1. TYPE 2 DIABETES MELLITUS Review of Clinical Practice Guidelines WEEK 1: Diagnosis and Evaluation UHN AIMGP CLINIC SEMINAR SERIES 2007 Updated by Dr. K. Tzanetos WEEK 1: Diagnosis and Evaluation UHN AIMGP CLINIC SEMINAR SERIES 2007 Updated by Dr. K. Tzanetos

2. TYPE 2 DIABETES MELLITUS Review of Clinical Practice Guidelines Canadian Diabetes Association (CDA): 2003 Clinical Practice Guidelines for the Prevention and Management of diabetes in Canada. Can J Diabetes 2003; 27 (Suppl 2). Can J Diabetes 2003; 27 (Suppl 2). http://www.diabetes.ca/cpg2003 http://www.diabetes.ca/cpg2003 American Diabetes Association (ADA): Clinical Practice Recommendations 2004. Diabetes Care 2004; 27 (Suppl 1). Diabetes Care 2004; 27 (Suppl 1). Canadian Diabetes Association (CDA): 2003 Clinical Practice Guidelines for the Prevention and Management of diabetes in Canada. Can J Diabetes 2003; 27 (Suppl 2). Can J Diabetes 2003; 27 (Suppl 2). http://www.diabetes.ca/cpg2003 http://www.diabetes.ca/cpg2003 American Diabetes Association (ADA): Clinical Practice Recommendations 2004. Diabetes Care 2004; 27 (Suppl 1). Diabetes Care 2004; 27 (Suppl 1).

3. TYPE 2 DIABETES MELLITUS Objectives: 1) Examine diagnostic criteria for type 2 diabetes 2) Discuss screening recommendations for type 2 diabetes 3) Explore the suggested evaluation for first visit 4) Appreciate the importance of follow-up 5) Identify specific disease complications - retinopathy/nephropathy/foot ulcerations Objectives: 1) Examine diagnostic criteria for type 2 diabetes 2) Discuss screening recommendations for type 2 diabetes 3) Explore the suggested evaluation for first visit 4) Appreciate the importance of follow-up 5) Identify specific disease complications - retinopathy/nephropathy/foot ulcerations

4. CASE: Mrs. X is a 58 year old woman referred to the AIMGP clinic by her GP with a random glucose of 12.0 mmol/L. She feels well with no complaints and this testing was done as a part of her routine blood work. Does she have diabetes ? Does she have diabetes ? What further testing could help you to decide? What further testing could help you to decide?CASE: Mrs. X is a 58 year old woman referred to the AIMGP clinic by her GP with a random glucose of 12.0 mmol/L. She feels well with no complaints and this testing was done as a part of her routine blood work. Does she have diabetes ? Does she have diabetes ? What further testing could help you to decide? What further testing could help you to decide? DIABETES MELLITUS Take a minute to discuss…

5. CASE: Mrs. X. Does she have diabetes? Does she have diabetes? Likely! BUT you must do further tests. Likely! BUT you must do further tests. Further testing needed…2 confirmatory laboratory glucose tests (FBG, random PG or 2hr 75g OGTT) on separate days in the absence of unequivocal hyperglycemia accompanied by an acute metabolic decompensation. Further testing needed…2 confirmatory laboratory glucose tests (FBG, random PG or 2hr 75g OGTT) on separate days in the absence of unequivocal hyperglycemia accompanied by an acute metabolic decompensation. CASE: Mrs. X. Does she have diabetes? Does she have diabetes? Likely! BUT you must do further tests. Likely! BUT you must do further tests. Further testing needed…2 confirmatory laboratory glucose tests (FBG, random PG or 2hr 75g OGTT) on separate days in the absence of unequivocal hyperglycemia accompanied by an acute metabolic decompensation. Further testing needed…2 confirmatory laboratory glucose tests (FBG, random PG or 2hr 75g OGTT) on separate days in the absence of unequivocal hyperglycemia accompanied by an acute metabolic decompensation. DIABETES MELLITUS Diagnostic Criteria for Type 2 DM

