Overview of Medical Care in Adults With Diabetes Mellitus

3/5/12 Overview of medical care in adults with diabetes mellitus

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Official reprint from UpToDate®

www.uptodate.com ©2012 UpToDate®

AuthorDavid K McCulloch, MD

Section EditorDavid M Nathan, MD

Deputy EditorJean E Mulder, MD

Overview of medical care in adults with diabetes mellitus

Disclosures

All topics are updated as new evidence becomes available and our peer review process iscomplete.Literature review current through: Jan 2012. | This topic last updated: Jan 30, 2012.

INTRODUCTION — The estimated prevalence of diabetes among adults in the United Statesranges from 4.4 to 17.9 percent (median 8.2 percent) [1]. However, because of the associatedmicrovascular and macrovascular disease, diabetes accounts for almost 14 percent of US healthcare expenditures, at least one-half of which are related to complications such as myocardialinfarction, stroke, end-stage renal disease, retinopathy, and foot ulcers [2,3].

Numerous factors, in addition to directly related medical complications, contribute to the impact ofdiabetes on quality of life and economics. Diabetes is associated with a high prevalence ofaffective illness [4] and adversely impacts employment, absenteeism, and work productivity [5].

This review will provide an overview of the medical care for patients with diabetes (table 1).Detailed discussions relating to screening, evaluation, and treatment of the individualcomplications of diabetes are discussed separately. Guidelines from the American DiabetesAssociation for health maintenance in diabetics are published yearly [6]. Consensusrecommendations for the management of glycemia in type 2 diabetes were published in 2006 andupdated in 2009 [7,8].

EVALUATION FOR DIABETIC COMPLICATIONS — Morbidity from diabetes is a consequence ofboth macrovascular disease (atherosclerosis) and microvascular disease (retinopathy,nephropathy, and neuropathy). In type 2 diabetes, disease onset is insidious, and diagnosis is oftendelayed. As a result, diabetic microvascular complications may be present at the time of diagnosisof diabetes [9], and their frequency increases over time (figure 1). The progression of thesecomplications can be slowed, but probably not stopped, with interventions such as aggressivemanagement of glycemia, laser therapy for retinopathy, and administration of an angiotensinconverting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) for nephropathy. (See"Prevention and treatment of diabetic retinopathy" and "Microalbuminuria in type 1 diabetesmellitus" and "Microalbuminuria in type 2 diabetes mellitus" and "Treatment of diabeticnephropathy".)

Routine eye examination — Patients with diabetes are at increased risk for visual loss, relatedboth to refractive errors (correctable visual impairment) and to retinopathy.

Screening for diabetic retinopathy — The efficacy of laser photocoagulation surgery inpreventing loss of vision is the major reason to screen regularly for diabetic retinopathy. (See"Prevention and treatment of diabetic retinopathy", section on 'Panretinal photocoagulation'.)

Recommendations for the type and frequency of routine eye examinations vary, based upon thetype of diabetes mellitus and the presence of specific eye findings (table 2) [6]. Serial



examinations are indicated because of the increased incidence of retinopathy over time in patientswith either type 1 or type 2 diabetes (figure 2). Screening for diabetic retinopathy is reviewed indetail separately. (See "Screening for diabetic retinopathy".)

Correctable visual impairment — A study using data from the National Health and NutritionExamination Survey (NHANES) in the US found that 11 percent of patients aged 20 years and olderwith diabetes had visual impairment (visual acuity <20/40 in their best eye with glasses) [10]. Theimpairment was correctable with an adequate corrective prescription for glasses or contact lensesin over two-thirds of the patients. These data indicate the need for visual acuity and refractiveerror assessment in addition to dilated eye examinations for retinopathy in diabetic patients toreduce injury risk and improve quality of life.

Routine foot examination — Foot problems due to vascular and neurologic disease are a commonand important source of morbidity in diabetic patients. Systematic screening examinations forneuropathic and vascular involvement of the lower extremities and careful inspection of feet maysubstantially reduce morbidity from foot problems. (See "Evaluation of the diabetic foot".)

Guidelines from the American Diabetes Association recommend performing a comprehensive footexamination annually on patients with diabetes to identify risk factors predictive of ulcers andamputation [6]. The comprehensive foot examination can be accomplished in the primary caresetting and should include inspection, assessment of foot pulses, and testing for loss of protectivesensation, as follows:

Perform a visual inspection of the feet at each routine visit. The skin should be assessed forintegrity, especially between the toes and under the metatarsal heads. The presence oferythema, warmth, or callus formation may indicate areas of tissue damage. Bonydeformities, joint mobility, and gait and balance should also be assessed.

Screen for peripheral artery disease by asking about a history of claudication and assessingthe pedal pulses. Consider obtaining an ankle brachial index as many patients with peripheralartery disease are asymptomatic. The presence of peripheral artery disease also suggests ahigh likelihood of cardiovascular disease. (See "Noninvasive diagnosis of arterial disease",section on 'Ankle-brachial index'.)

Test for loss of protective sensation using a Semmes-Weinstein 5.07 (10-g) monofilament atspecific sites to detect loss of sensation in the foot (figure 3), plus any one of the following:vibration using a 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibrationperception threshold with a biothesiometer. (See "Evaluation of the diabetic foot", section on'Screening tests for peripheral neuropathy'.)

Advice for prophylactic foot care should be given to all patients (see "Patient information:Foot care in diabetes mellitus (Beyond the Basics)"):

Avoid going barefoot, even in the home.Test water temperature before stepping into a bath.Trim toenails to shape of the toe; remove sharp edges with a nail file. Do not cutcuticles.Wash and check feet daily.Shoes should be snug but not tight and customized if feet are misshapen or have ulcers.Socks should fit and be changed daily.

Patients who may have neuropathy, based on abnormal results from a microfilament and one other



test, or who have callus or other foot deformities should be referred to clinicians with expertise indiabetic foot care (podiatrist, nurse, diabetes foot clinic, or other, depending on available localresources).

Screening for microalbuminuria — Increased urinary protein excretion is the earliest clinicalfinding of diabetic nephropathy. The routine urine dipstick, however, is a relatively insensitivemarker for proteinuria, not detecting protein until excretion exceeds 300 to 500 mg/day. (See"Treatment of diabetic nephropathy" and "Microalbuminuria in type 1 diabetes mellitus" and"Microalbuminuria in type 2 diabetes mellitus".)

The normal rate of albumin excretion is less than 20 mg/day (15 mcg/min); persistent valuesbetween 30 and 300 mg/day (20 to 200 mcg/min) in a patient with diabetes is calledmicroalbuminuria and is usually indicative of diabetic nephropathy (unless there is some coexistentrenal disease) [11]. Values above 300 mg/day (200 mcg/min) are considered to represent overtproteinuria [12].

