CLE RKSH IP

MITIGA TIN G DIABE TES MELLITUS OUTCOM ES

AT IN ITIAL CLINIC VISIT
Dr. Bien J. Matawaran, MD, FPCP, FPSEDM
April 29, 2020
B. Primary Prevention ..................................................... 6  
C. Secondary Prevention ................................................ 6  
Table of Contents D. Statin Intensity ............................................................ 6  
I. Decision Cycle for Patient-Centered Glycemic E. 2019 ESC/EAS Guidelines ......................................... 7  
Management ...................................................................... 1   F. ADA Lipid Guideline .................................................... 7  
II. Components of the Comprehensive Diabetes Medical G. Lipid Management: Lifestyle Intervention ................... 7  
Evaluation (Initial, Follow-up, and Annual Visits) ............... 2  
H. Ongoing Therapy and Monitoring with Lipid Panel ..... 8  
A. Past Medical and Family History ................................. 2  
VII. Urine Test ........................................................................ 8  
B. Lifestyle Factors .......................................................... 2  
A. Chronic Kidney Disease .............................................. 8  
C. Medications and Vaccinations .................................... 2  
B. Staging of Chronic Kidney Disease ............................ 8  
D. Technology Use .......................................................... 2  
VIII. Smoking Cessation ......................................................... 8  
E. Behavioral and Diabetes Self-management Skills ...... 2  
IX. Ophthalmologic ................................................................. 8  
F. Physical Examination .................................................. 2  
X. Sex-Related ....................................................................... 8  
G. Laboratory Evaluation ................................................. 3  
XI. Extremities ........................................................................ 8  
III. Major Diabetes Complications .......................................... 4  
XII. Blood Pressure ................................................................ 9  
A. Prevention of Diabetes Complications ........................ 4  
XIII. Aspirin ............................................................................. 9  
IV. Mnemonic for Diabetes Office Visits (Yale Diabetes
Center) ............................................................................... 4 XIV. Dental Issue ................................................................... 9  
GLUCOSE BAD CASES
V. Glycemic Control ............................................................... 4   XV. Case #1 ......................................................................... 10  
A. HbA1c ......................................................................... 4   XVI. Case #2 ........................................................................ 11  
B. Glycemic Targets ........................................................ 4   XVII. Case #3 ....................................................................... 12  
C. Approach to Type 2 DM .............................................. 4   OTHER ALGORITHM
D. Oral Agents for Type 2 DM ......................................... 5   XVIII. American Association of Clinical Endocrinologists ..... 13  
VI. Lipids ................................................................................ 6  
A. Atherosclerotic cardiovascular disease (ASCVD) ....... 6  
REMEMBER TEXTBOOK EDITOR PREVIOUS TRANS § Those who are using secretagogues, sulfonylureas, and
insulin
G & ! 4 § Impaired kidney and hepatic function – impaired
Refer to Dr. Matawaran’s PowerPoint Presentation as needed for gluconeogenesis
bigger images of the algorithm. J § Chronic diabetes
§ Cognitive impairement
I. Decision Cycle for Patient-Centered Glycemic § Hypoglycemia unawareness
∗ Manifestation of autonomic dysfunction; hypoglycemia
Management
triggers sympathetic and parasympathetic systems.
• The decision to start treatment is shared by the physician and ∗ Development of palpitations, tremors, and sweating as
the patient. counterregulatory effects of hypoglycemia
• The goals of treatment for diabetes ∗ Loss of sympathetic and parasympathetic response –
eventual response is neuroglycopenic response
A. Assess Key Patient Chracteristics (alteration in sensorium, dizziness, loss of
• Think of the patient first; establish at initial visit as well as the consciousness, coma, or death)
deciding what treatment to start § Patients on beta blockers
• Modifiable factors (i.e., age, glycosylated hemoglobin ∗ Blunting of the adrenergic response; prone to
[HbA1c], weight) help in deciding for the best treatment hypoglycemia unawareness
o Complexity of regimen (i.e., frequency, mode of
B. Consider Specific Factors that Impact Choice of administration)
§ In patients with poor grip or frailty score, insulin may not
Treatment
be a good agent unless there is a need for caregiver.
1. Individualized HbA1c target may differ between § Possibility of polypharmacy
physicians.
3. Shared decision making to create a management plan
2. Impact on weight and hypoglycemia o Patient empowerment and good communications skills
o If patient is overweight, give medications that will give o It is now advocated to call patients as patients or persons
weight loss. with diabetes, not diabetic patients. J
o If patient is cachectic or catabolic, medications that would
aggravate weight loss should not be given. 4. Subsequent boxes – what to do in follow ups
o Risk for hypoglycemia
§ Elderly
∗ Blunted response to hypoglycemia; frailty

