3/5/12

Overview of medical care in adults with diabetes mellitus

Official reprint from UpToDate® www.uptodate.com ©2012 UpToDate®

Overview of medical care in adults with diabetes mellitus
Author David K McCulloch, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan 2012. | This topic last updated: Jan 30, 2012. INTRODUCTION — The estimated prevalence of diabetes among adults in the United States ranges from 4.4 to 17.9 percent (median 8.2 percent) [1]. However, because of the associated microvascular and macrovascular disease, diabetes accounts for almost 14 percent of US health care expenditures, at least one-half of which are related to complications such as myocardial infarction, stroke, end-stage renal disease, retinopathy, and foot ulcers [2,3]. Numerous factors, in addition to directly related medical complications, contribute to the impact of diabetes on quality of life and economics. Diabetes is associated with a high prevalence of affective illness [4] and adversely impacts employment, absenteeism, and work productivity [5]. This review will provide an overview of the medical care for patients with diabetes (table 1). Detailed discussions relating to screening, evaluation, and treatment of the individual complications of diabetes are discussed separately. Guidelines from the American Diabetes Association for health maintenance in diabetics are published yearly [6]. Consensus recommendations for the management of glycemia in type 2 diabetes were published in 2006 and updated in 2009 [7,8]. EVALUATION FOR DIABETIC COMPLICATIONS — Morbidity from diabetes is a consequence of both macrovascular disease (atherosclerosis) and microvascular disease (retinopathy, nephropathy, and neuropathy). In type 2 diabetes, disease onset is insidious, and diagnosis is often delayed. As a result, diabetic microvascular complications may be present at the time of diagnosis of diabetes [9], and their frequency increases over time (figure 1). The progression of these complications can be slowed, but probably not stopped, with interventions such as aggressive management of glycemia, laser therapy for retinopathy, and administration of an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) for nephropathy. (See "Prevention and treatment of diabetic retinopathy" and "Microalbuminuria in type 1 diabetes mellitus" and "Microalbuminuria in type 2 diabetes mellitus" and "Treatment of diabetic nephropathy".) Routine eye examination — Patients with diabetes are at increased risk for visual loss, related both to refractive errors (correctable visual impairment) and to retinopathy. Screening for diabetic retinopathy — The efficacy of laser photocoagulation surgery in preventing loss of vision is the major reason to screen regularly for diabetic retinopathy. (See "Prevention and treatment of diabetic retinopathy", section on 'Panretinal photocoagulation'.) Recommendations for the type and frequency of routine eye examinations vary, based upon the type of diabetes mellitus and the presence of specific eye findings (table 2) [6]. Serial
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Section Editor David M Nathan, MD

Deputy Editor Jean E Mulder, MD

3/5/12

Overview of medical care in adults with diabetes mellitus

examinations are indicated because of the increased incidence of retinopathy over time in patients with either type 1 or type 2 diabetes (figure 2). Screening for diabetic retinopathy is reviewed in detail separately. (See "Screening for diabetic retinopathy".) Correctable visual impairment — A study using data from the National Health and Nutrition Examination Survey (NHANES) in the US found that 11 percent of patients aged 20 years and older with diabetes had visual impairment (visual acuity <20/40 in their best eye with glasses) [10]. The impairment was correctable with an adequate corrective prescription for glasses or contact lenses in over two-thirds of the patients. These data indicate the need for visual acuity and refractive error assessment in addition to dilated eye examinations for retinopathy in diabetic patients to reduce injury risk and improve quality of life. Routine foot examination — Foot problems due to vascular and neurologic disease are a common and important source of morbidity in diabetic patients. Systematic screening examinations for neuropathic and vascular involvement of the lower extremities and careful inspection of feet may substantially reduce morbidity from foot problems. (See "Evaluation of the diabetic foot".) Guidelines from the American Diabetes Association recommend performing a comprehensive foot examination annually on patients with diabetes to identify risk factors predictive of ulcers and amputation [6]. The comprehensive foot examination can be accomplished in the primary care setting and should include inspection, assessment of foot pulses, and testing for loss of protective sensation, as follows: Perform a visual inspection of the feet at each routine visit. The skin should be assessed for integrity, especially between the toes and under the metatarsal heads. The presence of erythema, warmth, or callus formation may indicate areas of tissue damage. Bony deformities, joint mobility, and gait and balance should also be assessed. Screen for peripheral artery disease by asking about a history of claudication and assessing the pedal pulses. Consider obtaining an ankle brachial index as many patients with peripheral artery disease are asymptomatic. The presence of peripheral artery disease also suggests a high likelihood of cardiovascular disease. (See "Noninvasive diagnosis of arterial disease", section on 'Ankle-brachial index'.) Test for loss of protective sensation using a Semmes-Weinstein 5.07 (10-g) monofilament at specific sites to detect loss of sensation in the foot (figure 3), plus any one of the following: vibration using a 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold with a biothesiometer. (See "Evaluation of the diabetic foot", section on 'Screening tests for peripheral neuropathy'.) Advice for prophylactic foot care should be given to all patients (see "Patient information: Foot care in diabetes mellitus (Beyond the Basics)"): 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. Patients who may have neuropathy, based on abnormal results from a microfilament and one other
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ACE inhibitors both lower urinary protein excretion and slow the rate of disease progression (figure 4A-B) [15]. The optimal therapy of diabetic nephropathy continues to evolve.or macroalbuminuria) [6] do not predict the likelihood of www. Abnormal results should be repeated at least two or three times over a three. additional interventions may be required. therefore. In addition. exercise. and poor glycemic control are among the factors that can cause transient microalbuminuria [13]. even if the patient is normotensive. persistent values between 30 and 300 mg/day (20 to 200 mcg/min) in a patient with diabetes is called microalbuminuria and is usually indicative of diabetic nephropathy (unless there is some coexistent renal disease) [11]. Values above 300 mg/day (200 mcg/min) are considered to represent overt proteinuria [12]. the most important of which is maintenance of strict glycemic control.3/5/12 Overview of medical care in adults with diabetes mellitus test. to institute therapy with an ACE inhibitor or angiotensin receptor blocker (ARB).to six-month period because of the large number of false positives that can occur [13]. The treatment of microalbuminuria is reviewed in detail elsewhere.) The normal rate of albumin excretion is less than 20 mg/day (15 mcg/min).com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 3/27 . (See "Treatment of diabetic nephropathy" and "Microalbuminuria in type 1 diabetes mellitus" and "Microalbuminuria in type 2 diabetes mellitus". It seems reasonable. positive family history of early coronary disease. Screening for microalbuminuria — Increased urinary protein excretion is the earliest clinical finding of diabetic nephropathy. nurse. Establishing the diagnosis of microalbuminuria requires the demonstration of a persistent (at least two abnormal tests) elevation in albumin excretion. Screening for microalbuminuria can be deferred for five years after the onset of disease in patients with type 1 diabetes because microalbuminuria is uncommon before this time. Similar considerations apply to patients with type 2 diabetes. in those patients who have microalbuminuria or overt nephropathy. not detecting protein until excretion exceeds 300 to 500 mg/day.) Screening for coronary heart disease — Patients with diabetes have an increased risk for atherosclerosis due both to diabetes and to the frequent presence of other risk factors. or who have callus or other foot deformities should be referred to clinicians with expertise in diabetic foot care (podiatrist. is a relatively insensitive marker for proteinuria. depending on available local resources).uptodate. diabetes foot clinic. CHD risk factors (dyslipidemia. Microalbumin may be tested by screening with either a specifically sensitive dipstick or a laboratory assay on a spot urine sample. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus".) Despite the frequency of silent ischemia. heart failure. some recommend that screening should begin at diagnosis in patients with type 2 diabetes because many have had diabetes for several years before diagnosis [6]. Furthermore. and presence of micro. it has not been proven that identifying asymptomatic disease or providing early intervention will improve outcomes in this population. Fever. Since these drugs do not completely prevent progression. The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARB) is the rationale for yearly screening of all patients with either type 1 or type 2 diabetes for microalbuminuria [14]. however. smoking. or other. diabetic patients with CHD are more likely to be asymptomatic or have atypical symptoms than nondiabetic patients with CHD. however. The routine urine dipstick. section on 'Silent ischemia and infarction'. In patients with type 1 diabetes who have microalbuminuria or overt nephropathy. hypertension. (See "Microalbuminuria in type 1 diabetes mellitus" and "Microalbuminuria in type 2 diabetes mellitus" and "Treatment of diabetic nephropathy". to determine an albumin-to-creatinine ratio.

