DIABETES MANAGEMENT









  • Reference [48]
ADA recommendations for medical evaluation in diabetics
All diabetics
  • Comprehensive physical exam and medical history - initial and annually
  • Labs - initial and annually
    • Hemoglobin A1C, if results not available in past 3 months
    • Lipid Profile
    • Liver function tests
    • Spot urine albumin-to-creatinine ratio
    • Serum creatinine with calculated GFR
    • Vitamin B12 - when indicated if taking metformin
    • Serum potassium - if taking ACE, ARB, or diuretic
  • Referrals
    • Dilated eye exam - see eye exam recommendations below
    • Family planning for women of reproductive age
    • Registered dietician for dietary counseling
    • Diabetes self-management education
    • Dental exam
    • Mental health professional, if needed [48]
Type 1 diabetics
  • Adults
    • Thyroid Stimulating Hormone (TSH)
    • Celiac disease screening
  • Children
    • Check a TSH at diagnosis and every 1 - 2 years thereafter. Consider testing for antithyroid peroxidase and antithyroglobulin antibodies soon after diagnosis.
    • Screen children with type 1 diabetes for celiac disease by measuring IgA tissue transglutaminase (tTG) antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes, or IgG to tTG and deamidated gliadin antibodies if IgA deficient. Repeat screening within 2 years of diabetes diagnosis and then again after 5 years and as indicated (see celiac disease for more).[48]












  • Reference [48]
ADA Blood Sugar Goals for Adults
Blood sugar goals
  • Preprandial (before meal): 80 - 130 mg/dl
  • Peak post-meal blood sugar (within 1 - 2 hours after the start of a meal): < 180 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 70 - 100 mg/dl
  • The ADA does not give specific goals for fasting blood sugars, but 70 - 100 mg/dl is typically considered a normal range
A1C goals
  • Less stringent: < 8.0%
    • Appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin.
  • Most diabetics: < 7%
  • More stringent: < 6.5%
    • If this can be achieved without significant hypoglycemia or other adverse effects of treatment (i.e., polypharmacy). Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease.

  • Reference [48]
ADA Blood Sugar Goals for Youth with Type 1 DM
Blood sugar goals
  • Preprandial (before meal): 90 - 130 mg/dl
  • Bedtime: 90 - 150 mg/dl
A1C goals
  • Least stringent: < 8.0%
    • May be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, or extensive comorbid conditions
  • Less stringent: < 7.5%
    • May be appropriate for patients who cannot articulate symptoms of hypoglycemia; have hypoglycemia unawareness; lack access to analog insulins, advanced insulin delivery technology, and/or continuous glucose monitors; cannot check blood glucose regularly; or have nonglycemic factors that increase A1C (e.g., high glycators).
  • Most youth: < 7.0%
  • More stringent: < 6.5%
    • For selected individual patients if they can be achieved without significant hypoglycemia, negative impacts on well-being, or undue burden of care, or in those who have nonglycemic factors that decrease A1C (e.g., lower erythrocyte life span). Lower targets may also be appropriate during the honeymoon phase.

  • Reference [48]
ADA Blood Sugar Goals for Youth with Type 2 DM
Blood sugar goals
  • Preprandial (before meal): 80 - 130 mg/dl
  • Peak post-meal blood sugar (within 1 - 2 hours after the start of a meal): < 180 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 70 - 100 mg/dl
  • The ADA does not give specific blood sugar goals for youth patients with T2DM, but they can be assumed to be similar to that of most adults
A1C goals
  • Most youth: < 7%
  • More stringent: < 6.5%
    • May be appropriate for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes and lesser degrees of b-cell dysfunction and patients treated with lifestyle or metformin only who achieve significant weight improvement.

  • ADL - Activities of daily living | LTC - Long-term care
  • Reference [48]
ADA Blood Sugar Goals for Elderly
Healthy (few coexisting chronic illnesses, intact cognitive and functional status)
  • A1C goal: < 7.5%
  • Preprandial (before meal): 90 - 130 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 90 - 130 mg/dl
  • Bedtime: 90 - 150 mg/dl
Complex / intermediate (multiple coexisting chronic illnesses or 21 instrumental ADL impairments or mild-to-moderate cognitive impairment)
  • A1C goal: < 8.0%
  • Preprandial (before meal): 90 - 150 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 90 - 150 mg/dl
  • Bedtime: 100 - 180 mg/dl
Very complex / poor health (LTC or end-stage chronic illnesses or moderate-to-severe cognitive impairment or 21 ADL dependencies)
  • A1C goal: < 8.5%
  • Preprandial (before meal): 100 - 180 mg/dl
  • Fasting blood sugar (after 8 hours of no calorie consumption): 100 - 180 mg/dl
  • Bedtime: 110 - 200 mg/dl


