Counseling DM Patients 2024 PDF

Counselling a patient with Diabetes Mellitus Jinan Usta MD Professor Clinical Medicine Family Medicine  Background Lebanon has the 22nd highest rate of DM in the world, and ranking 7th in MENA DM was responsible for 59% of limb amputations in Lebanon in...

Counselling a patient with Diabetes Mellitus Jinan Usta MD Professor Clinical Medicine Family Medicine  Background Lebanon has the 22nd highest rate of DM in the world, and ranking 7th in MENA DM was responsible for 59% of limb amputations in Lebanon in 2007, while some 6,600 deaths were linked to DM in 2013 Costly 834$- 870$/person w.dailystar.com.lb/News/Lebanon-News/2013/Dec-20/241732-diabeteson-the-rise-thanks-to-modern-lifestyle.ashx http://www.idf.org/sites/ default/files/Atlas-poster-2014_EN.pdf  From: 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2024 Diabetes Care. 2023;47(Supplement_1):S52-S76. doi:10.2337/dc24-S004 Figure Legend: Decision cycle for person-centered glycemic management in type 2 diabetes. Adapted from Davies et al. (294). BGM, blood glucose monitoring; BP, blood pressure; CGM, continuous glucose monitoring; CKD, chronic kidney disease; CVD, atherosclerotic cardiovascular disease; DSMES, diabetes self-management education and support; HF, heart failure. Date of Download: 8/27/2024 Copyright © 2024 American Diabetes Association. All rights reserved. Question1 A 28 year old lady is coming for check up. She asks you: Would you please order a lab test for me? I want to know if I am diabetic.. What more information do you need? What to order? Recommendations for Screening for diabetes or prediabetes in asymptomatic adults 1. Testing should be considered in adults (18 years and above) with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 ) who have one or more of the following risk factors: First-degree relative with diabetes High-risk race/ethnicity History of CVD Hypertension (≥130/80 mmHg or on therapy for hypertension) HDL cholesterol level 250 mg/dL (2.82 mmol/L) Women with polycystic ovary syndrome Physical inactivity Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) Screening for diabetes or prediabetes in asymptomatic adults- how frequent 2. Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], impaired glucose tolerance, or impaired fasting glucose]) should be tested yearly. 3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years. 4. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status. 5. People with HIV, exposure to high-risk medicine, history of pancreatitis 6. For all other people, testing should begin at age 35 years Diagnosis of Prediabetes A1C 5.7–6.4% (39–47 mmol/mol) OR FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) (IFG) OR 2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) (IGT) Preventing diabetes Achieve and maintain a minimum of 7% weight loss and 150 min of moderate intensity physical activity per week, such as brisk walking, reduced the incidence of type 2 diabetes by 44%. The recommended pace of weight loss was 1–2 lb/week Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people to prevent diabetes Metformin for the prevention of type 2 diabetes should be considered in adults at high risk of type 2 diabetes, especially those aged 25–59 years with BMI ≥35 kg/m2, higher fasting plasma glucose (e.g., ≥110 mg/dL [≥6 mmol/L]), and higher A1C (e.g., ≥6.0% [≥42 mmol/mol]), and in individuals with prior gestational diabetes mellitus  Diagnosing diabetes HbA1C ≥6.5% (≥48 mmol/mol) OR FPG ≥126 mg/dL (≥7.0 mmol/L). OR 2-h PG ≥200 mg/dL (≥11.1 mmol/L) during OGTT. OR In an individual with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (≥11.1 mmol/L). Diagnosis requires two abnormal screening test results, measured either at the same time or at two different time points (unless there is a clear clinical diagnosis e.g., individual with classic symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose ≥200 mg/dL [≥11.1 mmol/L]), Question 2 How low should my glucose or HbA1C go? Glycemic Targets Achieving HbA1c < 7% has been shown to reduce microvascular complications when instituted early in the course of disease A 1% reduction in HbA1c in patients with T2D was associated with a 25%-37% reduction of macrovascular and microvascular complications Reduction of 0.4% of HbA1c may be of clinical implication for patients with polypharmacy who require additional non-pharmacological intervention Glycemic targets Glycemic control is usually assessed by HbA1C and by self monitoring of blood glucose (SMBG) Pre prandial blood glucose level: 80-130 mg/dL Postprandial: 30 deg) Administration: pen needles, syringes, and insulin pump Medical Management of DM: insulin inhaled When compared to injectable insulin, inhaled insulin has faster onset and shorter duration compared with the rapid acting analog (RAA) insulin lispro, as well as clinically meaningful A1C reductions and weight