Diabetes: Guideline-Based

Management
Eric L. Johnson, M.D.
Assistant Medical Director
Altru Diabetes Center
Assistant Professor
Department of Family and Community Medicine
University of North Dakota
School of Medicine and Health Sciences

Objectives
Overview of diabetes
Discuss guideline based management
for diabetes
Apply Diabetes guideline based
management in clinical practice

What Well Do Today

Overview of Diabetes
Introduce Guidelines
Screening for Diabetes
Treating to Targets
Screening for Complications
Delivering Guideline Based Treatment
Settings
Case Studies

in Clinical

U.S. Prevalence of Diabetes

2010
Diagnosed: 26 million people8.3%
of population (90%+ have Type 2)
Undiagnosed: 7 million people
79 million people have pre-diabetes
CDC 2011

Diabetes In The U.S. 2010

8.3% of all Americans

11.3% of adults age 20 and older
27% of adults age 65 and older
1.9 million diagnosed in 2010
Could be 33% by 2050
Prediabetes
35% of adults age 20 and older
50% of Americans 65 and older

CDC 2011

Diabetes Disparities
Native American 16.1%
Black 12.6%
Hispanic 11.8%

Diabetes Mellitus
Type 1: autoimmune betacell destruction,
absolute insulin deficiency
Type 2: insulin resistance, other
mechanisms, eventual betacell failure
over time.

The Ominous Octet-Type 2

Islet -cell
Decreased
Incretin Effect
Impaired
Insulin Secretion

Increased
Lipolysis

Islet -cell

Increased Glucose
Reabsorption

Increased
Glucagon Secretion

Increased
HGP

Neurotransmitter
Dysfunction

Decreased Glucose
Uptake

Diabetes Mellitus
Type 1: Usually younger, insulin at
diagnosis
Type 2: Usually older, often oral agents at
diagnosis
Type 1.5 (Latent Autoimmune)
mixed
features ~10% of type 2
Gestational: Diabetes of Pregnancy

Diabetes Risk and

Prevention
Risk:
Type 1- mostly unknown, some familial
Type 2- obesity, smoking, sedentary lifestyle,
familial
Prevention:
Type 1- none known
Type 2- lifestyle management

Diabetes Guideline
Management
2 main sets of guidelines utilized in U.S.
American Diabetes Association (ADA)
American Association of Clinical
Endocrinology (AACE)
Lots of overlap, AACE considered
more intense

Diabetes Guideline
Management

Evidence based
Well accepted
Clinically relevant
Can be incorporated into clinical practice
Emphasize comprehensive risk
management

Diabetes Guideline
Management
ADA publishes guideline update every
January (Diabetes Care)
Clinical Practice Recommendations
http://professional.diabetes.org/

Diabetes Guideline
Management
AACE updates periodically (2011)
https://www.aace.com/publications/guidelines
AACE Medical Guidelines for Developing a
Diabetes Mellitus Comprehensive Care Plan
Includes discussion of treatment of risk factors,
role of team members, complication screening
and management, age groups

Screening For Diabetes

Screening For Diabetes

A1C or FPG or 75 g oral GTT
Testing should be considered in all adults
who are overweight
(BMI >25 kg/m2)
And
Have the following additional risk
factors.

Risk Factors for Screening

Physical inactivity
First-degree relative with diabetes
High-risk race/ethnicity

African American
Latino
Asian American
Native American, Pacific Islander

Women who delivered a baby weighing

9 lb or were diagnosed with GDM

Diabetes Care 34:Supplement 1, 2011

Risk Factors for Screening

Hypertension
(>140/>90 mmHg or on therapy for hypertension)
HDL <35 mg/dl and/or a triglycerides >250mg/dl
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

Diabetes Care 34:Supplement 1, 201

Risk Factors for Screening

In the absence of the previous criteria, testing
begins at age 45
Normal results, repeat at least at 3-year intervals
Consider more frequent testing depending results
and risk status
At-risk BMI may be lower in some ethnic groups
(i.e., Native American)

Diabetes Care 34:Supplement 1, 201

Type 2 Diabetes Screening

in Children/Adolescents
Overweight
-BMI >85th percentile
-weight for height >85th percentile
-weight >120% of ideal for height
Plus any two of the following risk factors.

