staged diabetes management complications of diabetes and metabolic syndrome

2004 Priorities of Care for Adults with DiabetesPrevention - Diagnosis Preventions Prediabetes IFG -IGT & Metabolic Syndrome Diagnosis Fasting glucose > 126 mg/dL 7 mmol/L or Casual glu

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Staged Diabetes Management: Complications

of Diabetes and Metabolic

Syndrome

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2004 Priorities of Care for Adults with Diabetes

Prevention - Diagnosis

Preventions Prediabetes (IFG -IGT) & Metabolic Syndrome Diagnosis Fasting glucose > 126 mg/dL (7 mmol/L) or

Casual glucose > 200 mg/mL (11.1 mmol/L) + Symptoms

History and Physical Exam

Preventions Prediabetes (IFG -IGT) & Metabolic Syndrome

Diagnosis Fasting glucose > 126 mg/dL (7 mmol/L) or Casual glucose > 200 mg/mL (11.1 mmol/L) + Symptoms

Lipid TargetsLDL < 100 mg/dL (2.6 mmol/L)

Triglyceride < 150 mg/dL (1.7 mmol/L)

HDL > 40 mg/dL (1.0 mmol/L)

Statin therapy Fibrate therapy Combination therapy

Blood Pressure Targets

Mean BP <130/80 mmHg

ACEI or Thiazide therapy Combination therapy

Blood Pressure TargetsMean BP <130/80 mmHg

Annual Screening Nephropathy

Care of the Hospitalized Patient with Diabetes Care of Gestational DM

Foot Care Oral & Dental Care Immunizations

Flu Shot + Pneumovax

Foot Care Oral & Dental Care Immunizations Flu Shot + Pneumovax

Lifestyle Behavioral Health Patient Education Emotional assessment

BG Monitoring distress, depression, complications Medical Nutrition Support needs Physical Activity family, peers, medical

Macrovascular Complications ASA, Tobacco cessation ACEI / ARB, Statin

Lipids Hypertension

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Rates of Coronary Heart Disease

3.5

20.2 18.8

45

0 10 20 30 40 50

No History of CVD Prior MI

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HDL > 40 mg/dL (1.0 mmol/L)

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Medical Nutrition Therapy for

Dyslipidemia

• Physical activity and weight loss

– modest decrease in TRI and increase in HDL

• Fat < 30% total calories

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International Diabetes Center

Medical Nutrition - Non Drug Therapy

Dietary changes Physical activity Weight management

Low HDL

Add Atorvastatin or Simvastatin if LDL >100

Consider-Nicotinic Acid Thiazolidinediones???

Add Atorvastatin or Simvastatin if LDL >100

Consider-Nicotinic Acid Thiazolidinediones???

Add Fibrate*

Consider-Nicotinic Acid

Add Fibrate*

Consider-Nicotinic Acid Add Resin

Add Resin

* when using a statin and fibrate in combination therapy, monitor for

myositis (muscle pain and weakness)

Therapy Selection

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Treatment with Simvastatin

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Potential Benefits of Different Therapies: Increasing HDL and Decreasing Triglycerides

Glucose control Statin Fibrates Metformin TZD Niacin

-25

-35

-60

-25 -15

Minimal

0 5 10 15 20 25 30

*DM Kendall Data adapted from multiple reference (meta-analysis).

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Aspirin Therapy

• Effective in primary and secondary prevention

• Blocks thromboxane (vasoconstrictor and platelet

aggregant) synthesis

– Reduces inflammation

• Enteric coated aspirin 81-325 mg/day for those >30

years of age

• Consider alternative antiplatelet therapy (i.e clopidogrel)

if aspirin not tolerated or allergy

Hansson, Lancet 351:1755-1762, 1998

Peterson, et al Am J Med 109371-377, 2000

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Lipid Targets

LDL < 100 mg/dL (2.6 mmol/L) Triglyceride < 150 mg/dL (1.7 mmol/L) HDL > 40 mg/dL (1.0 mmol/L) Statin therapy Fibrate therapy Combination therapy

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BP Control: Results from the UKPDS

N= 5102

• Tight BP control (Avg BP 144/82 mmHg) compared to

“less” tight BP control (Avg BP 154/87 mmHg)

resulted in reduction in risk of:

– 37% for microvascular complications (nephropathy

& retinopathy)

– 32% for diabetes related deaths (44% for strokes)

• ACE inhibitor (captopril) or beta-blocker (atenolol)

equally effective in reducing risk

• Continuous relationship between systolic BP and

diabetes related complications above 130 mmHg

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Type 2 Diabetes: Risk, Blood Glucose and Blood Pressure

HbA1c

BP

the risk of vascular complications.

2 Any increase in both raises the risk

of vascular disease still more.

United Kingdom

Prospective

Study (UKPDS)

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Blood Pressure Target in Diabetes

<130/80 mmHg

<120/75 mmHg With Renal Disease

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Number of Major Cardiovascular Events in

Subjects with Diabetes

The Hypertension Optimal Treatment (HOT) Trial

24.4

18.6

11.9

0 5 10 15 20 25 30

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Is hypertension being controlled? How do you know?

