Best Practice Care for People with type 2 Diabetes Mellitus Dr. Sergio Diez Alvarez Staff Specialist Physician Coffs Harbour Base Hospital.

Best Practice Care for Best Practice Care for People with type 2 Diabetes People with type 2 Diabetes

MellitusMellitus

Dr. Sergio Diez AlvarezDr. Sergio Diez AlvarezStaff Specialist PhysicianStaff Specialist Physician

Coffs Harbour Base Coffs Harbour Base HospitalHospital

Case 1Case 1

48 year old female presents with a history of 48 year old female presents with a history of fatigue & recurrent pruritic vaginal discharge to a fatigue & recurrent pruritic vaginal discharge to a community nursing based STD clinic.community nursing based STD clinic.

FHx of type 2 diabetesFHx of type 2 diabetes Background PCOS, dyslipidaemiaBackground PCOS, dyslipidaemia Meds: NilMeds: Nil O/E: BP: 138/80mmHg, BMI: 38, skin tags, O/E: BP: 138/80mmHg, BMI: 38, skin tags,

acanthosis nigricans, hirsute, central obesityacanthosis nigricans, hirsute, central obesity

Candidal vulvo-vaginitis diagnosed Candidal vulvo-vaginitis diagnosed clinically and patient discharged on clinically and patient discharged on fluconazole 100mg for 3 days fluconazole 100mg for 3 days

Sexual hygiene and dietary advice to lose Sexual hygiene and dietary advice to lose weight given & suggest follow up with her weight given & suggest follow up with her GP if not improving. GP if not improving.

Finger prick glucose (random) was Finger prick glucose (random) was 6.2mmol/l – patient re-assured she did not 6.2mmol/l – patient re-assured she did not have diabeteshave diabetes

Learning PointsLearning Points Recognize this patient as a high risk for type 2 Recognize this patient as a high risk for type 2

diabetes (AUSDIAB risk tool)diabetes (AUSDIAB risk tool) Recognize association between recurrent Recognize association between recurrent

infections and diabetesinfections and diabetes Excluded other concurrent STDs Excluded other concurrent STDs Recognize the difficulty interpreting her glucose Recognize the difficulty interpreting her glucose

test results test results HbA1c as diagnostic tool for diabetes HbA1c> HbA1c as diagnostic tool for diabetes HbA1c>

6.5%6.5% Waist circumference offers additional risk Waist circumference offers additional risk

stratificationstratification

High risk markers for type 2 diabetes :

Impaired glucose tolerance, impaired fasting glucose.

Aboriginal and Torres Strait Islanders aged > 35. Certain high risk ethnic people aged > 35 (Pacific

Islanders, people from the Indian subcontinent, people of Chinese origin).

People aged > 45 with one or more of the following risk factors:

– Obesity (BMI ≥ 30kg/m2) – Hypertension Patients with clinical cardiovascular disease. Women with polycystic ovarian syndrome or

gestational diabetes

Systematic reviewSystematic review

Cardiovascular symptoms Visual abnormalities Neurological symptoms Bladder and sexual function Foot and toe problems Recurrent infections (especially urinary

and skin)

Case 2Case 2

68 year old patient with type 2 Diabetes 68 year old patient with type 2 Diabetes diagnosed in 2008.diagnosed in 2008.

Presents to diabetic clinic with worsening Presents to diabetic clinic with worsening fatigue despite good glucose control.fatigue despite good glucose control.

PMHx: Hypertension, NASH, PMHx: Hypertension, NASH, hypertryglyceridaemiahypertryglyceridaemia

Habits: smoking 10 cigarettes/day, takes 4 Habits: smoking 10 cigarettes/day, takes 4 units of alcohol dailyunits of alcohol daily

Meds: Atorvastatin 10mg/day, metformin Meds: Atorvastatin 10mg/day, metformin XR 1g daily, atenolol 50mg/dayXR 1g daily, atenolol 50mg/day

O/E: BMI: 31 BP 146/90mmHg, HR: O/E: BMI: 31 BP 146/90mmHg, HR: 54/min, RR: 20/min, occasional wheeze, 54/min, RR: 20/min, occasional wheeze, 2cm hepatomegaly, pedal oedema2cm hepatomegaly, pedal oedema

Laboratory investigations: cholesterol: Laboratory investigations: cholesterol: 4.6mmol/l, HDL: 0.6mmol/l, TG: 5.8mmol/l, 4.6mmol/l, HDL: 0.6mmol/l, TG: 5.8mmol/l, ALT 76 I/U, TSH: 4.2 I/U, HbA1c : 8.8%, ALT 76 I/U, TSH: 4.2 I/U, HbA1c : 8.8%, Hb: 134g/lHb: 134g/l

What would your advice be?What would your advice be?

