Scientific Statement: Socioecological Determinants of Prediabetes and Type 2 Diabetes
Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome Chapter 3...
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Transcript of Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome Chapter 3...
Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome
Chapter 3
Ronald Goldenberg, Zubin Punthakee
Canadian Diabetes Association 2013 Clinical Practice Guidelines
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Key Messages
1. Screen wisely. Diagnose precisely.
2. Diagnosis of diabetes can be made with:• Fasting plasma glucose (FPG) level of ≥7.0 mmol/L
• 2-hr plasma glucose (2hPG) in 75 g OGTT ≥11.1 mmol/L
• A1C ≥6.5%
3. “Prediabetes” ↑ risk of developing diabetes• Impaired fasting glucose (FPG 6.1-6.9 mmol/L)
• Impaired glucose tolerance (2hPG 75g OGTT 7.8-11.0)
• A1C 6.0- 6.4%
2013
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Classification of Diabetes
Type Definition
Type 1 Diabetes Diabetes due to pancreatic beta destruction and prone to ketosis
Type 2 diabetes Diabetes that ranges from insulin resistance with relative insulin deficiency to a predominant secretory defect with insulin resistance
Gestational DiabetesMellitus
Glucose intolerance with onset or first recognition in pregnancy
Other types Variety of uncommon diseases, genetic forms, or diabetes associated with drug use.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
FPG ≥7.0 mmol/LFasting = no caloric intake for at least 8 hours
or
A1C ≥6.5% (in adults)Using a standardized, validated assay, in the absence of factors that affect the
accuracy of the A1C and not for suspected type 1 diabetesor
2hPG in a 75-g OGTT ≥11.1 mmol/Lor
Random PG ≥11.1 mmol/L Random= any time of the day, without regard to the interval since the last meal
2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose
Diagnosis of Diabetes 2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Single test in diabetes range
Repeat confirmatory test on different day
Use same test as confirmatory test
Use FPG, A1C or 2hPG OGTT as confirmatory test
Diagnosis made. Repeat not necessary
Symptoms*No symptoms*
If random PG used initially
If FPG, A1C or 2hPG used initially
If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.
2013Diagnosis of Diabetes
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Pima Indians
Egyptians
NHANES III
Glycemia and Retinopathy Thresholds
The International Expert Committee. Diabetes Care 2009; 32:1327-1334.
Threshold levels for the development of
retinopathy are similar in all 3 populations: FPG ≥7.0 mmol/L
2hPG ≥11.1 mmol/L A1C ≥6.5%
FPG2hPGHbA1c
70- 89- 93- 97- 100- 105- 116-109- 136- 226-364-244-185-156-138-126-116-106-94-38-
3.4- 4.8- 5.0- 5.2- 5.3- 5.5- 5.7- 6.0- 6.7-HbA1c (%)2hPG (mg/dl)
FPG (mg/dl)Re
tinop
athy
(%)
9.5-
15
10
5
0
FPG2hPGHbA1c
57- 79- 84- 89- 93- 99- 130-108- 178- 258-386-304-218-155-125-110-99-90-80-39-
2.2- 4.7- 4.9- 5.1- 5.4- 5.6- 6.0- 6.9- 8.5-HbA1c (%)2hPG (mg/dl)
FPG (mg/dl)
Retin
opat
hy (%
)
10.3-
50
20
10
0
40
30
FPG2hPGHbA1c
42- 87- 90- 93- 96- 98- 104-101- 109- 120-195-154-133-120-112-102-94-86-75-34-
3.3- 4.9- 5.1- 5.2- 5.4- 5.5- 5.6- 5.7- 5.9-HbA1c (%)2hPG (mg/dl)
FPG (mg/dl)
Retin
opat
hy (%
)
6.2-
15
10
5
0
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
DETECT-2: A1C ≥6.5% Threshold for Retinopathy
Colagiuri S et al. Diabetes Care 2011; 34:145-150.
