1	Diabetes Mellitus: Management Options
2	Criteria for the diagnosis of diabetes 1. Symptoms of diabetes and a casual plasma glucose ≥200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. OR 2. FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 hours
3	Criteria for the diagnosis of diabetes (con’t) 3. 2-h PG ≥ 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
4	Criteria for testing for diabetes in asymptomatic adult individuals Testing for diabetes should be considered in all individuals at age 45 years and above and, if normal, it should be repeated at 3-year intervals. Testing should be considered at a younger age or be carried out more frequently in individuals who: Are obese (≥ 120% desirable body weight or a BMI ≥ 27 kg/m²) Have a first-degree relative with diabetes Have delivered a baby weighing > 9 lb or have been diagnosed with GDM
5	Criteria for testing for diabetes in asymptomatic adult individuals (con’t) Are members of a high-risk ethnic population (e.g., African-American, Latino, Native American, Asian-American, Pacific Islander) Are hypertensive (≥ 140/90 mmHg) Have HDL cholesterol level ≤35 mg/dl (0.90 mmol/l) and/or a triglyceride level ≥ 250mg/dl (2.82 mmol/l) On a previous testing, had IGT or IFG Have other clinical conditions associated with insulin resistance (e.g., PCOS or acanthosis nigricans)
6	DCCT Risk of Sustained Retinopathy Progression by HbA_1cand Years of Follow-up
7	DCCT FINDINGS Lowering Blood Sugar Reduces Risk of: Eye disease 76% Kidney disease 50% Nerve disease 60% Cardiovascular disease 35%
8	UKPDS Similar reduction with Type II Diabetes Mellitus Moderate reductions in hypertension and dyslipidemia Significantly improved outcomes 11% reduction in MIs with each 10mm Hg â in SBP
9	HbA_1c Best determinant of glycemic exposure Mean is a quality indicator
10	Glycemic control for nonpregnant individuals with diabetes
11	"4" 4 60 5 90 6 120 7 150 8 180 9 210 10 240 11 270 12 300
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13	Options for monotherapy
14	Target Population
15	Target Population
16	Target Population
17	Target Population
18	Target Population
19	Advantages
20	Advantages
21	Advantages
22	Advantages
23	Advantages
24	Disadvantages
25	Disadvantages
26	Disadvantages
27	Disadvantages
28	Disadvantages
29	Total daily dose (mg) & dosing interval
30	Total daily dose (mg) & dosing interval
31	Total daily dose (mg) & dosing interval
32	Total daily dose (mg) & dosing interval
33	Total daily dose (mg) & dosing interval
34	Monotherapy Pearls All drugs except AGIs and nateglinide equally reduce HbA_1c Metformin usually best for obese- no weight gain Non-SU secretagogues may be useful for irregular meals Metformin and TZDs avoid hypoglycemia
35	Clinical Efficacy of Oral Hypoglycemic Agents
36	Options for combination therapy
37	Insulin Therapy in Type 2 DM Not 1^st line, except initially in some 50% need eventually ↓ gluconeogenesis and ↑ glucose uptake Can be combined with oral agents
38	Insulin Options: Long and Intermediate NPH Lente Ultralente Glargine
39	Short-acting Insulin Options Regular Lispro Aspartine
40	Combination Insulin Options 70 NPH/30 Reg premixture 50 NPH/50 Reg premixture 75 lispro protamine/25 lispro
41	IDC Insulin Staged Regimens OA – O – O – N R/N – O – R/N – O R/N – O – R – N R – R – R – N
42	BID Insulin Division AM PM Distribution 2/3 1/3 R/N Ratio 1:2 1:1 Premix: Best for drawing impaired
43	Insulin Therapy Profiles Variable absorption of NPH, Lente, Ultralente Peak effect late with regular Split/mixed insulin hypoglycemia Lantus more predictable absorption Humalog/Novolog more rapid peak/fall
