9/20/2012

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Diabetes Mellitus:Screening, Glycemic Targets, and

Pre- Pregnancy Counseling

Kendal Hamann, MD

Endocrinology

Sept 20, 2012

Disclosures

� No financial disclosures.

� I am not Pediatric trained.

� I think taking care of diabetes is fun.

Objectives

“By the end of the conference the residents will be able to…”

� 1) Diagnose type 1 or type 2 diabetes.

� 2) Educate patients at risk for diabetes.

� 3) Define appropriate glycemic targets for patients with diabetes.

� 4) Provide pre pregnancy counseling to women of child bearing age who have diabetes.

Type 1 Diabetes

� Insulin deficiency � insulin dependent

� Pancreatic beta cell failure

� Autoimmune mediated (usually)

� 5-10% of all diabetes mellitus

� Typical:

� thin, young, hx DKA, weight loss,

+/- family hx

Type 2 Diabetes

� Insulin resistance

� Eventual pancreatic “burnout”

� Oral meds, insulin, or both

� An epidemic due to obesity

� Typical:

� obese, strong fam hx, routine labs, weight

gain, hx gestational DM, PCOS,

acanthosis nigricans

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Gestational Diabetes

� Pregnancy induced diabetes

� Related to type 2 diabetes

� 1/3 will go on to have DM2 later on in life

*5% with DM during pregnancy may be early type 1 diabetes.

Clinical Presentation of DM

� Hyperglycemia

� Silent

� Fatigue

� Vision changes

� Infections

� Polyuria or Polydysia

� Wt gain (DM2) OR wt loss (DM1)

� Acute illness if DKA present� Nausea, vomiting, anion gap

Making the Diagnosis

ADA Criteria

ADA advises

labs be repeated

to rule out lab

error – unless

clinical symptoms

are obvious.

Making the Diagnosis

Practical Tips

� Always determine whether DKA present:

� Is the patient ill?

� Are there ketones or an anion gap?

� If yes, needs urgent eval, admission, fluids,

IV insulin.

� DKA usually = type 1 diabetes mellitus.

Making the Diagnosis

Practical Tips

� When in doubt as to the type of diabetes, insulin always works!

� Orals can be tried with good advice to

the patient about features of DKA to watch for:

� Feeling ill + high blood sugars

Risk Factors for Diabetes

� DM2

� Family history

� Obesity

� Metabolic syndrome

� PCOS

� Hx gestational DM

� Glucocorticoids

� DM1

� Autoimmunity

� Family history

� Pancreatic injury

� Other

� Genetic syndromes

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Impaired Fasting Glucose

Impaired Glucose Tolerance

Prevention of DM2:

DPP Trial

� Diabetes Prevention Program (DPP).

� RCT:

� Lifestyle mod: low fat diet, 150min/week exercise

� Metformin: 850mg BID

� Control

� 3234 adults ages 25-85 with impaired glucose tolerance.

� Primary outcome: new diagnosis of DM.

Prevention of DM2:

DPP Trial Outcome

� Participants who made lifestyle changes reduced their risk of getting type 2

diabetes by 58 percent.

� The lifestyle intervention was effective

for participants of all ages and all ethnic groups.

� Participants with standard care plus

metformin reduced their risk for getting type 2 diabetes by 31 percent.

Screening Guidelines for DM:

ADA

Screening Guidelines:

Summary

� DM1: no screening recommended

� Antibodies used among some families in clinic trials

� DM2: start age 45 or earlier if other risk factors present

� Every 3 years

� GDM: ASAP if risk factors present

� 24-28 gestation weeks if no risk factors

� Post partum 6 weeks and every 3 years for DM2

Target Blood Glucoses (ADA)

� 90-130 pre prandial

� <180 peak post prandial (1 hr)

� A1c <7.0*

* Special populations require individualized targets: pregnancy, elderly, co-morbidities (CVD), long duration of DM2

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Complications of DM2Why do glycemic targets matter?

