Type 2 Diabetes – CDA 2013 Guidelines

1 Given a symptomatic or asymptomatic patient at high risk for diabetes (e.g., patients with gestational diabetes, obese, certain ethnic groups, and those with a strong family history), screen at appropriate intervals with the right tests to confirm the diagnosis.

Who to screen

1. All pt >=40yo
2. Earlier if risk factors or at high / very high risk using a risk calculator “CANRISK”

How often & how to screen

• Screen Q3yr using a FPG and/or A1C

---

Risk Factors

1. Age >=40yo
2. 1o relative with DM2
3. Aboriginal, African, Asian, Hispanic, or South Asian descent
4. Hx of prediabetes (IGT, IFG, A1C 6-6.4%)
5. GDM or delivery of a macrosomic infant
6. Presence of end organ damage associated with DM
   • Microvascular – retinopathy, neuropathy, nephropathy
   • Macrovascular – coronary, cerebrovascular, peripheral, ED
7. Presence of vascular risk factors
   • HDL =1.7
   • HTN, overweight, abdominal obesity
8. Presence of associated diseases
   • PCOS, Acanthosis nigricans, OSA
   • psychiatric disorders (bipolar, depression, schizophrenia), HIV
9. Use of drugs associated with DM
   • Glucocorticoids, atypical antipsychotics, antiretroviral Tx
10. Other secondary causes

---

Complications of DM

• Macrovascular: CVD, CVA, PAD, ED
• Microvascular: retinopathy, nephropathy, neuropathy
• infection

---

Dx

• FPG (no caloric intake >8hr) >=7 mmol/L
  • Prediabetes – IFG – 6.1 – 6.9 mmol/L
• A1C >=6.5%
  • Prediabetes 6-6.4%
  • Not used in children, adolescents, pregnant women, suspected type 1 diabetes
  • Affected by hemoglobinopathies, iron deficiency, hemolytic anemia, severe hepatic or renal dz
• 2hPG in a 75g OGTT >=11.1 mmol/L
  • Prediabetes – IGT – 7.8-11.0 mmol/L
• Random PG >=11.1 mmol/L

In the asymptomatic hyperglycemia, a repeat confirmatory laboratory test (FPG, A1C, 2hPG) must be done on another day. Random PG should be confirmed with an alternate test. 

---

3 Given a patient with established diabetes, advise about signs and treatment of hypoglycemia/hyperglycemia during an acute illness or stress (i.e., gastroenteritis, physiologic stress, decreased intake.

Hyperglycemia Symptoms:

• Polyuria, polydipsia, polyphagia, dry mouth, unexplained weight loss
• Blurred visioin, fatigue, itchy skin, parasthesia, arrhythmia, coma

HONK symptoms:

• Kussmaul’s breathing (deep rapid), confusion / ↓LOC, impaired cognitive function
• N/V, Abd pain, dehydration, fruity smelling breath

Hypoglycemia symptoms (PG <4):

• Palpitations, sweating, pallor, clammy, n/v, seizures
• Dilated pupils, blurred vision, numbness, confusion, coma
• Tx with 15g of carbs (3 tsp sugar, 3/4 cup juice, 6 lifesavers), retest in 15min & repeat carbs if PG <4
• Tx with 1mg glucagon sc/IM if severe

Sick Day protocol

• feeling sick or having a fever x few days not getting better
• Vomiting, diarrhea > 6hr
• Tx: Avoid exercise
  • BG Q4h and more often if increasing
  • Check urine or blood for ketones
  • Modify insulin regimen: increase oral dose or insulin dose
  • Maintain adequate food (>50g carb Q3-4h) and fluid
  • If n/v, eat concentrated carbs – soft drink, juice, broth
  • Call MD if glucose >13.3 and remain increase x 24 hr (on oral agents) or despite extra insulin (on insulin)
• ED if positive ketones, constitutional symptoms, ?DKA with glucose >14

---

5 In patients with established diabetes:
a) Look for complications (e.g., proteinuria).
b) Refer them as necessary.

Investigations:

Initial

• EKG if >40yo, DM >15yr, HTN, proteinuria, decrease pulse
• Stress test in high risk CVD before recommending exercise

