Update on Diabetes Standards-What Community Physicians Should Know. Kevin Miller D.O.

Transcription

1 Update on Diabetes Standards-What Community Physicians Should Know. Kevin Miller D.O.

2 Know The ABC Targets A1C BP LDL Cholesterol

3 AACE Recommendations for A1C Testing A1C levels may be misleading in several ethnic populations (for example, African Americans) A1C may be misleading in some clinical settings Hemoglobinopathies Iron deficiency Hemolytic anemias Thalassemias Spherocytosis Severe hepatic or renal disease AACE/ACE endorse the use of only standardized, validated assays for A1C testing AACE. Endocrine Pract. 2010;16:

4 Limitations of A1c Indirect Measure Provides no information about glucose fluctuations or hypoglycemia incidence In the future may shift to CGMS (glucose range) and Glycated Albumin

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6 A1C On Target 2014 Data 55% of Type 2 Diabetes Patients have a1c less than 7% 45% of Patients are NOT at ADA Goal Frequency of A1c Testing (May be over testing) Every 6 mos. if a1c historically <7% Every 3 mos. if a1c >7% (6-8 week interval testing is too early)

7 A1c as Indicator for Treatment Intensification 8.9% is the National Average A1c of DM2 patient when treatment is intensified or augmented 2.9 years above 7% is the time duration to intensification It is recommended that 3 mos. with a1c greater than 7% is an indicator for intensification (some progressive providers using fructosamine or glycated Albumin as a 4-6 week indicator for change)

8 ADA 2015 Goals

9 ADA 2015 Meeting In T2DM patients that are younger <50, it is probably reasonable to recommend a near normal glucose target with A1C near normal, as long as there is limited hypoglycemia It is not the current standards but research is showing that a near normal A1c without hypoglycemia may be the future target for diabetic patients that we initiate and maintain throughout their disease course.

10 Consequences of Hypoglycemia Cognitive, psychological changes (eg, confusion, irritability) Accidents Falls Recurrent hypoglycemia and hypoglycemia unawareness Refractory diabetes Dementia (elderly) CV events Cardiac autonomic neuropathy Cardiac ischemia Angina Fatal arrhythmia

11 Cardiovascular Effects of Hypoglycemia Prolonged QT- intervals- Diabetologia 52:42,2009 Can be of prolonged duration IJCP Sup 129, 7/02 Greater with higher catecholamine levels Europace 10,860 Associated with Angina Diabetes Care 26, 1485, 2003 Ischemic EKG changes Porcellati, ADA2010 Associated with Arrhythmias Associated with Sudden Death Endocrine Practice 16,¾ 2010 Increased Variability- explains highest mortality in intensive group in ACCORD ( increases inflammation, ICU mortality Hirsch ADA2010)

12 Hypertension Up to 60% of Diabetics have HTN at some time in there disease. One of the greatest risk factor of development of CV disease, Micro-vascular disease, and Nephropathy 74% of Diabetics with HTN it NOT CONTROLLED

13 Blood Pressure Targets American Heart Association and American Diabetes Association 2016 Target less than 140/90 mmhg Accord Extension and Sprint Trial (Just released) Less than 120/80 mmhg Compelling Data for CV reduction Dr. George Bakris (Chief Nephrology University Chicago) There is a sweet spot for BP target and it is probably less than 130/80 mmhg with diastolic above 6O mmhg

14 Cardiovascular Risk Management

15 Cardiovascular Disease and Diabetes ~65% of deaths are due to CV disease Coronary heart disease deaths 2- to 4-fold Cardiovascular complications of T2DM No A1C threshold is apparent Finnish study by Kuusisto et al; UKPDS epidemiologic analysis; EPIC-Norfolk Study Stroke risk 2- to 4-fold T2DM = type 2 diabetes mellitus Bell DSH. Diabetes Care. 2003;26: Centers for Disease Control (CDC). Heart failure 2- to 5-fold Impaired glucose tolerance (IGT) and postprandial hyperglycemia are CV risk factors Funagata Diabetes Study;Honolulu Heart Program; DECODE Study; Rancho Bernardo Study

16 Comprehensive Management of CV Risk Manage CV risk factors Weight loss Smoking cessation Optimal glucose, blood pressure, and lipid control Use low-dose aspirin for secondary prevention of CV events in patients with existing CVD May consider low-dose aspirin for primary prevention of CV events in patients with 10-year CV risk >10% Consider measurement of coronary artery calcification or use coronary imaging to determine whether glucose, lipid, or blood pressure control efforts should be intensified CV = cardiovascular; CVD = cardiovascular disease.

17 Aggressive Medical therapy in Diabetes SGLT-2 Inh. Pioglitazone Incretins Metformin Hyperglycemia/ Insulin resistance Atherosclerosis, CV Outcomes, CV Risk Factors, Mortality ACE inhibitors ARBs β-blockers CCBs Diuretics Hypertension Statins Fibric acid derivatives Colsevalam PCSK-9 Inh Dyslipidemia ASA Clopidogrel Ticlopidine Platelet activation and aggregation Adapted from Beckman JA et al. JAMA. 2002;287:

18 Statin Use Use a statin regardless of LDL-C level in patients with diabetes who meet the following criteria: >40 years of age 1 major ASCVD risk factor Hypertension Family history of CVD Low HDL-C Smoking Majority of patients with T2D have a high cardiovascular risk LDL-C target: <70 mg/dl for the majority of patients with diabetes who are determined to have a high risk ASCVD = atherosclerotic cardiovascular disease; CVD = cardiovascular disease; HDL-C = high density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol.