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Figure 1 | Decision Cycle
II. Components of the Comprehensive Diabetes Medical
Evaluation (Initial, Follow-up, and Annual Visits)
A. Past Medical and Family History
1. Diabetes History
o Characteristics at onset
§ Reestablish the diagnosis.
§ Is the patient type 1 or type 2 diabetes mellitus (DM)?
§ Don’t presume that a patient in insulin has type 1 DM.
§ Not all young patients have type 1 DM, not all patients
with type 1 DM are young.
∗ They could have type 2 DM especially if obese, with
acanthosis nigricans, etc.
o Review of previous treatment regimens and response
o Assess frequency/cause/severity of past hospitalizations
§ Multiple admissions due to diabetic ketoacidosis may be
phenotypically type 1 or latent autoimmune diabetes of
adulthood (LADA).
2. Family History
o Diabetes in a first-degree relative
§ Type 2 DM has greater relationship to family history than
type 1 DM.
o Autoimmune disorder
§ Type 1 DM may have an overlapping autoimmune
disorder (as high as 30% possibility) (e.g., Graves’
disease, Hashimoto’s thyroiditis)
3. Personal History of Complications and Common
Comorbidities
o Assessing risk of diabetes complications; ASCVD and heart
failure history; ASCVD risk factors and 10-year ASCVD risk
assessment; staging of chronic kidney disease;
hypoglycemia risk
o Macrovascular and microvascular
o Common morbidities (e.g., obesity, OSA)
o Hypoglycemia (awareness, frequency, causes, timing of
episodes)
o Presence of hemoglobinopathies or anemias
§ HbA1c may be difficult to interpret in patients with
pernicious anemia and vitamin B12 deficiency.
§ Hemolytic anemia, thalassemia minor – HbA1c may be
used; relatively lower lifespan of red blood cells
o High blood pressure or abnormal lipids
o Dental visit
§ Increased risk for procedures
o Last dilated eye exam
o Visits to specialists
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4. Interval History
o Changes in medical/family history since last visit
B. Lifestyle Factors
• Eating patterns and weight history
• Physical activity and sleep behaviors
• Tobaccom alcohol, and substance use
C. Medications and Vaccinations
• Current medication regimen
o Since elderly patients are prone to polypharmacy, use fixed-
dose combinations (e.g., sulfonylurea + metformin)
• Medication-taking behavior
• Medication intolerance or side effects
• Complementary and alternative medicine use
o Prevalent in the Philippines
o Herbal medications causes diabetic nephropathy and
worsens diabetic kidney disease
• Vaccination history and needs
o Yearly influenza
o Pneumococcal vaccination (PPSV23, PCV13) for patients
above 65 years ols
o Hepatitis B vaccination
D. Technology Use
• Assess use of health apps, online education, patient portals,
etc.
o myfitnesspal, pedometer
• Glucose monitoring (meter/continuous glucose meter): results
and data use
• Review insulin pump settings and use
E. Behavioral and Diabetes Self-management Skills
1. Psychosocial Conditions
o Screen for depression, anxiety, and disordered eating; refer
for further assessment or intervention if warranted
§ Affects compliance to treatment
o Indentify existiinf social supports
o Consider assessment for cognitive impairment
2. Diabetes Self-management Education and Support
o History of dietician/diabetes educator visits/classes
o Assess diabetes self-management skills and barriers
o Assess familiarity with carbohydrate counting (type 1 DM)
3. Pregnancy Planning
o For women with childbearing capacity, review contraceptive
needs and preconception planning
§ Before allowing a woman of reproductive age to get
pregnant, mthere should have no uncontrolled blood
sugar
∗ Risk of malformation is higher; sugar freely passes the
uteroplacental circulation – baby will be hyperglycemic
– patient will have unregulated secretion of several
hormones including insulin – congenital malformation
F. Physical Examination
• Height, weight, and BMI
o Growth/pubertal development in children and adolescents
• Blood pressure determination
• Orthostatic blood pressure measures (when indicated)
o Establish autonomic neuropathy
o Orthostasis can be a manifestation of autonomic
neuropathy (e.g., 140/90 when supine, palpatory 90 when
standing)
o Difficult to manage since hypertensive medications may be
overdone.
• Funduscopic examination (refer to eye specialist)
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• Thyroid palpation
o Concomitant autoimmune disorder
• Skin examination
o Acanthosis nigricans – peripheral marker of insulin
resistance
o Insulin injection or insertion sites
o Lipodystrophy – if they inject insulin in the abdomen, those
are not good sites to reinject
• Comprehensive foot examination
o Visual inspection – skin integrity, callous formation, foot
deformity or ulcer, toenails (onychomysosis)
o Screen for peripheral arterial occlusive disease (PAD) –
refer for ankle-brachial index (ABI) if pedal pulses are
diminished
o Determination of temperature, vibration or pinprick
sensation, and 10-g monofilament exam
§ Helps in determining loss of perception sense (LOPS;
increases risk for diabetic foot ulcers)

G. Laboratory Evaluation
• HbA1c should be done if the results are not available within
the past 3 months
o Monitor quarterly
o If controlled, it can be measured twice or once a year
• If not performed/available within the past year
o Lipid profile, including total LDL, and HDL cholesterol and
triglycerides
o Liver function tests
o Spot urinary albumin-to-creatinine ratio
§ Screening for diabetic kidney disease; no need to
request for 24-hour urinary albumin (tedious to do, more
expensive)
o Serum creatinine and estimated glomerular filtration rate
o Thyroid-stimulating hormone in patients with type 1 DM
o Vitamin B12 if on chronic metformin use (when indicated)
§ There may be vitamin B12 deficiency.
o Serum potassium levels in patients on ACE inhibitors,
ARBs, or diuretics
§ In patients with chronic renal insufficiency who are
started with these meds, if there is 20-30% rise from the
baseline creatinine or potassium, discontinue drug or
refer to nephrology (early referral to prevent onset of
complications).

