engl J Med. 2011;64:1104-15. 4. 3EA9 rial n/e!ti$ator!. Lancet . 2006;68:106-1105.

5. or$er!on & et al. Diabetes Care. 2004;27:155-161. 6. Gar/e" <& et al. Diabetes Care. 2014;7:12-21.

7. =o!tro) >& et al. N Engl J Med . 2004;51:268-26.

?2. &ow is prediabetes managed@

Inter"ention,ollo+)-p

Perio#Re#-ction in Ri!& o' T2D

P "l-e "! plce(o/

Antihperglcemicgent!

Metformin1 2. years <1O =PI0.001>

Acarbose2 <.< years 25O =P0.0015>

!iogita/one< 2.8 years ;2O =PI0.001>

osigita/one8 <.0 years :0O =PI0.0001>

Weight lo!!inter"ention!

4ristat5 8 years <;O =P0.00<2>

!hentermineGtopiramate:2 years ;BO =PI0.05>

-ariatric surgery; 10 years ;5O =PI0.001>

i'e!tle mo#iction !ho-l# (e -!e# +ith ll phrmcologic or !-rgiclinter"ention!.




4utpatient "ucose ,argets for)onpregnant Aduts

Prmeter Tretment 3ol

A1C' O

Fndi$iduai/e on the basis of age'comorbidities' duration of disease' andhypogycemia ris36

• Fn genera' Q:.5 for mostH• Coser to norma for heathy• *ess stringent for Ress heathyS

(!"' mgGd* I110

27&our !!"' mgGd* I180

1:

?<. hat are gycemic treatment goas of #M@

?G @ 'a!tin$ la!)a $luco!e; G @ o!trandial $luco!e.

H!ro$ided target can be safey achie$ed.




4utpatient "ucose ,argets for!regnant omen

Con#ition Tretment 3ol

3e!ttionl #i(ete! mellit-! 3D/

!reprandia gucose' mgGd* QB5H

17&our !!"' mgGd* Q180H

27&our !!"' mgGd* Q120H

Preei!ting T1D or T2D

!remea' bedtime' and o$ernight gucose'mgGd*

:07BBH

!ea3 !!"' mgGd* 100712BH

A1C Q:.0OH

1;



?1;. &ow shoud diabetes in pregnancy bemanaged@

h i f




Fnpatient "ucose ,argets for)onpregnant Aduts

%o!pitl 6nit Tretment 3ol

Inten!i"e7criticl cre

"ucose range' mgGd* 180710H

3enerl me#icine n# !-rger8 non)IC6

!remea gucose' mgGd* I180H

andom gucose' mgGd* I10H

1

?<. hat are gycemic treatment goas of #M@

C @ inten!i/e care unit.


i hi d f




,herapeutic *ifestyeChanges

Prmeter Tretment 3oleight oss=for o$erweightand obesepatients>

educe by 5O to 10O

!hysica acti$ity

150 minGwee3 of moderate7intensity exercise =eg' bris3

wa3ing> pus Texibiity and strength training

#iet

• Eat reguar meas and snac3sL a$oid fasting to oseweight

• Consume pant7based diet =high in Dber' owcaoriesGgycemic index' and high inphytochemicasGantioxidants>

• nderstand )utrition (acts *abe information• Fncorporate beiefs and cuture into discussions• se mid coo3ing techni9ues instead of high7heat

coo3ing• Ueep physician7patient discussions informa

1B

?8. &ow are gycemic targets achie$ed for ,2#@




&eathfu EatingecommendationsCr(oh#rte

pecify heathfu carbohydrates =fresh fruits and $egetabes' egumes'whoe grains>L target ;710 ser$ings per day!referentiay consume ower7gycemic index foods =gycemic index scoreI55 out of 1006 mutigrain bread' pumpernic3e bread' whoe oats'egumes' appe' entis' chic3peas' mango' yams' brown rice>

,t pecify heathfu fats =ow mercuryGcontaminant7containing nuts'

a$ocado' certain pant ois' Dsh>*imit saturated fats =butter' fatty red meats' tropica pant ois' fastfoods> and trans fatL choose fat7free or ow7fat dairy products

Protein Consume protein in foods with ow saturated fats =Dsh' egg whites'beans>L there is no need to a$oid anima proteinA$oid or imit processed meats

icron-trien

t!

outine suppementation is not necessaryL a heathfu eating mea pan

can generay pro$ide suVcient micronutrientsChromiumL $anadiumL magnesiumL $itamins A' C' and EL and Co?10 arenot recommended for gycemic controitamin suppements shoud be recommended to patients at ris3 ofinsuVciency or deDciency

20


?8 & i t t hi d f ,2#@




&eathfu EatingecommendationsCr(oh#rte

pecify heathfu carbohydrates =fresh fruits and $egetabes' egumes'whoe grains>L target ;710 ser$ings per day!referentiay consume ower7gycemic index foods =gycemic index scoreI55 out of 1006 mutigrain bread' pumpernic3e bread' whoe oats'egumes' appe' entis' chic3peas' mango' yams' brown rice>

,t pecify heathfu fats =ow mercuryGcontaminant7containing nuts'

a$ocado' certain pant ois' Dsh>*imit saturated fats =butter' fatty red meats' tropica pant ois' fastfoods> and trans fatL choose fat7free or ow7fat dairy products

