1. Criteria for Diagnosis of DM * Testing must be repeated on separate day. FPG is the preferred test ** Symptoms of DM IFG = Impaired fasting glucose IGT = Impaired glucose tolerance Diabetes care 1997; 20 :7 FPG 126 mg/dL 110 mg/dL 7.0 mmol/L 6.1 mmol/L Impaired Fasting Glucose Normal 2-Hour PG on OGTT 200 mg/dL 140 mg/dL 11.1 mmol/L 7.8 mmol/L Diabetes Mellitus Impaired Glucose Tolerance Normal Diabetes Mellitus **

2. Overview of Type 2: Screening and Diagnosis FPG < 110 mg/dL (6.1 mmol/L) CPG< 140 mg/dL (7.8 mmol/L) Fasting Plasma Glucose (FPG) or Casual Plasma Glucose (CPG) Patient w. Risk Factors and/or Symptoms of Diabetes No Diabetes FPG > 126 mg/dL (7.0 mmol/L) CPG> 200 mg/dL (11.1 mmol/L) FPG 110-125 mg/dL (6.1 - 6.9 mmol/L) CPG 140-199 mg/dL (7.8 - 11.0 mmol/L) If only FPG criteria then: Impaired Fasting Glucose If CPG criteria then: Impaired Glucose Homeostasis Repeat FPG within 7 days Diagnosis of Diabetes if FPG > 126 mg/dL (7.0 mmol/L) Type 1 or Type 2 Diabetes dependent upon age and ketones May screen using capillary blood: FCG>110 mg/dL (6.1 mmol/L) or CCG>160 mg/dL (8.9 mmol/L) then proceed to diagnostic test

3. High-risk groups : screening 1. Age > 45 yrs if normal check 3 yrs interval 2. Age < 45 yrs with 2.1 Obesity (BMI > 27 kg/m 2 ) 2.2 First degree relatives 2.3 Hypertension (>140/90 mmHg.) 2.4 Dyslipidemia (HDL-cholesterol 250 mg/dl.) 2.5 Gestational DM or macrosomia ( > 4 kg.) 2.6 previous impaired glucose tolerance(IGT) or impaired fasting glucose (IFG) 2.7 Habitual physical inactivity 2.8 polycystic ovary syndrome ADA,Diacetes care 2001.

4. Overview of Type 2: Screening and Diagnosis FPG < 110 mg/dL (6.1 mmol/L) CPG< 140 mg/dL (7.8 mmol/L) Fasting Plasma Glucose (FPG) or Casual Plasma Glucose (CPG) Patient w. Risk Factors and/or Symptoms of Diabetes No Diabetes FPG > 126 mg/dL (7.0 mmol/L) CPG> 200 mg/dL (11.1 mmol/L) FPG 110-125 mg/dL (6.1 - 6.9 mmol/L) CPG 140-199 mg/dL (7.8 - 11.0 mmol/L) If only FPG criteria then: Impaired Fasting Glucose If CPG criteria then: Impaired Glucose Homeostasis Repeat FPG within 7 days Diagnosis of Diabetes if FPG > 126 mg/dL (7.0 mmol/L) Type 1 or Type 2 Diabetes dependent upon age and ketones May screen using capillary blood: FCG>110 mg/dL (6.1 mmol/L) or CCG>160 mg/dL (8.9 mmol/L) then proceed to diagnostic test

5. At Diagnosis Fasting plasma glucose < 200 mg/dL Casual plasma glucose < 250 mg/dL At Diagnosis Fasting plasma glucose 200-350 mg/dL Casual plasma glucose 250-400 mg/dL Medical Nutrition Therapy And Exercise ( within 3 months) Oral Hypoglycemic Agent BMI > 25 BMI < 25 Metformin Sulfonylurea Combination Different group of oral drugs (Awareness of side effect) target not reach in 4-8 wk หลักการพิจารณาการรักษาผู้ป่วย เบาหวาน Target control FPG 80-140 mg/dL 2 hr PP PG < 160 mg/dL HbA1c < 7%

6. At Diagnosis Fasting plasma glucose > 350 mg/dL Casual plasma glucose > 400 mg/dL Combination Different group of oral drugs (Awareness of side effect) target not reach in 4-8 wk Combination of Oral Agent + Bedtime Insulin (intermediate or long acting) : insulin stage 1 Insulin stage 2 + insulin enhancer (BID Regimen) R/N-0-R/N-0, LP/N-0-LP/N Insulin stage 3A : (R/N-0-R/N, LP/N-0-LP-N) Insulin stage 3A-Mid : (R-R-R/N-0, LP-LP-LP/n-0) Insulin stage 4A : (R-R-R-N, LP-LP-LP-N) Target control FPG 80-140 mg/dL 2 hr PP PG < 160 mg/dL HbA1c < 7% target not reach in 4-8 wk