Type 2 Diabetes Screening

in Children/Adolescents
FH of type 2 diabetes in 1st or 2nd-degree relative
Race/ethnicity (Native American, African American,
Latino, Asian American,Pacific Islander)
Signs of insulin resistance or conditions associated with
insulin resistance
(acanthosis nigricans, hypertension, dyslipidemia,
PCOS, or small-for -gestational-age (SGA) birth weight)
Maternal history of diabetes or GDM during gestation

Diabetes Care 34:Supplement 1, 201

Type 2 Diabetes Screening

for Children/Adolescents
Age of initiation: at-risk age 10 years or if
younger onset puberty
Screen every 3 years
No screening recommended for Type 1
Diabetes in asymptomatic individuals
outside of research protocols

Diabetes Care 34:Supplement 1, 201

Diabetes Diagnosis
Category

FPG (mg/dL)

2h 75gOGTT

Normal

<100

<140

Prediabetes 100-125
Diabetes

>126**

A1C

<5.7

140-199

5.7-6.4

>200

>6.5

Or patients with classic hyperglycemic symptoms with plasma glucose >200

** On 2 separate occasions
Diabetes Care 34:Supplement 1, 2011
https://www.aace.com/publications/guidelines 2011

Screening Review
>45 years old
Risk factors

Ethnicity
Obese
Smoking
CVD
Any Prediabetes syndrome

Risks for Complications in

Diabetes
Abnormal blood sugar/A1C
Abnormal lipids
Abnormal blood pressure
Sedentary lifestyle
Smoking

Avoiding Diabetes
Complications
Blood glucose control A1C <7%
Treat cholesterol profiles to targets
Total cholesterol <200
Triglycerides
<150
HDL (good)
>40 men, >50 women
LDL (bad)
<100, <70 high risk

Treat blood pressure to target <130/<80

For most non-pregnant adults

Treating To Targets
A1C <7%: Fewer microvascular
complications (eye, nerve, kidney)
Less glucose variability: Fewer
macrovascular complications (CVD, PAD)
BP <130/<80: reduced kidney disease
reduced CVD
Lipids to target: reduced CVD

Treating to Targets
Treating patients to target early in the
course of diabetes most likely to give
benefit
Tight control late in course of disease with
a history of poor control, less likely to
benefit

Glycemic Control

Targets for Glycemic (blood sugar)

Control In Most Non-Pregnant Adults
A1c (%)
Fasting (preprandial) plasma
glucose
Postprandial (after meal)
plasma glucose

ADA

AACE

<7*

6.5

70-130 mg/dL <110 mg/dL

<180 mg/dL

<140 mg/dL

*<6 for certain individuals

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement
at http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January 6, 2006.
AACE Diabetes Guidelines 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.

A1C ~ Average Glucose

A1C
%
6
6.5
7
7.5
8
8.5
9
9.5
10

eAG
mg/dL
126
140
154
169
183
197
212
226
240

mmol/L
7.0
7.8
8.6
9.4
10.1
10.9
11.8
12.6
13.4

Formula: 28.7 x A1C - 46.7 - eAG

American Diabetes Association

ADA Guidelines for Glucose Management

Children and Adolescents
Age

A1C

Blood Sugar
Goals-fasting/
before meals

Blood Sugar
Goals-bedtime/
overnight

Toddlers/
preschool
(06)

7.5-8.5

100-180

110-200

School age
(612)

<8

90-180

100-180

Adolescent/yo
ung adults
(1319)

<7.5

90-130

90-150

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Diabetes Care 2005;28:186212

Diabetes Medications
Glycemic Control
Type 1: Always insulin, maybe symlin in
combo
Type 2: Many oral med choices, insulin,
non-insulin injectable
Complete discussion in
Slide Deck/Podcast

ADA/EASD consensus algorithm

to manage type 2
Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and
then at least every 6 months. The interventions should be changed if A1C is 7%.