Protein Consume protein in foods with ow saturated fats =Dsh' egg whites'beans>L there is no need to a$oid anima proteinA$oid or imit processed meats

icron-trien

t!

outine suppementation is not necessaryL a heathfu eating mea pan

can generay pro$ide suVcient micronutrientsChromiumL $anadiumL magnesiumL $itamins A' C' and EL and Co?10 arenot recommended for gycemic controitamin suppements shoud be recommended to patients at ris3 ofinsuVciency or deDciency

21


?8 & i t t hi d f ,2#@




)oninsuin Agents A$aiabefor ,2#Cl!! Primr echni!m o' Action Agent!/ A"il(le !α7"ucosidase

inhibitors

• #eay carbohydrate

absorption from intestine

AcarboseMigito

!recose or generic"yset

Amyin anaogue

• #ecrease gucagon secretion

• ow gastric emptying

• Fncrease satiety

!ramintide ymin

-iguanide

• #ecrease &"!

• Fncrease gucose upta3e inmusce

Metformin "ucophage orgeneric

-ie acidse9uestrant

• #ecrease &"!@

• Fncrease incretin e$es@Coese$eam eCho

#!!78 inhibitors

• Fncrease gucose7dependent

insuin secretion


Aogiptin*inagiptinaxagiptin

itagiptin

)esina ,radenta4ngy/a

Wanu$ia#opamine72agonist

• Acti$ates dopaminergic

receptors

-romocriptine

Cycoset

"inides • Fncrease insuin secretion)ateginideepaginide

tarix or generic!randin

22

-4 @ dietid"l etida!e; BG @ eatic $luco!e roduction.

Garer A& et al. Endocr Pract . 201;1!ul 2D:1-48. nucci E& et al. Diabetes Care. 2012;5:164-17.


Contin"ed on ne4t 'lide

?8 & i t t hi d f ,2#@




)oninsuin Agents A$aiabe for ,2#

Cl!! Primr echni!m o' Action Agent!/ A"il(le !

"*!71 receptoragonists

• Fncrease gucose7dependent

insuin secretion


• ow gastric emptying

• Fncrease satiety

Abigutide#uagutideExenatideExenatide X*iragutide

,an/eum ,ruicity-yetta-ydureonicto/a

"*,2 inhibitors • Fncrease urinary excretion ofgucose

CanagiTo/in

#apagiTo/inEmpagiTo/in

Fn$o3ana

(arxiga Wardiance

ufonyureas • Fncrease insuin secretion

"imepiride"ipi/ide"yburide

Amary or generic"ucotro orgeneric

#iaβeta' "ynase'

Micronase' or

generic

,hia/oidinediones

• Fncrease gucose upta3e in

musce and fat

• #ecrease &"!

!iogita/oneosigita/one

ActosA$andia

2


G>-1 @ $luca$on-li+e etide; BG @ eatic $luco!e roduction; G>2 @ !odiu) $luco!e cotran!orter 2.

Garer A& et al. Endocr Pract . 201;1!ul 2D:1-48. nucci E& et al. Diabetes Care. 2012;5:164-17.Contin"ed 5rom /re&io"' 'lide

?8 & i t t hi d f ,2#@




EYects of Agents A$aiabe for ,2#

24


AG @ α-$luco!ida!e iniitor!; C3-F3 @ ro)ocritine uic+ relea!e; Cole! @ cole!e/ela); 4 @ dietid"l etida!e 4 iniitor!;

?G @ 'a!tin$ la!)a $luco!e; G>13A @ $luca$on-li+e etide 1 recetor a$oni!t!; 9et @ )et'or)in; 9od @ )oderate; G @

o!trandial $luco!e; G>2 @ !odiu)-$luco!e cotran!orter 2 iniitor!; @ !ul'on"lurea!; H @ tiaolidinedione!.

*9ild: ali$lutide and e,enatide; )oderate: dula$lutide& e,enatide e,tended relea!e& and lira$lutide.

et 3P1RA $3T2I DPP4I T:D A3I Cole! ;CR)<R$67

3lini#eIn!-lin Prm

,P3lo+ering

ModMid tomodH

Mod Mid Mod )eutra Mid )eutra6 mod"inide6

mid

Mod tomar3ed=basainsuin

orpremixe

d>

Mid

PP3lo+ering

MidMod tomar3ed

Mid Mod Mid Mod Mid Mid Mod

Mod tomar3ed=shortGrapid7actinginsuin

orpremixe

d>

Mod tomar3ed

Contin"ed on ne4t 'lide

?8 & i t t hi d f ,2#@





25



G>13A @ $luca$on-li+e etide 1 recetor a$oni!t!; 9et @ )et'or)in; 9od @ )oderate; A?>& nonalcoolic 'att" li/er di!ea!e; G>2

@ !odiu)-$luco!e cotran!orter 2 iniitor!; @ !ul'on"lurea!; H @ tiaolidinedione!.