) REDUCING THE RISK OF MACROVASCULAR DISEASE — Men and women with diabetes are at increased risk for developing and dying from cardiovascular disease (CVD) [19. However.17]. and 1.) With regard to cardiovascular disease risk reduction among patients with type 2 diabetes. but no longer recommend that these criteria be used to identify patients for stress testing [6].) A number of modifiable risk factors for coronary heart disease were identified in a cohort of over 3000 type 2 diabetics from the United Kingdom Prospective Diabetes Study (UKPDS) [23]. smoking) and many have evidence of overt atherosclerosis (past myocardial infarction. ACE inhibitors. and statin therapy. all CVD risk factors should be treated. hypertension. There are no randomized trial data to support the routine performance of exercise stress testing in asymptomatic patients with diabetes who are planning to begin an exercise program [6. Compared with nondiabetics. many patients already have one or more risk factors for macrovascular disease (obesity. the benefit of good blood pressure control has been confirmed. The vast majority of patients. In addition. multiple diabetes complications).5 for hemoglobin A1C. 0. 1.20]. (See "The metabolic syndrome (insulin resistance syndrome or syndrome X)".8 for systolic blood pressure. it may be indicated for asymptomatic individuals at high risk for CHD (eg. ischemic changes on electrocardiogram. men and women with diabetes have decreased life expectancy (six to eight years less). However.) Thus. (See 'Multifactorial risk factor reduction' below.uptodate. or peripheral vascular disease) [9.18]. particularly those with a sedentary lifestyle. (See "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type www. aggressive treatment of hypertension and dyslipidemia.) Treatment of diabetic patients with known CHD is reviewed in detail elsewhere. exercise testing is not necessary for most patients. the American Diabetes Association guidelines recommend annual assessment of risk criteria to identify patients who might benefit from interventions such as aspirin.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 4/27 .21. the increased risk for asymptomatic coronary artery disease in those with diabetes and other risk factors suggests that an exercise tolerance test be considered prior to changing exercise levels in patients with diabetes who also have peripheral or carotid or coronary artery disease. are encouraged to begin a gentle exercise program and to gradually progress to a more vigorous program as tolerated.6 for serum high-density-lipoprotein (HDL) cholesterol. We do not typically perform exercise stress testing in asymptomatic patients as long as they are beginning a gentle exercise program with gradual progression as tolerated. the DCCT/EDIC study demonstrated long-term benefit of intensive glycemic management on cardiovascular outcomes.22]. Estimated hazard ratios from this study for the upper third relative to the lower third were 2.3 for serum LDL cholesterol. 1. abnormal resting electrocardiogram.4 for smokers. whereas benefit from strict glycemic control has not been conclusively demonstrated [25]. reducing fatal and nonfatal heart disease and stroke by 57 percent compared with conventional diabetes management [26]. These and other observations suggest that a substantial reduction in cardiovascular mortality could be achieved by smoking cessation.3/5/12 Overview of medical care in adults with diabetes mellitus having ischemic findings on stress testing or coronary angiography [16. evidence of peripheral or carotid atherosclerotic vascular disease. The decision to perform stress testing prior to beginning an exercise program should be individualized. Thus. (See 'Blood pressure control' below and 'Dyslipidemia' below. dyslipidemia. (See "Screening for coronary heart disease in patients with diabetes mellitus". Among patients with type 1 diabetes. (See "Treatment of acute myocardial infarction in diabetes mellitus" and "Coronary artery revascularization in patients with diabetes mellitus". renal disease. and possibly daily low-dose aspirin (figure 5) [24]. At the time of diagnosis of type 2 diabetes.

