University of Vermont Project ECHO SessionNewly Diagnosed Type 2 DM

Types of Diabetes

Kaitlyn Barrett, DOAugust 13, 2020

Our goal:

• Empower primary care providers to address the needs of patients with type 1 and type 2 diabetes in their communities where access to routine specialty care may not be immediately available

• Provide the basic tool set for managing and treating patients with diabetes

Diabetes Report Card: Comprehensive Diabetes Care

Objectives

• Diabetes Classifications• Pathophysiology of Type 2• Diagnostic Tests• Screening• Initial Evaluation

Diabetes Classification

• Type 1 Diabetes- autoimmune B-cell destruction, usually leading to absolute insulin deficiency

• Autoimmune• Islet cell auto- antibodies

• Idiopathic

• www.diabetestrialnet.org

Type 1 Diabetes

Latent Autoimmune Diabetes of Adulthood (LADA)

• Slowly progressive autoimmune diabetes with adult onset

• Rate of beta cell destruction is variable

• Insulin is often not required for at least 6 months after diagnosis

• Adult age of onset

ADA 2020

C-peptide levels after IV Glucose and Glucagon

Latent Autoimmune Diabetes in AdultsGunnar Stenström, Anders Gottsäter, Ekaterine Bakhtadze, Bo Berger, Göran SundkvistDiabetes Dec 2005, 54 (suppl 2) S68-S72; DOI: 10.2337/diabetes.54.suppl_2.S68

Classifications Cont.

• Gestational Diabetes-Diagnosed during the second or third trimester and not clearly overt prior to gestation

• Specific types of diabetes due to other causes:

• Monogenic diabetes syndromes (such as neonatal diabetes and MODY)

• Disease of the exocrine pancreas (CF and pancreatitis)

• Drug or chemical induced (glucocorticoid use, PTDM)

ADA 2020

Type 2 Diabetes

How do we Differentiate?

Challenges:• DKA can develop in type 2 patients in the setting of severe infection or other illness• Patients with type 1 diabetes may have pathophysiologic elements of type 2 diabetes• LADA patients will also have antibodies and do not initially require insulin

• Consider antibody testing in the following patients: age of onset <50 years, acute symptoms, BMI <25 and personal history of autoimmune disease

• Insulin should be started in any patient who is catabolic or has evidence of ketogenesis

Diagnosis and Screening

Diagnostic Tests for Diabetes

• Marked discordance between measured A1c and plasma glucose should raise to possibility of A1c assay interference due to hemoglobin variants (i.e., hemoglobinopathies)

• Compared with FPG and A1c cut points, the 2-h PG value diagnoses more people with prediabetes and diabetes

ADA 2020

Screening

ADA 2020

Initial Management

Achieving Early Glycemic Control Leads to Better Outcomes

• Avoid delays in therapy intensification for people not meeting glycemic targets

Holmon RR, et al. N Engl J Med, 2008.;UKPDS 33. Lancet. 1998; 352:837-853.

• Discuss progressive nature of type 2 diabetes and the need for progressive therapy

• Reinforce the connection between achieving targets early and long-term health

• Mutually set individualized glycemic and HbA1c targets

• Utilize glycemia data to inform therapy changes

ADA 2020

ADA 2020

Components of the Comprehensive Diabetes Medical Eval

• Diabetes History• Characteristics at onset (e.g. age, symptoms)• Review of previous treatment regimens and response• Assess frequency/cause/severity of past hospitalizations

• Family History• ?diabetes in a first degree relative, ?fam history of an autoimmune

condition

• Personal history of complications and common comorbidities• Macrovascular and microvascular• Common comorbidities (e.g. obesity, OSA)• Hypoglycemia awareness/frequency/causes/timing• High BP, lipid abnormalities• Last dental visit• Last dilated eye exam

Medical Eval Cont.

• Lifestyle Factors• Eating patterns and weight history• Physical activity and sleep behaviors• Tobacco, alcohol and substance use

• Medications and Vaccinations

• Technology Use• Glucometers, CGM• Insulin pumps

Physical Examination and Laboratory Eval

• Physical Examination• Fundoscopic examination –refer to eye specialist, yearly• Skin examination –acanthosis nigricans, insulin injection or insertion sites,

lipodystrophy• Foot examination

• Skin integrity, foot deformity or ulcer• Determinatino of temp, vibration or pinprick sensation and 10 g monofilament exam

• Laboratory Evaluation• Annual lipid panel, spot urine microalbumin, creatinine• TSH, celiac panel with GI symptoms- in patients with type 1 • A1c q3- 6mo

Targets: A1c vs Time in Range?

• Time in range: the percentage of time glucose levels are between 70-180 mg/dl per unit of time

• Many platforms for remote data monitoring• Glooko• Tidepool

First Visit “Musts”

• Set the standards- diabetes overview, A1c goal

• Schedule a CDE Visit

• Provide a glucometer

• Start treatment

• Initial labs

• ?Discuss diabetes technology

Resources for Primary Care Doctors

• MyhealthVT.org• Diabetes Prevention Workshop- 16

weeks and then monthly maintenance sessions x 1 year

• Prediabetes• Free!

• Diabetes Management• 6 weeks