1. ADA guidelines for screening for diabetes

-Screen everyone over age 45

-Screen people under age 25 if they have a BMI>25 and one risk factor-- CAD, family history of diabetes, non Caucasian race. 

2. Diagnosis of diabetes: 

-Clinical symptoms of diabetes + a random glucose over 200 is immediately diagnostic of type II DM.

-All other tests for DM (fasting glucose, random glucose, Hb A1C, etc) need to be done twice on two separate occasions. 

3. Workup after first diagnosis of diabetes:

-ADA recommends getting an ekg at diagnosis to look for old MIs (q waves), and to set a baseline. 

-Look at protein in urine with urine microalbuinuria to cr ratio. Treat microalbuinuria with ACE.

4. Following severity of DM:

-An A1C of 6 is an avg sugar of 120, every one point higher on A1C is 30 points higher on glucose 

-Goal A1C <7 for most people, <8 for people with lots of comorbidities because its more dangerous to drop their sugars. 

-There is some evidence that attempting to get A1C below 6.5 or 6 may lead to increased hospitalizations 

-Goal sugars: 80-100 fasting, 100-140 postprandial (2 hrs after meals). For people with really badly controlled DM or people who you really don't want to be hypoglyclemic, you can have a goal of 100-120 fasting. 

5. Treating Diabetes: 

-Diet and exercise usually can drop A1C at most by 1-1.5 points, so it's not indicated in people with severe disease. Aim for 45-60 grams of carbs per meal. 

-Metformin is first line, causes weight loss (good for PCOS girls to lose weight), diarrhea/nausea 

-If that's not enough, then you add a sulfonylurea (need to have glucometer to check because it can push you into hypoglycemia) glipizide is more commonly used than glyburide. 

-If that's not enough, third line is DPP4 inhibitor if they can afford it, if they can't afford it then you go straight to insulin. 

-If that's not enough, then you start on basal Insulin: 0.2 units/kg/day basal (glargine aka lantus $15 for one month supply)

-If that's not enough, then you add prandial Insulin: 0.2 U/kg/day per day split between their meals. One good point to add prandial insulin is if their fasting sugar is normal but their overall glucose control is poor. You can also have an insulin sliding scale that depends on carb consumption 

-How to titrate insulin: have them start at their usual dose at night, and measure the fasting glucose the next morning. If glucose is 120-200, add 1 unit the next night. If glucose is 200-300, add 2 units the next night. If glucose is >300, add 3 units the next night. 

6. Diabetes in older people & people with ESRD:

-Diabetes tends to get worse with age 

-Older people have poorer renal function, and insulin is renally cleared, so whatever insulin you give them will have a longer-lasting, stronger effect than in a young person. Same for ESRD.

-Metformin is also renally cleared, so it's contraindicated in anyone with a Cr > 2.5

7. Diabetes and blood pressure: 

-ADA says aim for 130/80, or 140/90 if you can't get lower safely

-JNC 8 says 140/90 for everyone under 60, regardless of whether they are diabetic or not. 

8. Preventative care in someone with well controlled DM: 

-See PCP q6 months for diabetes checks. 

-Opthomology visit with dilated eye exam every year. 

-Pneumovax once before 65 and once after, 5 years apart (non-diabetics only need one after 65) people who are immunocompromised or have chronic lung dx need the same as diabetics. 

-Tdap once, then Td booster every 10 years

9. Refer to endocrine if someone is a really brittle diabetic, i.e. A1C is high but they have frequent significant hypoglycemic episodes. 

10. End of life care: 

-Executive PoA- finances, estate 

-Healthcare PoA- healthcare decisions

-Surrogate act of IL ranking of who gets to be the decision maker: 

Guardian > spouse > adult children > parents > adult siblings > adult grandchildren > close friend of patient > guardian of estate > courts