Download TYPE 2 DIABETES MELLITUS: REVIEW OF Clinical Practice

TYPE 2 DIABETES MELLITUS
Review of Clinical Practice Guidelines
WEEK 1: Diagnosis and Evaluation
UHN AIMGP CLINIC
SEMINAR SERIES 2007
Updated by Dr. K. Tzanetos
TYPE 2 DIABETES MELLITUS
Review of Clinical Practice Guidelines
Canadian Diabetes Association (CDA): 2003 Clinical
Practice Guidelines for the Prevention and
Management of diabetes in Canada.

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Can J Diabetes 2003; 27 (Suppl 2).
http://www.diabetes.ca/cpg2003
American Diabetes Association (ADA): Clinical
Practice Recommendations 2004.
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Diabetes Care 2004; 27 (Suppl 1).
TYPE 2 DIABETES MELLITUS
Objectives:
1) Examine diagnostic criteria for type 2 diabetes
2) Discuss screening recommendations for type 2
diabetes
3) Explore the suggested evaluation for first visit
4) Appreciate the importance of follow-up
5) Identify specific disease complications
- retinopathy/nephropathy/foot ulcerations
DIABETES MELLITUS
Take a minute to discuss…
CASE:
Mrs. X is a 58 year old woman referred to
the AIMGP clinic by her GP with a random
glucose of 12.0 mmol/L. She feels well with
no complaints and this testing was done as
a part of her routine blood work.
 Does she have diabetes ?
 What further testing could
decide?
help you to
DIABETES MELLITUS
Diagnostic Criteria for Type 2 DM
CASE: Mrs. X.
 Does she have diabetes?
 Likely! BUT you must do further tests.
 Further
testing needed…2 confirmatory
laboratory glucose tests (FBG, random
PG or 2hr 75g OGTT) on separate days
in the absence of unequivocal
hyperglycemia accompanied by an acute
metabolic decompensation.
DIABETES MELLITUS
Diagnostic Criteria for Type 2 DM
Random PG ≥ 11.1mmol/L* and symptoms of diabetes
OR
Fasting plasma glucose (FPG) ≥ 7.0 mmol/L†
OR
2h PG in a 75-g oral glucose tolerance test (OGTT) ≥ 11.1
mmol/L
* Symptoms include fatigue, polyuria, polydipsia and
weight loss
† Fasting is defined as no caloric intake for at least 8 h
DIABETES MELLITUS
Diagnostic Criteria for Type 2 DM
Glucose levels (mmol/L) for diagnosis:
FPG
2 h PG in a 75g OGTT
NA
IFG
6.1 - 6.9
IFG
(isolated)
IGT
(isolated)
IFG and
IGT
Diabetes
6.1 - 6.9
and
< 7.8
< 6.1
and
7.8 - 11.0
6.1 - 6.9
and
7.8 - 11.0
≥ 7.0
or
≥ 11.1
DIABETES MELLITUS
Take a minute to discuss…
BACK TO THE CASE: Mrs. X is a Caucasian
female who has no other PMHx. Her family
history is negative.

Should Mrs. X. have been screened before
now for type 2 diabetes?

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By what method?
What high risk groups should undergo more
frequent or earlier screening?
DIABETES MELLITUS
3) Screening for Type 2 DM
All individuals should be evaluated annually
for DM2 risk (demographic/clinical criteria)
 In persons 40 yrs of age screening for DM2
using a FPG should be performed every 3
yrs
 More frequent and/or earlier screening
should be considered in ‘high risk’ groups

DIABETES MELLITUS
3) Screening for Type 2 DM

Risk factors for Type 2 DM (CDA)
First-degree relative with diabetes
 Member of high-risk population (e.g. persons of
Aboriginal, Hispanic, S. African, Asian or S. Asian
descent)
 History of IGT or IFG
 Presence of complications of DM
 Vascular disease (**assoc. with the metabolic synD)
 History of GDM

DIABETES MELLITUS
3) Screening for Type 2 DM

Risk factors for Type 2 DM (CDA) cont’
History of macrosomal infant
 HTN (**)
 Dyslipidemia (**)
 Overweight (**)
 PCOS (**)
 Acanthosis nigricans (**)
 Schizophrenia (incidence 3X higher than the gen.
population)

DIABETES MELLITUS
3) Screening for Type 2 DM

CDA guidelines mandate yearly screening in
patients with:
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Hx of IFG or IGT
Presence of complications associated with diabetes
Hx of gestational diabetes or macrosomic infant
(>4kg)
Presence of HTN or CAD
Screening Method

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FPG (universal recommendation)
2 h PG OGTT if FPG not diagnostic
Lack of standardization of the HBA1C test precludes its
use for diagnosis
DIABETES MELLITUS
Take a minute to discuss…
CASE:
• Assume that you have taken a thorough
medical history from Mrs. X that has
included symptoms of hyperglycemia,
symptoms of macrovascular and
microvascular complications, nutritional
details, and medical co-morbidities.

