SOAP. – Diabetes Mellitus – SỔ TAY LÂM SÀNG

Diabetes Mellitus

Julie Adkins, Jill C. Cash, Mellisa A. Hall, Cheryl A. Glass, Angelito Tacderas, and Jenny Nelson Mullen

Definition

Diabetes is a group of diseases characterized by high levels of blood glucose with a defect in insulin secretion or action caused by a chronic disorder of carbohydrate, fat, and protein metabolism. There are four categories of diabetes: type 1, type 2, gestational diabetes, and diabetes from secondary causes.

A.Type 1 diabetes, formerly referred to as insulin-dependent diabetes mellitus (IDDM), type 1, or juvenile-onset diabetes, is an endocrine condition in which there is complete destruction of pancreatic beta cells or a complete absence of insulin.

B.Type 2 diabetes, formerly referred to as noninsulindependent diabetes mellitus (NIDDM), type 2, or adultonset diabetes, describes a condition in which individuals have an impairment in insulin production and/or insulin resistance.

C.Gestational diabetes is diagnosed during pregnancy. It usually disappears when the pregnancy is completed. It will increase the woman’s risk of developing type 2 diabetes later in life.

D.Diabetes resulting from secondary causes is due to genetic defects and/or diseases of the pancreas, such as cystic fibrosis. Other causes of this type of diabetes can be drug-/chemicalinduced diabetes from medications or therapies used when treating HIV/AIDS and in patients who receive treatments after organ transplantation.

E.People with diabetes are more prone to have unhealthy low-density lipoprotein cholesterol (LDL-C) and, therefore, are at increased risk for atherosclerotic cardiovascular disease (ASCVD). The incidence of cardiovascular disease (CVD) is two to four times higher in adults with diabetes. The risk of stroke is two to four times higher because 60% to 65% of the patients have hypertension (HTN). In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) published guidelines on the assessment of cardiovascular risk, lifestyle management, and treatment of cholesterol to reduce ASCVD risks. A downloadable spreadsheet enabling estimation of 10-year and lifetime risk for ASCVD and a web-based calculator are available at my.americanheart.org/cvriskcalculator and www.ahajournals.org/doi/abs/10.1161/01.cir.0000437738.63853.7a. These risk tools are used to drive conversations on patient risk factors for ASCVD, potential benefits, and negative aspects of risk and patient preferences regarding initiation of relevant therapies. The assessment of ASCVD risk factors is recommended every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD. Long-term and lifetime risk information may be used to motivate therapeutic lifestyle changes and encourage adherence to lifestyle and pharmacological therapies.

Incidence

A.It is estimated that more than 23 million Americans, or 9.4% of the population, have diabetes. Diagnosed cases account for 23.0 million, with an estimated 7.2 million who have not been diagnosed. Type 1 diabetes accounts for less than 10% of diagnosed cases. The percentage of adults 65 years old and older has reached 25.2%. In 2015 there were approximately 1.5 million new cases among adults ≥18 years, and 50% of those new cases are adults aged 45 to 64 years old.

Pathogenesis

A.Type 1 diabetes is an inherited defect causing an alteration in immunologic integrity, placing the beta cell at risk for inflammatory damage. The mechanism of damage is autoimmune. Environmental factors that may influence the etiology of diabetes include viral illnesses: mumps, coxsackievirus, cytomegalovirus, and hepatitis. Other factors that may influence the disease include diets high in dairy products, emotional and physical stress, and/or environmental toxins.

B.Type 2 diabetes involves impaired insulin secretion, insulin resistance, and/or an abnormally elevated glucose production by the liver. Genetics and obesity are major risk factors.

C.The severity of carbohydrate intolerance in gestational diabetes is unknown. Women identified at risk have screening done during the 24th and 28th weeks of gestation.

D.Genetic defects and medications/chemicals are thought to affect the beta-cell function and alter insulin function. Hemoglobin A1C levels may not be interpreted correctly in patients with blood disorders such as anemia/hemoglobinopathies. See www.ngsp.org/interf.asp for a complete list of laboratory methods recommended to be used to measure glycosylated hemoglobin (HgbA1C) values for patients with hemoglobin variants (sickle cell trait, HbC, HbS, HbE, HbD trait, or elevated HbE).

Predisposing Factors

A.First-degree relative with type 1 or type 2 diabetes.

B.Physical inactivity.

C.Body mass index (BMI) greater than or equal to 27 kg/m².

D.HbgA1C greater than or equal to 5.7%, impaired glucose tolerance (IGT).

