Download Standards of Medical Care in Diabetes by ADA—2016

Standards of Medical Care in
Diabetes by ADA—2016
Speaker: 內分泌新陳代謝科
蘇聖強醫師
Date: Jan. 05, 2016
1
• Introduction
• Diabetes care at OPD
• Diabetes care during hospitalization
• Summary of revisions
• Take home message
Introduction
Adv Drug Deliv Rev. 1999 Feb 1;35(2-3):157-177
Adv Drug Deliv Rev. 1999 Feb
1;35(2-3):157-177
Glucose (mg/dL)
Relative Amount
第2 型糖尿病病理生理學：疾病進展
Prediabetes
(IFG, IGT)
250
Diagnosed
diabetes
Insulin resistance
200
resistance rises, there is a
compensatory increase in
insulin secretion and
glucose levels remain
Insulin level
normal
 As β-cell dysfunction
worsens, insulin secretion
falls, IGT and hyperglycemia
Postmeal glucose
become apparent, and overt
type 2 diabetes develops
 Glucose levels, both pre- and
Fasting glucose
postprandially, increase
steadily as the individual
progresses from
normoglycemia to IGT and,
finally, type 2 diabetes
150
100
Incretin effect
50
β-cell function
 In early stages, as insulin
0
350
300
250
200
150
100
50
-15
-10
-5
0
Diabetes
Onset
5
10
Years
15
20
25
30
IFG=impaired fasting glucose;
IGT=impaired glucose tolerance.
Representative depiction of time course
and function.
Kendall DM et al. Am J Med. 2009;122(6A):S37-S50.
Trends Endocrinol Metab. 2010 Nov;21(11):652-9
Cell. 2012 Sep 14;150(6):1223-34
Nature. 2006 Dec 14;444(7121):840-6.
Diabetes. 2009 Apr;58(4):773-95.
DCCT/EDIC: glycaemic control reduces the risk of non-fatal
MI, stroke or death from CVD in type 1 diabetes
HbA1C (%)
9
Conventional treatment
8
Intensive treatment
7
0
Cumulative incidence of
non-fatal MI, stroke or
death from CVD
1
2
3
4
5
6
7
8
DCCT (intervention period
0.06
9
10
11 12 13 14 15 16 17
EDIC (observational follow-up)
57% risk reduction
in non-fatal MI, stroke or CVD death*
(P = 0.02; 95% CI: 12–79%)
0.04
0.02
Years
Conventional
treatment
Intensive
treatment
0.00
0
1
2
3
4
5
6
7
8
DCCT (intervention period)
9 10 11 12 13 14 15 16 17 18 19 20 21
EDIC (observational follow-up)
Years
DCCT. N Engl J Med 1993; 329:977–986.
DCCT/EDIC. N Engl J Med 2005; 353:2643–2653.
Effect of a multifactorial intervention on mortality in type 2 diabetes
(N Engl J Med 2008; 358; 580-91)
2011 ADA guideline
資料來源:健康局委託糖尿病衛教學會針對糖尿病健康促進機構抽樣調查
2006年 114家 7159人
2011年 145家 4296 人
Diabetes care at OPD
Strategies for Improving Care
•
•
•
•
•
•
Patient-centered communication style
Patient-centered approach should include :
Blood pressure and lipid control
Smoking prevention and cessation
Weight management
Physical activity, and healthy lifestyle choices
• 33–49% of patients still do not meet targets for
glycemic, blood pressure, or cholesterol
control
• Only 14% meet targets for all three measures
and nonsmoking status
• Assess adherence should be addressed as the
first priority.
• If adherence is 80%or above, then treatment
intensification should be considered
• If medication up-titration is not a viable
option, then changing to a different medication
• Intensive glucose control is not advised for the
improvement of poor cognitive function in
hyperglycemic individuals with type 2 diabetes
• Treating depression may improve short-term
glycemic control
• Patients with HIV should be screened for diabetes
and prediabetes with a fasting glucose level
• Before starting antiretroviral therapy and 3 months
after starting or changing it. (PI and NRTIs)
• If normal, fasting glucose each year is advised.
• If prediabetes, measure levels every 3–6 months
Classification and
Diagnosis of Diabetes
1. Type 1 diabetes
2. Type 2 diabetes
3. Gestational diabetes mellitus (GDM)
4. Specific types of diabetes due to other causes
• It is recommended that the same test be
repeated without delay using a new blood
sample for confirmation because there will be
a greater likelihood of concurrence
• If the A1C is 7.0% and a repeat result is
6.8% diabetes is confirmed
• If the A1C is 7.0% and FPG =110 mg/dl
recheck A1C for final Dx
• If the A1C (two results＞6.5) but not FPG (＜
126 mg/dL) DM is confirmed
• To test for prediabetes equally appropriate
• Fasting plasma glucose
• 2-h plasma glucose after 75-g oral glucose
tolerance test
• A1C
• In patients with prediabetes, identify and, if
appropriate, treat other cardiovascular disease
risk factors
N Engl J Med 2011; 364:1315-1325
2015 糖尿病臨床照護指引
Foundations of Care and
Comprehensive Medical Evaluation
Crit Care Med 2010 Vol. 38, No. 3
Prevention or
Delay of Type 2 Diabetes
• Patients with prediabetes should be
• An intensive diet and physical activity loss
of 7% of body weight
• Increase their moderate-intensity physical
activity (such as brisk walking) to at least 150
min/week
• Metformin therapy for prevention of type 2
diabetes in prediabetes, especially in:
• BMI ＞35 kg/m2
• Aged＜60 years
• Women with prior GDM
Glycemic Targets
• Perform the A1C test at least two times a year
in patients :
• Meeting treatment goals
• Stable glycemic control).
