Diabetes Mellitus and Type 2 Diabetes: Diagnosis & Management
Diabetes Mellitus and Type 2 Diabetes: Diagnosis & Management
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| Diabetes Mellitus and Type 2 Diabetes: Diagnosis & Management |
I've got a patient he's 60 years old he's got hyperlipidemia and obesity yeah recent routine lab analysis found the serum glucose level was 146 milligrams per deciliter he's a stuntman at this time what's the next best step in his care should we talk about lifestyle changes and recheck his glucose along with a hemoglobin a1c level in the next several weeks should we start metformin now or a sulfonylurea or a dipeptidyl peptidase-4 inhibitors what do you think given his lack of symptoms and that glucose level we're mandated to recheck his glucose level and
I would check an a1c to because with his risk factors sounds like he probably has Diabetes, of course, you're gonna advise him on lifestyle changes now and so that makes sense
he does not have to meet the formal criteria for Diabetes as of yet but many people do overall there are now more than 20 million Americans with type-2 Diabetes and this number is expected to more than double within the next 20 years or so so should we be screening for Diabetes well this is what the United States Preventive Services Task Force or USPSTF says among adults aged 40 "to 70 years which is somewhat the sweet spot for distinguishing Diabetes check for either glucose or a1c either one's a legitimate measure among patients who are large and" among those with a family history of Diabetes high risk racial or ethnic groups
which include Latinos and African Americans and what if the patient has a history of gestational diabetes or polycystic ovary syndrome those patients get screened - lots of people meet the screening criteria you can apply that fairly broadly across a population so how do we diagnose diet so it's a serum glucose level of 126 milligrams per deciliter or seven millimoles per liter on two separate occasions and also glucose in the urine can be supportive as well but
I think really we use the serum markers too to identify Diabetes or it could be an hba1c of 6.5 percent or more on two separate occasions but if a patient comes in with fatigue and polyuria and polydipsia and you check their glucose in the clinic and it's over 200 milligrams per deciliter no further testing is necessary they have Diabetes, of course, those patients will get a baseline hba1c level right away as well
so I think this is good for patient care and also good for what may come up on your exam this is the routine evaluation for patients with Diabetes with a schedule so patient
with type 2 Diabetes get there an automatic exam right away when they're diagnosed with a dilated pupil for a retinal exam and then there that's followed at least annually the hba1c if it's well-controlled can be every six months poorly controlled every three months a complete foot exam with monofilament testing at least every year lipids at least every several years
I probably draw them more often a urine micro album and creatinine ratio at the time of diagnosis and then annually and then blood chemistries and renal function at least every six months all those things fairly straightforward makes sense most of my patients are achieving those goals now we do an hba1c level and turns out 8.2 percent so besides lifestyle intervention what's the best treatment to prescribe for this patient now is it
- A glipizide
- B liraglutide
- C basal insulin at night or
- D metformin and in previous years you could make an argument you know
so which one might be better now it's fairly clear and the American Diabetes Association recommends along with the American Association of Clinical Endocrinology metformin is a foundational drug for Diabetes so we'll talk about
"various intercessions for Diabetes with medications in a second yet you generally start with a way of life first in light of the fact that simply consider it a multidisciplinary group can advance weight reduction of" up to 9% among
patients with Diabetes and that's gonna reduce the need to use anti-Diabetes drugs and
I know apprehensive drugs as well as physical activity is about as good as one of the weaker oral agents for reducing hba1c and diet advice is similar it can reduce the hba1c by another half to one percent for most people and it probably is better
when it comes from somebody with experience in counseling patients like a dietician or a surfeit certified Diabetes educator versus the physician who's trying to manage 20 things at once look a little pearl regarding home glucose testing we recommend this broadly and probably a little too broadly just in terms of stewardship of resources because it can get expensive to get new machines to get the lancets to get the test strips it's most helpful for patients with severe Diabetes who are taking insulin it hasn't really been shown to make much of a difference among patients who are fairly well controlled on oral medications especially those early in their illness and it doesn't necessarily change the quality of life where
