Internal Medicine 08: 55-year-old male with chronic disease

management
User: Julie Vaughan
Email: julivaug@iu.edu
Date: January 21, 2022 10:43PM

Learning Objectives

The student should be able to:

List the major causes of morbidity and mortality in diabetes mellitus.

Recognize the basic management of hypertension and hyperlipidemia in the diabetic patient.
Perform a diabetic foot exam.
Counsel patient on behavior change.
Recognize the value of a team approach to the management of diabetes.
Appreciate the impact diabetes mellitus has on a patient’s quality of life, well-being, ability to work, and family.

Knowledge

Hypoglycemia

Hypoglycemia is defined as a blood glucose < 70 mg/dL. It is important at each visit to ask diabetic patients if they have
experienced any hypoglycemic symptoms or events that required the assistance of another person.

It is common for patients not to record hypoglycemic values because they are preoccupied with treating their hypoglycemia when
they develop what they perceive to be the characteristic symptoms.

Diabetic Neuropathies

It is estimated that 50% of patients with diabetes will eventually struggle with one or more neuropathies related to their diabetes.

Axonal loss and atrophy are responsible for the majority of clinical symptoms and loss of function in patients with neuropathy.
There can also be evidence of demyelination and remyelination, with the actual number of large nerve fibers being reduced, while
small nerve fibers increase.

Distal polyneuropathy

Distal polyneuropathy is the most common type of diabetic neuropathy. It is the progressive loss of sensation in the classic
stocking/glove distribution. Diabetic foot ulcer incidence is greatly increased in patients with distal polyneuropathy.

Autonomic neuropathy

Autonomic neuropathy can take many forms and affect one or many organs. Specific types include:

cardiovascular (orthostatic hypotension, resting sinus tachycardia, postprandial hypotension)

gastrointestinal (gastroparesis, chronic constipation, esophageal motility disorders)
genitourinary (sexual dysfunction, neurogenic bladder)
abnormal pupillary responses and disorders of hidrosis

Diabetic Retinopathy

Diabetic retinopathy, a microvascular diabetic complication, is the leading cause of preventable blindness in the developed world.

Prevention

Two large prospective trials (DCCT studying patients with type 1 diabetes and UKPDS studying patients with type 2 diabetes)
revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic
retinopathy.
Duration of diabetes and level of glycemic control, as well as coexisting hypertension, nephropathy, dyslipidemia, and
tobacco abuse contribute to retinopathy onset and progression.

Two types of diabetic retinopathy

1. Non-proliferative diabetic retinopathy

Involves cotton wool spots, hard exudates, microaneurysms, and retinal hemorrhages. Vision loss usually results from severe
macular edema, a thickening of the retina with resultant edema of the macula.

2. Proliferative diabetic retinopathy

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 Involves neovascularization of the retinal vessels or optic disc, retinal hemorrhage (dot-blot, flame), retinal fibrosis with traction
detachment, and vitreous hemorrhage. Vision loss can result from macular edema or neovascularization causing tractional retinal
detachment or pre-retinal or vitreous hemorrhage.

Image of proliferative retinopathy with neovascularization

Onset

Development of diabetic retinopathy is directly related to disease duration and is generally not seen in patients who have had
diabetes less than five years. The exception is patients with type 2 diabetes who were likely hyperglycemic more than five years
prior to their diabetes diagnosis.

Screening

Annual dilated eye exams by an ophthalmologist are recommended for all patients with type 1 diabetes within five years of
diagnosis and shortly after diagnosis in patients with type 2 diabetes. Patients with progressive retinopathy are often seen
quarterly or biannually.

Panretinal Treatment

Panretinal laser photocoagulation is the treatment of choice for proliferative diabetic retinopathy and severe cases of non-
proliferative retinopathy. Screening is done aggressively due to the well-documented efficacy of laser photocoagulation in the
prevention of vision loss. Intravitreous injections of anti-vascular endothelial growth factors are indicated for central-involved
diabetic macular edema.

Diabetic Nephropathy

Epidemiology

Diabetic nephropathy occurs in 20% to 40% of diabetic patients and is the most common etiology of end-stage renal disease in
the U.S.

Risk factors associated with the progression of diabetic nephropathy include: obesity, increasing age, African American race, and
tobacco abuse.

Pathogenesis

Kidney insult appears to originate with glomerular hypertension and hyperfiltration. Chronic hyperglycemia leads to mesangial
expansion, deposition of matrix, increased amount of VEG-F and other cytokines, local inflammation, and activation of protein
kinase C.

