Diabetes

    Reference: Canadian Journal of Diabetes "Canadian Diabetes Association 2008 Clinical Practice Guidelines for the prevention and management of diabetes in Canada"

     

    Common Questions

    • Eating too much sugar causes diabetes: No (but can Increase calorie intake creating risk of DM)
    • Avoiding sweet foods manages DMII - No
    • Avoiding carbohydrate managers T2DM - No
    • There is a diabetes diet - No, diet no different than "healthy heart" diet.
    • Everyone with T2DM is overweight: - No

    Risk Factors

    • Age >40y
    • First degree relative
    • Member of high risk population
    • History of GDM/Macrosomic infant
    • Hypertension
    • Dyslipidemia
    • Overweight/Abdominal obesity
    • Polycystic ovarian syndrome
    • Acanthosis Nigricans
    • Schizophrenia

     

    • Mechanism:
      • InsulinPathophysiology.jpg

     

     

     

    Diagnostic Testing

    • If unclear Type I vs. Type II DM: (young patient with hyperglycemia)
      • Islet Cell Antibodies (ICA)
      • Glutamic Acid Decarboxyllase Antibody titres (GADA)
      • (If both negative -> diagnose Type II)
      • Must distinguish b/c treatments very different.
    • Screening:
      • Screen everyone >40yrs old every 3 years
      • Screen more frequently (i.e. yearly) if risk factors)
      • if fasting glucose >5.6, start to watch more carefully (i.e. OGTT)

    Based on 2008 Guidelines of the American Diabetes Association

    Pre-diabetes

    Impaired Fasting Glucose (IFG)

    Fasting Glucose 6.1-6.9

    Impaired Glucose Tolerance (IGT) 2hr post 75g glucose load (OGTT) 7.8-11.0

     

    HbA1c 6.0-6.4

    Diabetes

    1. Fasting Glucose >7.0

    2. Random Glucose >11.1 

    3. 2hr post 75g OGTT >11.1

    4. HbA1c >6.5% (most people know 7%)

     

    Prediabetes (IGT/IFG)

    • Increased risk of diabetes progression
    • Associated with CVD outcomes
    • Primary Prevention (Diabetes Prevention Program - Finnish Diabetes Prevention Trial)
      • Lifestyle & Diet: 60% relative risk reduction of progression to diabetes
        • Exercise: Advise 30min of moderate intensity exercise 5x/week
        • Dietary Counceling: Target weight loss: 5% body weight
        • Stop smoking
      • Metformin: 30% RRR
      • (Can also use Acarbose [alpha-glucosidase inhibitor], or rosiglitazone [not used generally], Orlistat)

     

    Other Tests

     

    Complications

     

    Microvascular

     

    • Retinopathy

      • 10-15% will have this at diagnosis of Type II DM
      • Must have retinal evaluations (either opthalmoscope or high quality retinal photograph)
      • Screening Guidelines:
        • Population Start Screening Screening Frequency
          Type I DM 5 years after dx Annual Retinal Exam

          Type II DM 

           

          At Diagnosis Annual Retinal Exam

          Pregnant (any DM)

          (accelerates retinopathy - DCCT trial)

          First Trimester Every trimester then annually
          Planning to Conceive At preconception Same as pregnant
        • (In pregnancy, lower glucose, lower 
      • Non-Proliferative Diabetic Retinopathy:
        • Chronic hyperglycemia causes edema, hard exudates, tiny hemorrhages on the retina
        • Microaneurysm in vessel walls + occlusions cause "soft exudates" (aka "cotton wool spots")
      • Proliferative Diabetic Retinopathy (more extensive)
        • Blood vessels fryable, rupture, cause more extensive intraocular bleeding
        • Fibrosis, contraction, causing retinal detachment. 
      • Treatment:
        • Laser Photocoagulation - to damage retina causing avascular scar
        • Reducing retinal surface area by 1/3 - perfusion of remaining retina improves. 
        • Lose some peripheral vision (esp noticed at night) - preserves central vision
        • NEW! Now can inject VEGF antagonists monthly

     

    • Nephropathy

      • Damage to glomerular basement membrane by glucose

      • Genetic predisposition: Some patients never get this, others do.

