Published on Feb 22, 2015

DM ABCs essential of management ; 2015 update

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1. DIABETES MELLITUS Standards Of Care- 2015 The ABCs Dr. Mohammad Daoud Consultant
Endocrinologist KAMC/ NGHA Jeddah Saudi Arabia

2. Type 2 diabetes is NOT a mild disease Diabetic Retinopathy Leading cause of blindness in working age
adults1 Diabetic Nephropathy Leading cause of end-stage renal disease2 Cardiovascular Disease Stroke 2 to
4 fold increase in cardiovascular mortality and stroke3 Diabetic Neuropathy Leading cause of non-traumatic
lower extremity amputations5 8/10 diabetic patients die from CV events4 1 Fong DS, et al. Diabetes Care
2003; 26 (Suppl. 1):S99S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94 S98. 3 Kannel
WB, et al. Am Heart J 1990; 120:672676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997.
5Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78S79. Mild Type 2 Diabetes ?

3. Aims of Mx of DM Improve quality of life Reduce acute symptoms Achieve euglycemia safely Avoid
Acute & Chronic Complications

4. ADA 2015 A patient-centered communication style that incorporates patient preferences, assesses literacy
and numeracy, and addresses cultural barriers to care should be used. B Treatment decisions should be
timely and founded on evidence-based guidelines that are tailored to individual patient preferences,
prognoses, and co-morbidities. B

5. Criteria for the Diagnosis of Diabetes A1C 6.5% Adults OR Fasting plasma glucose (FPG) 126 mg/dL
(7.0 mmol/L) OR 2-h plasma glucose 200 mg/dL (11.1 mmol/L) during an OGTT OR A random plasma
glucose 200 mg/dL (11.1 mmol/L) ADA. I. Classification and Diagnosis. Diabetes Care 2014;37(suppl
1):S15; Table 2

6. Testing for Diabetes in Asymptomatic Adult Patients Adults of any age who are overweight / obese
(BMI 25 kg/m2 or 23 kg/m2 in Asian Americans) and who have one or more additional risk factors for
diabetes. For all patients, particularly those who are overweight or obese, testing should begin at age 45
years. B To test for pre-diabetes, the A1C, FPG, or 2-h 75-g OGTT are appropriate B In those with prediabetes, identify and, if appropriate, treat other CVD risk factors E ADA. II. Testing for Diabetes in
Asymptomatic Patients. Diabetes Care 2015

7. Testing for Diabetes in Asymptomatic Adult Individuals Physical inactivity First-degree relative with
diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American,

Pacific Islander) Women who delivered a baby weighing >9 lb or were diagnosed with GDM
Hypertension (140/90 mmHg or on therapy for hypertension) HDL cholesterol level <35 mg/dL (0.90
mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) Women with polycystic ovarian syndrome
(PCOS) A1C 5.7%, IGT, or IFG on previous testing Other clinical conditions associated with insulin
resistance (e.g., severe obesity, acanthosis nigricans) History of CVD *At-risk BMI may be lower in some
ethnic groups. 1. Testing should be considered in all adults who are overweight (BMI 25 kg/m2 or 23
kg/m2 in Asian Americans) and have additional risk factors: ADA. Testing for Diabetes in Asymptomatic
Patients. Diabetes Care 2015

8. 2. If tests are normal, repeat testing at least at 3-year intervals is reasonable C Consider more frequent
testing depending on initial results and risk status (e.g., those with prediabetes should be tested yearly) ADA.
Testing for Diabetes in Asymptomatic Patients. Diabetes Care 2015 Testing for Diabetes in Asymptomatic
Adult Individuals

9. Recommendations: Detection and Diagnosis of GDM (1) Screen for undiagnosed type 2 DM at the first
prenatal visit in those with risk factors, using standard diagnostic criteria B Screen for GDM at 2428
weeks of gestation in pregnant women not previously known to have DM A Screen women with GDM for
persistent DM at 612 weeks postpartum, using OGTT, nonpregnancy diagnostic criteria E Women with a
+ve history of GDM should have lifelong screening for the development of DM or pre-DM at least every 3
years B Women with a history of GDM found to have pre-DM should receive TLC or Metformin to
prevent DM A Detection and Diagnosis of GDM. Diabetes Care 2015

10. One-step strategy (IADPSG Consensus) Perform a 75-g OGTT, with plasma glucose measurement
when patient is fasting and at 1 and 2 h, at 2428 weeks of gestation in women not previously diagnosed
with overt diabetes. The OGTT should be performed in the morning after an overnight fast of at least 8 h
The diagnosis of GDM is made when any of the following plasma glucose values are met or exceeded:
Fasting: 92 mg/dL (5.1 mmol/L) 1 h: 180 mg/dL (10.0 mmol/L) 2 h: 153 mg/dL (8.5 mmol/L)
Detection and Diagnosis of GDM. Diabetes Care 2015 Table 2.5Screening for and diagnosis of GDM