44	Multiple Dose Insulin Intensive Therapy Basal dose suppresses hepatic glucose output Bolus dose enhances postprandial glucose uptake Basal dose about 50% Bolus doses 10-20% before meals
45	Premeal Humalog or Novolog Insulin CHOgm intake/carbohydrate insulin ratio (CIR) CIR= 500 TDD TDD (total daily dose) = BW (lb) 4 Common ratio: 1u/5-15 gms CHO Correction Dose = 1800 /TDD = 1u ↓ of BG mg/dl Ideal BG rise post meal is 30 – 60 mg Out of Target adjustment range 1 u/30-50 BG mg/dl
46	"Diabetes Self-Management Skills" Diabetes Self-Management Skills Medical Nutrition Therapy, Activity Patient Education, Glucose Monitoring
47	"Diabetes Self-Management Skills" Diabetes Self-Management Skills Medical Nutrition Therapy, Activity Patient Education, Glucose Monitoring
48	Clinical Approaches to the Treatment of Dyslipidemia in Patients with Diabetes
49	"Diabetes Self-Management Skills" Diabetes Self-Management Skills Medical Nutrition Therapy, Activity Patient Education, Glucose Monitoring
50	Blood Pressure Management (every visit) Diagnosis and Rx Target < 130/80 mm Hg Nonpharmacologic Therapies Weight management Physical activity Sodium restriction Smoking cessation
51	"Diabetes Self-Management Skills" Diabetes Self-Management Skills Medical Nutrition Therapy, Activity Patient Education, Glucose Monitoring
52	"Diabetes Self-Management Skills" Diabetes Self-Management Skills Medical Nutrition Therapy, Activity Patient Education, Glucose Monitoring
53	Non Pharmacologic Therapy Diet Registered dietitian help preferable MNT (medical nutrition therapy) Weight loss usually needed in Type II Dietary fiber high intake advisable Artificial sweeteners okay Exercise Improves glucose control Reduces cardiovascular risk factors Improves well being Diabetic Education
54	Diabetes Management Quality Improvement in a Family Practice Residency Program Sutherland et al. J Am Board Fam Prac 2001;14:245-51
55	FPC - Longitudinal Interventions Point of care faculty staffing 1978 Elective rotations - IDC 1987 Chart Audits 1992 HbA_1c reminders 1993 Diabetic flow sheet 1993 Annual educational symposium 1994 PharmD educational interface 1995 Nursing foot exam preparation 1996 Endocrinology clinic rotation 1996 Community QA initiatives 1997 IFMC Diabetic Care Project 1997
56	HbA_1c Mean FPC’97 FPC’98 IA’97 IA’98 Nat’l (Mean) 7.32 7.25 8.83 8.36 9.5 % of Patients ³ 8 24.4 21.4 55.7 48.4 50
57	Glycemic Control
58	Diabetes Indicators Summary FPC had greater utilization of all indicators FPC laboratory monitoring superior and improving FPC foot exam documentation superior FPC eye exam better and improving FPC influenza v. similar but declined for FPC FPC pneumococcal v. rate superior and improving FPC counseling superior, both improving Statewide collaborators improved in most indicators FPC percentage with adequate control is superior
59	Indicator Monitoring and Control for NEIFPC (NE) and Iowa Providers (IA)
60	OTHER CLINICAL PEARLS – TYPE 2 DM Early Dx/Rx ↓ cardiovascular risks Elderly ↑ risk of hypoglycemia- careful aggressive Rx Prevention by lifestyle changes in obese and sedentary Educational interventions cause clinical improvements Most diabetics die of cardiovascular disease
61	OTHER CLINICAL PEARLS – TYPE 2 DM Audit or computer enhanced monitoring system improves outcomes Continuity of care improves quality of care HOPE and LIFE trials - ↓ DM with ACE & ARB use Dietary fiber high intake improves BS & lipids Gap exists between guidelines and care
62	Diabetes Mellitus: Management Options