Microalbumin may be tested by screening with either a specifically sensitive dipstick or alaboratory assay on a spot urine sample, to determine an albumin-to-creatinine ratio. Abnormalresults should be repeated at least two or three times over a three- to six-month period becauseof the large number of false positives that can occur [13]. Establishing the diagnosis ofmicroalbuminuria requires the demonstration of a persistent (at least two abnormal tests)elevation in albumin excretion. Fever, exercise, heart failure, and poor glycemic control are amongthe factors that can cause transient microalbuminuria [13].

The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme(ACE) inhibitors and angiotensin II receptor blockers (ARB) is the rationale for yearly screening ofall patients with either type 1 or type 2 diabetes for microalbuminuria [14].

Screening for microalbuminuria can be deferred for five years after the onset of disease inpatients with type 1 diabetes because microalbuminuria is uncommon before this time; somerecommend that screening should begin at diagnosis in patients with type 2 diabetes because manyhave had diabetes for several years before diagnosis [6].

The optimal therapy of diabetic nephropathy continues to evolve. In patients with type 1 diabeteswho have microalbuminuria or overt nephropathy, ACE inhibitors both lower urinary proteinexcretion and slow the rate of disease progression (figure 4A-B) [15]. It seems reasonable,therefore, to institute therapy with an ACE inhibitor or angiotensin receptor blocker (ARB), even ifthe patient is normotensive, in those patients who have microalbuminuria or overt nephropathy.Since these drugs do not completely prevent progression, additional interventions may berequired, the most important of which is maintenance of strict glycemic control. Similarconsiderations apply to patients with type 2 diabetes. The treatment of microalbuminuria isreviewed in detail elsewhere. (See "Microalbuminuria in type 1 diabetes mellitus" and"Microalbuminuria in type 2 diabetes mellitus" and "Treatment of diabetic nephropathy".)

Screening for coronary heart disease — Patients with diabetes have an increased risk foratherosclerosis due both to diabetes and to the frequent presence of other risk factors.Furthermore, diabetic patients with CHD are more likely to be asymptomatic or have atypicalsymptoms than nondiabetic patients with CHD. (See "Prevalence of and risk factors for coronaryheart disease in diabetes mellitus", section on 'Silent ischemia and infarction'.)

Despite the frequency of silent ischemia, however, it has not been proven that identifyingasymptomatic disease or providing early intervention will improve outcomes in this population. Inaddition, CHD risk factors (dyslipidemia, hypertension, smoking, positive family history of earlycoronary disease, and presence of micro- or macroalbuminuria) [6] do not predict the likelihood of



having ischemic findings on stress testing or coronary angiography [16,17].

Thus, the American Diabetes Association guidelines recommend annual assessment of risk criteriato identify patients who might benefit from interventions such as aspirin, ACE inhibitors, and statintherapy, but no longer recommend that these criteria be used to identify patients for stress testing[6].

There are no randomized trial data to support the routine performance of exercise stress testing inasymptomatic patients with diabetes who are planning to begin an exercise program [6,18]. Thevast majority of patients, particularly those with a sedentary lifestyle, are encouraged to begin agentle exercise program and to gradually progress to a more vigorous program as tolerated. Inaddition, all CVD risk factors should be treated. (See 'Blood pressure control' below and'Dyslipidemia' below.) Thus, exercise testing is not necessary for most patients. However, it maybe indicated for asymptomatic individuals at high risk for CHD (eg, evidence of peripheral orcarotid atherosclerotic vascular disease, renal disease, abnormal resting electrocardiogram,multiple diabetes complications). The decision to perform stress testing prior to beginning anexercise program should be individualized.

We do not typically perform exercise stress testing in asymptomatic patients as long as they arebeginning a gentle exercise program with gradual progression as tolerated. However, theincreased risk for asymptomatic coronary artery disease in those with diabetes and other riskfactors suggests that an exercise tolerance test be considered prior to changing exercise levels inpatients with diabetes who also have peripheral or carotid or coronary artery disease. (See"Screening for coronary heart disease in patients with diabetes mellitus".)

Treatment of diabetic patients with known CHD is reviewed in detail elsewhere. (See "Treatment ofacute myocardial infarction in diabetes mellitus" and "Coronary artery revascularization in patientswith diabetes mellitus".)

REDUCING THE RISK OF MACROVASCULAR DISEASE — Men and women with diabetes are atincreased risk for developing and dying from cardiovascular disease (CVD) [19,20]. Compared withnondiabetics, men and women with diabetes have decreased life expectancy (six to eight yearsless). At the time of diagnosis of type 2 diabetes, many patients already have one or more riskfactors for macrovascular disease (obesity, hypertension, dyslipidemia, smoking) and many haveevidence of overt atherosclerosis (past myocardial infarction, ischemic changes onelectrocardiogram, or peripheral vascular disease) [9,21,22]. (See "The metabolic syndrome(insulin resistance syndrome or syndrome X)".)

A number of modifiable risk factors for coronary heart disease were identified in a cohort of over3000 type 2 diabetics from the United Kingdom Prospective Diabetes Study (UKPDS) [23].Estimated hazard ratios from this study for the upper third relative to the lower third were 2.3 forserum LDL cholesterol, 0.6 for serum high-density-lipoprotein (HDL) cholesterol, 1.5 forhemoglobin A1C, 1.8 for systolic blood pressure, and 1.4 for smokers.

These and other observations suggest that a substantial reduction in cardiovascular mortality couldbe achieved by smoking cessation, aggressive treatment of hypertension and dyslipidemia, andpossibly daily low-dose aspirin (figure 5) [24]. (See 'Multifactorial risk factor reduction' below.)With regard to cardiovascular disease risk reduction among patients with type 2 diabetes, thebenefit of good blood pressure control has been confirmed, whereas benefit from strict glycemiccontrol has not been conclusively demonstrated [25]. Among patients with type 1 diabetes, theDCCT/EDIC study demonstrated long-term benefit of intensive glycemic management oncardiovascular outcomes, reducing fatal and nonfatal heart disease and stroke by 57 percentcompared with conventional diabetes management [26]. (See "Glycemic control and vascularcomplications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type



2 diabetes mellitus" and "Treatment of hypertension in patients with diabetes mellitus".)

Smoking cessation — A survey in the United States found that the prevalence of cigarettesmoking was higher among diabetic patients than nondiabetic subjects, even after adjusting forage, sex, race, and educational level [27]. Over 25 percent of newly diagnosed diabetic patientswere smokers. A meta-analysis of many of the cardiovascular risk reduction trials showed thatcessation of smoking had a much greater benefit on survival than most other interventions (figure5) [24]. These findings suggest that discontinuation of smoking is one of the most importantaspects of therapy in diabetic patients who smoke. (See "Smoking and cardiovascular risk indiabetes mellitus" and "Patterns of tobacco use".)

