Diabetes mellitus
Thursday, May 27, 2010
Retinopathy screening and treatment
Recommendations
General recommendations
* Optimal glycemic control can substantially reduce the risk and progression of diabetic retinopathy. (A)
* Optimal blood pressure control can reduce the risk and progression of diabetic retinopathy. (A)
* Aspirin therapy does not prevent retinopathy or increase the risks of hemorrhage. (A)
Screening
* Adults and adolescents with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 3–5 years after the onset of diabetes. (B)
* Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. (B)
* Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist. Less frequent exams (every 2–3 years) may be considered in the setting of a normal eye exam. Examinations will be required more frequently if retinopathy is progressing. (B)
* Women who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examination should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum. This guideline does not apply to women who develop GDM because such individuals are not at increased risk for diabetic retinopathy. (B)
Dyslipidemia/lipid management
2. Dyslipidemia/lipid management
Recommendations
Screening
* In adult patients, test for lipid disorders at least annually and more often if needed to achieve goals. In adults with low-risk lipid values (LDL <100 mg/dl, HDL >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years. (E)
Treatment recommendations and goals
* Lifestyle modification focusing on the reduction of saturated fat and cholesterol intake, weight loss (if indicated), and increased physical activity has been shown to improve the lipid profile in patients with diabetes. (A)
* In individuals without overt CVD
• The primary goal is an LDL <100 mg/dl (2.6 mmol/l). (A)
• For those over the age of 40 years, statin therapy to achieve an LDL reduction of 30–40% regardless of baseline LDL levels is
recommended. (A)
• For those under the age of 40 years but at increased risk due to other cardiovascular risk factors who do not achieve lipid goals with lifestyle modifications alone, the addition of pharmacological therapy is appropriate. (C)
Prevention And Management of Diabetes Complications
CVD is the major cause of mortality for individuals with diabetes. It is also a major contributor to morbidity and direct and indirect costs of diabetes. Type 2 diabetes is an independent risk factor for macrovascular disease, and its common coexisting conditions (e.g., hypertension and dyslipidemia) are also risk factors.
Studies have shown the efficacy of reducing cardiovascular risk factors in preventing or slowing CVD. Evidence is summarized in the following sections and reviewed in detail in the ADA technical reviews on hypertension, dyslipidemia , aspirin therapy , and smoking cessation and the consensus statement on CHD in people with diabetes. Emphasis should be placed on reducing cardiovascular risk factors, when possible, and clinicians should be alert for signs and symptoms of Atherosclerosis.
1. Hypertension/blood pressure control
H. Referral for diabetes management - Diabetes Care
H. Referral for diabetes management
For a variety of reasons, some people with diabetes and their health care providers do not achieve the desired goals of treatment (Table 6). Intensification of the treatment regimenis suggested and includes identification (or assessment) of barriers to adherence, culturally appropriate and enhanced DSME, comanagement with a diabetes team, change in pharmacological therapy, initiation of or increase in SMBG, more frequent contact with the patient, and referral to an endocrinologist.
I. Intercurrent illness
The stress of illness, trauma, and/or surgery frequently aggravates glycemic control and may precipitate diabetic ketoacidosis (DKA) or nonketotic hyperosmolar state. Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose and urine or blood ketones. A vomiting illness accompanied by ketosis may indicate DKA, a life-threatening condition that requires immediate medical care to prevent complications and death; the possibility of DKA should always be considered. Marked hyperglycemia requires temporary adjustment of the treatment program and, if accompanied by ketosis, frequent interaction with the diabetes care team. The patient treated with oral glucose-lowering agents or MNT alone may temporarily require insulin. Adequate fluid and caloric intake must be assured. Infection or dehydration is more likely to necessitate hospitalization of the person with diabetes than the person without diabetes. The hospitalized patient should be treated by a physician with expertise in the management of diabetes, and recent studies suggest that achieving very stringent glycemic control may reduce mortality in the immediate postmyocardial infarction period. Aggressive glycemic management with insulin may reduce morbidity in patients with severe acute illness.
G. Psychosocial assessment and care - Diabetes Care
G. Psychosocial assessment and care
Recommendations
* Preliminary assessment of psychological and social status should be included as part of the medical management of diabetes. (E)
* Psychosocial screening should include but is not limited to attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history. (E)
* Screening for psychosocial problems such as depression, eating disorders, and cognitive impairment is needed when adherence to the medical regimen is poor. (E)
* It is preferable to incorporate psychological treatment into routine care rather than wait for identification of a specific problem or deterioration in psychological status. (E)
Psychological and social state can impact the patient’s ability to carry out diabetes care tasks. As a result, health status may be compromised. Family conflict around diabetes care tasks is also common and may interfere with treatment outcomes. There are opportunities for the clinician to assess psychosocial status in a timely and efficient manner so that referral for appropriate services can be accomplished.