Q3-6m

• BP (<130/80), A1C (<7%), creatinine if albuminuria

Annual

• Lipid panel, Ref to optometry / ophthalmologist , ACR, monofilament foot exam (also ROM, skin, neuropathy, PAD)

ECG Q2y

Referral:

• ACR>60, eGFR<30
• Persistent hyperkalemia
• >30% increase in Cr within 3mo of starting ACEi / ARB
• Retinopathy / vitreous hemorrhage / macular edema
• ED and PDE5 is contraindicated or no response

---

2 Given a patient diagnosed with diabetes, either new-onset or established, treat and modify treatment according to disease status (e.g., use oral hypoglycemic agents, insulin, diet, and/or lifestyle changes).

Prevention (IGT to DM2)

• Lifestyle modifications (wt loss 5-10% + exercise 150min/week)
• consider Metformin (RRR 30%) or acarbose

Rx

Lifestyle Modifications – monotherapy if A1C <8.5% & try 2-3mo

• Diet: Mediterranean, vegetarian > DASH
  • <7% total energy from saturated fats
  • EtOH 2-3 hr after dinner
• Moderate aerobic exercise 50-70% HR 150min over >3d / week, resistance exercise 3x/week, exercise >4hr/week
• Wt loss 5-10%

Pharmacotherapy

• Symptomatic hyperglycemia at Dx with metabolic decompensation
  • Initiate Insullin +/- metformin
• At Dx if A1C <8.5% – start lifestyle intervention, if not at target in 2-3/12, start/increase metformin
  • A1C >=8.5% – start lifestyle intervention & metformin & consider adding another agent
• If not at glycemic target – add an appropriate agent and make timely adjustment to attain target A1C in 3-6/12
• Flu shot, consider pneumococcal vaccine

---

Target A1C <=7.0%

• 1% ↓ A1C = 21%↓ mortality
• Self-monitoring of BG – ensure pt can use BG meter and has a monitoring schedule
  • FPG or preprandial target of 4-7 mmol/L & a 2hr postprandial target of 5-10 mmol/L
  • If A1C not at target, 2 hr postprandial target to 5-8 mmol/L
  • No routine monitoring if on oral antihyperglycemics & monitoring when not in target w/ pre+postprandials
  • Insulin 1/d – monitor >=1x/d
  • Insulin >1/d – monitor >=3x/d w/ pre+postprandials
• a target A1C <6.5% may be considered to further lower the risk of nephropathy & retinopathy
  • must balance against the risk of hypoglycemia

Target A1C 7.1-8.5% if

1. Limited life expectancy, multiple commorbidities
2. High level of functional dependency
3. Extensive coronary artery disease at high risk of ischemic events
4. Hx of recurrent severe hypoglycemia or hypoglycemia unawareness
5. Longstanding DM – difficult to achemeve A1C target despite intensified basal-bolu insulin therapy

---

Pt characteristics

• Degree of hyperglycemia, risk of hypoglycemia, pt preferences
• Overweight / Obese, Commorbidities (renal, cardiac, hepatic)

Agent characteristics

• BG lowering efficacy & durability, risk of inducing hypoglycemia, cost and coverage
• Effect on weight, contraindications and s/e

---

1. Biguanide – Metformin – 1st line
   • <2550mg/d (Cr 60-90 <1700; Cr 30-60 <850)
2. Alpha-glucosidase inhibitor – Acarbose  ($$)
   • ↓ A1C, rare hypoglycemia, ↓ wt, GI s/e
   • Improve postprandial control
3. Incretin agents: DPP-4 inhibitor – Januvia ($$$) or GLP-1 receptor agonist  ($$$$)
   • ↓↓ A1C, rare hypoglycemia, ↓/↓↓ wt, GI s/e
4. Insulin ($-$$$$)
   • ↓↓↓ A1C, + hypoglycemia, ↑↑ wt
   • no dose ceiling, flexible regimens
5. Insulin Secretagogue: ↓↓ A1C, + hypoglycemia,↑Wt
   • Meglitinide ($$)
     • GlucoNorm– Less hypoglycemia with missed meals but Tid – Qid dosing
   • Sulfonylurea ($)
     • Gliclazide & glimepiride less hypoglycemia than glyburide
6. TZD – Actos ($$)
   • ↓↓ A1C, rare hypoglycemia,↑↑ Wt
   • CHF, edema, fracture, rare bladder ca (pioglitazone), CV controversy (rosiglitazone), 6-12 wk for max effect
7. Wt loss agent ($$$) Orlistat
   • ↓A1C, no hypoglycemia, ↓ Wt, GI s/E
8. Subtype 2 Sodium-glucose transport protein inhibitor (SGLT2)- Invokana