Table 1 | Components of Comprehensive Diabetes Medical

Evaluation

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III. Major Diabetes Complications

A. Prevention of Diabetes Complications (Secondary
Prevention)
• Eye care professional (microvascular complications)
• Family planning for women of reproductive age
• Registered dietitian for meal planning
• Dentist
• Diabetic self-management education (DSME) – educate on
diabetes, complications, blood sugar monitoring, insulin
injection
• Mental health professional – young patients with diabetes
(vulnerable group) must have parents with them during initial
visit

1. Eye problems
o Microvascular complications

2. Oral health

3. Cardiovascular disease

4. Kidney disease Figure 2 | Approach to Individualization of Glycemic Targets

o Baseline urinalysis, spot albumin-creatinine ratio, or
creatinine to establish nephropathy

5. Pregnancy complications

6. Diabetic foot

7. Nerve problems

GLUCOSEBAD
IV. Mnemonic for Diabetes Office Visits (Yale Diabetes
Center)
• Office visits should be scheduled every 3-4 months in well-
controlled patients
• Suboptimally controlled patients should be seen as frequently
as needed to help attain their targets.
• Glycemic control, Lipids, Urine, Cigarettes, Ophthalmologic,
Sex-related, Extremities, Blood pressure, Aspirin, Dental
issues
• For patients who have been very stable on diet or oral agent
monotherapy, office visits can be reduced to every 6 months.
V. Glycemic Control
A. HbA1c
• Perform at least twice a year in patients who are meeting
treatment goals and who have stable glycemic control
• Perform quarterly in patients whose therapy has changes or
who are not meeting targets

B. Glycemic Targets
• HbA1c <7%
• Preprandial CBG 80-130 mg/dL
o Peak postprandial CBG <180 mg/dL - Two hours from the
start of the meal

C. Approach to Type 2 DM
• Consider cardiovascular comorbidities, hypoglycemia risk,
impact on weight, cost, risk for side effects, and patient
preferences.
• Metformin is the preferred initial pharmacologic agent for the
treatment of type 2 DM.
• Early combination therapy can be considered in some
patients at treatment initiation.

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Figure 3 | Approach to Type 2 DM G

D. Oral Agents for Type 2 DM 1. Metformin

o Decreases fasting blood glucose
o Weight neutral but causes weight loss in some patients
o Should not be initiated in patients with GFR of <30 mL/min
o Continue (if already in metformin) but lower the dose if
GFR is 30-45 mL/min
§ Optimum dose is 2,000-2,500 mg/day – reduce dose to
1,000 mg/day
§ If patient is not on metformin, do not initiate

2. α-Glucosidase inhibitors
o Decrease postprandial blood glucose
o Take tablet after first spoonful of food.
o Gastrointestinal flatulence
§ Decreased transit time – fermentation of sugar in the gut

3. Dipeptidyl peptidase IV inhibitors

o Available in the Philippines – linagliptin, saxagliptin,
sitagliptin, vildagliptin, and teneligliptin
o Decreases both fasting and postprandial blood glucose
o Given at full doses
§ Linagliptin (5 mg/day) and teneligliptin can be given at
Table 2 | Oral Agents for the Treatment of Type 2 DM full dose regardless of eGFR

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4. Insulin secretagogues: Sulfonylureas § No previous myocardial infarction

o Glimepiride, gliclazide – long-acting; given once a day § No previous stroke
o Decreases both fasting and postprandial blood glucose § No peripheral arterial occlusive disease
o Insulin – anabolic hormone – weight gain § No established atherosclerotic event
o Initiating statin therapy based on risk
§ Statins are the drugs of choice for LDL cholesterol
5. Insulin secretagogues: Nonsulfonylureas
lowering and cardioprotection. G
o Decrease postprandial blood glucose o It is advisable to give statin in patients with diabetes-
o Take tablet after first spoonful of food. specific risk enhancers that are independent of other risk
factors in DM.
6. Sodium-glucose cotransporter 2 inhibitors
a. Diabetes-Specific Risk Enhancers that are Independent
o Available in the Philippines: canagliflozin, danagliflozin,
of other Risk Factors in DM
empagliflozin
o Loss of ~70 g of sugar in the urine (~280 calories) § Long duration (≥ 10 years T2D or ≥ 20 years T1D)
o Causes osmotic diuresis – mild reduction in systolic blood § Albuminuria (≥ 30 mcg albumin / mg creatinine)
pressure (~5 mmHg) § eGFR <60 mL/min/1.73m2
o Reduction in majoradverse cardiovascular events (non- § Retinopathy
fatal MI, non-fatal stroke, CV death) § Neuropathy
o Not recommended in patients with eGFR of <30 mL/min § ABI < 0.9
due to inefficiency in lowering HbA1c
b. Patients with Diabetes Ages 40-75 years old
7. Thiazolidinediones i. Without atherosclerotic cardiovascular disease
o Rosiglitazone has been taken out of the market due to ∗ Start on moderate-intensity statin (Class I)
cardiovascular events. ii. Patients at higher risk or aged 50-70 years
o Not recommended for patient with congestive heart failure § Risk assessment to consider high-intensity statin (Class
and those with ejection fraction of <30% IIa)
o Causes fractures especially in postmenopausal women c. Patients < 40 years old & > 75 years old