E.Native American, Hispanic, Asian, African American, and Pacific Islander heritage.

F.HTN with systolic pressure greater than 140 mmHg and diastolic pressure greater than 90 mmHg.

G.High-density lipoprotein (HDL) level of 35 mg/dL or less and/or triglyceride level of greater than or equal to 250 mg/dL.

H.History of giving birth to babies larger than 9 pounds or gestational diabetes.

I.History of IGT or fasting glucose.

J.Acanthosis nigricans or severe obesity.

K.Women with polycystic ovarian syndrome (PCOS).

L.History of CVD.

M.All patients 45 years or older should be screened for diabetes. If negative, screening should occur every 3 years unless other risk factors develop.

Common Complaints

A.Classic triad of symptoms:

1.Polyuria.

2.Polydipsia.

3.Polyphagia.

B.Weight loss.

C.Lack of energy.

D.Recurrent infections (urinary tract, vaginal, skin breakdown that is slow to heal).

E.Asymptomatic.

Other Signs and Symptoms

A.Weakness.

B.Fatigue.

C.Nausea and vomiting.

D.Abdominal pain.

E.Anorexia.

F.Sexual dysfunction, including impotence or dyspareunia

G.Itching.

H.Visual disturbances.

I.Signs and symptoms related to nephropathy, neuropathy, and/or retinopathy.

Subjective Data

A.Obtain a detailed history regarding onset, duration, and course of presenting symptoms.

B.Question the patient regarding all characteristic signs and symptoms of diabetes.

C.Determine the patient’s nutritional status, 24-hour recall, weight history, and eating patterns.

D.Review the family history of diabetes or other endocrine disorders.

E.Note predisposing factors to diabetes.

F.Review the patient’s social history, including smoking, alcohol, and exercise.

Physical Examination

A.Check pulse, respirations, blood pressure (blood pressure), and weight.

B.Inspect:

1.Observe overall appearance.

2.Perform oral examination. Diabetic patients are prone to thrush, gingivitis, plaque, and infections. A dental examination should be done every 6 months.

3.Complete funduscopic examination. Proliferative diabetic retinopathy is the leading cause of new blindness in adults in the United States. It occurs 60% of the time in those with type 1 and 30% of the time in those with type 2 diabetes. Patients with diabetes are 25 times more at risk for blindness and have four to six times the risk for cataracts and twice the risk for glaucoma.

4.Inspect the skin, including feet, hands, fingers, and insulin injection sites.

C.Auscultate:

1.Auscultate the heart.

2.Auscultate the lungs.

D.Percuss:

1.Percuss the chest, abdomen, and deep tendon reflexes (DTRs).

E.Palpate:

1.Palpate the neck (thyroid).

2.Palpate the abdomen.

3.Palpate the extremities and check pulses.

Diagnostic Tests

A.HgbA1c of 6.5% or higher.

B.Fasting plasma glucose: Greater than or equal to 126 mg/dL. All patients should have a baseline fasting blood sugar (fasting for at least 8 hours) performed at 45 years of age, then repeated every 3 years. The baseline should be performed earlier if any predisposing factors exist.

C.Random plasma glucose: Greater than or equal to 200 mg/dL with symptoms of diabetes.

D.Oral Glucose Tolerance Test (OGTT): After 75 g glucose load, a 2-hour plasma glucose greater than or equal to 200 mg/dL; IGT is a fasting plasma glucose greater than or equal to 126 mg/dL.

According to the Diabetes Control and Complications Trial, a HgbA1c of 7.2% or below decreases the risk of retinopathy, neuropathy, and nephropathy by 50% to 70%.

Differential Diagnoses

A.Diabetes mellitus (DM).

B.Benign pancreatic insufficiency.

C.Pheochromocytoma.

D.Cushing’s syndrome.

E.History of corticosteroid use.

F.Stress hyperglycemia.

G.Acromegaly.

H.Hemochromatosis.

I.Somogyi phenomenon: Early morning hyperglycemia due to very early morning (2:00–3:00 a.m.) hypoglycemia.

Plan

A.General interventions:

1.Establish, review, and evaluate individual goals with the patient on a routine basis.

2.Center goals around normal metabolic control and the prevention and delay of complications while maintaining a flexible, normal, high-quality life.

3.After a new diagnosis is made and treatment has begun, be alert for an initial remission or honeymoon phase with decreased insulin needs and better control that may last 3 to 6 months.

