3-Diabetes Update Presentation

Diabetes Update
2013
Dr. Erin Koepf, PharmD, BCACP
Assistant Professor, Ambulatory Care
University of New England College of Pharmacy
Maine Pharmacists Association, September 7, 2013
1
Objectives:
Based on the American Diabetes Association Standards of
Medical Care in Diabetes 2013:
Identify the classification, risk factors, diagnosis, and

screening criteria for diabetes
Explain pharmacologic and non-pharmacologic treatments

options for patients with diabetes or pre-diabetes
Describe measures that can be taken to prevent diabetes

progression and complications including immunization
recommendations
2
Objectives:
Identify the class, mechanism of action, dosing, and administration
of new and common diabetes medications
Discuss with patients and other health care practitioners diabetes

treatment options, monitoring, and the goals for therapy
Compare and contrast medication therapies available for the

treatment of diabetes and select appropriate options for a given
patient
Develop a comprehensive care plan for a given patient with

diabetes which included pharmacologic and non-pharmacologic
measures, monitoring, and preventative measures
3
What is Diabetes? Warmup

Spend 60 seconds thinking about and writing down a
description of Diabetes
Spend the next 2 minutes sharing your description

with someone next to you
Write down some of the concepts you come up with

4
What is Diabetes? Warmup

Endocrine condition that increases risks of
Cardiovascular events v.
Cardiovascular disease with abnormal processing and

distribution of glucose
Others?
Review: Diabetes
Pathogenesis
Insulin deficiency
Quantitative: decreased in production by the -cells of the
pancreas
Qualitative: insulin resistance especially muscle, liver,

adipose, myocardial
Improvements in insulin function

Weight loss to decrease insulin resistance
Can in turn improve -cell function
6
Review: Diabetes
Pathogenesis
Excess secretion of glucagon by -cells of pancreas
Glucose overproduction by liver; underutilized by body
Gluconeogenesis (making glucose from glycerol and amino
acids)
Renal tubular transport of glucose to the urine due to

hyperglycemia
Incretin system deviations (relationship to DM still not fully clear)

Glucagon-like peptide 1 (GLP-1)
Glucose dependent insulinotropic peptide (GIP)
7
Who has Diabetes?

Incidence of diabetes is rising (about 25 million adults in the
US)
Incidence is higher in certain populations

Many risk factors/associated conditions are also rising in
prevalence
About 2/3 of patients with diabetes in the US also have

hypertension (HTN)
How does Maine compare to the US when it comes to incidence

of Diabetes?
8
Incidence of Diabetes in the US
Centers For Disease Control and Prevention. Diabetes Data and Trends.
9
.http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.aspx?
mode=DBT
Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control
and Prevention, US Department of Health and Human Services; 2012.
Diabetes in the US
Incidence increases
with age
Incidence ranges from

7.1% - 16.1% between
different racial/ethnic
groups
10
New Cases of Diabetes
11
Rates of
Diabetes in
Maine have
been similar to
that of the US
12
Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention

and Control Program, Maine Center for Disease Control and Prevention; 2012.
Diabetes Incidence in Maine
13

Prevalence Varies
throughout Maine
from 7% to 10.7%
14
Diabetes Surveillance Report, Maine 2012. Augusta, ME:

Diabetes Prevention and Control Program, Maine Center for
Disease Control and Prevention; 2012.
Diabetes Disease Burden
2009 in Maine, diabetes related deaths had incidence of 65.8 per 100,000
Decreased from 81.5 per 100,000
US 2008 incidence was 72.2 per 100,000
Significantly increased risk of cardiovascular diseases
Leading cause of
Including stroke and myocardial infarction (MI)
Non-traumatic lower extremity amputations, blindness, and kidney failure
Medical expenditures are on average 2.3 times higher in patients with

diabetes than those without (~ $ 174 billion in direct + indirect costs in
2007)