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25th percentile

10th percentile

90th percentile

75th percentileMedian

25th percentile

10th percentile

BP Threshold

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100 125 150 175 200

BP at home for 2 weeks

of a person with Type 2

Diabetes and normal BP

( 129/79 mmHg) based

on office measurement

DX: Normotensive

Systolic BP (mmHg)

Diastolic BP (mmHg

Although the patient

had the same mean BP

based on SMBP, 63% of

systolic and 80% of the

diastolic values were

above the threshold for

hypertension

DX: Hypertensive

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Staged Management

Treatment of Hypertension in Diabetes

ACE Inhibitor

Drugs of choice Limits progression of nephropathy - Lowers CVD risk

Alternative = A II Receptor Blocker

Thiazide

Combo with ACEI

Useful in Elderly

Central  -Blockers Vasodilators

Combination Rx

Beta - Blockers

Effective Post MI Avoid if severe hypoglycemia

Ca++ channel Blockers

Useful in combination Non-DHP preferred

Diagnosis of Hypertension

> 130/80 mmHg

Non Pharmacologic Therapies

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Lipid Targets

LDL < 100 mg/dL (2.6 mmol/L) Triglyceride < 150 mg/dL (1.7 mmol/L) HDL > 40 mg/dL (1.0 mmol/L) Statin therapy Fibrate therapy

ACEI or Thiazide therapy

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Effect of Elevated Glucose

on the Kidney

Normal Glomerulus

Afferent Arteriole Efferent Arteriole

Waste Products Salts

Afferent Arteriole Efferent Arteriole

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Screening for Microalbuminuria

Normal < 20 ug/min Microalbuminuria 20-200 ug/min Macroalbuminuria >200 ug/min

Start ACE inhibitor if

microalbuminuria

Start ACE inhibitor if

microalbuminuria

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Albumin/Creatinine Ratio

• Random, spot urine collection

• First-void or other AM collection preferred

• Albumin level corrected with creatinine

• Normal: <30 mg/g

Microalbuminuria: 30-300 mg/g

Macroalbuminuria: >300 mg/g

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Treatment Strategies for Nephropathy

• Improved glycemic control HbA1c <7.0%

• Control blood pressure <120/75 mmHg

– ACE Inhibitor and/or Angiotensen II Receptor Blocker

preferred

• Smoking cessation

• Low protein diet (<0.8 g/kg/day) improves renal

function (slows increase in albumin level or the

decline in GFR or creatinine clearance)

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Benefit of ACE Inhibitor Therapy in

Diabetic Nephropathy

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Meta-Analysis of Antihypertensive Therapy

in Persons with Diabetes and Kidney

Calcium channel blockers

Control (Placebo)

ACE inhibitors

Beta Blockers

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Prevention and Treatment of

Diabetic Retinopathy

• Limits risk of retinal disease, slows rate of progression

• Benefits observed in both Type 1 and Type 2 diabetes

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Normal Retinal Exam

Proliferative

Retinopathy

Proliferative

Retinopathy

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Photocoagulation Therapy

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Prevalence of Diabetic Neuropathy

Diabetes - 20 Years Duration

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Diabetic Neuropathy Risk Reduction Based

on Glycemic Control

Diabetes Control and Complications Trial (n=1441)

DCCT Study Group N Engl J Med 329:977, 1993

0 2 4 6 8 10 12 14 16 18

Primary Prevention (No Neuropathy)

Secondary Prevention (With Baseline Neuropathy)

Intensive Standard

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Diabetic Peripheral Neuropathy

Diagnosis and Treatment

Reference: The Diabetic Foot: Evaluation and Patient Education

[Hospital Medicine 34(12):17-20, 23-24, 27, 1998 Quadrant HealthCom, Inc.]

Recognizing foot deformities:

• Prominent metatarsal heads

•Anterior displacement of plantar fat pad

• Hallux valgus and flat feet

Recognizing foot deformities:

• Prominent metatarsal heads

•Anterior displacement of plantar fat pad

• Hallux valgus and flat feet

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Diabetic Peripheral Neuropathy

• Diabetes and Neuropathy

– 2.4 million people with diabetes in the U.S develop

lower extremity ulcers/year

• 54,000 amputations/ yr as a result of complications of diabetes

• Prevention and Management of Neuropathy

– Glucose control and comprehensive foot care

– Systematic care of high risk feet = 90% reduction in

amputation risk

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Foot Care and Examination

• Annual comprehensive examination

– Inspect and check skin, nails, pulses

– Monofilament, reflexes, vibration

• Regular self-examination also advised

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HDL > 40 mg/dL (1.0 mmol/L)

Blood Pressure TargetsMean BP <130/80 mmHg

Foot Care Oral & Dental Care Immunizations Flu Shot + Pneumovax

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