INITIAL VISIT CONTENT

TREATMENT GOALS

ROUTINE VISIT CONTENT

MEDICATION /TREATMENT ALGORITHMS

ADA & USPSTF GRADING SYSTEMS

WEB LINKS

Latest version: 7/15/2003 DIAGNOSIS and SCREENING

Diagnostic Criteria

Normal

IFG or IGT*

Diabetes

FPG < 110 mg/dl

FPG > 110 and < 126 mg/dl

FPG > 126 mg/dl

2 hr PG < 140 mg/dl

2 hr PG > 140 and < 200 mg/dl

2 hr PG > 200 mg/dl or random plasma glucose > 200 mg/dl and symptoms

*IGT = impaired glucose intolerance IFG = impaired fasting glucose Fasting = no intake except water for > 8 hours 2 hr PG = 2 hours post 75 gm glucose load

ADA Risk Factors for Type 2 Diabetes Age > 45 years Overweight (BMI > 25) Family history of diabetes Habitual physical inactivity Race/ethnicity (African-American, Hispanic-American, Native American, Asian, Pacific Islander) Impaired fasting glucose or glucose tolerance History of gestational diabetes or delivery of infant > 9 lbs Hypertension HDL cholesterol < 35 mg/dl and/or triglycerides > 250 mg/dl Polycystic ovarian syndrome History of vascular disease

Screening No Randomized clinical trials demonstrating reduced morbidity and mortality from screening.

Preferred screen is the fasting plasma glucose. Repeat required for diagnosis confirmation. HbA1c is not used for screening or diagnosis

ADA recommendations (expert opinion)

Consider q 3 years starting age 45, particularly with BMI > 25

Consider at younger age and higher frequency if additional risks present

Children and adolescents q 2 years starting age 10 for overweight + 2 risk factors

Overweight = BMI > 85%ile for age and sex, or weight for height > 85%ile, or weight > 120% of ideal (50%ile) for height.

Risks are type diabetes in 1st or 2nd degree relative, high risk race/ethnicity (as above), signs of insulin resistance (HTN, hyperlipidemia, PCOS, acanthosis nigricans)

USPSTF recommendations: http://www.ahcpr.gov/clinic/uspstf/uspsdiab.htm

INITIAL VISIT CONTENT

ADA recommendations

http://care.diabetesjournals.org/cgi/content-nw/full/26/suppl_1/s33/T5

TREATMENT GOALS

ADA Treatment Goals:

HbA1c < 7.0% (Grade A for tight control and reduced complications, grade B for specific goal) Preprandial plasma glucose 90-130 mg/dl Peak postprandial glucose < 180 mg/dl No data concerning effects in elderly 65 or over, children < 13, and patients with advanced complications. Less stringent goals may be appropriate.

Blood pressure < 130/80 (Grade A for reduced complications, grade B for specific goal)

Lipids LDL < 100 mg/dl (Grade A for reduced cardiovascular events, B for goal) Triglycerides < 150 mg/dl HDL > 40 mg/dl ATP-III guideline secondary goal: non-HDL cholesterol (total minus HDL) < 130

American Association of Clinical Endocrinlogists has issued more stringent guidelines with goals of HbA1c < 6.5, Fasting glucose < 110, and postprandial peak < 140

http://www.aace.com/clin/guidelines/diabetes_2002.pdf

ROUTINE VISIT CONTENT

(All evidence grades are per ADA system)

Frequency q 1-2 weeks while establishing control of above parameters, then q 3-6 months

History

Patient concerns

Diet, exercise, and medication adherence

Symptoms of hypo or hyperglycemia

Review home blood glucose records

Intercurrent illness

ROS

Symptoms of complications: chest pain or anginal equivalents, paresthesias or foot ulceration, claudication, urinary symptoms, visual symptoms.

Physical

Weight (assess gain/loss)

Blood pressure

Targeted exam based on history and ROS

Foot exam for high risk (loss of protective sensation, deformity, prior ulcer, ASPVD, smoker)

Interventions

Address acute issues and patient concerns

Prn review of self-care: diet/exercise therapy, foot care, glucose monitoring, ect.