6. Random PG ≥ 11.1mmol/L* and symptoms of diabetes OR Fasting plasma glucose (FPG) ≥ 7.0 mmol/L † OR 2h PG in a 75-g oral glucose tolerance test (OGTT) ≥ 11.1 mmol/L * Symptoms include fatigue, polyuria, polydipsia and weight loss † Fasting is defined as no caloric intake for at least 8 h Random PG ≥ 11.1mmol/L* and symptoms of diabetes OR Fasting plasma glucose (FPG) ≥ 7.0 mmol/L † OR 2h PG in a 75-g oral glucose tolerance test (OGTT) ≥ 11.1 mmol/L * Symptoms include fatigue, polyuria, polydipsia and weight loss † Fasting is defined as no caloric intake for at least 8 h DIABETES MELLITUS Diagnostic Criteria for Type 2 DM

7. Glucose levels (mmol/L) for diagnosis: DIABETES MELLITUS Diagnostic Criteria for Type 2 DM FPG 2 h PG in a 75- g OGTT IFG 6.1 - 6.9 NA IFG (isolated) 6.1 - 6.9 and < 7.8 IGT (isolated) < 6.1 and 7.8 - 11.0 IFG and IGT 6.1 - 6.9 and 7.8 - 11.0 Diabetes ≥ 7.0 or ≥ 11.1

8. BACK TO THE CASE: Mrs. X is a Caucasian female who has no other PMHx. Her family history is negative. Should Mrs. X. have been screened before now for type 2 diabetes? By what method? What high risk groups should undergo more frequent or earlier screening? BACK TO THE CASE: Mrs. X is a Caucasian female who has no other PMHx. Her family history is negative. Should Mrs. X. have been screened before now for type 2 diabetes? By what method? What high risk groups should undergo more frequent or earlier screening? DIABETES MELLITUS Take a minute to discuss…

9. All individuals should be evaluated annually for DM2 risk (demographic/clinical criteria) All individuals should be evaluated annually for DM2 risk (demographic/clinical criteria) In persons 40 yrs of age screening for DM2 using a FPG should be performed every 3 yrs In persons 40 yrs of age screening for DM2 using a FPG should be performed every 3 yrs More frequent and/or earlier screening should be considered in ‘high risk’ groups More frequent and/or earlier screening should be considered in ‘high risk’ groups All individuals should be evaluated annually for DM2 risk (demographic/clinical criteria) All individuals should be evaluated annually for DM2 risk (demographic/clinical criteria) In persons 40 yrs of age screening for DM2 using a FPG should be performed every 3 yrs In persons 40 yrs of age screening for DM2 using a FPG should be performed every 3 yrs More frequent and/or earlier screening should be considered in ‘high risk’ groups More frequent and/or earlier screening should be considered in ‘high risk’ groups DIABETES MELLITUS 3) Screening for Type 2 DM

10. Risk factors for Type 2 DM (CDA) Risk factors for Type 2 DM (CDA) First-degree relative with diabetes First-degree relative with diabetes Member of high-risk population (e.g. persons of Aboriginal, Hispanic, S. African, Asian or S. Asian descent) Member of high-risk population (e.g. persons of Aboriginal, Hispanic, S. African, Asian or S. Asian descent) History of IGT or IFG History of IGT or IFG Presence of complications of DM Presence of complications of DM Vascular disease (**assoc. with the metabolic synD) Vascular disease (**assoc. with the metabolic synD) History of GDM History of GDM Risk factors for Type 2 DM (CDA) Risk factors for Type 2 DM (CDA) First-degree relative with diabetes First-degree relative with diabetes Member of high-risk population (e.g. persons of Aboriginal, Hispanic, S. African, Asian or S. Asian descent) Member of high-risk population (e.g. persons of Aboriginal, Hispanic, S. African, Asian or S. Asian descent) History of IGT or IFG History of IGT or IFG Presence of complications of DM Presence of complications of DM Vascular disease (**assoc. with the metabolic synD) Vascular disease (**assoc. with the metabolic synD) History of GDM History of GDM DIABETES MELLITUS 3) Screening for Type 2 DM

