Lunch CME Lecture: Diabetes Chris Pitsch, DO

Transcription

1 Lunch CME Lecture: Diabetes Chris Pitsch, DO

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 and Board Review in Osteopathic Family Medicine Dates and Location of CME Activity: August 20-23, 2015, Loews Chicago O Hare Hotel, Rosemont, IL Topic(s): Diabetes Lunch Lecture Friday, 8/21/15 11:45-12:45pm X Table Trainer -Breakout 1 - OMT for the Thoracic and Cervical Spine Friday, 8/21/15 2:45-4:15pm & 4:30-6:00pm Saturday, 8/22/15 8:30-10:00am & 10:15-11:45 am Table Trainer- Workshop: Examination Techniques for Office Orthopedics-Primary Orthopedics: What You Need to Know Friday, 8/21/15 7:30-9:30pm Proctor- Test-Taking Skills Workshop: Review of Clinical Scenarios Utilizing a Hands-On Approach in Preparation for Your Board Examination Saturday, 8/22/15 6:30-9:30pm Name of Faculty/Moderator: Chris Pitsch, DO 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: 1. Did you participate in company-provided speaker training related to your proposed topic? Yes No 2. Did you travel to participate in this training? Yes No 3. Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes No 4. Did the company pay the travel/lodging/other expenses? Yes No 5. Did you receive an honorarium or consulting fee for participating in this training? Yes No 6. Have you received any other type of compensation from the company? Please specify: Yes No 7. 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 8. Will your topic involve information or data obtained from commercial speaker training? Yes No DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCT X 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: Chris Pitsch, DO Date: Chris Pitsch, DO Please fax this form to ACOFP at or to joank@acofp.org as soon as possible Deadline: August 7, 2015

3 Diabetes Mellitus Chris Pitsch, DO Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI 30 kg/m 2 ) No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% Diabetes No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at Prevalence: In 1990 the prevalence of self-reported diabetes was 2.9% in the United States, increasing to almost 8% in the first decade of the 21 st century. In men and women, the prevalence of diabetes increases with age, the rate now is almost 1 in 4 in those older than 60. In those over 20, American Indians and Alaskan Natives have high prevalence (16.5%), Blacks (11.8%), Hispanics/Latinos (10.4%), and whites (6.6%) Education is inversely proportional with the highest prevalence among those not finishing high school. The Southeast has a much higher prevalence than other parts of the U.S. 1

4 Percentage with Diabetes Number with Diabetes (Millions) 8/6/2015 Number and Percentage of U.S. Population with Diagnosed Diabetes, Percentage with Diabetes Number with Diabetes Year 0 CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at Objectives I. Screening for Diabetes Mellitus II. Diagnosis of Diabetes Mellitus III. Complications of Diabetes Mellitus of Diabetes Mellitus I. Screening Question #1 The USPSTF Screening recommendation for diabetes is based on using which of the following risk factors as an important predictor of cardiovascular complications in people with type 2 diabetes mellitus? A) Activity Level B) Blood Pressure C) Coronary Artery Disease D) Dyslipidemia E) Ethnicity 2

5 I. Screening g/page/document/clinicalsummaryfinal/diab etes-mellitus-type-2-in-adultsscreening#copyright This document is a summary of the 2008 recommendation of the U.S. Preventive Services Task Force (USPSTF) on screening for type 2 diabetes mellitus in adults. This summary is intended for use by primary care clinicians. Clinical Summary of U.S. Preventive Services Task Force Recommendation Population Asymptomatic Adults with Sustained Blood Pressure Asymptomatic Adults with Sustained Blood Pressure greater than 135/80 mm Hg 135/80 mm Hg or lower Recs Screen for Type 2 Diabetes Mellitus Grade: B No Recommendation Grade: I (Insufficient Evidence) Risk Assessment These recommendations apply to adults with no symptoms of type 2 diabetes mellitus or evidence of possible complications of diabetes. Blood pressure measurement is an important predictor of cardiovascular complications in people with type 2 diabetes mellitus. The first step in applying this recommendation should be measurement of blood pressure (BP). Adults with treated or untreated BP >135/80 mm Hg should be screened for diabetes. Screening Tests Three tests have been used to screen for diabetes: Fasting plasma glucose (FPG). 2-hour postload plasma. Hemoglobin A 1c. The American Diabetes Association (ADA) recommends screening with FPG, defines diabetes as FPG 126 mg/dl, and recommends confirmation with a repeated screening test on a separate day. Screening Intervals Suggestions for practice regarding insufficient evidence The optimal screening interval is not known. The ADA, on the basis of expert opinion, recommends an interval of every 3 years. When BP is 135/80 mm Hg, screening may be considered on an individual basis when knowledge of diabetes status would help inform decisions about coronary heart disease (CHD) preventive strategies, including consideration of lipid-lowering agents or aspirin. To determine whether screening would be helpful on an individual basis, information about 10-year CHD risk must be considered. For example, if CHD risk without diabetes was 17% and risk with diabetes was >20%, screening for diabetes would be helpful because diabetes status would determine lipid treatment. In contrast, if risk without diabetes was 10% and risk with diabetes was 15%, screening would not affect the decision to use lipid-lowering treatment. I. Screening USPSTF Recommendations Grade Definition Suggestions for Practice A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service. B The USPSTF recommends the service. There is high Offer or provide this service. certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C The USPSTF recommends selectively offering or Offer or provide this service for selected patients providing this service to individual patients based on depending on individual circumstances. professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. D The USPSTF recommends against the service. There is Discourage the use of this service. moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I The USPSTF concludes that the current evidence is Read the clinical considerations section of USPSTF Statement insufficient to assess the balance of benefits and harms Recommendation Statement. If the service is offered, of the service. Evidence is lacking, of poor quality, or patients should understand the uncertainty about the conflicting, and the balance of benefits and harms balance of benefits and harms. cannot be determined. 3