Aspirin — The merits of daily aspirin therapy in patients with macrovascular disease are widelyaccepted. A meta-analysis from the Antithrombotic Trialists' Collaboration of randomized trials ofantiplatelet therapy for the secondary prevention of cardiovascular disease in high-risk patientsshowed that aspirin produced statistically significant and clinically important reductions in the riskof subsequent myocardial infarction (MI), stroke, and vascular death among a wide range of high-risk patients (acute MI or ischemic stroke, unstable angina, prior MI or stroke, peripheral arterydisease, and other high-risk groups) [28]. (See "Benefits and risks of aspirin in secondary andprimary prevention of cardiovascular disease".)

In the subset of patients with diabetes, there was a nonsignificant 7 percent decrease in seriouscardiovascular events [28]. Similarly, in The Primary Prevention Project, aspirin (100 mg/day) wasassociated with a nonsignificant 10 percent reduction in total cardiovascular events in the subset ofpatients with diabetes (RR 0.89, 95% CI 0.62-1.26) compared with a 30 percent reduction innondiabetic subjects (RR 0.69, 95% CI 0.53-0.90) [29]. (See "Benefits and risks of aspirin insecondary and primary prevention of cardiovascular disease".)

These trials suggest that aspirin may be less effective in the prevention of cardiovascular events inpatients with diabetes. Trials that assess the benefit of daily aspirin therapy specifically in patientswith diabetes show the following:

In the Early Treatment of Diabetic Retinopathy Study (ETDRS), patients with diabetes withand without cardiovascular disease were randomly assigned to aspirin (650 mg daily) orplacebo [30]. The relative risk among all aspirin-treated patients was 0.91 (99% CI 0.75-1.11) for death and 0.83 (99% CI 0.66-1.04) for fatal and nonfatal myocardial infarction.

In a trial of aspirin for the prevention of cardiovascular disease in 2539 Japanese patientswith type 2 diabetes (no history of atherosclerotic heart disease), patients were randomlyassigned to low-dose aspirin (80 to 100 mg daily) or to a nonaspirin group. After a medianfollow-up of 4.4 years, there were 13.6 and 17.0 cardiovascular events per 1000 person-years in the aspirin and nonaspirin groups, respectively (HR for primary composite endpointof any cerebrovascular, coronary, or peripheral vascular atherosclerotic event 0.80 [95% CI0.58-1.10]) [31].

The lower than expected event rate in this trial decreased the power of the analysis toassess the primary composite outcome or individual outcomes, such as fatal and nonfatalcoronary events. In addition, the generalizability of this study to Western populations withhigher cardiovascular risk is unknown.

In the Prevention of Progression of Arterial Disease and Diabetes (POPADAD) trial, 1276 UKadults with type 1 or type 2 diabetes with asymptomatic peripheral artery disease (anklebrachial pressure index of ≤0.99) were randomly assigned to aspirin (100 mg daily) plus anantioxidant, aspirin alone, antioxidant alone, or double placebo [32]. During a median 6.7



years of follow-up, there were 116 and 117 fatal and nonfatal cardiovascular events in theaspirin and nonaspirin groups, respectively (HR for primary composite endpoint of deathfrom coronary heart disease or stroke, nonfatal myocardial infarction or stroke, or above-ankle amputation for critical limb ischemia 0.98, 95% CI 0.76-1.26).

Thus, trials in patients with diabetes do not show a significant benefit of aspirin for the primaryprevention of cardiovascular events. However, both the Japanese trial and ETDRS suggest benefit.Larger trials with longer follow-up are required to clarify this issue. Two large trials investigatingthe role of aspirin for the prevention of cardiovascular events in patients with diabetes areunderway [33,34].

Bleeding — One of the main adverse effects of aspirin is bleeding. The United StatesPhysicians' Health Study found a nonsignificant trend toward an increase in hemorrhagic stroke andan increased risk of gastrointestinal bleeding in those who took aspirin [35]. In the Japanese trialdescribed above, there was no difference in the incidence of hemorrhagic stroke (0.4 and 0.2events per 1000 person-years in those assigned to the aspirin and nonaspirin groups,respectively). However, gastrointestinal and retinal bleeding occurred more commonly in theaspirin group, and four patients in the aspirin group required transfusion. Nevertheless, whilediabetes is associated with several platelet and coagulation abnormalities, the majority of strokesin diabetic patients are thrombotic, not hemorrhagic in nature [36]. (See "Prevalence of and riskfactors for coronary heart disease in diabetes mellitus".)

Guidelines — Based upon these data, the American Diabetes Association and American HeartAssociation recommend the following approach [6,37].

Aspirin (75 to 162 mg/day) is recommended for secondary prevention in diabetic patientswith a history of myocardial infarction, vascular bypass, stroke or transient ischemic attack,peripheral vascular disease, claudication, or angina.

Aspirin (75 to 162 mg/day) is recommended for primary prevention in any patient withdiabetes at increased cardiovascular risk (10 year risk >10 percent), which would includemost men >50 years and women >60 years who have at least one additional cardiovascularrisk factor (eg, cigarette smoking, hypertension, obesity, albuminuria, dyslipidemia, or afamily history of coronary heart disease). The ADA recognizes that the evidence to supportthis recommendation is weak.

Aspirin is not recommended for diabetic patients under the age of 30 years due to a lack ofevidence of benefit, and aspirin is contraindicated under the age of 21 years because of anincreased risk of Reye's syndrome.

Clopidogrel (75 mg/day) is recommended for patients with cardiovascular disease anddocumented aspirin allergy. (See "Secondary prevention of cardiovascular disease: Riskfactor reduction", section on 'Aspirin'.)

In spite of these recommendations, aspirin use in patients with diabetes is quite low: 74 and 38percent in patients with or without cardiovascular disease, respectively [38].

Blood pressure control — Hypertension is a common problem in type 1 and especially in type 2diabetes. The American Diabetes Association recommends measuring blood pressure at everyroutine diabetes visit [6,39]. Early and effective treatment of blood pressure is important, both toprevent cardiovascular disease and to minimize the rate of progression of diabetic nephropathyand retinopathy.

Among patients with diabetes, there is moderate evidence supporting a goal blood pressure less



than 140/90 mmHg in all patients and weaker evidence supporting a goal blood pressure less than130/80 mmHg. These issues and the choice of antihypertensive drugs are discussed in detailseparately. (See "Treatment of hypertension in patients with diabetes mellitus", section on 'Goalblood pressure' and "Treatment of diabetic nephropathy".)