11. Risk factors for Type 2 DM (CDA) cont’ Risk factors for Type 2 DM (CDA) cont’ History of macrosomal infant History of macrosomal infant HTN (**) HTN (**) Dyslipidemia (**) Dyslipidemia (**) Overweight (**) Overweight (**) PCOS (**) PCOS (**) Acanthosis nigricans (**) Acanthosis nigricans (**) Schizophrenia (incidence 3X higher than the gen. population) Schizophrenia (incidence 3X higher than the gen. population) Risk factors for Type 2 DM (CDA) cont’ Risk factors for Type 2 DM (CDA) cont’ History of macrosomal infant History of macrosomal infant HTN (**) HTN (**) Dyslipidemia (**) Dyslipidemia (**) Overweight (**) Overweight (**) PCOS (**) PCOS (**) Acanthosis nigricans (**) Acanthosis nigricans (**) Schizophrenia (incidence 3X higher than the gen. population) Schizophrenia (incidence 3X higher than the gen. population) DIABETES MELLITUS 3) Screening for Type 2 DM

12. CDA guidelines mandate yearly screening in patients with: CDA guidelines mandate yearly screening in patients with: Hx of IFG or IGT Hx of IFG or IGT Presence of complications associated with diabetes Presence of complications associated with diabetes Hx of gestational diabetes or macrosomic infant (>4kg) Hx of gestational diabetes or macrosomic infant (>4kg) Presence of HTN or CAD Presence of HTN or CAD Screening Method Screening Method FPG (universal recommendation) FPG (universal recommendation) 2 h PG OGTT if FPG not diagnostic 2 h PG OGTT if FPG not diagnostic Lack of standardization of the HBA1C test precludes its use for diagnosis Lack of standardization of the HBA1C test precludes its use for diagnosis CDA guidelines mandate yearly screening in patients with: CDA guidelines mandate yearly screening in patients with: Hx of IFG or IGT Hx of IFG or IGT Presence of complications associated with diabetes Presence of complications associated with diabetes Hx of gestational diabetes or macrosomic infant (>4kg) Hx of gestational diabetes or macrosomic infant (>4kg) Presence of HTN or CAD Presence of HTN or CAD Screening Method Screening Method FPG (universal recommendation) FPG (universal recommendation) 2 h PG OGTT if FPG not diagnostic 2 h PG OGTT if FPG not diagnostic Lack of standardization of the HBA1C test precludes its use for diagnosis Lack of standardization of the HBA1C test precludes its use for diagnosis DIABETES MELLITUS 3) Screening for Type 2 DM

13. CASE: Assume that you have taken a thorough medical history from Mrs. X that has included symptoms of hyperglycemia, symptoms of macrovascular and microvascular complications, nutritional details, and medical co-morbidities. Assume that you have taken a thorough medical history from Mrs. X that has included symptoms of hyperglycemia, symptoms of macrovascular and microvascular complications, nutritional details, and medical co-morbidities. What would you now like to emphasize on Mrs. X.’s physical examination during her initial visit? What would you now like to emphasize on Mrs. X.’s physical examination during her initial visit?CASE: Assume that you have taken a thorough medical history from Mrs. X that has included symptoms of hyperglycemia, symptoms of macrovascular and microvascular complications, nutritional details, and medical co-morbidities. Assume that you have taken a thorough medical history from Mrs. X that has included symptoms of hyperglycemia, symptoms of macrovascular and microvascular complications, nutritional details, and medical co-morbidities. What would you now like to emphasize on Mrs. X.’s physical examination during her initial visit? What would you now like to emphasize on Mrs. X.’s physical examination during her initial visit? DIABETES MELLITUS Take a minute to discuss…