Prevention / Treatment

Two large prospective trials (DCCT with type 1 diabetics and UKPDS with type 2 diabetics) revealed that intensive glucose
management resulted in prevention or delayed onset and progression of diabetic nephropathy, but studies have not shown that
tight glycemic control can reduce end stage renal disease.

Aggressive blood pressure lowering is critical for treatment of increased urinary albumin excretion. In patients with hypertension
with increased urinary albumin excretion, an ACE inhibitor or ARB therapy is recommended to delay the onset and decrease
progression of diabetic nephropathy.

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 Referral

Referral to nephrology is appropriate if the cause of kidney disease is not certain, and or there are challenging management issues
present, such as resistant hypertension or electrolyte derangement. The threshold for referral to nephrology varies across
providers; however, nephrology should be consulted if Stage 4 or greater chronic kidney disease (GFR < 30 ml/min per 1.73 m2)
develops since this has been found to reduce cost, improve quality of care, and keep people off dialysis longer.

Clinical Skills

When to Perform the Diabetic Foot Exam

It is important to do a thorough foot exam in a patient with diabetes on an annual basis for low-risk patients and more often in
patients at high risk for foot ulcer formation.

Patients at High Risk for foot Ulcer Formation

Patients with known diabetic polyneuropathy, sensory or vascular deficits, patients who smoke, and patients with a prior history of
diabetic foot ulcer, deformity, or amputation.

Foot Exam in Patients with Diabetes

Visually inspect the feet for callus formation, ulceration, nail infections, and bony deformities.

Assess skin integrity, especially between toes and under metatarsal heads.

Palpate the dorsalis pedis and posterior tibialis pulses to screen for peripheral vascular disease and look for signs of peripheral
vascular disease, such as hair loss.

Check sensation using a 128 Hz tuning fork (vibration) and a cool metal object, potentially the same tuning fork (temperature).

Check pressure sensation using a 10-g monofilament. Decreased monofilament sensation has been shown to increase risk of foot
ulcer and amputation in patients with diabetes.

Show the monofilament to the patient and try it on their hand to show them it will not hurt.
Ask the patient to close their eyes or look at the ceiling and tell you each time they feel the monofilament touch their foot.

Randomly place the end of the monofilament on the nine different areas of the foot (see image to the right) with enough
pressure to bend the monofilament.
If the patient does not say "yes" at a particular site, continue to the next site and re-test that site at the end.

Check Achilles reflexes.

Management

Diabetes Chronic Disease Management

Evaluate for and optimize prevention of diabetic complications

Macrovascular complications:

Cardiovascular disease
Cerebrovascular disease

Microvascular complications:

Retinopathy
Nephropathy
Neuropathy

In particular, cardiovascular disease is the No. 1 cause of mortality and one of the top causes of morbidity for people with
diabetes.

Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.

The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.

Remember the large role that the psychosocial aspects of a diabetes diagnosis play in management.

Non-adherence to medical recommendations may be due to economic, work-related, religious, social, or linguistic barriers to care.
Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to
successful diabetes care are minimized.

ADA Recommendations to Minimize the Risk of Cardiovascular Disease in Patients with Diabetes

Smoking cessation, blood pressure control, and lipid control are all recommended to reduce the risk of cardiovascular
disease.
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 Daily low dose aspirin is no longer recommended for primary prevention of cardiovascular disease in diabetic patients across the
board. Instead, it may be considered after a comprehensive discussion of risk and benefit with an individual patient, due to
increased recognition of bleeding risks and because trials failed to consistently show a significant reduction in overall ASCVD end
points. It remains recommended for secondary prevention of diabetic patients with a history of atherosclerotic disease.

Reduction of cardiovascular risk is achieved with a goal of optimal glycemic control, as well as control of many other health
factors that raise cardiovascular risk, such as tobacco use, obesity, poorly controlled hypertension, and hypercholesterolemia.

Effectiveness of Intravenous Insulin for Blood Glucose Control

Blood sugar control in critically ill patients has been the subject of considerable investigation. Previous research suggested that
tight control (80-120 mg/dL) was desirable, but more recent research shows that aggressive blood sugar control can be associated
with higher mortality.

Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight
glycemic control. A meta-analysis of 29 controlled trials involving more than 8,000 adult ICU patients showed no difference in in-
hospital mortality between the group assigned to tight glucose control versus usual care.

