1. Diabetes Type 2 in Family Medicine
2016
With contributions from Drs. Malek, Muldoon, Rangwala, Charapova, Mavriplis, McLaren, Nguyen

2. Note to presenter Equipment needed Monofilaments Tuning forks
Glucometers (lancets, test strips, etoh pads, bandaids)
Measuring tapes
Ophthalmoscopes
Insulin pens

3. Case #1 45 y.o. male Presenting complaint, erectile dysfunction
History?
Physical?
Investigations?
***ED is a marker of CAD!!!

4. ED history What does he mean by ED? Onset Duration Libido AM erections
Relationship
Patient expectations
Meds/alcohol

5. DM history Polydypsia Polyphagia Polyuria Weight changes Fatigue
Vision changes
Recurrent infections- candida

6. Name some risk factors for diabetes type 2 :

7. History – Risk Factors for Diabetes
Age >= 40
1st degree relative with DM2
High risk population (Aboriginal, Asian, South Asian, African, Hispanic)
History IFG, IGT
Presence of complications associated with DM
Presence of vascular risk factors:
Dyslipidemia, Hypertension, Overweight, Abdominal obesity

8. Risk Factors Gestational Diabetes OR macrosomic infant
Presence of associated diseases
PCOS
Acanthosis nigricans
Psychiatric disorders (bipolar disorder, depression, schizophrenia)
HIV infection
OSA

9. Acanthosis Nigrans

10. Risk Factors - 2 Use of drugs associated with DM: Glucocorticoids
Atypical antipsychotics
HAART

11. Diabetes Focused Exam
What is entailed in a focused exam for DM?

12. Diabetes: complications
MACROvascular
MICROvascular
Stroke
Diabetic eye
disease
(retinopathy & cataracts)
Heart disease & hypertension
Nephropathy
Peripheral vascular disease
Neuropathy
Foot problems

13. Case #1: Focused DM exam BMI Waist circumference
Vitals (consider postural BP, if indicated)
Cardiovascular
Eyes
Feet (checking for open sores, etc.)
Neurological : monofilament, vibration

14. Waist Circumference
Place a tape measure around your bare abdomen just above the iliac crest.
Be sure that the tape is snug, but does not compress skin, and is parallel to the floor.
Measure at the end of exhalation.

15. “Central Obesity” International Diabetes Federation classification
Waist circumference
Europids Men ≥94 cm; women ≥80 cm
South Asians Men ≥90 cm; women ≥80 cm
Chinese Men ≥90 cm; women ≥80 cm
Japanese Men ≥90 cm; women ≥80 cm
Ethnic South and Central Americans, First Nations: Use South Asian recommendations until more specific data are available
Sub-Saharan Africans, Eastern Med, Arabic: Use European data until more specific data are available
* In the USA, the ATP III values (102 cm male; 88 cm female) are likely to continue to be used for clinical purposes

16. Diabetic Foot Ulcer

17. Monofilament testing (from CDA guidelines)

18. Vibration sense (from CDA guidelines)

19. Diabetic Retinopathy Haemorrhage Cotton wool spots
Microaneurysms, edema, and exudates
Neovascularization

20. Case #1
Investigations?

21. Case #1 Investigations Fasting BS or HBA1C Lipids
Cr, K, Na, TSH, LFT’s
ACR
(Testosterone? For ED not DM)
EKG

22. Results FBS: 11.0 HbA1c: 0.08 ACR: 2 (<2.79) Cr 86, egfr 80
Testosterone: N
EKG: NSR
TC 7.0, LDL 5.1, TC: HDL ratio 5.3, Trig: 4.2
Liver enzymes: N

23. Diagnosis of Diabetes
In the case of symptomatic hyperglycemia, the diagnosis has been made and a confirmatory test is not required before treatment is initiated.

24. Considerations when using A1C for diagnosis
Advantages
Disadvantages
Convenient (done any time of the day)
Single sample
Predicts microvascular complications
Better predictor of macrovascular disease than other tests
Low day-to-day variability
Reflects long-term glucose concentration
Cost
Misleading in various medical conditions (e.g. hemoglobinopathies, iron deficiency, hemolytic anemia, severe hepatic or renal disease)*
Altered by ethnicity and aging
Standardized, validated assay required
Not for diagnostic use in children, adolescents, pregnant women, or those with suspected Type I DM
African Americans, American Indians, Hispanics and Asians have A1C values that are up to 0.4% higher than those of Caucasian patients at similar levels of glycemia
Important conditions where the rate of red blood cell turnover is significantly shortened or extended, or the structure of hemoglobin is altered, A1C may not accurately reflect glycemic status; this includes common conditions such as B12 and Fe deficiency (that can falsely increase hbA1c), increased red cell turn over, and states and factors that increase erythropoiesis (such as use of EPO, Fe, B12 deficiency – which can falsely lower HbA1c)
*see slide in Appendix for more information

25. Diagnostic Testing With 3 Different Tests
FPG
2hPG
A1C
Dealing with Discordance
Many people identified as having diabetes using A1C will not be identified as having diabetes by traditional glucose criteria, and vice versa.
There may be discordant results whereby one test is diagnostic of diabetes while another does not agree. If this does occur, the tests whose result is above diagnostic cut-point should be repeated, and the diagnosis made on the basis of the repeat test.
When results of more than one test are available (amongst FPG, A1C, 2hPG in a 75-g OGTT) and the results are discordant, the test whose result is above diagnostic cut-point should be repeated, and the diagnosis made on basis of the repeat test. 25