Tier 1:
Well-validated core therapies
Lifestyle and MET
+ intensive insulin

Lifestyle and MET

+ basal insulin

At diagnosis:
Lifestyle
+

MET

Lifestyle and MET+ SUa

Step 1

Step 2

Step 3

Tier 2: Less well-validated studies

Lifestyle and MET
+ pioglitazone
No hypgglycemia
No
edema/CHF
Bone loss
Lifestyle and MET
+ GLP-1 agonistb
No hypoglycemia
No
Weight loss
Nausea/vomiting
a

SU other than glyburide or chlorpropamide.

Lifestyle and MET

+ pioglitazone
+ SUa

Lifestyle and MET

+ basal insulin

Insufficient clinical use to be confident regarding safety.

MET: metformin; SU: sulfonylurea. Nathan et al. Diabetes Care 2009;32(1): 193-203

Glucose-lowering Potential of
Diabetes Therapies*
Treatment

FPG

HbA1C

Sulfonylureas

50-60 mg/dl

1-2%

Metformin

50-60 mg/dl

1-2%

-Glucosidase Inhibitors (Precose)

15-30 mg/dl

0.5-1%

Repaglinade (Prandin)

60mg/dl

1.7%

Thiazolidinediones

40-60 mg/dl

1-2%

Gliptins (Januvia,Onglyza)

targets ppd

0.5 - 0.8%

*based on package insert data as monotherapy

Glucose-lowering Potential of
Injection Diabetes Therapies*
Treatment

FPG

HbA1C

Exenatide (Byetta)

targets ppd

1-1.5%

Liraglutide (Victoza)

targets ppd

1-1.5%

Pramlintide (Symlin)

targets ppd

1-2%

Insulin

Limited by
hypoglycemia

1.5-3.5%

*based on package insert data as monotherapy

Diabetes Medications
Dr. Clarens overview of non-injectable
medications
More on injectable medications later

Key Points of
Medication Selection in Type
2

Metformin at diagnosis unless a

contraindication
Second line agents- basal insulin or many
other meds
A1C >9 at diagnosis-may need more than
one medication

Goals For Older Adults

Age and functional status dependent
Less than 3 year life expectancy, long- term
care, A1C ~8.0%
BP goals likewise individualized
HTN treatment-big bang for the buck
Statin?
Aspirin?
Johnson EL Brosseau J et al Clinical Diabetes 2008 (26) 4; 152-156
American Medical Directors Association,2002
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Blood Pressure
and
Lipids

Blood Pressure
Done at every visit
Target is <130/<80

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Lipids (Cholesterol)
Fasting lipid panel at least annually
Goals:
Total cholesterol <200
Triglycerides
<150
HDL
>40 men, >50 women
LDL
<100 (<70, CVD or high risk)
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Children with DM
Hypertension and Lipids
Lipids: start screening in childhood if
strong FH, or at age 10
Hypertension: BP >90th percentile for
height and weight or >130/>80
Consider medications (statins, ACE) if
necessary
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Blood Pressure and Lipids

Treatment
BP:
ACEI usually first line, ARB alternate
Other meds as necessary (often 2 or 3)
Lipids:
Statins usually first line
Fibrates, Fish Oil, Niacin

Aspirin
Men >50 years of age
Women >60 years of age
Younger if higher risk

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Complications Screening

Nephropathy

Nephropathy (Kidney
Disease)
Screening

Annual urine testing for

micro- or macro- albuminuria
Annual creatinine and GFR
Start at diagnosis for type 2
Start 5 years after diagnosis type 1