The current recommended blood glucose target for most hospitalized patients is 140 to 180 mg/dL.

Sodium-glucose Co-transporter 2 (SGLT2) Inhibitors

Empagliflozin, a member of the class of drugs known as sodium-glucose co-transporter 2 inhibitors (SGLT2i), has been shown to
reduce major adverse cardiovascular events (MACE), and a composite outcome of CV death or hospitalization for heart failure
compared to placebo in patients with established atherosclerotic cardiovascular disease. The same is true for canagliflozin,
another SGLT2 inhibitor that has been associated with decreased morbidity and mortality in patients with type 2 diabetes.

Mechanism of action: SGLT2 inhibitors reduce renal tubular glucose reabsorption via inhibition of the SGLT2 enzyme in the
proximal renal tubule, promoting glucose excretion in the urine and producing a reduction in blood glucose without increasing
insulin release.

Effects: SGLT2 inhibitors increase glucosuria, lower blood glucose and hemoglobin A1c by limiting the filtered load of glucose in
the kidney and promoting osmotic diuresis. In addition to their cardioprotective effects, they have been shown to reduce
progression of diabetic nephropathy, especially in patients with less-advanced chronic kidney disease. Overall, they cause the A1c
to decrease by 0.4% to 1.1%. SGLT2 inhibitors can also result in modest weight loss of 2 to 3kg on average.

Side effects: Due to the increase in glucosuria and osmotic diuresis, SGLT2 inhibitors can cause an increase in genitourinary tract
infections, including yeast infections and, in rare cases, potentially fatal bacterial infections, including necrotizing fasciitis of the
perineum. In addition, hypotension and acute kidney injury have been reported. Finally, there are reported increases in bone
fractures, diabetic ketoacidosis (including euglycemic DKA) and an increased risk of amputations, that vary between medications
in this class.

Warnings: Care should be used with these agents in patients with frequent urinary tract infections, vulvovaginal yeast infections,
advanced kidney disease, absent protective sensation in the feet (such as diabetic neuropathy), foot deformity, or prior foot
ulceration.

Contraindications: Patients with severe renal impairment (eGFR < 30 ml/min/1.73m2), ESRD requiring dialysis.

When to Refer Patients with Diabetes to an Endocrinologist

Primary care physicians' threshold for referral varies across providers. Conditions that would warrant endocrinology referral
include:

Recurrent or severe hypoglycemia (seizure, coma, or impairment that requires the aid of another person)
Hemoglobin A1c ≥ 8% more than twice in a 12-month period, despite intensive treatment
Initiation of a complex multiple daily injection insulin regimen
Initiation of continuous infusion insulin pump therapy

Self-Monitoring Glucose: Indications & Effectiveness

Effectiveness of Self-Monitoring Blood Glucose

Patients should be advised to check their blood sugar if they feel "low" because it is well recognized that people are not able to
accurately detect hypoglycemia (blood glucose of < 70 mg/dL) by symptoms alone. Eating high carbohydrate food to
treat perceived hypoglycemia rather than actual hypoglycemia leads to worsened overall glycemic control.

Clinical studies have shown that self-monitoring of blood glucose (SMBG) may improve glycemic control, although for some
patients self-monitoring increases depression and anxiety. It is important to evaluate patients' abilities to use SMBG techniques to
ensure they are using accurate data to evaluate their response to therapy and their degree of success in reaching blood-glucose
targets. After receiving education, patients can use SMBG data to adjust their activity level, food intake and choice, as well as drug
therapy to achieve optimal glycemic control.

When to Self-Monitor Blood Glucose

In patients on less frequent insulin injections, SMBG may be useful in achieving glycemic goals.

Patients on an insulin pump and those using multiple daily insulin injections should self-monitor blood glucose at the following

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 times:

before each meal

at bedtime
when they have symptoms of hyper- or hypoglycemia
after treating hypoglycemia to ensure return of euglycemia
before exercise
before critical activities, such as driving

Blood Glucose Goals

*Medically Complex **Very Medically Complex

Healthy Adults
Adults Adults

fasting and before meals 80-130 mg/dL (3.9-7.2 mmol/L) 90-150 mg/dL 100-180 md/dL

one to two hours after a

< 180 mg/dL (10.0 mmol/L)
meal

100-130 mg/dL (5.6-7.2

before bed 100-180 mg/dL 110-200 mg/dL
mmol/L)

*Medically complex adults have multiple coexisting chronic illnesses, two or more ADL impairments, or mild to moderate cognitive
impairment.

