Family Medicine 06: 57-year-old female diabetes care visit

User: Eduardo Ortiz

Email: eortiz075@usuniversity.edu
Date: December 15, 2020 6:07AM

Learning Objectives

The student should be able to:

Incorporate appropriate psychosocial, cultural, health literacy, and family data into the management plan of a patient with type
2 diabetes.
Apply evidence-based standards of care to the diagnosis, monitoring, and management of a patient with type 2 diabetes
mellitus.
Describe the barriers to coordination of diabetes care and systemwide improvements that could improve coordination of
diabetes care.
Describe the importance of an interprofessional team approach to the care of patients with diabetes.
Describe the utility of the electronic medical record in the care of your practice population and in the reporting of quality
measures.
Educate a patient about type 2 diabetes with attention to and respect for the patient's own disease model.

Knowledge

Comprehensive Annual Diabetes Visit

The American Diabetes Association (ADA) provides standards of care for diabetes management that are updated annually and can
be downloaded to a smartphone.

Clinician tasks for diabetes care:

Confirm the diagnosis and classify diabetes.

Evaluate for diabetes complications and potential comorbid conditions.
Review previous treatment and risk factor control in patients with established diabetes.
Begin patient engagement in the formulation of a care-management plan.
Develop a plan for continuing care.

See the American Diabetes Association's "Components of the Comprehensive diabetes medical evaluation at initial, follow-up, and
annual visits": Part 1 (.jpg) | Part 2 (.jpg)

Electronic Medical Record

An electronic medical record system:

Offers templates that increase the likelihood that patients will receive the recommended care.
May improve the quality of care in primary care settings.
Provides tools to evaluate patient care across an entire population.
Allows documentation of improved physician performance, which may increase reimbursements by some insurers.
Has been shown to interrupt the clinician-patient relationship—particularly via "screen gaze."

Pathophysiology of Diabetes

Type 1 diabetes mellitus

The pancreas is damaged through autoimmune inflammation leading to destruction of the beta cells. The loss of beta cells leads to
the complete inability to produce insulin, (immunologic etiology).

Type 2 diabetes mellitus

The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell
insulin secretion may initially compensate, but over time beta cells fail.

Chronic complications

Both types of diabetes can cause the same end-organ damage. High blood glucose eventually affects blood vessels and therefore
organs throughout the entire body. The heart, brain, kidneys, eyes, and the nerves that control sensation and autonomic function
are affected.

Remember: High blood pressure, which many patients with diabetes have, makes the vascular disease much worse.

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 Diabetes: Common Manifestations of End-Organ Damage

Cardiovascular disease, including coronary heart disease, cerebrovascular disease, and peripheral arterial disease

People with diabetes are two to four times more likely to have heart disease or stroke than people without diabetes. Patients with
diabetes who have a myocardial infarction have worse outcomes than patients without diabetes, and a diagnosis of diabetes is
considered equivalent in risk to having had a previous myocardial infarction. Management of cardiovascular risk factors so
commonly found in diabetes is therefore essential in preventing morbidity and mortality in these patients.

The American College of Cardiology/American Heart Association ASCVD risk calculator (Risk Estimator Plus) is generally a useful
tool to estimate 10-year ASCVD risk. These calculators include diabetes as a risk factor, since diabetes itself confers increased risk
for ASCVD, although it should be acknowledged that these risk calculators do not account for the duration of diabetes or the
presence of diabetes complications, such as albuminuria.

Retinopathy

Diabetes is the most common cause of new cases of blindness among adults aged 18-64 years. Five years after diagnosis of type
2 diabetes, patients with more severe or uncontrolled disease that requires insulin have a 40% prevalence of retinopathy while
those on oral hypoglycemic agents have a 24% prevalence. After 15 years of diabetes, almost all patients with type 1 diabetes and
two-thirds of patients with type 2 diabetes have background retinopathy. By the time the patient's vision is affected, substantial
retinal damage may have already occurred. Proliferative retinopathy is prevalent in 25% of patients with 25 or more years of
diabetes. In addition to optimizing glycemic control, optimizing blood pressure and serum lipid control can also slow the
progression of diabetic retinopathy.