14. PE in a patient with DM: PE in a patient with DM: General (height, weight, BMI, postural BP, HR) General (height, weight, BMI, postural BP, HR) H & N (Pupils, EOMs, Lens opacities, fundi, oral hygiene and dental caries, thyroid) H & N (Pupils, EOMs, Lens opacities, fundi, oral hygiene and dental caries, thyroid) CVS (signs of HTN, CHF, CAD; pulses, bruits, other signs of PVD) CVS (signs of HTN, CHF, CAD; pulses, bruits, other signs of PVD) Abdomen (hepatomegaly) Abdomen (hepatomegaly) GU (r/o fungal infections, bladder distension) GU (r/o fungal infections, bladder distension) MSK (foot inspection, colour, temperature, arthropathy) MSK (foot inspection, colour, temperature, arthropathy) Neuro (dysesthesiae, change in proprioception, vibration, light touch [monofilament], reflexes, autonomic nervous system) Neuro (dysesthesiae, change in proprioception, vibration, light touch [monofilament], reflexes, autonomic nervous system) Skin (infections, dyslipidemias, ulcers, trauma, injection sites) Skin (infections, dyslipidemias, ulcers, trauma, injection sites) PE in a patient with DM: PE in a patient with DM: General (height, weight, BMI, postural BP, HR) General (height, weight, BMI, postural BP, HR) H & N (Pupils, EOMs, Lens opacities, fundi, oral hygiene and dental caries, thyroid) H & N (Pupils, EOMs, Lens opacities, fundi, oral hygiene and dental caries, thyroid) CVS (signs of HTN, CHF, CAD; pulses, bruits, other signs of PVD) CVS (signs of HTN, CHF, CAD; pulses, bruits, other signs of PVD) Abdomen (hepatomegaly) Abdomen (hepatomegaly) GU (r/o fungal infections, bladder distension) GU (r/o fungal infections, bladder distension) MSK (foot inspection, colour, temperature, arthropathy) MSK (foot inspection, colour, temperature, arthropathy) Neuro (dysesthesiae, change in proprioception, vibration, light touch [monofilament], reflexes, autonomic nervous system) Neuro (dysesthesiae, change in proprioception, vibration, light touch [monofilament], reflexes, autonomic nervous system) Skin (infections, dyslipidemias, ulcers, trauma, injection sites) Skin (infections, dyslipidemias, ulcers, trauma, injection sites) DIABETES MELLITUS Evaluation at first visit

15. CASE: What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit ? What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit ?CASE: DIABETES MELLITUS Take a minute to discuss…

16. What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit (ADA)? What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit (ADA)? FPG (optional), HbA1c FPG (optional), HbA1c Fasting lipid profile Fasting lipid profile Serum creatinine, Urinalysis Serum creatinine, Urinalysis Test for microalbuminuria (type 1 diabetic patients after at least 5 years and in all patients with type 2 diabetes at diagnosis) Test for microalbuminuria (type 1 diabetic patients after at least 5 years and in all patients with type 2 diabetes at diagnosis) Urine culture (if indicated) Urine culture (if indicated) Thyroid-stimulating hormone (TSH) in all type 1 diabetic patients; in type 2 if clinically indicated Thyroid-stimulating hormone (TSH) in all type 1 diabetic patients; in type 2 if clinically indicated ECG ECG What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit (ADA)? What laboratory tests would you like to obtain on or shortly after Mrs. X.’s initial visit (ADA)? FPG (optional), HbA1c FPG (optional), HbA1c Fasting lipid profile Fasting lipid profile Serum creatinine, Urinalysis Serum creatinine, Urinalysis Test for microalbuminuria (type 1 diabetic patients after at least 5 years and in all patients with type 2 diabetes at diagnosis) Test for microalbuminuria (type 1 diabetic patients after at least 5 years and in all patients with type 2 diabetes at diagnosis) Urine culture (if indicated) Urine culture (if indicated) Thyroid-stimulating hormone (TSH) in all type 1 diabetic patients; in type 2 if clinically indicated Thyroid-stimulating hormone (TSH) in all type 1 diabetic patients; in type 2 if clinically indicated ECG ECG DIABETES MELLITUS Evaluation at first visit