*E!eciall" #it !ort raid-actin$ or re)i,ed.

et3P1R

A$3T2I DPP4I T:D A3I Cole! ;CR)<R

$673lini#e

In!-lin Prm

NA,D(enet

Mid Mid )eutra )eutra Mod )eutra )eutra )eutra )eutra )eutra )eutra

%po)glcemi

)eutra )eutra )eutra )eutra )eutra )eutra )eutra )eutra

6 mod

tose$ere"inide6mid tomod

Mod tose$ereH

)eutra

Weightightoss

*oss *oss )eutra "ain )eutra )eutra )eutra "ain "ain *oss

Contin"ed 5rom /re&io"' 'lide

?8 & i t t hi d f ,2#@





26


et3P1R

A$3T2I DPP4I T:D A3I Cole! ;CR)<R

$673lini#e

In!-lin Prm

Renlimpir)ment7 36

Contra7indicate

d instage

<-' 8' 5

CU#

Exenatide

contra7indicated CrCI<0

mgGm*

"infection

ris3

#oseadust7ment

=exceptina7

giptin>

Mayworsen

Tuidretentio

n

)eutra )eutra )eutra

Fncreased hypo7gycemia ris3

Fncreased ris3s

of hypo7gycemia andTuid

retention

)eutra

3I #"er!ee=ect!

Mod ModH )eutra )eutraH )eutra Mod Mid Mod )eutra )eutra Mod

C%, )eutra )eutra )eutra )eutraK Mod )eutra )eutra )eutra )eutra )eutra )eutra

CVD!ossibebeneDt

)eutra )eutra )eutra )eutra )eutra )eutra afe @ )eutra )eutra

;one )eutra )eutra-oneoss

)eutraModbone

oss

)eutra )eutra )eutra )eutra )eutra )eutra

Contin"ed 5rom /re&io"' 'lide

AG @ α-$luco!ida!e iniitor!; C3-F3 @ ro)ocritine uic+ relea!e; Cole! @ cole!e/ela); CB? @ con$e!ti/e eart 'ailure; CI @

cardio/a!cular di!ea!e; 4 @ dietid"l etida!e 4 iniitor!; G @ $a!trointe!tinal; G>13A @ $luca$on-li+e etide 1 recetor

a$oni!t!; G @ $enitourinar"; 9et @ )et'or)in; 9od @ )oderate; G>2 @ !odiu)-$luco!e cotran!orter 2 iniitor!; @

!ul'on"lurea!; H @ tiaolidinedione!.

*Caution in laelin$ aout ancreatiti!.J

Caution: o!!il" increa!ed CB? o!italiation ri!+ !een in CI !a'et" trial.

?8 &ow are gycemic targets achie$ed for ,2#@




Monotherapy' #ua ,herapy'and ,ripe ,herapy for ,2#

27



G>13A @ $luca$on-li+e etide 1 recetor a$oni!t!; 9et @ )et'or)in; G>2 @ !odiu)-$luco!e cotran!orter 2 iniitor!; @

!ul'on"lurea!; H @ tiaolidinedione!.

*nten!i'" tera" #ene/er A1C e,ceed! indi/idualied tar$et. old'ace denote! little or no ri!+ o' "o$l"ce)ia or #ei$t $ain& 'e#

ad/er!e e/ent!& andor te o!!iilit" o' ene'it! e"ond $luco!e-lo#erin$.

J

!e #it caution.

onotherp> D-l therp>

et'ormin orother r!t)line

gent/ pl-!

Triple therp>

,ir!t) n# !econ#)line gent pl-!

Metformin "*!1A "*!1A

"*!1A "*,2F "*,2F

"*,2F #!!8F ,+#K

#!!8F ,+#K -asa insuinK

A"F -asa insuinK #!!8F

,+#K Coese$eam Coese$eam

GginideK

-C7? -C7? A"F A"F

GginideK GginideK




?5 &ow shoud gycemia in ,1# be managed@




Fnsuin egimensFnsuin is re9uired for sur$i$a in ,1#

!hysioogic regimens using insuin anaogsshoud be used for most patients

<1

?5. &ow shoud gycemia in ,1# be managed@





!harmaco3inetics of Fnsuin

<2

AgentOn!et

h/Pe& h/

D-rtionh/

Con!i#ertion!

;!l

)!& 278 8710 1071: "reater ris3 of nocturna hypogycemiacompared to insuin anaogs

"argine#etemir

[178 )o pronouncedpea3H

p to 28K *ess nocturna hypogycemia compared to)!&

;!l)Prn#il

eguar 7500 Q0.5 [27< 12728 • Fnect <0 min before a mea• Fndicated for highy insuin resistant

indi$iduas• se caution when measuring dosage to

a$oid inad$ertent o$erdose

Pr

n#il

eguar [0.571 [27< p to • Must be inected <0785 min before a

mea• Fnection with or after a mea coud

increase ris3 for hypogycemia

Aspart"uisine*isproFnhaedinsuin

I0.5 [0.572.5 [<75 • Can be administered 0715 min before amea

• *ess ris3 of postprandia hypogycemiacompared to reguar insuin

* E,iit! a ea+ at i$er do!a$e!.

J o!e-deendent.

B& eutral rota)ine Ba$edorn.

9o$i!!i E et al. Endocr Pract . 201;1:526-55. Bu)ulin 3 -500 concentratedD in!ulin re!criin$ in'or)ation. ndianaoli!: >ill" A& >>C.






!rincipes of Fnsuin ,herapyin ,1#tarting dose based on weightange6 0.870.5 unitsG3g per day

#aiy dosing-asa 80O to 50O ,#F

"i$en as singe inection of basa anaog or 2 inections of )!& perday

!randia 50O to :0O of ,#F in di$ided doses gi$en 15 min before each

mea Each dose determined by estimating carbohydrate content of

mea

&igher ,#F needed for obese patients' those withsedentary ifestyes' and during puberty


@ total dail" in!ulin.