Any retinopathy≥ moderate NPDR
4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 15.0+10.0 10.5 11.0 11.5 12.0 12.5 13.0 13.5 14.0 14.5
45403530252015
Prev
alen
ce (%
)
FPG by 0.5 mmol/L intervals
4.0 5.0 6.0 7.0 8.0 9.0 18.0+12.011.0 13.010.0 14.0 15.0 16.0 17.0
Prev
alen
ce (%
)
2hPG by 0.5 mmol/L intervals
4540353025201510
4.0 5.5 6.0 6.5 7.0 7.5 12.0+9.08.5 9.58.0 10.0 10.5 11.0 11.5
Prev
alen
ce (%
)
HbA1c by 0.5% intervals5.04.5
50
4540353025201510
50
50
10
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Considerations when using A1C for Diagnosis
• Need validated standardized assay
• Repeat confirmatory test on another day
• Recognize conditions leading to misleading A1C
• A1C is not used for diagnosis in children,
adolescents, pregnancy or suspected type 1 diabetes
• Ethnicity and age can affect A1C results
Recognize pitfalls of A1C: conditions that can affect value
Factors affecting A1C
Increased A1C Decreased A1C Variable Change in A1C
Erythropoiesis B12/Fe deficiency Decreased erythropoiesis
Use of EPO, Fe, or B12Reticulocytosis Chronic liver Dx
Altered hemoglobin
Fetal hemoglobin Hemoglobinopathies Methemoglobin
Altered glycation Chronic renal failure ↓↓erythrocyte pH
ASA, vitamin C/E Hemoglobinopathies ↑ erythrocyte pH
Erythrocyte destruction
Splenectomy HemoglobinopathiesChronic renal failureSplenomegalyRheumatoid arthritisHAART meds, RibavirinDapsone
Assays HyperbilirubinemiaCarbamylated HbETOHChronic opiates
Hypertriglyceridemia
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Pros and Cons of Diagnostic TestsTest Advantages Disadvantages
FPG Established standardFast and easySingle Sample
Sample not stableDay-to-day variabilityInconvenient to fastGlucose homeostasis in single time point
2hPG in 75 g OGTT
Established standard Sample not stableDay-to-day variabilityInconvenient, UnpalatableCost
A1C ConvenientSingle sampleLow day-to-day variabilityReflects long term [glucose]
$$$Affected by medical conditions, aging, ethnicityStandardized, validated assay requiredNot used for age <18, pregnant women or suspected T1DM
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Diagnostic Testing With 3 Different Tests
Dealing with Discordance
• Many people identified as
having diabetes using A1C
will not be identified as
having diabetes by
traditional glucose criteria,
and vice versa.
• When results of more than one test are available (amongst FPG,
A1C, 2hPG in a 75-g OGTT) and the results are discordant, the test
whose result is above diagnostic cut-point should be repeated, and
the diagnosis made on basis of the repeat test.
FPG 2hPG
A1C
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Diagnosis of Prediabetes*
Test Result Prediabetes Category
Fasting Plasma Glucose(mmol/L)
6.1 - 6.9
Impaired fasting glucose (IFG)
2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L)
7.8 – 11.0 Impaired glucose tolerance (IGT)
GlycatedHemoglobin(A1C) (%)
6.0 - 6.4 Prediabetes
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
A1C Level and Future Risk of Diabetes: Systematic Review
A1C Category (%)5-year incidence of
diabetes
5.0-5.5 <5 to 9%
5.5-6.0 9 to 25%
6.0-6.5 25 to 50%
Zhang X et al. Diabetes Care. 2010;33:1665-1673.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
2013
Screening for Type 2 Diabetes in Adults
Algorithm presented on next slides
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Screening for Type 2 Diabetes in Adults (continued)
*If both FPG and A1C are available, but discordant, use the test that appears furthest to the right side of the algorithm.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
‡ In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.
‡ Diabetes: In the absence of symptomatic hyperglycemia, if a single laboratory test is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75-g OGTT) must be done on another day. It is preferable that the same test be repeated (in a timely fashion) for confirmation. If results of two different tests are available and both are above the diagnostic cutpoints, the diagnosis of diabetes is confirmed.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association **Prediabetes = IFG or IGT or A1C 6.0 to 6.4%
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Definition of Metabolic Syndrome
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 1
1. Diabetes should be diagnosed by any of the
following criteria:
• FPG ≥7.0 mmol/L [Grade B, Level 2]
• A1C ≥6.5% (for use in adults in the absence of conditions
that affect the accuracy of A1C and not for use in suspected
type 1 diabetes) [Grade B, Level 2]
• 2hPG in a 75-g OGTT ≥11.1 mmol/L [Grade B, Level 2]
• Random PG ≥11.1 mmol/L [Grade D, Consensus]
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 2
2. In the absence of symptomatic hyperglycemia, if
a single laboratory test is in the diabetes range, a
repeat confirmatory laboratory test (FPG, A1C, 2hPG in
a 75-g OGTT) must be done on another day. It is
preferable that the same test be repeated (in a
timely fashion) for confirmation, but a random PG in
the diabetes range in an asymptomatic individual
should be confirmed with an alternate test. Grade D,
Consensus.
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 2 (continued)
2. In the case of symptomatic hyperglycemia, the
diagnosis has been made and confirmatory test is
not required before treatment is initiated. In
individuals in whom type 1 diabetes is likely
(younger or lean or symptomatic hyperglycemia,
especially with ketonuria or ketonemia),
confirmatory testing should not delay initiation
of treatment to avoid rapid deterioration. [Grade D,
Consensus].
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
2. If results of two different tests are available and
both are above the diagnostic cutpoints, the
diagnosis of diabetes is confirmed. Grade D,
Consensus.
Recommendation 2 (continued) 2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 3
3. Prediabetes, defined as a state which places
individuals at high risk of developing diabetes and its
complications, is diagnosed by any of the following
criteria: • IFG (FPG 6.1 - 6.9 mmol/L) Grade A, Level 1.
• IGT (2hPG in a 75-g OGTT 7.8 to 11.0 mmol/L) Grade A,
Level 1.
• A1C 6.0 - 6.4% (for use in adults in the absence of factors
that affect the accuracy of A1C and not for use in suspected
type 1 diabetes) Grade B, Level 2 .
2013
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients