DM Standards of Care 2015 ;The ABcs

DIABETES MELLITUS Standards Of Care- 2015

The ABCs

Dr. Mohammad DaoudConsultant Endocrinologist

KAMC/ NGHA

Jeddah –Saudi Arabia

Type 2 diabetes is NOT a mild disease

Diabetic

Retinopathy

Leading cause

of blindness

in working age

adults1

Diabetic

Nephropathy

Leading cause of

end-stage renal disease2

Cardiovascular

Disease

Stroke

2 to 4 fold increase in cardiovascular mortality and stroke3

Diabetic

Neuropathy

Leading cause of

non-traumatic lower

extremity amputations5

8/10 diabetic patients

die from CV events4

1 Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–

S98. 3 Kannel WB, et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997.5Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.

Mild Type 2 Diabetes ?

Aims of Mx of DM

Improve quality of life

Reduce acute symptoms

Achieve euglycemia safely

Avoid Acute &

Chronic

Complications

ADA 2015

A patient-centered communication style that incorporates

patient preferences, assesses literacy and numeracy, and

addresses cultural barriers to care should be used. B

Treatment decisions should be timely and founded on

evidence-based guidelines that are tailored to individual

patient preferences, prognoses, and co-morbidities. B

Criteria for the Diagnosis of Diabetes

A1C ≥6.5% Adults

OR

Fasting plasma glucose (FPG)

≥126 mg/dL (7.0 mmol/L)

OR

2-h plasma glucose ≥200 mg/dL

(11.1 mmol/L) during an OGTT

OR

A random plasma glucose ≥200 mg/dL (11.1

mmol/L)

ADA. I. Classification and Diagnosis. Diabetes Care 2014;37(suppl 1):S15; Table 2

Testing for Diabetes in Asymptomatic Adult Patients

• Adults of any age who are overweight / obese (BMI ≥25

kg/m2 or ≥23 kg/m2 in Asian Americans) and who have

one or more additional risk factors for diabetes.

• For all patients, particularly those who are overweight

or obese, testing should begin at age 45 years. B

• To test for pre-diabetes, the A1C, FPG, or 2-h 75-g

OGTT are appropriate B

• In those with pre-diabetes, identify and, if appropriate,

treat other CVD risk factors E

ADA. II. Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2015

Testing for Diabetes in Asymptomatic Adult Individuals

• Physical inactivity

• First-degree relative with

diabetes

• High-risk race/ethnicity (e.g.,

African American, Latino, Native

American, Asian American,

Pacific Islander)

• Women who delivered a baby

weighing >9 lb or were diagnosed

with GDM

• Hypertension (≥140/90 mmHg or

on therapy for hypertension)

• HDL cholesterol level

<35 mg/dL (0.90 mmol/L) and/or a

triglyceride level >250 mg/dL (2.82

mmol/L)

• Women with polycystic ovarian

syndrome (PCOS)

• A1C ≥5.7%, IGT, or IFG on

previous testing

• Other clinical conditions associated

with insulin resistance (e.g., severe

obesity, acanthosis nigricans)

• History of CVD

*At-risk BMI may be lower in some ethnic groups.

1. Testing should be considered in all adults who are overweight

(BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and have additional risk

factors:

ADA. Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2015

2. If tests are normal, repeat testing at least at 3-year

intervals is reasonable C

Consider more frequent testing depending on initial

results and risk status (e.g., those with prediabetes should

be tested yearly)

ADA. Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2015

Testing for Diabetes in Asymptomatic Adult Individuals

Recommendations:Detection and Diagnosis of GDM (1)

• Screen for undiagnosed type 2 DM at the first prenatal visit in those with risk factors, using standard diagnostic criteria

B

• Screen for GDM at 24–28 weeks of gestation in pregnant women not previously known to have DM A

• Screen women with GDM for persistent DM at 6–12 weeks postpartum, using OGTT, nonpregnancy diagnostic criteria

E

• Women with a +ve history of GDM should have lifelong screening for the development of DM or pre-DM at least every 3 years B

• Women with a history of GDM found to have pre-DM should receive TLC or Metformin to prevent DM

A

Detection and Diagnosis of GDM. Diabetes Care 2015

One-step strategy (IADPSG Consensus)

• Perform a 75-g OGTT, with plasma glucose measurement when patient is fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed with overt diabetes.

