Diabetes

Diabetes is a metabolic disorder characterized by hyperglycemia due to ineffective insulin secretion and/or insulin utilization.

Definitions

 * Diabetes: see diagnosis section. A fasting plasma glucose level of 7.0 mmol/L, a 2-hour plasma glucose value in a 75 g oral glucose tolerance test of 11.1 mmol/L or a glycated hemoglobin (A1C) value of 6.5%
 * Pre-diabetes: impaired fasting glucose, impaired glucose tolerance, or an HbA1c between 6.0-6.4%. These people are at increased risk of developing diabetes and its macrovascular complications
 * Metabolic syndrome: Elevated waist circumference, triglycerides, reduced HDL-C, elevated Blood Pressure, elevated fasting plasma glucose

Symptoms

 * Hyperglycemia: polydipsia, polyuria, unexplained weight loss, polyphagia, blurred vision, fatigue, dry mouth, dry skin, arrhythmia, decrease LOC
 * Hypoglycemia: sweating, palpitations, sweating, clammy, blurred vision, dilated pupils, nausea, vomiting, confusion, seizures, decrease LOC

Microvascular

 * Retinopathy
 * Neuropathy
 * Nephropathy

Macrovascular

 * Cardiovascular disease
 * Cerebrovascular disease
 * Peripheral Vascular disease

Screening

 * No screening for T1DM
 * T2DM
 * Every 3 years >/= 40 years old or high risk with fasting plasma glucose and/or HbA1C.
 * Screen earlier +/- more frequently pending risk factors
 * Risk factors: first degree relative, member of high risk population (South Asian, Hispanic, Aboriginal, Asian, African), history of pre-diabetes, history of gestational DM, history of macrosomic infant, presence of end organ damage associated with DM, vascular risk factors (HDL<1.0, TG >1.7, HTN, overweight, abdominal obesity), associated diseases (PCOS, acanthosis nigricans, OSA, bipolar, schizophrenia, depression, HIV), drug use (steroids, antipsychotics, HIV treatment), endocrine disorders


 * Risk calculators:
 * CANRISK (ages 40-74) - low/moderate/high groups
 * age, sex, BMI, waist circumference, ethnicity, physical activity, diet, HTN, history of dysglycemia, family history, education level
 * CANRISK TOOL
 * FINDRISC - low/moderate/high groups
 * FINDRISC TOOL

Diagnosis

 * If asymptomatic a repeat confirmatory laboratory test on another day is indicated to confirm diagnosis
 * If symptomatic a diagnosis made. No confirmatory test required.
 * HbA1c is better predictor of macrovascular complications.  HbA1c cannot be used in patients with hemoglobinopathies, iron deficiency, hemolytic anemias, severe hepatic/renal dsease
 * HbA1c not recommended in children, teens, pregnant woman or suspected type 1 diabetes
 * If FPG 5.6-6.0 or A1c 5.5-5.9 + >1 risk factors consider 75 gram OGTT



Prevention

 * No prevention strategies for T1DM
 * Lifestyle changes: diet, exercise (moderate to high levels), and weight loss
 * 150minutes/week moderate to vigorous aerobic activity
 * Resistance training 2x/week
 * Medications: In individuals with impaired glucose tolerance metformin or acarbose can be used to reduce risk of T2DM

Management
General Principles
 * Chronic care model - important to advocate at the community and health system level
 * Support self management, regular follow-up, provide patient centered education
 * Use interdiscipinary team approach with shared care model
 * Consider specialist involvement for children with DM, T1DM, women with diabetes in pregnancy, complex T2DM

Targets

 * HbA1c < 7% general population
 * Can consider target HbA1C <6.5% to lower risk of nephropathy and retinopathy if young and healthy
 * HbA1C 7.1-8.5% in patients with one of the following:  multiple severe hypoglycemic episodes, unaware of hypoglycemia, multiple co-morbidities, fragility, limited life expectancy, high level of functional dependency, extensive coronary artery disease at high risk of ischemic events, longstanding diabetes for whom it is difficult to achieve an A1C <7.0% despite effective treatment
 * Elevated fasting and post-prandial glucose confer risk of cardiovascular disease