Neuropathy

Neuropathy is a heterogeneous condition that is associated with nerve pathology. The condition is classified according to the
nerves affected. The classification of neuropathy includes focal, diffuse, sensory, motor, and autonomic neuropathy. The
prevalence of neuropathy defined by loss of ankle jerk reflexes is 7% at 1 year, increasing to 50% at 25 years, for both type 1 and
type 2 diabetes.

Nephropathy

Nephropathy is common in diabetes: 20-40% of people with diabetes develop diabetic nephropathy. Diabetes was listed as the
primary cause of kidney failure in 44% of all new cases in 2014.

Acute Diabetic Decompensations (DKA and HHS)

Type 1 diabetes

In patients with type 1 diabetes, without sufficient insulin, blood sugar runs high, and diabetic ketoacidosis (DKA) can develop.

Type 2 diabetes

Patients with type 2 diabetes with hyperglycemia more often develop hyperosmolar hyperglycemic state (HHS).

Typically it is the patient with type 1 diabetes who is most at risk for developing DKA; however, patients with type 2 diabetes
can also develop DKA. This happens because, over time, type 2 diabetes starts to resemble type 1 diabetes as pancreatic
function dwindles and patients with type 2 diabetes may begin to require insulin. If insulin deficiency is severe enough, a patient
with type 2 diabetes may produce ketones and develop hyperglycemia. For example, an older adult patient with longstanding type
2 diabetes who becomes acutely ill with pneumonia could easily develop DKA.

Screening Recommendations for Type 2 Diabetes

American Diabetes Association recommendations

1. Testing should be considered in overweight or obese (BMI ≥ 25 kg/m 2 or ≥ 23 kg/m2 in Asian Americans*) adults who have one
or more of the following risk factors:

First-degree relative with diabetes

High-risk race/ethnicity** (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
History of CVD
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 ovary syndrome
Physical inactivity
Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

2. Patients with prediabetes (A1C ≥ 5.7%, impaired glucose tolerance (two-hour plasma glucose > 140 mg/dL following a 75 gram
glucose load) should be tested yearly.

3. Women who were diagnosed with GDM should have lifelong testing at least every three years.

4. For all other patients, testing should begin at age 45.

5. If results are normal, testing should be repeated at a minimum of three-year intervals, with consideration of more frequent
testing depending on initial results and risk status.
* This lower BMI cut off is due to the difference in distribution of fat. Asian Americans tend to exhibit more visceral than peripheral

fat, which is more closely associated with insulin resistance and type 2 diabetes.

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 **^ The American Diabetes Association recommends screening in these groups because they are disproportionately affected by
type 2 diabetes. It is important to keep in mind that race/ethnicity alone does not cause diabetes, and clinicians should address
the modifiable social and structural factors that contribute to these disparities.

United States Preventive Services Task Force (USPSTF) Recommendations

For adults aged 40 to 70 years who are overweight or obese, screen for abnormal blood glucose as part of cardiovascular
risk assessment. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling
interventions to promote a healthful diet and physical activity. Rating: grade B recommendation.
For obese or overweight adults under age 40 who have additional risk factors (e.g., family history of diabetes, history of
gestational diabetes), it may be reasonable to start screening before age 40.

Diagnostic Criteria for Diabetes Mellitus

1. A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia, such as polyuria or unexplained weight loss, or
hyperglycemic crisis.
2. A fasting plasma glucose of greater than or equal to 126 mg/dL. Fasting is defined as no caloric intake for at least eight
hours.
3. A hemoglobin A1C greater than or equal to 6.5%.
4. Two-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT).

The diagnosis requires two abnormal test results from the same sample or in two separate test samples unless there is a clear
clinical diagnosis (e.g., patient in a hyperglycemic crisis or with classic symptoms of hyperglycemia and a random plasma glucose
≥ 200 mg/dL).

Who Gets Diabetes?

Prevalence of diagnosed and undiagnosed diabetes in the United States, all ages, 2018:

Total: 34.2 million people (10.5% of the population) have diabetes

Diagnosed: 26.9 million people
Undiagnosed: 7.3 million people (21.4% of the total number of Americans with diabetes)

Prevalence of diabetes (diagnosed and undiagnosed) among people aged 18 years or older, United States, 2018:

Age 18 years or older: 34.1 million, 13% of all people in this age group have diabetes.
Age 65 years or older: 14.3 million, 26.8% of all people in this age group have diabetes.

