Download Diagnosis and Screening in Diabetes

Duke Internal Medicine Residency Curriculum
Diabetes: A Brief Summary on
Diagnosis and Screening
Jason Goebel, MD
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Duke Internal Medicine Residency Curriculum
Learning Objectives
•
•
•
•
•
•
•
•
•
Realize the economic impact and health care burden of diabetes
Understand epidemiological characteristics of diabetes
Describe both screening and definitive diagnosis of diabetes
Be able to describe testing for gestational diabetes
Recall the intervals and indications for screening for other comorbidities associated with diabetes
Apply current ADA standards to your patient care involving foot
care, eye exams, ASA therapy, and screening for CAD, HTN, and
HL
Encourage all smokers to stop smoking
Understand currently vaccination guidelines for diabetics
Be able to apply ADA guidelines to hypothetical patient
scenarios
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Overview
The following presentation will briefly review the
epidemiology, economic impact, current shortcomings in
care, and diagnosis of diabetes. In addition, it will give a
more in depth summary of screening and health
maintenance recommendations as outlined by the
American Diabetes Association.
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Epidemiology
• >7% of people in the US are known to have diabetes
• Health care costs account for approximately 20% of the
US Gross Domestic Product1
• DM accounts for 14% of US health care expenditures
– Mostly from vascular complications
•
•
•
•
•
Myocardial infarction
Strokes
ESRD
Retinopathy
Foot ulcers
– Costs in 2002 were estimated at 132 billion US dollars2
– This figure grossly underestimates current burden on health
care expenditures
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Current Compliance to Practice Guidelines
•
•
•
Despite well-published guidelines supported by sound data most
diabetics are not receiving recommended levels of healthcare3
In academic centers rates of testing for risk factors are quite high
(>90%). However, rates of medication adjustment were much lower (640%)4,5
NHANES III (US National Health and Nutritional Examination Survey)
demonstrated inadequacy of obtaining treatment goals:6
–
–
–
–
–
•
•
•
•
18%
34%
58%
37%
45%
had
had
had
had
had
A1C >9.5
BP > 140/90 (previous treatment goal)
LDL >130 (previous treatment goal)
no annual eye exam
no dedicated foot exam
Lower compliance has been demonstrated in uninsured populations6
Screening for other health issues is suboptimal in diabetic patients7
Data comparing compliance to practice guidelines by diabetic specialists
versus primary care physicians has been equivocal8
Outcomes are improved by implementing organized screening
programs9
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Classification of Diabetes10
• Type 1 Diabetes
– Results from beta-cell destruction and insulin deficiency
• Type 2 Diabetes
– Progressive insulin secretory defect in addition to insulin
resistance
• Gestational Diabetes (GDM)
– Diagnosed during pregancy
• Other types or acquired diabetes
• Impaired Fasting Glucose
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Diagnosis11
• Oral Gucose Tolerance Test (OGTT)
– Baseline fasting glucose followed by 75g oral glucose load
with measurement of serum glucose 1 and 2 hours later
– More sensitive and specific than fasting plasma glucose
(FPG)
– More difficult and time consuming for patients and more
costly
• Fasting Plasma Glucose (preferred method)
– Glucose measured 8 hours after fasting overnight
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Diagnosis
• Hemoglobin A1C
– Measure of average blood glucose over past 90 days
– Results variable depending on transfusions, acute illness,
and other factors
– Most patient who meet diagnostic criteria for diabetes by
OGTT but not FPG will have an A1C < 7
– Not an acceptable measure to diagnose diabetes
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Diagnosis
• Symptoms of diabetes plus a random plasma glucose
concentration >/=200 mg/dL
• Classic symptoms of diabetes such as unexplained weight loss,
polydipsia, polyuria, or blurred vision
-OR-
• Fasting plasma glucose concentration >/=126 mg/dL
• No caloric intake for 8 hours
-OR-
• 2-hr plasma glucose concentraion >/= 200 mg/dL on a
OGTT
• If symptoms are not present values should be
confirmed on repeat examination
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Gestational Diabetes-Diagnosis
• Gestational Diabetes
– Initial screening involves measurement of BG 1 hour after