I might use it in a patient who's on oral medications alone is pay our patients with highly fluctuating glucose going very high and then at risk of hypoglycemia for somebody who's chugging along and taking only metformin and their hba1c is six point eight to six point six percent every time I check it you know there's not really much of a need to do any home blues glucose testing at all so something to think about how
I mentioned metformin is the first-line agent why there's a low risk of hypoglycemia and it's danger has become a lot more apparent over the past few years and we'll talk about some agents that promote low sugar, it's usually associated with a very modest weight loss it doesn't create the cycle of more weight gain therefore more insulin resistance and then more need for drugs and the big complication with metformin that everybody worries about is lactic acidosis that's right and it's more common among patients with severe kidney disease but now the new rules and warnings on the drug state that it can be used for certain patients all the way down to a glomerular filtration rate of 30 millimeters per minute so that's kind of remarkable in it and a big change getting metformin to more patients who need it so far Ria's have been around a long time like metformin they're inexpensive and like metformin they promote about the same degree of hba1c reduction if you ever get stopped and have to answer in like half a second okay how much does this drug reduce this oral drug reduce hba1c 1% is always a good answer because they tend to be around that level but the problem with Sophia is is they can promote hypoglycemia and weight gain and therefore may be less favored there's also an unknown effect whether they improve mortality or not newer agents now dipeptidyl peptidase-4 inhibitors these are
I think the benefit to these drugs is they're really well tolerated they're fairly easy to use don't promote a lot of hypoglycemia a low rate of side effects overall they can even be used in moderate renal dysfunction as well the drawback they're not that effective so they're good for patients were right next to goal maybe with metformin but can't quite get there but they also have intolerance to multiple drugs you know a DPP-4 inhibitor could be a good idea for them as Aladin Deion's all 0 only rosiglitazone is available in the United States these drugs can promote weight gain which is partly water weight they can promote edema patients with history of bladder cancer or osteoporosis should not
I know apprehensive drugs as well as physical activity is about as good as one of the weaker oral agents for reducing hba1c and diet advice is similar it can reduce the hba1c by another half to one percent for most people and it probably is better
when it comes from somebody with experience in counseling patients like a dietician or a surfeit certified Diabetes educator versus the physician who's trying to manage 20 things at once look a little pearl regarding home glucose testing we recommend this broadly and probably a little too broadly just in terms of stewardship of resources because it can get expensive to get new machines to get the lancets to get the test strips it's most helpful for patients with severe Diabetes who are taking insulin it hasn't really been shown to make much of a difference among patients who are fairly well controlled on oral medications especially those early in their illness and it doesn't necessarily change the quality of life where
I might use it in a patient who's on oral medications alone is pay our patients with highly fluctuating glucose going very high and then at risk of hypoglycemia for somebody who's chugging along and taking only metformin and their hba1c is six point eight to six point six percent every time I check it you know there's not really much of a need to do any home blues glucose testing at all so something to think about how
I mentioned metformin is the first-line agent why there's a low risk of hypoglycemia and it's danger has become a lot more apparent over the past few years and we'll talk about some agents that promote low sugar, it's usually associated with a very modest weight loss it doesn't create the cycle of more weight gain therefore more insulin resistance and then more need for drugs and the big complication with metformin that everybody worries about is lactic acidosis that's right and it's more common among patients with severe kidney disease but now the new rules and warnings on the drug state that it can be used for certain patients all the way down to a glomerular filtration rate of 30 millimeters per minute so that's kind of remarkable in it and a big change getting metformin to more patients who need it so far Ria's have been around a long time like metformin they're inexpensive and like metformin they promote about the same degree of hba1c reduction if you ever get stopped and have to answer in like half a second okay how much does this drug reduce this oral drug reduce hba1c 1% is always a good answer because they tend to be around that level but the problem with Sophia is is they can promote hypoglycemia and weight gain and therefore may be less favored there's also an unknown effect whether they improve mortality or not newer agents now dipeptidyl peptidase-4 inhibitors these are