26. Diagnostic Testing
In the absence of symptomatic hyperglycemia, if a single lab test result is in the diabetes range, a repeat confirmatory test must be done on another day
Preferable for the same test to be repeated for confirmation (exception is random PG, which should be confirmed with an alternate test)

27. Diagnosing Prediabetes
Test
Result
Prediabetes Category
Fasting Plasma Glucose
(mmol/L)
Impaired fasting glucose (IFG)
2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L)
7.8 – 11.0
Impaired glucose tolerance (IGT)
Glycated
Hemoglobin
(A1C) (%)
Prediabetes

28. A1C Level and Future Risk of Diabetes: Systematic Review
A1C Category (%)
5-year incidence of diabetes
<5 to 9%
9 to 25%
25 to 50%
Script: Zhang et al did a systematic review on A1c level and future risk of diabetes and you as the A1C increased from 6.0 to 6.5%, this covereted to a 5-year incidence of diabetes across 25% -50%.
Zhang X et al. Diabetes Care. 2010;33: 28

29. Diabetes Prevention Program
3000 patients with IGT
3 arms:
Lifestyle changes: diet +150 min mod exercise/wk
Metformin 850 mg bid
Control

30. Results of DPP Reduced risk of progression to DM 2
In lifestyle group: by 58%
In metformin group: by 31%

31. Metabolic Syndrome From CDA website From the CDA:
Prediabetes and type 2 diabetes are often manifestations of a much broader underlying disorder , including the metabolic syndrome—a highly prevalent, multifaceted condition characterized by a constellation of abnormalities that include abdominal obesity, hypertension, dyslipidemia and elevated blood glucose
Individuals with metabolic syndrome are at significant risk of developing CVD
While metabolic syndrome and type 2 diabetes often coexist, those with metabolic syndrome without diabetes are at significant risk of developing diabetes
Evidence exists to support an aggressive approach to identifying and treating people, not only those with hyperglycemia but also those with the associated CV risk factors that make up the metabolic syndrome, such as hypertension, dyslipidemia and abdominal obesity, in the hope of significantly reducing CV morbidity and mortality
From CDA website

32. Management of Case #1
Non Pharmacological
Pharmacological
Always refer to Community Diabetes Education Program

33. Management Self-management Multidisciplinary
Electronic aids, reminders

34. Management -2 Discuss eating habits (refer to CFG- Diabetes)
Physical activity guidelines (150 minutes mod-intense activity per week, spread over at least 3 non-consecutive days) START SLOW
Resistance exercise (at least 2x/week)
Stress test if sedentary and high risk CAD
Use community resources!

35. Is it all working? Targets: HBA1C:<7 %, AC BS:4-7 (4-6)
PC BS:5-10(5-8)
Lipids: LDL < 2, ratio TC/HDL <4
HTN: 130/80

36. What other meds can help prevent complications?
Statin
ACE inhibitor
?ASA

37. Case #2, Obese patient Definition of obesity? BMI 18.5-24.9 Normal
BMI Overweight increased risk
BMI class I obesity (high risk)
BMI class II obesity (very high risk)
BMI 40+ class III obesity (extremely high risk)
Canadian Obesity guidelines
PHAC 2005

38. Case #3 Thin patient
What is the difference in your approach?

39. Case #4 Obese 12 year old Diabetes Education Program
Interdisciplinary care
Screen for DM periodically

40. Case #4 Screen q 2 years with FPG if at high risk
BMI >95%ile for age
High risk ethnic or family history
Exposed to DM in utero
HBP, dyslipidemia, acanthosis nigricans, NAFLD
IGT
Antipsychotics

41. Case #5 - 30 year old infertile woman
What would be a possible cause of her infertility which is related to this topic?

42. Case #6 Gestational Diabetes
50g glucose wk
75g OGTT if positive
Nutritional intervention
Home blood glucose monitoring
Insulin if needed

43. RESOURCES FOR DM-II
Canadian Diabetes Association Health Care Provider Tools
Resource for Insulin Rx in DM-II

44. Appendix Factors affecting A1C Increased A1C Decreased A1C
Variable Change in A1C
Erythropoiesis
B12/Fe deficiency Decreased erythropoiesis
Use of EPO, Fe, or B12
Reticulocytosis
Chronic liver Dx
Altered hemoglobin
Fetal hemoglobin Hemoglobinopathies Methemoglobin
Altered glycation
Chronic renal failure
↓↓erythrocyte pH
ASA, vitamin C/E
Hemoglobinopathies
↑ erythrocyte pH
Erythrocyte destruction
Splenectomy
Splenomegaly
Rheumatoid arthritis
HAART meds, Ribavirin
Dapsone
Assays
Hyperbilirubinemia
Carbamylated Hb
ETOH
Chronic opiates
Hypertriglyceridemia
Script:
While HbA1c is an excellent measure for diagnosis, it is essential to know conditions where the value may not adequate reflect true glycemic control and other measures such as fasting blood sugar or OGTT may be more helpful.
Important conditions where the rate of red blood cell turnover is significantly shortened or extended, or the structure of hemoglobin is altered, A1C may not accurately reflect glycemic status
This includes common conditions such as B12 and Fe deficiency that can falsely increase hbA1c and also increased red cell turn over states and factors that increase erythropoiesis such as use of EPO, Fe, B12 deficiency – which can falsely lower hbA1c.
So While HbA1c is convenient for patients understanding the factors that affect the accuracy of it’s ability to diagnose diabetes.
TT: point of slide is to teach practionners to recognize common pitfalls and conditions where HbA1c might not be an accurate measure to use for diagnosis.