Caring for Patients with Chronic Illness Introduction to Diabetes Mellitus Debra L. Simmons, MD Assistant Professor of Medicine Director, Arkansas Diabetes Program Director, Training Program Endocrinology, Diabetes and Metabolism University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System

General Attributes of Medical Visits Acute patient seeks doctors advice for a problem frequently a “complaint” –headache –chest pain –cough Chronic regularly scheduled appointment usually no “complaint” –fu effectiveness of treatment –monitor for complications of treatment or disease

General Attributes of Medical Visits cont. Acute History and physical –focuses on determining the cause of the complaint More likely to be physician directed for treatment Chronic History and physical –focuses on issues related to the chronic disease Usually requires the patient actively deciding goals of therapy and treatment

Introduction to Diabetes Mellitus Epidemiology Diagnosis and classification Goals of diabetes management

Epidemiology of Diabetes 15.7 million Americans have diabetes –10.3 million diagnosed –5.4 million not diagnosed 90% have type 2 diabetes 8.2% of people aged 45 to 64 in Arkansas have diabetes NDEP

Percentage of US Population by Age and Race With Diagnosed Diabetes Harris MI et al. Diabetes Care. 1998;21: *% based on medical history interview in subjects asked about previous Dx by physician. % Age group (yr) 

Seriousness of Diabetes Diabetes increases risk of –death –cardiovascular disease –stroke Diabetes is the leading cause of –adult blindness –end stage renal disease –nontraumatic amputations

> Age (yr) MenWomen Relative risk Risk vs nondiabetic Ford ES et al. Am J Epidemiol. 1991;133: Mortality in People With Diabetes: US Population

% of deaths Ischemic heart disease Other heart disease DiabetesCancerStrokeInfectionOther Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; chap 11. Mortality in People With Diabetes: Causes of Death

% of new cases of blindness Age (yr) Due to diabetesDue to diabetic retinopathy Klein R et al. In: Diabetes in America. 2nd ed. 1995; chap 14. New Blindness in US Adults: Contribution From Diabetes

Prevalence of ESRD by Primary Diagnosis, 1996* *Prevalence as of December 31, 1998 derived from Medicare billing records. 32.5% Diabetes 24.5% Hypertension Other 20.6% Glomerulo- nephritis 17.7% Cystic kidney disease 4.7% NIDDK. USRDS1998 Annual Report.

% of population Reiber GE et al. In: Diabetes in America. 2nd ed. 1995; chap 18. Diabetes and Lower Extremity Amputations: Prevalence of All Lower Extremity Amputations

Chronic Complications of Diabetes Macrovascular –coronary artery disease –cerebral vascular disease –peripheral vascular disease Microvascular –retinopathy –nephropathy –neuropathy

Introduction to Diabetes Mellitus Epidemiology Diagnosis and classification Goals of diabetes management

ADA 1997 Diagnostic Criteria for Diabetes Mellitus 1. Fasting plasma glucose >126 mg/dl* or 2. Symptoms plus random plasma glucose >200 mg/dl* or 3. Oral glucose tolerance test 2-hr plasma glucose >200 mg/dl* * Must confirm on another day unless DKA or HHNC; not for pregnancy ADA Diabetes Care 2000

ADA 1997 Diagnostic Criteria for Diabetes Mellitus 1. Fasting plasma glucose >126 mg/dl –8 hour fast –preferred test for diagnosis –NOT capillary blood glucose

ADA 1997 Diagnostic Criteria for Diabetes Mellitus 2. Symptoms plus random plasma glucose >200 mg/dl –polyuria –polydipsia –polyphagia –weight loss –fatigue –poor healing

ADA 1997 Diagnostic Criteria for Diabetes Mellitus 3. Oral glucose tolerance test plasma glucose 2-hr >200 mg/dl –75 gram glucose load –2 hour post glucose load plasma glucose –primarily for research

ADA 1997 Etiologic Classification of Diabetes Type 1 diabetes Type 2 diabetes Gestational diabetes Other specific types ADA Diabetes Care 2000

