Concise Update to Managing Adult Diabetes. (Featured CME Topic: Diabetes Mellitus).
THE PREVALENCE of type 2 diabetes type 2 diabetes
See diabetes mellitus. and obesity has reached epidemic proportions in the United States. (1) Diabetes is the seventh leading cause of death and accounts for approximately 15% of health care expenditures in the United States. While the prevalence of diabetes has been estimated at 6%, in many populations, such as veterans, the elderly, and minorities, the prevalence is considerably higher and has disproportionately severe consequences to both the patient and health care resources. Cardiovascular disease Cardiovascular disease
Disease that affects the heart and blood vessels.
Mentioned in: Lipoproteins Test
cardiovascular disease accounts for 75% to 80% of the mortality in diabetic patients. In the United Kingdom Prospective Diabetes Study, (2) a 14% reduction in myocardial infarction myocardial infarction: see under infarction. was linked to every 1% reduction in hemoglobin [A.sub.1c] ([HbA.sub.1c]) level. In the same study, no increase in cardiovascular disease resulted from intensive insulin use, despite previous data implicating im·pli·cate
tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates
1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.
2. hyperinsulinemia as a cardiovascular risk factor. (3) It is clear that early intervention ear·ly intervention
n. Abbr. EI
A process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay. with insulin is justified to achieve better diabe tic control. Uncontrolled blood sugar remains perhaps the most underrated cardiovascular risk factor; moreover, glucose intolerance is a significant risk factor for cardiac disease. The screening criteria for type 2 diabetes should help to detect a large number of undiagnosed type 2 diabetic patients (see Selected Guidelines, page 35).
The history and physical examination remain essential to the management of diabetes and are summarized in Table 1. The initial visit of a diabetic patient allows the primary care provider to discuss the concerns and wishes of the patient in the context of achieving good diabetic control. In rare instances, the patient may decline intensive treatment despite information regarding the consequences of protracted pro·tract
tr.v. pro·tract·ed, pro·tract·ing, pro·tracts
1. To draw out or lengthen in time; prolong: disputants who needlessly protracted the negotiations.
2. hyperglycemia hyperglycemia: see diabetes. ; moreover, the presence of disabling hypoglycemia hypoglycemia: see diabetes.
Below-normal levels of blood glucose, quickly reversed by administration of oral or intravenous glucose. Even brief episodes can produce severe brain dysfunction. with lack of hypoglycemic hypoglycemic /hy·po·gly·ce·mic/ (-gli-sem´ik)
1. pertaining to, characterized by, or causing hypoglycemia.
2. an agent that lowers blood glucose levels. awareness may prevent intensive control of blood sugar. Laboratory testing is an integral part of the initial evaluation. A list of desired laboratory tests is shown with ideal values in Table 2.
Avoidance of diabetic complications with excellent blood sugar control and minimal hypoglycemia is the desired goal in diabetes management. This process needs to be individualized and is dependent upon active patient participation. Documenting an individualized plan and the level of patient participation expected is a helpful addition to the patient's chart. A copy of such a document signed by the patient and physician may enhance communication and facilitate better outcomes.
ACHIEVING AN OPTIMAL [HBA.sub.1c] LEVEL
The importance of achieving an excellent glycosylated hemoglobin [A.sub.1c] level has now become widely recognized. Studies in both type 1 and type 2 diabetic patients confirm the benefits of tight blood sugar control. While optimal control has been defined as an [HbA.sub.1c] level <7%, more recently this value has been lowered to <6.5% by the American Association of Clinical Endocrinologists. In many cases, access to a multidisciplinary team specializing in diabetes care is needed to achieve this level of blood sugar control. The need for continuing patient participation and education is recognized as essential for achieving optimal glucose control.
