Diabetes Mellitus and Type 2 Diabetes: Diagnosis & Management – Family Medicine | Lecturio


diabetes mellitus is the most common

diagnosis in my practice so I feel like

I know it really well and I think I've

got some good information and gave you

particularly regarding diagnosis and

management so let's get underway so I've

got a patient he's 60 years old he's got

hyperlipidemia and obesity

yeah recent routine lab analysis found

the serum glucose level was 146

milligrams per deciliter he's a stuntman

at this time what's the next best step

in his care should we talk about

lifestyle changes and recheck his

glucose along with a hemoglobin a1c

level in the next several weeks

should we start metformin now or a

sulfonylurea or a dipeptidyl peptidase-4

inhibitors what do you think given his

lack of symptoms and that glucose level

we're mandated to recheck his glucose

level and I would check an a1c to

because with his risk factors sounds

like he probably has diabetes of course

you're gonna advise him on lifestyle

changes now and so that makes sense he

does not have meet the formal criteria

for diabetes as of yet but many people

do overall there there are now more than

20 million Americans with type-2

diabetes and this number is expected to

more than double within the next 20

years or so so should we be screening

for diabetes well this is what the

United States Preventive Services Task

Force or USPSTF says among adults aged

40 to 70 years which is kind of the

sweet spot for identifying diabetes

check for either glucose or a1c either

one's a valid measure among patients who

are obese and among those with a family

history of diabetes high risk racial or

ethnic groups which include Latinos and

African Americans and what if the

patient has a history of gestational

diabetes or polycystic ovary syndrome

those patients get screened - lots of

people meet the screening criteria you

can apply that fairly broadly across a

population so how do we diagnose diet

so it's a serum glucose level of 126

milligrams per deciliter or seven

millimoles per liter on two separate

occasions and also glucose in the urine

can be supportive as well but I think

really we use serum markers too to

identify diabetes or it could be an

hba1c of 6.5 percent or more on two

separate occasions but if a patient

comes in with fatigue and polyuria and

polydipsia and you check their glucose

in the clinic and it's over 200

milligrams per deciliter no further

testing is necessary they have diabetes

of course those patients will get a

baseline hba1c level right away as well

so I think this is good for a patient

care and also good for what may come up

on your exam this is the routine

evaluation for patients with diabetes

with a schedule so patient with type 2

diabetes get there an automatic exam

right away when they're diagnosed with a

dilated pupil for a retinal exam and

then there that's followed at least

annually the hba1c if it's well

controlled can be every six month poorly

controlled every three months a complete

foot exam with monofilament testing at

least every year lipids at least every

several years I probably draw them more

often a urine micro album and creatinine

ratio at the time of diagnosis and then

annually and then blood chemistries and

renal function at least every six months

all those things fairly straightforward

makes sense most of my patients are

achieving those goals now we do an hba1c

level and turns out 8.2 percent

so besides lifestyle intervention what's

the best treatment to prescribe for this

patient now

is it a glipizide B liraglutide C a

basal insulin at night or D metformin

and in previous years you could make an

argument you know so which one might be

better now it's fairly clear and the

American Diabetes Association recommends

along with the American Association of

Clinical Endocrinology metformin is a

foundational drug for diabetes so we'll

talk about different interventions

for diabetes with medicines in a second

but you always start with lifestyle

first because just think about it a

multidisciplinary team can promote

weight loss of up to 9% among patients

with diabetes and that's gonna reduce

the need to use anti diabetes drugs and

I know apprehensive drugs as well

physical activity is about as good as a

one of the weaker oral agents for

reducing hba1c and diet advice is

similar it can reduce the hba1c by

another half to one percent for most

people and it probably is better when it

comes from somebody with experience in

counseling patients like a dietician or

a surfeit certified diabetes educator

versus a physician who's trying to

manage 20 things at once look a little

pearl regarding home glucose testing we

recommend this broadly and probably a

little too broadly just in terms of

stewardship of resources because it can

get expensive to get new machines to get

the lancets to get the test strips it's

most helpful for patients with severe

diabetes who are taking insulin it

hasn't really been shown to make much of

a difference among patients who are

fairly well controlled on oral

medications especially those early in

their illness and it doesn't necessarily

change quality of life where I might use

it in a patient who's on oral

medications alone is pay our patients

with highly fluctuating glucose going

very high and then at risk of

hypoglycemia for somebody who's chugging

along and taking only metformin and

their hba1c is six point eight to six

point six percent every time I check it

you know there's not really much of a

need to do any any home blues glucose

testing at all so something to think


now I mentioned metformin is the

first-line agent why there's a low risk

of hypoglycemia hypoglycemia and it's

danger has become a lot more apparent

over the past few years and we'll talk

about some agents that promote low sugar

it's usually associated with a very

modest weight loss it doesn't create the

cycle of more weight gain therefore more

insulin resistance and then more need

for drugs

and the big complication with metformin

that everybody worries about is lactic

acidosis that's right and it's more

common among patients with severe kidney

disease but now the the new rules and

warnings on the drug state that it can

be used for certain patients all the way

down to a glomerular filtration rate of

