AUGUST 25-27, 2017 UPDATE & BOARD REVIEW. acofp INTENSIVE. Diabetes Review. Colleen Cagno, MD INNOVATIVE COMPREHENSIVE HANDS-ON

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1 acofp INTENSIVE UPDATE & BOARD REVIEW AUGUST 25-27, 2017 Loews Chicago O'Hare Hotel Rosemont, IL INNOVATIVE COMPREHENSIVE HANDS-ON Diabetes Review Colleen Cagno, MD acofp Am eric an College of Osteopathi c Family Physicians The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

2 ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: ACOFP Intensive Update & Board Review in Family Medicine Dates and Location of CME Activity: August 25-27, 2017, Loews Chicago O'Hare Hotel, Rosemont, IL, United States Topic(s): ENT for the Family Physician Friday, 8/25/17 10:30-11:00am High Yield Topics in Diabetes Mellitus Friday, 8/25/17 2:00-2:30pm Name of Faculty/Moderator: Colleen Cagno, MD DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services. B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care goods or services. Please check the relationship(s) that applies. Research Grants Stock/Bond Holdings (excluding mutual funds) Speakers Bureaus* Employment Ownership Partnership Consultant for Fee Others, please list: Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper: Organization With Which Relationship Exists Clinical Area Involved *If you checked Speakers Bureaus in item B, please continue: Did you participate in company-provided speaker training related to your proposed topic? Yes: No: Did you travel to participate in this training? Yes: No: Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No: Did the company pay the travel/lodging/other expenses? Yes: No: Did you receive an honorarium or consulting fee for participating in this training? Yes: No: Have you received any other type of compensation from the company? Please specify: Yes: No: When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation and/or lecture handout materials? Yes: No: Will your topic involve information or data obtained from commercial speaker training? Yes: No: DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational uses of products or devices. B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated below: I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement. Signature: Colleen Cagno, MD Date: Please fax this form to ACOFP at or to joank@acofp.org as soon as possible. Deadline: July 21, 2017

3 Diabetes Review Colleen K. Cagno, MD University of Arizona G Diabetes Mellitus Pre- Type 2 Case Vignette: Diabetes Mellitus () Paulette is a 46-year-old recently diagnosed with hypertension. On exam, BP is 150/94 mm Hg and BMI is 37 kg/m 2. The exam is otherwise benign. She does not smoke or drink alcohol. She does not exercise, and her daily life is fairly inactive. Which of the following is incorrect? A. BP >140/90mmHg in an overweight adult aged >45 yrs. is an indication for testing. B. screening is recommended for an asymptomatic overweight child with acanthosis nigricans. C. A FPG >100 mg/dl meets diagnostic criteria for D. Pneumococcal polysaccharide vaccine (PPSV23) is recommended for all people with diabetes 2-64 years of age. E. Optimal A1C target over 7% may be appropriate in a patient with short life expectancy. 1

4 : Testing in asymptomatic adults 1. Consider in overweight or obese (BMI > 25 kg/m2 or > 23 kg/m2 in Asian Am.) adults with one or more of the following: A1C >5.7%, IGT, or IFG on previous testing first-degree relative with diabetes high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) women with h/o G h/o CVD hypertension (>140/90 mmhg or on therapy for hypertension) HDL cholesterol level <35 mg/dl and/or a triglyceride level >250 mg/dl h/o polycystic ovary syndrome physical inactivity other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans). 2. For all patients, testing should begin at age 45 years. 3. 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 (e.g., those with prediabetes should be tested yearly) and risk status : Testing in asymptomatic children Overweight (BMI < 85 th % for age and sex, weight for height > 85%, or weight >120% for ideal height) Plus any of these 2 risk factors: Family h/o for type 2 in 1 st or 2 nd degree relatives Race / ethnicity (NA, AA, Latino, Asian Amer., Pacific Islander) Signs of insulin resistance (acanthosis nigricans, HTN, Dyslip, PCOS, SGA birth wt.) Maternal h/o G Initiate testing at age 10 yrs or at onset of puberty Frequency: every 3 yrs. : Criteria for Diagnosis FPG >126 mg/dl (fasting) OR 2-h PG > 200 mg/dl during an OGTT OR A1C > 6.5% With classic hyperglycemia symptoms or hyperglycemic crisis, a random plasma glucose >200 mg/dl. In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing 2