Diet remains a cornerstone in the management of all diabetic patients. The goal of nutritional intervention is to assist in achieving desired glucose and lipid values. These goals are achieved by regulating daily intake with consistent carbohydrate intake and promoting healthy eating habits. In our experience, teaching the patient to count carbohydrates forms the basis for successful dietary intervention in diabetes. This method of counting carbohydrates makes the assumption that carbohydrates are the major influence on blood sugar levels; it therefore focuses on carbohydrate intake when planning a meal. It also assumes that all carbohydrates have a similar effect on blood sugar levels. A summary of the guidelines for diet is given in Table 3.
Exercise can reduce cardiovascular risk, enhance well-being, and increase endurance while assisting with weight reduction. The risks of exercise include hypoglycemia, cardiac events, vitreous vitreous /vit·re·ous/ (vit´re-us)
1. glasslike or hyaline.
2. vitreous body.
primary persistent hyperplastic vitreous hemorrhage, and soft tissue injuries. The blood sugar profile may worsen with exercise if initial glycemic Glycemic
The presence of glucose in the blood.
Mentioned in: Cholesterol, High
pertaining to the level of glucose in the blood. control is poor. The guideline for exercise in patients with diabetes is given in Table 4. The importance of diet and exercise is underscored by recent data indicating that diabetes may be prevented by regular exercise and dietary modification. (4)
The use of drugs to aid weight loss in the management of diabetes has been of recent interest. The use of sibutramine sibutramine /si·bu·tra·mine/ (si-bu´trah-men?) an anorectic used as the hydrochloride salt in the management of obesity.
n. (Meridia) has resulted in significant metabolic benefit in type 2 diabetes Mellitus Type 2 diabetes mellitus
One of the two major types of diabetes mellitus, characterized by late age of onset (30 years or older), insulin resistance, high levels of blood sugar, and little or no need for supple-mental insulin. . (5) A similar outcome may be expected with the use of orlistat (Xenical), and these studies are pending.
Any diabetic patient with symptoms of hyperglycemia and/or persistent blood sugar levels of >300 mg/dL should initially be started on insulin. A persistently high blood sugar level is toxic to the beta cells and may contribute to peripheral insulin resistance. The usual daily starting dose for insulin is 0.5 to 1.0 unit per kilogram of body weight. Once the glycemic profile has improved with symptom relief, a transition to oral antidiabetic medication can be considered in appropriate type 2 patients. Patients with less severe hyperglycemia despite diet and exercise are normally started on oral antidiabetic agents. A wide range of oral agents for treating diabetes is now available. A guideline for initial use of oral hypoglycemic agents is shown in Figure 1.
Monotherapy may not be sufficient to achieve optimal diabetic control, and the addition of a second oral agent is often helpful. Useful oral dual-agent combinations are given in Figure 2. In some situations, a third oral agent may enhance glycemic control. Cost and patient compliance issues need to be considered before triple-agent antidiabetic therapy is begun.
Failure to achieve glycemic control with oral agents is an indication for insulin. In many cases, the addition of a bedtime injection of NPH insulin is sufficient to improve glycemic control. The approximate initial dose of bedtime NPH insulin can be calculated as 25% of patient weight in kilograms (eg, a 100 kilogram patient will receive 25 units of NPH NPH
isophane insulin suspension (NPH) and insulin injection (regular)
Humulin 50/50 (50% isophane insulin and 50% insulin injection), Humulin 70/30 (70% isophane insulin and 30% insulin injection), Humulin 70/30 PenFill, at bedtime).
Progressive deterioration of beta cell function may require multiple insulin injections. In many instances when insulin is added the use of sulfonylureas and/or meglitinides can be discontinued. Insulin-sensitizing agents should be continued, however, and may enable the dose of insulin required for glycemic control to be minimized. Traditionally, most physicians have focused on preprandial preprandial
before meals. or fasting hyperglycemia in the quest for optimizing glycemic control. Newer information indicates that postprandial postprandial /post·pran·di·al/ (-pran´de-al) occurring after a meal.