<<

?: &ow shoud hypogycemia be managed@




Conse9uences of&ypogycemiaCogniti$e' psychoogica changes =eg' confusion'

irritabiity>

Accidents

(as

ecurrent hypogycemia and hypogycemia unawareness

efractory diabetes

#ementia =edery>

C e$ents

Cardiac autonomic neuropathyCardiac ischemia

Angina

(ata arrhythmia

<8

?:. &ow shoud hypogycemia be managed@





ymptoms of &ypogycemia

<5

Cl!!iction

;loo#3l-co!ee"el

mg7#/

Tpicl $ign! n# $mptom!

Mid hypogycemia [507;0• )eurogenic6 papitations' tremor' hunger'

sweating' anxiety' paresthesia

Moderatehypogycemia

[507;0• )eurogycopenic6 beha$iora changes'

emotiona abiity' diVcuty thin3ing'confusion

e$ere hypogycemia I50H

• e$ere confusion' unconsciousness'sei/ure' coma' death

• e9uires hep from another indi$idua

He$ere hypogycemia symptoms shoud be treated regardess of bood gucose e$e.






,reatment of &ypogycemia

<:


!atient se$erey confusedor unconscious =re9uires

hep>• Consume gucose7containing

foods =fruit uice' soft drin3'crac3ers' mi3' gucose tabets>La$oid foods aso containing fat

• epeat gucose inta3e if M-"

resut remains ow after 15minutes

• Consume mea or snac3 afterM-" has returned to norma toa$oid recurrence

!atient conscious and aert

&ypogycemia symptoms=-" I;0 mgGd*>

• "ucagon inection'dei$ered by anotherperson

• !atient shoud be ta3en

to hospita for e$auationand treatment after anyse$ere episode

G @ lood $luco!e; 9G @ !el'-)onitorin$ o' lood $luco!e.

?; &ow shoud hypertension be managed@




-ood !ressure ,argets

<;

?;. &ow shoud hypertension be managed@

Prmeter Tretment 3ol

-ood pressure

Fndi$iduai/e on the basis of age'

comorbidities' and duration of disease' with

genera target of6

ystoic' mm &g [1<0

#iastoic' mm &g [0

A more intensi$e goa =such as I120G0 mm &g> shoud be

considered for some patients' pro$ided the target can be safeyreached without ad$erse eYects from medication.

More reaxed goas may be considered for patients withcompicated comorbidities or those experience ad$ersemedication eYects.

?; &ow shoud hypertension be managed@




-ood !ressure ,reatmentEmpoy therapeutic ifestye modiDcation#A& or other ow7sat diet

!hysica acti$ity

eect antihypertensi$e medications based on -!7owering eYectsand abiity to sow progression of nephropathy and retinopathyACE inhibitors

or

A-s

Add additiona agents when needed to achie$e bood pressuretargets

Cacium channe antagonists#iuretics

Combined αGβ7adrenergic boc3ers

β7adrenergic boc3ers

#o not combine ACE inhibitors with A-s

<

?;. &ow shoud hypertension be managed@

ACE @ an$ioten!in con/ertin$ en")e; A3 @ an$ioten!in recetor loc+er; @ lood re!!ure; AB @ ietar" Aroace! to to

B"erten!ion.

? &ow shoud dysipidemia be managed@




*ipid ,argets

<B

?. &ow shoud dysipidemia be managed@

Prmeter Tretment 3olo#erte ri!& %igh ri!&

Primr 3ol!

*#*7C' mgGd* I100 I;0

)on\&#*7C' mgGd* I1<0 I100

,rigycerides' mgGd* I150 I150

,CG&#*7C ratio I<.5 I<.0

$econ#r 3ol!

Apo-' mgGd* IB0 I0

*#* partices I1'200 I1'000

Ao @ aoliorotein ; ACI @ atero!clerotic cardio/a!cular di!ea!e; CI @ cardio/a!cular; B>-C @ i$ den!it" liorotein

cole!terol; >> @ lo#-den!it" liorotein; >>-C @ lo#-den!it" liorotein cole!terol; C @ total cole!terol.

Moderate ris3 diabetes or prediabetes with no AC# or maor C ris3 factors

&igh ris3 estabished AC# or 1 maor C ris3 factor

C ris3 factors &ypertension (amiy history *ow &#*7C

mo3ing

? &ow shoud dysipidemia be managed@




*ipid Management

80

?. &ow shoud dysipidemia be managed@

Ao @ aoliorotein ; B>-C @ i$ den!it" liorotein cole!terol; >> @ lo#-den!it" liorotein; >>-C @ lo#-den!it" liorotein

cole!terol; C @ total cole!terol; G @ tri$l"ceride!.

?B &ow is nephropathy managed in patients with




Assessment of #iabetic)ephropathy

81

?B. &ow is nephropathy managed in patients withdiabetes@

AE3 @ alu)in e,cretion rate; eG?3 @ e!ti)ated $lo)erular 'iltration rate; 1 @ t"e 1 diaete!; 2 @ t"e 2 diaete!.

