Management of diabetic individual:

A. With regards to preventing CAD:

1. Stress on the importance of a diet (low sugar, high fiber diet…

even low fat according to his lipid profile)
2. Stress on the importance of exercise (atleast 30 min walking per
day)
3. Stress on smoking cessation (since it is a CAD risk factor)
4. Measure his BP every time he comes to your clinic. If it is greater
than 130/80 then give an ACEI or ARB.

5. Order lipid profile test at least once per year.

- In patients with clinical cardiovascular disease (CVD) or over age
40 years with other CVD risk factors, statin therapy should be
added to lifestyle intervention regardless of baseline lipid levels.
- For patients without clinical CVD and under age 40 years, statin
therapy can be considered in addition to lifestyle intervention if
LDL cholesterol remains above 100 mg/dL or in those with
multiple CVD risk factors.
In individuals without overt cardiovascular disease, the goal LDL is
<100 mg/dL whereas in patients with overt CVD, a lower LDL goal
<70 mg/dL is an option.
Triglyceride levels <150 mg/dL and HDL levels > 40mg/dL for men and
>50 mg/dL for women are preferable.

6. Daily aspirin (75 to 162 mg/day) in diabetics above the age of 30

at increased cardiovascular risk (DL, HTN, smoking, obesity,
albuminuria, or family history of coronary heart disease) for
primary prevention.
It is recommended for secondary prevention (previous MI, history of
claudication, stroke, ischemia…)
It is contraindicated in patients below the age of 21 due to Reye’s
syndrome.

B. With regards to microvascular complications:

7. Eye screening by an ophthalmologist for diabetic retinopathy. This

is to be done yearly initially. Some studies suggest that with the
approval of the ophthalmologist, it can be done every 2 to 3 years
in low risk patients (good glycemic control, previous negative
tests, older age).
 8. Check BUN and Cr level at least once per year.

9. Screen for microalbumineria at least once per year. ACEI or ARB

is to be given if urine test is positive for microalbuminuria.
Not to be done via routine urine dipstick cause it does not detect protein
until excretion exceeds 300 to 500 mg/day.
Establishing the diagnosis of increased urinary albumin excretion
requires the demonstration of a persistent (at least two abnormal tests)
elevation in albumin excretion.
Fever, exercise, heart failure, and poor glycemic control are among the
factors that can cause transient microalbuminuria.

10. Check the feet at every visit.

- Inspection: skin assessed for integrity especially between the
toes and under the metatarsal heads. Check for any warmth,
erythema, bony deformities, gait and balance problems
- Screen for peripheral artery disease by asking about history
of claudication and assessing dorsalis pedis pulses.
Note: consider obtaining an ankle brachial index cause many
patients with peripheral artery disease would be asymptomatic
- Test for loss of protective sensation using a Semmes-
Weinstein monofilament at specific sites to detect loss of
sensation in the foot, plus any one of the following: vibration
using a 128Hz tuning fork, pinprick sensation or ankle reflexes.

+ Advice for prophylactic foot care should be given to all patients

● Avoid going barefoot, even in the home.

● Test water temperature before stepping into a bath.
● Trim toenails to shape of the toe; remove sharp edges with a
nail file. Do not cut cuticles.
● Wash and check feet daily.
● Shoes should be snug but not tight and customized if feet are
misshapen or have ulcers.
● Socks should fit and be changed daily

11. Recommend annual dental examination

12. Influenza vaccination yearly and pneumococcal vaccination,
repeating the pneumococcal vaccine once after age 65 years if the
initial vaccination was prior to age 65.
The hepatitis B vaccination should be given to unvaccinated adults
with diabetes mellitus who are ages 19 to 59 years.
 C. With regards to monitoring blood sugar:

13. Obtain an HbA1c at least twice yearly in patients who are meeting
treatment goals and who have stable glycemic control.
Obtain it every 3 months in patients whose therapy has changed or who
are not meeting glycemic goals.

14. Not all patients require self-monitoring of blood glucose (SMBG).

Usually those on mealtime insulin should test before meals and at
bedtime to adjust doses.
Patients on sulfonylurea or the nonsulfonylurea secretagogues should test
once or twice per day initially then after a stable dose and glycemic
control have been achieved, several times per week is enough usually in
the morning or before dinner.

All insulin and sulfonylurea patients need to test more frequently before
and during long car rides, during sick days, and when there are changes in
diet and exercise pattern