19 Lipid Targets Parameter Primary Goals Treatment Goal Moderate risk High risk LDL-C, mg/dl <100 <70 Non HDL-C, mg/dl <130 <100 Triglycerides, mg/dl <150 <150 TC/HDL-C ratio <3.5 <3.0 Secondary Goals ApoB, mg/dl <90 <80 LDL particles <1,200 <1,000 Moderate risk = diabetes or prediabetes with no ASCVD or major CV risk factors High risk = established ASCVD or 1 major CV risk factor CV risk factors Hypertension Family history Low HDL-C Smoking ApoB = apolipoprotein B; ASCVD = atherosclerotic cardiovascular disease; CV = cardiovascular; HDL-C = high density lipoprotein cholesterol; LDL = low-density lipoprotein; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol.

20 Secondary Targets for Disease Management Retinopathy, Nephropathy, Neuropathy, Tobacco Cessation, Weight Reduction, and Depression

21 Assessment of Diabetic Retinopathy Annual dilated eye examination by experienced ophthalmologist or optometrist Begin assessment At diagnosis of T2D More frequent examinations for: Pregnant women with DM during pregnancy and 1 year postpartum Patients with diagnosed retinopathy Patients with macular edema receiving active therapy DM = diabetes mellitus; T1D = type 1 diabetes; T2D = type 2 diabetes.

22 Assessment of Diabetic Nephropathy Annual assessments Serum creatinine to determine egfr Urine ACR (microalbinurea) Begin annual screening 5 years after diagnosis of T1D if diagnosed before age 30 years At diagnosis of T2D or T1D in patients diagnosed after age 30 years AER = albumin excretion rate; egfr = estimated glomerular filtration rate; T1D = type 1 diabetes; T2D = type 2 diabetes.

23 Management of Diabetic Nephropathy Optimal control of blood pressure, glucose, and lipids Smoking cessation RAAS blockade ACE inhibitor, ARB, or Direct renin inhibitors Do not combine RAAS blocking agents Monitor serum potassium Nephrologist referral Atypical presentation (ex patient with one kidney) Rapid decline in egfr or albuminuria progression Stage 4 CKD (GFR 15-29) ACE = angiotensin converting enzyme; ARB = angiotensin II receptor blocker; CKD = chronic kidney disease; egfr = estimated glomerular filtration rate; RAAS = renin angiotensin aldosterone system.

24 Diabetic Neuropathy Evaluations and Tests Foot inspection Neurologic testing Painful neuropathy Cardiovascular autonomic neuropathy Foot structure and deformities Skin temperature and integrity Ulcers Vascular status Pedal pulses Amputations Loss of sensation, using 10-g monofilament Vibration perception using 128-Hz tuning fork Ankle reflexes Touch, pinprick, and warm and cold sensation May have no physical signs Diagnosis may involve specialist or other surrogate measure Heart rate variability with: Deep inspiration Valsalva maneuver Change in position from prone to standing DM = diabetes mellitus; T1D = type 1 diabetes; T2D = type 2 diabetes.

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26 Tobacco Cessation Some emerging research suggests smoking can increase your risk of developing diabetes.(nih) Huge increased risk for Cardiovascular Disease, Lung CA, and Head and Neck CA Often just mentioning it as a provider and offering to help can be very effective

27 Diabetes and Depression Routinely screen all adults with DM for depression Untreated comorbid depression can have serious clinical implications for patients with DM Consider treatment and referring patients with depression to mental health professionals 27

28 Vaccinations for Patients with DM Vaccine, frequency of administration Patient age Adults with T2DM Influenza, annually High Dose Influenza, annually > 65 Pneumococcal Vaccine PPSV23, 1 injection PVC13 plus PPSV23, 1 injection each, in series Hepatitis B, 1 injection Tetanus-diphtheria booster, every 10 years in adults Individuals not already immunized for childhood diseases and those requiring vaccines for endemic diseases should be immunized as required by individual patient needs 2-18 years years 65 years years* 19 years Any age *Consider for patients 60 based on assessment of risk and likelihood of adequate immune response. 28

29 Care Considerations 2016 American Diabetes Association & American Academy of Clinical Endocrinologist

30 ADA 2016

31 AACE 2016

32 Dr. Stan Schwarz Treatment Targets Follow current AACE GUIDELINE PRINCIPLES Treat as many of the Egregious 11 Targets as needed, with least # of agents, to get lowest sugars/hga1c as possible without undue weight gain or hypoglycemia Early Combination Therapy- not sequential 1st-2nd-3 rd line Efficacy, CV event reduction, Weight Loss, side effect profile Treat with agents that address FBS AND PPG Ideal agents will stabilize and preserve β-cells and their function Ideal agents will have potential to synergistically decrease in CV risk factors / outcomes Treat CV risk factors

33 References ADA 2016 Care Recommendations AACE 2015/2016 Diabetes Comprehensive Care Plan Dr. Stan Schwarz Dr. Ralph De Franzo CDC 2014 Diabetes Epidemiological Data