After adjusting for population age differences, 2017-2018 national survey data for U.S. adults aged 18 years or older indicate that
the following percentages have diagnosed diabetes:

7.5% of non-Hispanic Whites

9.2% of Asian Americans
12.5% of Hispanics
11.7% of non-Hispanic Blacks
14.7% of American Indians/Alaska natives

Prediabetes

In 2018 prediabetes affected roughly 88 million adults in the U.S. Prediabetes is defined as the presence of either impaired fasting
glucose-IFG (fasting glucose 100—125 mg/dl) or impaired glucose tolerance-IGT (2 hr values of oral glucose tolerance testing 140
—199 mg/dl). New evidence shows that damage to end-organs is already occurring during prediabetes and that progression to
diabetes can be delayed or prevented with lifestyle modification and to a lesser degree with medication.

The Diabetes Prevention Program (DPP) was a randomized, five-year study to evaluate intensive lifestyle modification (education,
coaching in diet and exercise, etc.) versus diet/exercise information along with 850 mg of metformin twice a day. The study
population included 3,200 participants with impaired glucose tolerance. Intensive lifestyle modification produced a 58% reduction
in risk for type 2 diabetes or a delay of about 11 years. The metformin group showed a less impressive 31% risk reduction.

Diabetic Retinopathy

The most frequent cause of new blindness among adults (aged 20—74 years). Laser photocoagulation treatment can slow the
progression of retinopathy and reduce vision loss, but it doesn't restore lost vision. Since the treatment is aimed at preventing
vision loss, and retinopathy is asymptomatic for its initial course, it's important to identify and treat patients early in the course of
the disease.

In severe, non-proliferative retinopathy, look for the following findings on a fundoscopic exam:

Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction.
Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany
hemorrhages.
Microaneurysms are more punctate dark lesions that indicate vascular dilatation.

Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel
occlusion and hypoxia.

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 Diabetes Education: Blood Glucose

Optimal range for blood glucose:

Fasting blood glucose should be 80—120 mg/dl

Postprandial blood glucose between one to two hours after a meal should be < 180 mg/dl

Conditions that contribute to hyperglycemia:

Overeating, missing doses of medication, dehydration, infection and illness, and stress.

Clinical Skills

Understanding the Patient's Experience of His or Her Illness

Often in practice, clinicians use one-way communication to describe the biomedical explanation for the disease and the
recommended treatment. The LEARN model, developed by Berlin and Fowkes, is a simple way to remember the importance of
two-way dialogue with your patient about their understanding of their own disease.

Listen with empathy and understanding to the patient's perception of the problem.
Explain your perceptions of the problem and your strategy for treatment.
Acknowledge and discuss the differences and similarities between these perceptions.
Recommended treatment while remembering the patient's cultural parameters.
Negotiate an agreement. It is important to understand the patient's explanatory model so that medical treatment fits in
their cultural framework.

Think Cultural Health offers a Guide to Providing Effective Communication and Language Assistance Services. This is a tool from
the Office of Minority Health of the U.S. Department of Health and Human Services designed to help facilitate communication with
patients from various cultural and linguistic backgrounds.

Annual Foot Exam for Patients with Diabetes

The American Diabetes Association recommends that all patients with diabetes have an annual foot exam and provides standard
of care guidelines for this exam, including testing for neuropathy.

Foot ulceration is the result of impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes
vasculopathy and peripheral vascular disease), both of which are independent, strong risk factors for foot ulceration and
amputation.

The early recognition and appropriate management of neuropathy in the patient with diabetes is important because:

1. Up to 50% of diabetic peripheral neuropathy (DPN) may be asymptomatic but leave patients at risk of foot ulceration.
2. Nondiabetic neuropathies may be present in patients with diabetes and may be treatable.
3. While specific treatment for the underlying nerve damage is currently not available—other than improved glycemic control,
which may slow progression but not reverse neuronal loss—effective symptomatic treatments are available for some
manifestations of DPN.

