IB DIAGNOSIS Criteria for the diagnosis of DM include one of the following: © Fasting plasma glucose >7.0 mmol/L (2126 mg/dL) ‘© Symptoms of diabetes plus a random blood glucose concentration 211.1 mmol/L (2200 mg/dL) © 2h plasma glucose 211.1 mmol/L (2200 mg/dL) during a 75-g oral glu- cose tolerance test. * Hemoglobin A,.>6.5% These criteria should be confirmed by repeat testing on a different day, unless unequivocal hyperglycemia is present. ‘Two intermediate categories also have been designated: © Impaired fasting glucose (IFG) for a fasting plasma glucose level of 5.6-6.9 mmol/L (100-125 mg/dL) Impaired glucose tolerance (IGT) for plasma glucose levels of 7.8-11.1 mmol/L (140-199 mg/dL) 2 h after a 75-g oral glucose loadTABLE 184-1 CRITERIA FOR TESTING FOR PRE-DIABETES AND DIABETES IN ASYMPTOMATIC INDIVIDUALS* © First-degree relative with diabetes © Physical inactivity » Race/ethnicity (e.g., African American, Latino, Native American, Asian ‘American, Pacific islander) * Previously identified IFG, IGT, or a hemoglobin A,, of 5.7-6.4% © History of GDM or delivery of baby >4 kg (>9 Ib) © Hypertension (blood pressure >140/90 mmHg) © HDL cholesterol level <0.90 mmol/L (35 mg/dL) and/or a triglyceride level 22.82 mmoV/L (250 mg/dL) © Polycystic ovary syndrome or acanthosis nigricans © History of vascular disease Testing should be considered in all adults at age 45 and adults <45 y with BMI >25 kg/m? and one oF more of the following risk factors for diabetes. Abbreviations: BMI, body mass index; GDM, gestational diabetes melitus; HDL, high-density lipoprotein: IFG, impaired fasting glucose; IST, impaired glucose tolerance. ‘Source: Adapted from American Diabetes Association, 2011.TABLE 184-2 PROPERTIES OF INSULIN PREPARATIONS <0.25 <0.25 <0.25 051.0 14 1-4 1-4 Insulin combinations 75/25-75% protamine <0.25 lispro, 25% lispro 70/30-70% protamine <0.25 aspart, 30% aspart 50/50-50% protamine <0.25 lispro, 50% lispro 70/30-70% NPH, 30% 0.5—1 regular 0.5-1.5 0.5-1.5 0.5-1.5 23 Zul 10 1.5h 1.5h 1.5h Dual? 46 Up to 24 Upto 24 10-16 Upto 10-16 Up to 10-16 Up to 10-16 10-16 4Glargine and detemir have minima peak activity “Dual: two peaks—one at 2-3 h and the second one several hours later. Source: Adapted from JS Skyler: Therapy for Diabetes Mellitus and Related Déorders, American Diabetes Association, Alexandria, VA, 2004.TABLE 184-3 ORAL GLUCOSE-LOWERING AGENTS ed Biguanide Metformin ‘Sulfonylureas Glimepiride Gipizide Glipizide (ext. release) Glyburide Glyburide (micronized) Non-sulfonylurea ‘secretagogue Repagiinide Nateglinide o-Glucosidase inhibitor Acarbose Miglitol Thiazolidinedione Pioglitazone DPP-IV inhibitor Sitagliptin Saxagliptin Linagliptin Vildagliptin Daily ee) 500-2500 1-8 25-40 10 1.25-20 07512 05-16 180-360 25-300 25-300 15-45 100 25-5 50-100 ee) 1-3 1-2 1-2 1-2 14 13 ee te Creatinine >133 pmol/L (1.5 mg/dL) (men), >124 pumol/L. (1.4 mg/dL) (women); CHF; liver disease RenaVliver disease Renal/liver disease IBD, liver disease, or Cr >177 moll (2.0 mg/dL) | Dose with renal failure those with existing cardiovascular disease, the LDL target shouldbe <1.8 mmol/L (70 mg/dL).Patient with type 2 diabetes Medical nutrition therapy, increased physical activity, weight loss + metformin CReassess Ayo > Combination therapy -metformin + second agent Insulin + metformin < Reassess Aig J Combination therapy -metformin + two other agents FIGURE 184-1 Glycemic management of type 2 diabetes. Agents that can be com- bined with metformin include insulin secretagogues, thiazolidinediones, o:-glucosidase inhibitors, DPP-N inhibitors, and GLP-1 receptor agonists. A, , hemoglobin A,..oes TABLE 184-4 GUIDE_INES FOR ONGOING MEDICAL CARE FOR PATIENTS WITH DIABETES ‘¢ Self-monitoring of blood glucose {individualized frequency) A, testing (2-4 times/year) ¢ Pt education in diabstes management (annual) © Medical nutrition therapy and education (annual) © Eye examination (amual) © Foot examination (1-2 times/year by physician; daily by pt) © Screening for diabefc nephropathy (annual: see Fig. 344-11) © Blood pressure measurement (quarterly) © Lipid profile and serum creatinine (estimate GFR) (annual) Influenza/pneumococcal immunizations Consider antiplatelet therapy (see text) ———————————————— Abbreviation: A, , hemoglobin A,