11. Table 2.5Screening for and diagnosis of GDM Two-step strategy (2013 -NIH Consensus) Step 1:
Perform a 50-g GLT (non-fasting), with plasma glucose measurement at 1 h, at 2428 weeks of gestation in
women not previously diagnosed with overt diabetes. If the plasma glucose level measured 1 h after the
load is 140 mg/dL* (7.8 mmol/L), proceed to a 100-g OGTT NDDG, National Diabetes Data Group. *The
ACOG recommends a lower threshold of 135 mg/dL (7.5 mmol/L) in high-risk ethnic populations with
higher prevalence of GDM; Some experts also recommend 130 mg/dL (7.2 mmol/L). Detection and
Diagnosis of GDM. Diabetes Care 2015

12. Two-step strategy Step 2: The 100-g OGTT should be performed when the patient is fasting. The
diagnosis of GDM is made if at least two of the following four plasma glucose levels (measured fasting
and 1 h, 2 h, 3 h after the OGTT) are met or exceeded: Carpenter/Coustan or NDDG Fasting 95 mg/dL (5.3
mmol/L) 105 mg/dL (5.8 mmol/L) 1 h 180 mg/dL (10.0 mmol/L) 190 mg/dL (10.6 mmol/L) 2 h 155 mg/dL
(8.6 mmol/L) 165 mg/dL (9.2 mmol/L) 3 h 140 mg/dL (7.8 mmol/L) 145 mg/dL (8.0 mmol/L) Table 2.5
Screening for and diagnosis of GDM Detection and Diagnosis of GDM. Diabetes Care 2015

13. PREVENTION / DELAY OF TYPE 2 DIABETES

14. FPG 100125 mg/dL (5.66.9 mmol/L): IFG OR 2-h plasma glucose in the 75-g OGTT 140199 mg/dL
(7.811.0 mmol/L): IGT OR A1C 5.76.4% For all three tests, risk is continuous, extending below the lower
limit of the range and becoming disproportionately greater at higher ends of the range. Pre-Diabetes ADA. I.
Classification and Diagnosis. Diabetes Care 2015

15. Prevention /Delay of Type 2 DM Patients with IGT (A), IFG (E), or an A1C of 5.76.4% (E) Weight
loss of 7% of body weight Physical activity ; at least 150 min/ week Follow-up counseling for success.
(B) Diabetes prevention is cost-effective (B)

16. ADA 2015 All patients should limit the amount of time sitting to less than 90 minutes a stretch (Avoid
Sedentary Life )

17. Prevention /Delay of Type 2 DM Metformin therapy may be considered in: IGT (A), IFG(E), or an
A1Cof 5.76.4% (E) Especially for those with: (A) -BMI >35 kg/m2 -Age <60 years, -Prior GDM. At least
annual monitoring for the development of DM in those with pre-diabetes is suggested. (E)

18. ADA 2015 Micronutrients and Supplements Evidence does not support recommending omega-3
supplements for people with diabetes for the prevention or treatment of cardiovascular events. There is no
clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not
have underlying deficiencies. C Routine supplementation with antioxidants, such as vitamins E and C and
carotene, is not advised due to insufficient evidence of efficacy and concerns related to long- term safety. C .

19. ADA 2015 Micronutrients and herbal supplements There is insufficient evidence to support the routine
use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people
with diabetes C There is insufficient evidence to support the use of cinnamon or other herbs/supplements
for the treatment of diabetes. E

20. Routine screening for CAD is Not recommended In asymptomatic patients (It does not improve
outcomes as long as CVD risk factors are treated) (A) Coronary Heart Disease Screening ADA. VI.
Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S42

21. To reduce risk of cardiovascular events in patients with known CVD, use ACE inhibitor* (C)
Aspirin* (A) Statin therapy* (A) In patients with a prior MI Beta-blockers should be continued for at
least 2 years after the event (B) Coronary Heart Disease Treatment *If not contraindicated. ADA. VI.
Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S42

22. GLYCEMIC CONTROL 1. Assessment of Glycemic control Two primary techniques: A : Patient selfmonitoring of blood glucose (SMBG) or Interstitial Glucose (CGM) B : HbA1C 2. Glycemic goals in adults
ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21S22

23. ADA-2015

24. Glycemic Control SMBG Tight Glycemic control : SMBG is an integral part of the management
strategy. (A) Do SMBG 3 times a day for patients using Insulin pump or multiple insulin injections. (B)
Patients using less frequent insulin injections or oral agents or MNT alone, SMBG is useful (E) PP SMBG
may be appropriate. (E) Especially when getting closer to target; Lower A1c