I think the benefit to these drugs is they're really well tolerated they're fairly easy to use don't promote a lot of hypoglycemia a low rate of side effects overall they can even be used in moderate renal dysfunction as well the drawback they're not that effective so they're good for patients were right next to goal maybe with metformin but can't quite get there but they also have intolerance to multiple drugs you know a DPP-4 inhibitor could be a good idea for them as Aladin Deion's all 0 only rosiglitazone is available in the United States these drugs can promote weight gain which is partly water weight they can promote edema patients with history of bladder cancer or osteoporosis should not
be
using these drugs and then reduce hba1c by about 1% so there's still
have some role but it's probably a more limited secondary role in the
management of most cases of
type 2 Diabetes what about the glucagon-like peptide one receptor agonist so these are different drugs these are again even a newer wave they've been out for several years now so it's important for us to know them different dosing schedules but they're not there's no oral product out there right now they're subcutaneous injections they rarely are associated with pancreatitis and you can't use them among patients with the most severe chronic kidney disease but they can't be used in moderate kidney disease the beneficial effects of GLP-1 agonists they can promote weight loss sometimes it exceeds six or seven kilograms it routinely it's going to be at least four kilograms so weight loss is important and something that patients can really hold on to it's not easy to lose four kilograms of body weight for many patients and their hba1c action is a little bit stronger than other oral agents so between the fact that it promotes weight loss and it reduces a butt a1c fairly robustly
I like GLP-1 agonists another new kid on the block the sodium-glucose cotransport or two or sglt2 inhibitors these inhibit glucose reuptake they work in the kidneys they have been associated with a higher risk for UTI as well as genital fungal infections these also promote weight loss though as well as they lower blood pressure and of themselves - again a little bit weaker though for their hba1c reduction so not something not that strong the reduction you might experience with a GAP-1 agonist says the patient's not doing that well and continues to maintain a high a1c despite your best medical therapy so patients who come in with an HB hba1c above nine can be considered for insulin in my practical experience most most clinicians aren't thinking about using insulin right off the bat unless they come in with an a1c of eleven or more but one thing that's certainly true is patients who are failing badly and taking to oral anti-Diabetes drugs there's not much point in putting them on a third oral Diabetes drug at that point it's time to reconsider therapy and include insulin in that regimen the problem with
type 2 Diabetes what about the glucagon-like peptide one receptor agonist so these are different drugs these are again even a newer wave they've been out for several years now so it's important for us to know them different dosing schedules but they're not there's no oral product out there right now they're subcutaneous injections they rarely are associated with pancreatitis and you can't use them among patients with the most severe chronic kidney disease but they can't be used in moderate kidney disease the beneficial effects of GLP-1 agonists they can promote weight loss sometimes it exceeds six or seven kilograms it routinely it's going to be at least four kilograms so weight loss is important and something that patients can really hold on to it's not easy to lose four kilograms of body weight for many patients and their hba1c action is a little bit stronger than other oral agents so between the fact that it promotes weight loss and it reduces a butt a1c fairly robustly
I like GLP-1 agonists another new kid on the block the sodium-glucose cotransport or two or sglt2 inhibitors these inhibit glucose reuptake they work in the kidneys they have been associated with a higher risk for UTI as well as genital fungal infections these also promote weight loss though as well as they lower blood pressure and of themselves - again a little bit weaker though for their hba1c reduction so not something not that strong the reduction you might experience with a GAP-1 agonist says the patient's not doing that well and continues to maintain a high a1c despite your best medical therapy so patients who come in with an HB hba1c above nine can be considered for insulin in my practical experience most most clinicians aren't thinking about using insulin right off the bat unless they come in with an a1c of eleven or more but one thing that's certainly true is patients who are failing badly and taking to oral anti-Diabetes drugs there's not much point in putting them on a third oral Diabetes drug at that point it's time to reconsider therapy and include insulin in that regimen the problem with