50g oral glucose load
• If BG is greater than 140 one of two OGTT below should
be performed and if any value exceeds maximal
concentration below diagnosis of GDM is obtained
– 100g glucose load (can be initial test if high pre-test
probability)
Time
Plasma glucose (mg/dL)
Fasting
– 75g glucose load (not as well validated)
Time
Fasting
Plasma glucose (mg/dL)
1hr
95
2hrs
180
3hrs
155
1hr
95
2hrs
180
3hrs
155
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Diagnosis
• Impaired fasting glucose (IPG) 100-125 mg/dL
• Impaired glucose tolerance (IGT) 2 hr glucose 140-199
mg/dL
• IPG and IGT have been termed "pre-diabetes" and are
risk factors for future diabetes and cardiovascular disease
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Blood Glucose Screening
• Screening to detect IGT, IFG, or DM should be considered
in individuals >/= 45 years of age especially if BMI is >/=
25
• Perform screening on younger individuals if they exhibit
other risk factors of diabetes
• Repeat screening every three years
• In confirmed diabetics hemoglobin A1C should be
measured every 6 months in well controlled populations
and quarterly in those not at goal or undergoing changes
in medication regimens
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Diabetic Retinopathy
• By 20 years, retinopathy is present in almost all patients
with DM1 and 50-80% in DM212
• Following retinopathy treatment and screening guidelines
would result in 169,000 person-years of sight and 325
million US dollars annually13
• Screening is performed by dilated opthalmoscopy by welltrained personnel or seven-field stereoscopic fundus
photography
– Both are well validated, cost-effective, comparable, and the
former easier to perform14
– Opthalmoscopy performed by primary care physicians is of
less sensitivity and specificity15
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Diabetic Retinopathy
• Patients with DM1 should undergo opthalmoscopy five
years after diagnosis diabetes or after puberty and
annually thereafter
– Trials have shown that in type 1 diabetics of less than 5 year
duration, none had proliferative retinopathy requiring laser
treatment and only 0.4% had preproliferative retinopathy15
• Type 2 diabetics should undergo screening at the time of
diagnosis and annually thereafter
• Patients with macular edema, severe nonproliferative
retinopathy, or proliferative retinopathy should be
followed closely by an experienced opthalmologist
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Diabetic Retinopathy
• The degree of protection from retinopathy is greatest in
those with early stages of the disease and directly
correlates with the degree of glycemic control16
• Management of HTN controls progression to retinopathy
and reduces risk of vitreous hemorrhage
• Diastolic BP appears to be a better predictor of progression than
systolic17
• UKPDS showed therapy with atenolol or captopril and resultant
decreases of BP to 144/87 and 154/87, respectively, resulted in
47%reduction in deterioration of retinopathy and visual acuity18
• Lisinopril has been shown to decrease events in a similar
fashion19
• No conclusive study has shown aspirin to reduce
development or progression of opthalmic complications of
diabetes20
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Routine Foot Examination
• Foot complications due to peripheral neuropathy and PVD
are a major cause of morbidity and mortality in diabetics
• Diabetics should undergo a comprehensive annual foot
exam and visual inspection of feet at each visit
– Comprehensive foot exam performed with Semmes-Weinstein
5.07 (10g) monofilament
– Screen for PVD by taking are careful history regarding
claudication and checking peripheral pulses. The presence of
pulses may be misleading since stiff diabetic vessels may
transmit pulses despite minimal flow
– Check capillary refill and dependent rugor
– Evaluate skin for ulcers, calouses, fungus, or wounds
– Neurologic exam should include monofilament testing,
proprioception, light touch, and vibration
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Routine Foot Examination
• Diabetics should undergo a comprehensive annual foot
exam and visual inspection of feet at each visit
– Shoes should be checked to ensure proper fit
– High heels should be avoided as shoes should have a deep
toe box to allow adequate circulation and avoid excess
pressure
– Patients' family members should be trained in foot selfassessment
– Patients with any sign of diabetic complications in the foot
should be referred to a qualified podiatrist for further