Following a meal, especially dinner. hyperglycemia may also need intensive intervention. (6) In some patients, failure to achieve adequate [HbA.sub.lc] levels despite a good fasting blood sugar profile may indicate pronounced postprandial hyperglycemia. In these situations, agents that target postprandial blood sugar levels such as the meglitinides, [alpha]-glucosidase inhibitors, and rapid-acting insulin (Novolog and Humalog) may be considered. A value of less than 140 to 160 mg/dL in the postprandial period may be optimal but difficult to achi eve. Figure 3 provides an outline of the insulin regimens used in the treatment of diabetes based on the desired glucose goals.
The newer insulin glargine (Lantus) provides a 24-hour basal insulin requirement and may be associated with less nocturnal hypoglycemia. (7) Early results indicate good success combining glargine with a rapid-acting insulin (Humalog /Novolog) to cover meal-related blood sugar excursions. The basal coverage provided by insulin glargine and postprandial coverage with rapid-acting insulin is similar to the concept of the insulin pump. The rapid-acting insulin can also be used for supplemental insulin requirements via a sliding scale.
ACHIEVING OPTIMAL LIPID PARAMETERS
The death rate from myocardial infarction in diabetic patients is similar to the death rate in nondiabetic patients with preexisting pre·ex·ist or pre-ex·ist
v. pre·ex·ist·ed, pre·ex·ist·ing, pre·ex·ists
To exist before (something); precede: Dinosaurs preexisted humans.
v.intr. cardiac disease; thus, the presence of diabetes can be considered risk equivalent to established coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. . (8) An intensive effort to achieve the desired goals for lipid parameters (Table 3) is mandatory. It is important to note that lipid lowering is as effective (and possibly more effective) in reducing coronary artery disease in diabetic patients as it is in nondiabetic patients. Postprandial hyperlipidemia hyperlipidemia /hy·per·lip·id·emia/ (-lip?i-de´me-ah) elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc. may also contribute to the increased atherogenic ath·er·o·gen·ic
Initiating, increasing, or accelerating atherogenesis.
atherogenic adjective Referring to the ability to initiate or accelerate atherogenesis—the deposition of atheromas, lipids, and risk in diabetes. (9) Statin stat·in
Any of a class of drugs that inhibit a key enzyme involved in the synthesis of cholesterol and promote receptor binding of LDL cholesterol, resulting in decreased levels of serum cholesterol. therapy may be combined with fibric acid derivatives or niacin niacin: see coenzyme; vitamin.
or nicotinic acid or vitamin B3
Water-soluble vitamin of the vitamin B complex, essential to growth and health in animals, including humans. for optimal lipid levels. Statins Statins
A class of drugs commonly used to lower LDL cholesterol levels.
Mentioned in: C-Reactive Protein appear to be interesting agents, with potential promise in reducing the prevalence of diabetes in addition to their cardioprotective effects. The latter may include benefits in the setting of acute coronary ischemia.
Treatment with nicotinic acid should be considered in diabetic patients, especially if they have a combined hyperlipidemia and a good [HbA.sub.lc] level (ie, <7%). (10) Nicotinic acid is a potent agent for raising high-density lipoprotein (HDL (Hardware Description Language) A language used to describe the functions of an electronic circuit for documentation, simulation or logic synthesis (or all three). Although many proprietary HDLs have been developed, Verilog and VHDL are the major standards. ) levels and any potential effect on glucose tolerance can be monitored by close supervision of glucose levels and [HbA.sub.lc] levels. The addition of omega-3 fatty acids This is a list of omega-3 fatty acids.
Common name Lipid name Chemical name
α-Linolenic acid (ALA) 18:3 (n-3) octadeca-9,12,15-trienoic acid
Stearidonic acid 18:4 (n-3) octadeca-6,9,12,15-tetraenoic acid (1,000 to 3,000 mg daily) in the form of fish oil or flaxseed oil may also be beneficial in reducing elevated triglyceride levels. (11) Additional benefits of omega-3 fatty acids may include reduced coronary events (12) and reduced mortality, though further studies are needed.