VI. Lipids o Must have patient and physician discussion with regards to
the benefit and harm of the statin
i. Patients 20-39 years old with ASCVD risk factors
§ May be reasonable to initiate statin therapy in addition
to lifestyle therapy
d. Patients with DM & 10-year ASCVD Risk of ≥ 20%
§ May be reasonable to add Ezetimibe to maximally
tolerated statin therapy to reduce LDL cholesterol levels
by 50% or more
C. Secondary Prevention
1. Patients of all ages with diabetes and ASCVD
o High intensity statin therapy should be added to lifestyle
therapy
2. Patients with DM & ASCVD (Very High Risk)
o If LDL is ≥ 70 mg/dL on maximally tolerated statin dose,
consider adding additional LDL-lowering therapy
(Ezetimibe)
Figure 4 | 2018 Guideline on the Management of Blood
3. Patients who do not tolerate intended intensity
Cholesterol (2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/AphA/ASPC/NLA/PCNA. JACC 2018) G
o Maximally tolerated statin dose should be used
A. Atherosclerotic cardiovascular disease (ASCVD) 4. >75 years old Patients
• Defined as coronary heart disease, cerebrovascular disease, o If already on statin: continue statin therapy
or peripheral arterial disease presumed to be of
o May be reasonable to start statin therapy after discussion
atherosclerotic origin of potential benefits and risks
• Leading cause of morbidity and mortality for individuals with
diabetes 5. Pregnancy
1. Risk Calculator o Statin therapy is contraindicated

o American College of Cardiology/American Heart D. Statin Intensity G

Association ASCVD risk calculator: useful tool to estimate
10-year ASCVD risk
o Includes diabetes as a risk factor

B. Primary Prevention
• Assess ASCVD risk in each group
• Emphasize adherence to a healthy lifestyle
1. Lipid Management in Patients with Diabetes
o Primary prevention is given to patients without previous
events Table 3 | Statin Intensities

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• Patients with diabetes should either be on High-Intensity

Statins or Moderate-Intensity Statins
1. High-Intensity Statins
o Statins & doses of those statins that can lower your LDL by
as much as 50%
o Anytime you give Atorvastatin (40-80mg) or
Rosuvastatin (20-40mg), it means it can lower your LDL
by more than 50%
2. Moderate-Intensity Statins
o Achieve 30-49% reductions in LDL cholesterol
§ Atorvastatin 20-40 mg
§ Rosuvastatin 5-10 mg
§ Simvastatin 20-40 mg
3. Low-dose therapy
o Generally not recommended in patients with diabetes but is
sometimes the only dose of statin that a patient can
tolerate
4. Metaanalysis: Cholesterol Collaborative Trial
o Studied the dose equivalent of the statins
§ Rosuvastatin 5mg is equivalent to 10 mg of Atorvastatin Figure 6 | 2019 SCORE CV Risk Chart
§ 10 mg of Atorvastatin is equivalent to 20 mg Simvastatin
o Potency based on the dose § Based on systolic blood pressure, age, level of total
§ Simvastatin < Atorvastatin < Rosuvastatin cholesterol, nonsmoker/smoker
2. Why lower LDL?
E. 2019 ESC/EAS Guidelines G
• LDL is the primary target in reducing CV events in patients
with dyslipidemia
• Secondary targets: Triglyceride, HDL
i. Patients with fasting triglyceride levels ≥500mg/dL
∗ Evaluate for secondary causes of hypertriglyceridemia
∗ Consider medical therapy to reduce risk of pancreatitis
ii. Moderate hypertriglyceridemia
∗ Fasting or non-fasting: 175-499 mg/dL
∗ Address and treat lifestyle factors, secondary factors
and medications that raise triglyceride
iii. Low levels of HDL cholesterol
∗ Often associated with elevated triglyceride levels
∗ Most prevalent pattern of dyslipidemia in individuals
with type 2 DM
F. ADA Lipid Guideline
Age ASCVD Recommended Statin Intensity
None; Moderate-intensity statin may be
<40 No considered based on risk-benefit profile &
years presence of ASCVD risk factors
Figure 5 | Treatment Algorithm for Pharmacological LDL
Yes High intensity
Lowering
Moderate; High-intensity statin may be
≥40 No considered based on risk-benefit profile &
• X-axis shows the CV risk
years presence of ASCVD risk factors
• Y-axis shows baseline LDL Cholesterol
Yes High intensity
o Ideally when you give a statin, you expect a 50%
reduction from baseline Table 4 | ADA Lipid Guideline
o These will now be your target LDL or treatment goal

1. Risk scoring • ASCVD Risk

o Identify if the patient is either obese, has high blood
o ASCVD pressure, smoker
o SCORE
G. Lipid Management: Lifestyle Intervention
• Lifestyle modification focusing on weight loss (if indicated)
o Application of a Mediterranean style or Dietary
Approaches to Stop Hypertension (DASH) eating pattern
o Reduction of saturated fat and trans fat; increase of dietary
n-3 fatty acids, viscous fiber, and plant stanols/sterols
intake
o Increased physical activity should be recommended to
improve the lipid profile and reduce the risk of developing
atherosclerotic cardiovascular disease in patients with
diabetes