Learning PointsLearning Points

Silent inferior Myocardial InfarctionSilent inferior Myocardial Infarction Needs secondary prevention with aspirinNeeds secondary prevention with aspirin Coronary angiogram may be warranted if has a Coronary angiogram may be warranted if has a

positive non-invasive test (stress echo or MIBI)positive non-invasive test (stress echo or MIBI) Fibrate for his ↑ TGFibrate for his ↑ TG Exercise recommendedExercise recommended Alcohol & Smoking cessation adviceAlcohol & Smoking cessation advice Add ACEI/ARB for optimal BP controlAdd ACEI/ARB for optimal BP control Further investigations to differentiate COPD from Further investigations to differentiate COPD from

CCF (e.g pro-BNP, CXR, Spirometry)CCF (e.g pro-BNP, CXR, Spirometry)

Cardiovascular DiseaseCardiovascular Disease

Silent ischemia not uncommon ECG every two years, if > 50 years old and at

least one other vascular risk factor Other investigations in asymptomatic patients

controversial Some units perform stress echocardiogram in

high risk individuals Alternatives for symptomatic patients : stress

ECG, stress MIBI scan, Stress Echo

Cardiovascular diseaseCardiovascular disease

Often develop diastolic dysfunctionOften develop diastolic dysfunction Diabetic cardiomyopathy becoming a recognised Diabetic cardiomyopathy becoming a recognised

entity entity Aspirin in primary prevention controversialAspirin in primary prevention controversial HbA1c targets in established cardiovascular HbA1c targets in established cardiovascular

disease – HbA1c 7.5-8.0%disease – HbA1c 7.5-8.0% LDL targets in secondary prevention: 1.6mmol/lLDL targets in secondary prevention: 1.6mmol/l BP target < 140/90mmHgBP target < 140/90mmHg

Case 3 Case 3

56 year old male with type 2 diabetes 56 year old male with type 2 diabetes since 2003, complains of nausea after since 2003, complains of nausea after taking metformintaking metformin

PMHx: Obesity, hypertensionPMHx: Obesity, hypertension PSug Hx; Bariatric surgeryPSug Hx; Bariatric surgery Meds: pioglitazone 45mg/day, sitagliptin Meds: pioglitazone 45mg/day, sitagliptin

100mg/day, Indapamide SR 1.5mg/day 100mg/day, Indapamide SR 1.5mg/day O/E: BP: 130/80mmHg, HR: 92/min, BMI O/E: BP: 130/80mmHg, HR: 92/min, BMI

29, pre-proliferative retinopathy29, pre-proliferative retinopathy

Lab Investigations: chol: 4.6mmol/l, TG: Lab Investigations: chol: 4.6mmol/l, TG: 2.3mmol/l, HbA1c: 7.9%, Urine alb:creat 2.3mmol/l, HbA1c: 7.9%, Urine alb:creat ratio normalratio normal

You suggest he needs to go onto insulin You suggest he needs to go onto insulin but he is concerned about reports of but he is concerned about reports of cancercancer

You also recommend yearly You also recommend yearly ophthalmological reviewophthalmological review

Learning PointsLearning Points

Target BP <130/80mmHg (no benefit to lower BP unless Target BP <130/80mmHg (no benefit to lower BP unless patient has proteinuria>1g/day)patient has proteinuria>1g/day)

Target HbA1c 6.5-7.0% (no known cardiovascular Target HbA1c 6.5-7.0% (no known cardiovascular disease)disease)

Fenofibrate indicated to reduce retinopathy in patients Fenofibrate indicated to reduce retinopathy in patients with TG>2.3mmol/lwith TG>2.3mmol/l

Bariatric surgery – significant improvement in metabolic Bariatric surgery – significant improvement in metabolic parametersparameters

