Applications of SDM to Prevent Diabetes Complications

SDM: Applications to
Complications

Priorities of Care for Adults with Diabetes
Diagnosis–Prevention
Dx Fasting Glucose > 126 Casual > 200 + Symptoms
Prevent Pre-diabetes (IFG-IGT) & Metabolic Syndrome

Self-Management Knowledge and Skill
Monitoring Medication Problem solving Food plan & nutrition
Risk reduction Living & coping Physical activity

Microvascular Other essentials
Glucose Lipids Hypertension
complications of care

CVD Risk
ASA, tobacco, ACEI/ARB, statin

Hemoglobin A1C Annual Lipid Profile Blood Pressure Annual Screening
Target < 7.0% LDL < 100 (every visit) Nephropathy
HDL > 40 Dx and Rx < 130/80 Microalbumin screening Hospital care
SMBG Calculated GFR
Pre 70-120 mg/dL Trigs < 150 Foot care
Retinopathy
2 hr. post < 160 mg/dL Dilated retinal exam Dental care
(~ 50% of readings) DM + CVD Neuropathy Immunizations
Neuro and foot exam
LDL < 70
Sexual health

© 2008 International Diabetes Center.

Natural History of Type 2 Diabetes

350
Postmeal Glucose
(mg/dL)

300
Pre Diabetes
250
Metabolic Syndrome
Fasting Glucose
Glucose

200
150
100
50
Relative function

250
200 Insulin Resistance
150
Impaired Incretin Action
100
Insulin Level
50
β-cell Fn
0
-15 -10 -5 0 5 10 15 20 25 30
Onset
Diabetes Years
© 2007 International Diabetes Center, Minneapolis, MN All rights reserved.

Chronic Complications of Diabetes

Macrovascular

Brain
Cerebrovascular disease
• Transient ischemic attack
• Cerebrovascular accident

Heart
Coronary artery disease
• Myocardial infarction
• Congestive heart failure

Extremities
Peripheral vascular disease
• Ulceration
• Gangrene
• Amputation

Chronic Complications of Diabetes

Microvascular

Eye
Retinopathy
Cataracts
Glaucoma

Kidney
Nephropathy
• Microalbuminuria
• Gross albuminuria
• Kidney failure

Nerves
Neuropathy
• Peripheral
• Autonomic

Benefit of Glucose Control in
Reducing Microvascular Complications

 Type 1 Diabetes
– Diabetes Control and Complications
Trial (DCCT)
– Epidemiology of Diabetes in
Complications (EDIC)

Diabetes Control and Complications Trial (DCCT)
Type 1 Diabetes

24-76% reduction in microvascular complications

- Retinopathy

- Neuropathy

- Nephropathy

- Microalbuminuria

DCCT Study Group. N Engl J Med 329:977, 1993

EDIC Study Results
Intensive Glucose Control in Type 1 Diabetes

E D I C R e s e a r c h G r o u p . N E n g l J M e d 2 0 0 0 ; 3 4 2 : 3 8 1- 9

Sustained Benefit of Intensive Control
EDIC Study 4 Years Post DCCT

Metabolic
Memory

E D I C R e s e a r c h G r o u p . N E n g l J M e d 2 0 0 0 ; 3 4 2 : 3 8 1- 9

Reducing Microvascular Complications

 Type 1 Diabetes
– Diabetes Control and Complications
Trial (DCCT)
 Type 2 Diabetes
– United Kingdom Prospective Diabetes
Trial (UKPDS)
– UKPDS 10 Year Follow-up

UKPDS
Reduction in Microvascular Disease

10
5
Risk Reduction (%)

0
-5
-10
-15
-20
-25 -21
-25
-30
-35
-34
-40
Retinopathy Microalbuminuria Any Microvascular
p = 0.015 p = 0.00054 Endpoint
p = 0.0099

UKPDS: Lancet 352:837-853. 1998
BMJ 321:405-412, 2000

UKPDS: Long-term follow-up

Holman et al. NEJM 359(15):1577-1589, 2008

Metabolic Memory in Type 2 Diabetes

Holman et al. NEJM 359(15):1577-1589, 2008

Lowering blood glucose significantly reduces
the risk of microvascular complications
In both Type 1 and Type 2 diabetes

8
of Complications
Relative Risk

6

4

2

0
Hemoglobin A1c 6 7 8 9 10 11 12

Adapted from: Skyler JS. Endocrinol Metab Clin North Am. 1996 Jun;25(2):243-54.
DCCT Study Group. N Engl J Med 329:977, 1993
UKPDS 35. Stratton IM. BMJ 321:405-412, 2000.