6 I. Screening USPSTF: Recommends screening for diabetes in adults with HTN ADA: Recommends screening every 3 years beginning at age 45 especially if BMI 25 kg/m 2 I. Screening HOWEVER Based on Screening for Abnormal Glucose and Type 2 Diabetes Mellitus: A Systematic Review to Update the 2008 U.S. Preventative Services Task Force Recommendation This article was published online first at on April 14, 2015 Shelley Selph, MD, MPH; Tracy Dana, MLS; Ian Blazina, MPH; Christina Bougatsos, MPH; Hetal Patel, MD; and Roger Chou, MD; ocument/evidence-summary25/screening-forabnormal-glucose-and-type-2-diabetes-mellitus I. Screening Screening for Abnormal Glucose and Type 2 Diabetes Mellitus: A Systematic Review to Update the 2008 U.S. Preventative Services Task Force Recommendation Background: Screening for type 2 diabetes mellitus could lead to earlier identification and treatment of asymptomatic diabetes, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT), potentially resulting in improved outcomes. Purpose: To update the 2008 U.S. Preventive Services Task Force review on diabetes screening in adults. Data Sources: Cochrane databases and MEDLINE (2007 through October 2014) and relevant studies from previous Task Force reviews. Study Selection: Randomized, controlled trials; controlled, observational studies; and systematic reviews. Data Synthesis: In 2 trials, screening for diabetes was associated with no 10-year mortality benefit versus no screening (hazard ratio, 1.06 [95% CI, 0.90 to 1.25]). Sixteen trials consistently found that treatment of IFG or IGT was associated with delayed progression to diabetes. Most trials of treatment of IFG or IGT found no effects on all-cause or cardiovascular mortality, although lifestyle modification was associated with decreased risk for both outcomes after 23 years in 1 trial. For screen-detected diabetes, 1 trial found no effect of an intensive multifactorial intervention on risk for all-cause or cardiovascular mortality versus standard control. In diabetes that was not specifically screen-detected, 9 systematic reviews found that intensive glucose control did not reduce risk for all-cause or cardiovascular mortality and results for intensive blood pressure control were inconsistent. Conclusion: Screening for diabetes did not improve mortality rates after 10 years of follow-up. More evidence is needed to determine the effectiveness of treatments for screen-detected diabetes. Treatment of IFG or IGT was associated with delayed progression to diabetes. 4

7 I. Screening Risk factors for Type 2 Diabetes Family history HTN Dyslipidemia (high triglycerides and low HDL) Obesity High risk ethnic or racial groups (African- American, Hispanic, Native American) Previous history of impaired glucose tolerance Gestational diabetes, or birth of a child > 9 lbs Habitually physically inactive Cardiovascular disease Polycystic ovarian disease II. Diagnosis Question #2 All of the following are considered criteria for the diagnosis of diabetes mellitus in adults except. A) Random plasma glucose 200 mg/dl with polydipsia, polyuria, polyphagia, and/or weight loss B) Fasting plasma glucose 126 mg/dl C) Two-hour oral glucose tolerance test 200 mg/dl after a 75 gram glucose load D) A1C 6.0 II. Diagnosis Diagnostic Criteria for Diabetes Fasting plasma glucose 126 mg/dl on more than one occasion. Fasting is at least 8 hours. Random venous plasma glucose 200 mg/dl in a patient with classic symptoms of hyperglycemia. Plasma glucose 200 mg/dl measured 2 hour after a glucose load of 1.75 g/kg (maximum dose of 75 g) OGTT. Glycated hemoglobin A1C 6.5 percent. 5