• The OGTT should be performed in the morning after an overnight fast of at least 8 h

The diagnosis of GDM is made when any of the following plasma glucose values are met or exceeded:

• Fasting: ≥ 92 mg/dL (5.1 mmol/L)

• 1 h: ≥ 180 mg/dL (10.0 mmol/L)

• 2 h: ≥ 153 mg/dL (8.5 mmol/L)


Table 2.5—Screening for and diagnosis of GDM


Two-step strategy (2013 -NIH Consensus)

• Step 1: Perform a 50-g GLT (non-fasting), with plasma glucose

measurement at 1 h, at 24–28 weeks of gestation in women not

previously diagnosed with overt diabetes.

• If the plasma glucose level measured 1 h after the load is ≥140 mg/dL*

(7.8 mmol/L), proceed to a 100-g OGTT

NDDG, National Diabetes Data Group.

*The ACOG recommends a lower threshold of 135 mg/dL (7.5 mmol/L) in high-risk ethnic

populations with higher prevalence of GDM;

Some experts also recommend 130 mg/dL (7.2 mmol/L).


Two-step strategy…

• Step 2: The 100-g OGTT should be performed when the patient is fasting.

• The diagnosis of GDM is made if at least two of the following four plasma glucose levels

• (measured fasting and 1 h, 2 h, 3 h after the OGTT) are met or exceeded:

• Carpenter/Coustan or NDDG

Fasting 95 mg/dL (5.3 mmol/L) 105 mg/dL (5.8 mmol/L)

1 h 180 mg/dL (10.0 mmol/L) 190 mg/dL (10.6 mmol/L)





PREVENTION / DELAY OFTYPE 2 DIABETES

FPG 100–125 mg/dL (5.6–6.9 mmol/L): IFG

OR

2-h plasma glucose in the 75-g OGTT

140–199 mg/dL (7.8–11.0 mmol/L): IGT

OR

A1C 5.7–6.4%

For all three tests, risk is continuous, extending below the lower

limit of the range and becoming disproportionately greater at

higher ends of the range.

Pre-Diabetes

ADA. I. Classification and Diagnosis. Diabetes Care 2015

Prevention /Delay of Type 2 DM

Patients with IGT (A), IFG (E), or

an A1C of 5.7–6.4% (E)

Weight loss of 7% of body weight

Physical activity ; at least 150 min/ week

Follow-up counseling for success. (B)

Diabetes prevention is cost-effective (B)

ADA 2015

All patients should limit the amount of time

sitting to less than 90 minutes a stretch

(Avoid Sedentary Life )

Prevention /Delay of Type 2 DM

Metformin therapy may be considered in:

IGT (A), IFG(E), or an A1Cof 5.7–6.4% (E)

Especially for those with: (A)

-BMI >35 kg/m2

-Age <60 years,

-Prior GDM.

At least annual monitoring for the development

of DM in those with pre-diabetes is suggested. (E)

ADA 2015Micronutrients and Supplements

Evidence does not support recommending omega-3

supplements for people with diabetes for the prevention or

treatment of cardiovascular events.

There is no clear evidence of benefit from vitamin or

mineral supplementation in people with diabetes who do not

have underlying deficiencies. C

Routine supplementation with antioxidants, such as

vitamins E and C and carotene, is not advised due to

insufficient evidence of efficacy and concerns related to long-

term safety. C

.

ADA 2015Micronutrients and herbal supplements

There is insufficient evidence to support the routine use of

micronutrients such as chromium, magnesium, and vitamin D

to improve glycemic control in people with diabetes C

There is insufficient evidence to support the use of

cinnamon or other herbs/supplements for the treatment of

diabetes. E

Routine screening for CAD is

Not recommended

In asymptomatic patients

(It does not improve outcomes as long as CVD risk factors are treated)

(A)

Coronary Heart Disease Screening

ADA. VI. Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S42

• To reduce risk of cardiovascular events in

patients with known CVD, use

– ACE inhibitor* (C)

– Aspirin* (A)

– Statin therapy* (A)

• In patients with a prior MI

– Beta-blockers should be continued for at least 2

years after the event (B)

Coronary Heart Disease Treatment

*If not contraindicated.


GLYCEMIC CONTROL

1. Assessment of Glycemic control

Two primary techniques:

A : Patient self-monitoring of blood glucose

(SMBG) or Interstitial Glucose (CGM)

B : HbA1C

2. Glycemic goals in adults

ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21–S22

ADA-2015

Glycemic ControlSMBG

Tight Glycemic control : SMBG is an integral part of

the management strategy. (A)

Do SMBG ≥ 3 times a day for patients using Insulin

pump or multiple insulin injections. (B)

Patients using less frequent insulin injections or oral agents or MNT alone, SMBG is useful (E)

PP SMBG may be appropriate. (E)

Especially when getting closer to target; Lower A1c

Glycemic ControlRecommendations

EMPOWER

Patient should be able to use data

to adjust therapy. (E)

ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21–S22

Correlation of A1C with estimated Average Glucose

The correlation factor is (r 0.92)

A1C (%) Mean plasma glucose mg/dl mmol/l

6 126 ( ̴120)

7 154 ( ̴150)

8 183 ( 1̴80)

9 212 ( 2̴10)

10 240 ( 2̴40)

11 269 ( ̴270)

12 298 ( 3̴00)

ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S23; Table 8

ADA – EASD Consensus:

(June 2012)

ADA-2015

Inpatients Glycemia Mx

ADA-2015

Inpatients Glycemia Mx

Diabetes in ElderlyPharmacotherapy

Assess for hypoglycemia regularly

Hypoglycemia risk is linked more to treatment strategies

than to achieved lower A1C

Consider changing therapy and/or targets

Diabetes in older adults-ADA Consensus –

Diabetes Care published ahead of print October 25, 2012, doi:10.2337/dc12-1801


Consider poly-pharmacy

Avoid Glyburide / Glibenclamide

Metformin: Safely and is the preferred initial therapy

Assess renal function using e-GFR ;

Not Serum Creatinine alone




Assess the burden of treatment on older adult patients

(caregivers)

Consider patient/caregiver preferences,

and attempt to reduce treatment complexity



Diabetes in Elderly

Glycemic ControlKey Concepts

A1C is the primary target

SMBG

Goals to be individualized

Evidence –Based / Individualized Rx

HYPERTENSIONBP CONTROL

Goals

*People with diabetes and hypertension should be

treated to a (SBP) goal of <140 mmHg. A

Lower systolic targets, such as <130 mmHg, may be appropriate for

certain individuals, such as younger patients, if they can be achieved

without undue treatment burden. C

*Individuals with diabetes should be treated to a

(DBP) <90 mmHg. A

Lower (DBP) targets, such as <80 mmHg, may be appropriate for certain

individuals, such as younger patients, if they can be achieved without undue treatment burden. B

• Patients with confirmed office-based BP

>140/90 mm Hg

=

Prompt initiation of pharmacological therapy to

achieve blood pressure goals. A


• Lifestyle therapy for elevated BP B

– Weight loss if overweight/ obese

– DASH (Dietary Approaches to Stop Hypertension) -

style dietary pattern including reducing sodium,

increasing potassium intake

– Moderation of alcohol intake

– Increased physical activity



Hypertension MxRecommendations

ACE (-) or ARBs (Don’t combine)

or Diuretics

Monitor serum creatinine / (e GFR)

and serum potassium levels.

(E)

Hypertension MxRecommendations

Multiple Drug Therapy (≥ 2 agents) is

generally required (B)

Including a thiazide diuretic and ACE inhibitor/ARB, at maximal doses)

is generally required to achieve blood pressure targets

Administer one or more antihypertensive

medications at bedtime. (A)

DM / Hypertension Mx

< 130 c / 80 B mmHg

Minimal Goal is

< 140 A / 90 A mmHg

ADA-2015


DYSLIPIDEMIA

Intensity Vs Targets

DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012

Screening

• At the time of first diagnosis

• Initial medical evaluation

• and/or at age 40 years and

Re-assessments may be repeated

periodically every 1-2 years (E)

Recommendations:Dyslipidemia/Lipid Management

DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012.

LipidsRx Recommendations and Goals

Lifestyle modification (TLC) has been

shown to Improve the lipid profile in

patients with diabetes. (A)

This include:

- Reduction of saturated fat, trans fat, and cholesterol intake

-Increase of n-3 fatty acids, viscous fiber and plant stanols / sterols

-Weight loss (if indicated); and increased physical activity

Lipids

ADA 2014… was

To get specified LDL target

Statin therapy should be added, regardless of

baseline lipid levels, for DM patients:

- With overt CVD.