 * ​Fasting glood gluocse 4.0-7.0
 * Post-prandial 5.0-10.0

Non-pharmacologic Strategies
Diet: can lower HbA1c 1-2% Exercise
 * ​Consider referral to dietician
 * Recommend foods with low glycemic index (lower ability to raise blood glucose)
 * Dietary fiber (soluble) decreases post-prandial glucose by slowing gastric emptying and delaying absorption
 * Recommend saturated fats <7%
 * Canada's Food Guide
 * Diabetic Food Handout - CV toolbox
 * Diets that have been shown to help glycemic control: Mediterranean, vegan/vegetarian, DASH diet
 * Patients with Type 1 insulin should be taught to match insulin to carbohydrate quantity and quality
 *   Insulin users with ETOH at risk of delayed hypoglycemia. Should reduce insulin, increase BG monitoring or increase carbohydrate intake
 * 150 minutes moderate to vigouros exercise (aerobic)
 * Resistance exercise 2-3x per week
 * People with diabetes that want to start exercising at risk of CVD à baseline ECG +/-stress test, fundoscopic exam, neuropathy screen
 * Can use exercise prescription

Pharmacotherapy

 * If HbA1c <8.5 - start lifestyle changes and consider metformin
 * If HbA1c > 8.5% - start metformin immediately. Consider combination therapy.
 * After diagnosis and starting therapy it should take 3-6 months to reach target HbA1c
 * Insulin has the largest effect on lowering HbA1c

Examples:

 * Biguanide
 * Metformin: weight neutral, no hypoglycemia
 * S/E: N/V/D. Contraindication: CrCl<30ml/min
 * Glumetza
 * DPP4- inhibitor
 * Increase amount of circulating insulin. Less risk of hypoglycemia, risk pancreatitis
 * e.g. Siitagliptin (januvia), Linagliptin (Trajenta)
 * Sulfonylurea
 * Risk of hypoglycemia
 * e.g. Glyburide, Gliclazide (Diamicron)



Insulin

 * INSULIN PRESCRIPTION
 * When starting insulin consider stopping insulin secreatogoues  due to risk of hypoglycemia.

Monitoring
Type 1 diabetics: Type 2 diabetics: Calibrate blood glucose monitors once/year
 * should check finger prick glucose >3x/day and HbA1C q3 months
 * Real time continuous glucose monitoring may be used to improve glycemic control and reduce hypoglycemia
 * During periods of acute illness and elevated blood glucose/or symptoms of DKA patients should be instructed to test for blood ketones or urine ketones
 * Individuals with type 1 diabetes should be instructed to perform ketone
 * HbA1c q3months when glycemic targets not being met or when therapy is being changed
 * On insulin once/day: self monitored glucose once/day at variable times
 * On insulin >1/time: check glucose at least 3x/day with both pre/post-prandial values
 * In T2DM not on insulin consider self monitoring glucose (individualized). Consider risk of hypoglycemia with oral antiglycemics, not acheiveing control to assist with compliance,

Hypoglycemia

 * Definition: blood sugar <4 + autonomic symptoms + response to carbohydrate load
 * Symptoms: trembling, palpitations, sweating, anxiety, hunger, nausea, confusion, weakness, trouble concentrating, decrease LOC
 * Treatment of mild-moderate hypoglycemia- 15 grams carbohydrate load (dextrose tablets, lifesavers x 6, 3/4 cup orange juice, 1 tablespoon of honey), retest in 15 minutes

Vascular Protection

 * Statin therapy
 * Age > 40 (regardless of LDL-C)
 * Earlier if have macro/microvascular complications
 * DM > 15 years duration and age >30
 * ACEI/ARB
 * Age >55
 * Earlier if have macro/microvascular complications
 * Perindopril 8 mg PO daily or Ramipril 10mg Po daily or Telmisartan 80mg PO daily (full dose) - titrate up
 * ASA
 * All patients with diabetes who have had a vascular event
 * A1c < 7%, BP < 130/80, Cholesterol LDL<2.0, Drugs to protect heart (ACEI, statin, ASA), Smoking cessation, exercise, healthy eating

Other considerations

 * pneumococcal vaccination: over the age of 18 x 1 (at diagnosis) then one time revaccination if >65  (ensure >5 years between vaccinations)
 * Annual influenza vaccine

Patient Care Flow Sheet
Patient Care Flow Sheet
 * A1C q 3 months
 * ACr - yearly (target <2.0)
 * Retinopathy check - yearly
 * BP check (every visit)
 * Neuopathy check - monofilament - yearly
 * LDL-C yearly (new guidelines changing**)