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• Intensify lifestyle therapy and optimize glycemic control for • Risk of chronic kidney disease (CKD) progression, frequency
patients with elevated triglyceride levels (≥150 mg/dL [1.7 of visits, and referral to nephrology according to glomerular
mmol/L]) and/or low HDL cholesterol (< 40 mg/dL [1.0 filtration rate (GFR) and albuminuria
mmol/L] for men, < 50 mg/dL [1.3 mmol/L] for women). o The GFR and albuminuria grid depicts the risk of
progression, morbidity, and mortality by color, from best to
H. Ongoing Therapy and Monitoring with Lipid Panel worst (green, yellow, orange, red, dark red).
• In adults with diabetes o The numbers in the boxes are a guide to the frequency of
o Obtain a lipid profile (total cholesterol, LDL cholesterol, visits (number of times per year).
HDL cholesterol, and triglycerides)
§ At the time of diagnosis Color Frequency of Visits
§ At the initial medical evaluation, and CKD with normal eGFR and albumin-to-creatinine
§ At least every 5 years thereafter in patients under the ratio only in the presence of other markers of kidney
age of 40 years. Green damage, such as imaging showing polycystic kidney
• In younger patients with longer duration of disease (such as disease or kidney biopsy abnormalities, with follow-
those with youth-onset type 1 diabetes) up measurements annually
o More frequent lipid profiles Requires caution and measurements at least once
o A lipid panel should also be obtained immediately before
Yellow
per year
initiating statin therapy. Orange Twice per year
• Once a patient is taking a statin, LDL-cholesterol levels Red Three times per year
should be assessed 4–12 weeks after initiation of statin Dark red Four times per year
therapy, after any change in dose, and on an individual basis Table 6 | Frequency of Visits of Patients with CKD
(e.g., to monitor for medication adherence and efficacy).
o If LDL-cholesterol levels are not responding in spite of VIII. Smoking Cessation
medication adherence, clinical judgment is recommended • Elicit smoking history at initial and follow-up diabetes visits;
to determine the need for and timing of lipid panels. discourage smoking in youth who do not smoke and
VII. Urine Test encourage smoking cessation in those who do smoke
• E-cigarette use should be discouraged.
• At least once a year, assess urinary albumin (e.g. spot
urinary albumin-to-creatinine ratio) and eGFR in patients
with type 1 DM with duration of ≥ 5 years, in all patients with IX. Ophthalmologic
type 2DM (at time of diagnosis), and in all patients with co- • To reduce risk of ophthalmopathy, optimize glycemic and BP
morbid hypertension control to reduce the risk or slow the progression of
o eGFR should be calculated from serum creatinine using a retinopathy
validated formula First dilated & Routine Follow-up
o Chronic Kidney Disease Epidemiology Collaboration comprehensive
Equation Retinopathy
eye exam
• In non-pregnant patients with DM and HTN, either an ACE Within 5 years With Yearly
inhibitor or an ARB is recommended for those with modestly Type 1 DM
after diagnosis Without Every 2 years
elevated UACR (30-299 mg/g creatinine) and is strongly At the time of With Yearly
recommended for those with UACR ≥ 300 mg/g creatinine Type 2 DM
diagnosis Without Every 2 years
and/or eGFR <60 mL/min/1.73m2
Table 7 | When to do Dilated & Comprehensive Eye Exam and
• Measure albuminuria & eGFR to classify the patient
Follow-up Schedule
A. Chronic Kidney Disease
• Diagnosed by persistent presence of elevated urinary X. Sex-Related
albumin excretion (albuminuria), low estimated glomerular • Diabetic autonomic neuropathy may also cause GU
filtration rate (eGFR), or other manifestations of kidney disturbances, including sexual dysfunction and bladder
damage dysfunction
• Develops after diabetes duration of 10 years in type 1 • In men with DM they may have:
diabetes but may be present at diagnosis of type 2 diabetes o Sign of hypogonadism
• Can progress to end stage renal disease requiring dialysis or o Decrease sexual desire or activity
kidney transplantation o Erectile dysfunction
B. Staging of Chronic Kidney Disease G • Consider screening with a morning serum testosterone level
• Ask if the patient can initiate an erection and maintain an
erection
o DM patients usually have problems maintaining an erection
that can initiate penetration☹
o Must improve glucose control and bp control
o Ask for medications (beta blockers are not recommended
for erectile dysfunction)

XI. Extremities
• Diabetic peripheral neuropathy (DPN) is the primary risk
factor for the development of diabetic foot ulcers.
• Establish vasculopathy and neuropathy
o No hair growth at the extremities/metatarsal may indicate
vasculopathy
o Loss of protective sensation
§ Use a 10 g monofilament test
• Perform a comprehensive foot evaluation at least annually
Table 5 | KDIGO Guideline
to identify risk factors for ulcers and amputations

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• Patient with evidence of sensory loss or prior ulceration

or amputation should have their feet inspected at every
visit
• Patient with symptoms of claudication or decreased or
absent pedal pulses should be referred for ankle-branchial
index and for further vascular assessment

