ADA Guidelines for Management of the Diabetic Patient - 2016

Rick Smith, MS, PhDc, MDc

Wayne State University SOM, Center for Molecular Medicine and Genetics

(Source: American Diabetes Association Diabetes Care 2016 Jan)

Classification of Diabetes

  • Type I: Autoimmune pancreatic β-cell destruction → Loss of post prandial insulin response
    • Genetic factors
  • Type II: Target tissue insulin resistance
    • Secondary to risk factors (Next Slide)
  • Gestational (GDM): Dx during 2nd or 3rd trimester
  • Specifc syndromes due to other disease processes

Vascular Compliations of Non-Enzymatic Glycosylation and Free Radical Activity

  • Microvascular
    • Retinopathy - 10,000 new cases of blindness annually
      • Hemorrhagic/Background: Hard/lipid exudates
      • Proliferative: “Cotton-wool spots”
    • Nephropathy - Microalbuminuria → frank proteinuria
      • Increased GBM thickness
      • Microaneurysms
      • Kimmelsteil-Wilson Nodules
    • Neuropathy
      • Chronic sensorimotor distal symmetric polyneuropathy → painless foot ulceration

(Source: Michael J. Fowler, Microvascular and Macrovascular Complications of Diabetes, Clinical Diabetes, Apr 2008)

Vascular Compliations of Non-Enzymatic Glycosylation and Free Radical Activity (Cont'd)

  • Macrovascular
    • Atherosclerosis
    • Hypercoagulable state

Increased Risk of:

  • CVD
  • TIA/Stroke

(Source: Michael J. Fowler, Microvascular and Macrovascular Complications of Diabetes, Clinical Diabetes, Apr 2008)

Prevention First - DM Type II Risk Factors

  1. Physical inactivity - Screen patients for exercise in every visit
  2. First-degree relative with diabetes* - Directed family history
    • High-risk race or ethnicity*
  3. Women who delivered a baby weighing >9 lb or who have previously been diagnosed with GDM - Detailed Hx of gestations and deliveries
  4. HDL-C <35 mg/dL and/or TG >250 mg/dL
  5. HbA1C ≥5.7%, Impaired glucose tolerance (IGT), or Impaired Fasting (IFG)
  6. Hypertension (≥140/90 or on treatment, even if controlled) - Detailed medication Hx
  7. Hx of cardiovascular disease - Detailed ROS and review of medical Hx
  8. Conditions associated with insulin resistance†

*African-American, Latino, Native American, Asian American, Pacific Islander

†Severe obesity, acanthosis nigricans, polycystic ovarian syndrome

Diagnostic Criteria

Two Tests; Duplicate or Repeated Single

  • Fasting Plasma Glucose (FPG) ≥126 mg/dL (7.0 mmol/L)*
    • Prediabetes - IFG = 100-125 mg/dL (5.6-6.9 mmol/L)

-OR-

  • 2-hr PG ≥200 mg/dL (11.1 mmol/L) during Oral Glucose Tolerance Test (OGTT) (75-g)*
    • 75g anhydrous glucose dissolved in water
    • Prediabetes - IGT = 140-199 mg/dL (7.8-11.0 mmol/L)

-OR-

  • A1C ≥6.5% (48 mmol/mol)*
    • Prediabetes - 5.7-6.4% (39-46 mmol/mol)
    • Considered a more accurate accounting of long-term hyperglycemia

-OR-

  • Random PG ≥200 mg/dL (11.1 mmol/L)
    • In individuals with symptoms of hyperglycemia or hyperglycemic crisis

Testing

  • Overweight/Obese adults of any age AND 1 or more risk factors (Previous Slide)

-OR-

  • Adults > 45yo; rpt every 3yrs if normal

Management

AACE/ACE Consensus Jan 2016 - LIFESTYLE MODIFICATION

  • The only consistant, evidence-based non-pharmacological intervention shown to reduce HbA1C and/or FPG long term is a combination of:
    • Nutrition & Education with Nutritionist
      • Emphasis on optimizing BMI (22-24)
    • Physcial Activity
      • >175 minutes of moderate activity/week
      • Clear morbidity/mortality reduction
    • Regular Sleep
      • 7hrs/night
    • Behavioral Support
      • Emphasis on access to mood/psychiatric therapy
    • Smoking Cessation
      • Clear morbidity/mortality reduction

Medical Management

AACE/ACE Consensus Jan 2016

  • Initial A1c <7.5 / asymptomatic, motivated → 3 - 6 month lifestyle modifications
  • > 7.5 / symptomatic → metformin
    • Initial Metformin 500mg with evening meal → increase to BID in 1-2 weeks
  • A1c >9 / severe sypmtoms → insulin therapy adjunct
    • If contraindicated: liver or kidney dysfunction → Glipizide

Monitoring

  • Glycemic Control
    • Unstable - q 3 months
    • Stable - q 6 months
  • Dyslipidemia (>40yo)
    • Initiate interventions (statin, diet) with CVD or >40yo
    • Consider bariatric if severe
  • Eyes
    • Retinopathy - Annual
    • None - Biannual
  • HTN (>130/80)
    • Target according to pt tolerance - <130/80 acceptable range for most; may aim lower if pt young/can tolerate.
  • CAD Risk (>50yo)
    • Calculate annually → initiate aspirin, statin, or ACEI as indicated
  • Microalbumin
    • Annual
  • Feet
    • Routine screening w/ pulses and sensation