stroke.91 (99% CI 0. even after adjusting for age. race. 95% CI 0.) Smoking cessation — A survey in the United States found that the prevalence of cigarette smoking was higher among diabetic patients than nondiabetic subjects. sex. Trials that assess the benefit of daily aspirin therapy specifically in patients with diabetes show the following: In the Early Treatment of Diabetic Retinopathy Study (ETDRS). there was a nonsignificant 7 percent decrease in serious cardiovascular events [28]. aspirin alone. In a trial of aspirin for the prevention of cardiovascular disease in 2539 Japanese patients with type 2 diabetes (no history of atherosclerotic heart disease).26) compared with a 30 percent reduction in nondiabetic subjects (RR 0.0 cardiovascular events per 1000 personyears in the aspirin and nonaspirin groups. there were 13. The lower than expected event rate in this trial decreased the power of the analysis to assess the primary composite outcome or individual outcomes.83 (99% CI 0. in The Primary Prevention Project.3/5/12 Overview of medical care in adults with diabetes mellitus 2 diabetes mellitus" and "Treatment of hypertension in patients with diabetes mellitus".89. The relative risk among all aspirin-treated patients was 0.) These trials suggest that aspirin may be less effective in the prevention of cardiovascular events in patients with diabetes. A meta-analysis from the Antithrombotic Trialists' Collaboration of randomized trials of antiplatelet therapy for the secondary prevention of cardiovascular disease in high-risk patients showed that aspirin produced statistically significant and clinically important reductions in the risk of subsequent myocardial infarction (MI). During a median 6.53-0. In the Prevention of Progression of Arterial Disease and Diabetes (POPADAD) trial. and other high-risk groups) [28]. or peripheral vascular atherosclerotic event 0. such as fatal and nonfatal coronary events.99) were randomly assigned to aspirin (100 mg daily) plus an antioxidant. In addition.6 and 17.751.) Aspirin — The merits of daily aspirin therapy in patients with macrovascular disease are widely accepted. peripheral artery disease. patients with diabetes with and without cardiovascular disease were randomly assigned to aspirin (650 mg daily) or placebo [30]. and educational level [27]. coronary.11) for death and 0.10]) [31]. (See "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease".7 www.uptodate. respectively (HR for primary composite endpoint of any cerebrovascular.80 [95% CI 0.66-1. aspirin (100 mg/day) was associated with a nonsignificant 10 percent reduction in total cardiovascular events in the subset of patients with diabetes (RR 0. Over 25 percent of newly diagnosed diabetic patients were smokers.4 years. the generalizability of this study to Western populations with higher cardiovascular risk is unknown. antioxidant alone. patients were randomly assigned to low-dose aspirin (80 to 100 mg daily) or to a nonaspirin group.) In the subset of patients with diabetes. (See "Smoking and cardiovascular risk in diabetes mellitus" and "Patterns of tobacco use".04) for fatal and nonfatal myocardial infarction. or double placebo [32]. 95% CI 0. After a median follow-up of 4. prior MI or stroke.58-1. (See "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease".90) [29]. unstable angina. These findings suggest that discontinuation of smoking is one of the most important aspects of therapy in diabetic patients who smoke.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 5/27 . Similarly. 1276 UK adults with type 1 or type 2 diabetes with asymptomatic peripheral artery disease (ankle brachial pressure index of ≤0.62-1. A meta-analysis of many of the cardiovascular risk reduction trials showed that cessation of smoking had a much greater benefit on survival than most other interventions (figure 5) [24].69. and vascular death among a wide range of highrisk patients (acute MI or ischemic stroke.

or angina. respectively [38].26). and aspirin is contraindicated under the age of 21 years because of an increased risk of Reye's syndrome. Thus. trials in patients with diabetes do not show a significant benefit of aspirin for the primary prevention of cardiovascular events.37]. 95% CI 0. peripheral vascular disease.uptodate.4 and 0. Aspirin (75 to 162 mg/day) is recommended for secondary prevention in diabetic patients with a history of myocardial infarction. aspirin use in patients with diabetes is quite low: 74 and 38 percent in patients with or without cardiovascular disease. (See "Secondary prevention of cardiovascular disease: Risk factor reduction".2 events per 1000 person-years in those assigned to the aspirin and nonaspirin groups. claudication. In the Japanese trial described above.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 6/27 . which would include most men >50 years and women >60 years who have at least one additional cardiovascular risk factor (eg. both the Japanese trial and ETDRS suggest benefit. nonfatal myocardial infarction or stroke. there were 116 and 117 fatal and nonfatal cardiovascular events in the aspirin and nonaspirin groups. Aspirin is not recommended for diabetic patients under the age of 30 years due to a lack of evidence of benefit.) In spite of these recommendations. Aspirin (75 to 162 mg/day) is recommended for primary prevention in any patient with diabetes at increased cardiovascular risk (10 year risk >10 percent). while diabetes is associated with several platelet and coagulation abnormalities. The American Diabetes Association recommends measuring blood pressure at every routine diabetes visit [6. Nevertheless. there was no difference in the incidence of hemorrhagic stroke (0. and four patients in the aspirin group required transfusion. Two large trials investigating the role of aspirin for the prevention of cardiovascular events in patients with diabetes are underway [33. Bleeding — One of the main adverse effects of aspirin is bleeding. Among patients with diabetes.) Guidelines — Based upon these data. stroke or transient ischemic attack. there is moderate evidence supporting a goal blood pressure less www.34]. the American Diabetes Association and American Heart Association recommend the following approach [6. not hemorrhagic in nature [36]. dyslipidemia. gastrointestinal and retinal bleeding occurred more commonly in the aspirin group. the majority of strokes in diabetic patients are thrombotic. Early and effective treatment of blood pressure is important. hypertension.76-1. both to prevent cardiovascular disease and to minimize the rate of progression of diabetic nephropathy and retinopathy. Larger trials with longer follow-up are required to clarify this issue. cigarette smoking. respectively (HR for primary composite endpoint of death from coronary heart disease or stroke. or a family history of coronary heart disease). The United States Physicians' Health Study found a nonsignificant trend toward an increase in hemorrhagic stroke and an increased risk of gastrointestinal bleeding in those who took aspirin [35]. The ADA recognizes that the evidence to support this recommendation is weak. Clopidogrel (75 mg/day) is recommended for patients with cardiovascular disease and documented aspirin allergy.3/5/12 Overview of medical care in adults with diabetes mellitus years of follow-up. respectively).98. section on 'Aspirin'. Blood pressure control — Hypertension is a common problem in type 1 and especially in type 2 diabetes. or aboveankle amputation for critical limb ischemia 0. However. albuminuria.39]. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus". However. vascular bypass. obesity.

