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Diabetes is a metabolic disorder characterized by hyperglycemia due to ineffective insulin secretion and/or insulin utilization.

Definitions Edit

  • Diabetes: see diagnosis section. A fasting plasma glucose level of 7.0 mmol/L, a 2-hour plasma glucose value in a 75 g oral glucose tolerance test of 11.1 mmol/L or a glycated hemoglobin (A1C) value of 6.5%
  • Pre-diabetes: impaired fasting glucose, impaired glucose tolerance, or an HbA1c between 6.0-6.4%. These people are at increased risk of developing diabetes and its macrovascular complications
  • Metabolic syndrome: Elevated waist circumference, triglycerides, reduced HDL-C, elevated Blood Pressure, elevated fasting plasma glucose

SymptomsEdit

  • Hyperglycemia: polydipsia, polyuria, unexplained weight loss, polyphagia, blurred vision, fatigue, dry mouth, dry skin, arrhythmia, decrease LOC
  • Hypoglycemia: sweating, palpitations, sweating, clammy, blurred vision, dilated pupils, nausea, vomiting, confusion, seizures, decrease LOC

Complications Edit

MicrovascularEdit

  • Retinopathy
  • Neuropathy
  • Nephropathy

Macrovascular Edit

  • Cardiovascular disease
  • Cerebrovascular disease
  • Peripheral Vascular disease

Screening Edit

  • No screening for T1DM
  • T2DM
    • Every 3 years >/= 40 years old or high risk with fasting plasma glucose and/or HbA1C.
    • Screen earlier +/- more frequently pending risk factors
    • Risk factors: first degree relative, member of high risk population (South Asian, Hispanic, Aboriginal, Asian, African), history of pre-diabetes, history of gestational DM, history of macrosomic infant, presence of end organ damage associated with DM, vascular risk factors (HDL<1.0, TG >1.7, HTN, overweight, abdominal obesity), associated diseases (PCOS, acanthosis nigricans, OSA, bipolar, schizophrenia, depression, HIV), drug use (steroids, antipsychotics, HIV treatment), endocrine disorders
  • Risk calculators:
    • CANRISK (ages 40-74) - low/moderate/high groups
      • age, sex, BMI, waist circumference, ethnicity, physical activity, diet, HTN, history of dysglycemia, family history, education level
      • CANRISK TOOL 
    • FINDRISC - low/moderate/high groups

DiagnosisEdit

Test

Pre-DM

Diabetes

Fasting blood glucose (mmol/l) (no intake >8h)

6.1-6.9 (impaired fasting glucose)  IFG

>/= 7.0

2hour plasma glucose in a 75 OGTT

7.8-11.0 (impaired glucose tolerance) IGT

>/= 11.0

HbA1C (%)

6.1-6.4%

>/=6.5

Random Plasma Glucose

>/=11.1

  • If asymptomatic a repeat confirmatory laboratory test on another day is indicated to confirm diagnosis
  • If symptomatic a diagnosis made. No confirmatory test required.
  • HbA1c is better predictor of macrovascular complications. HbA1c cannot be used in patients with hemoglobinopathies, iron deficiency, hemolytic anemias, severe hepatic/renal dsease
  • HbA1c not recommended in children, teens, pregnant woman or suspected type 1 diabetes
  • If FPG 5.6-6.0 or A1c 5.5-5.9 + >1 risk factors consider 75 gram OGTT
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Prevention Edit

  • No prevention strategies for T1DM
  • Lifestyle changes: diet, exercise (moderate to high levels), and weight loss
    • 150minutes/week moderate to vigorous aerobic activity
    • Resistance training 2x/week
  • Medications: In individuals with impaired glucose tolerance metformin or acarbose can be used to reduce risk of T2DM

Management Edit

General Principles

  • Chronic care model - important to advocate at the community and health system level
  • Support self management, regular follow-up, provide patient centered education
  • Use interdiscipinary team approach with shared care model
  • Consider specialist involvement for children with DM, T1DM, women with diabetes in pregnancy, complex T2DM

TargetsEdit

  • HbA1c < 7% general population
  • Can consider target HbA1C <6.5% to lower risk of nephropathy and retinopathy if young and healthy
  • HbA1C 7.1-8.5% in patients with one of the following: multiple severe hypoglycemic episodes, unaware of hypoglycemia, multiple co-morbidities, fragility, limited life expectancy, high level of functional dependency, extensive coronary artery disease at high risk of ischemic events, longstanding diabetes for whom it is difficult to achieve an A1C <7.0% despite effective treatment
  • Elevated fasting and post-prandial glucose confer risk of cardiovascular disease
    • ​Fasting glood gluocse 4.0-7.0
    • Post-prandial 5.0-10.0