New drug classes available e.g. incretin mimetic/DPP-4 New drug classes available e.g. incretin mimetic/DPP-4 inhibitorsinhibitors

Legacy effect of early managementLegacy effect of early management Home based glucose monitoring in type 2 diabetesHome based glucose monitoring in type 2 diabetes

Bariatric surgery Bariatric surgery

Case 4Case 4

76 year old female with poorly controlled type 2 diabetes 76 year old female with poorly controlled type 2 diabetes for 12 years, now presents with painful feet, mainly at for 12 years, now presents with painful feet, mainly at night. Also complains she feels dizzy at times and has night. Also complains she feels dizzy at times and has been feeling “hypo” often for which she uses jelly beansbeen feeling “hypo” often for which she uses jelly beans

Complicated by pre-proliferative retinopathy, cataracts, Complicated by pre-proliferative retinopathy, cataracts, micro-albuminuria, renal dysfunction, previous Lt. 1micro-albuminuria, renal dysfunction, previous Lt. 1stst toe toe amputation and TIA.amputation and TIA.

Meds: Aspirin 100mg day, simvastatin 40mg/day, Meds: Aspirin 100mg day, simvastatin 40mg/day, perindopril 4mg/day, carbamazepine 100mg tds, insulin perindopril 4mg/day, carbamazepine 100mg tds, insulin glargine 24 units nocte, actrapid 12-15 units tdsglargine 24 units nocte, actrapid 12-15 units tds

O/E: BP 130/78mmHg, Rt. Carotid bruit, poor peripheral O/E: BP 130/78mmHg, Rt. Carotid bruit, poor peripheral pulses bilaterally, ↓ sensation bilaterally up to mid-foot, pulses bilaterally, ↓ sensation bilaterally up to mid-foot, absent ankle reflexes bilatabsent ankle reflexes bilat

Lab investigations: alb:creat ratio ↑, HbA1c Lab investigations: alb:creat ratio ↑, HbA1c 7.2%, cholesterol 3.8mmol/l, urea 8.6mmol/l, 7.2%, cholesterol 3.8mmol/l, urea 8.6mmol/l, creat 136creat 136μμmol/lmol/l

Suggest ↑ frequency of glucose monitoring, she Suggest ↑ frequency of glucose monitoring, she wants to know about a continuous glucose wants to know about a continuous glucose monitor devicemonitor device

↑ ↑ perindopril to 8mg/day perindopril to 8mg/day Change her neuropathic medication to Change her neuropathic medication to

gabapentin in increasing doses gabapentin in increasing doses Doppler studies of carotids recommendedDoppler studies of carotids recommended

Learning pointsLearning points

Neuropathic pain benefits from medication Neuropathic pain benefits from medication specifically targeting neuropathic pain e.g. specifically targeting neuropathic pain e.g. amitryptaline, carbamazepine, valproic acid, amitryptaline, carbamazepine, valproic acid, gabapentin, pregabalingabapentin, pregabalin

Specific advice on preventive strategies for Specific advice on preventive strategies for diabetic foot complications with regular podiatrist diabetic foot complications with regular podiatrist reviewreview

Continuous glucose monitoring systems may be Continuous glucose monitoring systems may be useful in diagnostic dilemmas in patients with useful in diagnostic dilemmas in patients with type 2 diabetes on insulintype 2 diabetes on insulin

Hypoglycemia is common in patients on insulin Hypoglycemia is common in patients on insulin and a specific hypoglycemic management plan and a specific hypoglycemic management plan is useful (including glucagon penset)is useful (including glucagon penset)

Pharmacy, dietitian and educator review often Pharmacy, dietitian and educator review often important in patients with recurrent important in patients with recurrent hypoglycemiahypoglycemia

Natural supplements that may result in hypoglycemia - fenugreek, bitter melon, chromium, zinc, ginseng

Diabetes and the feetDiabetes and the feet

Sensation and circulation Skin condition Pressure areas Interdigital problems Abnormal bone architecture ABI should be checked in all patients at

risk

Neurological ExaminationNeurological Examination

Tendon reflexes Sensation: Touch (e.g.: with 10g monofilament) Vibration (e.g: with 128 hz tuning fork) Charcot's joint is specific neuropathic

complication requiring specialist input