TYPE 2 DIABETES MELLITUS Web Module Last Updated: December 1st, 2009 Caroline Hurd, R3

LEARNING OBJECTIVES •

1) Become familiar with the American Diabetes Association (ADA) guidelines and consensus statements for screening, diagnosis and initial management of type 2 diabetes mellitus (T2DM).

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2) Learn how to initiate, titrate and discuss side effects of common medications for T2DM.

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3) Learn how to screen for and manage nonglycemic risk factors in patients with T2DM.

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4) Become familiar with quality measures in the care of patients with T2DM.

I. Screening

I. Screening A. Risk Factors Week 1 Mr. Awon See is a 47 y/o man who presents to your clinic to establish care. He thought he should see a doctor since both his brother and his paternal grandmother have T2DM and he is wondering if he should also be screened. In order to better understand Mr. A1C’s overall risk of T2DM you ask him more about his medical history. He tells you he is stably housed and self employed as a tow truck operator. He does not get regular exercise, has smoked a ½ pack of cigarettes daily since he was 17 and drinks ~3-4 beers per week. His ROS is negative, aside from some episodic low back pain related to heavy lifting during his job. He’s been told in the past that he needed to loose weight and that he has high blood pressure but takes no medications. •

Q: What are some of Mr. A1C's risk factors for developing diabetes?

I. Screening A. Risk Factors 6 Metabolic -Obesity -PCOS -Pre-diabetes -Gestational T2DM -Metabolic Syndrome

Modifiable Lifestyle Factors -Exercise -Smoking -Diet Demographic Factors -FHx -Age -Race/Ethnicity -Socioeconomic Status

Medications -Pentamidine -Beta Blockers -Corticosteroids -Niacin (high dose) -Thiazides (high dose) -SSRI +TCAs, clomipramine -Hormones (progestin-only OCPs) -Antiretrovirals (protease inhibitors) -Antipsychotics (olanzapine, clozapine)

Co-morbid Medical Conditions -HTN -Depression -Chronic Hep C -Hemochromatosis **Note: Mr. A1C’s risk factors are underlined

I. Screening B. Risk Calculator •

Q: Now that you know some of Mr. A1C's risk factors, can you predict Mr. A1C's % chance of developing T2DM in the next 10 years? – A. 40% – B. 30% – C. 20% – D. 10%

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Lets use the following risk calculator, the QDSCORE7, to see if your guess was correct. We will need to know Mr. A1C’s age (47), height (175cm) and weight (95kg) : http://www.qdscore.org/ 39%!!!

I. Screening C. Who? •

Q: Should Mr. A1C be screened for T2DM? – A. No – B. Yes

I. Screening C. Who? •

Q: Should Mr. A1C be screened for T2DM? – A. No – B. Yes – Mr. A1C should be screened because he is over the age of 45 and he has at least one risk factor (+FHx, BMI > sedentary lifestyle, and probable HTN)

I. Screening C. Who? ADA 2009 Recommends the following people be screened for T2DM 8: 1) Age > 45 2) Age 140/90 any age who have a BP • BMI > 25kg/m2 >135/80.9 • 1º relative w/ T2DM • Sedentary lifestyle • H/o vascular disease • Acanthosis nigricans • High risk ethnic groups • H/o impaired OGTT/FPG • Clinical sx/sx of insulin resistance • DLD (HDL250mg/dl) • H/o GDM or giving birth to an infant >9lbs

I. Screening C. Who? Q: Based on the ADA screening guidelines which of these patients should be screened?

40 yo M Obese

35 yo F Pacific Islander

65 yo M HTN

38 yo F Mother has T2DM

YES

YES

YES

YES

I. Screening D. Testing •

Q: Now that you decided Mr. A1C needs screening for T2DM, how do you want to screen him? – – – –

A. Check a Hemoglobin A1C (A1C) B. Check a fasting plasma glucose (FPG) C. Check a random plasma glucose (RPG) D. Check an oral glucose tolerance test (OGTT)

I. Screening D. Testing •

Q: Now that you decided Mr. A1C needs screening for T2DM, how do you want to screen him? – – – –

A. Check a A1C B. Check a fasting plasma glucose (FPG) C. Check a random plasma glucose (RPG) D. Check an oral glucose tolerance test (OGTT)

– Theoretically you can check an OGTT. This is more cumbersome for patients and mainly reserved for GDM screening. However, OGTT is more sensitive, so if you think your patient is high risk for T2DM and their FPG is normal, you can check an OGTT. A1C will be discussed in a later slide. RPG can be used in the setting of symptoms or when incidentally found when checking labs for another reason and diagnose someone with T2DM but is not used as a screening tool because it would miss many people who actually had T2DM.

I. Screening D. Testing Algorithm10 Age >45 OR Age 60)

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Q: Does Mr. A1C have – A) No diabetic nephropathy – B) Microalbuminuria – C) Macroalbuminuria

IV. Nonglycemic Risk Factors: Nephropathy •

Week 6 You check Mr. A1C's ACR and Cr: – ACR: 35mg/day – Cr: 1.0mg/dl (eGFR >60)

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Q: Does Mr. A1C have – A) No diabetic nephropathy – B) Microalbuminuria – C) Macroalbuminuria

IV. Nonglycemic Risk Factors: Nephropathy •

Screening – Check urine albumin excretion annually • Spot ACR (mg/g roughly equals mg/24hrs) – Check plasma Cr annually • Some pts can have nephropathy with minimal or no albuminuria • Stage CKD and estimate GFR using the MDRD equation

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Diagnosis – Need 2 of 3 ACR checks over a 3-6mth period to diagnose albuminuria – 30-299mg/24hrs: microalbuminuria – > 300mg/24hrs: macroalbuminuria (overt nephropathy)

IV. Nonglycemic Risk Factors: Nephropathy • •

Week 6 Q: Since Mr. A1C’s ACR shows he has microalbuminuria, what are ways you can slow Mr. A1C’s progression to macroalbuminuria? – A) Good BP control – B) Good glycemic control – C) ACEI/ARB – D) All of the above

IV. Nonglycemic Risk Factors: Nephropathy • •

Week 6 Q: Since Mr. A1C’s ACR shows he has microalbuminuria, what are ways you can slow Mr. A1C’s progression to macroalbuminuria? – A) Good BP control – B) Good glycemic control – C) ACEI/ARB – D) All of the above

IV. Nonglycemic Risk Factors: Nephropathy

N: nodular glomerulosclerosis in diabetic nephropathy. Dense deposits w/ rim of cells around nodule.

Normal Glomerulus w/ 1-2 cells per capillary tuft, open capillary lumens.

IV. Nonglycemic Risk Factors: Nephropathy •

Microalbuminuria why is it so bad? – It is the earliest sign of impending nephropathy and often precedes overt renal impairment by many years. – Marker of increased CVD risk 31, 32 – Patients who progress from micro to macroalbuminuria are at significant risk of progression to ESRD. 33, 34 ~20% will develop ESRD w/in 20 years after onset of macroalbuminuria. – Strong association of microalbuminuria with presence of diabetic retinopathy.

IV. Nonglycemic Risk Factors: Nephropathy •

ACEI/ARB Why so good? – ACEI reduce microvascular outcomes and major CVD outcomes (MI, stroke, death)35 – ARBs reduce progression from micro to macroalbuminuria and ESRD 36, 37, 38

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Start ACEI/ARB if: • Microalbuminuria with or without HTN Or • HTN plus normoalbuminuria

IV. Nonglycemic Risk Factors □ BP