whereas in patients with overt CVD.6 mmol/L]. weight loss. and undoubtedly contribute to the increase in risk of cardiovascular disease.39]. The optimal therapy of dyslipidemia is discussed in detail separately. In patients with clinical cardiovascular disease (CVD) or over age 40 years with other CVD risk factors. section on 'Summary and recommendations' and "Clinical trials of cholesterol lowering in patients with coronary heart disease or coronary risk equivalents".7 mmol/L) and HDL levels >40 mg/dL (1. section on 'UKPDS'. section on 'Treatment in diabetes' and "Intensity of lipid lowering therapy in secondary prevention of coronary heart disease". increased physical activity) to improve the lipid profile in all patients with diabetes [6].7 mmol/L]) may be screened every two years. section on 'ACCORD Lipid trial'.5 percent with intensive therapy) Tight blood pressure control (target <140/85 mmHg for most of the study and <130/80 mmHg for the last two years) Angiotensin converting enzyme (ACE) inhibitor therapy regardless of blood pressure Lipid-lowering therapy (target total cholesterol <190 mg/dL [4. independently of its effects on glycemic control. These issues and the choice of antihypertensive drugs are discussed in detail separately.2 percent with conventional therapy). which included the following [41]: Reduced dietary fat Light to moderate exercise Smoking cessation Tight glycemic control (target A1C <6.9 mmol/L] for most of the study and <175 mg/dL [4. Adults with low-risk lipid values (LDL <100 mg/dL [2.5 versus +0. section on 'Goal blood pressure' and "Treatment of diabetic nephropathy". 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.5 mmol/L] for the last two years. The American Diabetes Association (ADA) recommends screening for lipid disorders at least annually in diabetic patients.3/5/12 Overview of medical care in adults with diabetes mellitus than 140/90 mmHg in all patients and weaker evidence supporting a goal blood pressure less than 130/80 mmHg. For patients without clinical CVD and under age 40 years.3 mmol/L]. vitamin D. folate. and chrome picolinate The attained differences between the two groups revealed significantly greater improvements with intensive therapy in glycemic control (A1C -0. this effect is far from established [40]. HDL >50 mg/dL [1. and more often if needed to achieve goals [6. In individuals without overt cardiovascular disease. (See "Treatment of hypertension in patients with diabetes mellitus". a lower LDL goal (<70 mg/dL [1. and triglycerides <150 mg/dL [1.) Dyslipidemia — Lipid abnormalities are common in patients with diabetes mellitus. The ADA recommends lifestyle intervention (diet. target fasting serum triglyceride <150 mg/dL [1. However.) Multifactorial risk factor reduction — The benefit of multiple risk factor intervention to reduce coronary risk in type 2 diabetes was demonstrated in the relatively small Steno-2 trial of 160 subjects with microalbuminuria who were randomly assigned to either conventional therapy or an intensive therapy regimen. statin therapy should be added to lifestyle intervention regardless of baseline lipid levels.3 mmol/L) for women are preferable.8 mmol/L]) is an option [6]. These issues are discussed in detail elsewhere.0 mmol/L) for men and >50 mg/dL (1. (See "Treatment of lipids (including hypercholesterolemia) in secondary prevention". the goal LDL is <100 mg/dL (2.) Metformin — Metformin has been suggested to reduce the risk of macrovascular complications.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 7/27 .7 mmol/L]) Aspirin Vitamin C. www. (See "Glycemic control and vascular complications in type 2 diabetes mellitus".uptodate.6 mmol/L). Triglyceride levels <150 mg/dL (1.

Thus. nephropathy. (See "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetes mellitus". It is notable that only one patient in the observational Steno study described above reached all five treatment goals at the end of follow-up. percutaneous coronary intervention. and autonomic neuropathy occurred less frequently in the intensive group. nephropathy. section on 'Macrovascular disease'.) The importance of tight glycemic control for protection against cardiovascular disease in diabetes has been established in the DCCT/EDIC study for type 1 diabetes [26]. More www. The role of glycemic control in reducing cardiovascular risk has not been established for patients with long-standing type 2 diabetes. 95% CI 0. 130 remaining patients participated in an observational followup study (5. Blood pressure.7 and 8. the American Diabetes Association recommends the following [6]: Aim to achieve normal or near normal glycemia with an A1C goal of <7 percent. and neuropathy [43-46]. At a mean of 7.94).com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 8/27 . section on 'Hyperglycemia and Microvascular disease'.32-0. during which time all participants were encouraged to follow intensive multifactorial treatment regimens [42]. nonfatal MI. the United Kingdom Prospective Diabetes Study (UKPDS). A1C values were similar in the groups previously assigned to intensive and conventional therapy (7. After the intervention study ended.uptodate.19-0. (See "Glycemic control and vascular complications in type 2 diabetes mellitus". In spite of evidence that aggressive risk factor reduction lowers the risk of both micro. Every 1 percent drop in A1C was associated with improved outcomes and there was no threshold effect.89).5 years).1 percent. and management of dyslipidemia. stroke. the average A1C achieved in the intensive therapy groups of these trials was around 7 percent. During the entire follow-up period (13. At the end of the follow-up period. and total cholesterol (-50 versus -3 mg/dL [-1.0 percent. HR 0. coronary artery bypass grafting. blood pressure control.47. 95% CI 0. randomized clinical trials such as the Diabetes Control and Complications Trial (DCCT).8 years. and fasting serum cholesterol and triglycerides were also similar. with an A1C less than 6. retinopathy.22-0.) Based upon these data.3 years). (See 'Adequacy of care' below. or peripheral vascular surgery (18 versus 38 percent. renewed efforts to implement multifactorial risk factor reduction strategies early in the course of type 2 diabetes are necessary.and macrovascular complications in patients with diabetes.08 mmol/L]).3 versus -0. and autonomic neuropathy. body mass index (BMI). 95% CI 0.74). amputation. patients on intensive therapy had a significant reduction in the primary aggregate end point of cardiovascular death. the vast majority of patients do not achieve recommended goals for A1C. and the Kumamoto Study have demonstrated that intensive therapy aimed at lower levels of glycemia results in decreased rates of retinopathy. there were fewer deaths (30 versus 50 percent) in the intensive therapy group (hazard ratio for death 0.3/5/12 Overview of medical care in adults with diabetes mellitus blood pressure control (-14/12 versus -3/8 mmHg). respectively). These results suggest a sustained benefit of multifactorial risk reduction.54.) GLYCEMIC CONTROL Monitoring and target A1C — Prospective.43. Progression of diabetic retinopathy. Significant reductions were also seen in progression of nephropathy. which was a predefined secondary endpoint. These benefits have to be weighed against an increased risk of severe hypoglycemia associated with intensive therapy (particularly in type 1 diabetes). Intensive therapy was also associated with a lower risk of cardiovascular deaths (HR 0. Although the goal of the intensive interventions in these studies was normoglycemia.