Table 8 | Physical Exam of the Foot

Risk Risk Risk Risk

Category 0 Category 1 Category 2 Category 3

LOPS with either

History of
Loss of Poor Vascular
Normal Ulceration,
Protective Circulation or
Plantar Amputation or
Sensation Structural foot
Sensation Neurapathic
(LOPS) Deformities and
Fracture
Onychomychosis Figure 8 | 2020 ADA Guidelines (newest)
Moderate Very High
Low Risk High Risk • In all guidelines initial treatment for elevated blood pressure
Risk Risk
in DM patients is the use of ACEi or ARB specially with
If with active proteinuria. G
ulcer or
• Do not combine ACEi and ARBS – doubles creatinine levels
Charcot foot:
and increases risk for renal replacement therapy (ONSITE
Every 12 Every 6 Immediate
Every 3 months study) G
months months referral

If none: Every Guideline Recommendation Target BP

month Single ACEi or ARB at
2017 ACC/AHA <130/80
Table 9 | IDF 2017 Diabetic Foot Screening 130/80
ACEi or ARB + CCB at
2018 ESH/ESC half maximal dose for <140
XII. Blood Pressure
systolic BP of 140
A. Guidelines ACEi or ARB with BP
2020 ADA <130/80
of 140/90
Table 11 | ACEi and ARB Recommendations

XIII. Aspirin
• For preventing cardiovascular accidents
• No longer recommended for primary prevention without
any indications
• Aspirin 75-162mg: For patients > 50 years of age with at
least 1 risk factor without increased GI Bleeding risk
Table 10 | 2017 ACC/AHA Hypertension Guidelines • Aspirin 75-162mg: For diabetic patients <50 yrs of age with
1 or more CV risk factor
• Risk factors:
o Smoking
o Hypertension
o Dyslipidemia
o Family history of CAD

XIV. Dental Issue

• At initial dental visit the following must be addressed
o Measure to increase saliva flow
§ Common complaint is dryness due to decreased
salivary flow
o Controlling bacterial plaque
o Increasing remineralisation capacity
Figure 7 | 2018 ESH/ESC Hypertension Guidelines o Dietary consultation/advice

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Cases
XV. Case #1
• Patient: Rona, 47, F
• Chief Complaint: polyuria, polydipsia, polyphagia, and
vaginal discharge
• Known diabetic for 2 years, Metformin 1,500 mg OD
• FHx: both parents: (+) DM
• Non-smoker
• BP: 130/80 mmHg
• BMI: 22 kg/m2
• Physical examination: essentially normal

Results Normal Value

FBS 194 mg/dL 70 – 100
Figure 9 | Rates of Vascular Disease in Patients with Diabetes
HbA1c 8.6% 4.5 – 5.6
§ Decreasing in persons with DM but are still higher than
Creatinine 0.9 mg/dL 0.6 – 1.2 in persons without DM
eGFR 110 mL/min/1.73m2 90 – 120 § Diabetic patients have higher risk for acute MI, stroke,
Urinalysis ESRD, and amputation
Albumin ++ ∗ If you have established that a patient has higher risk
Glucose ++ for cardiovascular diseases or have an established
WBC Too numerous to count ASCVD, CKD, or HF then you’ll have a specific list of
RBC 5-10/lpf agents to give to address their hyperglycemia.
Lipid Profile § Since the patient has no risk and the A1c is above the
target, check for the following:
Total Cholesterol 210 mg/dL < 200
Compelling need/Issue
Triglycerides 170 mg/dL < 150
No. Patient has a low risk for
HDL-C 38 mg/dL > 50 To minimize hypoglycemia
hypoglycemia.
LDL-C 138 mg/dL < 100
To minimize weight gain or
No since the BMI is 22.
promote weight loss
A. Glycemia Cost She can afford.
1. HbA1c Target (Refer to Figure 2, Page 4) Table 12 | Needs to be Addressed
o There are modifiable and non-modifiable factors that will
tell us how to individualize the HbA1c targets § Since patient has no established ASCVD or CKD then
o In most patients, our target should be less than 7%. on top of metformin, you can add the following agents
o If the patient has these following characteristics then your Drug Comments
target may be more stringent (target lower than 7%) DPP4 inhibitor
§ Low risk for hypoglycemia
Injectable; patient might not like
§ Newly diagnosed diabetic GLP1 receptor agonist
it
§ Longer life expectancy
§ Not so much comorbidities Patient has pruritus and vaginal
§ No established vascular complications SGLT2 inhibitor discharge; may worsen condition
§ Highly motivated or cause UTI
§ Resources are readily available No risk for osteoporosis since
o Given the patient characteristics, then a target of less than TZD patient is not menopausal;
6.5% would be the best for her since we get more benefits weight gain
with a lower HbA1c. Sulfonylurea
Table 13 | Regimen that can be Added
2. Regimen (Refer to Figure 3, Page 5)
o Patient is already in Metformin so we can add another B. Lipids
agent to achieve the HbA1c target 1. Lipid Target (Refer to Figure 5, Page 7)
o Dependent on the risk of the patient
a. Comorbidities o Patient is ≥ 45 years old, already on moderate or high
intensity statin depending on the risk.
§ Find out whether or not the patient has indicators for
§ The patient actually has elevated LDL so the risk is
high risk or established ASCVD, CKD, or HF.
relatively bad to moderate risk
§ Indicators for high risk
o All diabetics, at worst, should be at moderate risk.
∗ 55 years old and up
§ The target should be less than 100mg/dL and you can
∗ Any documentation of coronary, carotid, or lower
already start off the patient with a moderate intensity
extremities obstruction of more than 50%, and/or LVH
statins.

