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Using American Diabetes Association Standards of Medical Care In the Free Clinic Setting DM-2, By the Rules Gary Greenberg, MD Medical Director, Open Door.

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Presentation on theme: "Using American Diabetes Association Standards of Medical Care In the Free Clinic Setting DM-2, By the Rules Gary Greenberg, MD Medical Director, Open Door."— Presentation transcript:

1 Using American Diabetes Association Standards of Medical Care In the Free Clinic Setting DM-2, By the Rules Gary Greenberg, MD Medical Director, Open Door Clinic Urban Ministries of Wake County (919) 256-2167; GNGreenberg@gmail.com April, 2010

2 Whose Rules? American Diabetes Association (ADA) 01/10 European Assoc. for the Study of Diabetes (now = ADA’s) American College of Clinical Endocrinology 05/07 US Preventive Services Task Force (USPSTF) 06/08 Health Plan Employer Data & Information Set (HEDIS) –National Committee for Quality Assurance (NCQA), 2009 Centers for Medicare & Medicaid Services (CMS) –(previous HealthCare Finance Admin, HCFA) Community Care of N. Carolina (based on ADA, 01/05)

3 How do you FIND the Rules? Finding Guidelines WWW.Guidelines.gov –All the world’s guidelines WWW.eMedicine.com –Free access narrative, with links WWW.OpenDoorDocs.org (mine) –Bulletted links to accepted standards, including this presentation

4 How do you FIND the Rules?

5 General Principles Diagnosis is categorical, leading to automatic risks & clinical interventions Managed as a chronic disease, with life- long, multi-dimensional concerns Rx is far-reaching, in tools, goals, tactics DM-2 isn’t “DM-II” any more, but when did it become T2DM ?

6 Diagnosis of Diabetes Previously: It took TWO of either of these: Fasting glucose ≥ 126 mg/dl (8 hours) 2-hour post-challenge ≥200 mg/dl (75 g) Or in a symptomatic patient with: Polyuria, polydipsia, and unexplained weight loss Single random (incl. post-prandial) ≥200 mg/dl

7 HgbA 1C It still takes TWO, but: HemoglobinA 1C > 6.5% Advantages: Non-fasting Easier transport, sample preservation Non-momentary (eg during steroids or acute illness) More standardized than glucose from lab-to-lab (not as true for point-of-care tests) Leads directly to measures of control Soon reported in interpolated units of glucose, “mg/dl”

8 HgbA 1C Circulating hemoglobin is seen as the perfect passive witness Disadvantages: Cost: $14-$18 Short RBC survival –Hemolysis –Bleeding or donor Abnormal hemoglobin phenotype Recent Transfusion

9 Hemoglobin A 1c More generically: Glycohemoglobin “Average” glucose, cumulative over the age of the RBC witnessing plasma levels Legitimate use of extrapolation, eg: –Baseline: A 1C = 12.0, began metformin –One month later: A 1C = 10.0 –Rate of fall: 2 points/mo –Expected / eventual A 1C seems on-target Consider: other serum glycosylated proteins –fructosamine = 3 week avg HbA 1c  Avg Glucose 6% 126 mg/dL 6.5% 140 mg/dL 7% 154 mg/dL 7.5% 169 mg/dL 8% 183 mg/dL 8.5% 197 mg/dL 9% 212 mg/dL 9.5% 226 mg/dL 10% 240 mg/dL 11% 269 mg/dL 12% 298 mg/dL

10 Pre-Diabetes or “Increased risk of Diabetes” A serious diagnosis, with legitimate therapies, including medications Impaired Fasting Glucose (IFG) : Fasting glucose 100-125 mg/dl Impaired Glucose Tolerance (IGT): 2-hr post-challenge 140-199 mg/dl New: HgbA 1C between 5.7 – 6.4

11 Screening for Diabetes Every 3 years: All overweight adults 45 & older (BMI ≥ 25 kg/m 2 ) Annual: high-risk + overweight Sedentary Family History (1 o relative) Ethnic risks (AA, Latino, Native Amer.) Prior gestational (or baby ≥ 9 lbs) Hypertensive Metabolic Syndrome (Low HDL or hypertriglyceridemia) Polycystic Ovaries Syndrome Known Pre-diabetes Acanthosis Nigracans Known vascular disease

12 Diabetes Prevention Lifestyle efforts Documented success (up to ~58% reduction in 3 years) –Weight loss, even modest –Exercise, even mild “increased activity” –Clinical monitoring Medications –Metformin (especially with both pre-diabetes criteria) –Acarbose, Orlistat, Rosiglitazone

13 Major Classes of Medications 1.Insulin Sensitizers sensitize the body to insulin and/or control hepatic glucose production 2. Secretagogues stimulate the pancreas to make more insulin Thiazolidinediones –Avandia (rosiglitazone), gone –Actos (pioglitazone) Biguanides –Metformin Sulfonylureas –Glimepiride (Amaryl) –Glipizide (Glucotrol) –Glyburide (Diabeta, Glynase, Micronase) no longer recommended Meglitinides –Nateglinide (Starlix) –Repaglinide (Prandin)

14 Newer Classes of Medications Incretin: short-lived gut hormones, multiple actions: Release insulin Suppress glucagon Reduce gastric emptying Trigger satiety 3. Injected drugs that mimic Incretin (but longer t 1/2 ) 4. Drugs that delay Incretin degradation Exenatide (Byetta) Liraglutide (Victoza) Sitagliptin (Januvia)

15 Other Medications 5. Carbohydrate digestion interference 6. Amylin mimic  -Glucosidase inhibitor –Acarbose (Precose) –Miglitol (Glyset) Pramlintide (Symlin)