Non-pharmacologic StrategiesEdit

Diet: can lower HbA1c 1-2%

  • ​Consider referral to dietician
  • Recommend foods with low glycemic index (lower ability to raise blood glucose)
  • Dietary fiber (soluble) decreases post-prandial glucose by slowing gastric emptying and delaying absorption
  • Recommend saturated fats <7%
  • Canada's Food Guide
  • Diabetic Food Handout - CV toolbox
  • Diets that have been shown to help glycemic control: Mediterranean, vegan/vegetarian, DASH diet
  • Patients with Type 1 insulin should be taught to match insulin to carbohydrate quantity and quality
  •  Insulin users with ETOH at risk of delayed hypoglycemia. Should reduce insulin, increase BG monitoring or increase carbohydrate intake

Exercise

  • 150 minutes moderate to vigouros exercise (aerobic)
  • Resistance exercise 2-3x per week
  • People with diabetes that want to start exercising at risk of CVD à baseline ECG +/-stress test, fundoscopic exam, neuropathy screen
  • Can use exercise prescription

PharmacotherapyEdit

  • If HbA1c <8.5 - start lifestyle changes and consider metformin
  • If HbA1c > 8.5% - start metformin immediately. Consider combination therapy.
  • After diagnosis and starting therapy it should take 3-6 months to reach target HbA1c
  • Insulin has the largest effect on lowering HbA1c

Examples:Edit

  • Biguanide
    • Metformin: weight neutral, no hypoglycemia
      • S/E: N/V/D. Contraindication: CrCl<30ml/min
    • Glumetza
  • DPP4- inhibitor
    • Increase amount of circulating insulin. Less risk of hypoglycemia, risk pancreatitis
    • e.g. Siitagliptin (januvia), Linagliptin (Trajenta)
  • Sulfonylurea
    • Risk of hypoglycemia
    • e.g. Glyburide, Gliclazide (Diamicron)


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InsulinEdit

  • INSULIN PRESCRIPTION 
  • When starting insulin consider stopping insulin secreatogoues  due to risk of hypoglycemia. 

Insulin type

Onset

Peak

Duration

Bolus (prandial insulins)

Rapid acting (aspart-novorapid, glulisine-apidra, lispro-humalog)

10-15 minutes

1-2 hours

3-5 hours

Short acting (humulin R, novolin ge Toronto)

30 minutes

2-3 hours

6.5 hours

Basal insulin – intermediate acting (cloudy) (humulin N, Novulin ge NPH)

1-3 hours

5-8 hours

Up to 18 hours

Basal insulin – long acting (clear) (detemir –Levemir, glargine – lantus)

90 minutes

No peak

Up to 24 hours

Premixed insulins

Monitoring Edit

Type 1 diabetics:

  • should check finger prick glucose >3x/day and HbA1C q3 months
  • Real time continuous glucose monitoring may be used to improve glycemic control and reduce hypoglycemia
  • During periods of acute illness and elevated blood glucose/or symptoms of DKA patients should be instructed to test for blood ketones or urine ketones
  • Individuals with type 1 diabetes should be instructed to perform ketone

Type 2 diabetics:

  • HbA1c q3months when glycemic targets not being met or when therapy is being changed
  • On insulin once/day: self monitored glucose once/day at variable times
  • On insulin >1/time: check glucose at least 3x/day with both pre/post-prandial values
  • In T2DM not on insulin consider self monitoring glucose (individualized). Consider risk of hypoglycemia with oral antiglycemics, not acheiveing control to assist with compliance,

Calibrate blood glucose monitors once/year

Diabetic Ketoacidosis (DKA)Edit

Hyperosmolar Hyperglycemia SyndromeEdit

HypoglycemiaEdit

  • Definition: blood sugar <4 + autonomic symptoms + response to carbohydrate load
  • Symptoms: trembling, palpitations, sweating, anxiety, hunger, nausea, confusion, weakness, trouble concentrating, decrease LOC
  • Treatment of mild-moderate hypoglycemia- 15 grams carbohydrate load (dextrose tablets, lifesavers x 6, 3/4 cup orange juice, 1 tablespoon of honey), retest in 15 minutes

Vascular ProtectionEdit

  • Statin therapy
    • Age > 40 (regardless of LDL-C)
    • Earlier if have macro/microvascular complications
    • DM > 15 years duration and age >30
  • ACEI/ARB
    • Age >55 
    • Earlier if have macro/microvascular complications
    • Perindopril 8 mg PO daily or Ramipril 10mg Po daily or Telmisartan 80mg PO daily (full dose) - titrate up
  • ASA
    • All patients with diabetes who have had a vascular event
  • A1c < 7%, BP < 130/80, Cholesterol LDL<2.0, Drugs to protect heart (ACEI, statin, ASA), Smoking cessation, exercise, healthy eating

Other considerationsEdit

  • pneumococcal vaccination: over the age of 18 x 1 (at diagnosis) then one time revaccination if >65  (ensure >5 years between vaccinations)
  • Annual influenza vaccine

Patient Care Flow SheetEdit

Patient Care Flow Sheet

  • A1C q 3 months
  • ACr - yearly (target <2.0)
  • Retinopathy check - yearly 
  • BP check (every visit)
  • Neuopathy check - monofilament - yearly
  • LDL-C yearly (new guidelines changing**)

ReferencesEdit

Canadian Diabetes Guidelines

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