The foot exam should include:

Testing for loss of protective sensation

Sensory testing, according to the ADA, should be conducted with a 10-gram monofilament PLUS any one of the following:

1. Vibration using a 128-Hz tuning fork

2. Pinprick sensation
3. Ankle reflexes (Achilles necessary but patellar not needed)

Assessment of pedal pulses (dorsalis pedis and posterior tibial arteries). Assessing the arterial supply to the lower limbs
and feet is essential in evaluation for peripheral vascular disease, the strongest risk factor for delayed ulcer healing and
amputation in diabetes patients.
Inspection: Skin changes such as hair loss and temperature changes may signal vascular insufficiency. Since foot
ulceration is usually caused by breaks in the skin due to accidental trauma or poorly fitted footwear, at each visit the
patient's feet should be inspected for breaks in the skin, pressure calluses that precede ulceration, existing ulceration, and
infection, and bony abnormalities that lead to abnormal pressure distribution and ulceration. The patient's footwear should
also be inspected for abnormal patterns of wear and appropriate sizing.

Monofilament Testing for Patients with Diabetes

Video on Monofilament Sensory Testing

How to Request a Referral

Include pertinent patient information and a clear request or question to be addressed by the consultant. Sending a patient
summary that includes the past medical history, medication list, allergies, and insurance information is very helpful. If there are
relevant laboratory or imaging results, these should be included or summarized.

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 Diabetes Education: Conversation Map

Health Interactions Conversation Maps are ADA-approved tools for facilitating diabetes education. Based on adult learning
principles, the maps are designed to engage the group participants in discussion of various aspects of diabetes care (nutrition,
glucose monitoring, exercise, complications, etc). The U.S. Conversation Map tools meet the ADA Recognition criteria from a
complete DSME curriculum.

Management

Management of Specific ASCVD Risk Factors

Atherosclerotic cardiovascular disease or ASCVD (i.e., coronary heart disease and stroke) is the leading cause of death in patients
with diabetes. Patients with diabetes are two to four times more likely to have heart disease or stroke than people without
diabetes. Diabetes patients with myocardial infarction have worse outcomes than patients without diabetes, and a diagnosis of
diabetes is considered equivalent in risk to having had a previous myocardial infarction. Management of cardiovascular risk
factors so commonly found in patients with diabetes is therefore essential in preventing morbidity and mortality in patients with
diabetes.

Management of specific ASCVD risk factors:

Smoking cessation:

Advise all patients not to use cigarettes and other tobacco products (level of evidence A) or e-cigarettes (level of
evidence A).

Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care (level
of evidence A).

Advising all patients to simply cut back on their smoking has not been shown to improve cardiovascular outcomes. Strong and
convincing evidence exists for a causal link between cigarette smoking and health risk, making smoking the most important
modifiable cause of premature death. Patients with diabetes who smoke have a higher risk of premature development of
microvascular complications, CVD, and premature death. A number of large randomized clinical trials have demonstrated the
efficacy and cost-effectiveness of smoking cessation counseling in changing smoking behavior. Also, there is no evidence that e-
cigarettes are a healthier alternative to smoking or that e-cigarettes can facilitate smoking cessation.

Hypertension:

Lower blood pressure in diabetic patients with stage 1 hypertension > 130/80 mmHg. Clear observational evidence
indicates that lower blood pressures are associated with improved cardiovascular and renal outcomes for patients with diabetes,
and this relationship extends as low as systolic pressures of 115 mmHg. In the meta-analysis produced for the 2017 ACC/AHA
blood pressure guideline, researchers found evidence that treating patients to a blood pressure < 130/80 mmHg helped prevent
such outcomes, AND they found similar outcomes for patients with and without diabetes. Thus the 2017 guideline recommends
using both behavioral interventions and medications to lower blood pressures in adults with diabetes to below a goal of 130/80
mmHg. They specifically mention that physicians may choose any of the four classes of medications for patients with diabetes:
thiazides, ACE inhibitors, angiotensin receptor blockers (ARBs), or calcium channel blockers. For more required information about
hypertension management in patients with diabetes, read the Aquifer Hypertension Guidelines Module.

