DIABETES

PATIENT CARE
1) Signs and Symtpoms
Diabetic Eye Exam: Dilated eye exam should be performed once a year to look
for diabetic retinopathy, cataracts and glaucoma
o Hallmark lesion for retinopathy is microanneruysms usually in the
posterior pole
Diabetic Foot Exam: On most visits. Use 10g monofilament to test sensation.
Apply to at least four sites. If unable to feel on four sites significant peripheral
neuropathy.
o Also check pedal pulses, look for ulcers, onychomycosis and check nail
care
o Patient should perform a daily self-foot exam
Laboratory data related to diabetic control and end organ damage
o HbA1c: Goal is < 6.5. 6.0 corresponds to glc of 130. Each 1 pt adds 30.
o Nephropathy: monitor with UA or microalbuminurea every 6-12 mo.
Normal = < 30 mg/day or < 30 ug / mg Cr on spot urine
Refer to nephrology if Cr > 2.0
o CAD / MI: EKG, TnI, CK-MB etc.
o PVD: Check ABI (Systolic BP of arm / Systolic BP or leg)
Normal = > 0.95, < 0.3 = likely necrosis
o Renal Artery Stenosis: MRA or plasma renin levels
o Gastroparesis: Upper GI series or nuclear emptying study
o Neuropathy: Nerve conduction study if need to differentiate from radicular
2) Goals and risks of poor management
Risks = End Organ Damage: CVA, CAD, PVD, Nephropathy, Neuropathy (both
sensory and autonomic), Retinopathy
Indicators of control:
o AACE: HbA1c < 6.5. Fasting Glc < 110, 2h post prandial Glc < 140.
o ADA: HbA1c < 7.0, Fasting Glc 90-130, peak post prandial Glc < 180
3) Lifestyle changes
Blood Glucose Monitoring. Detailed Guide
o Type 1 = at least 3x/day.
o Type II = tailored to treatment and whether controlled. Increased if ill or
medication adjustment. As often as type I if using insulin.
o Be explicit about when to test. For a non-insulin dependant type II,
fasting am blood sugars some days as well as some pre and post
prandials throughout the day are good.
o Bring logbook and meter to visit

Dietary Recomendations: Reduce calorie intake, fat < 30% of calories, sat fat <
10% of calories, increase fiber.
o CHOs should come from whole grains, beans, fruits and vegetables.
Exercise Recomendations: Evaluate for vascular, neruo or eye damage that
would inhibit from certain types of exercise.
o Improves glycemic control, lipids, HTN, CAD
o 30 of moderate activity on most days of the week

4) Prevention and Health Maintenance

A1C every 6 mo or every 3 mo if on insulin or poorly controlled
Lipids every year, UA or microalbuminuria every year
Foot exam and eye exam every year
EKG for all newly Dxed type IIs and if chest or repiratory complaint.
Pneumococcal vaccine and influenza vaccine for all diabetic adults. Even more
important if > 65yo or end-organ damage. Supporting data and recomendations
5) Explainig metabolic syndrome to patients
Insulin resistance leads to beta cell dysfunction and hyperinsulinemia which leads
to HTN, high TG, low HDL.
Obesity, genetics and PCOS can all lead to insulin resistance.
Remember to use nutritionist, nurse, health educator and pharmacist to help
MEDICAL KNOWLEDGE
1) Epidemiology and Screening
Rate of DM II is rapidly rising
Increased in low SES, AA and Native Americans
Important to screen as most type IIs have for 10-12 years b/f Dx
ADA screening guidelines: For asymptomatic individuals start q 3 yrs at age 45,
esp if age > 45. Consider earlier if FH, HTN, low HDL or high TG, race, PCOS,
GDM Hx, previous IGT or IFG.
USPTF screening guidelines: I for asymptomatic adults. B evidence for those
with hypertension or hyperlipidemia. (see bottom of hyperlink for link to
evidence used to generate these recommendations)
2) Pathophysiology of Metabolic Syndrome
Diagnosis is three of following
o Waist > 40 in in males, > 35 in females
o TG > 150
o HDL < 40 in males, < 50 in females
o BP > 130/85
o FPG > 100

Insulin resistance at peripheral tissues leads to increased beta cell release and
hyperinsulinemia.
o Increased blood insulin levels increase TG, decrease HDL, and
proinflmatory markers leading to HTN and Atherosclerosis
IR comes from adipose reducing muscle ability to use insulin and through genetic
factors (thus lifestyle and genetic factors)
Not all obese people become insulin resistant. There is thought to be a
multifactorial genetic component to the development of insulin resistance.

3) Pathophysiology of Diabetes (Cecils from MD Consult p 1431)

Type I: Autoimmune destruction of pancreatic beta-cells
Type II: From insulin resistance at peripheral targets. Initial beta cell secretion is
initially normal or elevated but is relatively deficient. With time, may get beta
cell burnout.
End Organ Complications: All result from vascular complications
o Macrovascular: CAD, MI, PVD, CVA, RAS
o Microvascular: Retinopathy, Nephropathy, Neuropathy (impotence,
sensory, gastroparesis, autonomic)
o Increased fungal and staph infections due to impaired NO diapedesis
Diagnoses of Diabetes: single plasma glc > 200 w/ sxs of poly D,P,U
o 2 fasting plasma glc > 125.
o Type I: young age, abrupt presentation (DKA). Type II: older, more
insidious
o FPG 100-125 = prediabetes (previous recommendations were 110)
Initial Eval
o Hx: CV Sx, neuro or vision changes
o PE: BP, eye, thyroid, bruits, sensory, extremties, skin, acanthosis nigricans
DM changes goals for HTN and Lipids
o HTN: changes from 140/90 to 130/80
o Lipids: LDL goal to < 100
o Must treat PVD and CAD more aggressively. (Ex bypass for two vessel
disease if DM present)
4) Oral hypoglycemics (See Hard Copy Table for more detail) or Detailed Guide
Sulfonureas: stimulate B-cells, hypoglycemia, weight gain
o Ex. Glyburide or glipizide: $8
Biguandies: reduce hepatic GNG and increase insulin sensitivity. Risk of LA.
Contraindicated if Cr < 1.5 or shock, liver disease, pulm insuff or hypoperf
(increase LA). 1st line if overweight
o Ex. Glucophage or Metformin: $50
TZDs: increase sensitivity via PPAR-gamma. Liver damage (must check LFTs),
edema, weight gain, CHF.
o Ex Actos Avandia: $100

Meglitinides: stimulate B-cells, shorter acting. Use pre-prandially. Same SEs as

SUs, skip med if skipping meal.
o Ex. Starlix, Prandin: $35
Alpha-Glucosidase Inhibitors: acarbose: inhibit brush boarder enzyme. Low
compliance due to bloating and abdominal discomfort.
Algorithm: Start with sulfoylurea or metformin if overweight. Combine if not
enough and then add other agents to control.
Remember diet, exercise and weight loss.

5) Insulin
Neccesary in about 1/3 of type IIs and in all Type Is
Insulin
Onset
Peak
Lispro/ Humalog /
5-15 min
1h
Aspart
Regular
30min
2-4h
NPH (Lente) =
2h
6-10h
Humalin
Ultralente
4h
10-20h
70/30 (NPH:
30min
3-12h
Regular)
Glargine = Lantus
2h
None

Duration
2-4h
5-8h
18-28h
12-20h
16-24h
24h