Diabetic Retinopathy
 It is estimated that more than 2.5 million
people worldwide are affected by diabetic
retinopathy.
 Diabetic retinopathy is the leading cause
of vision loss in adults of working age (20
to 65 years) in industrialized countries.
 Largely preventable

International Diabetes Federation, 2008

Optic Nerve
Hard exudates

Macula
Early Nonproliferative
Normal Retina Retinopathy

Hemorrhage

Neovascularization
Proliferative Retinopathy

Prevention of Diabetic
Retinopathy
 Annual dilated eye examination
– Retinal lesions occur in up to 90% of
individuals at 20 years
 Glycemic control
 Limits risk of retinal disease, slows rate of
progression
 Benefits observed in both Type 1 and Type 2
diabetes
 Blood pressure control

Treatment of Diabetic Retinopathy

– Glucose control
– Blood pressure
control
– Photocoagulation

Diabetes-related Kidney Disease

 Diabetes is the largest
cause of kidney failure in
developed countries and is
responsible for huge
dialysis costs.
 Type 2 diabetes has
become the most frequent
condition in people with
kidney failure in countries
of the Western world.


Diabetic Glomerulosclerosis
Normal Glomerulus

Diminished &
Leaking
Filtering Space

Messangial
Proliferation Proteinuria
and Sclerosis
↓ CrCl
HTN

Thickening
Basement
Membrane
ESRD
Longstanding Diabetes
Dialysis

Screening Recommendations
 Annual microalbuminuria screen
– Albumin/creatinine (A/C) ratio preferred
– Serum creatinine/ estimated GFR
 Type 1 Diabetes
– After 5 years duration
 Type 2 Diabetes
– At diagnosis
– During pregnancy

American Diabetes Association Standards of Medical
Care Position Statement Diabetes Care 2006; 29:S21-S23.

Kate ref for 2008

Screening for Kidney Disease

Obtain random albumin-to-
creatinine ratio (A/C ratio);
first am urine preferred

A/C ratio NO Repeat screen
>30 mg/g? annually

YES
Staged Diabetes Management Quick Guide,
Repeat screen twice within International Diabetes Center, 2009

60 days, R/O UTI

Screening for Kidney Disease
Continued
2 of 3 A/C
NO Repeat screen
ratios >30
mg/g? annually

YES

A/C ratio NO Diagnosis of
>300 mg/g? microalbuminuria

YES
International Diabetes Center, 2009
Diagnosis of
macroalbuminuria

Treatment of Early Kidney Disease
 Glucose control (A1C <7%)
 Blood pressure control (<130/80 mmHg; consider target
<120/75 mmHg)
 Smoking cessation
 Start ACE Inhibitor or ARB
– Baseline serum creatinine and potassium
– Monitor for side effects, may experience cough
with ACE inhibitor
– Monitor response in 3-6 months
– Adjust dose as necessary

Benefit of ACE Inhibitor Therapy
Type 2 Diabetes

Proteinuria (mg/24 hr)
400
Placebo
Enalapril
300

200

100

0
0 1 2 3 4 5
Years follow-up
Ravid M. Ann Intern Med 118:577, 1993

Neuropathy in Diabetes
Peripheral Neuropathy Autonomic Neuropathy
 Pain  Orthostatic hypotension
 Loss of sensation  Gastroparesis
 Loss of position sense  Diarrhea / constipation
(proprioception)  Cardiac – tachycardia
 Impaired protective sensation  Erectile dysfunction
 Risk for foot ulcer, loss of  Gustatory sweating
limb

Managing Peripheral Neuropathy

Prevention Symptom Management
 Glucose control  Analgesia (aspirin, NSAIDs)
 Annual comprehensive foot  Anti-depressant Rx
examination (amitriptylline, venlafaxine,
 ? ά-Lipoic acid duloxetine, others)

 Daily self foot inspection  Anti-seizure meds (gabapentin)

 Foot care
 Wear appropriate shoes
 Vascular lesions

Cardiovascular Disease (CVD) in
Diabetes*
 Heart disease and stroke account for about 65% of deaths in
people with diabetes.
 Adults with diabetes have heart disease death rates about 2 to 4
times higher than adults without diabetes.
 The risk for stroke is 2 to 4 times higher and the risk of death from
stroke is 2.8 times higher among people with diabetes
 Diabetes is a CVD (risk) equivalent
– Risk of MI comparable to those with known CVD

*US Data
American Diabetes Association, 2008

Diabetes is a Cardiovascular
Risk Equivalent !
Incidence of Heart Attack or Stroke during 7 year follow-up
8
7
Events / 100 person-yr

6
5
No DM
4
DM
3
2
1
0
No CAD CAD

Haffner S et al. N Engl J Med 1998;339:229-234

Reducing Macrovascular Complications

 Type 1 Diabetes

Reducing Macrovascular Complications

 Type 1 Diabetes
 Type 2 Diabetes
– ACCORD
– ADVANCE
– UKPDS 10 Year Follow-up

Additional Therapies to Reduce
Cardiovascular Disease

 Encourage active lifestyle & healthy diet
 Lower LDL cholesterol levels:
– Primary Prevention (CARDS study)
– Target LDL <100 mg/dL all individuals with
type 2 diabetes
– If diabetes and CVD target LDL < 70 mg/dL
 Control blood pressure <130/80 mmHg
 Daily aspirin therapy

Diabetes and Hypertension

 75% of individuals with diabetes have
hypertension


Type 2 Diabetes:
Blood Pressure Control and Complication Risk (UKPDS)

Microvascular
40 Myocardial Infarction
Complication Rate
per 1000 person-years

30

20

10
~ 15% reduction in risk
for each 10 mm Hg decrease in SBP
0
110 130 150 170
Mean systolic blood pressure (mm Hg)
Adler A. BMJ 321;412-419, 2000

Hypertension Treatment in Type 2 Diabetes

International Diabetes Center, 2009

Aspirin Recommendations in
Diabetes

Primary Prevention?
Secondary Prevention?