17. CASE: How frequently should patients like Mrs. X be followed after the initial visit? How frequently should patients like Mrs. X be followed after the initial visit? Consider the following patient circumstances: Consider the following patient circumstances: Diabetes is Diet controlled Diabetes is Diet controlled Patient on oral hypoglyemics (at initiation, when titrating, on maintenance dosing) Patient on oral hypoglyemics (at initiation, when titrating, on maintenance dosing) Patient on insulin (at initiation, when titrating, on maintenance dosing) Patient on insulin (at initiation, when titrating, on maintenance dosing) For routine visits if they are meeting goals For routine visits if they are meeting goals For routine visits if they are not meeting goals For routine visits if they are not meeting goalsCASE: How frequently should patients like Mrs. X be followed after the initial visit? How frequently should patients like Mrs. X be followed after the initial visit? Consider the following patient circumstances: Consider the following patient circumstances: Diabetes is Diet controlled Diabetes is Diet controlled Patient on oral hypoglyemics (at initiation, when titrating, on maintenance dosing) Patient on oral hypoglyemics (at initiation, when titrating, on maintenance dosing) Patient on insulin (at initiation, when titrating, on maintenance dosing) Patient on insulin (at initiation, when titrating, on maintenance dosing) For routine visits if they are meeting goals For routine visits if they are meeting goals For routine visits if they are not meeting goals For routine visits if they are not meeting goals DIABETES MELLITUS Take a minute to discuss…

18. Follow-up Visit Frequency (ADA)? Follow-up Visit Frequency (ADA)? Daily for initiation of insulin or change in regimen Daily for initiation of insulin or change in regimen Weekly for initiation of oral hypoglycemic agents or change in regimen Weekly for initiation of oral hypoglycemic agents or change in regimen (Are we meeting, or do we need to meet, these guidelines in AIMGP?) Routine diabetes visits: Routine diabetes visits: Quarterly for patients who are not meeting goals Quarterly for patients who are not meeting goals (Is this frequent enough?) (Is this frequent enough?) Semi-annually for patients with well- controlled diabetes Semi-annually for patients with well- controlled diabetes Follow-up Visit Frequency (ADA)? Follow-up Visit Frequency (ADA)? Daily for initiation of insulin or change in regimen Daily for initiation of insulin or change in regimen Weekly for initiation of oral hypoglycemic agents or change in regimen Weekly for initiation of oral hypoglycemic agents or change in regimen (Are we meeting, or do we need to meet, these guidelines in AIMGP?) Routine diabetes visits: Routine diabetes visits: Quarterly for patients who are not meeting goals Quarterly for patients who are not meeting goals (Is this frequent enough?) (Is this frequent enough?) Semi-annually for patients with well- controlled diabetes Semi-annually for patients with well- controlled diabetes DIABETES MELLITUS Evaluation in follow-up

19. CASE: What historical information will you gather on Mrs. X’s follow-up visits? What historical information will you gather on Mrs. X’s follow-up visits? What would you like to emphasize on Mrs. X.’s physical examination during her follow-up visits? What would you like to emphasize on Mrs. X.’s physical examination during her follow-up visits? Include discussion on appropriate frequency of various maneuvers Include discussion on appropriate frequency of various maneuvers What laboratory tests would you like to obtain on or shortly after Mrs. X.’s follow-up visits? What laboratory tests would you like to obtain on or shortly after Mrs. X.’s follow-up visits? Include discussion on appropriate frequency of various tests Include discussion on appropriate frequency of various testsCASE: What historical information will you gather on Mrs. X’s follow-up visits? What historical information will you gather on Mrs. X’s follow-up visits? What would you like to emphasize on Mrs. X.’s physical examination during her follow-up visits? What would you like to emphasize on Mrs. X.’s physical examination during her follow-up visits? Include discussion on appropriate frequency of various maneuvers Include discussion on appropriate frequency of various maneuvers What laboratory tests would you like to obtain on or shortly after Mrs. X.’s follow-up visits? What laboratory tests would you like to obtain on or shortly after Mrs. X.’s follow-up visits? Include discussion on appropriate frequency of various tests Include discussion on appropriate frequency of various tests DIABETES MELLITUS Take a minute to discuss…

