Transcript University Internal Medicine Adult Diabetes Practice

Standard 3: Care
Management
a.) Guidelines for important conditions
University Internal Medicine
Adult Type 2 Diabetes Practice Guideline
Diabetes Mellitus – Diagnostic Criteria (Non-Pregnant Adults)
Casual plasma glucose > 200 mg/dl and symptoms of diabetes (polyuria, polydipsia, ketoacidosis, or unexplained weight loss) OR Fasting plasma
glucose (FPG)* >126 mg/dl OR Results of a 2-hour 75-g Oral Glucose Tolerance Test (OGTT)* > 200 mg/dl OR A1C >6.5%
• • * These tests should be confirmed by a repeat test, on a different day, unless unequivocally high
Initial Diagnosis
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History
Symptoms of hypoglycemia/hyperglycemia
Atherosclerotic risk factors
Exercise and diet
Pneumovax, influenza and Hep B status
Medications and allergies
Tobacco and alcohol use
Family history
Past medical history
Psychosocial history with assessment for
mood disorder and factors that might affect
management
Contraception and reproductive history
Laboratory assessment
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Hgb A1C point of care testing
Urine microalbumin
Fasting lipid pane
Serum creatinine and calculated GFR
Management
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Initiate treatment
Refer for Diabetes Education
Refer for nutrition counseling
Physical Exam
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Blood pressure
Weight/height and BMI
Evaluation of pulses
Foot examination with monofilament testing
Retinal camera exam or dilated retinal exam
by an eye specialist (Type2)
Metformin preferred
Reference: Standards of Medical Care in Diabetes -2013. Diabetes Care January 2013 vol 36 no. Supplement 1 S11-S66.
http://care.diabetesjournals.org/content/36/Supplement_1/S11.long#sec-18
Every Visit
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Interval history
Symptoms of hypoglycemia/hyperglycemia
Review glucose testing results
Tobacco cessation counseling, if needed
Medication reconciliation
Obtain weight
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Calculate BMI
Review exercise and diet
Adjust therapeutic regimen to goal
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A1C <7% for most – individualize goals
BP < 140/<80 based on individualized risks
LDL <100; statin for all patients with CAD
or high risk
Flu, pneumovax, Hep B up to date
ACEI/ARB for nephropathy
Anti-platelet agents – all patients for
secondary prevention; primary prevention
if 10 year risk of CAD >10%
Quarterly to semi-annually
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Review patient self-management
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Glucose testing, self-foot exam, exercise,
diet
Importance of good dental care and regular
exams
At least once a year
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Test A1C
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Point of care testing every 3 months, or
twice yearly if in good control
Annually
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Complete foot exam
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Nephropathy screening
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No known nephropathy – urine
microalbumin
(normal <30)
Known nephropathy – consider
nephrology consult
Serum creatinine and GFR
measurements
Obtain fasting lipid panel
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Inspection, pulses, monofilament
LDL goal <100, or <70 if CVD or
high risk
Retinal eye exam
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Retinal images and/or dilated exam
performed by eye care professional
•Reference: Standards of Medical Care in Diabetes -2013. Diabetes Care January 2013 vol 36 no. Supplement 1 S11-S66.
http://care.diabetesjournals.org/content/36/Supplement_1/S11.long#sec-18
University Internal Medicine
Adult Hypertension Practice Guideline
Hypertension Diagnostic Criteria
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The average of 2 or more BP readings in two or more office visits with properly sized blood pressure cuff, measured by
auscultation, patient seated at least 5 minutes prior to the exam, feet on the floor and arm resting at heart level.
