| 7/9/06
Clinical Practice Guidelines for Type 2 Diabetes
(note that the American Assn. for Clin. Endo [AACE] is stricter
that the American Diabetes Association [ADA])
1. Criteria for Diagnosis of Diabetes
FBS 126 mg/dl or above (normal is up to 99 mg/dl)
-or-
Random BS 200 mg/dl or above (check ketones if BS > 200
mg/dl) (normal is up to 140 mg/dl)
Test patients who are age 45 and then every 3 years. Test
patients younger than 45 years old if they are at higher risk
(obese, first degree relative with diabetes, high risk ethnic
population [African-American, Hispanic, Native American, Asian-
American], delivery of a baby weighing more than than 9 lb,
gestational diabetes, hypertension, hyperlipidemia, neuropathy,
erectile dysfunction, PCOS.
Although screening with the FBS is currently the accepted
standard, this clearly misses some patients who have
predominantly postprandial hyperglycemia (a fact figured out by
insurance companies many years ago, which is why they test FBS
plus HbA1c).
But even the FBS and HbA1c may miss subtle diabetes, which is why
the evaluation for impotence usually includes the gold standard
test of a 75 gram OGTT (0, 30, 60, 120 minutes).
2. Glycemic Control Goals
Fingerstick Self Monitoring Capillary Blood Glucose (CBG)
Preprandial BG goal: 80 - 120 mg/dl
One hour postprandial BG goal (ADA): less than 180 mg/dl
Oct 2001 -(AACE): less than 140 mg/dl
[Recording what was eaten is very helpful in
interpreting postprandial BG and educational for
patient.]
Bedtime BG goal: 100 - 140 mg/dl
Hemoglobin A1c:
<6.5 Excellent 3 month BG control (AACE)
<7% Excellent 3 month BG control (ADA)(NYC)
<8% Good 3 month BG control
>8% Patient at higher risk for complications
Better BG control is achieved by attention to activity,
weight control, and diet (low carbohydrate, low fat, high
fiber).
3. Management Schedule
At every visit:
- Measure weight. Ideal body weight is estimated as follows:
Women: 100 lbs for first 5 ft, 5 lbs for each inch above 5
ft. Men: 106 lbs for first 5 ft, 6 lbs for each inch above
5 ft. Thus a 5'4" woman would have an IBW of 100 + 20 =
120 lbs. Can add 10% to IBW if "large frame".
[If using BMI, keep BMI <25]
- Review diet and activity:
Daily caloric intake can be estimated at 10 Calories/lb of
ideal body weight. Thus a sedentary 5'4" women would need
no more than 120 x 10 = 1200 Calories/day. Choosing foods
from the vegetable food group and picking lower fat meats
such as seafood helps to promote appropriate weight loss,
as does avoiding higher fat foods from the meat group
(cheese, steak) and minimizing the fat group. Most
patients benefit from keeping carbohydrates at less than
40% of total calories. Concentrated sweets and fruit juice
should be very limited.
Safe aerobic activity (e.g., walking, swimming) is to be
encouraged.
- Perform foot exam (high risk feet) including inspection for
lesions, palpation of pulses, testing sensation with tuning
fork and/or monofiliment. Podiatric referral should be
considered for high risk feet).
- Review CBG record: Encourage patients to test some pre-
and postprandial CBG and to assist in interpreting results.
- Review and adjust medication.
Metformin (Glucophage) is useful for decreasing
glycogenolysis, sometimes acts as a mild appetite
suppressant, and does not tend to cause hypoglycemia, but
is contraindicated in CHF, liver disease, decreaed GFR, and
may cause GI symptoms (and lactic acidosis). Thus it
should be titrated up slowly. Long acting form may be a bit
kinder to GI system and perhaps a bit less efficacious.
Insulin sensitizers (drugs that stimulate the PPAR nuclear
receptor ["glitizones"]), may take several weeks to improve
sensitivity to insulin, but seem to be most effective in
the most overweight patients. Both pioglitizone (Actos)
and rosiglitazone (Avandia) usually do not contribute to
hypoglycemia. LFTs should be monitored every two months,
and salt retention may lead to frank CHF in susceptible
individuals. The "glitizones" may be used in combination
with metformin and other diabetes medications.
Drugs that stimulate endogenous insulin secretion
(sulfonylureas and repaglinide-[Prandin], may contribute
to hypoglycemia and promote weight gain, but if diet,
activity, and the above medications are not successful,
then adding a sulfonylurea (glyburide, glipizide) may be a
useful temporizing measure before adding insulin. They,
too, are contraindicated in renal insufficiency.
Drugs which block the conversion of starch to sugar
(Glyset, Precose [acarbose]), are rarely helpful in
patients requiring multiple other medications to control
sugar, but they may work in patients with very mild
diabetes characterized by predominantly postprandial
hyperglycemia.
When it is deemed appropriate to add insulin, an evening
dose of NPH, Ultralente, or Lantus that normalizes the FBS,
may
allow the daytime oral hypoglycemics to function more
efficiently. Even with attention to diet, activity, and
intentional weight loss, additional insulin may be needed.
- Review self-management skills, including symptoms of
hypoglycemia and hypoglycemic unawareness, medications that
may contribute to such unawareness (beta blockers),
medications which may raise the BS (niacin, thiazides).
Request that patient wears identification indicating
diabetes. Patients should know what to do on "sick days".
- Counsel on smoking cessation.
Twice a year:
- Order HbA1c in stable patients (quarterly if not well
controlled). Review this information with the patient.
Annually:
- Order lipid profile, creatinine, BUN, electrolytes
- U/A including microalbumin
- Flu vaccine
- Othalmology evaluation
- Dental exam
- Foot exam for low risk feet (more often if high risk)
- Preconception counselling in fertile women
By age 35 and periodically thereafter
- TSH
4. Category of Risk Based on Lipoprotein Levels
Risk LDL(mg/dl) HDL Triglyceride
Higher >130 <35 >400 (fasting)
Lower <100 >45 <200
The American Heart Association diet for hyperlipidemia is
less than 200-300 mg/d in cholesterol, and low in saturated
fat. Vegetables and seafood fulfill those criteria.
Control of BS, weight loss, treatment of hypothyroidism
should be considered before adding lipid lowering
medications. Although niacin lowers both cholesterol and
triglyceride, it tends to raise BS. Fibrates mostly lower
triglyceride (and raise HDL). HMG-CoA inhibitors with or
without a resin are most effective at lowering LDL
cholesterol.
5. Treatment of Cholesterol based on LDL
No cardiac risk factors:
Diet for LDL > 100; add medication if LDL stays > 100
If cardiac risk factors:
Diet plus medication for LDL > 100 mg/dl
6. Hypertension in Adults with Diabetes
Systolic Diastolic (mmHg)
Definition >140 >90
Rx Goal <130 <85
Frequently more than one medication is needed to control
elevated BP. ACE inhibitors have the advantage of decreasing
proteinuria and possibly preserving renal function, but
control of BP may be as important as which agents
are used. Non-selective beta blockers may contribute to
hypoglycemic unawareness; peripheral alpha blockers, if
orthostatic hypotension is not present, may also help
symptoms of prostatism.
References:
National Institutes of Health and the Centers for Disease Control and
Prevention National Diabetes Education Program: http://ndep.nih.gov
American Diabetes Association Clinical Practice Recommendations 2000
http://www.diabetes.org
http://www.diabetes.org/caresup1jan00.htm
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