Dyslipidemia — Lipid abnormalities are common in patients with diabetes mellitus, andundoubtedly contribute to the increase in risk of cardiovascular disease. The American DiabetesAssociation (ADA) recommends screening for lipid disorders at least annually in diabetic patients,and more often if needed to achieve goals [6,39]. Adults with low-risk lipid values (LDL <100mg/dL [2.6 mmol/L], HDL >50 mg/dL [1.3 mmol/L], and triglycerides <150 mg/dL [1.7 mmol/L])may be screened every two years.

The ADA recommends lifestyle intervention (diet, weight loss, increased physical activity) toimprove the lipid profile in all patients with diabetes [6]. In patients with clinical cardiovasculardisease (CVD) or over age 40 years with other CVD risk factors, statin therapy should be added tolifestyle intervention regardless of baseline lipid levels. For patients without clinical CVD and underage 40 years, statin therapy can be considered in addition to lifestyle intervention if LDLcholesterol remains above 100 mg/dL or in those with multiple CVD risk factors. In individualswithout overt cardiovascular disease, the goal LDL is <100 mg/dL (2.6 mmol/L), whereas inpatients with overt CVD, a lower LDL goal (<70 mg/dL [1.8 mmol/L]) is an option [6]. Triglyceridelevels <150 mg/dL (1.7 mmol/L) and HDL levels >40 mg/dL (1.0 mmol/L) for men and >50 mg/dL(1.3 mmol/L) for women are preferable.

The optimal therapy of dyslipidemia is discussed in detail separately. (See "Treatment of lipids(including hypercholesterolemia) in secondary prevention", section on 'Treatment in diabetes' and"Intensity of lipid lowering therapy in secondary prevention of coronary heart disease", section on'Summary and recommendations' and "Clinical trials of cholesterol lowering in patients withcoronary heart disease or coronary risk equivalents", section on 'ACCORD Lipid trial'.)

Metformin — Metformin has been suggested to reduce the risk of macrovascular complications,independently of its effects on glycemic control. However, this effect is far from established [40].These issues are discussed in detail elsewhere. (See "Glycemic control and vascular complicationsin type 2 diabetes mellitus", section on 'UKPDS'.)

Multifactorial risk factor reduction — The benefit of multiple risk factor intervention to reducecoronary risk in type 2 diabetes was demonstrated in the relatively small Steno-2 trial of 160subjects with microalbuminuria who were randomly assigned to either conventional therapy or anintensive therapy regimen, which included the following [41]:

Reduced dietary fatLight to moderate exerciseSmoking cessationTight glycemic control (target A1C <6.5 percent with intensive therapy)Tight blood pressure control (target <140/85 mmHg for most of the study and <130/80mmHg for the last two years)Angiotensin converting enzyme (ACE) inhibitor therapy regardless of blood pressureLipid-lowering therapy (target total cholesterol <190 mg/dL [4.9 mmol/L] for most of thestudy and <175 mg/dL [4.5 mmol/L] for the last two years; target fasting serum triglyceride<150 mg/dL [1.7 mmol/L])AspirinVitamin C, vitamin D, folate, and chrome picolinate

The attained differences between the two groups revealed significantly greater improvements withintensive therapy in glycemic control (A1C -0.5 versus +0.2 percent with conventional therapy),



blood pressure control (-14/12 versus -3/8 mmHg), and total cholesterol (-50 versus -3 mg/dL[-1.3 versus -0.08 mmol/L]).

At a mean of 7.8 years, patients on intensive therapy had a significant reduction in the primaryaggregate end point of cardiovascular death, nonfatal MI, coronary artery bypass grafting,percutaneous coronary intervention, stroke, amputation, or peripheral vascular surgery (18 versus38 percent, HR 0.47, 95% CI 0.22-0.74). Significant reductions were also seen in progression ofnephropathy, retinopathy, and autonomic neuropathy.

After the intervention study ended, 130 remaining patients participated in an observational follow-up study (5.5 years), during which time all participants were encouraged to follow intensivemultifactorial treatment regimens [42]. At the end of the follow-up period, A1C values were similarin the groups previously assigned to intensive and conventional therapy (7.7 and 8.0 percent,respectively). Blood pressure, body mass index (BMI), and fasting serum cholesterol andtriglycerides were also similar.

During the entire follow-up period (13.3 years), there were fewer deaths (30 versus 50 percent) inthe intensive therapy group (hazard ratio for death 0.54, 95% CI 0.32-0.89). Intensive therapy wasalso associated with a lower risk of cardiovascular deaths (HR 0.43, 95% CI 0.19-0.94), which wasa predefined secondary endpoint. Progression of diabetic retinopathy, nephropathy, and autonomicneuropathy occurred less frequently in the intensive group. These results suggest a sustainedbenefit of multifactorial risk reduction.

In spite of evidence that aggressive risk factor reduction lowers the risk of both micro- andmacrovascular complications in patients with diabetes, the vast majority of patients do not achieverecommended goals for A1C, blood pressure control, and management of dyslipidemia. It isnotable that only one patient in the observational Steno study described above reached all fivetreatment goals at the end of follow-up. Thus, renewed efforts to implement multifactorial riskfactor reduction strategies early in the course of type 2 diabetes are necessary. (See 'Adequacy ofcare' below.)

GLYCEMIC CONTROL

Monitoring and target A1C — Prospective, randomized clinical trials such as the Diabetes Controland Complications Trial (DCCT), the United Kingdom Prospective Diabetes Study (UKPDS), and theKumamoto Study have demonstrated that intensive therapy aimed at lower levels of glycemiaresults in decreased rates of retinopathy, nephropathy, and neuropathy [43-46]. Every 1 percentdrop in A1C was associated with improved outcomes and there was no threshold effect. Thesebenefits have to be weighed against an increased risk of severe hypoglycemia associated withintensive therapy (particularly in type 1 diabetes). Although the goal of the intensive interventionsin these studies was normoglycemia, with an A1C less than 6.1 percent, the average A1C achievedin the intensive therapy groups of these trials was around 7 percent. (See "Glycemic control andvascular complications in type 1 diabetes mellitus" and "Glycemic control and vascularcomplications in type 2 diabetes mellitus", section on 'Hyperglycemia and Microvascular disease'.)

The importance of tight glycemic control for protection against cardiovascular disease in diabeteshas been established in the DCCT/EDIC study for type 1 diabetes [26]. The role of glycemic controlin reducing cardiovascular risk has not been established for patients with long-standing type 2diabetes. (See "Glycemic control and vascular complications in type 2 diabetes mellitus", sectionon 'Macrovascular disease'.)