Diabetes Care. 2011;34(suppl 1)

Kidney Disease
Management
ACEI or ARB for microalbuminuria or proteinuria
Serum creatinine and creatinine clearance (or
GFR)
May need 24 hour urine protein
May need nephrology referral
Blood pressure to target <130/<80
A1C <7
Diabetes Care. 2011;34(suppl 1)

Retinopathy

Retinopathy Screening
Type 1 annual starting after age 10 or after
5 years post diagnosis
Type 2 annual starting shortly after
diagnosis
Consider less frequent if one or more
normal exams (not usually done)
Diabetes Care. 2011;34(suppl 1)

Retinopathy Management
A1C < 7
Laser photocoagulation by
ophthalmologist or retinologist

Neuropathy

Neuropathy Screening
Screen at diagnosis and annual thereafter
Be aware of less common presentations
Foot inspection every visit plus annual/prn:
Filament testing
Vibratory testing (128 HZ)
Reflexes
American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Neuropathy: Treatment
Optimize blood glucose control
Consider other differentials, i.e. B12 deficiency in
metformin users, thyroid
Anti-seizure meds (gapapentin, pregabelin)
Tricyclic anti-depressants (amitriptyline)
Duloxetine-antidepressant with neuropathy indication
Capsazin creme

Other Screening

Celiac Disease Screening

At diagnosis in Type 1 and periodic (?), pregnant
Rescreen if GI symptoms, failure to thrive, glycemic control
changes
~10% of type 1?
Test:
Tissue transglutaminase IgA and IgG
Or
Anti-endomysial antibiodies with serum IgA
Small bowel biopsy to confirm

American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Thyroid Screening
Type 1 screen at diagnosis and every
1 to 2 years, and if pregnant
At diagnosis, thyroid peroxidase and
thyroglobulin antibodies
TSH thereafter

Liver Disease

NAFLD, NASH
~30% of adults with DM
LFTs periodic
Imaging (CT, Ultrasound, MRI) if persistent
abnormal LFTs
May need biopsy and referral

Other
Screening/Interventions

Tobacco cessation
Smoking contributes to poor glucose control and
increased CVD risk
Smokers should be directed to a cessation
program, i.e., Quitline, Quitnet, Quitplan, 3 rd party
payer, etc.
Medication(if appropriate)
Other routine screens (i.e.,cancer)

Diabetes Clinical
Encounters:
Delivering Guideline Based Care

Routine Diabetes Clinical

Encounter

Physical Exam-Diabetes Directed

Labs
Team management
Systematic clinical encounterskeep everything organized
See patient 2 to 4 times a year, prn

Diabetes Clinical Encounters

HPI-My EHR Template
Patient comes in today for follow up on type (1 or 2) diabetes
(Other problem list)
Home Blood glucose monitoring:
Ambulatory/Home Blood Pressures:
Current concerns:
Last educator appointment:
Last dietician appointment:
Last eye appointment:
Last dental:
Flu vaccine (seasonal):
Other recent appointments:
Complete medication review

Diabetes Clinical Encounters

Review of Systems-My EHR Template
General: Fatigue/Energy level, appetite,
recent illnesses, polydipsia
HEENT: Vision change, sore throat, neck
pain/masses
Cardiopulmonary: CP, dyspnea, palpitations
Abdomen: Diarrhea, constipation, pain

Diabetes Clinical Encounters

Review of Systems (contd)
Genitourinary: Polyuria, Dysuria, Urgency,
Frequency, Nocturia
Musculoskeletal: Muscle or Joint Pain, Foot or Leg
Pain
Neurologic: Dizzy, Lightheaded, Parasthesias,
Weakness, Pain
Skin: Rash or other
Psych: Depression, Anxiety

Diabetes Clinical Encounters

Physical Exam
VS: Height, Weight, BP (x2?),Pulse,
Tobacco status
Fundus exam
Cardiopulmonary
Carotids
Thyroid
Abdomen (enlarged liver-fatty liver)

