Classification & Diagnosis of Diabetes

Classification & Diagnosis of Diabetes.pptx
By Dr. Usama Ragab Youssif

Lecturer of Internal Medicine Zagazig University

Email: [email protected], [email protected]
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: [phone]

1. Diagnosis and Classification of Diabetes Usama Ragab Youssif, MD Lecturer of Medicine - Zagazig University Member of ESMA Email: [email protected] , [email protected] SlideShare: https://www.slideshare.net/dr4spring/ Facebook : https://www.facebook.com/doc.usama Facebook Clinic : https://www.facebook.com/usamaclinic Mobile: [phone] Egyptian Society of Metabolic Syndrome (ESMA) World Diabetes Day Celebration 2023 16 NOV 2023 – Sharkia Medical Syndicate

2. Cost related to diabetes Dr. Usama Ragab Youssif 2

3. Represents 2 million people. Diabetes is mostly (85–95%) T2D. 1 T2D approximately doubles the risk of death 2 Diabetes caused 6.7 million deaths in 2021 1 CVD is the principal cause of death in T2D 2,3 1.76 1.85 1 1.5 2.0 T2D is increasingly prevalent and CVD is the leading cause of death in this population 3 1. IDF Diabetes Atlas, 2021. 10th Edition. http://www.idf.org/diabetesatlas. 2. Nwaneri et al. Br J Diabetes Vasc Dis 2013;13:192–207. 3. Morrish et al. Diabetologia 2001;44( suppl 2):S14–21. Globally, 537 million people are living with diabetes 1 Rising to 783 million by 2045 1 Relative risk for all-cause mortality Relative risk for CV mortality

4. Diabetes in Middle-East and North Africa

5. Top 10 countries with diabetes In adults aged 20 – 79 years and diabetes-related health expenditure, 2021 10

6. Top 10 countries or territories for number of adults (20–79 years) with diabetes in 2021 and 2045

7. Definition

8. Many definitions BUT Blood glucose still the basis for diabetes diagnosis

9. Concept of classification

10. Diabetes can be classified into the following general categories Type 1 diabetes Type 2 diabetes Specific types of diabetes due to other causes Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation) Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

11. Type 1 vs Type 2 DM Completely different

12. Type 1 DM

13. Classification and Diagnosis of Diabetes Introduction and Methodology: ElSayed NA, Aleppo G, Aroda VR, et al., American Diabetes Association. Introduction and methodology: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S1–S4 13 Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

14. Type 1 Diabetes Classification and Diagnosis of Diabetes 2.5 Screening for presymptomatic T1D using screening tests that detect autoantibodies to insulin, glutamic acid decarboxylase (GAD), islet antigen 2, or zinc transporter 8 is currently recommended in the setting of a research study or can be considered an option for fi rst-degree family members of a proband with type 1 diabetes . B 2.6 Development of and persistence of multiple islet autoantibodies is a risk factor for clinical diabetes and may serve as an indication for intervention in the setting of a clinical trial or screening for stage 2 type 1 diabetes . B Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

15. Type 2 DM

16. Sometimes diabetes cannot fit onto certain category T1D before 6 months of age Young obese child Young NON obese, NON catabolic, MILD, with family history Diabetes developing after intervention

17. Specific types of Diabetes Genetic defects of beta -cell function = monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young) Genetic defects in insulin action e.g., insulin dystrophy Diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis) Drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation) Endocrinopathies e.g., Cushing syndrome… Genetic syndromes associated with diabetes e.g., Down syndrome

18. Monogenic diabetes Certain genetic defect Mostly AD Defect leads to abnormal beta cell function Different types Includes neonatal diabetes and MODY

19. The diagnosis of monogenic diabetes should be considered in children and adults diagnosed with diabetes in early adulthood with the following

20. *Neonatal diabetes is a form of diabetes with onset <6 months of age, requires genetic testing, and may be amenable to therapy with oral sulfonylurea in place of insulin therapy Clinical features Type 1 diabetes Type 2 diabetes Monogenic diabetes Age of onset (yrs) Most <25 by can occur at any age (but not before the age of 6 months) Usually >24 but incidence increasing in adolescents, paralleling increasing rate of obesity in children & adolescents Usually <25 Neonatal diabetes <6 months* Weight Usually thin, but with obesity epidemic, can have overweight or obesity >90% at least overweight Similar to general population Islet auto-antibodies Usually present Absent Absent C-peptide Undetectable/low Normal/high Normal Insulin production Absent Present Usually present First line treatment Insulin Non-insulin antihyperglycemic agents, gradual dependence on insulin may occur Depends on subtype of MODY Family history of diabetes Infrequent (5-10%) Frequent (75-90%) Multigenerational, autosomal pattern of inheritance DKA Common Rare Rare (except for neonatal diabetes*) 2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome 2018

21. Pancreatic diabetes Commonly misdiagnosed as T2D Has been called “type 3c diabetes” or pancreoprivic diabetes Easily use pancreatic diabetes as umbrella term Due to loss of structural and functional insulin secretion in context of exocrine pancreatic dysfunction It includes: Pancreatitis (acute and chronic), trauma or pancreatectomy, neoplasia, fibrocalculous pancreatopathy idiopathic forms