16 Previous Charted Algorithm

17 Meds for Glucose Control Tier 1: well-validated core Step 1, initial therapy (estimated HgbA 1c improvement) –Lifestyle to decrease weight and increase activity (1 - 2) –Metformin (1 - 2) Step 2, additional therapy –Insulin (1.5 – 3.5) –Sulfonylurea (1 - 2) Tier 2: less well validated –TZD’s (0.5 – 1.4) –GLP-1 agonist (0.5 – 1) “Other therapy” -  -Glucosidase inhibitor (0.5–0.8) - Pramlintide (0.5 – 1.0) - DPP-4 inhibitor (0.5 – 0.8) Consensus Statement from ADA’s Diabetes Care 32:193–203, 2009

18 Insulin Older forms: –NPH: 8 hr peak, 12 hr duration, $62 for 1,000 units –Regular: 2-4 hr peak, 8 hr duration, $62 for 1,000 units Newer synthetic forms –Lantus (glargine), Levemir (detemir): Flat kinetics, all- day basal effect, $112 for 1,000 units –Humalog (aspart), Apidra (glulisine): immediate onset, life-style responsive, flexible, $119 for 1,000 units

19 Insulin Initial Dosing: Lantus 10 units, adjust at least weekly Auto-titration (not “sliding scale”) for the well informed Phone management is critical For immediate insulin, we use a “2-dimensional” table, NOT a calculation or sugar-only look-up Meal Sugar Snack or Breakfast Lunch or small supper Dinner <100024 100-200246 200-300468 >3006810

20 Insulin Sensitizers Metformin Direct approach to physiological problem (insulin receptor resistance) Usually mild weight loss (?from GI distress) Cheap as generic Use-able in conjunction with insulin Renal concerns (maximum serum creatinine, I 2 -dye risks) “Glitazones” or TZD’s Pioglitazone (Actos) or Rosiglitazone (Avandia) Cardiac risk controversies Delayed onset Fluid / sodium retention No generic Improve lipid parameters

21 Insulin Secretory Stimulators Sulfonylureas and meglitinides Historic tales of increased mortality (UGDP), missing evidence for health benefit (as opposed to intermediate goal of glucose control) is hard to find Modern generational drugs without [Na + ] shifts Hypoglycemia remains a concern Generics are available

22 The rest of the patient Prescribed comprehensive management of many clinical parameters, often remote to the metabolic disorder. Risks are no longer from hyperglycemia and D.K.A., but from cumulative damage and atherosclerosis Coronary disease remains the main cause for mortality. Arterial insufficiency leads to amputation.

23 Cardiac Risk Factors Lipids LDL < 100 (even lower, to <70 if uncontrolled other risks, eg smoking) BP < 130/80 HCTZ OK even though glucose elevation ACE or ARB shown beneficial for renal protection Aspirin, based on overall CAD risk factors –Men: 40 y/o if additional risks, 50 y/o even if none –Women: 50 y/o if additional risks, 60 y/o if none

24 Lipid “screening” Rx actions are based on overall CV risk: General patient population –Rx treatment threshold is high (LDL-C>160 mg/dl) –Screening with simple Cholesterol is enough ($6-$8) Diabetic population (or with known CVD) –Rx treatment threshold is low (LDL-C>100 mg/dl) –Screening with directly measured LDL ($13-$18)

25 Infection Concerns Pneumonia Despite antibiotic Rx, high-mortality group warrants pneumococcal vaccine, once at diagnosis, then at 65 y/o Influenza Mortality is huge, with additional coronary, metabolic complications, so annual “regular” flu-shot Skin, foot infections Ulcers, cellulitis, merit closer monitoring, earlier and more aggressive therapy. Polymicrobial flora

26 Renal Dangers BP control is for glomerular protection: <130/80 Annual monitoring: –Serum Creatinine (excretory capacity) –Urinary microalbumin excretion (resorptive, tubular capacity), corrected for hydration with ratio to urinary creatinine excretion) Renin Angiotensin System priority for Rx –First choice for BP Rx –ACE’s even just for (+) urinary microalbumin –ARB’s more costly, similar effect –Renin inhibitor: Tekturna

27 Direct End-Organ DM Effects Ocular Retinal exam by specialist, annually (unless told otherwise) Cataract monitoring Delay refraction until BS controlled Neuropathy Long axonal function, standardized monofilament testing Is vibration sense more ‘sensitive’ ?

28 Tactics for Organized Care Consensus approach for standards of clinical management –Display of standard of care is effective for providers & patients –Signs for patient to remind clinician for flu shot, foot exam, labs Pre-visit labs for HgbA 1c, lipids, renal monitoring (proteinuria and creatinine)

29 Tactics for Organized Care Checklist on entering room: Last labs: –HgbA 1C –Creatinine –LDL cholesterol –LFT’s (if on statin) –Urine Microalbumin Vaccines –Pneumovax –Fluvax Exams –Eye (date) –Feet –Dental –Gyn

30 Tactics for Organized Care Low threshold for performing clinical tasks: –Flow-sheets for reminders, results, logging prior interventions –Flags on charts for missing interventions –Stickers / stamps for check-lists –Standing orders to decompress physician demands

31 Tactics for Organized Care Full utilization of a Diabetic Team, including Pharmacist Nursing DM educator Nutritionist, Dietician Exercise coach/therapist Podiatrist Eye specialist Family

32 Important & New Changes HgbA 1C as diagnostic tool, DM & pre-DM Glyburide dismissed Metformin limitations Treating diabetics with HgbA 1C < 7.0

33 Resources WWW.OpenDoorDocs.org GNGreenberg@gmail.com = GGreenberg@urbanmin.org (919) 256-2167


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