Remember these target values G

Total cholesterol < 200 mg/dL
Triglycerides < 150 mg/dL
HDL-C > 50 mg/dL
LDL-C < 70 or 100 mg/dL (risk dependent)
Table 14 | Lipid Target Values

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C. Summary of Rona’s Diabetes Office Visit o For patients with established or high risk ASCVD, several
GLUCOSE BAD agents are proven to have benefits in terms of
Metformin + Sulfonylurea or DPP4 cardiovascular and renal outcomes and these agents are
Glycemic control Inhibitor GLP-1Ras and SGLT-2 Inhibitors
o MACE stands for major adverse cardiovascular events
Target HbA1c: < 6.5%
§ Nonfatal myocardial infarction
Atorvastatin 20 mg HS
Lipids § Nonfatal stroke
Target LDL: < 100 mg/dL
§ Cardiovascular death
Urine Treat UTI o hHF – hospitalization for heart failure
Cigarettes Maintain smoking cessation o Patient has indicators for high risk or established ASCVD
Ophthalmologic Yearly eye examination § 57 years old
Sex-related Discourage pregnancy for now § LVH
Extremities Periodic foot examination and care § PAOD due to the poor peripheral pulses
Maintain BP o Recommendation is to start patient with preferably the
Blood Pressure following agents
Lifestyle management
Aspirin Not indicated § GLP-1 receptor agonist with proven CVD benefits or
Dental Issues Periodic evaluation § SGLT2 inhibitor with proven CVD benefit if eGFR is
adequate
XVI. Case #2
B. Lipids
• Patient: Hans, 57, M 1. Lipid Target (Refer to Figure 5, Page 7)
• Chief Complaint: executive check-up
• Known diabetic for 8 years, Sitagliptin-Metformin 50+1,000 o Even though the patient does not have an established
mg BID CVD, he’ll most likely be placed between moderate and
high risk
• FHx: both parent: (+) HTN and (+) DM
o Therefore, your lipid target will be <70 or at worst <100
• 17 pack years smoking
o Give the patient a high intensity statin
• BP: 140/90 mmHg
§ Atorvastatin 40 mg or 80 mg or
• BMI: 29 kg/m2 § Rosuvastatin 20 mg or 40 mg
• Lower extremities pulses: +/++
C. Blood Pressure
Results Normal Value
• Patient’s BP is 140/90 mmHg
FBS 134 mg/dL 70 – 100
• (+) dyslipidemia, (+) albuminuria, (+) LVH
HbA1c 7.6% 4.5 – 5.6
Creatinine 1.0 mg/dL 0.6 – 1.2
eGFR 96 mL/min/1.73m2 90 – 120
Urinalysis
Albumin +
Lipid Profile
Total Cholesterol 238 mg/dL < 200
Triglycerides 167 mg/dL < 150
HDL-C 48 mg/dL > 50
LDL-C 149 mg/dL < 100
Other Ancillaries
CXR and ECG LVH • Target BP should be less than 130/80 mmHg but SBP
should not be lower than 110 mmHg
• You may start the patient with a single agent ACEi or ARB
A. Glycemia according to the ADA recommendation or
1. Glycemic Target (Refer to Figure 2, Page 4) • According to the ESC recommendation, you can use a half
o Characteristic of the patient maximum combined agent of RAAS blocker and CCB
§ Smoker
§ Relatively young D. Aspirin
§ LVH based on CXR and ECG • Since the patient has PAOD, he will be given Aspirin 80
o A good target for him is 6.5% or 7% mg/tab as a primary prevention
§ He doesn’t have an established cardiovascular disease
except for the LVH
§ Although he is a smoker so you can push the target to 7
or even 6.5%

2. Regimen (Refer to Figure 3, Page 5)

Table 15 | Regimen that can be Added

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E. Summary of Han’s Diabetes Office Visit o Symptoms of hyperglycemia are present, or

GLUCOSE BAD o A1C levels are very high (>10% or blood glucoses levels
Metformin + DPP4 inhibitor or SGLT2 >300mg/dL)
Glycemic control inhibitor
Target HbA1c: < 6.5%
Atorvastatin 40 mg HS
Lipids
Target LDL: < 70 mgl/dL
Address albuminuria
Urine
Start ACEi or ARB
Cigarettes Compel smoking cessation
Ophthalmologic Yearly eye examination
Ask about sex-related problems like
Sex-related
erectile dysfunction
Extremities Periodic foot examination and care
Target BP: < 130/80 mmHg
Blood Pressure
RAAS blocker
Aspirin 80 mg/tab OD (primary
Aspirin
prevention)
Dental Issues Periodic evaluation

XVII. Case #3
• Patient: Nines, 63, M
• Chief Complaint: regular check-up
• Known diabetic and hypertensive for 8 years s/p CABG
• Medications
o Dapagliflozin-Metformin 5+1000 mg BID
o Linagliptin 5 mg OD
o Perindopril-Amlodipine-Atorvastatin
o 10+40+10 mg OD
o Nebivolol 5 mg OD
o Aspirin 100 mg OD
• Non-smoker
• BP: 120/80 mmHg
• BMI: 23 kg/m2 Figure 10 | Algorithm on Injectable Therapy
• Heart: cardiomegaly