Annua assessmentserum creatinine to determine e"(

rine AE

-egin annua screening5 years after diagnosis of ,1# if diagnosed

before age <0 years

At diagnosis of ,2# or ,1# in patients

diagnosed after age <0 years

?B. &ow is nephropathy managed in patients with




taging of Chronic Uidney#isease

82


CK @ cronic +idne" di!ea!e; G?3 @ $lo)erular 'iltration rate; K? @ ational Kidne" ?oundation.

>e/e" A& et al. Kidney Int . 2011;80:17-28.

!ersistent abuminuria categories#escription and range

!re$ious )U(CU#

stage

"uide to fre9uency of monitoring=number of times per year> by"( and abuminuria category

A1 A2 A<

)orma tomidy

increased

Moderateyincreased

e$ereyincreased

I<0 mgGgI< mgGmmo

<07<00 mgGg<7<0

mgGmmo

J<00 mgGgJ<0

mgGmmo

"(categories

=m*GminG1.;<m2>#escriptionandrang

e

1 "1 )orma or high B0 1 i' C?D 1 2

2 "2 Midy decreased :07B 1 i' C?D 1 2

<

"<a

Mid to

moderateydecreased 8575B 1 2 @

"<bModeratey to

se$ereydecreased

<0788 2 @ @

8 "8e$erey

decreased1572B @ @ 4

5 "5 Uidney faiure I15 4 4 4

?B. &ow is nephropathy managed in patients with




Management of #iabetic)ephropathy4ptima contro of bood pressure' gucose' and

ipids

mo3ing cessation

AA boc3adeACE inhibitor' A-' or renin inhibitor

#o not combine AA boc3ing agents

Monitor serum potassium

)ephroogist referraAtypica presentation

apid decine in e"( or abuminuria progression

tage 8 CU#

8<


ACE @ an$ioten!in con/ertin$ en")e; A3 @ an$ioten!in recetor loc+er; CK @ cronic +idne" di!ea!e; eG?3 @ e!ti)ated

$lo)erular 'iltration rate; 3AA @ renin an$ioten!in aldo!terone !"!te).

?10. &ow is retinopathy managed in patients with




Assessment of #iabeticetinopathy

88

?10. &ow is retinopathy managed in patients withdiabetes@

9 @ diaete! )ellitu!; 1 @ t"e 1 diaete!; 2 @ t"e 2 diaete!.

Annua diated eye examination by experiencedophthamoogist or optometrist

-egin assessment

5 years after diagnosis of ,1#At diagnosis of ,2#

More fre9uent examinations for6!regnant women with #M during pregnancy and

1 year postpartum!atients with diagnosed retinopathy

!atients with macuar edema recei$ing acti$etherapy

?10. &ow is retinopathy managed in patients with




Management of #iabeticetinopathy

85

? p y g pdiabetes@


ow retinopathy progression by maintainingoptima contro of -ood gucose

-ood pressure*ipids

(or acti$e retinopathy' refer toophthamoogist as needed

(or aser therapy(or $ascuar endotheia growth factor therapy

?11. &ow is neuropathy diagnosed and managed in




Assessment of #iabetic)europathyCompete neuroogic examination annuay

-egin assessment5 years after diagnosis of ,1#

At diagnosis of ,2#

8:

? o s eu opa y d ag osed a d a agedpatients with diabetes@

1 @ t"e 1 diaete!; 2 @ t"e 2 diaete!.





#iabetic )europathy E$auationsand ,ests,oot in!pection (oot structure and deformities

3in temperature and integritycersascuar status!eda pusesAmputations

Ne-rologic te!ting *oss of sensation' using 1 and 107g monoDamentibration perception using 127&/ tuning for3An3e reTexes

,ouch' pinpric3' and warm and cod sensation

Pin'-l ne-ropth May ha$e no physica signs#iagnosis may re9uire s3in biopsy or other surrogate

measure

Cr#io"!c-lr-tonomicne-ropth

&eart rate $ariabiity with6• #eep inspiration• asa$a maneu$er• Change in position from prone to standing

8;

? p y g gpatients with diabetes@


i b i h





#iabetic )europathyManagementAll ne-ropthie! • !re$ent by controing bood gucose to indi$idua

targets• )o therapies pro$en to re$erse neuropathy once it is

estabished• May sow progression by maintaining optima gucose'

bood pressure' and ipid contro and using other

inter$entions that reduce oxidati$e stress

Pin'-lne-ropth

• ,ricycic antidepressants' anticon$usants' serotoninreupta3e inhibitors' or norepinephrine reupta3einhibitors

rge)(erne-ropthie!

• trength' gait' and baance training• 4rthotics to pre$entGtreat foot deformities

• ,endon engthening for pes e9uinus• urgica reconstruction• Casting

$mll)(erne-ropthie!

• (oot protection =eg' padded soc3s>• upporti$e shoes with orthotics if needed• eguar foot inspection

• !re$ention of heat inury• Emoient creams 8

? p y g gpatients with diabetes@

?12. &ow is C# managed in patients with




Comprehensi$e Management of Cis3Manage C ris3 factorseight oss

mo3ing cessation

4ptima gucose' bood pressure' and ipid contro

se ow7dose aspirin for secondary pre$ention of Ce$ents in patients with existing C#May consider ow7dose aspirin for primary pre$ention

of C e$ents in patients with 107year C ris3 J10O

Measure coronary artery caciDcation or usecoronary imaging to determine whether gucose'ipid' or bood pressure contro eYorts shoud beintensiDed

8B

? g pdiabetes@

CI @ cardio/a!cular; CI @ cardio/a!cular di!ea!e.

?12. &ow is C# managed in patients with




tatin seMaority of patients

with ,2# ha$e a highcardio$ascuar ris3

!eope with ,1# are atee$atedcardio$ascuar ris3

*#*7C target6 I;0mgGd*]for the

maority of patientswith diabetes who aredetermined to ha$e ahigh ris3

se a statin regardessof *#*7C e$e inpatients with diabeteswho meet thefoowing criteria6J80 years of age

1 maor AC# ris3factor

&ypertension (amiy history of C# *ow &#*7C

mo3ing

50

? g pdiabetes@

ACI @ atero!clerotic cardio/a!cular di!ea!e; CI @ cardio/a!cular di!ease; B>-C @ i$ den!it" liorotein cole!terol;

>>-C @ lo#-den!it" liorotein cole!terol.

?1<. &ow is obesity managed in patients with




#iagnosis of 4besity and taging offor Management#iagnose obesity according to body mass index =-MF>4$erweight6 -MF 2572B.B 3gGm2

4beseH6 -MF <0 3gGm2

Consider waist circumference measurement forpatients with -MF between 25 and <5 3gGm2

*arger waist circumference higher ris3 for metaboicdiseaseMen6 J102 cm =80 in>

omen6 J cm =<5 in>E$auate patients for obesity7reated compications to

determine disease se$erity and appropriatemanagement

51

y g pdiabetes@

51

*9 2-24. )a" e con!idered oe!e in certain etnicitie!; er'or) #ai!t circu)'erence and u!e etnicit"-!eci'ic criteria in ri!+ anal"!i!.

M di C i ti f

?1<. &ow is obesity managed in patients with




Medica Compications of4besity

52

A?>

Cr#io"!c-lrDi!e!e

i!)otilit"di!ailit"

"E#

*ung functiondefects

4steoarthritis

eep apnea

rinaryincontinence

rediaetic !tate!

B"erten!ion"!liide)ia

C

Di(ete!

Cr#iomet(olic;iomechnicl

Other

GE3& $a!troe!oa$eal re'lu, di!ea!e; A?>& nonalcoolic 'att" li/er di!ea!e; C& ol"c"!tic o/ar" !"ndro)e.

i-un"er L. Postgrad Med . 200;121:21-.

Andro$en

de'icienc"

Cancer

"abadderdisease

!sychoogicadisorders

O(e!it

y g pdiabetes@




?18. hat is the roe of seep medicine in the care




4bstructi$e eep Apnea

Ri!& ,ctor! Tretment Option!

4besity

Mae sex

)ec3 circumference J88cm

Age

)arrowed airway

(amiy history&ypertension

Acoho or sedati$es

mo3ing

eight oss

Continuous positi$e airway

pressure =C!A!>Additiona optionsAdustabe airway pressure

de$ices

4ra appiances

urgery $uopaatopharyngopasty

=!!!>

Maxiomandibuarad$ancement

,racheostomy

58

of the patient with diabetes@

" i d

?15. &ow is diabetes managed in the hospita@




"ucose creening andMonitoring*aboratory bood gucose testing on admission'

regardess of #M historyUnown #M6 assess A1C if not measured in past <

months

)o history of #M6 assess A1C to identify undiagnosedcases

-edside gucose monitoring for duration of hospitastay

#iagnosed #M)o #M but recei$ing therapy associated with

hypergycemia Corticosteroids

Entera or parentera nutrition

55

9 @ diaete! )ellitu!.





Fnpatient "ucose ,argets for)onpregnant Aduts

%o!pitl 6nit Tretment 3ol

Inten!i"e7criticl cre

"ucose range' mgGd* 180710H

3enerl me#icine n# !-rger8 non)IC6!remea gucose' mgGd* I180H

andom gucose' mgGd* I10H

5:







"ucose Contro

%perglcemi %poglcemi

Criticay iGFC patientseguar insuin by

intra$enous infusion)oncriticay i Fnsuin anaogs by schedued

subcutaneous basa'nutritiona' and correctionacomponents

ynchroni/e dosing withmeas or entera orparentera nutrition

Excusi$e use of siding scaeinsuin is discouraged

Estabish pan for treating

hypogycemia in eachinsuin7treated patient

#ocument each episode ofhypogycemia in medicarecord

5;


Di!chrge Pln!Fncude appropriatepro$isions for gucosecontro in the outpatientsetting

A F id f #M i

?1:. &ow is a comprehensi$e care pan estabished




Annua Fncidence of #M in %outh

5

A @ A)erican ndian!; A @ A!ian!aci'ic !lander!; 9 @ diaete! )ellitu!; B @ Bi!anic!; B @ non-Bi!anic lac+!;

B< @ non-Bi!anic #ite!.

