Wayne Gravois, MD August 6, 2017

Transcription

1 Wayne Gravois, MD August 6, 2017

2

3 Americans with Diabetes (Millions) Source: National Diabetes Statistics Report, 2011, 2017 Millions

4 $174 Billion $245 Billion $1 out of every $5 national healthcare dollars are spent caring for people with diabetes

5 12.7 % of LA residents estimated to have DM BRFSS national prevalence is 7.4% Source: Louisiana Behavioral Risk Factor Surveillance System (LBRRFS), data.

6 African Americans 17.1% Caucasian: 11% Hispanic 10.4% Other 9.6% Source: Louisiana Behavioral Risk Factor Surveillance System (LBRRFS), data.

7 A metabolic disorder characterized by a deficiency of insulin and/or insulin resistance Type I 5-10% Type II 90-95% Other 5% ADA Classification of DM (Patel, 2010)

8

9 Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI 30 kg/m 2 ) No Data <1 4.0% 1 4.0% 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. United States Surveillance System available at

10 DIAGNOSIS OF DIABETES

11 Who Should be Screened? Adults with BP greater than 135/80 mmhg (AAFP and USPSTF)) All Adults over age 45 (ADA) Adults with BMI > 25 and one or more of the following: Limited physical activity HDL < 35 TG > st degree relative with DM Ethnic groups: Hispanic, African American, or Native American Presence of Acanthosis nigricans History of gestational diabetes or PCOS (Patel, 2010; Diabetes Care, 2013)

12

13 47 yo M with PMH panic disorder, gout, asthma, brain cancer s/p excision 2007 Initially presented to ED with nausea, vomiting, and abdominal pain BG 500+, anion gap acidosis ADMITTED to ICU with DKA, with AKI and acute metabolic encephalopathy -HbA1c 15.8, diagnosed with Type 2 Diabetes Diabetes education counseling (including diet and exercise) given prior to discharge, refused Insulin on D/C Metformin 500 mg bid and januvia 100 mg daily at discharge 3 mos later remains only on metformin with last HbA1c 7.4

14 Ketosis prone diabetes mellitus (KPD) aka Diabetes Type 1.5, Atypical diabetes, or Flatbush diabetes Form of diabetes that is intermediate between Type 1 and Type 2 More common in African Americans, and Hispanics, 2-3X More common in men, ages Short h/o symptoms, average 4 weeks of polyuria, polydipsia prior to onset of DKA DKA often without precipitating cause Up to 20-50% of new diabetics present in DKA Within 12 weeks, many patients are able to become insulin independent At 10 years, 50% will remain insulin independent

15 A + A - AB System of DM Classification A + A - 8 % 18 % 54 % 20 % A+ A- B+ B- Source: Medscape 2016

16

17

18

19 Medscape 2017

20

21 Lifestyle Modification Exercise Weight Loss Reduce Calories

22 Lifestyle Modification Reduce Calories Fewer high-glycemic index carbs & fats Exercise 150 minutes exercise per week Weight Loss At least 7% of body weight

23 Biguanides Sulfonylureas Thiazolidinediones (TZDs) Incretin modifiers (GLP-1 agonists & DPP-4 inhibitors) Alpha glucosidase inhibitors SGLT2 Inhibitors Insulin

24 Biguanides Metformin (drug of first choice) Decreases hepatic glucose production Improves insulin sensitivity GI side effects may occur Does not cause weight gain Don t use if creatinine > 1.5 in men or 1.4 in women A1c reduction: 1-2%

25 Sulfonylureas Glimeperide, Glyburide, Glipizide Stimulates insulin secretion Can cause modest weight gain May cause hypoglycemia A1c reduction: 1-2%

26 Thiazolidinediones (TZDs) Pioglitazone, Rosiglitazone Improves insulin sensitivity Decreases hepatic glucose production Stimulates insulin secretion Can cause weight gain, edema, liver injury, heart failure May cause hypoglycemia A1c reduction: 1-1.5%

27 DPP-4 inhibitors Sitagliptin, Linagliptin, Alogliptin, Saxagliptin Causes glucose-dependent insulin secretion (DPP-4 inhibition increases GLP-1 concentration) Decreases hepatic glucagon production Does not cause weight gain Does not cause hypoglycemia A1c reduction: %

28 Alpha glucosidase inhibitors Acarbose, Miglitol Decreases GI absorption of glucose May cause GI side effects Limited effectiveness A1c reduction: 0.5%

29 SGLT2 Inhibitors Canagliflozin, Empagagliflozin, Dapagliflozin Reduces reabsorption of glucose in kidneys, increases urinary glucose excretion Insulin independent Effective in all stages of diabetes A1c reduction: 0.5%

30 GLP-1 Agonists (Incretin Mimetics) Exenatide, Liraglutide Causes glucose-dependent insulin secretion (by mimicking the effects of endogenous GLP-1) Injectable only Decreases hepatic glucagon production Causes weight loss delaying gastric emptying (incretin mimetic) Does not cause hypoglycemia A1c reduction: 1%

31 Insulin Basal Intermediate Short acting Ultra-short Glargine Detemir NPH Regular Lispro Aspart

32 Starting Basal Insulin Therapy Determine the total daily insulin dose: units/kg/day (if significant hyperglycemia, units/kg/d)

33 Why? prevent End Organ Damage reduce morbidity and mortality improve quality of care and quality of life recognize Pay for Performance measures How? focused routine exams and lab multi-disciplinary approach

34

35 CVD Annual Risk Management in Diabetics Dyslipidemia HBP Smoking FHx of Premature CAD

36 US Prediabetes Epidemic

37 % Prevalence of Prediabetes in LA Reported Un Reported Source: 8.7% of LA residents reporting they have prediabetes in % is estimated prevalence of prediabetes in LA from CDC s 2014 National Diabetes Statistics Report Source: 2015 Louisiana BRFSS. BRFSS data represents both type 1 and type 2 diabetes

38 STUDY: Diet and Exercise vs. Metformin (850 mg BID) 3,234 overweight men and women yo with IGT /Prediabetes RESULTS: 1 % reduced risk of progression to Type 2 DM in Lifestyle Group 31 % risk reduction in the metformin treated group

39 Lifestyle RCTs have shown that persons at high risk of developing type 2 diabetes can significantly decrease the rate of diabetes onset with intensive lifestyle modification programs. Follow-up of these studies has shown sustained reduction in the rate of conversion to type 2 diabetes. Given these results and the known risks of progression from prediabetes to diabetes, persons with an A1C of 5.7% to 6.4%, impaired glucose tolerance, or impaired fasting glucose should be counseled on lifestyle changes to achieve 7% weight loss and moderate-intensity physical activity of at least 150 minutes per week.

40 of Health LA Department awareness access Resource

41 Source: National Diabetes Statistics Report, 2011, 2017

42 8.7 % 37% % Prevalence of Prediabetes in LA Reported Un Reported 8.7% of LA residents reporting they have prediabetes in % is estimated prevalence of prediabetes in LA from CDC s 2014 National Diabetes Statistics Report Source: 2015 Louisiana BRFSS. BRFSS data represents both type 1 and type 2 diabetes

43