ACHIEVING OPTIMAL BLOOD PRESSURE READINGS
Inadequately controlled blood pressure remains a frequent problem in many outpatient clinics. The target blood pressure goal should be less than 130/80 mm Hg. A blood pressure level lower than this, such as 120/80 mm Hg, may be desirable in selected patients. Although the evidence is less convincing in older people, reduction of blood pressure to similar levels in older diabetic hypertensive hypertensive /hy·per·ten·sive/ (-ten´siv)
1. characterized by increased tension or pressure.
2. an agent that causes hypertension.
3. a person with hypertension. patients may be desirable if the medication is tolerated. In a recent study of diabetic patients, (2) a modest reduction in systolic blood pressure Systolic blood pressure
Blood pressure when the heart contracts (beats).
Mentioned in: Hypertension on the order of 10 to 15 mm Hg was associated with a 10% to 15% reduction in death, myocardial infarction, and microvascular complications. A progressive reduction in cardiovascular events with concurrent reduction in diastolic blood pressure Diastolic blood pressure
Blood pressure when the heart is resting between beats.
Mentioned in: Hypertension was also noted. (13)
The choice of antihypertensive antihypertensive /an·ti·hy·per·ten·sive/ (-ten´siv) counteracting high blood pressure, or an agent that does this.
Reducing high blood pressure.
n. agents in diabetes has been widely discussed. Angiotensin-converting enzyme inhibitors Angiotensin-Converting Enzyme Inhibitors Definition
Angiotensin-converting enzyme inhibitors (also called ACE inhibitors) are medicines that block the conversion of the chemical angiotensin I to a substance that increases salt and water retention in the remain agents of choice for hypertension and / or the presence of microalbuminuria / proteinuria proteinuria /pro·tein·uria/ (-ur´e-ah) an excess of serum proteins in the urine, as in renal disease or after strenuous exercise.proteinu´ric
1. . New information also indicates that they can offer benefits in diabetic patients in the context of acute coronary ischemia. (14) The Heart Outcomes Prevention Evaluation (HOPE) study (15) indicated a 25% reduction of cardiovascular death, stroke, and myocardial infarction in high-risk patients given ramipril. The beneficial effects of ramipril were demonstrable even after adjusting for blood pressure effects.
PREVENTIVE MEASURES AND OUTCOMES
Diabetic patients are generally considered hypercoagulable and an aspirin a day (81 to 325 mg/day) is recommended for patients older than 30 years of age. Flu vaccinations, pneumococcal pneumococcal /pneu·mo·coc·cal/ (-kok´al) pertaining to or caused by pneumococci. vaccinations, and smoking cessation programs should be offered to diabetic patients. Recent information suggests that these simple measures are relatively underutilized.
The best outcome in terms of diabetes management will result from a concerted team effort to achieve and maintain the desired blood sugar levels, lipid parameters, and blood pressure levels in diabetic patients. Failure to achieve desired objectives is an indication for an appropriate subspecialty subspecialty,
n a limited portion of a narrowly defined professional discipline. E.g., surgery is a specialty of medicine and pediatric vascular surgery is a subspecialty. consultation.
Many advances such as nasal insulin, insulin analogues, new glucose sensors (transcutaneous transcutaneous /trans·cu·ta·ne·ous/ (-ku-ta´ne-us) transdermal.
Transdermal. as well as implantable) and islet cell transplantation Islet transplantation is the transplantation of isolated islets from a donor pancreas and into another person. It is an experimental treatment for type 1 diabetes mellitus. offer potential significant quality of life improvements to the diabetic patient. Newer medications and new uses of existing medications (such as thiazolidinediones being used for their beneficial endothelial endothelial /en·do·the·li·al/ (-the´le-al) pertaining to or made up of endothelium.
A layer of cells that lines the inside of certain body cavities, for example, blood vessels. effects) may offer enhanced cardioprotection to diabetic patients.