8]. or to switch to insulin (algorithm 1). and individuals with comorbid conditions. Most patients with type 2 diabetes can be treated with one or two daily injections. in contrast to patients with type 1 diabetes for whom intensive insulin therapy with multiple daily injections is indicated. older adults.) www. in parallel. but may not be effectively sustained due to side effects. and often much more) to achieve acceptable glycemic control.uptodate. (See "Nutritional considerations in type 1 diabetes mellitus" and "Nutritional considerations in type 2 diabetes mellitus" and "Effects of exercise in diabetes mellitus in adults". Less stringent treatment goals (ie. which was updated in 2009 [7. (See "Prediction and prevention of type 2 diabetes mellitus". these changes in lifestyle also slow progression of impaired glucose tolerance to overt diabetes [47].48].com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 9/27 . Nonpharmacologic therapy in type 2 diabetes — There are three major components to nonpharmacologic therapy of blood glucose in type 2 diabetes (see "Initial management of blood glucose in type 2 diabetes mellitus". including insulin. Type 2 diabetic patients often need large daily doses of insulin (>65 units per day. The UKPDS suggested that worsening beta cell dysfunction with decreased insulin release was primarily responsible for disease progression [48]. patients with limited life expectancies.) Pharmacotherapy for weight loss may also be used for patients with type 2 diabetes. the natural history of most patients with type 2 diabetes is for blood glucose concentrations and A1C to rise over time (figure 6) [43.) The therapeutic options for patients who fail initial therapy with lifestyle intervention and metformin are to add a second oral or injectable agent. More severe insulin resistance or decreased compliance with the dietary regimen also may contribute to progression.) Regardless of the initial response to therapy.) Diet and exercise are important components of therapy in patients with type 1 diabetes. <6. (See "Drug therapy of obesity".3/5/12 Overview of medical care in adults with diabetes mellitus stringent goals (ie.1 percent) can be considered in individual patients. (See "Initial management of blood glucose in type 2 diabetes mellitus". <8 percent) may be appropriate for patients with a history of severe hypoglycemia. Because of the difficulty in achieving and sustaining goal glycemia and significant weight loss.) Surgical treatment of obese patients with diabetes results in the largest degree of sustained weight loss and. (See "Insulin therapy in type 2 diabetes mellitus" and "Insulin therapy in adults with type 1 diabetes mellitus". (See "Management of persistent hyperglycemia in type 2 diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus". the largest improvements in blood glucose control. (See "Treatment of type 2 diabetes mellitus in the elderly patient". section on 'Glycemic targets' and "Glycemic control and vascular complications in type 2 diabetes mellitus". a normal A1C. (See "Surgical management of severe obesity".) Obtain an A1C at least twice yearly in patients who are meeting treatment goals and who have stable glycemic control. section on 'Intensive lifestyle modification'): Dietary modification Exercise Weight reduction In addition to improving glycemic control. section on 'Glycemic targets'. the consensus group concluded that metformin therapy should be initiated concurrent with lifestyle intervention at the time of diagnosis.) Pharmacologic therapy for type 2 diabetes — The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) issued a 2006 consensus statement for the management of glycemia in type 2 diabetes. and quarterly in patients whose therapy has changed or who are not meeting glycemic goals.

67-0.000 Canadian women aged 50 to 67 years.3/5/12 Overview of medical care in adults with diabetes mellitus OTHER ASPECTS OF HEALTH MAINTENANCE Routine health maintenance — The potential exists for the clinician to overlook health maintenance not specifically targeted at diabetes.25. nonalcoholic fatty liver disease rather than cancer is a common cause. and pancreatic cancer. Elevated serum alanine aminotransferase (ALT) concentrations occur commonly in patients with diabetes [56.47) [51].900 patients). This is of concern because in some.68.3) [58]. bladder.14-1. consistent with a direct effect of hyperglycemia on cancer risk. The increased risk of death was associated specifically with cancers of the liver. adults with diabetes compared to those without had an increased risk of death from cancer (HR 1. and pathogenesis of renal cell carcinoma". although causation is not well established. lung. including 69. women with type 2 diabetes had a slightly higher risk of breast cancer than non-diabetic women [55]. renal cancer. In comparison. 67 www.uptodate.47). hepatocellular carcinoma. Although the etiology may be multifactorial.27 (95% CI 1. 95% CI 0.191.09-1. but not all studies. As examples: In a 10-year prospective study of 98. ovary. were less likely to have a mammogram within a two-year period than non-diabetics (odds ratio [OR] 0. In a systematic review of individual patient data from 97 prospective studies (820. Annual dental examination is recommended in both dentate and non-dentate diabetic patients [59]. bladder cancer. Adults with type 2 diabetes also have an increased risk of cancer mortality. In a prospective cohort study of 64. endometrial. despite having more frequent physician visits. the relative risk was substantially reduced when A1C levels were considered in multivariate analyses. rising levels of fasting and post oral glucose challenge glucoses were associated with an increase in cancer risk for women in the highest quartile versus lowest quartile of fasting glucose (RR 1. colorectum. given the intensity and complexity of care required for prevention and treatment of complications in diabetic patients [49]. In a 2004 US survey. Severe periodontal disease was shown to be an independent risk factor for mortality from ischemic heart disease and nephropathy in one longitudinal study of Pima Indians with type 2 diabetes (RR 3. pathology. (See "Overview of preventive medicine in adults".) Cancer screening — Some studies have suggested an increased risk of cancer in patients with diabetes. The most common cancers associated with high glucose values were pancreatic. found that women with diabetes.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 10/27 .57].21. clinical features. 95% CI 1. 95% CI 1.) Dental screening — Periodontal disease is a common complication of diabetes and itself contributes to poor glycemic control.000 Japanese persons aged 40 to 69.) A retrospective study of over 700. risk factors. the association of cancer risk and diabetes for women was only borderline (HR 1.1-9.168 with diabetes. and melanoma. Diabetes mellitus and insulin resistance may also be associated with an increased risk of colon cancer. and protective factors" and "Epidemiology and etiologic associations of hepatocellular carcinoma" and "Epidemiology.70) [54].6. In addition. possibly related to the coincident obesity [50-53]. There was no significant increased risk in men.26.31) [20]. 95% CI 0. (See "Colorectal cancer: Epidemiology. section on 'Diabetes mellitus' and "Epidemiology and etiology of urothelial (transitional cell) carcinoma of the bladder" and "Epidemiology and risk factors for exocrine pancreatic cancer".99-1. and breast.000 Swedish men and women aged 29 to 61.42) [50]. the hazard ratio (HR) for any cancer among men with diabetes was 1. (See "Epidemiology. pancreas. and diagnosis of nonalcoholic steatohepatitis". 95% CI 1.