15
Microvascular Complications:
Nephropathy
Retinopathy
Neuropathy
Foot ulcers/lesions
Numbness, pain
Sexual dysfunction
Gastroparesis
16
http://www.mayomedicallaboratories.com/images/articles/communique/2009/09fig1.jp
g
Macrovascular
Complications
Cardiovascular Diseases (CVD)
Coronary Artery Disease
(CAD)
Myocardial Infarction (MI)

Stroke or transient ischemic
attack (TIA)
Peripheral Artery Disease (PAD)

17http://womenshealth.gov/heart-health-stroke/images/heart-attacksigns.gif
Additional Concerns
Depression and other
mental disorders
Dental disease
Increased risk of infection
Can affect fertility
Severe hyper- or hypoglycemic events
http://diabeticradio.com/wp-content/uploads/2010/06/hypoglycemia.jpg
18
Diabetes Preventative
Care
19
Preventative Care in
Maine

20
How do we classify and

diagnose diabetes?
Types
Diagnosis
Screening
Case
http://a.abcnews.com//images/Health/diabetes_Screening3_mn.jp
g
21
Diabetes Classification
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes (GDM)
Other types related to other causes
Exocrine diseases (i.e. cystic fibrosis)
Genetic defects affecting insulin action or production
Drug/chemically induced (i.e. HIV/AIDs treatments)
22
American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11S66.
Diagnosis of Diabetes:
Measurements that may be used
Fasting Plasma Glucose (FPG)
Blood glucose measured after 8 hours fasting
Oral Glucose Tolerance test (OGTT)
Blood glucose measured 2 hours after 75 gram glucose load (use of

anhydrous glucose solution)
Glycosylated hemoglobin or Hemoglobin A1c (A1C)
Test without regard to meals, provides 3 month mean glucose
Random plasma glucose (PG)
For use in patients with symptoms of hyperglycemia/hyperglycemic crisis

23
Symptoms/Presentation
Assessment for signs and symptoms of hyperglycemia
Excess thirst, urination, and/or hunger
Blurry vision or vision changes
In severe hyperglycemia (BG > 240 mg/dL)
Ketones may be present in urine
Ketoacidosis can occur when the body breaks down fat and other
molecules for energy
Can not use glucose for energy without insulin

24
Values for Diabetes/Pre-Diabetes
Measurement
Criteria for
Diabetes
Criteria for PreDiabetes
FPG
126 mg/dL
100 - 125 mg/dL
OGTT
200 mg/dL
140 - 199 mg/dL
A1C
6.5%
5.7 - 6.4%
Random PG
200 mg/dL
N/A
25
Pre-Diabetes Diagnosis
Plasma glucose and/or A1C level between normal range
and diabetes
Risk for developing DM and CVD

Estimates for developing diabetes over 5 years
range from 9 - 50 %
Evaluate and treat other risk factors:

Obesity/overweight, dyslipidemia, and hypertension
26
Who to Test/Screen for Diabetes?

For which patients should you be
recommending testing/screening for Diabetes?
When/How often should they be screened?

Evaluate individual patient risk
Assess previous screening results
What risk factors can you name?
27
Risk Factors*
Obesity/overweight (BMI 25 kg/m2)
History of CVD
Physical inactivity
Prior diagnosis of pre-diabetes
First degree relative with DM
HDL cholesterol < 35 mg/dL
Triglycerides > 250 mg/dL
High risk ethnicity/race:

African American
Latino
Native American
Asian Amerian
Pacific Islander
Hypertension: BP 140/90 mmHg

or on treatment
Women with history of GDM or

delivering a baby weighing > 9 lbs
Conditions associated with insulin

resistance:
Severe obesity (BMI 40 kg/m2)
Acanthosis Nigrans
Women with Polycystic Ovarian

Syndrome (PCOS)
28
Who to Screen for

Diabetes?
All adults ( 18 years old) with BMI 25 kg/m2 and 1 or
more additional risk factors*
In adults without additional risk factors