insulin
is there's just a lot of variability how often the patient uses it
their diet how you they are to checking their home glucose how
involved their health literacy all these things factor in the
efficacy of insulin it's frankly probably easier to take a pill
but you can start with something basic like augmentation of their
usual therapy with basal insulin there's the dose point three units
per kilogram per day, that's this is really
where you want it if you haven't initiated doing home glucose monitoring you're gonna want to initiate home glucose monitoring and telling it warning the patient about hypoglycemic symptoms and how to react because of course, that's one of the downsides of insulin treatment it is a nice opportunity in my opinion to check on lifestyle because you can follow along and you notice when they go when the patient goes high with their glucose readings at home when they go low what happens oh that's the day an exercise that's the day I forgot to eat or when it's high oh that was a big party
I went to and I kind of went nuts and ate whatever I wanted that's why my glucose was 450 so it can give you some insights into how to counsel patients about you know because of lifestyle never leaves just because the patient goes through Diabetes education classes and meets with an NGO an educator a Promotora or whatever it's you know it's never quite over you have to keep up that lifestyle and importantly once you initiate insulin treatment don't let go of metformin foundational drug and can help mitigate against the weight gain you're going to experience with insulin but sulfide Riyaz once you start prandial insulin there's not much point" in utilizing yourself on zones any longer get them off in light of the fact that they may advance hypoglycemia weight increase and hypoglycemia is a genuine hazard so truly screen it intently keeps these levels" in mind goal glucose levels for fasting patients 90 to 130 milligrams of per deciliter for postprandial less than 180 milligrams per deciliter okay so with that happy to that that to give you that overview on Diabetes care
I think the keys get the diagnosis right and usually requires a couple of readings to do so also never "disregard way of life and attempt to keep the patient on metformin however much as could reasonably be expected on the grounds that it truly is a distinct advantage of medication and can set aside an effort to work" its effects make sure they get their screening on a routine basis for their eyes and for their feet as well as for kidney disease with the microglia and creatinine ratio and you should have some very satisfied and healthy patients Thanks
where you want it if you haven't initiated doing home glucose monitoring you're gonna want to initiate home glucose monitoring and telling it warning the patient about hypoglycemic symptoms and how to react because of course, that's one of the downsides of insulin treatment it is a nice opportunity in my opinion to check on lifestyle because you can follow along and you notice when they go when the patient goes high with their glucose readings at home when they go low what happens oh that's the day an exercise that's the day I forgot to eat or when it's high oh that was a big party
I went to and I kind of went nuts and ate whatever I wanted that's why my glucose was 450 so it can give you some insights into how to counsel patients about you know because of lifestyle never leaves just because the patient goes through Diabetes education classes and meets with an NGO an educator a Promotora or whatever it's you know it's never quite over you have to keep up that lifestyle and importantly once you initiate insulin treatment don't let go of metformin foundational drug and can help mitigate against the weight gain you're going to experience with insulin but sulfide Riyaz once you start prandial insulin there's not much point" in utilizing yourself on zones any longer get them off in light of the fact that they may advance hypoglycemia weight increase and hypoglycemia is a genuine hazard so truly screen it intently keeps these levels" in mind goal glucose levels for fasting patients 90 to 130 milligrams of per deciliter for postprandial less than 180 milligrams per deciliter okay so with that happy to that that to give you that overview on Diabetes care
I think the keys get the diagnosis right and usually requires a couple of readings to do so also never "disregard way of life and attempt to keep the patient on metformin however much as could reasonably be expected on the grounds that it truly is a distinct advantage of medication and can set aside an effort to work" its effects make sure they get their screening on a routine basis for their eyes and for their feet as well as for kidney disease with the microglia and creatinine ratio and you should have some very satisfied and healthy patients Thanks
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