8 II. Diagnosis Diabetes Type 1 Up to 10% of cases of diabetes Polyuria, polydipsia, nocturia, weight loss Etiology: complex interaction of genetic and environmental factors. Destruction of pancreatic β cells and loss of body s ability to produce insulin. Type 1A: approx. 85%, autoimmune destruction of pancreatic beta cells Type 1B: approx. 15%, no evidence of autoimmune destruction of pancreatic beta cells II. Diagnosis Diabetes Type 1 Bimodal distribution: one peak at 4 to 6 years of age and a second at early puberty, 10 to 14 years of age 45% of children present before age 10 Most common in non-hispanic white II. Diagnosis Diabetes Type 1 Signs/Symptoms: Fatigue, malaise, nausea and vomiting, irritability and weight loss Hyperglycemia without acidosis is the most common presentation of childhood Type 1 Diabetes DKA is the second most common form of presentation for T1DM in most populations 6

9 II. Diagnosis Diabetes Type 2 Up to 90% of cases of diabetes Etiology: increasing cellular resistance to insulin, accelerated by obesity and inactivity. Some patients have latent autoimmune diabetes with onset similar to type 2 but with destruction of the β cells, and a more rapid progression to insulin dependence. II. Diagnosis Diabetes Type 2 Signs/Symptoms: Fatigue, irritability, drowsiness, blurred vision, numbness or tingling in extremities, slow wound healing, frequent infections of the skin, gums, or urinary tract including candidal infections III. Complications Question # 3 The most common cause of end-stage renal disease in the United States is: A) NSAID overuse B) IV drug abuse C) Diabetic nephropathy D) Autoimmune disease E) HTN 7

10 III. Complications Ketoacidosis: insufficient insulin to meet body s needs resulting in increased gluconeogenesis, fatty acid oxidation, and ketogenesis Infections: community-acquired pneumonia, influenza, cholecystitis, UTI, pyelonephritis, fungal infections, skin infections, eye infections, foot infections Retinopathy Neuropathy Cardiovascular Disease Hyperlipidemia Diabetic Feet: 15% of diabetics will have a foot ulcer and 20% of these will lead to amputation. III. Complications Nephropathy: Risk factors: poor glycemic control, smoking, HTN, family history, and glomerular hyperinfiltration All patients should be screened yearly with a microalbumin or microalbumin/creatinine ratio. Microalbuminuria is defined as mg protein in a 24 hour urine collection. More than 300 mg/24 hour constitutes macroalbuminuria or nephropathy. Risk of microalbuminuria increases by 25% for each 10% rise in A1c ACE inhibitors are the drug of choice. Ramipril has been showed to reduce ESRD and death by 41% and proteinuria by 20% when compared with amlodipine. ARBs have comparable efficacy and should be used when use of ACE inhibitors is limited. The most common cause of ESRD is diabetic nephropathy American Diabetes Association: Diabetic nephropathy (Position Statement). Diabetes Care 2003; 26 (Suppl. 1): S94-S98 III. Complications Retinopathy: About 20% of Type 2 diabetic patients show signs of retinopathy at time of diagnosis. Patients with Type 1 diabetes may begin yearly opthalmologic visits 5 years after diagnosis, type 2 diabetics should begin yearly visits as soon as diagnosis is made. 8

11 III. Complications Cardiovascular disease: heart disease is the leading cause of death in patients with diabetes Aspirin therapy at 81 mg/day is indicated for men older than 50 and women older than 60 years with one additional cardiovascular risk factor. Statins are the drugs of choice in treating hyperlipidemia in diabetic patients. American Heart Association, American College of Cardiology, and American Diabetic Association. Diabetes Care 2010; 33: 1395 and J Am Coll Cardiol 2010; 55: 2878 Education Nutrition Exercise Home Glucose Monitoring Pharmacologic Therapy Diabetes Type 1, Treatment Diet Exercise Insulin replacement: two-thirds total dose in the morning (split 2:1, regular: intermediate) and one-third total dose in the evening (split 2:1, regular: intermediate). Also consider basal insulin plus prandial insulin. 9

12 Diabetes Type 2, Treatment Diet Weight control Exercise Oral meds with or without insulin Nutrition: Weight loss of 10%-15% significantly improves glucose control, insulin sensitivity, and decreases mortality. It can be achieved with a reduction of kcal/day Mediterranean diet with exercise and not smoking Limit alcohol Consistent daily caloric intake for those on insulin Carbs: 55% - 60% Fats: < 30% (saturated < 7% - 10%) Protein: 10% - 20% Sodium: < 2400 mg if hypertensive Home Glucose Monitoring The consensus panel of the American Diabetes Association has recommended that all patient with diabetes should perform home glucose monitoring. Type 1 diabetics should monitor blood glucose at least 4 times a day Type 2 diabetics can monitor once or twice daily with fasting and postprandial values being most helpful 10