30 millimeters per minute so that's kind

of remarkable in it and a big change

getting metformin to more patients who

need it so far Ria's have been around a

long time

like metformin they're inexpensive and

like metformin they promote about the

same degree of hba1c reduction if you

ever get stopped and have to answer in

like half a second okay how much does

this drug reduce this oral drug reduce

hba1c 1% is always a good answer because

they tend to be around that level but

the problem with Sophia is is they can

promote hypoglycemia and weight gain and

therefore may be less favored there's

also an unknown effect whether they

improve mortality or not newer agents

now dipeptidyl peptidase-4 inhibitors

these are I think the benefit to these

drugs is they're really well tolerated

they're fairly easy to use don't promote

a lot of hypoglycemia a low rate of side

effects overall they can even be used in

moderate renal dysfunction as well the

drawback they're not that effective so

they're good for patients were right

next to goal maybe with metformin but

can't quite get there but they also have

intolerance to multiple drugs you know a

dpp-4 inhibitor could be a good idea for


as Aladin Deion's all 0 only

rosiglitazone is available in the United

States these drugs can promote weight

gain which is partly water weight they

can promote edema patients with history

of bladder cancer or osteoporosis should

not be using these drugs and then reduce

hba1c by about 1% so there's still have

some role but it's probably a more

limited secondary role in the management

of most cases of type 2 diabetes what

about the glucagon-like peptide one

receptor agonist so these are different

drugs these are again even a newer wave

they've been out for several years now

so it's important for us to know them

different dosing schedules but they're

not there's no oral product out there

right now they're subcutaneous

injections they rarely are associated

with pancreatitis and you can't use them

among patients with the most severe

chronic kidney disease but they can't be

used in moderate kidney disease the

beneficial effects of glp-1 agonists

they can promote weight loss sometimes

it exceeds six or seven kilograms it

routinely it's going to be at least four

kilogram so weight loss is important and

something that patients can really hold

on to it's not easy to lose four

kilograms of body weight for many

patients and there hba1c action is a

little bit stronger than other oral

agents so between the fact that it

promotes weight loss and it reduces a

butt a1c fairly robustly I like glp-1

agonists another new kid on the block

the sodium-glucose cotransport or two or

sglt2 inhibitors these inhibit glucose

reuptake they work in the kidneys they

have been associated with a higher risk

for UTI as well as genital fungal

infections these also promote weight

loss though as well as they lower blood

pressure and of themselves - again a

little bit weaker though for their hba1c

reduction so not not something not that

strong reduction you might experience

with a glp-1 agonist say the patient's

not doing that well and continues to

maintain a high a1c despite your best

medical therapy so patients who come in

with an HB hba1c above nine can be

considered for insulin in my practical

experience most most clinicians aren't

thinking about using insulin right off

the bat unless they come in with an a1c

of eleven or more but one thing that's

certainly true is patients who are

failing badly and taking to oral

anti-diabetes drugs there's not much

point in putting them on a third oral

diabetes drug at that point it's time to

reconsider therapy and include insulin

in that regimen the problem with insulin

is there's just a lot of variability how

often the patient uses it their diet how


they are to checking their home glucose

how involved their health literacy all

these things factor in the efficacy of

insulin it's it's frankly probably

easier to take a pill but you can start

with something basic like augmentation

of their usual therapy with basal


there's the dose point three units per

kilogram per day that's this is really

where you want it if you haven't

initiated doing home glucose monitoring

you're gonna want to initiate home

glucose monitoring and telling it

warning the patient about hypoglycemic

symptoms and how to react because of

course that's one of the downsides of

insulin treatment it is a nice

opportunity in my opinion to check on

lifestyle because you can follow along

and you notice when they go when the

patient goes high with their glucose

readings at home when they go low what

what happens oh that's the day exercise

that's the day I forgot to eat or when

it's high oh that was a big party I went

to and I kind of went nuts and ate

whatever I wanted that's why my glucose

was 450 so it can give you some insights

into how to counsel patients about you

know because lifestyle never leaves just

because the patient goes through

diabetes education classes and meets

with an NGO an educator a Promotora or

whatever it's you know it's never quite

over you have to keep up that lifestyle

and importantly once you initiate

insulin treatment don't let go of

metformin foundational drug and can help

mitigate against the weight again you're

going to experience with insulin but

sulphide Riyaz once you start a prandial

insulin there's not much point in using

yourself on areas anymore get them off

because they might promote hypoglycemia

weight gain and hypoglycemia is a

serious risk so really monitor it


keep these levels in mind goal glucose

levels for fasting patients 90 to 130

milligrams of per deciliter for

postprandial less than 180 milligrams

per deciliter okay so with that happy to

that that to give you that overview on

diabetes care I think the keys are get

the diagnosis right and usually requires

a couple of readings to do so also never

forget lifestyle and try to keep the

patient on metformin as much as possible

because it really is a game changer of a

drug and can take time to work its


make sure they get their screening on a

routine basis for their eyes and for

their feet as well as for kidney disease

with the microglia and creatinine ratio

and you should should have some very

satisfied and healthy patients Thanks