• Perform the A1C test quarterly in patients:
• Whose therapy has changed
• Not meeting glycemic goals
2011 ADA Guidelines
Glycemic Goal for non-pregnant adults with diabetes
HbA1c
Preprandial capillary plasma glucose
Peak postprandial plasma capillary glucose
■
<7%
70-130 mg/dL
<180 mg/dL
Goals should be individualized based on:
● duration of Diabetes
● age/life expectancy
● comorbid conditions
● known CVD or advanced microvascular complications
● hypoglycemia unawareness
■ More or less stringent goal may be appropriate for individuals
■ Target postprandial glucose goals if A1C goals are not met despite
reaching preprandial glucose goals
(ADA: Standards of Medical Care in Diabetes. Diabetes Care 2010; 34: S21)
Obesity Management for the
Treatment of Type 2 Diabetes
• At each patient encounter, BMI should be
calculated and documented in medical record
• When choosing glucose-lowering medications
for overweight or obese patients with type 2
diabetes, consider their effect on weight
Approaches to
Glycemic Treatment
Cardiovascular Disease and
Risk Management
• Systolic Targets: <140 mmHg and lower as
<130 mmHg, may be appropriate for 
• Younger patients
• Albuminuria
• Hypertension and one or more additional
ASCVD risk factors
• Diastolic Targets:
• <90 mmHg and lower diastolic targets, such as
＜80 mmHg, may be appropriate for  as the
SBP
• Patients with BP>120/80 mmHg should be
advised on lifestyle changes
• Patients with confirmed office-based blood
pressure>140/90 mmHg should have prompt
initiation and timely subsequent titration of
pharmacological therapy
2011 ADA Guidelines
成年糖尿病人脂質異常治療之目標
目標
無併CVD
Total Chol LDL-Chol HDL-Chol
<160
併有CVD(1) <160
<100
<70
>40
>50
>40
>50
TG Non-HDL-C Apo-B
(M) <150
(F)
(M) <150
(F)
<130
<90
<100
<80
(1) 併有CVD，或年齡>40歲且具一個CVD危險因子以上，應服statin
(2) LDL-Chol >100 mg/dL者，應服statin
(3) Statin最大量未達目標，宜併服niacin, fenofibrate, ezetimibe,
bile acid sequesterants
(4) 減少飽和和反式脂肪酸、多攝取fiber、多運動、減少體重
(5) 控制血糖和血壓
Older Adults
Diabetes care during
hospitalization
N Engl J Med 2006;355:1903-11
Am J Health-Syst Pharm—Vol 67 Aug 15, 2010 Suppl 8
Diabetes Care 2015;38(Suppl. 1):S80–S85
Am J Health-Syst Pharm—Vol 67
Aug 15, 2010 Suppl 8
Summary of revisions
GENERAL CHANGES
• Diabetes does not define people, the word
“diabetic” will no longer be used
• Continue to use the term “diabetic” as an
adjective for complications related to diabetes
(e.g., diabetic retinopathy)
Classification and
Diagnosis of Diabetes
• Fasting plasma glucose
• 2-h plasma glucose after a 75-g oral glucose
tolerance test
• A1C criteria
• No one test is preferred over another for
diagnosis
• Now to test all adults beginning at age 45
years, regardless of weight
• Asymptomatic adults of any age:
• Overweight or obese
• One or more additional risk factors for
diabetes
Prevention or Delay of
Type 2 Diabetes
• Encouraging the use of new technology such
as apps and text messaging to affect lifestyle
modification to prevent diabetes
Glycemic Targets
• People who use continuous glucose monitoring
and insulin pumps should have continued
access after they turn 65 years of age
Obesity Management for
the Treatment of Type 2 Diabetes
• New recommendations related to the
comprehensive assessment of weight in
diabetes
• Treatment of overweight/obesity with behavior
modification an pharmacotherapy
Cardiovascular Disease and
Risk Management
• “Atherosclerotic cardiovascular disease”
(ASCVD) has replaced the former term
“cardiovascular disease” (CVD), as ASCVD is
a more specific term
• Consider aspirin therapy in women aged ＞60
years has been changed to include women
aged ＞＝50 years.
• Address antiplatelet use in patients aged ＜50
years with multiple risk factors.
• Adding ezetimibe to moderate-intensity statin
provides additional cardiovascular benefits
• A new table provides efficacy and dose details
on high- and moderate intensity statin therapy.
Microvascular
Complications and Foot Care
• “Nephropathy” was changed to “diabetic
kidney disease”
• Diabetic retinopathy:
• Intravitreal anti- VEGF agents for the
treatment of center-involved diabetic macular
edema
• More effective than monotherapy or
combination therapy with laser.
Older Adults
•
•
•
•
•
•
Neurocognitive function
Hypoglycemia,
Treatment goals
Care in skilled
Nursing facilities/nursing homes
End-of-life considerations
Children and Adolescents
• Obtain a fasting lipid profile in children
starting at age 2 years has been changed to age
10 years
Management of Diabetes
in Pregnancy
• A1C recommendations for pregnant women
with diabetes were changed from a
recommendation of ＜6% to a target of 6–
6.5%
• Glyburide in GDM may be inferior to insulin
and metformin.
Diabetes Care in the
Hospital
• More detailed information on glycemic targets
and antihyperglycemic agents, standards for
special situations
• New table on basal and bolus dosing
recommendations for continuous enteral, bolus
enteral, and parenteral feedings.
Take home message