4.Include the following in the treatment plan:

a.Exercise plan:

i.Develop a consistent, individualized exercise plan with the patient to improve insulin sensitivity, blood sugars, weight reduction, and reduction of cardiovascular complications.

ii.Evaluation by a healthcare provider, including a complete physical examination and ECG, must precede any exercise program.

iii.Generally, the goals for physical activity are to reduce LDL-C and non-HDL-C and to lower BP. The exercise should involve moderate-to-vigorous intensity.

iv.Exercise should not be done if the fasting blood sugar is greater than 250 mg/dL and ketones are present in the urine or if the glucose level is greater than 300 mg/dL at any time regardless of the presence of ketones.

v.Because exercise can lower blood sugar concentration, special precautions such as medication adjustment and meal planning should be done before and after exercise if the patient is taking insulin or a glucose-lowering medication.

b.Self-monitoring blood glucose (SMBG): The process of monitoring the patient’s blood gives valuable information to the patient on a daily basis and assists the provider in identifying trends:

i.Several different meters are available with a variety of options. A certified diabetes educator can show examples of different types before the patient purchases one.

ii.Frequency of testing depends on the type of medication the patient is taking and the patient’s compliance and motivation.

iii.Additional testing should be done at times of changes in medication, meal plans, and/or exercise; and during illness or stress.

iv.The Food and Drug Administration (FDA) has approved an automatic blood glucose suspend feature for continuous blood glucose monitoring that is recommended for patients with hypoglycemia unawareness or frequent nocturnal hypoglycemia.

c.Psychosocial support: It is important from the beginning of treatment to give the patient a sense of control:

i.Consistent involvement of family members will influence compliance.

ii.Assess and discuss psychosocial issues at each visit.

B.Patient teaching:

1. See Section III: Patient Teaching Guide Diabetes.

2.Topics in the educational plan include the pathophysiology of diabetes, procedures for SMBG and medication therapies, recognition and treatment of hypoglycemia, and instructions for special situations such as illness and traveling.

3.Include preventive care, instructions for family members, and the importance of wearing a Medic Alert tag.

4.Smoking cessation and avoidance of all tobacco products should be advised to all patients. Counseling regarding smoking/tobacco cessation methods and classes should be offered.

C.Dietary/physical activity management:

1.Nutritional plan: The patient should meet with a dietitian who has experience with diabetes nutritional therapy.

2.Eating patterns and ideal percentage of calories from protein, carbohydrates, and fat should be individualized for each patient and determined along with a dietitian.

3.Involve the family in improving compliance with the individualized meal plan.

4.Overweight/obese patients are encouraged to set a goal of healthy eating strategies to enhance weight loss. Along with dietary management, exercise programs should be encouraged as soon as the primary care provider has approved that the patient is safe to perform physical exercise on a routine basis. It is recommended to perform at least 150 minutes per week of moderate intensity physical exercise for at least 3 days a week, with not more than two

consecutive days of rest. Resistance training is recommended for all patients with type 2 diabetes at least 2 days a week after authorization from the primary care provider.

D.Pharmaceutical therapy:

1.Type 1 diabetes depends on exogenous insulin for treatment.

2.Type 2 diabetes is dependent on the severity of disease at diagnosis. If the glucose is less than 300 mg/dL, treatment is usually begun with an exercise program and nutrition plan. If glycemic goals are not reached in 2 or 3 months, monotherapy of medications is considered:

a.Monotherapy for type 2 diabetes: Metformin is the preferred oral medication for type 2 diabetes. If monotherapy at the maximum dose (usually 2000 mg/day in divided doses) is not achieved after 3 months, a second oral medication should be added. Be aware of contraindications for the use of metformin. Metformin should not be prescribed when the estimated glomerular filtration rate (eGFR) is <30 mL/min or other contraindications. Insulin may eventually be required for patients who are not controlled on oral agents:

i.Sulfonylureas (SUs): first-generation (Orinase, Diabinese) and second-generation (Micronase, Glucotrol, Amaryl); biguanides: metformin (Glucophage); thiazolidinediones (TZDs): rosiglitazone (Avandia) and (Actos); alpha-glucosidase inhibitors: acarbose (Precose).

b.Combination therapy:

i.Two-drug combination:

Metformin + SU.

Metformin + TZD.

Metformin + dipeptidyl peptidase-4 (DPP-4) inhibitor.

Metformin + glucagon-like peptide-1 (GLP-1) receptor agonist (RA).

Metformin + insulin (basal).

ii.Three-drug combinations:

Metformin + SU + TZD, DPP-4 inhibitor, GLP-1 RA, or insulin.