management and/or orthotics
– Lifestyle modification and management of blood pressure
and glucose are of equal importance in maintaining good
foot care
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Diabetic Nephropathy
• Nearly one third of diabetic patients will develop nephropathy and
more type 1 diabetics will progress to ESRD
• Increased urinary protein excretion is the earliest clinical finding
of diabetic nephropathy and not detectible by urine dipstick until
levels are greater than 300 mg/dL
• Normal levels are less than 20mg/day and levels between 20 and
300 mg/dL are termed microalbuminuria and indicative of
nephropathy21
• Values can be obtained by 24 hour urine collection or spot
morning assessment of protein/creatinine ratio
– Spot values >30 mg/g are indicative of nephropathy but should be
confirmed by repeat measurement on at least two separate occasions
to prevent false positives22
• Albuminuria (>300mg/dL) is associated with a 4-8 fold increase of
CAD in diabetics
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Diabetic Nephropathy
• Screening for microalbuminuria should begin at diagnosis in DM2,
patients with GDM, and after 5 years in DM1 and repeated
annually
• It is less clear if annual testing is of benefit in patients already
diagnosed with microalbuminuria
– Expert opinion suggests that normalizing micoalbuminuria to normal
range can improve renal and cardiovascular prognosis
• Febrile illness, hematuria, glycosuria, heavy exercise and UTI can
all cause proteinuria in normal persons
• Patients to be educated to decrease dietary protein to less than
0.8 g/kg body weight daily26
• Several large clinical trials have proven that nephropathy can be
prevented with tight BG23, 24 and BP control25 with ACE-I and ARBs
• Early referral to nephrologist is cost-effective, maintains renal
function, and improve quality of care27
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Diabetic Nephropathy
• ACE-I and ARBs should be used in micro- and macroalbuminuria
unless patient is pregnant
• Role of ACE-I and ARB are unproven in normotensive patients
with abnormal proteinuria but recommended by expert opinion
• In DM1 with HTN and albuminuria ACE-I have been shown to
delay the progression of nephropathy
• In DM2 with HTN and microalbuminuria ACE-I have been shown
to delay the progression to macroalbuminuria
• In DM2 with HTN, macroalbuminuria and creatinine >1.5 ARBs
have been shown to delay progression of nephropathy
• Some evidence suggests ARBs have a smaller rise in serum
potassium than ACE-I28
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Cardiovascular Disease
• Cardiovascular disease is a major cause of morbidity and
mortality in diabetics
• Diabetics often have metabolic syndrome and other
comorbidities which substantially increase CAD risk29
• UKPDS identified modifiable risk factors for CAD in diabetics that
should be managed appropriately30
•
•
•
•
•
LDL in upper third tertile (Hazard Ratio 2.3)
HDL in upper third tertile – beneficial (HR 0.6)
Elevated Hemoglobin A1C (HR 1.5)
Systolic Blood Pressure (HR 1.8)
Smoking (HR 1.4)
• The ADA recommends that cardiovascular risk factors be
assessed annually and as follows:
• Cardiac stress testing in patients with a history of peripheral or
carotid occlusive disease, sedentary lifestyle, age >35 year, prior
to beginning an aggressive exercise program, or two or more
CHD risk factors
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Smoking Cessation
• Cigarette smoking contributes to 1 in 5 deaths in the US
and is the most modifiable cause of premature death33
• A large survey found that the prevalence of cigarette
smoking was greater in diabetics than nondiabetic
subjects32
• All smokers should be advised to stop smoking at every
clinic visit
• Several large RCTs have demonstrated the efficacy and
cost-effectiveness of smoking cessation counseling30,31
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Aspirin Therapy
• A large meta-analysis has demonstrated that the greatest
benefit from ASA is in patients over 65 and those with DM
and diastolic HTN
• The US Physicians Health Survey demonstrated a nonsignificant increased trend in hemorrhagic stroke and GI
bleed. However, the risk is far outweighed by the benefit in
most diabetics.35
• Current ASA use in appropriate diabetics is very low
• 74% in secondary prevention
• 38% in primary prevention
• The ADA has made the following recommendations:
– ASA 75-162 mg/day for secondary prevention in diabetics with
a history of MI, PVD, CVA or TIA, claudication, or angina.