Dyslipidemia:

Dyslipidemia is a known risk factor for CVD in diabetic and non-diabetic populations. Abundant evidence supports the use of
statins in the prevention of cardiovascular morbidity and mortality in patients with diabetes. Measurement of fasting lipids is
recommended at the time of diagnosis of diabetes and annually for patients on statins.

The American College of Cardiology and American Heart Association (ACC/AHA) recommends the following blood cholesterol
treatment for patients with diabetes and LDL-c 70—189 mg/dL:

Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus
(level of evidence A).
High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated
10-year ASCVD risk unless contraindicated (level of evidence B).
In adults with diabetes mellitus who are younger than 40 or older than 75 years of age, it is reasonable to evaluate the
potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when
deciding to initiate, continue, or intensify statin therapy (level of evidence C). Note, the ACC/AHA recommends all patients
older than 21 (with or without diabetes) who have an LDL-c > 190 should be started on statin therapy (level of evidence
B).

For more required information about cholesterol management in patients with diabetes, read the Aquifer Cholesterol
Guidelines Module.

Lifestyle modification—weight loss, increase exercise, decrease fat intake (level of evidence A).

Aspirin:

Aspirin is effective in reducing cardiovascular morbidity and mortality in patients with previous MI or stroke (secondary
prevention). For patients with no previous cardiovascular events (primary prevention), the net benefit is not as evident.

Aspirin therapy for primary prevention can be discussed with a patient through a process of shared decision-making, weighing the
potential cardiovascular benefits with the risk of bleeding. Recommendations for using aspirin as primary prevention include men
and women aged ≥ 50 years with diabetes and at least one additional major risk factor: family history of premature ASCVD,

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 hypertension, dyslipidemia, smoking, or chronic kidney disease/albuminuria and who are not at increased risk of bleeding. For
patients over the age of 70 years (with or without diabetes), the use of aspirin may have greater risk than benefit.

The American Diabetes Association (ADA) recommends:

Aspirin therapy (75 to 162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at
increased cardiovascular risk, after a discussion with the patient on the benefits versus increased risk of bleeding (level of
evidence A).
Use aspirin therapy (75 to 162 mg/day) as a secondary prevention strategy in those with diabetes and a history of
atherosclerotic cardiovascular disease (level of evidence A).
For patients with atherosclerotic cardiovascular disease and documented aspirin allergy, clopidogrel (75 mg/day) should be
used (level of evidence B).
Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) is reasonable for a year after an acute coronary
syndrome (level of evidence A) and may have benefits beyond this period (level of evidence B).

The U.S. Preventive Services Task Force (USPSTF) recommends:

Adults aged 50 to 59 years with a ≥ 10% 10-year CVD risk:

The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and
colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk
for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years
(level of evidence B).

Adults aged 60 to 69 years with a ≥ 10% 10-year CVD risk:

The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60 to 69 years who
have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have
a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to
benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose
aspirin (level of evidence C).

The commonly prescribed dose in the U.S. is 81 mg daily.

Glycemic control:

Lowering patients’ A1Cs to < 7% has been shown conclusively to prevent microvascular disease (retinopathy and nephropathy).
Whether this glycemic control prevents macrovascular disease has been less clear. A recent meta-analysis of 5 randomized
controlled trials of intensive (A1C of 6–6.5) versus standard (A1C of 7%) glycemic control showed a significant reduction in CVD
outcomes (fatal and non-fatal myocardial infarction) but very importantly failed to show a decrease in stroke or all-cause
mortality.

A recent randomized trial of intensive glycemic control found no benefit for preventing CVD over five years, but disturbingly found
an increase in all-cause mortality. This isolated finding warrants further study, but the current ADA guidelines recommend that the
A1C goal is still close to or less than 7% and that treatment should be tailored to the patient to avoid hypoglycemia and weight
gain. More or less stringent targets may be appropriate for individual patients if achieved without significant hypoglycemia or
adverse events.

Additionally, other organizations may interpret the evidence differently, and recommend higher or lower A1C goals. For example,
the American College of Physicians (ACP) recommends aiming to achieve an A1C between 7% and 8%.