Metformin + TZD + SU, DPP-4-I, GLP-1-RA, or insulin.

Metformin + DPP-4 inhibitor + SU, TZD, or insulin.

Metformin + GLP-1 receptor agonist + SU, TZD, or insulin.

Metformin + insulin (basal) + TZD, DPP-4-I, or GLP-1-RA.

iii.For patients with cardiovascular disease and cannot tolerated metformin, glucagon-like peptide-1 (GLP-1) receptor agonist (Liraglutide or semaglutide) or sodium-glucose co-transporter 2 (SGLT2) inhibitor (empagliflozin or canagliflozin is recommended for cardiovascular protection.

iv.Patients with cardiovascular disease and chronic renal disease may be prescribed sulfonylureas, dipeptidyl peptidase (DPP-4) inhibitors, repaglinide or insulin.

v.Patients without cardiovascular disease and HgbA1c <8.5 percent have many options of treatment such as insulin, GLP-1 receptor agonists, sulfonylureas, SGLT2 inhibitors, DPP-4 inhibitors, repaglinide, or pioglitazone.

vi.Insulin or GLP-1 receptor agonist is recommended for initial treatment for patients without cardiovascular disease and significantly elevated HgbA1c (>8.5%).

vii.Complicated, uncontrolled patients on previous therapy require insulin.

c.Criteria for initiation of insulin therapy:

i.Glucose level at diagnosis of type 2 diabetes greater than 300 mg/dL.

ii.HgbA1c greater than or equal to 10%.

iii.Ketonuria.

iv.Specific to comorbidities and glucose-stimulating medications to be determined through shared decision of provider–patient/surrogate.

Although patients with type 2 diabetes do not depend on exogenous insulin, many will require supplemental insulin during times of stress, illness, or pregnancy or routinely along with oral medication (see Tables 24.1 and 24.2).

d.Additional medications that may need to be considered:

i.Angiotensin-converting enzyme (ACE) inhibitors are the antihypertensive drug of choice to retard renal dysfunction associated with diabetes.

ii.ACE inhibitors or angiotensin II receptor blockers (ARBs) are recommended for patients with an elevated urinary albumin excretion (30–299 mg/24 hour).

iii.Calcium channel blockers may reduce microalbuminuria and proteinuria.

iv.Aspirin therapy (75–162 mg/d) is recommended for primary prevention in patients with type 1 or type 2 diabetes with an increased risk of CVD (men >50 years, women >60 years with one or more risk factors, such as CVD, HTN, smoking, dyslipidemia, or albuminuria). For patients who have a history of CVD with an allergy to aspirin, clopidogrel 75 mg/d should be used.

e.Some medications adversely affect diabetes:

i.Nicotinic acids affect glycemic control by increasing insulin resistance.

ii.Beta blockers increase the risk of hypoglycemia episodes in patients taking oral hypoglycemia agents.

iii.Thiazide diuretics increase insulin resistance.

3.In 2013 the ACC/AHA published guidelines on the primary prevention of the treatment of cholesterol with people with DM and LDL-C of 70 to 189 mg/dL; they include the following:

a.Moderate-intensity statin therapy initiated or continued for adults with DM 40 to 75 years of age.

b.High-intensity statin therapy is reasonable for adults with DM 40 to 75 years of age with a greater than or equal to 7.5% estimated 10-year ASCVD risk unless contraindicated. (Utilize the lifetime risk calculator to define percentage of risk.)

c.In adults with DM who are older than 75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, to assess drug–drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy.

Follow-Up

A.Determine follow-up appointments by the type of diabetes, age, patient compliance, any treatment changes, and presence of any complications related to diabetes or other health problems.

B.A HgbA1c determination every 3 months can assist the provider in measuring control. There are several computer software packages that print the glucometer readings for assessing compliance; this can be done by the provider or the patient.

C.American Diabetes Association management goals:

1.Preprandial glucose level 80 to 120 mg/dL.

2.1 to 2 hours after meals, a glucose level less than 180 mg/dL.

3.A bedtime glucose level 100 to 140 mg/dL.

4.HgbA1c less than 7%.

5.In 2013, the American Diabetes Association recommended the BP goal for diabetics with HTN should be a systolic blood pressure (SBP) of less than 140 mmHg and a diastolic blood pressure (DBP) of less than 80 mmHg. The 2014 report from the Eighth Joint National Committee (JNC VIII) recommends that in the diabetic population aged older than 18 years, pharmacologic treatment should be initiated at a SBP greater than 140 mmHg or a DBP greater than 90 mmHg and treated to a goal of SBP less than 140 mmHg and a goal of DBP less than 90 mmHg. The JNC VIII has the same recommendation for initiation of BP medication and treatment goals for patients older than 18 years of age with chronic kidney disease.