≥ 60 yo: <150/<90
<60 yo: <140/<90
Initial Diagnosis
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History
Symptoms – focused on secondary causes including
OSA
Atherosclerotic risk factors
Exercise and diet
Medications and allergies
Tobacco and alcohol use
Family history
Past medical history
Psychosocial history with assessment for mood
disorder and factors that might affect management
Contraception and reproductive history
Physical Exam
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Blood pressure properly measured – both arms
Weight/height and BMI
Retinal examination or retinal pictures
Palpation of thyroid
Auscultation for bruits: carotid, abdominal, femoral
Heart, lung and abdomen exam
Lower extremity exam – edema and pulses
Neurological exam
Laboratory assessment
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12-lead EKG
Urinalysis
Complete metabolic panel (including calcium,
creatinine and GFR)
Fasting lipid panel
Hematocrit
Management
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Lifestyle modifications (table 1)
Initiate treatment
Table 1: Recommended Lifestyle Modifications
• Weight reduction
• Aerobic physical activity
― At least 30 minutes most days of the week
• Dietary Approaches to Stop Hypertension (DASH) diet
― Rich in fruits and vegetables, low in saturated fat
• Dietary sodium reduction
― <2.4 g Na or <6 g NaCl
• Moderation of alcohol consumption
― <2 drinks per day for men, 1 for women
Reference: 2014 Evidence-Based Guideline for the management of high blood pressure in adults: report from the panel members appointed to the
eight Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
JNC 7 - http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm
Annually
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Nephropathy screening
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Obtain fasting lipid panel
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Serum creatinine and GFR measurements
LDL goal as per hyperlipidemia guidelines
and risk factors
Obtain CMP
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Follow affects of drug therapy
References: 2014 Evidence-Based Guideline for the management of high blood pressure in adults: report from the panel members appointed to the
eight Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
JNC 7 - http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm
University Internal Medicine
Adult Obesity Practice Guideline
Overweight/Obesity– BMI Diagnostic Criteria (Non-Pregnant Adults)
• Overweight 25-29.9
• Obesity ≥ 30
Prevention of Overweight and Obesity
Advice for patients with weight concerns:
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Decrease intake of energy-dense foods (animal fats, other high fat foods, sugary foods or beverages) by selecting
low energy-dense foods instead (wholegrains, fruits, vegetables)
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Reduce consumption of “fast food”
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Decrease alcohol intake
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Increase physical activity and decrease TV watching or other sedentary behaviors
Overweight and Obesity Treatment Goals
W eight loss targets should be based on the individual’s comorbidities and risks, rather than their weight alone:
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ƒin patients with BMI 25-35 obesity-related comorbidities are less likely to be present and a 5-10% weight loss (approximately
5-10 kgs) is required for cardiovascular disease and metabolic risk reduction.
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ƒin patients with BMI>35 obesity-related comorbidities are likely to be present therefore weight loss interventions should be
targeted to improving these comorbidities; in many individuals a greater than 15-20% weight loss (will always be over 10 kg)
will be required to obtain a sustained improvement in comorbidity
Review secondary causes of Overweight/Obesity and Modify
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Smoking cessation
Medications
Atypical antipsychotics
Beta adrenergic blockers
Insulin in Type 2 Diabetics
Lithium
Sodium valproate
Sulfonylureas
Thiazolidinediones
Tricyclic antidepressants
Counsel Patients on the Health Benefits of Weight Loss
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improved lipid profiles
ƒreduced osteoarthritis-related disability.
lowered all-cause, cancer and diabetes mortality in some patient groups
ƒreduced blood pressure
ƒimproved glycaemic control
ƒreduction in risk of type 2 diabetes
ƒpotential for improved lung function in patients with asthma.
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Assess willingness to change – discuss with patient then target weight loss interventions
Weight management programs should include physical activity, dietary change and behavioral components
Diet should be calculated to produce a 600kcal/day energy deficit
Physical activity should equal 1800-2500 kcal/week or 225-300 min/week of moderate intensity physical activity
Pharmacologic treatment should be considered as an adjunct to lifestyle interventions
Bariatric surgery should be considered on an individual basis for all patients with BMI ≥ 40 or BMI ≥ 35 with one or more
comorbid medical conditions (arthritis, obstructive sleep apnea, diabetes mellitus type 2, hypertension, dyslipidemia) who have
completed a structured weight management program
References: Scottish Intercollegiate Guidelines Network Management of Obesity 2010 . http://www.sign.ac.uk/pdf/sign115.pdf. NHLBI 1998