Download Clinical Slide Set. Type 2 Diabetes

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© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
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© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
in the clinic
Type 2 Diabetes
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
Should we screen for type 2 diabetes?
 Many people with diabetes are unaware of it
 Unclear if screening improves outcomes
 Consensus lacking
 Who should be screened? How often?
 Magnitude of benefit (if any)?
 Some groups recommend:
 Screen every third year if >45 or if ≤45 + risk factors
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
Risk Factors for Type 2 Diabetes
 Age >45 years
 First-degree relative with type 2 diabetes
 African American, Hispanic, Asian, Pacific Islander, or
Native-American ethnicity
 History of gestational diabetes or delivery of infant
weighing ≥9 lb
 The polycystic ovary syndrome
 Overweight, especially abdominal obesity
 Cardiovascular disease, hypertension, dyslipidemia,
other features of the metabolic syndrome
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
Which patients are likely to benefit from
screening?
 Patients with hypertension
 Blood pressure treatment goals should be the same for
those with and without diabetes
 Patients with risk factors for cardiovascular disease
 Diabetes screening most likely to improve outcomes in
these patients
 Knowledge of diabetes status alters likelihood of treatment
 When managing lipids: use a risk calculator that includes
diabetes as risk factor
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
Can type 2 diabetes be prevented?
 Diet and exercise
 Substantially reduce incidence in those with prediabetes
 Prediabetes = impaired fasting glucose / glucose tolerance
 Modest weight loss (5%–7% body weight) can be effective
 Medications
 Prevent diabetes onset in prediabetes
 Metformin
 Acarbose
 Rosiglitazone
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
CLINICAL BOTTOM LINE: Screening
and Prevention...
 Evidence doesn’t support broad-based screening programs
 Diabetes can be prevented in persons with prediabetes
 Diet and exercise universally beneficial
 Medications for those who can’t achieve lifestyle goals
 Loss of 7% of body weight + 150 minutes of exercise per
week substantially reduces diabetes risk
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
What are the diagnostic criteria for type 2
diabetes in nonpregnant adults?
 Pre-diabetes
 HbA1c level 5.7–6.4%
 Fasting plasma glucose 5.55-6.94 mmol/L (100-125 mg/dL)
on 2 occasions ≥1 day apart
 Diabetes
 HbA1c level ≥6.5%
 Fasting plasma glucose ≥7.0 mmol/L (≥126 mg/dL)
 Classic symptoms
 Polyuria, polydipsia, polyphagia, weight loss
 Evidence of diabetes complications
 Retinopathy, nephropathy, neuropathy, impotence,
acanthosis nigricans, or frequent infections
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
What should the initial evaluation of
patients with newly diagnosed type 2
diabetes include?
 Detailed history and physical
 Review of diet and physical activity
 Assessment of cardiovascular, cerebrovascular, ED
 Blood pressure measurement
 Inspect for possible diabetes complications via
cardiovascular, neurologic, skin, and foot examinations
 Lab tests to assess levels of glucose control,
cholesterol levels, nephropathy, liver function
 Ophthalmologic assessment to evaluate for retinopathy
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
CLINICAL BOTTOM LINE: Diagnosis
and Evaluation...
 Consider type 2 diabetes when patients present with
 Suggestive symptoms or signs
 Complications of disease
 Confirm diagnosis
 HbA1c ≥6.5% or fasting plasma glucose levels >7.0 mmol/L
(126 mg/dL) on 2 occasions ≥1 day apart
 Examine newly diagnosed patients for hypertension and
neurologic, ophthalmologic, and podiatric complications
 Lab evaluation should include assessment of glucose control,
lipid profile, and urine microalbumin-creatinine ratio
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
What are the components of nondrug therapy
for patients with type 2 diabetes?
 Lifestyle changes are cornerstones of management
 Diet and exercise
 First-line therapy unless severe hyperglycemia requires
immediate medication treatment
 ADA nutrition guidelines:
http://care.diabetesjournals.org/content/37/Supplement_1/S
120.full
 Individualize assessment to develop feasible strategy
 No one diet or exercise regimen applies to all patients
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
What is the role of home glucose monitoring?
 Allows longitudinal monitoring of glucose control
 Real-time feedback on effect of treatments
 Standard of care for persons receiving insulin therapy
 Allows sensible dose adjustments
 Shows if symptoms are from hyper- or hypoglycemia
 Frequency left to discretion of patient and provider
 Monitor fasting and premeal glucose levels
 Postprandial measurement may be helpful if HbA1c levels
elevated despite normal fasting levels
 Role to guide oral therapy is less clear
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
What is the target HbA1c level?
 No clear single HbA1c target applies to all patients
 Adjust targets to life expectancy + comorbid conditions
 Most organizations and quality measurement groups
advocate a target ≤7% for most patients
 Moderate control (HbA1c 7%-8.5%) probably provides the
most benefit for most patients
 Patients with long life expectancy (≥20 years) may eventually
realize benefit from more intensive control (HbA1c <7%)
 But more aggressive control may increase mortality
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
When should treatment include drugs?