​Using the Pooled Cohort Equations risk calculator, you estimate Ms. Sanchez's ten-year ASCVD risk at 15.2%.
Aspirin therapy should be considered for primary prevention in patients with diabetes with a 10-year risk > 10%, which
includes females with diabetes 50 years of age or older who have at least one additional major risk factor. Her additional
risk factor would be elevated blood pressure (hypertension). You would need to discuss a risk of bleeding, and have a
discussion of the benefits and risks with the patient.

ADA Standards of Medical Care in Diabetes

The American Diabetes Association recommends a patient-centered approach to choosing appropriate pharmacologic treatment of
blood glucose. This includes consideration of key factors:

1) Important comorbidities such as atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), and heart failure
(HF)

2) Hypoglycemia risk

3) Effects on body weight

4) Side effects

5) Cost

6) Patient preferences

Lifestyle modifications that improve health should be emphasized along with any pharmacologic therapy. Due to recent evidence
in support of some of the newer agents for diabetes, the ADA recently changed its algorithm for medication management for this
important disease. While metformin remains the first-line therapy in addition to lifestyle changes, this new algorithm highlights the
importance of recognizing patient comorbidities, such as ASCVD or CKD. For patients with established ASCVD or major ASCVD risk
factors, a GLP-1 receptor agonist or a SGLT2 inhibitor is preferred based on cardiovascular risk reduction. For patients with heart
failure (particularly LVEF <45%) or CKD, SGLT2 inhibitors are recommended with evidence of reducing HF and CKD progression.
For patients without established ASCVD or CKD, the choice of a second agent to add to metformin is not as evidence-based.
Rather, it is based on avoidance of side effects, particularly hypoglycemia and weight gain, cost, and patient preferences.

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 Recent evidence supports the use of GLP-1 Receptor Agonists in patients with type 2 diabetes who need greater glucose lowering
than can be obtained with oral agents. Most GLP-1 RA products are injectable, but there is an oral formulation of semaglutide now
available. Trials comparing the addition of an injectable GLP-1 RA or insulin in patients needing further glucose lowering show a
similar efficacy between the two treatments. But, GLP-1 RAs in these trials had a decreased risk of hypoglycemia and greater
benefit on body weight compared with insulin, although they did have more gastrointestinal side effects. Therefore, in patients
with type 2 diabetes who need greater glucose lowering than can be obtained with oral agents, GLP-1 RAs are preferred to insulin
when possible (level of evidence B). Still, one must consider the high costs and side effect profile as potential barriers to the use of
GLP-1 RAs.

Table: available agents for type 2 diabetes management.

Dual Therapy:
Monotherapy: Metformin +
One of These

DPP-4 SGLT2 GLP-1

Metformin Sulfonylurea Thiazolidinedione Insulin
Inhibitor Inhibitor Agonist

Inhibits DPP-4,
Inhibits Activates GLP- Overcomes
Activates AMP- Stimulates insulin Activates nuclear increases
Mechanism SGLT2 in the 1 receptors, insulin
Kinase secretion transcription factor incretin
kidney mimics incretin resistance
secretion

Glipizide, Pioglitazone, Sitagliptin, Canagliflozin, Exenatide, Glargine,

Examples Metformin
glimepiride rosiglitazone saxagliptin empagliflozin liraglutide lispro

A1C
1% to 2% 1% to 2% 1% to 2% 0.5% to 1% 0.5% to 1% 1% to 2% > 2%
Reduction

Weight Neutral or
Gain Gain Neutral Reduction Reduction Gain
Effect reduction

GI,
GU
GI; Lactic Heart failure; pancreatitis,
Side Effects Hypoglycemia Rare symptoms, Hypoglycemia
acidosis edema medullary
dehydration
thyroid cancer

Evidence of
CVD Yes No Yes No Yes Yes No
reduction

Costs Low Low Low High High High Intermediate

Barriers to Initiation of Injectable Therapy

Mindset that injectable therapy is a medication of last resort and that initiating insulin equals failure.

This is not true. Remember that good glucose control is more important than the means used to achieve it.

Patient fear of injecting medication with a needle.

Most patients with diabetes are surprised at how easy administering injectable therapy is, and often share that it is less painful
than fingerstick glucose monitoring.

Physical limitations regarding drawing up injectable therapy.

Presents an impediment for some patients due to poor vision or poor dexterity; pens make it easy to "draw up" the correct amount
of medication.