20. DIABETES MELLITUS Evaluation in follow-up History taking on follow-up visits: History taking on follow-up visits: Treatment regimens (frequency of hyper/hypoglycemia, acute symptoms, self- monitoring BG results, pt regimen adjustments, adherence problems) Treatment regimens (frequency of hyper/hypoglycemia, acute symptoms, self- monitoring BG results, pt regimen adjustments, adherence problems) Lifestyle changes Lifestyle changes Symptoms of chronic complications (including ensuring visits to opthomologist) Symptoms of chronic complications (including ensuring visits to opthomologist) Changes in co-morbidities Changes in co-morbidities Psychosocial issues Psychosocial issues Immunization status Immunization status History taking on follow-up visits: History taking on follow-up visits: Treatment regimens (frequency of hyper/hypoglycemia, acute symptoms, self- monitoring BG results, pt regimen adjustments, adherence problems) Treatment regimens (frequency of hyper/hypoglycemia, acute symptoms, self- monitoring BG results, pt regimen adjustments, adherence problems) Lifestyle changes Lifestyle changes Symptoms of chronic complications (including ensuring visits to opthomologist) Symptoms of chronic complications (including ensuring visits to opthomologist) Changes in co-morbidities Changes in co-morbidities Psychosocial issues Psychosocial issues Immunization status Immunization status

21. Type 2 diabetes: Type 2 diabetes: At time of diagnosis At time of diagnosis 1 year or less if retinopathy present 1 year or less if retinopathy present Every 1-2 yrs on advice of eye care professional if no evidence of retinopathy Every 1-2 yrs on advice of eye care professional if no evidence of retinopathy Type 2 diabetes: Type 2 diabetes: At time of diagnosis At time of diagnosis 1 year or less if retinopathy present 1 year or less if retinopathy present Every 1-2 yrs on advice of eye care professional if no evidence of retinopathy Every 1-2 yrs on advice of eye care professional if no evidence of retinopathy DIABETES MELLITUS A Note on Retinopathy: Opthomology Follow-up DIABETES MELLITUS A Note on Retinopathy: Opthomology Follow-up

22. Physical Examination at Follow-up Visits (ADA)? Physical Examination at Follow-up Visits (ADA)? At every regular diabetes visit: At every regular diabetes visit: Weight Weight BP BP Previous abnormalities on physical exam Previous abnormalities on physical exam Complete physical exam annually Complete physical exam annually Comprehensive foot examination annually and visual inspection at every visit (and shoes!!) Comprehensive foot examination annually and visual inspection at every visit (and shoes!!) Physical Examination at Follow-up Visits (ADA)? Physical Examination at Follow-up Visits (ADA)? At every regular diabetes visit: At every regular diabetes visit: Weight Weight BP BP Previous abnormalities on physical exam Previous abnormalities on physical exam Complete physical exam annually Complete physical exam annually Comprehensive foot examination annually and visual inspection at every visit (and shoes!!) Comprehensive foot examination annually and visual inspection at every visit (and shoes!!) DIABETES MELLITUS Evaluation in follow-up