ADA Primary Prevention Recommendations
2009 vs 2010

2009 2010
 Aspirin 75-162 mg/day in  Aspirin 75-162 mg/day in
type 1 and type 2 at type 1 and type 2 if 10 yr
increased CV risk CHD risk >10%
– Age >40 years  Men >50 yrs and
– Family history CVD  Women >60 yrs with at
– Hypertension least one additional
risk factor
– Smoking  Family history CVD
– Dyslipidemia  Hypertension
 Smoking
– Albuminuria  Dyslipidemia
 Albuminuria

ADA Clinical Practice Recommendations 2009. Diab Care 32:Suppl. 1;
ADA Clinical Practice Recommendations 2010. Diab Care 33:Suppl. 1.

Comprehensive Foot
Examination
Patient Education

The Foot Examination
Standards of Care at Diagnosis & Annually

Careful inspection
 Skin, shoes, shape of foot
Vascular integrity
 Pulses
 Capillary refill
Neurological examination and function
 Light touch (5.07/ 10g monofilament)
 Vibratory sensation (128-Hz tuning fork)
 Reflexes

Source: Staged Diabetes Management, 5th edition, Quick Guide, pages 7-26.

Inspection

 Skin
 Nails
 Shoes/socks
 Presence of
deformities

Vibration Sensation

• Vibration Detection/Perception Threshold has been
shown to predict the development of foot ulcers1
• The tuning fork (128 Hz) is a practical tool to screen

vibratory sensation loss

Young MJ, et at, Diabetes Care 1994; 17:557-560. Abbott CA, et al, Diabetes Care
1998; 21:1071-1075. Coppini DV, et al, J Clinical Neuroscience 2001; 8:520-524.

Neurological Exam
Vibratory Sensation


Vibratory Sensation Testing

 Help patient differentiate vibration vs. pressure
 Fork on unsupported DIP joint of 1st toe
 When vibration sensation on toe ceases, compare to
examiners distal forefinger in seconds
 If this is normal, no need to do monofilament test

Normal = 0-10 seconds
Abnormal = Greater than 10 seconds
Absent = No vibration sensed

Monofilament testing

Staged Diabetes Management 4th Edition Quick Guide – Page 7-28

Monofilament Examination

Locations on the foot
8-10 = Normal protective
sensation
1-7 = Abnormal
0 = Absent

Plantar Dorsal


Neurological Exam
Protective Sensation

 10g monofilament
 10 locations on foot
 Apply at 90 degrees with
enough pressure to bend
filament (10 grams)
for 1.5 seconds


Prevention is Essential!!

Provide ongoing patient education
•Maintain good diabetes control
•Practice good foot care habits
•Check feet every day
•Treat problems right away
•Have regular health check-ups

Good Foot Care Habits

 Keep feet clean and dry
 If skin is dry, use a lotion daily
 Protect feet from hot and cold
 Trim toenails weekly

Nail Care
• Trim after washing a
drying feet
•Use a nail clipper (or
nipper) and trim straight
across
•Do not cut too short or
cut into nail corners
•Have a podiatrist or foot
specialist trim nails if the
patient cannot see or
reach their nails OR if
fungal nails present

Good Foot Care Habits

 Keep feet clean and dry
 If skin is dry, use a lotion daily
 Protect feet from hot and cold
 Trim toenails weekly
 Wear shoes and socks at all times

Appropriate Footwear

 Wear shoes that fit
well
 Avoid open toed
sandals, high heels
and pointed toe shoes
 Do not go barefoot
especially if
neuropathy present

Foot Self Inspection

 Inspect feet daily
 Check top and bottom of
each foot, toes and nails
and inside shoes
 Use a mirror if unable to
see feet well
 Have someone check for
you if unable
 Contact doctor if concerns

Essentials of Foot Care
 Comprehensive Foot Examination by HCP
Annually
– Patients with neuropathy - visual inspection of feet at every visit with
a health care professional

 Advise patients to:
– Inspect their feet daily
– Use lotion to prevent dryness and cracking (not between toes)
– File calluses with a pumice stone (no razors!)
– Cut toenails straight across or see podiatrist
– Always wear (natural fiber) socks and well-fitting shoes
– Notify their health care provider immediately if any foot problems
occur

Applications of SDM to Prevent Diabetes Complications

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