– ASA 75-162 mg/day for primary prevention in diabetics with a
history of one additional CHD risk factor unless <21 years old
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Hypertension
• BP should be checked at every diabetic visit
• Cardiovascular complications in diabetics are reduced with
diastolic BP down as low as 85 mm/Hg.37 Similar benefit is seen
with SBP below 120 mm/Hg.38
• Blood pressure for most diabetics should be 130/80
• Target BP for Diabetics with CKD and nephrotic range
proteinuria is 120/75 mm/Hg39
• ALLHAT found that high risk patients including diabetics have
better outcomes with thiazide diuretics than ACE-I40
• Diabetics with HTN should be initiated on a thiazide or ACE-I
unless they have other compelling indications (nephropathy,
microalbuminuria, retinopathy- all indicating ACE-I)
• ARBs should be substituted in patients intolerant of ACE-I
because of cough or other minor side effects.
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Hyperlipidemia
• Patients with diabetes should be screened for
hyperlipidemia at least annually if higher risk and
biannually for those with favorable lipid profiles
• Diabetes is considered a CAD equivalent and therapy
should be directed at lowering LDL below 100 mg/dL
• Particular attention should be given to the metabolic
syndrome often associated with diabetics
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Vaccinations
• Observational studies have shown that diabetics have higher inhospital morbidity and mortality from influenza than matched
cohorts41
• The influenza vaccine has been shown to reduce hospital related
admission for influenza by 79%42
• Patients with diabetes also have an increased risk of the
bacteremic form of nosocomial pneumonia and a higher
mortality (>50%) than non-diabetics41
• All diabetics should receive annual influenza vaccinations
• Provide at least one lifetime pneumococcal vaccine to adults
with diabetes
– One-time revaccination is recommended for individuals >64 years of
age if immunized before age 60 (>5 yrs prior)
– Repeat vaccination indicated in patients with nephrotic syndrome,
CKD, and other immunocompromised states
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Summary
• Diabetes accounts for a substantial portion of US health care
expenditures
• US health care providers grossly under-diagnose diabetes
• Diabetics often have multiple co-morbidities which can be
medically managed and reduce overall complications
• Multiple medical problems make it more difficult for health care
providers to meet standards of care in managing diabetes
• Practitioners must be cognizant of screening guidelines in order
to improve quality of care and outcomes in diabetics
• It is imperative to refer patients to the appropriate subspecialist
when they demonstrate certain complications of diabetes
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Case #1
Stacy G. is a 29 y/o male with a hx of heavy smoking who
presents to your PM clinic as a new patient. He has a multitude of
complaints but most concerning to you (and him for different
reasons) is polyuria for several months as well as weight loss.
You think he has diabetes, which of the following is appropriate to
diagnose diabetes?
• A. check a hemoglobin A1C and tell him he has diabetes when it
returns at 7.4
• B. check a chem 7 which reveals a BG of 218 mg/dL
• C. give him a 50g OGTT test
• D. wait until the following morning and check a fasting glucose
and if >125 mg/dL have the test repeated at a later time.
• E. Don't do any testing because you know he will be noncompliant
on his medications and will continue to eat Krispy Kreme
doughnuts
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Case #2
Andy "Toughguy" W. is a 30 y/o male who you see for routine
follow up of his diabetes which has been complicated by
severe retinopathy w/ 20/400 vision in both eyes. He has
missed several appointments and has not seen his
opthalmologist. On exam you note his BP is 138/86 after
being repeated on several occasions. He asks you if he should
be treated for his BP and if so with what drug?
A.
B.
C.
D.
E.
Yes, start lisinopril 10mg po daily
Yes, start long-acting metoprolol 25mg po daily
Yes, start chlorthalidone 10mg po daily
Yes, start amlodipine 2.5mg po daily
No, his blood pressure is at goal of <140/90
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Case #3
Sascha T. is a 75 y/o patient with diet controlled diabetes, HTN,
HL, PVD, and smoking. He comes to clinic with a list of things
he wants you to "fix". However, he said his wife told him he
can't multi-task with anything in life and wants to know what
one thing will give him the best chance of living to 100. Which
of the following measures will result in the greatest mortality
benefit.
•
•
•
•
A. Send him for his annual eye exam
B. Tell him to stop smoking
C. Increase his atorvastatin to get his LDL below 100
D. Take off his shoes, examine his feet, and suggest that he cut
his 2" fungus laden toenails
• E. Tell him to eat a steak and baked potato with every meal
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Case #4
You have just finished your rotation on diabetes management when
you see one of seven patients with diabetes scheduled to see you in
continuity clinic. You feel a little guilty because you have been content
with A1C's in the 8-9 range. Now you pull out your ADA guidelines on
screening and management for diabetes. Which of these would meet
standard of care as established by the ADA?