F. Physical activity - Diabetes Care
F. Physical activity
Recommendations
* To improve glycemic control, assist with weight maintenance, and reduce risk of CVD, at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate) is recommended and/or at least 90 min/week of vigorous aerobic exercise (>70% of maximum heart rate). The physical activity should be distributed over at least 3 days/week and with no more than 2 consecutive days without physical activity. (A)
* In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance exercise three times a week, targeting all major muscle groups, progressing to three sets of 8–10 repetitions at a weight that cannot be lifted more than 8–10 times. (A)
Indications for graded exercise test with electrocardiogram monitoring
* A graded exercise test with electrocardiogram (ECG) monitoring should be seriously considered before undertaking aerobic physical activity with intensity exceeding the demands of everyday living (more intense than brisk walking) in previously sedentary diabetic individuals whose 10-year risk of a coronary event is likely to be 10%.
Diabetes Care - E. DSME
E. DSME
Recommendations
* People with diabetes should receive DSME according to national standards when their diabetes is diagnosed and as needed thereafter. (B)
* DSME should be provided by health care providers who are qualified to provide that DSME based on their professional training and continuing education. (E)
* DSME should address psychosocial issues, since emotional well-being is strongly associated with positive diabetes outcomes. (C)
* DSME should be reimbursed by third-party payors. (E)
DSME is an essential element of diabetes care, and National Standards for DSME are based on evidence for its benefits. Education helps people with diabetes initiate effective self-care when they are first diagnosed. Ongoing DSME also helps people with diabetes maintain effective self-management as their diabetes presents new challenges and treatment advances become available. DSME helps patients optimize metabolic control, prevent and manage complications, and maximize quality of life, in a cost-effective manner.
Diabetes Care - Diagnosing And Managing Diabetes
D. MNT
Recommendations
* People with diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. (B)
* Both the amount (grams) of carbohydrate as well as the type of carbohydrate in a food influence blood glucose level. Monitoring total grams of carbohydrate, whether by use of exchanges or carbohydrate counting, remains a key strategy in achieving glycemic control. (A)
* The use of the glycemic index/glycemic load may provide an additional benefit over that observed when total carbohydrate is considered alone. (B)
* Low-carbohydrate diets (restricting total carbohydrate to <130 g/day) are not recommended in the management of diabetes. (E)
* To reduce the risk of nephropathy, protein intake should be limited to the recommended dietary allowance (RDA) (0.8 g/kg) in those with any degree of CKD. (B)
Glycemic goals
Recommendations
* Lowering A1C has been associated with a reduction of microvascular and neuropathic complications of diabetes. (A)
* The A1C goal for patients in general is an A1C goal of <7%. (B)
* The A1C goal for the individual patient is an A1C as close to normal (<6%) as possible without significant hypoglycemia. (E)
* Less stringent treatment goals may be appropriate for patients with a history of severe hypoglycemia, patients with limited life expectancies, very young children or older adults, and individuals with comorbid conditions. (E)
* Aggressive glycemic management with insulin may reduce morbidity in patients with severe acute illness, perioperatively, following myocardial infarction, and in pregnancy. (B)
Glycemic control is fundamental to the management of diabetes. The goal of therapy is to acheive an A1C as close to normal as possible (representing normal fasting and postprandial glucose concentrations) in the absence of hypoglycemia. However, this goal is difficult to achieve with present therapies. Prospective randomized clinical trials such as the DCCT and the U.K. Prospective Diabetes Study (UKPDS) have shown that improved glycemic control is associated with sustained decreased rates of retinopathy, nephropathy, and neuropathy. In these trials, treatment regimens that reduced average A1C to 7% (1% above the upper limits of normal) were associated with fewer long-term microvascular complications; however, intensive control was found to increase the risk of severe hypoglycemia and weight gain. The potential of intensive glycemic control to reduce CVD is supported by epidemiological studies and a recent meta-analysis, but this potential benefit on CVD events has not yet been demonstrated in a randomized clinical trial.
Diabetes Care
A. Initial evaluation
A complete medical evaluation should be performed to classify the patient, detect the presence or absence of diabetes complications, assist in formulating a management plan, and provide a basis for continuing care. If the diagnosis of diabetes has already been made, the evaluation should review the previous treatment and the past and present degrees of glycemic control. Laboratory tests appropriate to the evaluation of each patient’s general medical condition should be performed. A focus on the components of comprehensive care (Table 5) will assist the health care team to ensure optimal management of the patient with diabetes.
Table 5— Components of the comprehensive diabetes evaluation
Medical history
* Symptoms, results of laboratory tests, and special examination results related to the diagnosis of diabetes
* Prior A1C records
* Eating patterns, nutritional status, and weight history; growth and development in children and adolescents
* Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes, and health beliefs
* Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring and patients’ use of data