American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP DiabetesMonthly



In the News for the month of January 2014




Highlights

ADA standards call for further tailoring of diabetes care to each patient

Doctors should further individualize care in the treatment of diabetes, the American Diabetes Association (ADA) stated in its 2014 Standards of Medical Care. More...

Type 2 diabetes in younger women associated with early menopause

Type 2 diabetes is associated with early menopause in women younger than 45 years, a new study found. More...

Nonsurgical periodontal therapy doesn't appear to help glycemic control

Patients with type 2 diabetes and significant chronic periodontitis derived no glycemic benefit from nonsurgical periodontal therapy, according to a new study. More...


Test yourself

MKSAP Quiz: type 1 diabetic admitted for hip replacement

This month's quiz asks readers to evaluate a 62-year-old man with a 36-year history of type 1 diabetes mellitus admitted to the hospital for a right hip replacement. More...


From ACP InternistWeekly

Diuretics, statins increased risk of diabetes in high-risk patients

Starting a diuretic or a statin in patients with impaired glucose tolerance significantly increased their risk of developing diabetes, a new study found. More...


From Annals of Internal Medicine

The Consult Guys talk about hyperglycemia

A new video from the Consult Guys, Geno J. Merli, MD, FACP, and Howard H. Weitz, MD, FACP, addresses inpatient glucose control. "Hyperglycemia: Am I a Control Freak?" was released online Dec. 17, 2013. More...


Tool of the month

Check for diabetes complications

Perform a careful history and physical examination in all patients with hyperglycemia to evaluate for the complications of diabetes. More...


Keeping tabs

Spotlight on diabetic eye disease

The prevalence and treatment of diabetes complications affecting the eye were analyzed by multiple studies published in the past month. More...


Physician editor: David V. O'Dell, MD, FACP



Highlights


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ADA standards call for further tailoring of diabetes care to each patient

Doctors should further individualize care in the treatment of diabetes, the American Diabetes Association (ADA) stated in its 2014 Standards of Medical Care.

Specifically, doctors should explore a variety of options when prescribing medication to treat neuropathy, consider 2 types of screening for gestational diabetes, and encourage people with diabetes to work with a nutritionist or dietitian on a diet that best fits their needs. An executive summary and the full set of standards (which are revised annually) were released online Dec. 19, 2013, and appeared in a supplement to the January 2014 Diabetes Care.

The new standards encourage doctors to try a variety of medications when treating people with diabetes for neuropathy and to carefully monitor how the patient responds to the drugs to ensure maximum relief, because no drug affects all patients the same way. The ADA committee noted that there is limited clinical evidence about the most effective treatments given the wide range of available medications: 2 drugs approved for relief of distal symmetric polyneuropathy in the U.S.—pregabalin and duloxetine—and other drugs such as venlafaxine, amitriptyline, gabapentin, valproate and opioids. "Head-to-head treatment comparisons and studies that include quality-of-life outcomes are rare, so treatment decisions must often follow a trial-and-error approach," the authors concluded.

For treating gestational diabetes, an expert panel convened by the National Institutes of Health recommended a 2-step process, in which a nonfasting test is given first, followed by a glucose tolerance test only for a subset of women whose glucose levels reach a certain threshold. Previously, the standards recommended a 1-step screening method endorsed by the International Association of the Diabetes and Pregnancy Study Groups (IADPGS). Both panels reviewed the same data but reached different conclusions.

Regarding choice of an appropriate medical nutrition therapy, no particular diet—low-carb, high-carb or low-fat—was recommended over another, although evidence supported greater use of dietitians and nutritionists in helping patients lower their hemoglobin A1c (HbA1c) levels.

The new standards also:

  • maintain support of the previous recommendation that people with diabetes limit their intake of sodium to 2,300 mg/d, the same amount recommended for people without diabetes. People who have both diabetes and high blood pressure should try to lower their intake further on an individualized basis,
  • clarify that the HbA1c test is one of 3 appropriate methods for diagnosing diabetes, and
  • discourage the sole use of sliding-scale insulin in the inpatient hospital setting.

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Type 2 diabetes in younger women associated with early menopause

Type 2 diabetes is associated with early menopause in women younger than 45 years, a new study found.

In a cross-sectional study in 11 Latin American countries, 6,079 women between ages 40 and 59 years who accompanied patients to medical centers agreed to complete a questionnaire. Data were collected on age, educational level, menopausal status, years of postmenopause, surgical menopause, marital/partner status, and various lifestyle factors such as smoking and exercise. The women also completed the Menopause Rating Scale, which assesses the presence and intensity of 11 symptoms.

Seven percent (n=410) of women were diabetic; the mean age of all women was 49.7 years. Fifty-eight percent of women were postmenopausal. Women with diabetes had a lower average age of menopause (48.4 vs. 50.1 years). In women age 40 to 44 years, having diabetes was associated with nearly 3 times the odds of being postmenopausal compared with not having diabetes (29.5% vs 13.2%; odds ratio, 2.76; 95% CI, 1.32 to 5.67). This relationship remained after adjustment for confounding variables.

In women age 45 years or older, however, having diabetes wasn't associated with a greater risk of being postmenopausal. In all women, being menopausal also didn't increase the risk of diabetes. Diabetic women were at higher risk of reduced quality of life; however, this risk disappeared with adjustments for variables like obesity, hypertension and age. The study was published in the December 2013 Climacteric.

There may be a subgroup of women with diabetes "in whom the metabolic disorders of the disease will accelerate reproductive aging, and they will therefore experience an early menopause," the authors wrote. Study limitations include its cross-sectional nature and its generalizability to non-Hispanic women.


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Nonsurgical periodontal therapy doesn't appear to help glycemic control

Patients with type 2 diabetes and significant chronic periodontitis derived no glycemic benefit from nonsurgical periodontal therapy, according to a new study.

Researchers performed a 6-month, single-masked, multicenter randomized clinical study, the Diabetes and Periodontal Therapy Trial, to test whether hemoglobin A1c (HbA1c) levels would improve with nonsurgical periodontal therapy in patients who had type 2 diabetes and moderate to advanced chronic periodontitis. Eligible patients had HbA1c levels between 7% and 9% and were enrolled from diabetes clinics, dental clinics and communities that were affiliated with 5 academic medical centers.

Patients assigned to the treatment group underwent scaling and root planing and received oral rinse with chlorhexidine at baseline; they also received supportive periodontal therapy at 3 and 6 months. Patients assigned to the control group received no periodontitis treatment. The study's primary outcome measure was the between-group difference in change in HbA1c level at 6 months, while secondary outcome measures were changes in periodontal measures (including probing pocket depths, clinical attachment loss, bleeding on probing, gingival index, and Homeostasis Model Assessment score) and fasting glucose level. The study results were published in the Dec. 18, 2013, Journal of the American Medical Association.

Two hundred fifty-seven patients were assigned to the treatment group and 257 patients were assigned to the control group between November 2009 and March 2012. The data and safety monitoring board recommended that trial enrollment be stopped early due to futility. Two hundred forty-four patients (47%) took oral hypoglycemic agents only, 80 (16%) took only insulin, 179 (35%) took both, and 11 (2%) didn't take any diabetes medications. Overall, at 6 months, mean HbA1c levels increased 0.17% in the treatment group compared with 0.11% in the control group, and the 2 groups did not differ significantly in a linear regression model that was adjusted for clinical site (mean difference, −0.05%; P=0.55). The treatment group did see statistically significant improvement in probing depth, clinical attachment loss, bleeding on probing and gingival index at 6 months compared with the control group. No serious adverse events related to the study were noted in either group.

The authors noted that they did not use antibiotics or surgical treatment for periodontitis and that their results may not apply to patients with HbA1c levels other than 7% to 9%, among other limitations. However, they concluded that while nonsurgical periodontal treatment appeared to improve chronic periodontitis in diabetic patients, it did not help glycemic control. "These findings do not support the use of nonsurgical periodontal treatment in patients with diabetes for the purpose of lowering levels of HbA1c," they wrote.