23. Initial visit and annually thereafter IDENTIFY: Initial visit and annually thereafter IDENTIFY: Peripheral neuropathy (monofilament or vibration) Peripheral neuropathy (monofilament or vibration) Altered biomechanics (evidence of increased pressure - callus, erythema; limited joint mobility; bony deformity; or severe nail pathology - thick nails) Altered biomechanics (evidence of increased pressure - callus, erythema; limited joint mobility; bony deformity; or severe nail pathology - thick nails) Peripheral vascular disease (hx of claudication, pulse exam, skin exam) Peripheral vascular disease (hx of claudication, pulse exam, skin exam) History of ulcers or amputation History of ulcers or amputation The presence of any of these risk factors requires visualization of the patient’s feet at every subsequent visit The presence of any of these risk factors requires visualization of the patient’s feet at every subsequent visit Initial visit and annually thereafter IDENTIFY: Initial visit and annually thereafter IDENTIFY: Peripheral neuropathy (monofilament or vibration) Peripheral neuropathy (monofilament or vibration) Altered biomechanics (evidence of increased pressure - callus, erythema; limited joint mobility; bony deformity; or severe nail pathology - thick nails) Altered biomechanics (evidence of increased pressure - callus, erythema; limited joint mobility; bony deformity; or severe nail pathology - thick nails) Peripheral vascular disease (hx of claudication, pulse exam, skin exam) Peripheral vascular disease (hx of claudication, pulse exam, skin exam) History of ulcers or amputation History of ulcers or amputation The presence of any of these risk factors requires visualization of the patient’s feet at every subsequent visit The presence of any of these risk factors requires visualization of the patient’s feet at every subsequent visit DIABETES MELLITUS A Note on Foot Care

24. Laboratory tests at follow-up visits (ADA) Laboratory tests at follow-up visits (ADA) HbA1c HbA1c Quarterly if medications change or patient not meeting goals Quarterly if medications change or patient not meeting goals Semi-annually if stable Semi-annually if stable FPG (optional) FPG (optional) Fasting lipid profile annually, unless low risk Fasting lipid profile annually, unless low risk Urinary microalbumin measurement annually (if indicated) Urinary microalbumin measurement annually (if indicated) Laboratory tests at follow-up visits (ADA) Laboratory tests at follow-up visits (ADA) HbA1c HbA1c Quarterly if medications change or patient not meeting goals Quarterly if medications change or patient not meeting goals Semi-annually if stable Semi-annually if stable FPG (optional) FPG (optional) Fasting lipid profile annually, unless low risk Fasting lipid profile annually, unless low risk Urinary microalbumin measurement annually (if indicated) Urinary microalbumin measurement annually (if indicated) DIABETES MELLITUS Evaluation in follow-up

25. Annual screening with a random daytime urine albumin: creatinine ratio (ACR) Annual screening with a random daytime urine albumin: creatinine ratio (ACR) For values ≥ 2.8 for females and 2.0 for males the test should be repeated For values ≥ 2.8 for females and 2.0 for males the test should be repeated confirmed in 2 out of 3 measurements over 3 months confirmed in 2 out of 3 measurements over 3 months Uncertainty is clarified by 24h urine for protein Uncertainty is clarified by 24h urine for protein Microalbuminuria = 30 - 299 mg of albumin/24hrs Microalbuminuria = 30 - 299 mg of albumin/24hrs NB: If patients are dipstick positive, they will likely have macroalbuminuria NB: If patients are dipstick positive, they will likely have macroalbuminuria Annual screening with a random daytime urine albumin: creatinine ratio (ACR) Annual screening with a random daytime urine albumin: creatinine ratio (ACR) For values ≥ 2.8 for females and 2.0 for males the test should be repeated For values ≥ 2.8 for females and 2.0 for males the test should be repeated confirmed in 2 out of 3 measurements over 3 months confirmed in 2 out of 3 measurements over 3 months Uncertainty is clarified by 24h urine for protein Uncertainty is clarified by 24h urine for protein Microalbuminuria = 30 - 299 mg of albumin/24hrs Microalbuminuria = 30 - 299 mg of albumin/24hrs NB: If patients are dipstick positive, they will likely have macroalbuminuria NB: If patients are dipstick positive, they will likely have macroalbuminuria DIABETES MELLITUS A Note on Nephropathy: Screening

26. DIABETES MELLITUS UHN AIMGP CLINIC SUMMER SERIES 2007 Next week - Therapy of Type 2 DM Non-pharmacologic and pharmacologic DIABETES MELLITUS UHN AIMGP CLINIC SUMMER SERIES 2007 Next week - Therapy of Type 2 DM Non-pharmacologic and pharmacologic