**Very medically complex adults or adults in poor health have long term care or end-stage chronic illnesses, moderate to severe
cognitive impairment, or two or more ADL dependencies.

See the associated reference ranges in conventional and SI units.

Body Weight Management in Patients with Diabetes

Classification BMI in kg/m 2

Normal 19-24

Overweight 25-29

Obese (Class 1) 30-34

Obese (Class 2) 35-39

Morbidly obese (Class 3) 40+

Maintenance of a healthy body weight is essential in the management of patients with diabetes. However, for some patients,
attainment of an ideal body weight is too large a goal, especially if they are morbidly obese. Studies have shown that a modest
weight loss of approximately 5-10% of the current weight can lead to significant improvement in glycemic control, blood
pressure control, and lipid parameters.

Multidisciplinary Approach to Diabetes Care

The care of the patient with diabetes is a team endeavor. Through a multidisciplinary approach, patients can be offered the very
best chance of optimizing their blood glucose control and reducing their risks of morbidity and mortality.

Refer to a registered nutritionist for medical nutrition therapy regarding daily food choices and portion sizes.
Refer to an accredited diabetes care center for diabetes management self-education, both in group and one-on-one
settings. Numerous studies have shown that diabetes management self-education is effective in improving patients' self-
care behaviors, lowering their A1c, improving their knowledge of diabetes and enhancing their quality of life.
Office-based counseling of basic ADA recommendations for diet and exercise can be reviewed with the patient. For example,
patients can be taught how to monitor their carbohydrate intake through carbohydrate counting, food exchanges, or self-
reflection. Thirty minutes of moderately intense exercise, more days than not, may be a good recommendation for many
patients. Less than 10% of daily calories should be from fat.
Patient education materials are a useful adjunct to office-based counseling, and can be found at the ADA website section on
diet/exercise.
Numerous medications used for the treatment of diabetes can affect weight. For example, metformin and glucagon-like
peptide-1 (glp1) receptor agonists can promote modest weight loss in some patients, while other medications, such as
insulin and sulfonylureas, can promote weight gain.
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 Blood Pressure Goal for Patients with Diabetes

There is ample, well-validated evidence that blood pressure control is one way of lowering the cardiovascular risk for a patient
with diabetes. According to the ADA, the optimal blood pressure goal in patients with diabetes is less than 140/90 mmHg. Patients
with diabetes at elevated cardiovascular risk may benefit from a lower target blood pressure (>/= 130/80 mmHg.). An individual
patient's blood pressure goal may be higher or lower based on their response to therapy and personal characteristics.

Other organizations recommend different blood pressure goals for all patients, including those with diabetes. The ACC/AHA
guidelines on hypertension published in late 2017 suggested lower numbers for a definition of HTN; now anything over 130/80 is
considered hypertension per ACC/AHA and blood pressure lowering treatments are recommended to target a goal blood pressure
of less than 130/80 mmHg.

Pharmaceutical management

Most diabetic patients require multiple agents to reach and maintain their individual blood pressure goal. ACE inhibitor and ARB
therapy are first-line treatment options in patients with diabetes and albuminuria or CAD because they also delay the onset and
decrease the progression of diabetic nephropathy. Thiazide diuretics and calcium channel blockers can also be used to attain
blood pressure goals.

Reasons for uncontrolled blood pressure

There are multiple reasons why a patient may have uncontrolled blood pressure. Blood pressure may be uncontrolled in patients
needing increased dosages of their medications or additional agents. It may be elevated from medications (e.g. NSAIDs) or
alcohol. Secondary causes of hypertension should also be considered, including primary aldosteronism, Cushing disease, renal
artery stenosis, and untreated obstructive sleep apnea.

Patients may not be taking their medications regularly, may not have taken their medications on the day of the office visit, or may
have run out of their medication prior to the visit. Before adding another medication or increasing the dose of existing medication,
it is critical that nonadherence be explored first as a possible cause of uncontrolled hypertension.

Foot Care for Patients with Diabetes

It is important to review and provide information about foot self-care with diabetic patients.