A.
B.
C.
D.
E.
Ordering your long-time 65 y/o diabetic patient their first
pneumococcal vaccine
Testing for microalbuminuria in patient with a random glucose of 400
mg/dL
Checking A1C every six months on your diabetic patient who has been
<7 for 3 years
Performing a brief foot exam once a year on a diabetic who sees you
every 2 months in clinic.
Telling the patient to try the Ultimate Double Gravy Biscuit at
Biscuitville so you can utilize "shock & awe" when he sees his blood
sugar surpass your SAT score
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Final Question
Which of the following is true of diabetics?
a.
b.
c.
d.
e.
They have similar rates of smoking than nondiabetic
counterparts
All diabetics should have a dilated eye exam at the time of
diagnosis
Daily aspirin is recommended for all diabetics for primary
prevention
They are less likely to have an annual mammogram performed
if indicated
When seen at Academic centers like Duke, the majority
(>50%) of the time their diabetic medications are titrated
appropriately
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References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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12.
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References Continued
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References Continued
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References Continued
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36.
37.
38.
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40.
41.
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Persell, SD, Baker, DW. Aspirin use among adults with diabetes: recent trends and emerging sex disparities.
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Hansson, L, Zanchetti, A, Carruthers, SG, et al, for the HOT Study Group. Effects of intensive blood-pressure
lowering and low-dose aspirin in patients with hypertension: Principal results of the Hypertension Optimal
Treatment (HOT) randomised trial. Lancet 1998; 351:1755.
Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes:
UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317:703.
Adler, AI, Stratton, IM, Neil, HA, et al. Association of systolic blood pressure with macrovascular and
microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000;
321:412.
Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or
calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack
Trial (ALLHAT). JAMA 2002; 288:2981.
Bridges, CB, Fukuda K, Uyeki TM, Cox NJ, Singleton JA: Prevention and control of influenza: recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2002; 51:1.
Colquhoun, AJ, Nicholson KG, Botha JL, Raymond NT: Effectiveness of influenza vaccine in reducing hospital
admissions in people with diabetes. Epidemiol Infect 1997; 119:335.
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Answers Case #1
Stacy G. is a 29 y/o male with a hx of heavy smoking who presents to your PM clinic as a
new patient. He has a multitude of complaints but most concerning to you (and him
for different reasons) is polyuria for several months as well as weight loss. You think
he has diabetes, which of the following is appropriate to diagnose diabetes?
A. Incorrect. According to the ADA an A1C should never be used to diagnose diabetes.
B. Correct. Diabetes can be diagnosed with a one time measurement of random
plasma glucose if two conditions are met: BG should be greater than 200 mg/dL –
and- the patient has to be demonstrating classic symptoms of diabetes at that time.
C. Incorrect. A 50g OGTT is indicated only for screening in pregnancy. In GDM, if the
initial 50g OGTT is >140 at one hour then a confirmatory test should be performed
using a 100g load OGTT. Note that in the patient above a 75g OGTT would be used
since he is not being screened for GDM. The 100g OGTT is not recommended in nonpregnant adults.
D. Incorrect. Though this is a correct way to diagnose diabetes, the patient has active
classic symptoms and a random BG>200 will secure the diagnosis without further
testing..
E. Incorrect. Though this may be true of the patient it is not c/w the ADA guidelines
and innapropriate.
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Answers Case #2
Andy "Toughguy" W. is a 30 y/o male who you see for routine follow up of his
diabetes which has been complicated by severe retinopathy w/ 20/400 vision in
both eyes. He has missed several appointments and has not seen his
opthalmologist. On exam you note his BP is 138/86 after being repeated on
several occasions. He asks you if he should be treated for his BP and if so with
what drug?
A.
B.
C.
D.
E.
Correct. The patient has confirmed diabetic retinopathy. Both lisinopril and
captopril have been shown in RCTs to slow the progression of diabetic
retinopathy. Other anti-hypertensives have not. In addition, since the patient
has severe retinopathy, he likely has some early diabetic nephropathy which
would be another indication for ACE-I (or ARB).
Incorrect. There is good data for beta blocker therapy in diabetics even
without CAD. No data supports BB use to curtail diabetic retinopathy.