  • I = Intensive therapy group was significantly better | S = Standard therapy group was significantly better | NS = No significant difference between groups
  • Values represent average A1C acheived in each group during the trial
  • Average length of time subjects had been diagnosed with diabetes upon enrollment: UKPDS < 1 year; ACCORD 10 years; ADVANCE 8 years; VADT 12 years [3]
  • Kidney disease defined as incidence of proteinuria. For kidney failure, there was no significant difference between intensive and standard therapy in any of the trials. [4]
Effect of Intensive vs Standard Therapy on Outcomes in T2DM
Trial
(trial length)
Intensive A1C Standard A1C Overall mortality Heart disease Eye disease Kidney disease Neuropathy
UKPDS
(11 yrs)
7.0 7.9 NS NS I I I
ACCORD
(3.5 yrs)
6.4 7.5 S S I I I
ADVANCE
(5 yrs)
6.4 7.0 NS NS NS I NS
VADT
(5.6 yrs)
6.9 8.5 NS NS NS I NS







  • Reference [36]
A1C conversion table
A1C values (%) Average blood sugar (mg/dl)
5 97
6 126
7 154
8 183
9 212
10 240
11 269
12 298
13 326
14 355
15 384

























  • Reference [43]
Features of distal symmetric polyneuropathy (DSPN)
Small nerve fibers
Function
  • Pain sensation (nociception)
  • Hot/cold sensation
Symptoms
  • Pain, burning, electric shocks, tingling
  • Exaggerated response to painful stimuli (hyperalgesia)
  • Pain from minimal contact (e.g. socks, shoes, bed sheets) (allodynia)
  • Pain is typically worse at night
Exam findings
  • Loss of thermal discrimination (hot/cold)
  • Loss of pinprick sensation
  • Hyperalgesia
Large nerve fibers
Function
  • Pressure
  • Balance and position sense (proprioception)
Symptoms
  • Numbness
  • Tingling
  • Poor balance
Exam findings
  • Loss of ankle reflexes
  • Loss of sense of vibration
  • Loss of proprioception
  • Loss of light touch sensation (10-g monofilament)


  • Reference [43]
System Symptoms
Cardiovascular
  • Resting tachycardia
  • Orthostatic hypotension
  • Abnormal blood pressure regulation
  • Hypoglycemia unawareness
Gastrointestinal
  • Gastroparesis
  • Esophageal dysfunction (dysphagia, GERD)
  • Diarrhea and constipation
  • Fecal incontinence
  • Hypoglycemia unawareness
Urogenital
  • Bladder dysfunction (incontinence, frequency, etc.)
  • Erectile dysfunction
  • Female sexual dysfunction
Sudomotor (sweat glands)
  • Gustatory sweating (face and neck sweating when eating)
  • Dry skin
  • Hypoglycemia unawareness


  • Dosing recommendations are from the ADA
  • Reference [43,48]
FDA-approved therapies for DM neuropathy
Drug Dosing Other
Pregabalin (Lyrica®)
  • Starting: 25 - 75 mg one to three times a day
  • Effective: 300 - 600 mg a day
  • FDA-approved for diabetic peripheral neuropathy
  • Preferred first-line agent by ADA
  • See pregabalin for more
Duloxetine (Cymbalta®)
  • Starting: 20 - 30 mg once daily
  • Effective: 60 - 120 mg/day
  • May be given in one or two divided doses
  • FDA-approved for diabetic peripheral neuropathy
  • Preferred first-line agent by ADA
  • See duloxetine for more
Other therapies (non FDA-approved)
Gabapentin (Neurontin®)
  • Starting: 100 - 300 mg one to three times a day
  • Target: 900 - 3600 mg/day
  • Efficacy has been mixed in clinical trials
  • Preferred first-line agent by ADA
  • See gabapentin for more
Venlafaxine (Effexor XR®)
  • Starting: 37.5 mg once daily
  • Target: 75 - 225 mg/day
  • Has shown some effectiveness in clinical trials
  • See venlafaxine for more
Amitriptyline (Elavil®)
  • Starting: 10 - 25 mg once daily
  • Target: 25 - 100 mg/day
  • Has shown some effectiveness in small trials
  • See amitriptyline for more