Based upon these data, the American Diabetes Association recommends the following [6]:

Aim to achieve normal or near normal glycemia with an A1C goal of <7 percent. More



stringent goals (ie, a normal A1C, <6.1 percent) can be considered in individual patients.Less stringent treatment goals (ie, <8 percent) may be appropriate for patients with ahistory of severe hypoglycemia, patients with limited life expectancies, older adults, andindividuals with comorbid conditions. (See "Treatment of type 2 diabetes mellitus in theelderly patient", section on 'Glycemic targets' and "Glycemic control and vascularcomplications in type 2 diabetes mellitus", section on 'Glycemic targets'.)

Obtain an A1C at least twice yearly in patients who are meeting treatment goals and whohave stable glycemic control, and quarterly in patients whose therapy has changed or whoare not meeting glycemic goals.

Nonpharmacologic therapy in type 2 diabetes — There are three major components tononpharmacologic therapy of blood glucose in type 2 diabetes (see "Initial management of bloodglucose in type 2 diabetes mellitus", section on 'Intensive lifestyle modification'):

Dietary modificationExerciseWeight reduction

In addition to improving glycemic control, these changes in lifestyle also slow progression ofimpaired glucose tolerance to overt diabetes [47]. (See "Prediction and prevention of type 2diabetes mellitus".) Diet and exercise are important components of therapy in patients with type 1diabetes. (See "Nutritional considerations in type 1 diabetes mellitus" and "Nutritionalconsiderations in type 2 diabetes mellitus" and "Effects of exercise in diabetes mellitus in adults".)

Surgical treatment of obese patients with diabetes results in the largest degree of sustained weightloss and, in parallel, the largest improvements in blood glucose control. (See "Surgicalmanagement of severe obesity".) Pharmacotherapy for weight loss may also be used for patientswith type 2 diabetes, but may not be effectively sustained due to side effects. (See "Drug therapyof obesity".)

Pharmacologic therapy for type 2 diabetes — The American Diabetes Association (ADA) and theEuropean Association for the Study of Diabetes (EASD) issued a 2006 consensus statement for themanagement of glycemia in type 2 diabetes, which was updated in 2009 [7,8]. Because of thedifficulty in achieving and sustaining goal glycemia and significant weight loss, the consensusgroup concluded that metformin therapy should be initiated concurrent with lifestyle intervention atthe time of diagnosis. (See "Initial management of blood glucose in type 2 diabetes mellitus".)

The therapeutic options for patients who fail initial therapy with lifestyle intervention andmetformin are to add a second oral or injectable agent, including insulin, or to switch to insulin(algorithm 1). (See "Management of persistent hyperglycemia in type 2 diabetes mellitus" and"Insulin therapy in type 2 diabetes mellitus".)

Regardless of the initial response to therapy, the natural history of most patients with type 2diabetes is for blood glucose concentrations and A1C to rise over time (figure 6) [43,48]. TheUKPDS suggested that worsening beta cell dysfunction with decreased insulin release was primarilyresponsible for disease progression [48]. More severe insulin resistance or decreased compliancewith the dietary regimen also may contribute to progression.

Type 2 diabetic patients often need large daily doses of insulin (>65 units per day, and often muchmore) to achieve acceptable glycemic control. Most patients with type 2 diabetes can be treatedwith one or two daily injections, in contrast to patients with type 1 diabetes for whom intensiveinsulin therapy with multiple daily injections is indicated. (See "Insulin therapy in type 2 diabetesmellitus" and "Insulin therapy in adults with type 1 diabetes mellitus".)



OTHER ASPECTS OF HEALTH MAINTENANCE

Routine health maintenance — The potential exists for the clinician to overlook healthmaintenance not specifically targeted at diabetes, given the intensity and complexity of carerequired for prevention and treatment of complications in diabetic patients [49]. (See "Overview ofpreventive medicine in adults".)

Cancer screening — Some studies have suggested an increased risk of cancer in patients withdiabetes, possibly related to the coincident obesity [50-53]. As examples:

In a 10-year prospective study of 98,000 Japanese persons aged 40 to 69, the hazard ratio(HR) for any cancer among men with diabetes was 1.27 (95% CI 1.14-1.42) [50]. Incomparison, the association of cancer risk and diabetes for women was only borderline (HR1.21, 95% CI 0.99-1.47).

In a prospective cohort study of 64,000 Swedish men and women aged 29 to 61, rising levelsof fasting and post oral glucose challenge glucoses were associated with an increase incancer risk for women in the highest quartile versus lowest quartile of fasting glucose (RR1.26, 95% CI 1.09-1.47) [51]. The most common cancers associated with high glucose valueswere pancreatic, endometrial, and melanoma. There was no significant increased risk inmen.

Diabetes mellitus and insulin resistance may also be associated with an increased risk of coloncancer, hepatocellular carcinoma, renal cancer, bladder cancer, and pancreatic cancer, althoughcausation is not well established. (See "Colorectal cancer: Epidemiology, risk factors, andprotective factors" and "Epidemiology and etiologic associations of hepatocellular carcinoma" and"Epidemiology, pathology, and pathogenesis of renal cell carcinoma", section on 'Diabetesmellitus' and "Epidemiology and etiology of urothelial (transitional cell) carcinoma of thebladder" and "Epidemiology and risk factors for exocrine pancreatic cancer".)

A retrospective study of over 700,000 Canadian women aged 50 to 67 years, including 69,168 withdiabetes, found that women with diabetes, despite having more frequent physician visits, were lesslikely to have a mammogram within a two-year period than non-diabetics (odds ratio [OR] 0.68,95% CI 0.67-0.70) [54]. This is of concern because in some, but not all studies, women with type 2diabetes had a slightly higher risk of breast cancer than non-diabetic women [55].

Adults with type 2 diabetes also have an increased risk of cancer mortality. In a systematic reviewof individual patient data from 97 prospective studies (820,900 patients), adults with diabetescompared to those without had an increased risk of death from cancer (HR 1.25, 95% CI 1.19-1.31) [20]. The increased risk of death was associated specifically with cancers of the liver,pancreas, ovary, colorectum, lung, bladder, and breast. In addition, the relative risk wassubstantially reduced when A1C levels were considered in multivariate analyses, consistent with adirect effect of hyperglycemia on cancer risk.

Elevated serum alanine aminotransferase (ALT) concentrations occur commonly in patients withdiabetes [56,57]. Although the etiology may be multifactorial, nonalcoholic fatty liver diseaserather than cancer is a common cause. (See "Epidemiology, clinical features, and diagnosis ofnonalcoholic steatohepatitis".)