and disparities in access to care and targeting of risk factor reduction [64]. particularly patients under age 45 years [72] and women [73. In a study of 80.3/5/12 Overview of medical care in adults with diabetes mellitus percent of respondents with diabetes reported a dental visit in the preceding 12 months [60].) Women of childbearing age — Contraception and pregnancy planning should be discussed with all diabetic women who are premenopausal. the proportion of patients who are simultaneously at goal for all measured targets is low. (See "Pregnancy risks in women with type 1 and type 2 diabetes mellitus" and "Prepregnancy evaluation and management of women with type 1 or type 2 diabetes mellitus". Even when patients are achieving goals for individual components of diabetes care. and foot examination [62]. ADA guidelines state that the selection of a contraceptive method for an individual patient should use the same guidelines that apply to women without diabetes. nephropathy. though rates for individual targets ranged from 23 to 41 percent [63]. however.) We recommend that the most reliable method of contraception be used. III). because the risk of unplanned pregnancy is significant. Overall.74]. The reason for this discrepancy is unknown but may be related to gender differences in the pathophysiology of coronary artery disease. less accurate diagnosis of CVD in women. small improvements in diabetes management and cardiovascular risk factor reduction have decreased cardiovascular and all-cause mortality rates in some patients [64]. and blood pressure. Prior to pregnancy. using aspirin. 33 percent had blood pressure >140/90 mm.4 mmol/L). or other vascular disease [61]. comparing the US NHANES databases for 1988 to 1994 and 1999 to 2002.) ADEQUACY OF CARE — Despite extensive data suggesting large benefits with preventive and treatment strategies. Even when recommended www. no change in mean A1C.4 mmol/L). only 4 percent were simultaneously at ADA goal for A1C.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 11/27 . indicate that glycemic control has improved only minimally (nonsignificant decrease in proportion of patients with A1C >9 percent. About 20 percent of patients in 1999 to 2002 had A1C >9 percent. and receiving annual influenza vaccination. retinopathy. II. Improvements were seen in the proportion of patients with LDL cholesterol <130 mg/dL (3. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) are more cautious and recommend "on theoretical concerns" that use of oral contraception be limited to nonsmoking diabetic women who are younger than 35 years and are without hypertension. and blood pressure distribution has remained unchanged. Nevertheless. increase in patients with A1C between 6 and 8 percent). the majority of diabetic patients are not receiving recommended levels of healthcare [6671]. Vaccination — Patients with diabetes mellitus should receive influenza vaccination yearly and pneumococcal vaccination. Surveys of patients aged 18 to 75 years with diabetes. and 40 percent had LDL cholesterol >130 mg/dL (>3. suggest that mortality rates are decreasing in diabetic men but not in women [65]. prepregnancy counseling and planning is important.000 diabetic patients receiving care in a VA system. and both ACE inhibitor and statin medications should be discontinued (table 3). glycemic control should be optimized. Data from the National Health and Nutrition Examination Surveys (NHANES I. Tetanus and diphtheria vaccinations should also be updated. there has been little improvement in diabetes management in the US. (See "Tetanus-diphtheria toxoid vaccination in adults". and despite increasing media attention. For women who do not wish to become pregnant. (See "Risks and side effects associated with estrogen-progestin contraceptives".uptodate. eye examination. when not contraindicated by other health concerns. For women with diabetes who are contemplating pregnancy. repeating the pneumococcal vaccine once after age 65 years if the initial vaccination was prior to age 65. LDL cholesterol. lipid testing.

concern about patient's pill burden. but does not adequately serve the needs of those with a chronic illness such as diabetes mellitus [76]. Lower risks of neuropathy and nephropathy were reported in association with specialist care for type 1 diabetes [84]. Multiple factors may be contributory: lack of awareness of therapeutic goals.3/5/12 Overview of medical care in adults with diabetes mellitus screening data are obtained. rates of medication adjustment to address abnormal results are low [75].82 for patients who received care from both diabetes clinics and generalists as compared with those who received care only from generalists. There are several reasons for the large discrepancy between what should be done and what is being done: Treatment of acute and chronic disease — Traditional medical practice is organized to respond quickly to acute patient problems. examined the fiveyear mortality of 3288 patients with diabetes who received medical care exclusively from generalists and of 4200 patients who received care from generalists and also had examinations in a diabetes clinic [80]. reluctance to treat asymptomatic conditions. although diabetes-specific tests were performed more often in a diabetes clinic. were more likely to have had an eye examination and A1C test in the past year (73 versus 52 percent) [83]. time limitations. It is difficult to distinguish how much of the difference in care is due to expert knowledge or to the application of a systematic and organized approach. A major unresolved controversy is the place of the generalist and the specialist in the treatment of patients with type 2 diabetes. Other strategies for improving the routine care of diabetic patients www. One study.uptodate. In one study. when compared with family practitioners. Clinical inertia — Failure to make adjustments in a therapeutic regimen in response to an abnormal clinical result has been termed "clinical inertia" [77]. and the place of the specialist remains unsettled. Lack of an organized system for care — Outcomes are better when diabetic patients are seen in the context of organized programs [79. Who should take care of the patient — The majority of diabetic patients (greater than 90 percent) receive their care from primary care providers. These reports have generated much discussion and disagreement [85]. except for improved foot care and lower infection risk [81. The relative risk of all-cause mortality was 0. In one study of modifications in therapy for various cardiovascular risk conditions. the mean A1C value (9.82]. diabetic patients were more likely to get inquiries about the presence of cardiac symptoms if they received their care in a general internal medicine clinic [81]. medication adjustments were made for 66 percent of patients whose A1C level was >8 percent [78]. Overall functional status at four years and mortality at seven years were similar. However. as an example. compared with those seen in a general medicine clinic.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 12/27 .7 percent) in the two clinics was similar and suboptimal.80]. A retrospective study of 112 patients (primarily type 2 diabetes) at a Veteran Administration Medical Center found that patients seen in a diabetes clinic. or attention to acute medical issues that take priority over risk factor management [78]. Studies comparing care by specialists and generalists have generated conflicting findings: A large observational study (the Medical Outcomes Study) found little advantage for patients under the care of endocrinologists.

91] Management by nurse specialists under the supervision of a diabetologist [92. Beyond the Basics patient education pieces are longer. more sophisticated. Processes of care (performance of retinal examination. aspirin therapy) may be more readily improved by disease management interventions than intermediate outcomes (blood pressure control. and more detailed.42 percent (95% CI 0. or by asking for data on random samples of diabetic patients. A1C measurements. Across all trials. The most comprehensive set of diabetes measures has recently been launched by the American Diabetes Association (ADA). These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.87] Better organization and delivery of patient education [88.98]. easy-to-read materials. laboratory data. “The Basics” and “Beyond the Basics. Several organizations are encouraging adherence to routine standards of care for diabetic patients by auditing charts. flu vaccination. and a patient survey and measures eye. the mean A1C reduction was 0. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest. cardiac risk reduction. These include the following: "Diabetes miniclinics" [86. nephropathy screening. Individual providers or groups of providers may apply to receive recognition that they are delivering a certain standard of diabetes care. lipid testing. cosponsored by the National Committee for Quality Assurance. foot exam. at the 5th to 6th grade reading level. or A1C level) [96]. Strategies incorporating team changes (expanded roles for non-MD clinicians and shared care) or case management programs (multidisciplinary coordinated care for patient scheduling and follow-up) were most effective.) Basics topics (see "Patient information: The ABCs of diabetes (The Basics)" and "Patient information: Type 1 diabetes (The Basics)" and "Patient information: Type 2 diabetes (The Basics)" and "Patient information: Treatment for type 2 diabetes (The Basics)" and "Patient information: Diabetic retinopathy (The Basics)" and "Patient information: Reducing the costs of medicines (The Basics)") www.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 13/27 . These articles are best for patients who want a general overview and who prefer short.” The Basics patient education pieces are written in plain language. and they answer the four or five key questions a patient might have about a given condition. Recognition requires review of the medical chart. lipid control.89] Structured behavioral intervention [90. and renal care. Here are the patient education articles that are relevant to this topic. and patient satisfaction (table 4). INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials.93] Multidisciplinary disease management programs [94-96] The optimal intervention strategy to improve diabetes care in the primary care setting has not been established. We encourage you to print or e-mail these topics to your patients.uptodate.290. A1C improvement was greatest for strategies that allowed medication dose adjustments without awaiting physician approval. foot. Strategies to improve diabetes primary care — Several approaches have been tried in order to improve the care of diabetic patients within a primary care setting.3/5/12 Overview of medical care in adults with diabetes mellitus are reviewed below. and the effects of intervention may be short-lived [97.34) over a median of 13 months follow-up. glycemic control. A meta-analysis reviewing 66 publications of trials evaluating the impact of 11 different strategies for improving diabetes care found study limitations and likely publication bias [99]. Further information is available through the National Committee for Quality Assurance.

