T2 D

MREAL. DEADLY. NOT FUNNY.

by Christine Hortillosa

FAST FACTS

7th Leading Cause of Death, 2007

$174B Total Costin 2007

90% are withT2DM

25.8 MDiabetics in US

Ref: Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States. 2011. CDC.

OUTLINE

• Clinical Presentation• Diagnosis• Monitoring• Treatment Options• Other Considerations

– Immunization– Lifestyle Modification– Hypoglycemia Awareness

CLINICAL PRESENTATION

• Hallmark symptoms1. Polyuria2. Polydipsia3. Polyphagia

• Criteria for testing for DM in asymptomatic adults

1. Overweight (BMI ≥ 25) and have at least one of the following:

• Physical inactivity• 1st-degree relative with DM• High-risk race • Women delivering a baby >9 lbs• Hypertension• Women with PCOS• History of CVD• HDL < 35 and/or TG >250 mg/dl

2. If did not meet first criteria, start at age 45 yo3. If results are normal, test Q3 years

DIAGNOSIS

1. Fasting Plasma Glucose (FPG) ≥ 126 mg/dl. Fasting is defined as no caloric intake for at least 8 hours OR

2. HbA1c ≥6.5% in a laboratory OR3. In patient with classic symptoms,

random plasma glucose ≥ 200mg/dl OR

4. Using an Oral Glucose Tolerance Test (OGTT), with a 75 gram glucose load, a 2 hour plasma glucose ≥ 200 mg/dl.

THERAPEUTIC GOALS

Glycemic Target

ADA AACE

A1c <7% ≤6.5%

Preprandial 70-130 mg/dl

<110 mg/dl

Postprandial <180 mg/dl <140 mg/dl

TREATMENT OPTIONS

1. Individualized glycemic targets and glucose lowering therapies

2. Diet, education, and exercise 3. Metformin: first-line drug4. After metformin, combination therapy5. If failed oral agents, insulin 6. Involve the patient 7. Comprehensive cardiovascular reduction

• Diabetes Complications:– Macrovascular (i.e. CVD)– Microvascular (retinopathy, nephropathy,

neuropathy)

• CVD Risk Factors:– Hypertension– Dyslipidemia

• ADA Recommendations– Routine BP monitoring (new goal: 140/80)– Annual lipid screening

• Goals: LDL <100, TG <150, HDL >40 (men), HDL >50 (women)

– Aspirin as 1o prevention for select patients

OTHER CONSIDERATIONS

• ADA Recommendations cont. – Dilated eye exam upon diagnosis and

annually after– Screen for increased urinary albumin

excretion yearly– Screen for diabetic peripheral neuropathy

starting at diagnosis and yearly after

OTHER CONSIDERATIONS

IMMUNIZATION

• Annual influenza vaccine (> 6 months of age)

• PPV (> 2yo and then after 64 yo with 5 years between 2 vaccination)

• Hepatitis B (19- 59 yo)• Others: Tetanus and Pertussis

LIFESTYLE MODIFICATION

• Medical nutrition therapy• Moderate weight loss (7% body weight)• Limit alcoholic drinks (1/day for women,

2/day for men)• Moderate intensity aerobic exercise 50

min/day x 3 days a week• Smoking cessation

I AM BARACK OBAMA AND I APPROVE THIS MESSAGE.

HYPOGLYCEMIA AWARENESS

• Hypoglycemia can cause falls, MVA, and other injuries

• Preferred treatment: – 15 to 20 g of glucose then – BG check after 15 minutes– Consume a meal to prevent recurrence

PREVENTIVE CARE

• Impact on Diabetes Management:

Complication targeted

Intervention Risk Reduction

Microvascular Glucose control 40%

Amputations Comprehensive foot care exams

45%-85%

Vision Loss Laser screening for eye disease

50%-60%

Loss of kidney function

HTN screening + treatment

30%-70%

Proteinuria HTN screening + treatment

35%

CV disease HTN screening + treatment

33%-50%

Ref: Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States. 2011. CDC.

2030 || 552 MILLIONDiabetics

Worldwide

Stop the Spread. Watch the Bread.

How ‘bout tortilla?

REFERENCES

1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States. 2011. CDC.

2. American Diabetes Association. Standards of medical care in diabetes 2013. Diabetes Care 2013; 36(Suppl1); S11-S66.

3. Hilaire ML. Woods TM. Type 2 Diabetes: A focus on new guidelines. Formulary 48: 55-67, 2013.