-Without CVD who is > 40 years old and have ≥ 1 other

CVD risk factors. (A)

A reduction in LDL cholesterol of 30–40% from

baseline is an alternative therapeutic goal. (A)

Statins use is based on desired

LDL-C Intensity lowering

rather than LDL target number

Adjustment of intensity of statin therapy

may be needed based on individual patient response to

medication

(e.g., side effects, tolerability, LDL cholesterol levels). E

Lipids

ADA 2015

NICE Guidelines -Dyslipidemia and (CVD)

Do not use a risk assessment tool for people

1-With type 1 DM

2-With pre-existing CVD

3-Familial hyper-cholesterolemia

4-With CKD ; e GFR < 60 ml/min/1.73 m2 and/or

albuminuria

Statins intensity categories of lowering LDL –C NICE vs ACC/AHA

NICE

low intensity

20% to 30%

medium intensity

31% to 40%

high intensity > 40%

ACC/AHA

low intensity

<30%

medium intensity

30% to <50%

high intensity ≥ 50%

Statins intensity categories of lowering LDL –C

ACC/AHA

Again…

Adjustment of intensity of statin therapy

may be needed based on individual patient

response to medication

(e.g., side effects, tolerability, LDL cholesterol levels). E

Lipids

ADA 2015

Lipids

ADA 2014… was

If targets are not reached;

Use combination therapy

of lipid lowering agents.

(No outcome studies;

CVD outcomes or safety. (E)

Combination therapy

(statin/ fibrate and statin/niacin)

has not been shown to provide additional

cardiovascular benefit above statin therapy alone

and is Not generally recommended

A

Lipids

ADA 2015

A1C <7.0%

<6.5%

Blood pressure <140/90 mmHg

Lipids: Statins Moderate – High

Intensity

Glycemic, BP, Lipid Control in Adults


DIABETES CARE , JANUARY 2015

NEPHROPATHY

Nephropathy-Screen

At least once a year

Assess , quantitatively

Urinary albumin

(e.g., urine albumin /creatinine ratio [UACR]) and

estimated glomerular filtration rate (e GFR)

Type 1 DM ≥ 5 years / All Type 2 DM

Nephropathy-Screen

Nephropathy-Treatment

ACE inhibitor or (ARB) is

Not recommended

for the primary prevention of diabetic kidney

disease in patients with DM with

Normal BP and normal UACR (< 30 mg/g)

B

Nephropathy-Nutrition

Diabetic kidney disease

Reducing the amount of dietary protein below the

recommended 0.8 g/kg/day

Not recommended

(it does not alter glycemic measures, CV risk measures,

or the course of GFR decline)

A

NephropathyKey Concepts

Optimize DM & HTN control (A)

Treatment of Albuminuria

with ACE(-) or ARB based Rx (A)

DIABETES CARE, , JANUARY 2015


Anti-Platelets

& DIABETES

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Aspirin

Use aspirin therapy (75–162 mg/day) as a

secondary prevention strategy in those

with diabetes with a history of CVD. (A)

* U.S. Physicians' Health Study, Early Treatment Diabetic Retinopathy Study

(ETDRS), Hypertension Optimal Treatment (HOT)

DIABETES CARE, SUPPLEMENT 1, JANUARY 2015

Aspirin- Primary prevention

Consider ASA as a primary prevention strategy in those with type 1 or type 2 DM at increased cardiovascular risk (10-year risk > 10%)

This includes most men >50 years or women >60 yearsWith at least one additional major risk factor

(Family Hx. of CVD, Hypertension, Smoking, Dyslipidemia,or Albuminuria)

(C)

-US Preventive Services Task Force (USPSTF): Aspirin for the prevention of cardiovascular disease:

U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;150:396–404

-Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the

evidence for the (USPSTF): . Ann Intern Med 2009;150:405–410 238.

DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012

Take Home

Messages

Take Home Messages

Guidelines …evolving

Treat patients …Not numbers !

Individualize

Team work

Take Home Messages

TLC

(dietary and exercise) modifications are

essential for all patients with DM

EMPOWER

Individualize and get patient involved

Take Home Messages

• Treat

Hyperglycemia, HTN & Dyslipidemia

with the same intensity

• Achieve Targets

….Safely

Diabetes Mellitus Targets For Control (ADA-2015)

Parameter Goal Action

Suggested AC Glucose

Post-P Glucose

80-130

< 180

<80 or >140

>180

HS glucose 100-140 <100 or >160

HbA1c % <7 (6.5) >7

BP (mmHg.) <140/90 >140/90

LDL-Chol

TG

≥ 40-50%

<150

DM patients

HDL-Chol >40 males

>50 females

<40

<50

Remember Your ABCs

A:

A1C ASA Albuminuria

B: Blood Pressure

C: Cholesterol

Cardiac

D: Diabetes education

Diet / Dietician

E: Eye exam

Exercise

F: Foot care

G: Glucose monitoring

H: Health ;

Vaccination

D/C Smoking

I: Identify need for

referral

Health & Medicine

DM Standards of Care 2015 ;The ABcs