Dental screening — Periodontal disease is a common complication of diabetes and itselfcontributes to poor glycemic control. Severe periodontal disease was shown to be an independentrisk factor for mortality from ischemic heart disease and nephropathy in one longitudinal study ofPima Indians with type 2 diabetes (RR 3.6, 95% CI 1.1-9.3) [58]. Annual dental examination isrecommended in both dentate and non-dentate diabetic patients [59]. In a 2004 US survey, 67



percent of respondents with diabetes reported a dental visit in the preceding 12 months [60].

Vaccination — Patients with diabetes mellitus should receive influenza vaccination yearly andpneumococcal vaccination, repeating the pneumococcal vaccine once after age 65 years if theinitial vaccination was prior to age 65. Tetanus and diphtheria vaccinations should also be updated.(See "Tetanus-diphtheria toxoid vaccination in adults".)

Women of childbearing age — Contraception and pregnancy planning should be discussed with alldiabetic women who are premenopausal. For women who do not wish to become pregnant, ADAguidelines state that the selection of a contraceptive method for an individual patient should usethe same guidelines that apply to women without diabetes. Guidelines from the American Collegeof Obstetricians and Gynecologists (ACOG) are more cautious and recommend "on theoreticalconcerns" that use of oral contraception be limited to nonsmoking diabetic women who areyounger than 35 years and are without hypertension, nephropathy, retinopathy, or other vasculardisease [61]. (See "Risks and side effects associated with estrogen-progestin contraceptives".) Werecommend that the most reliable method of contraception be used, when not contraindicated byother health concerns, because the risk of unplanned pregnancy is significant.

For women with diabetes who are contemplating pregnancy, prepregnancy counseling and planningis important. Prior to pregnancy, glycemic control should be optimized, and both ACE inhibitor andstatin medications should be discontinued (table 3). (See "Pregnancy risks in women with type 1and type 2 diabetes mellitus" and "Prepregnancy evaluation and management of women with type1 or type 2 diabetes mellitus".)

ADEQUACY OF CARE — Despite extensive data suggesting large benefits with preventive andtreatment strategies, and despite increasing media attention, there has been little improvement indiabetes management in the US.

Surveys of patients aged 18 to 75 years with diabetes, comparing the US NHANES databases for1988 to 1994 and 1999 to 2002, indicate that glycemic control has improved only minimally(nonsignificant decrease in proportion of patients with A1C >9 percent, no change in mean A1C,increase in patients with A1C between 6 and 8 percent), and blood pressure distribution hasremained unchanged. Improvements were seen in the proportion of patients with LDL cholesterol<130 mg/dL (3.4 mmol/L); using aspirin; and receiving annual influenza vaccination, lipid testing,eye examination, and foot examination [62]. About 20 percent of patients in 1999 to 2002 had A1C>9 percent, 33 percent had blood pressure >140/90 mm, and 40 percent had LDL cholesterol >130mg/dL (>3.4 mmol/L).

Even when patients are achieving goals for individual components of diabetes care, the proportionof patients who are simultaneously at goal for all measured targets is low. In a study of 80,000diabetic patients receiving care in a VA system, only 4 percent were simultaneously at ADA goalfor A1C, LDL cholesterol, and blood pressure, though rates for individual targets ranged from 23 to41 percent [63].

Nevertheless, small improvements in diabetes management and cardiovascular risk factorreduction have decreased cardiovascular and all-cause mortality rates in some patients [64]. Datafrom the National Health and Nutrition Examination Surveys (NHANES I, II, III), however, suggestthat mortality rates are decreasing in diabetic men but not in women [65]. The reason for thisdiscrepancy is unknown but may be related to gender differences in the pathophysiology ofcoronary artery disease, less accurate diagnosis of CVD in women, and disparities in access tocare and targeting of risk factor reduction [64].

Overall, the majority of diabetic patients are not receiving recommended levels of healthcare [66-71], particularly patients under age 45 years [72] and women [73,74]. Even when recommended



screening data are obtained, rates of medication adjustment to address abnormal results are low[75].

There are several reasons for the large discrepancy between what should be done and what isbeing done:

Treatment of acute and chronic disease — Traditional medical practice is organized torespond quickly to acute patient problems, but does not adequately serve the needs of thosewith a chronic illness such as diabetes mellitus [76].

Clinical inertia — Failure to make adjustments in a therapeutic regimen in response to anabnormal clinical result has been termed "clinical inertia" [77]. Multiple factors may becontributory: lack of awareness of therapeutic goals, reluctance to treat asymptomaticconditions, concern about patient's pill burden, time limitations, or attention to acute medicalissues that take priority over risk factor management [78]. In one study of modifications intherapy for various cardiovascular risk conditions, medication adjustments were made for 66percent of patients whose A1C level was >8 percent [78].

Lack of an organized system for care — Outcomes are better when diabetic patients are seenin the context of organized programs [79,80]. One study, as an example, examined the five-year mortality of 3288 patients with diabetes who received medical care exclusively fromgeneralists and of 4200 patients who received care from generalists and also hadexaminations in a diabetes clinic [80]. The relative risk of all-cause mortality was 0.82 forpatients who received care from both diabetes clinics and generalists as compared withthose who received care only from generalists.

Who should take care of the patient — The majority of diabetic patients (greater than 90percent) receive their care from primary care providers. A major unresolved controversy is theplace of the generalist and the specialist in the treatment of patients with type 2 diabetes. Studiescomparing care by specialists and generalists have generated conflicting findings:

A large observational study (the Medical Outcomes Study) found little advantage for patientsunder the care of endocrinologists, when compared with family practitioners, except forimproved foot care and lower infection risk [81,82]. Overall functional status at four yearsand mortality at seven years were similar.

A retrospective study of 112 patients (primarily type 2 diabetes) at a Veteran AdministrationMedical Center found that patients seen in a diabetes clinic, compared with those seen in ageneral medicine clinic, were more likely to have had an eye examination and A1C test inthe past year (73 versus 52 percent) [83]. However, the mean A1C value (9.7 percent) in thetwo clinics was similar and suboptimal.

Lower risks of neuropathy and nephropathy were reported in association with specialist carefor type 1 diabetes [84].

It is difficult to distinguish how much of the difference in care is due to expert knowledge or to theapplication of a systematic and organized approach. In one study, although diabetes-specific testswere performed more often in a diabetes clinic, diabetic patients were more likely to get inquiriesabout the presence of cardiac symptoms if they received their care in a general internal medicineclinic [81].

These reports have generated much discussion and disagreement [85], and the place of thespecialist remains unsettled. Other strategies for improving the routine care of diabetic patients



are reviewed below.

