Doctor's Blog

February, 2010

Diabetes Mellitus Update

Diabetes mellitus (DM) is prevalent in the United States. The American Diabetes Association estimates 57 million people are pre-diabetic. The increase in the rate of diabetes correlates with obesity. There have been recent changes to the guidelines for diagnosis and management of diabetes.

Previously, the diagnosis criteria for diabetes was a fasting blood glucose >126. The new guidelines also use another lab value to diagnose diabetes. A hemoglobin A1C (HgA1C) >6.5% indicates a diagnosis of diabetes.

Who should be screened for diabetes?

• Overweight individuals: body mass index (BMI) > 25
• Physical inactivity
• Family history of DM
• Gestational DM (test 6-12 weeks postpartum)
• Ethnicity (African-American, Latino, Native American, Asian American)
• Low HDL <35
• High triglycerides >250
• Hypertension (BP >140/90)
• Age> 45. If tests are normal, rescreening should occur every 3 years.

The standard goal of diabetes has been to achieve HgbA1C <7. Well known late effects of uncontrolled diabetes include damage to eyes, nerves and kidneys. An early sign of kidney damage is protein in the urine. 20-40% of patients with diabetes develop kidney disease. Diabetes is the leading cause of end stage kidney disease requiring dialysis. The ADVANCE study showed that achieving HgbA1C <6.5 decreased the amount of protein in the urine, thereby preventing kidney disease.

Metformin is a medication that decreases intestinal absorption of glucose and increases insulin sensitivity. Metformin is now recommended in patients with impaired glucose tolerance (pre-diabetes). Impaired glucose tolerance has been re-defined as a HgA1C 5.7-6.4% or a fasting blood glucose between 100-125.

Diabetes is commonly associated with high blood pressure and high cholesterol, both of which increase mortality from cardiovascular disease. The blood pressure goal <130/80 decreases the risk of heart attacks and strokes. A class of medications, ACE inhibitor and ARB, have been shown to lower the risk of cardiovascular disease. The new recommendation is that diabetic patients over age 40 with one cardiovascular risk factor should be started on lipid-lowering therapy with statins regardless of baseline lipid values. The goal LDL is <100. For high risk patient who have had a heart attack or stroke should achieve a goal LDL<70. In addition, aspirin 81mg daily is indicated for patients with high risk for cardiovascular disease. A meta-analysis found that aspirin reduces the risk of vascular events by 12%.

Influenza and pneumonia are common diseases with high mortality and morbidity in the elderly. All people with diabetes of any age should receive a pneumonia vaccine. A one-time revaccination is recommended at age 65. Diabetics should also receive a yearly influenza vaccine.

Please see your primary care provider to discuss your individual risk factors.

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