Patients should be instructed to check the dorsal and plantar surfaces of their feet everyday for cuts, sores, redness, and
swelling.
If the patient is unable to view their entire foot on their own, then a caregiver should be asked to do it for them.
Feet should be washed daily and dried well.
Remind patients to use their forearm to check water temperature to prevent burns.
Patients should keep the skin of their feet smooth and soft with lotion.
Toenails should be trimmed weekly or as needed.
Patients should be encouraged to wear white socks, as these will show any drainage from a previously unknown sore, and
well-fitting, comfortable shoes.
Shoes and socks should be worn at all times.
There is no robust evidence to warrant the recommendation that all patients with diabetes be fitted with special shoes to
prevent diabetic foot ulcers.
High-risk patients should be referred to a podiatrist for comprehensive foot care.

Vaccinations for Patients with Diabetes

Patients with diabetes should receive a pneumococcal vaccination and should be immunized for influenza annually. They should
also receive the Hepatitis B vaccine series if they are between 19 and 59 years old.

Dental Care for Patients with Diabetes

Patients with diabetes should be seen by a dentist regularly; the recommendation is twice a year.

Metformin Contraindications

Metformin is not recommended for patients with reduced ejection fraction requiring pharmacologic therapy, in particular patients
with unstable or acute heart failure. It is likely safe in patients with well-compensated, stable CHF. It is prudent to stop a patient's
metformin in the setting of a recent heart failure diagnosis but it may also be reasonable to restart it in the future should their
symptoms stabilize.

Metformin is also contraindicated in patients with a GFR of < 30 mL/min/1.73m2. In addition, it shouldn't be started in patients
with a GFR of 30 to 45 mL/min/1.73m2 though can be continued at a reduced dose with a GFR in this range in patients started on
the medication when kidney function was normal. It is also contraindicated in patients with alcohol use disorder or marked liver
disease. These contraindications exist due to the increased risk of lactic acidosis in these patients. Metformin should be routinely
discontinued when patients are hospitalized due to the increased risk of dehydration and opportunity for IV contrast dye use,
which could reduce renal function.

Additional Medications for Type 2 Diabetes

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 There are a number of additional pharmacologic therapies for glycemic control, including insulin.

In patients on a single oral agent whose A1c is within one percentage point of goal, adding another oral agent or non-insulin
injectable should be considered. A meta-analysis found that for each non-insulin agent added from a different class, the A1c could
be expected to decrease 0.9-1.1%.

In patients with type 2 diabetes who need greater glucose lowering than can be obtained with oral agents, glucagon-like peptide 1
receptor agonists are preferred to insulin when possible. GLP-1 receptor agonists, including exenatide and liraglutide, increase
insulin secretion in a blood glucose dependent manner. They also decrease postprandial glucagon secretion, slow gastric
emptying, centrally increase satiety, and decrease appetite. Many of these agents have proven cardiovascular benefits and are
now specifically recommended as second line agents after metformin. They generally lead to HgA1c decreases of approximately
1% and have the added perk of statistically significant weight loss for most patients. GLP-1 receptor agonists are delivered by
subcutaneous injection and come in monthly, weekly, daily, and twice daily formulations. The most common side effect is nausea,
which can be significant, and tumors of the C-cells have been reported. There have been post marketing reports of exenatide-
induced pancreatitis, so its use in patients with a history of pancreatitis should be avoided.

In patients with type 2 diabetes and established atherosclerotic cardiovascular disease or indicators of high risk, as well as
established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor (SGLT2i) or glucagon-like peptide 1
receptor agonist (GLP1RA) is recommended independent of A1C.

However, the ADA Standards of Medical Care in Diabetes state, "consider initiating insulin therapy (with or without additional
agents) in patients with newly diagnosed type 2 diabetes who are symptomatic and/or have A1c 10% or greater and/or blood
glucose levels 300 mg/dL or greater."

Information about the different types of insulin used to manage diabetes can be found by selecting the link.

When insulin is used, typically a basal insulin such as glargine or detemir is initiated first, with continuation of one or more oral
medications (usually metformin, unless there is a contraindication). The regimen is then escalated until the A1c goal is attained.

For an approach to the many types of anti-diabetic agents and the patient-specific factors that may be considered in medication
selection, refer to figure 9.1 and 9.2 from the 2020 ADA guidelines.