7. Choosing the “Best” Therapy--Type 2 First Step: Major Contraindications for Oral Agents Liver function and serum creatinine Serum creatinine > 2 mg/dL Serum creatinine 1.4-2 mg/dL Serum creatinine <1.4 mg/dL Metformin contraindicated No liver disease consider other oral agents Liver disease select insulin No liver disease select Thiazolidinedione Liver disease select insulin no yes *Since oral agents pass through the placental barrier they should be avoided in pregnancy. Oral agents have not been tested in individuals <18 years of age. yes

8. Repaglinide Post-meal hyperglycemia Variable schedule Alternative to SU May use in renal insufficiency Acarbose Post meal hyperglycemia No hypoglycemia Limited potency Oral Agent - Monotherapy Metformin Obese, insulin resistant Dyslipidemia Cr <1.5 ? Thiazolidinediones Insulin resistant Inappropriate for metformin Can use in renal insufficiency Troglitazone not advised as MonoRx Sulfonylurea Lean patient Initial Rx-early in disease Use with caution in renal disease Alternate Rx First Line Rx

9. Insulin Therapy in Type 2 Diabetes Insulin Therapy Two daily injections R/N - 0 - R/N - 0 LP/N - 0 - LP/N - 0 Insulin Sensitizer + Bedtime Insulin Metformin + Bedtime NPH Thiazolidinedione + Bedtime NPH ( Metformin or TZD) + SU + Bedtime NPH Sulfonylurea + Bedtime NPH (limited benefit) Two Daily injections + Insulin Sensitizer Three daily injections R/N - 0 - R - N LP/N - 0 - LP - N Three daily injections + Insulin Sensitizer Four daily injections R/(N) - R - R - N LP/(N) - LP - LP - N LP/U - LP - LP/U - (LP) LP/U - LP - LP - N Four daily injections + Insulin Sensitizer Stage 2 Stage 3 Stage 4

10. Hypertension: Diagnosis and Treatment Initiation Blood Pressure Evaluation at Every Office Visit Diagnosis of HTN BP>130/85 (2X) Microalbuminuria Repeat Every Visit Yes No Systolic BP >140 or Diastolic BP >90 Initiate ACE inhibitor Yes No Yes Initiate Drug Therapy Food Plan and Activity Follow-up 1-2 months Staged Diabetes Management

11. Dyslipidemia: Diagnosis and Treatment Initiation Annual Fractionated Lipid Profile Diagnosis of Dyslipidemia Tg > 1000 mg/dl Repeat Screening in 1 year Yes No LDL Cholesterol Elevated? LDL > 100 with CVD LDL > 130 without CVD Fibric Acid Yes No Yes Statin Food Plan and Activity Follow-up 1-2 months Staged Diabetes Management

12. Treatment Decisions LDL Cholesterol in Adults with Diabetes Risk Profile Diabetes + Known CVD Diabetes + High Risk Diabetes + Lower Risk Initiate Rx LDL > 100 (statin) LDL > 130 (statin) LDL > 130 (MNT) Target LDL < 100 Staged Diabetes Management Institute for Clinical Systems Integration Adapted from American Diabetes Association. Diabetes Care 21 (Suppl 1):S36, 1998.

13. Retinopathy: S creening and Diagnosis Complete Eye Examination Evidence of Retinal Lesion Repeat Annually Yes No NPDR: microvascular abnormalities, severe dot hemorrhages, venous dilation Tight glycemic control HbA1c <7 % Refer to Eye Specialist within 1-3 Months Staged Diabetes Management ENPDR: microaneurysms, dot hemorrhages, hard exudates PDR: new vessels on disc, retinal detachment Immediate Referral to Eye Specialist

14. SDM Algorithm for Screening, Diagnosis of Microalbuminuria Obtain annual random urine sample (first Am urine preferred) Repeat screen twice within 60 days, R/O occult UTI, exercise Test positive? Repeat screen annually If hypertension present consider ACEI or other Rx NO YES

15. SDM Algorithm for Screening, Diagnosis of Microalbuminuria (continued) 2 of 3 tests positive? Diagnosis of microalbuminuria Repeat screen annually NO YES Initiate ACE inhibitor

16. Definitions of Abnormalities in Albumin Excretion Random** 24 hr Urine Timed (microgram/min) Normal <30 mg/g <30 mg/24h <20 Microalbuminuria 30-300 mg/g 30-300 mg/24h 20-200 Macroalbuminuria >300 mg/g >300 mg/24h >200 ** Random urine = Alb/Cr ratio Diabetes Care 28, Supple 1, Jan 1998

17. Prevention & Treatment of Nephropathy Y Y Tight glucose control Y Low protein diet Y Tight blood pressure control ( < 130/85 mmHg ) Y ACE Inhibitors (Low dose) Y Cessation of smoking Y Treatment of dyslipidemia

18. Diabetic Foot: Assessment and Treatment Complete Foot Examination: deformities, sensation, ulcers, circulation, ischemia Evidence of Ulcer Assess and Treat : measurements, surgical debridement, antibiotics, vascular evaluations No Yes Abnormal foot: deformity, insensate, ischemia Foot assessment each visit, self-care Special foot wear, palliative foot care, self-care Staged Diabetes Management Normal foot