CC. ational diaete! !tati!tic! reort& 2014. tt:###.cdc.$o/diaete!u!!tat!reort14national-diaete!-reort-#e.d'.

10 years 10-19 years

A )& )&- & A!F AFA)H A )& )&- & A!F AFA)H0

10

20

<0

80

50

,ype 2 ,ype 1Rte per 1008000 per er/

in chidren and adoescents@

?1:. &ow is a comprehensi$e care pan estabished




Management of #M

T1D T2D

se M#F or CFF insuin Fn chidren younger than 8

years' bous insuin may begi$en after' rather thanbefore' meas due to

$ariabe carbohydrate inta3e

&igher insuin7to7carbohydrate ratios may be

needed during puberty!ubescent girs may re9uire

20O to 50O increases in

insuin dose during

menstrua periods

*ifestye modiDcation isDrst7ine therapy

Metformin' aone or incombination with insuin'is appro$ed by the (#A totreat ,2# in pediatric

patientsosigita/one and

gimepiride ha$e asobeen studied in pediatricpatients with ,2#

5B

in chidren and adoescents@

i f

?1;. &ow shoud diabetes in pregnancy be




4utpatient "ucose ,argets for!regnant omen

Con#ition Tretment 3ol

3e!ttionl #i(ete! mellit-! 3D/

!reprandia gucose' mgGd* QB5H

17&our !!"' mgGd* Q180H

27&our !!"' mgGd* Q120H

Preei!ting T1D or T2D

!remea' bedtime' and o$ernight gucose'mgGd*

:07BBH

!ea3 !!"' mgGd* 100712BH

A1C Q:.0OH

:0



managed@

,reatment of #M #uring

?1;. &ow shoud diabetes in pregnancy be




,reatment of #M #uring!regnancyA women with ,1#' ,2#' or pre$ious "#M

shoud recei$e preconception care to ensureade9uate nutrition and gucose contro before

conception' during pregnancy' and in thepostpartum period

se insuin to treat hypergycemia in ,1# and ,2# and when ifestye measures do not contro

gycemia in "#M-asa insuin6 )!& or insuin detemir

!randia insuin6 insuin anaogs preferred' butreguar insuin acceptabe if anaogs not a$aiabe

:1

managed@

?1. hen and how shoud gucose monitoring bed@




ef7monitoring of -ood "ucose=M-">

:2

9G& !el'-)onitorin$ o' lood $luco!e.

used@

Nonin!-lin 6!er! In!-lin 6!er!

Fntroduce at diagnosis

!ersonai/e fre9uency of

testingse M-" resuts to inform

decisions about whether totarget (!" or !!" for anyindi$idua patient

A patients using insuinshoud test gucose

2 times daiy -efore any inection of

insuin

More fre9uent M-" =aftermeas or in the midde of

the night> may be re9uired (re9uent hypogycemia

)ot at A1C target

,esting positi$ey aYectsgycemia in ,2# when theresuts are used to6• Modify beha$ior• Modify pharmacoogic

treatment





M-" (re9uency $s A1C

used@

9iller K9& et al. Diabetes Care. 201;6:200-2014.

171< years

1<72: years

2:750 years

50N years

$;3 per #

072 <78 57: ;7 B710

11712

1<:.5

;.0

;.5

.0

.5

B.0

B.5

10.0

10.5

11.0

4 e n A

1 C

C ti " M it i





Continuous "ucose Monitoring=C"M>

6!e! imittion!

Consider for ,1# patients =andinsuin7using ,2# patients> toimpro$e A1C and reducehypogycemia

(eaturesRea7timeS gucose $aues

=but ;7 to 157minute agbetween pasma and

interstitia gucose and recei$erdispay>

&ypo7 and hypergycemiaaarms

ireess interfaces withdownoadabeGprintabe data

Fn$asi$e =worn i3e apump>

e9uires daiy caibrationwith Dngerstic3 M-"

*engthy data downoadtime

e9uires highymoti$atedGinformed

patients and heathcaresupport teamMust be abe to interpret

data trends rather thandata points

:8

Bir!c . J Clin Endocrinol Metab. 200;4:222-228.

used@

?1B. hen and how shoud insuin pump therapy bed@




Continuous ubcutaneous FnsuinFnfusion =CFF>

Consider for ,1# patients

Fnsuinopenic ,2# patients unabe to achie$e

optima gucose contro with mutipe daiyinections of insuin

A patients shoud be moti$ated and weeducated in #M sef7management as we as

CFF use!rescribing physicians shoud ha$e expertise

in CFF

CFF de$ices with a threshod7suspend

function may be considered :5

used@

CFF Meta Anayses in ,1#





CFF Meta7Anayses in ,1#and ,2#

eference (indings

eissberg7-enche et a'Dia)ete' Care.

200<L2:=8>610;B710;

Compared with M#F' CFF therapy was associated with signiDcantimpro$ements in gycemic contro based on &bA1c and mean bood gucose

decreases

Weiter et a' Dia)etoloia.

200L51=:>6B817B51

&bA1c reduction greater and insuin re9uirements ower with CFF than with M#F

in aduts and adoescents with ,1#ML hypogycemia ris3 comparabe among

adut patients =data una$aiabe for adoescent subects>L no concusi$e CFFbeneDts for patients with ,2#M

(atourechi et a' ! Clin Endocrinol Meta).

200BLB8=<>6;2B7;80

Fn patients with ,1#M' &bA1c was midy decreased with CFF $s. M#FL CFF

eYect on hypogycemia uncearL simiar CFF and M#F outcomes amongpatients with ,2#M

!ic3up ^ utton'Dia)et Med.