Incorrect. Though ALLHAT showed substantial mortality benefit and primary
endpoint reduction with thiazides, no trial has examined the relationship
between thiazide use and the progression of diabetic retinopathy. JNC VII would
classify diabetes as a compelling indication to initiate ACE-I as first line therapy
for HTN in diabetics. ADA guidelines would support HCTZ or chlorthalidone as
first line therapy if the patient has uncomplicated diabetes.
Incorrect. Large RCTs have not shown non-dihydropyridine CCBs to prevent
progression of retinopathy (or CAD, nephropathy, or PVD).
Incorrect. His blood pressure goal is 130/80. If his diabetes was complicated
by nephrotic range proteinuria his goal would be 120/75
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Answers to Case #3
Sascha T. is a 75 y/o patient with diet controlled diabetes, HTN, HL, PVD, and
smoking. He comes to clinic with a list of things he wants you to "fix". However, he
said his wife told him he can't multi-task with anything in life and wants to know what
one thing will give him the best chance of living to 100 years of age. Which of the
following measures will result in the greatest mortality benefit.
A. Incorrect. Though patient needs annual eye exam, there is little short term
mortality benefit when compared to other options listed below.
B. Correct. This is the number one modifiable cause of death in the US and all
patients who smoke should be encouraged to quit at every visit.
C. Incorrect. If the patient is already on a statin increasing the dose to get his LDL
<100 is standard of care. NHANES III found that only 42% of diabetics had LDL
<130. This was prior to ATP III recommended a goal of <100. We can assume
that the numbers are likely no better today- and perhaps worse.
D. Incorrect. Though this may be true, and the patient needs to have his feet
examined at every diabetic visit- this answer just is not right!
E. Incorrect. The starch in the potato will make his BG elavated. If he has
proteinuria, there is some evidence to support protein restriction to 0.8g/kg/day.
A large steak can easily have a daily allowance of protein in this setting.
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Answers to Case #4
You have just finished your rotation on diabetes management when you see one
of seven patients with diabetes scheduled to see you in continuity clinic. You
feel a little guilty because you have been content with A1C's in the 8-9 range.
Now you pull out your ADA guidelines on screening and management for
diabetes. Which of these would meet standard of care as established by the
ADA?
A.
B.
C.
D.
E.
Incorrect. All diabetics should receive annual influenza vaccinations.
You should rovide at least one lifetime pneumococcal vaccine to adults with
diabetes. One-time revaccination is recommended for individuals >64 years of
age if immunized before age 60 (>5 yrs prior). Repeat vaccination indicated in
patients with nephrotic syndrome, CKD, and other immunocompromised states
Incorrect. Spot microalbuminuria should be confirmed by repeat testing over a
6 month period. In addition, febrile illness, hematuria, glycosuria, heavy
exercise and UTI can all cause proteinuria in normal persons
Correct. The ADA recommends checking hemoglobin A1C twice yearly in
pharmacologically stable patients with A1Cs at goal. They recommend checking
quarterly in those with elevated A1Cs of those undergoing medication changes.
Incorrect. The feet should be examined at every diabetic clinic visit and a
complete and thourough foot exam should be performed annually.
Incorrect. Though Biscuitville gravy biscuits taste great (and they are really
good when you are post-call) but they should be off limits to your diabetics. You
know they have already had a few anyway.
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Answer Question #5
Which of the following is true of diabetics?
A.
B.
C.
D.
E.
False. They have higher rates of smoking than nondiabetic
counterparts
False. Type 2 diabetics should have a dilated eye exam at the time of
diagnosis. However, type 1 diabetics should have a dilated eye exam
5 years after diagnosis.
False. Aspirin (75-162 mg/day) is recommended for all diabetics for
secondary prevention. It should be used for primary prevention in
adults 21 or older with one additional CHD risk factor.
True. They are less likely to have an annual mammogram performed
if indicated. Diabetic women have trends towards increased rates of
breast cancer. Ironically, studies have shown that they are less likely
than non-diabetics to receive mammograms and other routine health
maintenance.
False. When seen at Academic centers like Duke, less than half of the
time diabetic medications are titrated appropriately. However, we do
a good job at checking for other comorbidities (>90% screening for
HTN and HL).
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