� Microvascular

� Retinopathy

� Neuropathy

� Autonomic, peripheral, gastroparesis

� Nephropathy

� Macrovascular

� Acute MI, stroke, PVD, multi-infarct dementia

� Other

� Duputryen’s contractures

� Carpel tunnel syndrome

� Infections

� Osteoporosis

� Erectile dysfunction

UKPDS and DCCT(landmark trials for DM2 and DM1)

� RCT’s of intensive vs. conventional control

� Both showed reduction in diabetes

related complications with improved glycemic control

DM (1 and 2):

Preconception Counseling

� Risks of Hyperglycemia

� Fetal

� Maternal

� Medications

� Glycemic agents

� Insulin

� ACE I’s and ARB’s

� Statins and others

DM and Pregnancy:

Fetal Risks of Hyperglycemia

� Risk of major fetal anomaly:

� No DM 1%

� Well controlled DM 2%

� Poorly controlled DM 6-12%

� 20% increase for every 1% increase in A1c

above 5.5

Greenspan et al., Basic and Clinical Endocrinology, McGraw Hill, 2004.

DM and Pregnancy:

Fetal Risks of Hyperglycemia

� Major Congenital

� Anencephaly

� Spina bifida

� Cardiac

� Anal atresia

� Renal agenesis

� Situs Inversus

All of these occur by 8 weeks gestation!

DM and Pregnancy:

Other Fetal Risks of Hyperglycemia

� Polyhydramnios

� Intrauterine growth retardation

� Stillbirth

� Macrosomia

� Shoulder dystocia

� Respiratory Distress

� Hypoglycemia

� Hyperbilirubinemia

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DM and Pregnancy:

Maternal Risks of Hyperglycemia

� Spontaneous abortion

� Pre term labor

� Pre-eclampsia

� Progression of retinopathy*

� Progression of nephropathy*

� C Section

*Preconception counseling should ensure that all

DM related screening is current.

DM Treatment Guidelines

During Pregnancy

� ADA:

� Fasting glucose 60-99 mg/dL

� Post prandial glucose <130 mg/dL

� A1c <6.0

� These goals should apply prior to conception.

ADA Standards of Medical Care in Diabetes 2009; Diabetes Care; 2009;32(S1):13-61.

DM and Pregnancy

Oral Agents

� Generally not recommended

� Generally class C

� Risk cannot be ruled out

� Exceptions

� metformin (B)

� Can decrease SAB in PCOS with hx SAB

� glyburide (B)

� Increasing safety data emerging

DM and Pregnancy

Insulin

� NPH and Regular insulin

� Well known safety

� Aspart and Lispro (Novolog and Humalog)

� Sufficiently safe

� Lantus and Detemir

� Insufficient safety data

DM and Pregnancy:

ACE I’s and ARB’s

� Class C, 1st trimester

� Cardiac defects

� CNS defects

� Class D, 2nd and 3rd trimesters

� Renal defects

� Oligohydramnios

� Pulmonary hypoplasia

� Limb contraction

DM and Women of Childbearing

Age: ACE I’s and ARB’s

� Primary prevention, normotensive DM1: no role

� Primary prevention, normotensive DM2: no role

� Secondary prevention, DM1 and DM2: definite role

� Hypertensive DM1 and DM2: definite role

� For women with childbearing potential:

� Use only if truly indicated AND

� Using contraception AND

� Pre pregnancy counseling provided and documented AND

� Patient is reliable

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DM and Pregnancy:

Cholesterol Lowering Agents

� Statins:

� Category X (contraindicated)

� CNS defects

� Limb abnormalities

� First trimester

� Low absolute risk with inadvertent

exposure

� All other lipid lower agents are class C

DM and Women of Childbearing

Age: Statins

� For women with childbearing potential:

� Use only if truly indicated AND

� Using contraception AND

� Pre pregnancy counseling provided and documented AND

� Patient is reliable

DM and Pregnancy:

Changing Times

� Pre pregnancy counseling and diabetes used to apply mostly to DM1 patients.

� DM2 is a new epidemic.

� Pre pregnancy counseling is becoming

more important for all women of child bearing age who are at risk for DM2:

� Obese

� Family history DM2

� PCOS

Any Extra Time?

� Questions?

� Suggestions for next time?

� Kendal.L.Hamann@kp.org, 571-3909

� Feedback welcome!

THANK YOU!