Screening should start at age 45
If results of screening are normal; repeat in 3 years
Repeat yearly in those with Pre-diabetes values
For diagnosis screening test must be repeated
Is better to use same test (i.e. A1C, FPG, etc) for repeat
29
Screening in Children and

Adolescents
Test for type 2 diabetes and pre-diabetes in children/adolescents
Overweight (BMI > 85th percentile for age and gender or >
120% of ideal weight for height)
Plus 2 risk factors:

Family history in 1st or 2nd degree relative
Race/ethnicity (same as in adults)
Signs of insulin resistance or associated conditions
Gestational DM in mother while child was in utero
30
Screening for Gestational

Diabetes
Screen at first pre-natal visit for those with risk factors
Without risk factors screen at 24-28 weeks
Use OGTT for diagnosis (fasting, 1 hour, and 2 hour)
FPG 92 mg/dL
1 hour 180 mg/dL
2 hour 153 mg/dL
In women with gestational DM, screen for type 2 DM at 6-12
weeks post-delivery then every 3 years
31
Who to screen for

Diabetes?
1.
Which of the following symptom-free patients is due to be screened for
diabetes today?
A.
50 year old Latina female who delivered a baby weighing 10 lbs when
she was 27, but had a negative diabetes screening test 24 months ago
B.
25 year old Caucasian female with a BMI of 28 kg/m2 who reports low
to no physical activity and is taking medication to treat his hypertension
C. 40 year old African American male with a BMI of 24 kg/m2 and family
history significant for diabetes in his mother and maternal grandfather
D.
42 year old Caucasian male with a BMI of 26 kg/m2 who has no
comorbidities and is physically active, but has never been screened

32
Meet Mr. L. Labor

33
Patient: L. Labor
25 year old Caucasian Male who frequents your community pharmacy
and has just been to his doctors office (routine visit)
Claims he is generally healthy (admits his diet could be better)

BMI = 28 kg/m2 (height: 73 inches; weight: 215 lbs)
Has a wife and daughter (~ 1 year old)
Previously had a very physically active job, but now spends most of
his time sitting at a computer both at work and at home
Carpentry and Coaching little league v.
Webpage design and Watching games from the stands with snacks
34
Patient: L. Labor
He mentions his doctor wants him to get lab work done to
check for diabetes
He does not understand why

He feels he is young and healthy
How can you explain to him the importance and potential
benefit to having the tests done?
Can you explain to him what diabetes is and what it means

for his health?
35
Interpreting test results

Which of the following values is one of the criteria for
the diagnosis of pre-diabetes?
A. Glycosylated Hemoglogbin (A1C) = 6.2 %

B. Fasting Plasma Glucose (FPG) = 90 mg/dL
C. Plasma Glucose 2 hours after a 75 grams glucose
load = 130 mg/dL
D. Glycosylated Hemoglogbin (A1C) = 5.7 %

36
Values for Diabetes/PreDiabetes
Measurement
Criteria for
Diabetes
Criteria for PreDiabetes
FPG
126 mg/dL
100 - 125 mg/dL
OGTT
200 mg/dL
140 - 199 mg/dL
A1C
6.5%
5.7 - 6.4%
Random PG
200 mg/dL
N/A
37
Interpreting test results

What does it mean if LLs lab test shows:
Glycosylated Hemoglogbin (A1C) = 6.0 %
And
Fasting Plasma Glucose (FPG) = 110 mg/dL
What else would you like to know about him or test for?
What should we recommend for him going forward?
38
Next Steps
To prevent/delay the onset of Type 2 Diabetes in patients who have
been diagnosed with Pre-diabetes, which of the following are
recommended as part of an ongoing support plan:
A. Weight loss of 7% of the patients initial body weight

