2002 Clinical Practice Guidelines RECOMMENDATIONS FOR CARE OF DIABETES

Transcription

1 Type 1 Diabetes- An autoimmune disease in which the body does not produce any insulin, mostly occurring in children and young adults. People with type 1 diabetes must take daily insulin injections to stay alive. Type 1 diabetes accounts for five to 10 percent of diabetes conditions.* * According to the ADA 2002 Clinical Practice Guidelines CLASSIFICATIONS Type 2 Diabetes- A metabolic disorder resulting from the body s inability to make enough or properly use insulin. It is the most common form of the disease. Type 2 diabetes accounts for 90 to 95 percent of diabetes conditions. Type 2 diabetes is nearing epidemic proportions, due to an increased number of older Americans, and a greater prevalence of obesity and sedentary lifestyles. * * According to the ADA Other There are other classifications of diabetes related to pregnancy (gestational) or genetic disorders. Classifications also include malnutrition-related diabetes and mature onset diabetes of the young (MODY). SIMPLIFIED TESTING AND DIAGNOSIS Diabetes can be diagnosed in any one of the following three ways and confirmed, on a different day, by any one of these same tests: 1. A fasting plasma glucose (FPG)** of 126 mg/dl or greater (after no caloric intake for at least 8 hours); or 2. A random plasma glucose of 200 mg/dl with the classic diabetes symptoms of increased urination, increased thirst and unexplained weight loss (taken at any time of day without regard to time of last meal); or 3. An oral glucose tolerance test (OGTT) value of 200 mg/dl in the two-hour sample (using a glucose load of 75g). ** Because of its ease of administration, convenience, acceptability to patients, and lower cost (compared to the OGTT), FPG is the preferred testing method. Prior to 1998 The upper limit of normal blood glucose FPG = 115 mg/dl From 1998 Onward The upper limit of normal blood glucose FPG = 110 mg/dl Two categories of impaired glucose metabolism (or impaired glucose homeostasis) are now considered risk factors for future diabetes and cardiovascular disease: 1. Impaired Fasting Glucose (IFG), a new category, is defined by a FPG =110 but <126 mg/dl. 2. Impaired Glucose Tolerance (IGT), an existing category, is defined by OGTT results = 140 but < 200 mg/dl (in the two-hour sample). It is recommended that testing for diabetes be considered for all adults at age 45 and above, and if normal, be repeated at three-year intervals. Testing may begin at a younger age, or more frequently, for those who are at higher risk for diabetes, including: People who are obese (> 120% of their ideal body weight), or with a BMI > 27 ht/m 2 ; People who have a first degree relative with diabetes; Members of a high-risk ethnic group (e.g., African American, Hispanic, Native American, Asian); Women who delivered a baby weighing more than nine pounds or were diagnosed with gestational diabetes mellitus (GDM); People who have hypertension (blood pressure at or above 140/90); People with an HDL cholesterol level of 35 mg/dl or lower and/or a triglyceride level of 250 mg/dl or higher; or People who, on previous testing, had IFG or IGT. SPECIAL RECOMMENDATIONS FOR PREGNANT WOMEN While the category of gestational diabetes (which complicates about four percent of U.S. pregnancies) is retained, the recommendation for screening of all pregnant women has been dropped. It is recommended that women who satisfy any of the following criteria be screened between the 24 th and 28 th week of gestation: Greater than 25 years of age Greater than normal body weight Family history of diabetes Member of an ethnic group with a high prevalence of diabetes