25. Glycemic Control Recommendations EMPOWER Patient should be able to use data to adjust therapy.
(E) ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S21S22

26. Correlation of A1C with estimated Average Glucose The correlation factor is (r 0.92) A1C (%) Mean
plasma glucose mg/dl mmol/l 6 126 ( 120) 7 154 ( 150) 8 183 ( 180) 9 212 ( 210) 10 240 ( 240) 11 269
( 270) 12 298 ( 300) ADA. V. Diabetes Care. Diabetes Care 2014;37(suppl 1):S23; Table 8

27. ADA EASD Consensus: (June 2012)

28. ADA-2015 Inpatients Glycemia Mx

29. ADA-2015 Inpatients Glycemia Mx

30. Diabetes in Elderly Pharmacotherapy Assess for hypoglycemia regularly Hypoglycemia risk is linked
more to treatment strategies than to achieved lower A1C Consider changing therapy and/or targets Diabetes
in older adults-ADA Consensus Diabetes Care published ahead of print October 25, 2012,
doi:10.2337/dc12-1801

31. Diabetes in Elderly Pharmacotherapy Consider poly-pharmacy Avoid Glyburide / Glibenclamide

Metformin: Safely and is the preferred initial therapy Assess renal function using e-GFR ; Not Serum
Creatinine alone Diabetes in older adults-ADA Consensus Diabetes Care published ahead of print October
25, 2012, doi:10.2337/dc12-1801

32. Diabetes in Elderly Pharmacotherapy Assess the burden of treatment on older adult patients (caregivers)
Consider patient/caregiver preferences, and attempt to reduce treatment complexity Diabetes in older adultsADA Consensus Diabetes Care published ahead of print October 25, 2012, doi:10.2337/dc12-1801

33. Diabetes in Elderly

34. Glycemic Control Key Concepts A1C is the primary target SMBG Goals to be individualized Evidence
Based / Individualized Rx

35. HYPERTENSION BP CONTROL Goals *People with diabetes and hypertension should be treated to a
(SBP) goal of <140 mmHg. A Lower systolic targets, such as <130 mmHg, may be appropriate for certain
individuals, such as younger patients, if they can be achieved without undue treatment burden. C
*Individuals with diabetes should be treated to a (DBP) <90 mmHg. A Lower (DBP) targets, such as <80
mmHg, may be appropriate for certain individuals, such as younger patients, if they can be achieved without
undue treatment burden. B

36. Patients with confirmed office-based BP >140/90 mm Hg = Prompt initiation of pharmacological

therapy to achieve blood pressure goals. A HYPERTENSION BP CONTROL

37. Lifestyle therapy for elevated BP B Weight loss if overweight/ obese DASH (Dietary Approaches to
Stop Hypertension) - style dietary pattern including reducing sodium, increasing potassium intake
Moderation of alcohol intake Increased physical activity HYPERTENSION BP CONTROL ADA. VI.
Prevention, Management of Complications. Diabetes Care 2014;37(suppl 1):S36

38. Hypertension Mx Recommendations ACE (-) or ARBs (Dont combine) or Diuretics Monitor serum
creatinine / (e GFR) and serum potassium levels. (E)

39. Hypertension Mx Recommendations Multiple Drug Therapy ( 2 agents) is generally required (B)
Including a thiazide diuretic and ACE inhibitor/ARB, at maximal doses) is generally required to achieve
blood pressure targets Administer one or more antihypertensive medications at bedtime. (A)

40. DM / Hypertension Mx < 130 c / 80 B mmHg Minimal Goal is < 140 A / 90 A mmHg ADA-2015
Evidence Based / Individualized Rx

41. DYSLIPIDEMIA Intensity Vs Targets DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY
2012

42. Screening At the time of first diagnosis Initial medical evaluation and/or at age 40 years and Reassessments may be repeated periodically every 1-2 years (E) Recommendations: Dyslipidemia/Lipid
Management DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012.