---

4 In a patient with poorly controlled diabetes, use effective educational techniques to advise about the importance of optimal glycemic control through compliance, lifestyle modification, and appropriate follow-up and treatment.

Vascular Protection

• A1C – <=7%
• BP <130/80 mmHg
• Cholesterol LDL <=2.0mmol/L
• Drugs:
  • ACEI/ARB if macrovascular or microvascular dz or age >=55yo
  • Statin if macro/microvascular dz, age >=40yo, DM>15yr & age >30yo
• Exercise – Encourage moderate aerobic (50-70% max HR) 150min/wk & resistance exercise 3x/week – exercise >4hr/wk
• Smoking Cessation – encourage at every visit

---

DM Care visit

• Hx: Ask about hypoglycemia & CAD risk assessment & psychiatric disorder screening & ED screening
• O/E:  BP (<130/80), BMI (18.5-24.9), waist circumference
  • screen retinopathy Q1-2y, foot exam Q1y
• Investigations:
  • A1C q3m (target <=7.0%)
  • compare BG meter to lab results Q1y (within 20%);
  • ACR & eGFR at Dx and Q1y (ACR <2.0mg/mmol & eGFR >60) – CKD screening
  • ECG Q2y, lipid panel Q1y (LDL <=2)
• Encourage: smoking cessation, nutritional Tx,aerobic & resistance exercise
• Ensure: BG monitoring – Preprandial 4-7, Postprandial 5-10
• Flu shots & consider pneumococcal vaccine
• Psychosocial interventions: motivation interventions, stress management, coping skills training, family therapy

---

6 In the acutely ill diabetic patient, diagnose the underlying cause of the illness and investigate for diabetic ketoacidosis and hyperglycemia.

Hx:

• Polyuria, polydipsia
• fatigue, lethargy,
• Coma / decreased LOC (HHS)
• H/A, N/V, Abd pain, decreased appetite

O/E:

• decreased skin turgor, decreased sweat
• Postural HoTN
• Kussmaul breathing (deep rapid)
• Fruity smell breath (DKA)

Dx of DKA:

• BG >14, presence of urine/plasma ketones, pH<7.3, serum bicarbonate <18

Dx of HHS

• Glucose >33 often >55, pH>7.3 and mild to none ketosis
• Profound dehydration

Precipitants:

• Infection
• EtOH misuses
• Psychological stress
• CV events: MI, PE, stroke
• Trauma
• Pregnancy
• Cushing dz
• Acute GI dz: pancreatitis, obstruction
• Medications: corticosteroids, thiazide

Ix:

• Glucose, ketones,
• blood gas (pH),
• lytes, lipase (pancreatitis), Cr/Urea (dehydration),
• CBC, urine + blood Cx (infection),
• CXR (PNA), ECG (potassium, MI)

---

7 Given a patient with diabetic ketoacidosis, manage the problem appropriately and advise about preventing future episodes.

1. Rehydration – NS 1L /hr (severe dehydration) or 500ml/hr (moderate dehydration) & add KCL if K <5.2 + pt urinating
   • K <3.3 – no insulin and give 40mmol KCl/hr
   • K 3.3-5.2 – give 20 mmol KCl /hr
   • K >5.2 – check K q2hr
2. lab work Q2h min
3. Insulin (if K >3.3)
   • Insulin Regular infusion 0.1u/kg/hr
   • Give D5NS if BG<14
4. Resolution if bicarb >15, pH >7.3, anion gap <12, glucose <11.1

Complications:

• Overhydration: Cerebral edema, ARDS
• Electrolytes imbalance: hypoglycemia, hypokalemia, hypophosphatemia
• Vascular occlusions, rhabdomyolysis