Patient's perception that insulin or other injectable medications actually cause the comorbidities associated with
diabetes.

Many patients have family members or friends with diabetes who were placed on insulin late in the progression of their disease.
When complications occurred, the insulin was blamed for the poor outcomes.

Physicians may lack the time and support staff to teach patients.

Patients need to be educated about administering, storing, and dosing injectable medications, and monitoring blood glucose.

Vaccines Recommended for Patients with Diabetes

Influenza vaccine should be provided to patients with diabetes annually.

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 Pneumococcal 23-valent polysaccharide (Pneumovax) should be provided to all adults with diabetes. At age 65 (or
older), a patient will need a second dose of Pneumovax, provided at least five years have passed since the first dose.
Hepatitis B vaccine should be administered to all unvaccinated adults with diabetes. There is evidence that patients with
diabetes are at increased risk for developing hepatitis B, perhaps due to the frequent use of needles for injectable
medications and glucometers.

CDC Vaccine Information for Adults: Diabetes Type 1 and Type 2 and Adult Vaccination. 2016.
https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/diabetes.html. Accessed November 6, 2020.

CDC Recommended Adult Immunization Schedule: For Ages 19 Year or Older. 2020.
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. Accessed November 6, 2020.

Importance of Dental Care for Patients with Diabetes

When diabetes is not controlled properly, high glucose levels in saliva may help bacteria that attack tooth enamel thrive. Going to
the dentist and brushing your teeth helps remove decay-causing plaque, which can result in cavities and gum disease.

It is also important to go to the dentist regularly because gum diseases and fungal infections appear to be more frequent and more
severe due to immunosuppression among people with diabetes.

Additionally, periodontal disease can increase the risk of cardiovascular disease.

Team-Based Care for Patients with Diabetes

People with diabetes should receive medical care from a team which may include nurse practitioners, physician assistants, nurses,
dietitians, pharmacists, health educators, and mental health professionals. Each patient deserves an individualized plan using
some combination of resources that are appropriate for them.

When to Request an Ophthalmology Referral

Early detection and treatment of diabetic retinopathy can improve outcomes. Yearly dilated ophthalmoscopic exams are needed
because many patients with retinopathy may not notice symptoms. The dilated exam is very sensitive for detecting retinal
thickening from macular edema and for early neovascularization. The use of fundus photography is more sensitive for detecting
retinopathy but is more difficult to obtain because of the need for a trained photographer and reader.

Type 1 diabetes patients should have their first annual eye exam five years after diagnosis. However, type 2 diabetes patients
should have their first dilated exam when they are first diagnosed (evidence level B) because roughly 20% of patients will already
have some degree of retinopathy at diagnosis.

Evidence from two large trials, the Diabetic Retinopathy Study (DRS) and the Early Treatment Diabetic Retinopathy Study
(ETDRS), demonstrates the value of referring patients for photocoagulation surgery in order to prevent vision loss in diabetes
patients.

Diabetes Education: Daily Foot Care

Inspect, wash, and dry feet daily. Dry well between the toes.
Report injuries, ulcers, blisters, red areas or painful areas to your physician right away.
Apply moisturizer to prevent cracking, dry skin. Do not put lotion between toes.
Always wear socks and close-toed shoes; never go barefoot!
Cut toenails straight across, or have a health care professional cut them for you.
Feel inside your shoes with your hands before putting them on to avoid injury.
Purchase properly-fitted footwear preferably at the end of the day when feet are slightly swollen.

Diabetes Education: Resources to Improve Diet

Many patients with diabetes struggle with knowing what to eat. No “one-size-fits-all” nutrition plan exists, and meal
planning should be individualized. All individuals with diabetes should be referred for individualized medical nutrition
therapy with a registered dietitian/ nutritionist.
See ADA 2020 Guidelines Table 5.1 for specific nutrition recommendations.

The American Diabetes Association website has many resources for patients, including recipes and a tool for meal planning
and researching nutritional information about various foods while creating a shopping list, called Diabetes Food Hub.

Studies

Recommended Diabetes Follow-Up Laboratory Studies

There are four reasons for ordering lab tests at a diabetes follow-up visit: monitoring diabetic control, assessing end-organ
damage, monitoring side effects of treatment, and uncovering management complications.