200L25=;>6;:57;;8

&bA1c was ower for CFF than for M#F' with greatest impro$ement in patients

with highest initia &bA1c $aues on M#FL se$ere hypogycemia ris3 was

decreased with CFF $s. M#FL greatest reduction in patients with diabetes ofongest duration andGor highest baseine rates of se$ere hypogycemia

Monami et a'E4/ Clin Endocrinol

Dia)ete'. 200BL11;=5>62207222

&bA1c was signiDcanty ower with CFF $s. M#FL &bA1c reduction was ony

e$ident for studies with mean patient age J10 yearsL se$ere hypogycemiaoccurred at comparabe rates with CFF and M#F therapy

::

CFF' continuous subcutaneous insuin infusionL #UA' diabetic 3etoacidosisL &bA1c' hemogobin A1cL M#F' mutipe daiy

inectionsL C,' randomi/ed controed triaL ,1#M' type 1 diabetes meitusL ,2#' type 2 diabetes.

used@





CFF andomi/ed' Controed ,riasin ,2#

A1C B/

Re'erence De!ign ;!eline C$II DI P "l-e

)oh et a' Dia)ete' Meta) %e'

%e& . 200L28=5>6<87<B1.

<07wee3 obser$ationa

study =)15>

;.B 5.0 )A I0.001

!ar3ner et a' Dia)ete' ()e'Meta). 200L10=;>655:75:<.

4bser$ationa study' <successi$e nights

=)10>

(asting pasmagucose6

20B mgGd*

BB.1mgGd*

)A I0.0001

-erthe et a' +orm Meta) %e'.

200;L<B=<>6228722B.

Crosso$er study' 2 127

wee3 periods =)1;>

B.0 ;.; .: I0.0<

&erman et a' Dia)ete' Care.

2005L2=;>615:715;<.

1 year parae study

=)10;>

CFF6 .8

M#F6 .1

:.: :.8 0.1B

as3in et a' Dia)ete' Care.

200<L2:=B>625B72:0<

28 wee3 parae study

=)1<2>

CFF6 .2

M#F6 .0

;.: ;.5 )

ainstein et a' Dia)et Med.

2005L22=>610<;7108:.

Crosso$er study' 2 17

wee3 periods =)80>

CFF7M#F6 10.1

M#F7CFF 10.2

_0. N0.8 0.00;

:;

CFF6 continuous subcutaneous insuin infusionL M#F6 mutipe daiy inectionL ,2#M6 type 2diabetes.

used@

#M C h i

?20. hat is the imperati$e for education and teamapproach in #M management@




#M Comprehensi$eManagement ,eam

approach in #M management@

Ptient

En#ocrin)ologi!t

PCP

Ph!icin!!i!tnt7 N-r!eprcti)tioner

Regi!tere# n-r!e

CDE

Dietitin

Eerci!e!pecili!t

entlhelthcre

pro'e!)!ionl

:

accinations for !atients with

?21. hat $accinations shoud be gi$en to patientswith diabetes@




accinations for !atients with#MVccine8 're-enc o' #mini!trtion Ptient ge

outine chidhood immuni/ations' according to standardschedue =eg' meases' mumps' rubea' $aricea' poio' tetanus7diphtheria>

: months to 1 years

FnTuen/a' annuay : months

!neumococca poysaccharide $accine 2 years

!C1<' 172 inections 271 years

!!2<' 1 inection 1B7:8 years

!C1< pus !!2<'1 inection each' in series

:5 years

&epatitis -' 1 inection 2075B yearsH

,etanus7diphtheria booster' e$ery 10 years in aduts 1B years

Fndi$iduas not aready immuni/ed for chidhood diseases andthose re9uiring $accines for endemic diseases shoud beimmuni/ed as re9uired by indi$idua patient needs

Any age

HConsider for patients :0 based on assessment of ris3 and i3eihood of ade9uateimmune response.

:B

with diabetes@

?22. &ow shoud depression be managed in thecontext of diabetes@




#M and #epression

;0

context of diabetes@

creen a aduts with #M for depressionntreated comorbid depression can ha$e

serious cinica impications for patients with #M

Consider referring patients with depression tomenta heath professionas who are3nowedgeabe about #M

?2<. hat is the association between diabetes andcancer@




#M and Cancercreen obese indi$iduas with #M more fre9uenty and rigorousy

for certain cancersEndometria' breast' hepatic' badder' pancreatic' coorecta cancers

Fncreased -MF =25 3gGm2> aso increases ris3 of some cancerstrong associations6 endometria' ga badder' esophagea ' rena'

thyroid' o$arian' breast' and coorecta cancer

ea3er associations6 eu3emia' maignant and mutipe meanoma'pancreatic cancer' non7&odg3in ymphoma

,o date' no deDniti$e reationship has been estabished betweenspeciDc hypergycemic agents and increased ris3 of cancer or

cancer7reated mortaityConsider a$oiding medications considered disad$antageous to

speciDc cancers in indi$iduas at ris3 for or with a history of thatcancer

;1

cancer@

#M and 4ccupationa

?28. hich occupations ha$e speciDc diabetesmanagement re9uirements@



#M and 4ccupationa&a/ards

management re9uirements@

Commercia dri$ers at high ris3 for de$eoping ,2#creen as appropriate

Encourage heathy ifestye change

-e aware of management re9uirements and useagents with reduced ris3 of hypogycemia inpatients with occupations that coud put others atris3' such as =not incusi$e>6Commercia dri$ers

!iotsAnesthesioogists

Commercia or recreationa di$ers

diabetes slides 4-21-15

Documents