What would you now like to emphasize on
Mrs. X.’s physical examination during her
initial visit?
DIABETES MELLITUS
Evaluation at first visit

PE in a patient with DM:
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General (height, weight, BMI, postural BP, HR)
H & N (Pupils, EOMs, Lens opacities, fundi, oral hygiene
and dental caries, thyroid)
CVS (signs of HTN, CHF, CAD; pulses, bruits, other signs
of PVD)
Abdomen (hepatomegaly)
GU (r/o fungal infections, bladder distension)
MSK (foot inspection, colour, temperature, arthropathy)
Neuro (dysesthesiae, change in proprioception, vibration,
light touch [monofilament], reflexes, autonomic nervous
system)
Skin (infections, dyslipidemias, ulcers, trauma, injection
sites)
DIABETES MELLITUS
Take a minute to discuss…
CASE:

What laboratory tests would you like to
obtain on or shortly after Mrs. X.’s initial
visit ?
DIABETES MELLITUS
Evaluation at first visit

What laboratory tests would you like to obtain on or
shortly after Mrs. X.’s initial visit (ADA)?
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FPG (optional), HbA1c
Fasting lipid profile
Serum creatinine, Urinalysis
Test for microalbuminuria (type 1 diabetic patients after at
least 5 years and in all patients with type 2 diabetes at
diagnosis)
Urine culture (if indicated)
Thyroid-stimulating hormone (TSH) in all type 1 diabetic
patients; in type 2 if clinically indicated
ECG
DIABETES MELLITUS
Take a minute to discuss…
CASE:
 How frequently should patients like Mrs. X be
followed after the initial visit?

Consider the following patient circumstances:
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Diabetes is Diet controlled
Patient on oral hypoglyemics (at initiation, when titrating,
on maintenance dosing)
Patient on insulin (at initiation, when titrating, on
maintenance dosing)
For routine visits if they are meeting goals
For routine visits if they are not meeting goals
DIABETES MELLITUS
Evaluation in follow-up

Follow-up Visit Frequency (ADA)?
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Daily for initiation of insulin or change in
regimen
Weekly for initiation of oral hypoglycemic
agents or change in regimen
(Are we meeting, or do we need to meet, these
guidelines in AIMGP?)
Routine diabetes visits:
 Quarterly for patients who are not meeting
goals
(Is this frequent enough?)
 Semi-annually for patients with wellcontrolled diabetes
DIABETES MELLITUS
Take a minute to discuss…
CASE:

What historical information will you gather on Mrs. X’s
follow-up visits?

What would you like to emphasize on Mrs. X.’s physical
examination during her follow-up visits?
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Include discussion on appropriate frequency of various maneuvers
What laboratory tests would you like to obtain on or shortly
after Mrs. X.’s follow-up visits?

Include discussion on appropriate frequency of various tests
DIABETES MELLITUS
Evaluation in follow-up

History taking on follow-up visits:
Treatment regimens (frequency of
hyper/hypoglycemia, acute symptoms, selfmonitoring BG results, pt regimen adjustments,
adherence problems)
 Lifestyle changes
 Symptoms of chronic complications (including
ensuring visits to opthomologist)
 Changes in co-morbidities
 Psychosocial issues
 Immunization status

DIABETES MELLITUS
A Note on Retinopathy: Opthomology
Follow-up
•
Type 2 diabetes:
•
•
•
At time of diagnosis
1 year or less if retinopathy present
Every 1-2 yrs on advice of eye care professional
if no evidence of retinopathy
DIABETES MELLITUS
Evaluation in follow-up

Physical Examination at Follow-up Visits
(ADA)?
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At every regular diabetes visit:
 Weight
 BP
 Previous abnormalities on physical exam
Complete physical exam annually
Comprehensive foot examination annually and
visual inspection at every visit (and shoes!!)
DIABETES MELLITUS
A Note on Foot Care
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Initial visit and annually thereafter IDENTIFY:
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Peripheral neuropathy (monofilament or vibration)
Altered biomechanics (evidence of increased pressure callus, erythema; limited joint mobility; bony deformity;
or severe nail pathology - thick nails)
Peripheral vascular disease (hx of claudication, pulse
exam, skin exam)
History of ulcers or amputation
The presence of any of these risk factors requires
visualization of the patient’s feet at every
subsequent visit
DIABETES MELLITUS
Evaluation in follow-up
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Laboratory tests at follow-up visits (ADA)
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HbA1c
 Quarterly if medications change or patient
not meeting goals
 Semi-annually if stable
FPG (optional)
Fasting lipid profile annually, unless low risk
Urinary microalbumin measurement annually (if
indicated)
DIABETES MELLITUS
A Note on Nephropathy: Screening

Annual screening with a random daytime urine albumin:
creatinine ratio (ACR)
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For values ≥ 2.8 for females and 2.0 for males the test should
be repeated
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confirmed in 2 out of 3 measurements over 3 months
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Uncertainty is clarified by 24h urine for protein
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Microalbuminuria = 30 - 299 mg of albumin/24hrs

NB: If patients are dipstick positive, they will likely have
macroalbuminuria
DIABETES MELLITUS
UHN AIMGP CLINIC
SUMMER SERIES 2007
Next week - Therapy of Type 2 DM
Non-pharmacologic and
pharmacologic