Strategies to improve diabetes primary care — Several approaches have been tried in order toimprove the care of diabetic patients within a primary care setting. These include the following:

"Diabetes miniclinics" [86,87]Better organization and delivery of patient education [88,89]Structured behavioral intervention [90,91]Management by nurse specialists under the supervision of a diabetologist [92,93]Multidisciplinary disease management programs [94-96]

The optimal intervention strategy to improve diabetes care in the primary care setting has notbeen established, and the effects of intervention may be short-lived [97,98]. Processes of care(performance of retinal examination, foot exam, A1C measurements, lipid testing, nephropathyscreening, flu vaccination, aspirin therapy) may be more readily improved by disease managementinterventions than intermediate outcomes (blood pressure control, lipid control, or A1C level) [96].

A meta-analysis reviewing 66 publications of trials evaluating the impact of 11 different strategiesfor improving diabetes care found study limitations and likely publication bias [99]. Strategiesincorporating team changes (expanded roles for non-MD clinicians and shared care) or casemanagement programs (multidisciplinary coordinated care for patient scheduling and follow-up)were most effective. Across all trials, the mean A1C reduction was 0.42 percent (95% CI 0.29-0.34) over a median of 13 months follow-up. A1C improvement was greatest for strategies thatallowed medication dose adjustments without awaiting physician approval.

Several organizations are encouraging adherence to routine standards of care for diabetic patientsby auditing charts, or by asking for data on random samples of diabetic patients. The mostcomprehensive set of diabetes measures has recently been launched by the American DiabetesAssociation (ADA), cosponsored by the National Committee for Quality Assurance. Individualproviders or groups of providers may apply to receive recognition that they are delivering acertain standard of diabetes care. Recognition requires review of the medical chart, laboratorydata, and a patient survey and measures eye, foot, and renal care; cardiac risk reduction;glycemic control; and patient satisfaction (table 4). Further information is available through theNational Committee for Quality Assurance.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “TheBasics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language,at the 5 to 6 grade reading level, and they answer the four or five key questions a patient mighthave about a given condition. These articles are best for patients who want a general overview andwho prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,more sophisticated, and more detailed. These articles are written at the 10 to 12 grade readinglevel and are best for patients who want in-depth information and are comfortable with somemedical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print ore-mail these topics to your patients. (You can also locate patient education articles on a variety ofsubjects by searching on “patient info” and the keyword(s) of interest.)

Basics topics (see "Patient information: The ABCs of diabetes (The Basics)" and "Patientinformation: Type 1 diabetes (The Basics)" and "Patient information: Type 2 diabetes (TheBasics)" and "Patient information: Treatment for type 2 diabetes (The Basics)" and "Patientinformation: Diabetic retinopathy (The Basics)" and "Patient information: Reducing the costsof medicines (The Basics)")

th th

th th



Beyond the Basics topics (see "Patient information: Diabetes mellitus type 1: Overview(Beyond the Basics)" and "Patient information: Diabetes mellitus type 2: Overview (Beyondthe Basics)" and "Patient information: Diabetes mellitus type 2: Treatment (Beyond theBasics)" and "Patient information: Reducing the costs of medicines (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Morbidity from diabetes involves both macrovascular (atherosclerosis) and microvasculardisease (retinopathy, nephropathy, and neuropathy). Interventions can limit end organdamage and are the focus of care for the diabetic patient. Monitoring recommendations forpatients with diabetes are presented in the table (table 1). (See 'Evaluation for diabeticcomplications' above and 'Reducing the risk of macrovascular disease' above.)

Prevention of cardiovascular morbidity is a major priority for patients with diabetes,especially type 2. Smoking cessation is essential for patients who smoke. Cardiovascularmorbidity can also be significantly reduced with aggressive management of hypertension,cholesterol (goal LDL less than 100 mg/dL [2.6 mmol/L]) and use of aspirin (75 to 162mg/day) in patients with or at high risk for cardiovascular disease. (See 'Reducing the risk ofmacrovascular disease' above and "Treatment of hypertension in patients with diabetesmellitus", section on 'Goal blood pressure'.)

Glycemic control can minimize risks for retinopathy, nephropathy, and neuropathy in bothtype 1 and type 2 diabetes, and has been shown to decrease the risk for cardiovasculardisease for type 1 diabetes. (See 'Glycemic control' above.)

A1C goal is <7 percent for most patients; more stringent control (A1C <6 percent) may beindicated for individual patients with type 1 diabetes and during pregnancy. (See "Glycemiccontrol in women with type 1 and type 2 diabetes mellitus during pregnancy", section on'Target blood glucose values'.)

A higher target A1C (ie, <8 percent) may be preferable for some type 2 patients withcomorbidities or with an anticipated lifespan, owing to advanced age or other factors, that istoo brief to benefit from the effects of intensive therapy on long-term complications. (See'Monitoring and target A1C' above and "Glycemic control and vascular complications in type 1diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetesmellitus".)

The majority of diabetic patients are not receiving recommended levels of healthcare anddevelopment of systems of care, involving disease management principles, may beimportant in delivering improved care. (See 'Adequacy of care' above.)

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Topic 1750 Version 18.0



GRAPHICS

Monitoring in patients with diabetes mellitus

Intervention Frequency Notes

History and physical examination

Smokingcessationcounseling

Every visit For smokers only

Blood pressure Every visit Goal <130/80

Dilated eyeexamination

Annually* Begin at onset of type 2 diabetes, 3 to 5 years after onset oftype 1 diabetes. Examine more than annually if significantretinopathy

Footexamination

Annually Every visit if peripheral vascular disease or neuropathy

Laboratory studies

Fasting serumlipid profile

Annually May obtain every two years if profile is low risk

A1C Every 3 to 6months

Goal <7% (may be lower or higher in selected patients)

Microalbuminuria Annually Begin 3 to 5 years after onset of type 1 diabetes; proteinexcretion and serum creatinine should also be monitored ifpersistent albuminuria is present

Serumcreatinine

Initially, asindicated

Vaccinations

Pneumococcus One time Patients over age 65 need a second dose if vaccine wasreceived ≥5 years previously and age was <65 at time ofvaccination

Influenza Annually

Education, selfmanagementreview

Annually

* Less frequent screening (every two to three years) may be appropriate for some patients.



Onset of retinopathy precedes diagnosis of type 2diabetes

Prevalence of retinopathy in relation to years after onset ofdiabetes among patients in southern Wisconsin (blue circles)and rural western Australia (red squares). At diagnosis (yearzero), retinopathy was already present in 10 to 20 percent ofpatients. The lines extrapolate back to an estimated onset ofretinopathy four to seven years before the clinical diagnosiswas made. Data from Harris, MI, Klein, R, Welborn, TA, Knuiman, MW,Diabetes Care 1992; 15:815.



Ophthalmologic examination schedule

Patientgroup Recommended first examination Minimum routine

follow-up*

Type 1diabetes

Within 5 years after diagnosis of diabetes oncepatient is age 10 years or older•

Yearly

Type 2diabetes

At time of diagnosis of diabetes Yearly

Pregnancy inpreexistingdiabetes

Prior to conception and during first trimester.Counsel on the risk of development and/orprogression of retinopathy.