Diabetes Clinical Encounters

Physical Exam (contd)
Filament and vibratory testing (feet)
Reflexes
General foot exam
(skin, nails, lesions, color, pulses)
General skin/injection sites
Other complaint directed
Growth parameters-children

Diabetes Foot Exam

Every visit: visual inspection of skin, nails,
lesions, color, deformity
(i.e.,
hammertoes, charcot joint),
edema
Annual complete foot exam skin, nails,
lesions, color, pulses, deformity, edema,
10gm monofilament sensitivity, 128
vibratory sensation, reflexes

Diabetes Clinical Encounters

Other:
Age appropriate recommendations
(cancer screening, etc)
Vaccinations

Diabetes Labs
A1C 2-4 times yearly
Chemistry panel, to include renal and hepatic 1-2 times
yearly, prn
Urine for microalbumin annually
CBC annually, particularly if on aspirin and/or renal disease
Celiac screening in type 1 periodically
(ever 3 years
and prn)
Thyroid screening usually annual in type 1

Diabetes Care 34:Supplement 1, 2011

The Diabetes Team

Physician: Primary Care, Diabetologist,
Endocrinologist
Mid-level provider: Physician Assistant,
APRN,or Nurse Practitioner
Other appropriate specialists (eye, kidney,
heart, psychologist, foot, dentist)

The Diabetes Team

Diabetes Nurse Educator or Certified
Diabetes Educator (CDE)
Registered Dietician
The patient !

Self Monitored Blood

Glucose
On insulin, generally minimum TID,
usually more if MDI or pump
CGM clinic or home may be useful
Type 2 on orals, maybe less if stable

Lifestyle Management
Medical Nutrition Therapy (MNT)
Exercise/Activity Prescriptionsalmost everybody can do something
Indicated for all patients with Diabetes

ADA Nutrition Strategies

Encourage weight loss in overweight/obese
Modest weight loss-improve insulin
resistance
Reduce calories and fat
Saturated fat <7%, minimize trans-fat
Customize plans for patients

Weight Loss
(Bariatric)Surgery
BMI >40
BMI >35 and
one
obesity and/or diabetes related issue
Usually results in dramatic improvement in
type 2 and related issues
Effective tool if combined with medical
management in appropriate patients

EHR
Electronic health records have great
potential to monitor diabetes labs,
progress, goals, etc
Work with your IT department, many
systems have customizable built in
diabetes systems

Summary
Implementation of evidenced based
guidelines improves diabetes outcomes
Guidelines are easily available
Getting patients to goals is important
Organized clinical encounters help get
patients to goals

Acknowledgements

North Dakota Department of Health, Karalee Harper

Dakota Diabetes Coalition, Tera Miller
Centers for Disease Control
Office of Continuing Medical Education, UNDSMHS,
Mary Johnson
Department of Family and Community Medicine,
UNDSMHS, Melissa Gardner
Brandon Thorvilson, UNDSMHS IT

Slide Decks and iTunes

Podcasts
Podcasts 5 to 10 minute Diabetes Topics
Google
Dr. Eric Johnson Diabetes Podcasts
All slide decks downloadable to view
Google
Dr. Eric Johnson Diabetes Slide Decks

Contact Info/Slide
Decks/Media
e-mail
eric.l.johnson@med.und.edu
ejohnson@altru.org
Phone
701-739-0877 cell
Slide Decks (Diabetes, Tobacco, other)
http://www.med.und.edu/familymedicine/slidedecks.html
iTunes Podcasts (Diabetes) (Free downloads)
http://www.med.und.edu/podcasts/ or iTunes>> search UND
WebMD Page: (under construction)
http://www.webmd.com/eric-l-johnson
Diabetes e-columns (archived):

http://www.diabetesnd.org/?id=73&page=Dr.+Eric+Johnson+Archive