13 Biguanides Biguanides: Metformin (Glucophage) MOA: Decrease gluconeogenesis in the liver, increase insulin sensitivity Advantages: No hypoglycemia, lowers insulin levels, possible weight loss, improves lipids and endothelial function, decreases mortality Side effects/precautions: Nausea, diarrhea, not for use when creatinine 1.5 mg/dl, hold before and after IV contrast, caution with CHF and hepatic dysfunction Question #4 All of the following are true regarding sulfonylureas except: A) They are contraindicated in a patient with sulfa allergy. B) They tend to cause weight gain. C) Most are metabolized by the liver to substances that are cleared by the kidney, thus they are generally not used in significant liver or kidney disease. D) Their efficacy tends to wear out after approximately 5 years of treatment. E) They help improve insulin sensitivity. Sulfonylureas Sulfonylureas: Glipizide (Glucotrol), Glyburide (Diabeta, Micronase), Glimeperide (Amaryl) MOA: Induce insulin secretion from pancreatic β cells Metabolized in the liver and excreted primarily through urine Side effects/precautions: Hypoglycemia, weight gain 11

14 Question #5 Which of the following regarding thiazolidinediones such as pioglitazone (Actos) and rosiglitazone (Avandia) is true? A) They lead to weight loss by improving insulin sensitivity. B) They should not be combined with sulfonylureas to avoid drug interactions. C) They should be avoided in patients with congestive heart failure because of their tendency toward fluid retention. D) They are insulin secretagogues. E) A main advantage is that liver function tests do not have to be monitored. Thiazolodinediones Thiazolodinediones: Pioglitazone (Actos), Rosiglitazone (Avandia) MOA: Insulin sensitizers in muscle and adipose tissue Side effects/precautions: Cannot use in Class III or IV heart failure, must monitor liver function tests Meglitinides Meglitinides: Repaglinide (Prandin), Neteglinide (Starlix) MOA: Induce secretion of insulin from pancreatic β cells Advantages: Can be used in renal failure, rapid onset and short half-life Side effects/precautions: Caution in hepatic insufficiency 12

15 α-glucosidase inhibitors α-glucosidase inhibitors: Acarbose (Precose), Miglitol (Glyset) MOA: inhibit breakdown of disaccharides and delay carbohydrate absorption in brush border of small intestine Advantages: No hypoglycemia Side effects/precautions: Flatulence, cannot use with GI disorders, cirrhosis, Crt > 2 mg/dl DPP-4 inhibitor DPP-4 inhibitor: Sitagliptin (Januvia), Saxagliptin (Onglyza) MOA: Block the breakdown of natural incretins Advantages: Do not cause hypoglycemia, Lowers postprandial glucose Side effects/precautions: Nausea and vomiting, must decrease dose in renal impairment Incretin Mimetics Incretin Mimetics: Exenatide (Byetta), Pramlintide (Symlin) MOA: Enhance glucose-dependent insulin secretion, suppress inappropriate glucagon secretion and slow gastric emptying Advantages: Early satiety and weight loss Side effects/precautions: Nausea and vomiting, hypoglycemia, Exenatide associated with hemorrhagic or necrotizing pancreatitis 13

16 Our Role for our Diabetic Patients? History and physical Discuss nutrition, physical activity, management of diabetes and cardiovascular risk factors and diabetes related complications BP and feet checks at every visit Annual dilated eye exams A1C every 3 months, every 6 months in stable patients Fasting lipids and urine albumin-to-creatinine ratio annually Understand up to date treatment guidelines Standards of medical care in diabetes-2015: summary of revisions. Diabetes Care 2015; 38 Suppl:S4 References 1. American Diabetes Association: Diabetic nephropathy (Position Statement). Diabetes Care 2003; 26 (Suppl. 1): S94-S98 2. American Diabetes Association: Standards of medical care in diabetes, Diabetes Care 2011; 34, Suppl 1:S11 3. American Heart Association, American College of Cardiology, and American Diabetic Association. Diabetes Care 2010; 33: 1395 and J Am Coll Cardiol 2010; 55: Tallia, Alfred, Swanson s Family Medicine Review, A Problem-Oriented Approach, 6 th Edition, 2005, Diabetes Mellitus, Chp 41, pp Rakel, Robert E., Rakel, David P., Textbook of Family Medicine, Eight Edition, 2007, pp betes-mellitus-type-2-in-adults-screening#copyright Vail, Belinda, MD, MS, "Diabetes," Chp 35, Current Diagnosis and Medical Treatment, Family Medicine, Third Edition, 2011, pp UptoDate, Diabetes Mellitus, Treatment of Diabetes Mellitus 14