B. Moderate physical activity for a minimum of 150 minutes/week
C. Initiation of canagliflozin therapy
D. A and B are correct
E. A, B, and C are all correct
39
Treatment for PreDiabetes
40
http://www.diabetes-warrior.net/wp-content/uploads/2010/10/prediabetes1.jpg
Lifestyle Modifications for

Pre-Diabetes and Diabetes
Medical Nutrition Therapy (MNT)
Moderation, variety of carbohydrates
Increased physical activity
Minimum 150 minutes/week moderate level
Weight loss/maintenance
Initial 7% of body weight and maintenance of weight loss
Smoking cessation
Encourage and support with counseling and/or
pharmacotherapy
41

Can decrease progression from pre-DM to DM
Group and individual delivery methods have both been found to
be effective
Monitoring for and managing other CVD risk factors:

Hypertension (HTN)
Hyperlipidemia (HLD)
Overweight/obesity (especially excessive abdominal fat)
Tobacco use
42

What specifically could you recommend
for LL?
Work with 1 -2 others for 2-3 minutes

writing down specific recommendations
for LL
43
Specific Recommendations for LL:

Smoking cessation (assessment of readiness to quit)
Healthful diet and exercise plan with goal of 15 lbs weight loss
Limit intake of high sugar beverages
Increase intake of whole grains to obtain recommended intake of
fiber
Recheck BP, recommend treatment if it continues to be elevated

Check fasting lipid panel, recommend treatment if levels are
elevated
Annual monitoring for development of DM

Medication therapy for Pre-Diabetes?
44
Pharmacotherapy for
Pre-Diabetes
Which of the following answers lists medications that can help
prevent/delay the progress from pre-diabetes to diabetes?
A. Pioglitazone and Glipizide

B. Orlistat and Sitagliptin
C. Acarbose and Pioglitazone
D. Any of the above
45
Metformin for PreDiabetes

Can be considered for all patients with Pre-diabetes as
adjunct to lifestyle modification
Especially recommend for patients with

Elevated FPG ( > 100 mg/dL)
BMI > 35 kg/m2
Aged < 60 years old
History of GDM (women)
46
Progress.
LL follows recommendations from you and his other health
care providers
He is able to quit smoking with nicotine patches and

counseling, but during this time his weight goes up 2.5 kg
About 6 months later he begins a diet and exercise

program for patients with Pre-Diabetes
He is able to loose ~ 20 lbs but has been struggling to

keep from gaining it back
47
Progress.
LL has tolerated Metformin therapy and is now
taking 1 gram BID
He is exercising more, but he is still having

difficulties balancing his diet
He was diagnosed with high blood pressure

Not currently on therapy - improved with
smoking cessation and weight loss
48
8 years later.
He comes into the pharmacy today for his Metformin
refill and reports bad news
Despite his lifestyle changes he has been diagnosed

with type 2 diabetes
His A1c has reached 8.1% and he has had two FPGs >
140 mg/dL drawn by the lab over 2 weeks
He is motivated to continue with his lifestyle changes,

but wants to know more about additional medications
49
Adding on more
medications
Individually take 1 minute to list additional diabetes
therapies that could be added to LLs Metformin for
better glycemic control
In pairs take a few minutes to discuss your options

Select and write down one agent/class that you
would recommend for him based on his current
status
Write down why you think it is a good choice for him

50
Adding on Therapy
While metformin is still the preferred first line therapy for patients with diabetes, if
maximum doses of metformin do result in an A1C at goal, how should an additional
agent be chosen?
A. The second agent added on should be a Glucagon-Like-Peptide-1 (GLP-1)

receptor agonist
B. The second agent added on should be selected based on patient specific factors
with consideration of cost, potential side-effects, and comorbidities
C. The second agent should be insulin therapy with insulin glargine daily and
insulin aspart or lispro TID with meals
D. A second agent should not be added until diet and lifestyle goals have been
achieved to reduce insulin resistance
51
A Patient Centered
Approach
American Diabetes Association (ADA) and the European
Association for the Study of Diabetes (EASD) 2012
recommendations
Patient be involvement in decision making