ACCORD Study - Intensive vs Standard Blood Pressure Control in T2DM, NEJM (2010) [PubMed abstract]
  • The ACCORD study enrolled 4733 type 2 diabetics with an average SBP of 139 mmHg
Main inclusion criteria
  • SBP 130 - 180
  • Type 2 diabetes
  • HgA1C 7.5% - 11%
  • Documented CVD or risk factors for CVD
Main exclusion criteria
  • BMI ≥ 45
  • Serum creatinine > 1.5 mg/dl
  • Significant liver disease
  • Cardiovascular event within last 3 months
Baseline characteristics:
  • Average age 62 years
  • Previous cardiovascular event - 34%
  • Average BMI - 32
  • Average BP - 139/76
  • Median duration of diabetes - 10 years
  • Average HgA1C - 8.3%
  • Average LDL - 110 mg/dl
  • Average GFR - 92 ml/min
Randomized treatment groups
  • Group 1 (2362 patients) - Target SBP < 120 mmHg (intensive therapy)
  • Group 2 (2371 patients) - Target SBP < 140 mmHg (standard therapy)
  • Blood pressure medications used were ACE/ARBs, thiazide diuretics, beta blockers, calcium channel blockers, reserpine, and/or alpha blockers
  • No specific treatment regimen or drug was required
Primary outcome: Composite of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes
Results

Duration: Average of 4.7 years
Outcome Intensive Standard Comparisons
Average BP at 1 year (mmHg) 119/64 133/71 p<0.05
Primary outcome (%/year) 1.87% 2.09% HR 0.88, 95%CI [0.73 - 1.06], p=0.20
Overall mortality (%/year) 1.28% 1.19% HR 1.07, 95%CI [0.85 - 1.35], p=0.55
Stroke (%/year) 0.32% 0.53% HR 0.59, 95%CI [0.39 - 0.89], p=0.01
Nonfatal myocardial infarction (%/year) 1.13% 1.28% HR 0.87, 95%CI [0.68 - 1.10], p=0.25
Hypokalemia (< 3.2 mEq/L) 2.1% 1.1% p=0.01
Estimated GFR < 30 ml/min 4.2% 2.2% p<0.001
Macroalbuminuria 6.6% 8.7% p=0.009
Average # of BP meds after first year 3.4 2.1 N/A

Findings: In patients with type 2 diabetes at high risk for cardiovascular events, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, did not reduce the rate of a composite outcome of fatal and nonfatal major cardiovascular events

  • Reference [48]
ADA Blood Pressure Recommendations for Adults with Diabetes
Blood pressure goals
  • Diabetics at lower risk of CVD: < 140/90 mmHg
  • Diabetics at higher risk of CVD: < 130/80 mmHg
    • Higher risk defined as existing CVD or 10-year atherosclerotic CVD risk > 15% (AHA risk estimator)
Blood pressure medications
  • If BP is ≥ 160/100 mmHg, a two-drug regimen may be initiated
  • Drugs of choice include ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers
  • Do not combine ACE inhibitors, ARBs, and/or direct renin inhibitors
  • ACE or ARB is indicated in patients with urinary albumin-to-creatinine ratio ≥ 30 mg/g
  • Patients with resistant hypertension should be be considered for mineralocorticoid receptor antagonist therapy [48]
Other guidelines

  • Reference [48]
ADA Blood Pressure Recommendations for Youth with Diabetes
Blood pressure goals
  • < 13 years old: SBP and DBP < 90th percentile for age, sex, and height
  • ≥ 13 years old: SBP < 120 mmHg | DBP < 80 mmHg
  • Elevated BP should be confirmed on 3 separate days
Blood pressure treatment
  • < 13 years old
    • BP > 90th percentile but < 95th percentile: Initial treatment should be diet and exercise for 3 - 6 months. If goal BP is not achieved, medications should be considered.
    • BP ≥ 95th percentile: Treat with diet and weight loss and consider medication. ACE inhibitors and ARBs are preferred, but their potential for teratogenic effects should be considered with females.
  • ≥ 13 years old
    • SBP 120 - 139 mmHg | DBP 80 - 89 mmHg: Initial treatment should be diet and exercise for 3 - 6 months. If goal BP is not achieved, medications should be considered.
    • SBP ≥ 140 mmHg | DBP ≥ 90 mmHg: Treat with diet and weight loss and consider medication. ACE inhibitors and ARBs are preferred, but their potential for teratogenic effects should be considered with females.

















  • Reference [48]
ADA Classification of Hypoglycemia
Level Blood sugar (mg/dl)
I 54 - 69
II < 54
III A severe event characterized by altered mental and/or physical status requiring assistance




  • Intranasal dose was 3 mg. Intramuscular dose was 1 mg in deltoid muscle.
  • Average blood sugar when glucagon was administered was 55 mg/dl
  • Reference [49]
Average rise in plasma glucose (mg/dl) in type 1 diabetic adults after glucagon administration
Drug 15 minutes 30 minutes 45 minutes 60 minutes
Glucagon intranasal 20 58 79 100
Glucagon intramuscular 29 71 92 113





  • Reference [48]
ADA recommendations for daily aspirin in diabetes
Primary prevention
  • Aspirin therapy (75 – 162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a discussion with the patient on the benefits versus increased risk of bleeding
Secondary prevention
  • Use aspirin therapy (75 – 162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease.
  • For patients with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be used
  • Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary syndrome and may have benefits beyond this period