Regimen modification to meet therapeutic targets as above (BP, lipids, glucose)

Indicated periodic screenings for complications

Indicated referrals

Periodic Monitoring and Screening for Complications (add diabetic modifier in HM in EPIC)

HbA1c q 3-6 months (grade E)

Home glucose monitoring: GDM and type 1 > 3/day, type 2 adequate to reach goals

Annual spot urine for microalbuminuria (grade E, no trials showing less nephropathy)

Annual foot exam and monofilament testing for protective sensation (grade B)

Foot exam q visit if high risk (grade E)

Lipids annually and as needed to optimize therapy (grade E)

Baseline EKG

Baseline BUN/creatinine and as indicated

Prevention

Annual flu vaccine (grade C)

Pneumovax, repeat at age 65 if > 5 years since first dose (grade C)

Smoking cessation advice (grade A)

Cessation counseling/treatments (grade B)

Aspirin 75-325 mg/ day

All adults with macrovascular disease (grade A)

Consider for adults with one or more additional CV risk factors

Age > 40 (grade A)

Between age 30 and 40 (grade B)

Do not use under age 21 (Reyes syndrome risk) (grade A)

Family planning/preconception counseling for reproductive age women

Referrals

Foot ulcer + high risk foot for multidisciplinary management (grade A)

Diabetic education, self-monitoring instruction at diagnosis and as needed (grade B)

Annual dilated eye exam starting at diagnosis for type 2, 3-5 years post dx for type 1 (B)

GFR < 60 or difficulties with hyperkalemia (Grade B for less cost, delayed dialysis)

Vascular evaluation for claudication (grade C)

Specialty preventive care for high risk feet (grade C)

BP not controlled with 3 drugs (grade E)

MEDICATION AND TREATMENT ALGORITHMS

General

Aspirin as above

ACE for type 1 with/without HTN, micro or macro albuminuria (grade A)

ACE or ARB for type 2 with HTN and microalbuminuria (grade A)

ARB for type 2 with macroalbuminuria, HTN and Cr > 1.5 mg/dl (grade A)

B blocker for history of MI (grade A for reduced mortality)

B blocker, diuretic, or ACE for initial tx of HTN (grade A)

Statins to lower LDL (grade A)

Fibrates to raise HDL, lower LDL (grade B)

Antidiabetic Agents

Medication potency for lowering HbA1c:

Metformin and sulfonylureas ~ 1-1.5%

Metiglinides ~ 1%

Thiazolidinediones and alpha glucosidase inhibitors ~ 0.5-1%

Given these potencies, HbA1c elevations at 9-11% often warrant initial combination therapy, and severe elevations > 11% may warrant initial insulin therapy as control is unlikely with oral meds and absolute insulin insufficiency is highly likely.

Use ABFP monograph for detailed discussion of medications and a suggested treatment algorithm. Link goes to monograph listing, open diabetes pdf file.

http://www.familypractice.com/references/guidesframe.htm

GRADING SYSTEMS

ADA evidence grading system

http://care.diabetesjournals.org/cgi/content-nw/full/26/suppl_1/s33/T1

A. Clear evidence from well-conducted, generalizable randomized controlled trial that are adequately powered or supportive evidence from well-conducted randomized controlled trials that are adequately powered. B. Supportive evidence from well-conducted cohort studies or case-control studies. C. Supportive evidence from poorly controlled or uncontrolled studies, or weight of conflicting evidence supporting the recommendation. E. Expert consensus or clinical experience.USPSTF evidence grading system http://www.ahcpr.gov/clinic/ajpmsuppl/harris3.htm

A. Strongly recommend. Good evidence the service improves important health outcomes and that benefits substantially outweigh harms. B. Recommend. At least fair evidence that the service improves important health outcomes and that benefits outweigh harms. C. No recommendation for or against. At least fair evidence that the service can improve health outcomes, but the balance of benefits and harms is too close to justify a general recommendation. D. Recommend against. At least fair evidence that the service is ineffective or that harms outweigh benefits. I. Insufficient evidence to recommend for or against. Evidence is lacking, conflicting, or poor quality.

WEB LINKSADA Guides (updates yearly)

http://care.diabetesjournals.org/content/vol26/suppl_1/

ABFP Guides (updates q 2 years) http://www.familypractice.com/references/guidesframe.htm

USPSTF (2003 screening) http://www.ahcpr.gov/clinic/uspstf/uspsdiab.htm