5 : Immunizations in All ages Provide routine vaccinations >6 months of age Annual influenza vaccine 2-64 years of age Pneumococcal polysaccharide vaccine (PPSV23) >65 years of age Pneumococcal conjugate vaccine (PCV13) at least 1 year after PPSV23, followed by another dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the last dose of PPSV years of age Hepatitis B vaccine series : Glycemic Targets A1C < 7% glucose mg/dl glucose <180 mg/dl Reasonable goal in nonpregnant adult Pre-prandial plasma glucose Peak postprandial plasma Less stringent AIC targets can be considered in patients with: high risk of hypoglycemia Long duration of Short life expectancy Severe comorbidities or vascular complications Case Vignette: Prediabetes Paulette, our 46-year-old patient, with uncontrolled hypertension (150/94), obesity (BMI 37 kg/m 2 )and an inactive lifestyle underwent testing for diabetes. Her FPG was 120 mg / dl. Which of the following is incorrect? A. Patients with prediabetes should be retested every year. B. Modest weight loss (through reduced calorie intake and lifestyle modification (moderate intensity physical activity of at least 150 min. / week) is recommended in prediabetes. C. Screening for and treatment of modifiable risk factors for cardiovascular disease is suggested in prediabetes. D. A1C should be ordered in addition to the Fasting Plasma Glucose to screen for. E. Metformin is not FDA approved for use in patients with prediabetes despite recent recommendations to consider its use in prediabetes to prevent or delay onset of. Pre- 3

6 Prediabetes: Diagnosis FPG mg / dl OR 2-h PG in 75g OGTT mg / DL OR AIC % Pre- Prediabetes: Treatment Retested every year Modest weight loss (through reduced calorie intake and lifestyle modification Moderate intensity physical activity of at least 150 min. / week Screening for and treatment of modifiable risk factors for CV disease Metformin is not FDA approved for use in patients with prediabetes despite recent recommendations to consider its use in prediabetes to prevent or delay onset of. Pre- Case Vignette: A 19 year old college student is home from the summer. Her parents note she has lost quite a bit of weight. The daughter explains the weight loss is unintentional. She notes increased thirst, hunger and urine output. Her parents schedule a visit with her family doctor who does the following? A. Reassures the family that the stress adjusting to college is the likely cause of the weight loss. B. Asks patient to return for fasting plasma blood glucose levels the next day because the lab is closed for the night. C. Orders urine analysis including ketone levels to assess for ketoacidosis. D. Physician suspects and starts patient on Metformin 500mg daily. E. Immediately orders autoantibodies to distinguish type 1 from type 2 4

7 diabetes: Classification Due to autoimmune B-cell destruction Usually leading to absolute insulin deficiency Classification is important, but not always possible at time of diagnosis, but comes more obvious over time Old paradigm that = occurs in childhood and Type 2 = occurs in adults is no longer true Both diseases can occur in both cohorts diabetes: Presentation Children with typically present with polyuria / polydipsia and 1/3 with life-threatening DKA In adults, presentation is more variable Many paths of demise of the B-cell including genetic and environmental, idiopathic Staging of (Stage 1, 2, 3) diabetes: Diagnosis Blood glucose rather than A1C should be used to diagnose the acute onset of type 1 diabetes in individuals with symptoms of hyperglycemia. Screening for type 1 diabetes with a panel of autoantibodies is currently recommended only in the setting of a research trial or in first-degree family members with type 1 diabetes. Persistence of two or more autoantibodies predicts clinical diabetes (islet cell, to Glutamic Acid Decarboxylase, insulin, to tyrosine phosphatases) Islet autoantibodies are typically tested after acute illness 5