Patient factors be considered in selecting treatments
and goals of therapy
Most add-on therapy will offer similar glycemic benefit,

but compliance and risk of adverse events varies
Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 52
diabetes: a patientcentered approach, Position Statement by the ADA and the EASD. Diabetes Care. 2012;35:1364-79.
Factors to Consider
Think of each element as a continuous spectrum:
Patient attitude and expected treatment efforts
Risks of hypoglycemia and other adverse events
Disease duration
Life expectancy
Important comorbidities
Established vascular complications
Resources, support system available
Factors to Consider
Factors should also be considered in prescribing lifestyle
modifications
Setting goals that are realistic

Adapting to patient situations
These may include:
Access to healthful foods
Access to a safe environment for exercise
Patients physical ability (i.e. Fall risk, respiratory conditions)
55
Adding on Therapy
While metformin is still the preferred first line therapy for patients with
diabetes, if maximum doses of metformin do result in an A1C at goal, how
should an additional agent be chosen?
B. The second agent should be insulin therapy with insulin glargine daily
and insulin aspart or lispro TID with meals
This strategy of starting insulin as first line (with or without metformin) may
be appropriate for patients with severe hyperglycemia at time of diagnosis or
therapy initiation
A1C 10% or Blood glucose > 300 mg/dL
Adding on Therapy
While metformin is still the preferred first line therapy for
patients with diabetes, if maximum doses of metformin do
result in an A1C at goal, how should an additional agent be
chosen?
A. The second agent added on should be a Glucagon-LikePeptide-1 (GLP-1) receptor agonist
This may be appropriate for patients in whom weight gain is

desirable, patient has insurance that will cover cost (reasonable
copay), and patient feels comfortable with injectable therapy
Oral Medication Options
58
New Oral Options

Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors
Dapagliflozin (Forxgia)
2011, FDA declined approval (concerns over risk of breast
and bladder cancer)
July 2012 NDA resubmitted to FDA with new data

Has been approved in the EU, Australia, New Zealand,
Mexico, and Brazil
Canagliflozin (Invokana) - approved earlier this year

59
New Oral Options

Sodium-Glucose cotransporter 2 (SGLT2) inhibitors
Lowers blood glucose by decreasing the amount of
glucose re-absorbed by the kidneys
Canagliflozin (Invokana)
Moderate A1C reduction and weight reduction
Low incidence of hypoglycemia
Renal monitoring and dose adjustment
60
Invokana (package insert). Janssen Pharmaceuticals, Inc. Titusville, NJ. March 2013; http://www.invokanahcp.com/. Accessed: 08/28/13.
Canagliflozin
(Invokana)
Approved for treatment of adults with type 2 Diabetes in conjunction with

lifestyle interventions
Initiate at 100 mg PO daily, before first meal of the day
Can increase to 300 mg PO daily if eGFR 60 mL/min (if less max dose =
100 mg/day)
Contraindicated with hypersensitivity, ESRD, dialysis
Avoid or discontinue if eGFR < 45 mL/min
Additional Warnings include:
Hypotension, hyperkalemia, hypoglycemia, mycotic genital infections,

and increased LDL cholesterol
61
Canagliflozin
(Invokana)
62
Injectable Medication
Options
Insulins
Long acting, short acting, rapid acting, and premixes
Insulin Degludec - FDA declined approval; requesting more data
Glucagon-like peptide - 1 receptor agonists
Exenatide, liraglutide
Albiglutide - may be next agent in class (FDA petition submitted by

GlaxoSmithKline Jan 2013); proposed for once weekly injection
Amylin mimetics
Pramlintide - use with insulin; mostly in patients with type 1 DM

63
Ultra-long Acting Insulin?

Insulin Degludec
Proposed to have > 24 hour activity to give better once
daily dose coverage than other products
Half-life ~ 42 hours
FDA declined to approve as of Feb 2013
Requested more long term cardiovascular safety data from
dedicated trial
Has been approved in the European Union

64
Tucker ME. FDA rejects Novo Nordisks Insulin Degludec. Medscape News. Available at: http://www.medscape.com/viewarticle/779077
Injectable Agent Dosing

Which of the following answers correctly lists medication name,
strength, and starting dose for a Glucagon-Like Peptide-1 (GLP-1)
receptor agonist?
A. Liraglutide (Victoza) 0.6 mg injected SubQ once daily without

regard to meals
B. Exenatide (Byetta) 5 mg injected SubQ BID 60 minutes or less

before a meal
C. Exenatide (Bydureon) 2 mg injected SubQ once weekly, must be

with a meal
D. Both A and C are correct

65
Back to adding on
therapy
Any changes in what you would like to recommend for LL?
Comparative analysis of add-on therapy has indicated
that most 2 drug combinations have similar A1C lowering
effects
Variance is greater in incidence of hypoglycemia and

other side-effects
For each patient must consider risk v. benefit of each

medications positive and negative effects
Bennett WL, Maruthur NM, Singh S, et al. Comparative effectiveness and safety of medications
for type 2
66
diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med. 2011;154:602-13.
Goals for therapy

Choosing an A1C goal for a patient should be individualized just like
the therapy selected
Guidelines recommend lowering A1C to below or around 7% to

reduce microvascular complications (range 6.5% - 8%)
May also reduce macrovascular complications in some patients if

implemented soon after diagnosis
For other patients, older, greater duration of disease, benefit of

lower A1C may not outweigh risk of hypoglycemia
Variance in cardiovascular outcomes between large trials

Brief on Trials for Tight Glycemic

Control
UKPDS
Intensive Control associated with improved microvascular outcomes
ACCORD
Intensive therapy/targets increased mortality without significantly reducing

cardiovascular events
ADVANCE
Intensive control resulted in relative reduction of combined major cardiovascular

events and microvascular events
VADT
No significant effect on rates of major cardiovascular events, death, or

microvascular complications
The Action in Diabetes and Vascular Disease: Preterax and Diamicron

Modified Release Controlled Evaluation (ADVANCE) Collaborative
Group. NEJM. 2008;358(24):2560-72.
69
Duckworth W, Abraira C, Moritz T, et al. NEJM. 2009;360(2):129-39.
Stratton IM, Adler AI, Neil HAW, et al. BMJ. 2000;321:405-12.
The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group. NEJM. 2008;358(24):2545-59.
Meta-analysis on tight glycemic

control
Lancet 2009: based on 5 randomised trials
Intensive therapy reduces coronary events without an increased
risk of death
Notes variance between populations and rate of A1C reduction

BMJ 2011: based on 14 randomised trials (used trial sequence analysis)
Intensive control has not been proven to reduce all cause mortality
Increase in relative risk of hypoglycemia by 30 %
Evidence insufficient to draw conclusions on cardiovascular
mortality, non-fatal MI, composite microvascular complications, or
retinopathy
Ray KK, Kondapally Seshasai S, Wijesuriya S, et al. Lancet. 2009;373:1765-72.
70
Hemmingsen B, Lund SS, Gluud C, et al. BMJ. 2011;343:d6898 Doi: 10.1136/bmj.d6898.
Meta-analysis on tight glycemic

control
BMJ 2011: based on 13 studies
Limited benefits to all cause mortality and cardiovascular-related
death
Values on both sides of the debate can not be ruled out by this
analysis
Risk and benefit for microvascular and macrovascular

complications - inconclusive
Risk of harm with hypoglycemia noted

Need for more trials
71
Boussageon R, Bejan-Angoulvant T, Saadatian-Elahi M, et al. BMJ. 2011;343:d4169 doi:10.1136/bmj.d4169.
What should be goal for

LL?
What do you think we should set at LLs A1C goal?
How about other goals/plans?
Self-monitoring of blood glucose (SMBG)
Preventative Care
Cardiovascular risk reduction
Medical Nutrition Therapy (MNT)
72
Potential Plans for LL

A1C 7% (depending on response to therapy)
Check A1C at least twice per year
Check more often when changing therapies or above goal
Diabetes Self-Management Education (DSME) and support
Initial education plus follow-up
Education should address quality of life and psychosocial
issues
May be recommended for patients with Pre-Diabetes as well

73
Potential Plans for LL

SMBG
Part of comprehensive DM education and care discussion with
patient
Daily monitoring is not required for most patients not taking insulin
Consider patient comfort, access to testing supplies, and risk of
hypoglycemia based on medication therapy
Goals and frequency should be individualized; can consider:

Fasting BG range 70 - 130 mg/dL
Peak Post-prandial BG < 180 mg/dL (taken 1-2 hours after meal)
74
Medical Nutrition Therapy
Weight loss (overweight/obese) and weight maintenance
Use of low carbohydrate, low fat calorie-restricted, or Mediterranean diet
Monitor lipids, renal function, and protein intake
Individual diet plan for intake of carbohydrates, proteins, and fats
Saturated fat < 7 % of total calories (9 calories per gram of fat); limit trans
fats
Addition of physical activity (design to meet patients ability)
Increase intake of whole grains to get recommended daily intake for fiber
Limit alcohol intake to moderate (1 drink per day women; 2 per day men)
Specific vitamin supplementation not currently supported by evidence

75
Cardiovascular
Prevention
Hypertension
New goal option of systolic < 140 mmHg; Diastolic < 80 mmHg
Lower targets (< 130 mmHg) may be appropriate for specific
patients (younger)
Preferred treatment
DASH Diet and lifestyle modification
Angiotensin Converting Enzyme (ACE) Inhibitors or Angiotensin
Receptor Blocker (ARB) (monitor renal function and electrolytes)
Addition of diurectics or other agents may be required to reach goal

76
Cardiovascular
Prevention
Hyperlipidemia
Monitor fasting lipids annually
Or every 2 years if at goal and stable
Lifestyle modifications recommended for all patients
Recommend addition of HMG-CoA Reductase Inhibitor (statin)
therapy regardless of baseline lipid values if patient has CVD
or
Over the age of 40 with 1 or more CVD risk factors

Family history of CVD, HTN, smoking, albuminuria,
dyslipidemia
77
Cardiovascular
Prevention
Hyperlipidemia
For lower risk individuals add statin if
Lifestyle changes alone do not reduce LDL to < 100 mg/dL
Patient has multiple CVD risk factors
If patients do not meet goals (see next slide) on maximum
tolerated statin dosing
Alternative goal: LDL reduction by 30 - 40 % from baseline

Combination therapy has not been shown to have additional
cardiovascular benefit
78
Cardiovascular
Prevention
Hyperlipidemia
LDL Goals (primary target of therapy)
< 100 mg/dL for patients without CVD
< 70 mg/dL for patients with CVD
Triglyceride goal < 150 mg/dL
HDL goal for men > 40 mg/dL
HDL goal for women > 50 mg/dL
79
Cardiovascular
Prevention
Anti-platelet agents
Can use aspirin 81 mg daily as primary prevention in patients
with type 1 or type 2 DM at increased risk( 10 year risk > 10%)
Includes most men > 50, women > 60 with at least 1 risk
factor
For patients with lower risk (10 risk < 5%) with no risk factors therapy is not recommended
For patients at moderate risk, must weigh risks and benefits

For secondary prevention, aspirin 81 mg is recommended
May use clopidogrel with documented aspirin allergy
80
General Prevention
Monitoring of renal function
Treatment of elevated urinary albumin excretion with ACE
Inhibitors or ARBs
Eye exams yearly