Diabetic control is monitored via the hemoglobin A1C. The A1C is a measurement of glycosylated hemoglobin and represents
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 plasma glucose concentrations over a four- to 12-week period of time. Current standards of care recommend initial A1C testing at
diagnosis, and follow-up testing at least two times a year in patients who are stable and meeting the goal of A1C < 7; perform the
A1C quarterly in patients when therapy is changing or they are not meeting the goal. Point-of-care testing for A1C provides the
opportunity for more timely treatment changes.

Measuring a fingerstick of blood sugar is indicated if a patient acutely endorses symptoms of hyperglycemia or hypoglycemia at
the time of the visit. Otherwise, in the setting of diabetes follow-up care, this one measurement does not provide the useful
information about glycemic control that can be obtained from an A1C measurement.

Screening for and monitoring diabetic nephropathy is important for assessing end-organ damage. It is recommended at diagnosis
and annually according to ADA guidelines. In addition, many diabetes medications are excreted through the kidneys and require
annual monitoring to identify renal insufficiency and avoid drug toxicity (e.g., metformin, which can cause metabolic acidosis). 24-
hour or timed urine collections are difficult to obtain and add little to the prediction of the accuracy of protein and creatinine
measurements. The spot urine albumin-to-creatinine ratio is the screening test for microalbuminuria. In patients with urinary
albumin > 30 mg/g creatinine and/or an eGFR < 60 mL/min/1.73 m2, consider monitoring twice annually.

The serum creatinine and calculated GFR are used to monitor or stage chronic kidney disease. Automatic calculators are now
available that can directly calculate the GFR. Calculated GFR is obtained using the serum creatinine level. The Modification of Diet
in Renal Disease (MDRD) Study equation is the recommended method of calculation according to the National Kidney Disease
Education Program.

In addition to renal insufficiency, metformin can cause another side effect to take into account when deciding which labs to order.
During clinical trials, up to 7% of patients receiving metformin developed asymptomatic subnormal serum vitamin B12 levels. In
the setting of neuropathy, too, serum B12 levels would be a very reasonable diagnostic test to order.

Consider screening patients with type 1 diabetes for autoimmune thyroid disease and celiac disease soon after diagnosis.

In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes
diagnosis, at the initial medical evaluation, and every five years thereafter if under the age of 40 years. Also, obtain a lipid profile
at the initiation of statins or other lipid-lowering therapy, four to 12 weeks after initiation or a change in dose, and annually
thereafter.

Clinical Reasoning

Hyperosmolar Hyperglycemic State (HHS) versus Diabetic Ketoacidosis (DKA)

Hyperosmolar hyperglycemic state (HHS) should not be confused with diabetic ketoacidosis (DKA), the other severe diabetic
decompensation. Both HHS and DKA are life-threatening conditions that require prompt management.

HHS DKA

Increases with increasing age and serum osmolality. The average Mortality rate is roughly 2% for patients
Mortality mortality rate in many studies is 15% but can be as high as 20-30% in under 65 years old but as high as 22% for
the presence of significant infection. patients over 65 years old.

Serum Not a metabolic acidosis. Serum pH is generally > 7.3, with a Metabolic gap acidosis associated with a pH
pH bicarbonate > 15 mEq/L (> 15 mmol/L). < 7.3.

Plasma
Plasma glucose levels are usually > 600 mg/dL. Lower plasma glucose levels, i.e., 250 mg/dL.
glucose

Ketones are absent or only mildly elevated because type 2 diabetes

Ketones patients usually have enough endogenous insulin to suppress or greatly Ketosis
limit ketogenesis.

Physical findings of HHS:

HHS is characterized by severe dehydration. A profound fluid deficit is usually present, in excess of 9 L on average in adults.
Serum osmolality usually exceeds 320 mOsm/kg. Fluid replacement is a key component of treatment.

Precipitants of HHS:

Infections, such as pneumonia and urinary tract infections, accompanied by decreased fluid intake, are the most common
underlying causes of HHS. Other acute conditions, such as stroke, MI, or pulmonary embolism, may also precipitate HHS.

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