Close follow-up throughoutpregnancy and for one yearpostpartum.

* Abnormal findings necessitate more frequent follow-up.• Some evidence suggests that the prepubertal duration of diabetes may be important in thedevelopment of microvascular complications; therefore, clinical judgment should be used when applyingthese recommendations to individual patients. Copyright © 2004 American Diabetes Association FromDiabetes Care Vol 27, Supplement 1, 2004. Reprinted with permission from The American DiabetesAssociation. Modifications from Standards of Medical Care in Diabetes--2009. Diabetes Care Vol 32,Supplement 1, 2009.



Incidence of diabetic retinopathy increases overtime

Percent of diabetic patients with retinopathy according toduration of disease in patients under the age of 30 years whowere treated with insulin (primarily type 1 diabetes) andpatients over the age of 30 years who were not treated withinsulin (primarily type 2 diabetes). Retinopathy increased overtime in both groups, affecting virtually all patients with type 1diabetes by 20 years. The increased incidence in type 2diabetes at three years is a probable reflection of the difficultyin determining the time of onset of that disease. Data from Klein,R, Klein, BE, Moss, SE, et al, Arch Ophthalmol 1984; 102:520,527.



Testing sites for pressure sensation in evaluation ofdiabetic foot

The monofilament used to evaluate pressure sensation shouldbe tested at each of the 12 sites shown, which represent themost common sites of ulcer formation. Failure to detectcutaneous pressure at any site indicates that the patient is athigh risk for future ulceration.



Captopril delays progression of microalbuminuria indiabetes

Effect of captopril or placebo in 225 patients with type 1diabetes mellitus, normal blood pressure, andmicroalbuminuria. At two years, captopril slowed the rate ofprogression to overt, dipstick-positive proteinuria and loweredthe albumin excretion rate (AER) compared to placebo. Datafrom The Microalbuminuria Study Group, Diabetologia 1996; 39:587.



ACE inhibitor slows progression of diabeticnephropathy

The effect of the administration of placebo or captopril topatients with type 1 diabetes with overt proteinuria and aplasma creatinine concentration equal to or greater than 1.5mg/dL (132 µmol/L). The likelihood of a doubling of theplasma creatinine concentration (Pcr) was reduced by morethan 50 percent in the captopril group. Data from Lewis, EJ,Hunsicker, LG, Bain, RP, Rohde, RD, N Engl J Med 1993; 329:1456.



Increased cardiovascular risk in type 2 diabetes

Calculated effects of different interventions on coronary and total deathsin 1000 normal and 1000 men with type 2 diabetes aged 35 to 57 yearswithout a history of myocardial infarction. Although risk was reduced bythe therapeutic interventions (particularly cessation of smoking), therewas a residual three to four fold increase in mortality in the diabetic men,due presumably to the effects of hyperglycemia or hyperinsulinemia. Datafrom Yudkin, JS, BMJ 1993; 306:1313.



Initiation and adjustment of insulin regimens

Insulin regimens should be designed taking lifestyle and meal scheduleinto account. The algorithm can only provide basic guidelines forinitiation and adjustment of insulin. bg: blood glucose.* Premixed insulins are not recommended during adjustment of doses; however, theycan be used conveniently, usually before breakfast and/or dinner if proportion of rapid-and intermediate-acting insulins is similar to the fixed proportions available.Reproduced with permission from: Nathan, DM, Buse, JB, Davidson, MB, et al. MedicalManagement of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for theInitiation and Adjustment of Therapy: A consensus statement of the AmericanDiabetes Association and the European Association for the Study of Diabetes. DiabetesCare 2009; 32: 193. Copyright © 2009 American Diabetes Association.



Glycemic control in type 2 diabetes

Glycemic control, estimated from the median hemoglobin A1Cvalue, in patients with type 2 diabetes mellitus in the UnitedKingdom Prospective Diabetes Study (UKPDS) who were randomlyassigned to receive intensive therapy with a sulfonylurea or insulinor to conventional treatment with diet; drugs were added if therewere hyperglycemic symptoms or if the fasting blood glucoseconcentration was greater than 270 mg/dL (15 mmol/L). TheHbA1c values were lower in the intensive therapy group but rosein both groups over time. The circles represent data for allpatients, while the lines represent data for patients followed forten years. Data from UK Prospective Diabetes Study (UKPDS) Group, Lancet1998; 352:837.



Preconception evalaution and management of women with type 1 or type2 diabetes

History and physical examination

Hypertension

goal blood pressure less than 140/90 mmHg except goal blood pressure less than 130/80 mmHgin patients with diabetic nephropathy and proteinuria

stop antihypertensive drugs, if possible, or switch to agents with fewest risks to fetus

Retinopathy

ophthalmology consult

treat active proliferative retinopathy before pregnancy

Cardiac

screen for coronary heart disease as per guidelines for nonpregnant women with diabetes

Renal

measure serum creatinine concentration and total protein-to-creatinine ratio

women with an elevated serum creatinine concentration are at risk for deterioration of renalstatus

Thyroid

obtain serum thyrotropin and free thyroxine

DiabetesAchieve good glucose control before conception.

If A1c is above the normal range for women without diabetes, intensive insulin therapy iswarranted.

3-4 injections/day of short and long acting insulin subcutaneously are usually required to achievegood glycemic control. Either subcutaneous insulin injections or an insulin infusion pump isacceptable

Self-blood glucose monitoring is performed before and after each meal and at bedtime

Repeat A1c one month after initiation of this program.

Retest every month until target A1c value is achieved. Once in the target range, the patient cantry to conceive.

A pregnancy test is done 1 week after a missed period to confirm pregnancy.

PsychosocialAssess "readiness" of patient for pregnancy

OtherAdvise patient to stop smoking and stop use of illicit drugs

Review medications. Discontinue those that are associated with potential fetal risks or change tomedications with fewer fetal effects, if possible.



American Diabetic Association provider recognition measures

Measure Frequency

HbA1c test (calculate proportion of patients with HbA1c value of less than 8 and10 percent)

At least oncea year

Retinal examination At least oncea year

Foot care evaluation At least oncea year

Blood pressure measurement (calculate proportion of patients with diastolicpressures of less than 90 mm Hg)

At least twicea year

Measurement of urinary protein/microalbumineria Once a year

Lipid profile evaluation Once a year

Tobacco smoking status and counseling referral (document in chart)

Assessment of patient monitoring of blood glucose (obtained from patient survey)

Patient satisfaction questions (obtained from patient survey)



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Overview of Medical Care in Adults With Diabetes Mellitus

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