Diabetes diagnosis

current guidelines in diagnosis of diabetes

1. CURRENT GUIDELINES IN THE DIAGNOSIS OF DIABETES RAMYAPRASAD

2. TOPICS DEFINITION CLASSIFICATION- TYPES - STAGES DIAGNOSTIC TESTS FOR DIABETES CRITERIA FOR DIAGNOSIS OF DIABETES PREDIABETES CRITERIA FOR TESTING IN ASYMPTOMATIC ADULTS CRITERIA FOR TESTING IN ASYMPTOMATIC CHILDREN

3. DEFINITION Diabetes Mellitus is recognised as being a syndrome, a collection of disorders that have hyperglycemia and glucose intolerance as their hallmark, due either to insulin deficiency or to impaired effectiveness of insulin’s action, or to a combination of these.

4. CURRENT CLASSIFICATION OF DIABETES TYPES : - TYPE 1 : (beta cell destruction, usually leading to absolute insulin deficiency) - Autoimmune - Idiopathic - TYPE 2 : (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with or without insulin resistance)

5. OTHER SPECIFIC TYPES : Genetic defects of beta cell function Genetic defects in insulin action Diseases of the exocrine pancreas Endocrinopathies Drug or chemical induced Infections Uncommon forms of immune mediated diabetes Other genetic syndromes sometimes associated with diabetes GESTATIONAL DIABETES

6. STAGES : - Normoglycemia / Normal glucose tolerance - Hyperglycemia : - Impaired glucose tolerance and/or impaired fasting glucose - Diabetes mellitus : - Not insulin requiring - Insulin: for control - Insulin: for survival

7. DIAGNOSTIC TESTS FOR DIABETES A1C Fasting plasma glucose 2 hours plasma glucose after a 75 g oral glucose tolerance test Random plasma glucose ( The same tests will also detect PREDIABETES)

8. CRITERIA FOR DIAGNOSIS OF DM 4 OPTIONS 1. A1C >= 6.5% 2. Fasting plasma glucose >= 126 mg/dl (7 mmol /l) (fasting defined as no caloric intake for >=8 hours) 3. 2-hr plasma glucose >=200 mg/dl during OGTT (75 g) performed as described by the WHO, using glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water

9. 4. Random plasma glucose >= 200 mg/dl, in persons with the symptoms of hyperglycemia or hyperglycemic crisis. In the absence of unequivocal hyperglycemia, results should be confirmed using repeat testing. Unless clinical diagnosis is clear, same test to be repeated using a new blood sample for confirmation. 2 discordant results? Result above cutpoint should be repeated

10. CRITERIA FOR TESTING IN ASYMPTOMATIC ADULTS Considered in all adults who are overweight or obese (BMI >=25 or >=23 in Asian Americans) & who have >=1 diabetes risk factor

11. DIABETES RISK FACTORS Physical inactivity First degree relative with diabetes High risk race/ethnicity Women who delivered a baby >9lb or were diagnosed with GDM HDL-C < 35 mg/dl +/- TG > 250 mg/dl Hypertension (140/90 mmhg or on therapy) A1C >= 5.7%, IGT or IFG on previous testing CVD history Conditions associated with insulin resistance- severe obesity, acanthosis nigricans , PCOS

12. Testing should begin at age 45, especially if the individual is overweight or obese If normal results: repeat testing in >=3year intervals, with consideration of more frequent testing depending on earlier results( prediabetes – yearly ) and risk status.

13. PREDIABETES Term used for individuals with impaired fasting glucose and/or impaired glucose tolerance Risk factor for diabetes and CVD Associated with obesity (abdominal/ visceral), dyslipidemia with high TG and/or low HDL, and hypertension.

14. PREDIABETES TESTING Done using A1C, FPG or 2-hour PG after 75 g OGTT. Identify and treat other CVD risk factors Prediabetes testing should be considered in children and adolescents who are overweight/obese and have >=2 diabetes risk factors

15. PREDIABETES CUTPOINTS A1C : Increased risk (ADA) : 5.7 % to 6.5 % High risk : 6.0 % to 6.5 % Impaired fasting glucose : 110 to 125 mg/dl 100 - lower cutpoint as per ADA Impaired glucose tolerance : 2 hour post glucose load : 140 - 199

16. CRITERIA FOR TESTING IN ASYMPTOMATIC CHILDREN Overweight (BMI 85 th percentile for age & sex, wt for ht, 85 th percentile for wt, 120 % of ideal for height ) Plus any 2 of the following : - Family history of type 2 diabetes in first or second degree relative - Race/ethnicity - Signs of insulin resistance or conditions associated with insulin resistance ( acanthosis nigricans , hypertension, dyslipidemia , polycystic ovarian syndrome or small for gestational age ) - Maternal history of Diabetes/GDM during the child’s gestation

17. Age of initiation : age 10 years or at the onset of puberty, if puberty occurs at younger age Frequency : every 3 years

18. A1C Lowering its level helps in reduction of microvascular complications ( also macrovascular , if treatment administered early) Advantages : - Greater convenience ( fasting not required) - Greater pre analytical stability - less day to day perturbations during stress and illness

19. A1C Disadvantages : - Greater cost - limited availability - its incomplete correlation with average blood glucose in certain individuals - age, race/ethnicity and all RBC affecting conditions including anemia, hemoglobinopathies , pregnancy, blood loss, erythropoietin therapy, etc., should be given consideration.

20. Type 1 diabetes : incidence and prevalence is increasing - autoimmune markers ( islet cell antibodies, autoantibodies to GAD (GAD65), autoantibodies to the tyrosine phosphates IA-2, IA-2b, autoantibodies to zinc transporter 8, etc., ) - relatives of those with type 1 diabetes should be subjected for risk assessment (but only in the setting of clinical research study ), as early diagnosis may limit acute complications and extend long term endogenous insulin production.

21. Certain medications, such as glucocorticoids , thiazide diuretics, atypical antipsychotics, which are known to increase the risk of diabetes, should be considered before ascertaining the diagnosis of diabetes.

22. Thank you

23. A1C TESTING - FREQUENCY Atleast 2 times each year : In individuals meeting treatment targets and have stable glycemic control Quarterly : In individuals whose therapy has changed or who are not meeting glycemic targets A1C testing allows for more timely treatment changes.

24. GLYCEMIC TARGETS NONPREGNANT ADULTS WITH DIABETES A1C : <7 % Lowering below or around 7% has been shown to reduce microvascular complications, macrovascular disease (if implemented soon after diagnosis) Preprandial capillary PG : 80-130 mg/dl

25. Peak postprandial capillary PG < 180 mg/dl Postprandial glucose measurements should be made 1-2 hours after the beginning of the meal

26. Individualize targets based on : Age/life expectancy Comorbid conditions Diabetes duration Hypoglycemia status Individual patient considerations Known CVD/ advanced microvascular complications

27. More or less stringent targets may be appropriate if can be achieved without significant hypoglycemia or adverse events.

28. MORE STRINGENT TARGET (<6.5 % ) : - Short duration of diabetes - Long life expectancy - No significant CVD/vascular complications

29. LESS STRINGENT TARGET (<8 % ) - Severe hypoglycemia history - Limited life expectancy - Advanced microvascular or macrovascular complications - Extensive comorbidities - Long term diabetes in whom general A1C target difficult to attain