      • Diagnosis:

        • Urine Albumin Creatinine Ratio (creatinine adjusts for hydration)

        • 24hr Urine Correction (no longer done)

        • VERY sensitivy tests: becomes positive during menses, UTI, fevers, vigorous exercise

      • Start releasing protein (microalbuminuria), worsens over time.

      • At 1-3 grams/day of protein loss, creatinine starts to rise, causing hypertension and progressive CKD

      • NOTE: Any patient with microalbuminuria has 4-8x risk of cardiovascular disease

        • Risk factor modification: i.e. smoking cessation

      • Screening:

        • Same as Retinopathy

     

     

     

     

     

     

    • CKD stage.png

     

    • Treatment:
      • ACE inhibitors & ARBs - Slows rate of progression

     

    • Neuropathy

    • Nerve cells are long + thin, and vulnerable to damage from glucose
    • Appear late in diabetes that is not controlled
    • Acute distal neuropathy can occur after hyperglycemia (demyelination - stocking glove distribution)
    • Symptoms:
      • Sharp stabbing burning pain in toes, fingers and hands. 
      • Dysesthesia: Often discomfort when touched 
      • Heaviness/clumsiness in feet
      • Noticed at night (distracted during day)
    • Treatment:
      • Topical: Capsaicin Cream
        • Apply to painful areas + put clean socks on (so don't get removed by bed sheets)
        • Re-apply in the night
      • Drugs:
        • TCAs, and SNRIs are mainstays of therapy
        • Gabapentin/Pregabalin: not very effective
      • Education: Tell patients if control their HBA1c < 7% - can get improvement
    • Types:
      • Symmetric Polyneuropathy (MOST COMMON)
      • Acute Mononeuropathy
        • Microvascular occlusion or vasa vasorum.
        • Usually resolve spontaneously in a few months.
        • No Treatment
      • Diabetic Amyotrophy
        • Proximal leg pain + weakness
      • Entrapment Neuropathy
        • Carpal tunnel
        • Meralgia paresthetica (Lateral cutaneous nerve of thigh under inguinal liagment)
      • Ohers:
        • Autonomic Neuropathy (Gi, CV, bladder, erectile problems

        • Mononeuropathy (CNIII palsy, carpal tunnel)

        • Polyradiculopathy (Lumbar radiculopathy - Femoral Nerve Muscle W

    • Progression:

      • Anesthetic: Eventually lose complete sensation - high risk of ulceration, infection, amputation

      • Annual foot exam to detect sensory deficits, ulcers, deformities

      • Patients should examine their feet too

    • Most Severe:

      • Charcot's Foot (french): Anesthetic foot.  Small muscles lose innervation, integrity of foot is lost. Painless collapse of midfoot deformities. VERY high risk of ulcers. 

     

    Skin

    • Condition Description Photo
      Eruptive Xanthoma

      Blisters on extensor

      surfaces and buttock areas

       

      - Occurs in uncontrolled

      diabetics and high lipids

      Necrobiosis

      lipoidica

      Red swollen hard patches

      on legs

       

      Acanthosis 

      Nigricans

         

    Management

     

    Outpatient CDA Targets

    • Based on CDA Guidelines 2013
    • Glycemic Control Outpatient Targets (CDA 2013)
      • HbA1c: <7.0% (for Type I and Type II or even <6.0 if safe)
        • Most <7%
        • Young and healthy: ≤6.5%
        • Frail Elderly <8.5%
       
      • Fasting/Preprandial Capillary Glucose: 4.0-7.0
        • 2hr Postprandial Capillary Glucose: 5.0-10.0 (5.0-8.0 IF A1c not at target)

      Other Targets:

      • Blood Pressure: <130/80
      • Lipids (same as high-risk framingham targets)
      • LDL <2.0 mmol/L
      • TG <1.5 mmol/L
      • TC/HDL <4.0 mmol/L

       

      Measure yearly ACR in ALL Diabetes pts (start 5 yrs after dx for Type I DM)

     

    • Keep pre-hospital oral hypoglycemics and insulin therapy if possible 

     

     

    In Hospital CDA Targets

    • Based on CDA Guidelines 2013
    • Non-Critically Ill (as long as can be safely achieved)

      • Pre-prandial Target 5.0 - 8.0 mmol/L
        • (if BG < 3.9 --> modify regimen, unless can be explained (skipped meal))
      • Target random < 10.0 mmol/L
      • Insulin is recommended to achieve control (scheduled basal, bolus and correction (supplemental) insulin is the preferred method.  Sliding-scale insulin (SSI) is discouraged)

      Critiaclly Ill

      • Target 8.0 - 10.0 mmol/L
      • Based on NICE-SUGAR study (intensive control --> hypoglycemia risk)
      • Infusion protocols recommended

       

      Perioperative Control

          For CABG:

      • Maintain 5.5 - 10.0 mmol/L
      • Continuous IV insulin infusion should be used.