8 diabetes: Glycemic Target and Treatment Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged >25 years) with type 1 diabetes Multiple daily injections of prandial insulin and basal insulin (starting dose u kg/day) or continuous subcutaneous insulin infusion. Rapid-acting insulin analogs to reduce hypoglycemia risk. Matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity. If successful, continuous subcutaneous insulin infusion even > 65 years of age. Case Vignette: Type 2 Paul is a 58 year old male delivery truck driver diagnosed with type 2 diabetes and after several months of working on lifestyle modifications his A1C is 8.0%. You suggest starting a medication but he is concerned about getting a low sugar reaction that would interfere with his job. He takes no other medications and his BMI is 33 kg/m 2 and recent creatinine is 1.2 mg/ dl. Which of the following medications would be least likely to causes hypoglycemia in this patient? A. Canagliflozin (Invokana) B. Glimepiride (Amaryl) C. Glipizide (Glucotrol) D. Insulin glargine (Lantus) E. Metformin (Glucophage) Type 2 Type 2 : Treatment Metformin, if not contraindicated and if tolerated, is the preferred initial pharmacologic agent for the treatment of type 2 diabetes. A1C > to 9% - Consider Dual Therapy A1C > to 10%, blood and/or blood glucose levels > 300 mg/dl or symptomatic - Consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed type 2 diabetes who are symptomatic and/or have A1C >10%. If noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target after 3 months, add a second oral agent, a glucagon-like peptide 1 receptor agonist, or basal insulin For patients with type 2 diabetes who are not achieving glycemic goals, insulin therapy should not be delayed. Type 2 6

9 Type 2 : Treatment Start: Basal Insulin Start 10 U / day or U/kg /day Adjust: 10-15% or 2-4 U once or twice a week to reach FBG target For Hypoglycemia: determine and address cause, if no clear reason, reduce dose by 4 U or 10-20% If A1C not controlled, consider combination injectable therapy. Add rapid acting pre-meal insulin prior to largest meal Add GLP-1 RA Change to premixed insulin twice daily (pre-breakfast and pre-dinner) Type 2 Type 2 : Medications With long-standing suboptimally controlled type 2 diabetes and established atherosclerotic cardiovascular disease, empagliflozin or liraglutide should be considered as they have been shown to reduce cardiovascular and all-cause mortality when added to standard care. Ongoing studies are investigating the cardiovascular benefits of other agents in these drug classes Type 2 7

10 Case Vignette: Gestational Diabetes Mellitus (G) Jessica is a 26-year-old woman who is gravida 2, para 1. She presents to your office for prenatal care at 12 weeks gestation. She delivered a healthy, 4,082-g (9-lb 0-oz) girl under your care 2 years ago; the birth was complicated by shoulder dystocia. Jessica has a body mass index of 31 kg/m 2, and she reports a 3-kg (6.6-lb) weight gain over the past 2 months. Medical and family history are negative for gestational and type 2 diabetes. Which of the following is correct? A. Screening for G should occur at 24 weeks gestation. B. Both a one-step and two-step screen for G are acceptable. C. Increasing physical activity is acceptable part of lifestyle changes in women diagnosed with G. D. Women with G should be screened at six to 12 weeks postpartum, and every three years thereafter. E. All of the above G G: Screening and Diagnosis Screening for G should occur after 24 weeks of gestation in all women without known diabetes mellitus. One-step or Two Step Strategy G 8

11 G G: Management and Targets Initial management of G involves dietary changes, increased physical exercise, and blood glucose self-monitoring. Pharmacologic therapy with metformin (Glucophage), glyburide, or insulin is appropriate for women with G whose glucose values are above goal despite lifestyle modifications. 95 mg/dl fasting 140 mg/dl 1-hr postprandial 120 mg/ dl 2-hr postprandial G G: Management Delivery The optimal timing is unclear. Induction of labor before 39 weeks should occur only if glycemic control remains poor despite medication use, or if another indication for delivery is present. Postpartum Should be screened at six to 12 weeks postpartum, and every three years thereafter, for abnormal glucose metabolism. G 9

12 References Standards of Medical Care in Diabetes diacare/suppl/2016/12/15/40.supplemen t_1.dc1/dc_40_s1_final.pdf Garrison, Andrew. "Screening, Diagnosis, and Management of Gestational Diabetes Mellitus."American Family Physician. N.p., 01 Apr Web. 21 July G Diabetes Mellitus Pre- Type 2 10