Type 1 Diabetes  -cell destruction Usually leading to absolute insulin deficiency Ketosis prone Two forms –immune-mediated –idiopathic which is rare and without known cause

Type 1 Diabetes Immune-mediated Commonly occurs in childhood May occur any age, even 9th decade Rate of  -cell destruction variable –usually rapid in childhood –may be slow in adults Markers include –islet cell autoantibodies –autoantibodies to glutamic acid decarboxylase

Type 1 Diabetes: Typical Presentation Young age Thin Classic symptoms –polyuria, polydipsia, polyphagia and weight loss May have diabetic ketoacidosis No family history of diabetes

Type 2 Diabetes Impaired insulin action –insulin resistance –primarily peripheral tissue defect Impaired insulin secretion –relative insulin deficiency –primarily  -cell defect

Glucose Liver Peripheral Tissues (Muscle) Pancreas Increased glucose production Impaired insulin secretion Insulin resistance Causes of Hyperglycemia in Type 2 Diabetes

Type 2 Diabetes Most are obese Spontaneous ketoacidosis rare Ketoacidosis may occur with stress Strong genetic predisposition

Type 2 Diabetes: Typical Presentation Many people are asymptomatic –Routine physical –Preop labs Not uncommon to present with complication –MI –Peripheral neuropathy –Foot ulcer Frequently family history diabetes

Gestational Diabetes Mellitus Any degree of glucose intolerance First recognition during pregnancy Reclassify 6 weeks postpartum

Other Specific Types Diseases of the exocrine pancreas –pancreatitis Drug- or chemical-induced –glucocorticoids –nicotinic acid Many others

Introduction to Diabetes Mellitus Epidemiology Diagnosis and classification Goals of diabetes management

Goals of Diabetes Management Prevention of acute complications –significant hypoglycemia –symptomatic hyperglycemia including DKA Prevention of microvascular complications Prevention of macrovascular complications Attainment of normal quality of life

Diabetes Control and Complication Trial 1441 type 1 diabetes Conventional therapy: 1-2 insulin injections per day Intensive therapy: 3-4 insulin injections per day or insulin pump Followed average of 6.5 years Published 1993

Effect of Intensive Glycemic Control in the DCCT: HbA 1c Levels Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329: HbA 1c (%) Study year Conventional therapy Intensive therapy 6.05 Normal

Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329: DCCT: Results of Intensive Therapy  Retinopathy76%  Nephropathy54%  Neuropathy60%

Rate/100 person- years Mean HbA 1c = 11% 10% 9% 8% 7% Conventional treatment Time during study (y) DCCT Research Group. Diabetes. 1995;44: DCCT: Absolute Risk of Sustained Retinopathy Progression by HbA 1c and Years of Follow-up

United Kingdom Prospective Diabetes Study 5102 newly diagnosed type 2 diabetes Conventional policy: diet Intensive policy: sulfonylurea, metformin (in overweight patients), or insulin Mean 10-year follow-up Published 1998, designed 1970s

Cross-sectional and 10-Year Cohort Data: Intensive vs Conventional Policy UKPDS Group UKPDS Group. Lancet. 1998;352: All patients assigned to regimen Intensive Conventional Patients followed for 10 years Intensive Conventional Time from randomization (y) Time from randomization (y) FPG Median FPG (mg/dL) HbA 1c Median HbA 1c (%)

UKPDS Results of Intensive Policy: Sulfonylurea/Insulin  Microvascular complications 25%  Retinopathy progression 21%  Nephropathy 34% UKPDS Group. Lancet. 1998;352:

ADA Recommendations for Glycemic Control GoalTake Action Preprandial glucose mg/dl <80 >140 Bedtime glucose mg/dl <100 >160 HbA1c %<7>8 ADA Diabetes Care 2000

Prevention of Macrovascular Disease Control of hypertension Control of lipids Cessation of smoking Aspirin use