43. Lipids Rx Recommendations and Goals Lifestyle modification (TLC) has been shown to Improve the
lipid profile in patients with diabetes. (A) This include: - Reduction of saturated fat, trans fat, and cholesterol
intake -Increase of n-3 fatty acids, viscous fiber and plant stanols / sterols -Weight loss (if indicated); and
increased physical activity

44. Lipids ADA 2014 was To get specified LDL target Statin therapy should be added, regardless of
baseline lipid levels, for DM patients: - With overt CVD. -Without CVD who is > 40 years old and have 1
other CVD risk factors. (A) A reduction in LDL cholesterol of 3040% from baseline is an alternative
therapeutic goal. (A)

45. Statins use is based on desired LDL-C Intensity lowering rather than LDL target number Adjustment of
intensity of statin therapy may be needed based on individual patient response to medication (e.g., side
effects, tolerability, LDL cholesterol levels). E Lipids ADA 2015

46. NICE Guidelines -Dyslipidemia and (CVD) Do not use a risk assessment tool for people 1-With type 1
DM 2-With pre-existing CVD 3-Familial hyper-cholesterolemia 4-With CKD ; e GFR < 60 ml/min/1.73 m2
and/or albuminuria

47. Statins intensity categories of lowering LDL C NICE vs ACC/AHA NICE low intensity 20% to 30%
medium intensity 31% to 40% high intensity > 40% ACC/AHA low intensity <30% medium intensity 30%
to <50% high intensity 50%

48. Statins intensity categories of lowering LDL C ACC/AHA

49. Again Adjustment of intensity of statin therapy may be needed based on individual patient response to
medication (e.g., side effects, tolerability, LDL cholesterol levels). E Lipids ADA 2015

50. Lipids ADA 2014 was If targets are not reached; Use combination therapy of lipid lowering agents.
(No outcome studies; CVD outcomes or safety. (E)

51. Combination therapy (statin/ fibrate and statin/niacin) has not been shown to provide additional
cardiovascular benefit above statin therapy alone and is Not generally recommended A Lipids ADA 2015

52. A1C <7.0% <6.5% Blood pressure <140/90 mmHg Lipids: Statins Moderate High Intensity Glycemic,
BP, Lipid Control in Adults Evidence Based / Individualized Rx DIABETES CARE , JANUARY 2015

53. NEPHROPATHY

54. Nephropathy-Screen At least once a year Assess , quantitatively Urinary albumin (e.g., urine albumin
/creatinine ratio [UACR]) and estimated glomerular filtration rate (e GFR) Type 1 DM 5 years / All Type 2
DM

55. Nephropathy-Screen

56. Nephropathy-Treatment ACE inhibitor or (ARB) is Not recommended for the primary prevention of
diabetic kidney disease in patients with DM with Normal BP and normal UACR (< 30 mg/g) B

57. Nephropathy-Nutrition Diabetic kidney disease Reducing the amount of dietary protein below the
recommended 0.8 g/kg/day Not recommended (it does not alter glycemic measures, CV risk measures, or the
course of GFR decline) A

58. Nephropathy Key Concepts Optimize DM & HTN control (A) Treatment of Albuminuria with
ACE(-) or ARB based Rx (A) DIABETES CARE, , JANUARY 2015 Evidence Based / Individualized Rx

59. Anti-Platelets & DIABETES

60. Aspirin Use aspirin therapy (75162 mg/day) as a secondary prevention strategy in those with diabetes
with a history of CVD. (A) * U.S. Physicians' Health Study, Early Treatment Diabetic Retinopathy Study
(ETDRS), Hypertension Optimal Treatment (HOT) DIABETES CARE, SUPPLEMENT 1, JANUARY 2015

61. Aspirin- Primary prevention Consider ASA as a primary prevention strategy in those with type 1 or type
2 DM at increased cardiovascular risk (10-year risk > 10%) This includes most men >50 years or women
>60 years With at least one additional major risk factor (Family Hx. of CVD, Hypertension, Smoking,
Dyslipidemia,or Albuminuria) (C) -US Preventive Services Task Force (USPSTF): Aspirin for the
prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann
Intern Med 2009;150:396404 -Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular
events: an update of the evidence for the (USPSTF): . Ann Intern Med 2009;150:405410 238. DIABETES
CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012

62. Take Home Messages

63. Take Home Messages Guidelines evolving Treat patients Not numbers ! Individualize Team
work

64. Take Home Messages TLC (dietary and exercise) modifications are essential for all patients with DM
EMPOWER Individualize and get patient involved

65. Take Home Messages Treat Hyperglycemia, HTN & Dyslipidemia with the same intensity Achieve
Targets .Safely

66. Diabetes Mellitus Targets For Control (ADA-2015) Parameter Goal Action Suggested AC Glucose PostP Glucose 80-130 < 180 <80 or >140 >180 HS glucose 100-140 <100 or >160 HbA1c % <7 (6.5) >7 BP
(mmHg.) <140/90 >140/90 LDL-Chol TG 40-50% <150 DM patients HDL-Chol >40 males >50 females
<40 <50

67. Remember Your ABCs A: A1C ASA Albuminuria B: Blood Pressure C: Cholesterol Cardiac
D: Diabetes education Diet / Dietician E: Eye exam Exercise F: Foot care G: Glucose monitoring
H: Health ; Vaccination D/C Smoking I: Identify need for referral
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