Test yourself


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MKSAP Quiz: type 1 diabetic admitted for hip replacement

A 62-year-old man is admitted to the hospital for a right hip replacement. The patient has a 36-year history of type 1 diabetes mellitus. He also has proliferative diabetic retinopathy treated previously with laser therapy and peripheral and autonomic neuropathy. Before admission, the patient's diabetes was treated with premixed 70/30 insulin (neutral protamine Hagedorn [NPH] insulin/regular insulin); he took 18 units of this preparation before breakfast and 12 units before his evening meal. His most recent hemoglobin A1c value indicated good glycemic control.

mksap.gif

On physical examination, temperature is normal, blood pressure is 138/79 mm Hg, pulse rate is 88/min, and respiration rate is 16/min; BMI is 22. Other physical examination findings are consistent with the previously established diagnoses of diabetic retinopathy with laser scars, autonomic neuropathy, and osteoarthritis of the right hip.

Which of the following is the most appropriate insulin therapy after surgery?

A. Insulin glargine once daily and insulin aspart before each meal
B. Intravenous insulin infusion
C. Previous schedule of 70/30 insulin
D. Sliding-scale insulin schedule with regular insulin given whenever the blood glucose level is 150 mg/dL (8.3 mmol/L) or greater
E. Subcutaneous insulin infusion

Click here or scroll to the bottom of the page for the answer and critique.


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From ACP InternistWeekly


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Diuretics, statins increased risk of diabetes in high-risk patients

Starting a diuretic or a statin in patients with impaired glucose tolerance significantly increased their risk of developing diabetes, a new study found.

Researchers reanalyzed data from the multinational Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research (NAVIGATOR) trial. They looked at patients who started taking 1 or more of the drug classes for the first time during the study's 5-year follow-up: 915 patients on beta-blockers, 1,316 on diuretics, 1,353 on statins, and 1,171 on calcium-channel blockers (the metabolically neutral control group). Results were published by BMJ on Dec. 9, 2013.

After adjustment for baseline characteristics and time-varying confounders, a significant association with new-onset diabetes was found with diuretics (hazard ratio [HR], 1.23; 95% CI, 1.06 to 1.44) and statins (HR, 1.32; 95% CI, 1.14 to 1.46) compared to the group as a whole. Beta-blockers increased risk of diabetes by an insignificant amount (HR, 1.10; 95% CI, 0.92 to 1.31) and an insignificant decrease in risk was seen with calcium-channel blockers (HR, 0.95; 95% CI, 0.79 to 1.13).

The increase in diabetes found with diuretics and statins is similar to results from previous studies, the authors said, although the current study is larger and highlights the greater risk faced by patients with impaired glucose tolerance at baseline. According to their calculations, 1 additional case of diabetes would occur in 5 years for every 17 such patients given a diuretic and every 12 patients given a statin. Other studies have also shown an increase in diabetes with beta-blockers, and the trend toward an increase in risk found in this study is not inconsistent with that possibility. A larger sample size would be needed to detect an effect from beta-blockers, the authors said.

As an observational analysis, this study is limited by the risk of confounding, although the use of calcium-channel blockers as a control was meant to correct that, the authors noted. The data also did not include information on the specific drug within a class or dosage used, both of which have been previously shown to be factors in diabetes risk. The study's findings should be confirmed in prospective randomized trials, the authors said. In the interim, however, glycemia should be better monitored in patients with impaired glucose tolerance taking these drugs, they recommended.



From Annals of Internal Medicine


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The Consult Guys talk about hyperglycemia

A new video from the Consult Guys, Geno J. Merli, MD, FACP, and Howard H. Weitz, MD, FACP, addresses inpatient glucose control. "Hyperglycemia: Am I a Control Freak?" was released online Dec. 17, 2013.

The Consult Guys, a new service free to ACP Members, bring a new perspective to the art and science of medicine with lively discussion and analysis of real-world cases and situations. This specific episode addresses the appropriate target for blood sugar control in critically ill patients.

For more videos from and information on The Consult Guys, visit the Annals website.



Tool of the month


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Check for diabetes complications

Perform a careful history and physical examination in all patients with hyperglycemia to evaluate for the complications of diabetes.