 If diet and exercise don’t achieve the goal within ≈6 wks
 In all patients except those with only mild HbA1c
elevations
 Severe hyperglycemia or symptoms may require
pharmacologic intervention immediately
 Sometimes with insulin
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
How should physicians select therapies
from among the many oral drug options?
 Most drugs achieve similar glycemic control
 Insufficient data on relative efficacy for clinical end points
 Differ in mechanism, tolerability, timing of administration
 Metformin is often first-line therapy
 If metformin contraindicated or not tolerated, consider
patient preferences on potential side effects, efficacy, cost
 Worsening glycemic control over time requires >1 agent
 If increasing the dose of existing oral agents isn’t enough
 Combination formulations may provide advantages in
convenience or cost
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
When should physicians consider insulin
therapy?
 If patients can’t achieve goals through oral medications
 If rapid reduction of blood glucose needed
 If HbA1c levels are markedly elevated at diagnosis
 Many formulations (biphasic, prandial, basal) available
 Separated primarily by their onset of action and duration
 Unclear that any particular regimen is superior
 Primary risks: hypoglycemia and weight gain
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
What other options are available if control is
inadequate on traditional oral drugs or insulin?
 Glucagon-like peptide-1 (GLP-1) agonists
 Act through GLP-1, a naturally occurring hormone involved
in glucose homeostasis
 Dipeptidyl peptidase-IV (DPP-IV) inhibitors
 Work through the incretin and GLP-1 pathway
 Sodium glucose-linked transporter-2 (SGLT2) inhibitors
 Block glucose transport in the kidney
 Synthetic forms of pancreatic hormones
 Pramlintide: subcutaneously administered synthetic form
of amylin
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
Noninsulin Medications for Type 2
Diabetes
 Biguanides (metformin, metformin XR)
 Sulfonylureas (glimepiride, glipizide, glipizide SR, glyburide,
glyburide micronized)
 Thiozolidinediones (pioglitazone, rosiglitazone)
 Alpha-glucosidase inhibitors (acarbose, miglitol)
 Nonsulfonylurea insulin secretagogues (repaglinide, nateglinide)
 DPP-IV inhibitors (sitagliptin, saxagliptin, linagliptin, alogliptin)
 SGLT2 inhibitors (canaglifozin, empaglifozin, dapagliflozin)
 GLP-1 agonists (injectable) (exenatide, exenatide XR, liraglutide,
abliglutide, dulaglutide)
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
What novel therapeutic options are on the
horizon?
 Additional DPP-IV inhibitors
 Vildagliptin approved for use in the EU
 Anagliptin and teneligliptin approved for use in Japan
 Additional SGLT2 inhibitors
 Also in development
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
Aside from glycemic control, what other
clinical interventions reduce complications?
 Control of blood pressure
 Use of lipid-lowering agents
 Aspirin therapy
 Retinal examination
 Neuropathy screening
 Foot care
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
Therapies to Reduce Neuropathy Symptoms
 Tricyclic antidepressants
 Duloxetine
 Capsaicin cream
 Antiepileptic agents
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
How frequently should physician see
patients with type 2 diabetes, and what
should be included in follow-up visits?
 Quarterly
 Based on expert opinion
 Recommended frequency of monitoring HbA1c levels
 Once disease is stable, reduce to every 6 months
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
When should specialists be consulted?
 Certified diabetes educator
 To improve key domains in diabetes care (glycemic control)
 Endocrinologist
 To address questions about diagnosis or when glucose
management has become difficult
 Refer patients if pregnant or contemplating pregnancy
 Ophthalmologist
 For examination every 1 to 3 years
 Frequency depends on prior exam results + glucose control
 Nephrologist
 If GFR <30 ml/min/1.73 m2 or renal insufficiency origin unclear
 If patients have hyperkalemia, acidemia, trouble controlling BP
 Podiatrist
 To manage lesions to reduce risk for foot ulcers, amputation
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
When should patients with type 2 diabetes
be hospitalized?
 Severe, symptomatic hyperglycemia
 Diabetic ketoacidosis or hyperosmolar coma
 Diabetes complications
 Cellulitis or osteomyelitis may require IV antibiotics or
surgery
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.
CLINICAL BOTTOM LINE: Treatment...
 Achieve glycemic targets on individual basis
 Based on life expectancy and patient preference
 Aim for at least moderate level of control (HbA1c <8.0%–8.5%)
 Minimizes hyperglycemia
 Limits microvascular risk
 Reserve more aggressive targets (<7.0%) for patients with a
long life expectancy
 Reductions in advanced diabetes complications take 15 to
20 years to accrue
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (3): ITC3-1.