Prevention of Macrovascular Disease: Control of Hypertension UKPDS substudy proved effectiveness of BP control –Intensive control (mean 144/82 vs 154/87) reduced strokes 44%, diabetes related deaths 32% and heart failure 56% Goal <130/85 mmHg ACE inhibitor currently preferred due to renal protective effect ADA Diabetes Care 2000

Prevention of Macrovascular Disease: Control of Lipids Primary goal is LDL cholesterol <100 mg/dl –same as NCEP guidelines for secondary prevention –due to very high risk of CAD in diabetes Secondary goal is HDL cholesterol >45 mg/dl for men and >55 mg/dl in women ADA Diabetes Care 2000

Prevention of Macrovascular Disease: Cessation of Smoking Cigarette smoking and diabetes –increases risk of morbidity and mortality of CVD Counsel to quit smoking ADA Diabetes Care 2000

Prevention of Macrovascular Disease: Aspirin Use Low dose aspirin – mg/day if >21 YO Secondary prevention –MI, stroke, TIA, PVD, angina, claudication Primary prevention if high risk –family history CVD, cigarette smoking, hypertension, obese, albuminuria, dyslipidemia ADA Diabetes Care 2000

Attainment of Normal Quality of Life Patient at center of team of health care providers Psychosocial issues extremely important

Diabetes Team PATIENT Primary care provider Endocrinologist Diabetes educator Nutritionist Podiatrist Social worker Psychologist Exercise physiologist

Patient Education: Diabetes Self-Management Understand diabetes disease process –emphasis on benefit of good control Learn appropriate diet –individualized diet plans Learn self-monitoring of blood glucose –use of meter –what to do with the results

Patient Education: Diabetes Self-Management cont. Learn how to use prescribed medications –how it works –when to take it –side effects Learn how to balance diet, exercise and medications as well as stress Learn sick day rules

Psychosocial Issues: Impact of the Disease May be devastating due to fear of complications May be overwhelming due to complexity of caring for the disease –must watch what they eat, when they eat, take medications on time, juggle activity with food intake and medications, go to the doctor regularly –can not just think about it occasionally

Psychosocial Issues: Other Many psychosocial issues may impact the ability of the patient to care for themselves –lack of money, access to healthcare providers –turmoil in family such as caring for a dying parent, spouse with Alzheimer’s disease, child involved with drugs –psychiatric illness such as depression greatly impairs the patient’s ability to care for diabetes

Summary of Goals of Diabetes Management HbA1c <7% BP <130/85 LDL cholesterol <100 mg/dl Smoking cessation 1 aspirin/day Normal quality of life

Follow Up Visit for Diabetes Chief complaint History since last visit Physical exam Laboratory

Follow Up Visit for Diabetes: Chief Complaint Usually routine visit May have additional complaint(s) –evaluate as usual in addition to routine visit if possible

Follow Up Visit for Diabetes: Basic History Can be from chart and/or obtain from the patient –type of diabetes –duration of diabetes –complications of diabetes –medications for treatment of diabetes (always confirm) –all other medications (always confirm)

Follow Up Visit for Diabetes: History Since Last Visit Problems with management plan –medication, diet, exercise Results of self-monitoring of blood glucose –review log book of results and comments Specifically question about hypoglycemia –do not assume they will tell you or that it is marked in their log book

Follow Up Visit for Diabetes: History Since Last Visit cont. Question about any changes –health –social issues –family history that effects patient’s CVD risk Review need for referral for yearly dilated eye exam (screening for retinopathy)

Follow Up Visit for Diabetes: Laboratory Review HbA1c results and goals Review lipid results and goals Review need for yearly lab –microalbuminuria (screening for early nephropathy)

Follow Up Visit for Diabetes: Physical Exam BP, weight, height (yearly for adults) Previous abnormalities on exam –Focus is commonly cardiovascular as well as funduscopic exam and insulin injection sites Foot exam in high risk patients –peripheral neuropathy –prior foot ulcer or amputation