<8 percent) may be preferable for some type 2 patients with comorbidities or with an anticipated lifespan.) Glycemic control can minimize risks for retinopathy. involving disease management principles.) Use of UpToDate is subject to the Subscription and License Agreement.6 mmol/L]) and use of aspirin (75 to 162 mg/day) in patients with or at high risk for cardiovascular disease. owing to advanced age or other factors. especially type 2. Topic 1750 Version 18. cholesterol (goal LDL less than 100 mg/dL [2. (See 'Adequacy of care' above. Monitoring recommendations for patients with diabetes are presented in the table (table 1). nephropathy. that is too brief to benefit from the effects of intensive therapy on long-term complications. (See 'Evaluation for diabetic complications' above and 'Reducing the risk of macrovascular disease' above. (See 'Monitoring and target A1C' above and "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetes mellitus". Interventions can limit end organ damage and are the focus of care for the diabetic patient. section on 'Goal blood pressure'.3/5/12 Overview of medical care in adults with diabetes mellitus Beyond the Basics topics (see "Patient information: Diabetes mellitus type 1: Overview (Beyond the Basics)" and "Patient information: Diabetes mellitus type 2: Overview (Beyond the Basics)" and "Patient information: Diabetes mellitus type 2: Treatment (Beyond the Basics)" and "Patient information: Reducing the costs of medicines (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Morbidity from diabetes involves both macrovascular (atherosclerosis) and microvascular disease (retinopathy. Smoking cessation is essential for patients who smoke.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 14/27 . and neuropathy). section on 'Target blood glucose values'. (See "Glycemic control in women with type 1 and type 2 diabetes mellitus during pregnancy".) Prevention of cardiovascular morbidity is a major priority for patients with diabetes. and has been shown to decrease the risk for cardiovascular disease for type 1 diabetes.) The majority of diabetic patients are not receiving recommended levels of healthcare and development of systems of care. Cardiovascular morbidity can also be significantly reduced with aggressive management of hypertension. may be important in delivering improved care. (See 'Glycemic control' above. (See 'Reducing the risk of macrovascular disease' above and "Treatment of hypertension in patients with diabetes mellitus". nephropathy.0 www.uptodate.) A higher target A1C (ie. more stringent control (A1C <6 percent) may be indicated for individual patients with type 1 diabetes and during pregnancy. and neuropathy in both type 1 and type 2 diabetes.) A1C goal is <7 percent for most patients.

protein excretion and serum creatinine should also be monitored if persistent albuminuria is present Frequency Every visit For smokers only Notes History and physical examination Every visit Annually* Goal <130/80 Begin at onset of type 2 diabetes.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 15/27 . self management review Annually Annually * Less frequent screening (every two to three years) may be appropriate for some patients.3/5/12 Overview of medical care in adults with diabetes mellitus GRAPHICS Monitoring in patients with diabetes mellitus Intervention Smoking cessation counseling Blood pressure Dilated eye examination Foot examination Laboratory studies Fasting serum lipid profile A1C Microalbuminuria Annually Every 3 to 6 months Annually May obtain every two years if profile is low risk Goal <7% (may be lower or higher in selected patients) Begin 3 to 5 years after onset of type 1 diabetes. 3 to 5 years after onset of type 1 diabetes. Examine more than annually if significant retinopathy Every visit if peripheral vascular disease or neuropathy Annually Serum creatinine Vaccinations Pneumococcus Initially.uptodate. www. as indicated One time Patients over age 65 need a second dose if vaccine was received ≥5 years previously and age was <65 at time of vaccination Influenza Education.

3/5/12 Overview of medical care in adults with diabetes mellitus Onset of retinopathy precedes diagnosis of type 2 diabetes Prevalence of retinopathy in relation to years after onset of diabetes among patients in southern Wisconsin (blue circles) and rural western Australia (red squares). MI. At diagnosis (year zero). Welborn. The lines extrapolate back to an estimated onset of retinopathy four to seven years before the clinical diagnosis was made. R.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 16/27 . www. Data from Harris. TA. Diabetes Care 1992. Knuiman. retinopathy was already present in 10 to 20 percent of patients. Klein. MW. 15:815.uptodate.

Modifications from Standards of Medical Care in Diabetes--2009.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 17/27 . Supplement 1.3/5/12 Overview of medical care in adults with diabetes mellitus Ophthalmologic examination schedule Patient group Type 1 diabetes Type 2 diabetes Pregnancy in preexisting diabetes Recommended first examination Within 5 years after diagnosis of diabetes once patient is age 10 years or older• At time of diagnosis of diabetes Prior to conception and during first trimester. * Abnormal findings necessitate more frequent follow-up. 2009. Diabetes Care Vol 32. • Some evidence suggests that the prepubertal duration of diabetes may be important in the development of microvascular complications. Copyright © 2004 American Diabetes Association From Diabetes Care Vol 27. clinical judgment should be used when applying these recommendations to individual patients. Reprinted with permission from The American Diabetes Association. www. 2004. Supplement 1. Minimum routine follow-up* Yearly Yearly Close follow-up throughout pregnancy and for one year postpartum. Counsel on the risk of development and/or progression of retinopathy. therefore.