In the patient history, document key items regarding risk factors for diabetes, history of diabetes, and complications of diabetes, including:

  • Medication history, including the use of antihyperglycemic agents in the past, including during hospitalizations
  • Cardiovascular risk factors
  • Diet and exercise
  • Infections, particularly fungal infections, recurrent urinary tract infections, or non-healing skin infections
  • Other endocrine disorders, including thyroid and adrenal disorders
  • Visual disturbances
  • Neuropathic pain, especially in the feet

In the physical exam, document key items that are manifestations of diabetes or its complications, including:

  • Height and weight for calculation of BMI
  • Blood pressure and pulse
  • Skin exam for acanthosis nigricans or striae
  • Eye exam for retinopathy, macular edema, glaucoma, cataracts (dilated exam should be done by specially trained personnel or by an ophthalmologist)
  • Thyroid exam
  • Cardiac exam
  • Foot exam including sensory exam

This content is from ACP Smart Medicine, the College's new Web-based clinical decision support tool developed specifically for internal medicine physicians. Information about ACP Smart Medicine is online.



Keeping tabs


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Spotlight on diabetic eye disease

The prevalence and treatment of diabetes complications affecting the eye were analyzed by multiple studies published in the past month.

An international report, covering the U.S., France, Germany, Italy, Spain, the United Kingdom and Japan, calculated the prevalence of diabetic retinopathy. Those countries had 4,889,171 cases in 2012, which are expected to increase to 7,176,537 by 2022. The authors of the report by Research and Markets noted that while retinopathy is on the rise, it is not expected to increase at the same rate as diabetes, due to improving medical management of diabetic patients.

Patients diagnosed with diabetic macular edema (DME) were surveyed about their medical care in a study published online Dec. 19, 2013, in JAMA Ophthalmology. The study used data from the National Health and Nutrition Examination Survey to find that only 44.7% of U.S. adults age 40 and over with DME remembered being told by a physician that diabetes had affected their eyes. About 60% of the patients with DME had received an eye examination with pupil dilation in the past year. More than a quarter of the patients with DME were visually impaired at initial evaluation, and 16% had visual impairment even with correction. The results highlight the importance of educating diabetics about eye complications and ensuring they receive proper treatment for eye problems, the authors said.

The best way to treat DME was addressed by another study, a cost-effectiveness analysis published in the Jan. 7, 2014, Annals of Internal Medicine. Researchers used a Markov model to compare laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor and combination therapy. VEGF inhibitor alone or combined with laser treatment provided the greatest benefit, with combination treatment having a slight edge. The only option that didn't reduce costs was laser monotherapy, and the only option that didn't increase quality-adjusted life-years was triamcinolone monotherapy. The choice between VEGF inhibitor monotherapy and adding laser treatment may come down to patient preference, the authors concluded, recommending that primary care clinicians provide patients the information needed to share in this decision. They also noted that the choice of a specific VEGF inhibitor remains controversial.


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MKSAP Answer and Critique



The correct answer is A. Insulin glargine once daily and insulin aspart before each meal. This item is available to MKSAP 16 subscribers as item 63 in the Endocrinology section. Information about MKSAP 16 is available online.

This patient should begin receiving insulin glargine (once daily) and insulin aspart (before each meal) after surgery. A patient with long-standing type 1 diabetes mellitus makes no endogenous insulin and needs a flexible insulin regimen that includes half his daily requirements as a basal insulin (such as insulin glargine) and the rest as boluses of rapid-acting insulin (such as insulin aspart) before meals.

Neither intravenous nor subcutaneous insulin infusions are necessary in this patient, and both would likely require his transfer to the intensive care unit for safe administration.

Given his unpredictable levels of activity and eating while in the hospital, restoring the patient's previous outpatient dosage of premixed insulin is inappropriate.

A sliding scale that does not include basal insulin and does not begin insulin administration unless the blood glucose level is at or above 150 mg/dL (8.3 mmol/L) will cause wide swings from hyperglycemia to hypoglycemia and thus is inappropriate treatment for this patient.

Key Point

  • A sliding-scale insulin regimen that includes no basal insulin is inappropriate for a hospitalized patient with diabetes mellitus.

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A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is adherent to her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most appropriate next step in management?

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