(1.) Mokdad AH, Bowman BA, Ford ES, et al: The continuing epidemics of obesity and diabetes in the United States. JAMA JAMA
Journal of the American Medical Association 2001;286:1195-2000
(2.) Adler AI, Stratton IM, Neil HA, et al: Association of systolic blood pressure with macrovascular and microvascular cmplications of type 2 diabetes (UKPDS UKPDS UK Prospective Diabetes Study 35): prospective observational study. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift 2000; 321:412-419
(3.) Stratton IM, Adler AI, Neil HA, et al: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321:405-412
(4.) Fruchter O: Prevention of type 2 diabetes mellitus by changes in lifestyle. N Engl J Med 2001; 345:696-697
(5.) Gokcel A, Karakose H, Ertorer EM, et al: Effects of sibutramine in obese female subjects with type 2 diabetes and poor blood glucose control. Diabetes Care 2001; 24:1957-1960
(6.) Bell DS: Importance of postprandial glucose control. South Med J 2001; 94:804-809
(7.) Rosenstock J, Schwartz SL, Clark CM Jr, et al: Basal insulin therapy in type 2 diabetes: 28-week comparison of insulin glargine (HOE 901) and NPH insulin. Diabetes Care 2001; 24:631-636
(8.) LaRosa JC: Prevention and treatment of coronary heart disease coronary heart disease: see coronary artery disease.
coronary heart disease
or ischemic heart disease
Progressive reduction of blood supply to the heart muscle due to narrowing or blocking of a coronary artery (see atherosclerosis). : who benefits? Circulation 2001; 104:1688-1692
(9.) Ginsberg HN, Illingworth DR: Postprandial dyslipidemia: an atherogenic disorder common in patients with diabetes mellitus. Am J Cardiol 2001; 88:9H-15H
(10.) Elam MB, Hunninghake DB, Davis KB, et al: Effect of niacin on lipid and lipoprotein lipoprotein (lĭp'əprō`tēn), any organic compound that is composed of both protein and the various fatty substances classed as lipids, including fatty acids and steroids such as cholesterol. levels and glycemic control in patients with diabetes and peripheral arterial disease: the ADMIT study: a randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. trial. Arterial Disease Multiple Intervention Trial. JAMA 2000; 284:1263-1270
(11.) Sirtori CR, Crepaldi G, Manzato E, et al: One-year treatment with ethyl ethyl (ĕth`əl), CH3CH2, organic free radical or alkyl group derived from ethane by removing one hydrogen atom. esters of n-3 fatty acids in patients with hypertriglyceridemia and glucose intolerance: reduced triglyceridemia, total cholesterol, and increased HDL-C HDL-C high-density-lipoprotein cholesterol. without glycemic alterations. Atherosclerosis 1998; 137:419-427
(12.) Harris WS, Isley WL: Clinical trial evidence for the cardio-protective effects of omega-3 fatty acids. Curr Atheroscler Rep 2001; 3:174-179
(13.) Elliott WJ: Intensive antihypertensive treatment to the new lower blood pressure targets. Curr Hypertens Rep 1999; 1:313-319
(14.) Zuanetti C, Latini R, Maggioni AP, et al: Effect of the ACE inhibitor lisinopril on mortality in diabetic patients with acute myocardial infarction acute myocardial infarction (·kyōōtˑ mī·ō·karˑ·dē· : data from the GISSI-3 study. Circulation 1997; 96:4239-4245
(15.) Yusuf S, Sleight P, Pogue J, et al: Effects of an angiotensinconverting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342:145-153