Results Normal Value

FBS 156 mg/dL 70 – 100
HbA1c 9.2% 4.5 – 5.6
Creatinine 1.2 mg/dL 0.6 – 1.2
eGFR 56 mL/min/1.73m2 90 – 120
Urinalysis
Albumin -
Lipid Profile
Total Cholesterol 168 mg/dL < 200
Triglycerides 107 mg/dL < 150
HDL-C 55 mg/dL > 50
Figure 11 | OHA + Injectables
A. Glycemia (Refer to Figure 2, Page 4) • But you have to remember these when you start your
patients on injectables
• Patient is on triple agent (Dapagliflozin-Metformin and
Linagliptin) but if the HbA1c is still above target then we can
intensify the treatment by adding the following agents based Drug
on the algorithm Can be continued if you start your patient with
Metformin
o GLP1 receptor agonist injectables like insulin or GLP1 receptor agonist
o DPP4 inhibitor - patient already has this drug Sulfonylurea Reduce the dose if insulin is started
o Insulin Stop or reduce dose because of associated
TZD
o Thiazolidinedione edema
o Sulfonylurea DPP4 inhibitor prolongs the endogenous effect
• Since our HbA1c target for this patient is 7%, we can also of GLP1 receptor agonist; anytime GLP1
DPP4 inhibitor
intensify the treatment by adding injectables receptor agonist is started as an injectable,
• If the patient’s glycemia is uncontrolled, we will need an DPP4 inhibitor should be discontinued.
injectable to achieve reduction in HbA1c Table 16 | Regimen that can be Added
o Recommended agents is GLP1 receptor agonist then you
can eventually add or give insulin • Since patient is post-MI and post CABG, GLP1 receptor
• In patients with T2DM who need greater glucose lowering agonist would be a good agent but we have to take out
that can (probably cannot) be obtained with oral agents, DPP4 inhibitor
GLP1RA are preferred to insulin when possible
• The early introduction of insulin should be considered if
o There is evidence of ongoing catabolism (weight loss)

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B. Summary of Nines’ Diabetes Office Visit

GLUCOSE BAD
Metformin + DPP4 Inhibitor, add SGLT2
Glycemic control inhibitor or GLP1 receptor agonist
(discontinue DPP4 inhibitor if ever)
Continue Atorvastatin 40 mg HS
Lipids
Target LDL: < 70 mg/dL
Urine Continue ACEi or ARB
Cigarettes Maintain smoking cessation
Ophthalmologic Yearly eye examination
Ask about sex-related problems like
Sex-related
erectile dysfunction
Extremities Periodic foot examination and care
Maintain BP with ACEI + CCB + Beta
Blood Pressure
blocker
Aspirin Maintain Aspirin for secondary prevention
Dental Issues Periodic evaluation
Figure 13 | ASCVD Risk Factor Modifications Algorithm
Other Algorithms • This highlights what to do in patients depending on risk
stratification

XVIII. American Association of Clinical Endocrinologists

Principles of the AACE/ACE Comprehensive Type 2 Diabetes
Management Algorithm
1. Lifestyle modification underlies all therapy (e.g., weight control,
physical activity, sleep, etc.)
2. Avoid hypoglycemia
3. Avoid weight gain
4. Individualize all glycemic targets (A1c, FPG, PPG)
5. Optimal A1c is ≤6.5% or as close to normal as is safe and
achievable
6. Therapy choices are patient centric based on A1c at
presentation and shared decision-making.
7. Choice of therapy reflects ASCVD, CHF, and renal status
8. Comorbidities must be managed for comprehensive care.
9. Get to goal as soon as possible—adjust at ≤3 months until at
goal.
10. Choice of therapy includes ease of use and affordability.
11. CGM is highly recommended, as available, to assist patients
in reaching goals safely.
Figure 14 | Glycemic Control Algorithm
• Disadvantage - glucocentric so decisions are based on
HbA1c, not the patient; however, this is also applicable
• Monotherapy – Metformin
• If with high risk or established ASCVD then we add SGLT2
inhibitor or GLP1 receptor agonist
• If uncontrolled, we may need to start injectables like insulin

Outcomes
• Analyze the decision cycle in a patient centered approach in
the management of DM
• Understand the comprehensive diabetes medical evaluation
at initial office visit
• Dissect the recent recommendation in the pharmacological
management of hyperglycemia as well as other
comorbidities in patients with diabetes
• Apply concepts to different cases of patient with DM

Figure 12 | Lifestyle Therapy Risk Stratification - END -

• This shows risk stratification for diabetes complication
• Places importance on nutrition, physical activities, and sleep
o Sleep should be around 6 to 8 hours per night
o Anything more than or less than that may be harmful
o Sleep studies may be requested especially for those are
suffering from obstructive sleep apnea or OSA
REFERENCES
• Dr. Matawaran’s PowerPoint presentation
• Harrison’s Principles of Internal Medicine, 20th edition
• 2020 ADA; AACE/ACE; 2017 ACC/AHA, 2018 ESH/ESC
Hypertesion Guidelines; KDIGO CKD Guidelines; 2018
Guideline on the Management of Blood Cholesterol (2018
AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/AphA/ASPC/NLA/PCNA. JACC 2018)

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