Moss. R. Retinopathy increased over time in both groups. affecting virtually all patients with type 1 diabetes by 20 years. BE.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 18/27 . SE. 102:520.uptodate. et al. Arch Ophthalmol 1984. Data from Klein. The increased incidence in type 2 diabetes at three years is a probable reflection of the difficulty in determining the time of onset of that disease.3/5/12 Overview of medical care in adults with diabetes mellitus Incidence of diabetic retinopathy increases over time Percent of diabetic patients with retinopathy according to duration of disease in patients under the age of 30 years who were treated with insulin (primarily type 1 diabetes) and patients over the age of 30 years who were not treated with insulin (primarily type 2 diabetes). Klein. www.527.

Failure to detect cutaneous pressure at any site indicates that the patient is at high risk for future ulceration.uptodate.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 19/27 . which represent the most common sites of ulcer formation.3/5/12 Overview of medical care in adults with diabetes mellitus Testing sites for pressure sensation in evaluation of diabetic foot The monofilament used to evaluate pressure sensation should be tested at each of the 12 sites shown. www.

normal blood pressure. At two years. Data from The Microalbuminuria Study Group. 39:587.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 20/27 . Diabetologia 1996.3/5/12 Overview of medical care in adults with diabetes mellitus Captopril delays progression of microalbuminuria in diabetes Effect of captopril or placebo in 225 patients with type 1 diabetes mellitus. www. dipstick-positive proteinuria and lowered the albumin excretion rate (AER) compared to placebo.uptodate. and microalbuminuria. captopril slowed the rate of progression to overt.

RP. Rohde.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 21/27 .5 mg/dL (132 µmol/L). Data from Lewis. 329:1456.3/5/12 Overview of medical care in adults with diabetes mellitus ACE inhibitor slows progression of diabetic nephropathy The effect of the administration of placebo or captopril to patients with type 1 diabetes with overt proteinuria and a plasma creatinine concentration equal to or greater than 1. The likelihood of a doubling of the plasma creatinine concentration (Pcr) was reduced by more than 50 percent in the captopril group. www. N Engl J Med 1993. EJ. Bain. RD. Hunsicker.uptodate. LG.

com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 22/27 . Data from Yudkin. JS. Although risk was reduced by the therapeutic interventions (particularly cessation of smoking). BMJ 1993. there was a residual three to four fold increase in mortality in the diabetic men. www.uptodate. 306:1313.3/5/12 Overview of medical care in adults with diabetes mellitus Increased cardiovascular risk in type 2 diabetes Calculated effects of different interventions on coronary and total deaths in 1000 normal and 1000 men with type 2 diabetes aged 35 to 57 years without a history of myocardial infarction. due presumably to the effects of hyperglycemia or hyperinsulinemia.

com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 23/27 . Diabetes Care 2009. Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. * Premixed insulins are not recommended during adjustment of doses.uptodate. however. JB. they can be used conveniently. Copyright © 2009 American Diabetes Association. bg: blood glucose. The algorithm can only provide basic guidelines for initiation and adjustment of insulin.3/5/12 Overview of medical care in adults with diabetes mellitus Initiation and adjustment of insulin regimens Insulin regimens should be designed taking lifestyle and meal schedule into account. Buse. et al. MB. Reproduced with permission from: Nathan. www. 32: 193. usually before breakfast and/or dinner if proportion of rapidand intermediate-acting insulins is similar to the fixed proportions available. DM. Davidson.

Data from UK Prospective Diabetes Study (UKPDS) Group. in patients with type 2 diabetes mellitus in the United Kingdom Prospective Diabetes Study (UKPDS) who were randomly assigned to receive intensive therapy with a sulfonylurea or insulin or to conventional treatment with diet.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 24/27 .3/5/12 Overview of medical care in adults with diabetes mellitus Glycemic control in type 2 diabetes Glycemic control. 352:837. The HbA1c values were lower in the intensive therapy group but rose in both groups over time. The circles represent data for all patients. drugs were added if there were hyperglycemic symptoms or if the fasting blood glucose concentration was greater than 270 mg/dL (15 mmol/L). estimated from the median hemoglobin A1C value. www.uptodate. Lancet 1998. while the lines represent data for patients followed for ten years.

Discontinue those that are associated with potential fetal risks or change to medications with fewer fetal effects. or switch to agents with fewest risks to fetus Retinopathy ophthalmology consult treat active proliferative retinopathy before pregnancy Cardiac screen for coronary heart disease as per guidelines for nonpregnant women with diabetes Renal measure serum creatinine concentration and total protein-to-creatinine ratio women with an elevated serum creatinine concentration are at risk for deterioration of renal status Thyroid obtain serum thyrotropin and free thyroxine Diabetes Achieve good glucose control before conception.com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 25/27 . if possible. Psychosocial Assess "readiness" of patient for pregnancy Other Advise patient to stop smoking and stop use of illicit drugs Review medications. Either subcutaneous insulin injections or an insulin infusion pump is acceptable Self-blood glucose monitoring is performed before and after each meal and at bedtime Repeat A1c one month after initiation of this program. www. 3-4 injections/day of short and long acting insulin subcutaneously are usually required to achieve good glycemic control. A pregnancy test is done 1 week after a missed period to confirm pregnancy. if possible. Retest every month until target A1c value is achieved. intensive insulin therapy is warranted. the patient can try to conceive. Once in the target range. If A1c is above the normal range for women without diabetes.3/5/12 Overview of medical care in adults with diabetes mellitus Preconception evalaution and management of women with type 1 or type 2 diabetes History and physical examination Hypertension goal blood pressure less than 140/90 mmHg except goal blood pressure less than 130/80 mmHg in patients with diabetic nephropathy and proteinuria stop antihypertensive drugs.uptodate.

com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 26/27 .3/5/12 Overview of medical care in adults with diabetes mellitus American Diabetic Association provider recognition measures Measure HbA1c test (calculate proportion of patients with HbA1c value of less than 8 and 10 percent) Retinal examination Foot care evaluation Blood pressure measurement (calculate proportion of patients with diastolic pressures of less than 90 mm Hg) Measurement of urinary protein/microalbumineria Lipid profile evaluation Tobacco smoking status and counseling referral (document in chart) Assessment of patient monitoring of blood glucose (obtained from patient survey) Patient satisfaction questions (obtained from patient survey) Frequency At least once a year At least once a year At least once a year At least twice a year Once a year Once a year www.uptodate.

com/contents/overview-of-medical-care-in-adults-with-diabetes-mellitus?view=print 27/27 . All rights reserved. Inc.133.C20.2 .3/5/12 Overview of medical care in adults with diabetes mellitus © 2012 UpToDate.com-108.3 | Support Tag: [ecapp1104p. | Licensed to: Touro Coll Of Osteopathic Med E976FD7FC7-4752.uptodate.14] Subscription and License Agreement | Release: 20.46.14- www.utd.