reductions compared with the RAA insulin aspart over 24 weeks Use of inhaled insulin may result in a decline in lung function (reducedFEV1]). Inhaled insulin is contraindicated in individuals with chronic lung disease, such as asthma and chronic obstructive pulmonary disease, and is not recommended in individuals who smoke or who recently stopped smoking. All individuals require spirometry (FEV1) testing to identify potential lung disease prior to and after starting inhaled insulin therapy. Medical management: Cardiovascular prevention Atherosclerotic cardiovascular disease (ASCVD) is the main cause of morbidity and mortality in DM It includes ACS, hx of MI, angina, coronary or another arterial revascularization, stroke, TIA, or PAD Physicians should assess CV risk factors at least once per year: DL, HTN, smoking, family hx of premature coronary disease, and albuminuria An online ASCVD risk calculator can be used through the following link: http://tools.acc. org/ASCVD-Risk-Estimator/ Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Chamberlain et al. Ann Intern Med. March 2016 Medical management: Heart Failure Rates of incident heart failure hospitalization (adjusted for age and sex) were twofold higher in people with diabetes compared with those without Rates of heart failure hospitalization significantly decreased with use of sodium–glucose cotransporter 2 (SGLT2) inhibitors Hypertension is often a precursor of heart failure Medical management: what about my BP BP should be routinely measured at every visit Target BP for HTN patients with DM → 20% → Add ezetimibe + max statin (goal lower LDL by 50% or more) >75y, less evidence Statin dosing Dosage Low-intensity Moderate-intensity High-intensity (LDL-C reduction (LDL-C reduction 30% (LDL-C reduction Statin 30mg/g) out of 3 over 3-6 months. Persistently high levels of albuminuria (>300 mg/g) can predict ESRD →when the physician is uncertain about the cause of kidney disease→ nephro referral →In patients with comorbid HTN and diabetic kidney disease→ use ACEIs or ARBs to delay the progression of kidney disease Microvascular disease management: retinopathy Optimal control of glycemia, blood pressure, and lipid profile → decrease risk and progression of diabetic retinopathy Yearly referral to ophthalmologist is needed for comprehensive eye exam  Microvascular disease management: neuropathy All people with diabetes should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and at least annually thereafter Manifested as hypoglycemia unawareness, gastroparesis, constipation, diarrhea, fecal incontinence, erectile dysfunction, neurogenic bladder, and pseudomotor dysfunction Orthostatic hypotension and resting tachycardia →manifestations of CV autonomic neuropathy → increased mortality Other causes of neuropathy should be considered like: toxins (e.g., alcohol), neurotoxic medications (e.g., chemotherapy), vitamin B12 deficiency, hypothyroidism, renal disease, malignancies (e.g., multiple myeloma, bronchogenic carcinoma), infections (e.g., HIV), chronic inflammatory demyelinating neuropathy, inherited neuropathies, and vasculitis Microvascular disease management: neuropathy Can be focal, peripheral, autonomic, or proximal. Assessment of either temperature or pinprick sensation (small-fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function). All people with diabetes should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation Is the patient responsive to the Ipswich Touch Test? Peripheral: more common- includes dysesthesia (abnormal sensation) and numbness Orthostatic hypotension and resting tachycardia →manifestations of CV autonomic neuropathy →increased mortality Autonomic: Manifested as hypoglycemia unawareness, gastroparesis, constipation, diarrhea, fecal incontinence, erectile dysfunction, neurogenic bladder, and pseudomotor dysfunction. Microvascular disease management: Foot care Yearly foot exam should be done by a health care provider, including skin inspection, deformity, pedal pulses, in addition to monofilament test, pinprick sensation, vibration, and ankle reflexes. Educate about daily foot care Antibiotherapy is not usually needed for diabetic foot wounds with no evidence of soft tissue or bone infection Highly recommended immunizations for adults with diabetes Vaccine Recommended ages Schedule COVID-19 Recommended for all 6 months of age and Current initial vaccination and older boosters Hepatitis B Recommended for adults with diabetes aged 65 years ≤−2.0 Low BMI Frequent hypoglycemic events Sex Diabetes duration >10 years Malabsorption Diabetes medications: insulin, Recurrent falls thiazolidinediones, sulfonylurea Glucocorticoid use A1C >8% Family history Peripheral and autonomic Alcohol/tobacco abuse neuropathy Rheumatoid arthritis Retinopathy and nephropathy References : ADA Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers – including later updates