2 Goals for Glycemic Control Where Appropriate I. Preprandial glucose mg/dl II. Postprandial glucose <160 mg/dl III. Bedtime glucose mg/dl IV. Hemoglobin A 1c < 7.0 Approach to Glycemic Control I. Individual tailored plan by physician for self-monitoring of glucose II. Comprehensive diabetic education including nutritional counseling III. Regular exercise IV. Multiple insulin injections or oral hypoglycemic agents; mimic normal physiology V. Instruction in prevention/treatment of hypoglycemia VI. Continuing diabetic education reinforcement VII. Periodic assessment of treatment goals Referral to Diabetic Education/Disease Management I. Newly diagnosed diabetes II. Inadequate diabetic control and/or compliance problems with treatment III. Progressive diabetic complications Referral to Endocrinologist I. For difficult to control diabetes 1. Hemoglobin A 1c > 8 and the patient remains refractory to therapy for consult 2. Hemoglobin A 1c > 10 refer for consultation and two additional visits within a six-month period for education 3. Plasma glucose frequently above 200 mg/dl 4. More than one ER visit or hospitalization for hyperglycemia or hypoglycemia within a six-month period II. For diabetic complications 1. High triglycerides, low HDL 2. Nephropathy: increased BUN and creatinine 3. Proteinuria > 300 mg/day or microalbuminuria > 30 mg/day 4. Neuropathy 5. Retinopathy 6. Peripheral vascular disease 7. Coronary heart disease HEDIS Measure

3 Nutritional Guidelines I. Refer to a registered dietician II. Avoid concentrated sweets, sugar, and juices III. Type 2 patients attain/maintain normal body weight; moderate caloric restriction ( less than usual intake) to achieve a BMI of < 27 ht/m 2 IV. Improve food choices (low-fat = low calorie) V. Avoid saturated fat (less than 10% calories) and high cholesterol food VI. Protein 10% to 20% of calories; for nephropathy 0.8 gm/kg/day VII. Carbohydrates; not specifically restricted as a percentage of calories Not always covered by Oxford. Check Member s benefits. Follow-up Evaluation of Diabetes I. Annual office visit each visit must contain the following items: Complete history Review home monitoring records Inquire about symptoms of hyperglycemia in all patients Inquire about symptoms of hypoglycemia in patients on sulfonylureas, other secretogogues, and/or insulin Review elements of the treatment plan Complete physical exam with focus on: Blood pressure and weight Neurological/peripheral vascular exam Examination of the feet with shoes and socks off Dilated fundoscopic exam by ophthalmologist or optometrist Lab analysis Hemoglobin A 1c Lipid Profile Blood glucose TSH level BUN/ creatinine Urine screen for albuminuria (dipstick); if negative, test for microalbuminuria 24-hour (or timed overnight) urine protein and creatinine clearance for patients with microalbuminuria or proteinuria EKG for all type 2 diabetics, and when appropriate for type 1 diabetics HEDIS Measure

4 II. Regular office visits at least every three months (four months on oral therapy if well controlled); each visit must contain the following items: Interim history Review home monitoring records Inquire about symptoms of hyperglycemia in all patients Inquire about symptoms of hypoglycemia in patients on sulfonylureas, other secretogogues and/or insulin Review the elements of the treatment plan Physical exam with focus on: Blood pressure and weight Peripheral vascular exam Examination of the feet with shoes and socks off Lab analysis Hemoglobin A 1c Plasma glucose Urine screen for albuminuria (dipstick) Prevention of Complications I. Metabolic control of hyperglycemia (hemoglobin A 1c less than 7) II. Aggressive treatment of hypertension Goal: BP less than or equal to 130/85 - Risk factor for cardiovascular and renal disease - Slows progression of nephropathy III. ACE inhibitors for proteinuria over 100 mg/day ; aspirin therapy for all people with diabetes unless contraindicated IV. Aggressive treatment of hyperlipidemia Goals: LDL less than 100 Total cholesterol less than 200 mg/dl HDL cholesterol raised to >45 mg/dl for men and >55 mg/dl for women Triglycerides less than 150 mg/dl V. Smoking cessation VI. Reduction in alcohol intake when appropriate HEDIS Measure

5 VII. Regular foot care by podiatrist for high-risk patients - peripheral neuropathy - vascular disease - structural deformity - abnormal gait - history of foot problems - unable to care for feet properly - poor vision VIII. IX. Regular ophthalmologist or optometrist exam/treatment Repeated reinforcement of diabetic education

6 MS