TABLE 1. History and Physical Diagnosis History 1. Presenting symptoms; evidence of hypoglycemia or hyperglycemia 2. Previous laboratory evaluations and results pertaining to diagnosis of diabetes 3. Record of previous [HbA.sub.1c] evaluations 4. Previous treatment programs; dietary history and evaluation of diabetic education and level of understanding 5. Active diabetic treatment; drugs, dietary measures, monitoring, and integration of information with self-care by patient 6. Exercise history 7. History of acute diabetic complications; frequency and precipitants (to include evaluation of patient, family, and caregiver response) 8. History of foot, skin, dental, and genitourinary infections 9. Evaluation of chronic complications of diabetes, eg, ophthalmologic, podiatric, neurologic, and cardiac 10. Evaluation of patient's medications that impact diabetic control 11. Evaluation for risk factors of atherosclerosis 12. Family history of diabetes 13. Gestational diabetes and history of macrosomia, polyhydramnios, and still-births 14. Assessment of sociocultural factors with an influence on diabetic management, eg, education level 15. Use of alcohol and tobacco 16. Comorbid conditions 17. Family history and ethnicity Physical Examination: 1. Height, weight, and body habitus 2. Attainment of developmental milestones (in children and adolescents) 3. Determination of blood pressure (including orthostatic measurements) 4. Fundoscopic evaluation (under dilatation) 5. Oropharyngeal examination under direct visiualization 6. Thyroid palpation 7. Cardiovascular system evaluation (to include evaluation for peripheral circulation and assessment for abdominal bruits) 8. Abdominal examination (eg, for hepatomegaly) 9. Evaluation of extremities for adequacy of circulation, signs of infection , and morphology of joints 10. Skin; injection sites, pigmentation, body hair patterns, and striae 11. Neurologic assessment 12. Hand and foot examination Adapted from Diabetes Care 2001; 24 (suppl 1) TABLE 2. Laboratory Testing Test Ideal Value [HbA.sub.1c] <7% (*) Triglycerides <200 mg/dL LDL cholesterol <100 mg/dL Fasting blood glucose <120 mg/dL Bedtime glucose <140 mg/dL Urine microalbumin (+) Negative Urine protein Negative Liver function (**) Normal (*)<6.5% per American Associationof Clinical Endocrinology (+)May be screened with albumin/creatinine ratio, normal <30, or assessed with a timed urine collecton (**)The possibility of hepatic steatosis and potential use of oral agents influenced by liver dysfunction make a liver panel desirable in type 2 diabetes. TABLE 3. Prescribing a Diet for the Diabetic Patient 1. Determine the ideal body weight 2. Calculate basal calorie ingestion (can be approximately 30 cal/kg) 3. Determine desired daily calorie intake based on ideal body weight, physical activity, and lifestyle (individualize calorie needs) 4. Recommended daily amount: Carbohydrate 55%-60% of total calories Protein 15%-20% of total calories Fat <30% of total calories Cholesterol <300 mg/day Sodium <2,400-3,000 mg/day Fiber 35-40 g/day 5. Carbohydrate calories per day = total calories x % carbohydrate 6. Carbohydrate grams per day = carbohydrate calories/4 calories/g 7. Allocate carbohydrates throughout the day and teach the patient to count carbohydrates (15 grams = 1 carb) Examples of 15 gram carbohydrate portions: 1/2 cup orange juice, 1/2 cup Coca-Cola, 1 cup Gatorade, 1/2 cup cream soup, 3 graham cracker squares, 1/2 cup regular ginger ale TABLE 4. Exercise and Diabetes 1. Screening before exercise * Perform physical evaluation * Assess glycemic control * Consider exercise stress test if patient is at high risk for cardiac disease * Perform retinal and podiatric examinations 2. Recommendations for diabetic patients * Start exercise cautiously and avoid unplanned, spontaneous exercise * Monitor blood glucose before, during, and after exercise, and consume extracarbohydrates for unplanned exercise (20 to 30 grams per 30 mm of exercise) * Exercise 1 to 3 hours after meals and consume extra carbohydrates before strenuous exercise * Reduce insulin dosages by 20% to 30% for planned exercise * Exercise with partners who can assist if needed * Exercise should have a consistent pattern (time of day, relation to meals, etc) * Ensure adequate pre-exercise hydration, appropriate level of warm-up, and adequate cool-down * People with preexisting complications should exercise extra caution 3. Goal * Minimum of 20 to 30 minutes of aerobic activity daily