       

          For Other Surgery

      • Target 5.0 and 10.0 mmol/L  Perioperative
      • Use "appropriate protocol"

     

    Approach/Counselling

     

    Management of Prediabetes (IGT/IFG)

    1. Excercise
      • 60% relative risk reduction of progression of diabetes
      • Advised to exercise 150min per week (moderate intensity) --CDA Guideline
        • Biking
        • Brisk Walking
        • Swimming
        • Dancing
        • Raking Leaves
    2. Refer to dietary counselling (target wt loss 5%)
    3. Counsel to stop smoking (most important)
    4. Metformin = 30% relative risk reduction of progression to diabetes

     

    Management of Diabetes

    1. Excellent glycemic control - Lab fasting glucose, A1c (Hypoglycemics, Insulin)
    2. Address CV risk factors (20% increased risk)
      • Hypertension BP (Target <130/80) - use ACEi and ARBs first line for DM 
      • Dyslipidemia Labs (Target LDL <2.0mmol/L, and Total Cholesterol/HDL <4.0)
      • Smoking, Weight
    3. Screen for complications
      • Diabetic Nephropathy:
        • Screen ACR, creatinine (YEARLY!)
        • Treat miroabluminuria with ACEi and ARB, helps even in absence of HTN or CKD.
      • Diabetic Retinopathy:
        • Macular Edema, Non-proliferative (intraretinal hemorrhages, microaneurisms), Proliferative retinopathy.
        • Visual fields testing, Fundoscopy, Optho consult.
      • Diabetic Neuropathy

        • 10g monofilament (risk of foot ulcerations, cannot be reversed)

        • Vibration Sense

        • Pinprick Sensation

        • Reflexes

        • Foot Exam - ulcers etc..

     

    Approach to Drugs

    • Type 1 DM:
      • Mainstay is insulin therapy
      • Once stable on insulin (know insulin requirements), can apply for an insulin pump, which improves glucose control.
      • Government of Ontario supplies insulin pumps (>$7000 value) every 5 years to all Type I DM patients. 
    • Type 2 DM:
      • Start with metformin
      • Add another oral agent (see Oral Agents Section)
      • Once control cannot be established through oral agents, add Insulin (see Insulin Section)
      • Generally keep some oral agents to prevent side effects of insulin (hypoglycemia, and weight gain).
        • I.e. often add GLP-1 agonists and SGLT-2 antagonists for their weight loss and cardiovascular benefits, and to decrease insulin requirements.
    • Risk Factor Modification
      • Quit Smoking
      • Assess Cardiovascular Risk
      • Check Lipids
      • Yearly screening (see Complications of Diabetes)

    Notable Trials

    • DM Type II
      • UKPDS 33 - intensive glucose congrol: reduced diabetes endpoints.
      • UKPDS 35 - for each 1% drop in HbA1c - 37% reduction in microvascular complications.
      • ACCORD (Action to Control CV Risk in Diabetes)
        • Large randomized control trial ~10,000 pts. (3.5 years)
        • intensive glycemic control vs. standard.
        • No difference in CVD
        • 20% higher risk of death for ever 1.0% increase in HbA1c below 6.0%
      • ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation).
        • Large randomized control trial ~10,000pts (5years)
        • Intensive vs. standard glycemic control.
        • No difference in CVD
      • VADT Trial: (Veterans)
        • 1791pts
        • CV risk depends on length of time pts have diabetes.
        • Intensive control only helps for <15yrs diabetes.
      • Conclusions:
        • Target <7.0% is reasonable, but <6% increases mortality --> try to attain if pt has DMII of short duration, long life expectancy, or no significant CVD or hypoglycemia.
        • Target >7.0% reasonable if limited life expectancy, severe hypoglycemia, established microvascular and macrovascular complications, other comorbidities, or if <7.0 is difficult to attain. (Skyler et al - 2009 - Intensive glycemic control and the prevention of CV events....)
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