Foot care and exams
Skin care
Vaccinations
Social support
81
Prevention:
Immunizations
You are working with a 30 year old gentleman who has just
been diagnosed with type 2 Diabetes. Which vaccines would
you recommend he receive if he has not done had them
already?
A. Hepatitis B series
B. Influenza (to be repeated annually)
C. Pneumoccal Polysaccharide
D. Both B and C are correct
82
Useful Abbreviations:
ADA
American Diabetes Association
A1c or A1c
Hemoglobin A1c
FPG
Fasting Plasma Glucose
OGTT
Oral Glucose Tolerance Test
BG
Blood Glucose
IFG
Impaired Fasting Glucose
IGT
Impaired Glucose Tolerance
DM
Diabetes Mellitus
HTN
Hypertension
HLD
Hyperlipidemia
MI
Myocardial Infarction
CAD
Coronary Artery Disease
CVD
Cardiovascular Disease
PAD
Peripheral Artery Disease
TIA
Transient Ischemic Attack

83
References:
American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care.
2013;36(1): S11-S66.
Centers for Disease Control and Prevention. Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department
of Health and Human Services; 2012. Available at: www.cdc.gov/diabetes/pubs/pdf/DiabetesReportCard.pdf
Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2011. Atlanta, GA: Centers for Disease Control and Prevention, US
Department of Health and Human Services; 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.
Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention and Control Program, Maine Center for Disease Control and
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3-Diabetes Update Presentation

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Diabetes Update

Identify the classification, risk factors, diagnosis, and

Explain pharmacologic and non-pharmacologic treatments

Describe measures that can be taken to prevent diabetes

Discuss with patients and other health care practitioners diabetes

Compare and contrast medication therapies available for the

Develop a comprehensive care plan for a given patient with

What is Diabetes? Warmup

Spend the next 2 minutes sharing your description

Write down some of the concepts you come up with

What is Diabetes? Warmup

Cardiovascular disease with abnormal processing and

Qualitative: insulin resistance especially muscle, liver,

Improvements in insulin function

Renal tubular transport of glucose to the urine due to

Incretin system deviations (relationship to DM still not fully clear)

Who has Diabetes?

Incidence is higher in certain populations

About 2/3 of patients with diabetes in the US also have

How does Maine compare to the US when it comes to incidence

Incidence of Diabetes in the US

Incidence ranges from

New Cases of Diabetes

Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention

Diabetes Incidence in Maine

Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention

Diabetes Surveillance Report, Maine 2012. Augusta, ME:

Diabetes Disease Burden

Decreased from 81.5 per 100,000

US 2008 incidence was 72.2 per 100,000

Significantly increased risk of cardiovascular diseases

Including stroke and myocardial infarction (MI)

Non-traumatic lower extremity amputations, blindness, and kidney failure

Medical expenditures are on average 2.3 times higher in patients with

Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention

Myocardial Infarction (MI)

Peripheral Artery Disease (PAD)

Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention

How do we classify and

Fasting Plasma Glucose (FPG)

Blood glucose measured after 8 hours fasting

Oral Glucose Tolerance test (OGTT)

Blood glucose measured 2 hours after 75 gram glucose load (use of

Glycosylated hemoglobin or Hemoglobin A1c (A1C)

Test without regard to meals, provides 3 month mean glucose

Random plasma glucose (PG)

For use in patients with symptoms of hyperglycemia/hyperglycemic crisis

Can not use glucose for energy without insulin

Criteria for PreDiabetes

100 - 125 mg/dL

140 - 199 mg/dL

Risk for developing DM and CVD

Evaluate and treat other risk factors:

Who to Test/Screen for Diabetes?

When/How often should they be screened?

Prior diagnosis of pre-diabetes

First degree relative with DM

HDL cholesterol < 35 mg/dL

Triglycerides > 250 mg/dL

High risk ethnicity/race:

Hypertension: BP 140/90 mmHg

Women with history of GDM or

Conditions associated with insulin