Studies

Chronic Diabetes Evaluation

Hemoglobin A1c

Hemoglobin A1c should be ordered every six months in patients who are meeting their individualized treatment goals, and
every three months if they are not or if therapy is changing.
An HbA1c goal of < 7% is generally a reasonable goal for a nonpregnant, otherwise healthy adult patient. More stringent
A1c goals (< 6.5%) may be appropriate in some patients, with shorter disease duration, long life expectancy, and no
significant cardiovascular disease, if it can be attained without significant hypoglycemia.
The ADA Standards of Medical Care in Diabetes state, "less stringent A1c goals (such as < 8%) may be appropriate for
patients with history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular
complications, extensive comorbid conditions, and those with longstanding diabetes in whom a stringent goal is difficult to
attain." For patients who have limited resources, a poor support system, and/or are unable to prioritize self-care due to
social, economic or psychological stressors, a less stringent A1c goal may also be appropriate.
Other professional societies, such as the American College of Physicians, have offered conflicting guidance statements
suggesting that less stringent A1c targets (7%-8% for most patients) are appropriate for a larger number of patients and
emphasize personalized goals and shared decision making.
Remember that HbA1c levels are unreliable in patients with hemoglobin variants, such as sickle cell disease, with end-stage
kidney failure/on dialysis, and who have recently had blood transfusions or large blood loss.

Individuated Hemoglobin A1c Goals

Healthy Nonpregnant Adults, without severe recurrent hypoglycemia/hypoglycemic unawareness < 7%

Medically Complex Adults, with history of severe hypoglycemia and/or longstanding diabetes < 8%

Medically Complex Adults/Adults in Poor Health, with severe recurrent hypoglycemia/hypoglycemic unawareness < 8.5% - 9%

Fasting lipid profile

The ADA and the AHA/ACC are overall in agreement regarding lipid management in patients with diabetes.

The ADA guidelines are:

Lifestyle modification (weight loss, increased physical activity, Mediterranean style or Dietary Approaches to Stop
Hypertension (DASH) eating pattern, reduced saturated and trans fat intake, increased fiber intake) should be
recommended for all patients with diabetes, where appropriate.
All patients with diabetes and cardiovascular disease, regardless of age, should be on a high intensity statin.
All patients aged 40 to 75 with diabetes should be on a moderate-intensity statin. In those with multiple atherosclerotic
cardiovascular disease risk factors or aged 50–70 years a high-intensity statin may be reasonable.
For patients aged < 40 or > 75 with diabetes, consider statin therapy depending on risks/benefits and patient preferences.

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 The ACC/AHA does not recommend lipid goals at this point.
See the Aquifer Cholesterol Guidelines for more information about this.

Basic metabolic profile

Renal function monitoring is indicated for patients taking metformin and in patients with diabetes in general. Estimated GFR
based on the serum creatinine should also be used to assess for chronic kidney disease, at least annually, looking at
declining GFR as another marker of kidney disease progression.

Spot urine albumin/creatinine ratio

Screening for microalbuminemia is indicated annually in patients with type 2 diabetes without evidence of increased urinary
albumin excretion (< 30 mcg albumin/mg creatinine) and more often to assess for progression and effect of therapy in
patients with established increased urinary albumin excretion (30 mcg albumin/mg creatinine or greater). A diagnosis of
increased urinary albumin excretion is made when two of three specimens collected within a 3- to 6-month period show 30
mcg albumin/mg creatinine or greater. Remember that vigorous exercise within the last 24 hours, menstruation, illness,
fever, markedly elevated blood pressure, CHF exacerbation, and acute hyperglycemia can cause false-positive results.
Urine dipstick measurements are not used to diagnose or follow increased urinary albumin excretion because of the
insensitivity of the method for detecting the initial small increases in protein excretion. Protein excretion must exceed 300
mcg per day to turn the dipstick positive.

Liver function profile

Indicated if the patient takes a thiazolidinedione (TZD).

See the associated reference ranges in conventional and SI units.

References

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2020. American Diabetes Association. 2020;43(Suppl.
1):S193-SS202. Accessed June 21, 2021.

American Diabetes Association Standards Of Medical Care In Diabetes-2020. Diabetes Care. 2020 Jan; 43 (Supplement 1).
https://care.diabetesjournals.org/content/43/Supplement_1. Accessed June 22, 2021.

Economic Costs of Diabetes in the U.S. in 2017. American Diabetes Association. Diabetes Care. March 2018; 41(5):917-928.. Accessed
June 21, 2021.

Qaseem A, Wilt TJ, et al. Clinical Guidelines Committee of the American College of Physicians. Hemoglobin A1c Targets for Glycemic
Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the
American College of Physicians. Ann Intern Med. 2018 Apr 17;168(8):569-576.

Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA.
2008;300(8):933.

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