22. Post Pancreatitis Diabetes Mellitus (PPDM)

23. Cystic fibrosis–related diabetes (CFRD) Moran A, et al. Pediatr Diabetes 2018;19(Suppl. 27):64–74

24. Cystic fibrosis–related diabetes

25. Pregnancy

26. Diabetes in Pregnancy: 2 Categories Pregestational diabetes Gestational diabetes Pregnancy in pre-existing diabetes Type 1 diabetes Type 2 diabetes Diabetes diagnosed in pregnancy 2018 Diabetes Canada CPG – Chapter 36. Diabetes and Pregnancy

27. Universal screening for GDM @ 24-28 weeks gestational age Screen earlier if risk factors for GDM 2018 Diabetes Canada CPG – Chapter 36. Diabetes and Pregnancy Gestational Diabetes (GDM) Screening

28. Screening of GDM

29. One-step Strategy

30. Two-step Strategy

31. Because the old definition is sometimes having limitations

32. سكر خفيف

33. Diagnostic pathway for Diabetes in Pregnancy

34. Diagnosis of Diabetes

35. Classification and Diagnosis of Diabetes Introduction and Methodology: ElSayed NA, Aleppo G, Aroda VR, et al., American Diabetes Association. Introduction and methodology: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S1–S4 37 Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

36. Confirmatory test NOT required In the case of symptomatic hyperglycemia , the diagnosis has been made and a confirmatory test is not required before treatment is initiated. To avoid rapid metabolic deterioration in individuals in whom type 1 diabetes is likely (younger or lean or symptomatic hyperglycemia, especially with ketonuria or ketonemia), the initiation of treatment should not be delayed in order to complete confirmatory testing 2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome 2hPG, 2-hour plasma glucose; AlC , glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose.

37. Considerations when using A1C for Diagnosis Need validated standardized assay Repeat confirmatory test on another day Recognize conditions leading to misleading A1C A1C is not used for diagnosis in children, adolescents (as the sole diagnostic test), pregnant women as part of routine screening for GDM, those with cystic fibrosis (CFRD) or those with suspected T1DM Ethnicity and age can affect A1C results 2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome

38. Pitfalls of A1c Radin MS. Pitfalls in hemoglobin A1c measurement: when results may be misleading. J Gen Intern Med. 2014 Feb;29(2):388-94.

39. Pros and Cons of Diagnostic Tests Test Advantages Disadvantages FPG Established standard Fast and easy Single Sample Sample not stable Day-to-day variability Inconvenient to fast Glucose homeostasis in single time point 2hPG in 75 g OGTT Established standard Sample not stable Day-to-day variability Inconvenient, Unpalatable Cost A1C Convenient Single sample Low day-to-day variability Reflects long term glucose $$$ Affected by medical conditions, aging, ethnicity Standardized, validated assay required Not applicable to every patient type 2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome A1C, glycated hemoglobin; FPG, fasting plasma glucose; PG, plasma glucose

40. Dealing with discordance in results Many people identified as having diabetes using A1C will not be identified as having diabetes by traditional glucose criteria, and vice versa. When results of more than one test are available (FPG, A1C, 2hPG in a 75-g OGTT) and the results are discordant, the test whose result is above diagnostic cut-point should be repeated, and the diagnosis made on basis of the repeat test. FPG 2hPG A1C 2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome A1C, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose

41. Health Day A1c 2.1b Point-of-care A1C testing for diabetes screening and diagnosis should be restricted to U.S. Food and Drug Administration – approved devices at laboratories pro fi cient in performing testing of moderate complexity or higher by trained personnel. B

42. Years from diagnosis 5 -10 -5 10 15 Onset Diagnosis Insulin secretion Sources: Ramlo -Halsted BA et al. Prim Care. 1999;26:771-789 Nathan DM et al. NEJM 2002;347:1342-1349 Fasting glucose Insulin resistance Microvascular complications Macrovascular complications Type II diabetes Pre-diabetes Postprandial glucose Natural History of Type II Diabetes Mellitus

43. https://www.cdc.gov/diabetes/library/socialmedia/infographics/prediabetes.html

44. Classification and Diagnosis of Diabetes Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

45. Criteria for screening for diabetes or prediabetes in asymptomatic adults Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

46. Prediabetes and Type 2 Diabetes Classification and Diagnosis of Diabetes 2.10 If tests are normal, repeat screening recommended at a minimum of 3-year intervals is reasonable, sooner with symptoms or change in risk (i.e., weight gain). C 2.11 To screen for prediabetes and type 2 diabetes, fasting plasma glucose, 2-h plasma glucose during 75-g oral glucose tolerance test, and A1C are each appropriate. B 2.12 When using oral glucose tolerance testing as a screen for diabetes, adequate carbohydrate intake (at least 150 g/day) should be assured for 3 days prior to testing. A

47. Classification and Diagnosis of Diabetes Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023 . Diabetes Care 2023;46(Suppl. 1):S19-S40

48. To sum-up Diabetes= Prediabetes= Types of diabetes= T1D= T2D= GDM=

49. Thanks Email: [email protected] , usama.ragab.zu@gmail. com SlideShare: https://www.slideshare.net/dr4spring/ Facebook : https://www.facebook.com/doc.usama Facebook Clinic : https://www.facebook.com/usamaclinic Mobile: [phone]