TABLE 24.2 Diabetes Medication/Class

Drug	Brand Name	Drug Classification
Acarbose	Precose	Alpha-glucosidase inhibitor
Pioglitazone + Metformin	ActoPlus Met	TZD plus biguanide
Glimepiride	Amaryl	SU
Insulin glulisine	Apidra	Rapid-acting insulin
Rosiglitazone + Metformin	Avandamet	TZD plus biguanide
Rosiglitazone + Glimepiride	Avandaryl	TZD plus SU
Exenatide	Byetta	Incretin mimetic
Exenatide ER	Bydureon	GLP-1 receptor agonist
Glyburide	DiaBeta	SU (second generation)
Pioglitazone + Glimepiride	Duetact	TZD plus SU
Glucagon	–N/A–	Antihypoglycemic
Metformin ext. release	Glucophage	Biguanide
Glipizide ext. release	Glucotrol	SU (second generation)
Glyburide + metformin	Glucovance	SU plus biguanide
Glyburide micronized	Glynase PresTab	SU (second generation)
Miglitol	Glyset	Alpha-glucosidase inhibitor
Insulin lispro	Humalog	Rapid-acting insulin
NPH/Regular insulin	Humulin 70/30	Short- and intermediate-acting insulin
NPH/Regular insulin	Humulin 50/50	Short- and intermediate-acting insulin
Regular insulin	Humulin R	Rapid-acting insulin
NPH insulin	Humulin N	Intermediate-acting insulin
Sitagliptin + metformin	Janumet	Dipeptidyl peptidase-4 inhibitor plus biguanide
Sitagliptin	Januvia	Dipeptidyl peptidase-4 inhibitor
Insulin glargine	Lantus	Long-acting insulin
Insulin detemir	Levemir	Long-acting insulin
Linagliptin	Tradjenta	Dipeptidyl peptidase-4 inhibitor
Liraglutide	Victoza	Glucagon-like peptide-1 receptor agonist
Metformin + glipizide	Metaglip	Biguanide plus SU
Glyburide	Micronase	SU (second generation)
Miglitol	Glyset	Alpha-glucosidase inhibitor
Nateglinide	Starlix	Amino acid derivative
Insulin isophane + regular insulin	Novolin 70/30	Short- and intermediate-acting insulin
Insulin aspart	NovoLog	Rapid-acting Insulin
Insulin aspart protamine/Insulin aspart	NovoLog Mix 70/30	Short- and intermediate-acting insulin
Insulin lispro protamine/insulin lispro	Humalog Mix 75/25	Short- and intermediate-acting insulin
Insulin lispro protamine/insulin lispro	Humalog Mix 50/50	Short- and intermediate-acting insulin
Nateglinide	Starlix	Insulin secretagogue
Insulin isophane suspension NPH	Novolin	Intermediate-acting insulin
Saxagliptin	Onglyza	Dipeptidyl peptidase-4 inhibitor
Pioglitazone	Actos	TZD
Repaglinide + metformin	Prandimet	Meglitinide analogue plus biguanide meglitinide
Pramlintide	Symlin	Amylin analogue/amylinomimetic
Repaglinide	Prandin	Meglitinide analogue
Rosiglitazone	Avandia	TZD
Semaglutide	Ozempic	GLP-1 receptor agonist
Ertugliflozin	Steglatro	Sodium-glucose co-transporter inhibitors
Ertugliflozin + metformin	Segluromet	Sodium-glucose co-transporter inhibitors + biguinide
Ertugliflozin + sitagliptin	Steglujan	Sodium-glucose co-transporter inhibitors + dipeptidyl peptidase-4 inhibitor (2018)

GLP-1, glucagon-like peptide-1; NPH, normal pressure hydrocephalus; SU, sulfonylurea; TZD, thiazolidinedione.

6.Cholesterol less than 200 mg/dL, triglycerides less than 150 mg/dL, HDLs greater than 35 mg/dL, and LDLs less than 100 mg/dL and less than 70 mg/dL if heart disease is present or patient is at high risk for atherosclerotic disease.

D.Annual tests or examinations should include a dilated funduscopic examination by an ophthalmologist to screen for retinopathy every 2 years, an annual ECG, monofilament foot examination, flu vaccination and other adult vaccines as recommended, thyroid studies, serum creatinine, blood urea nitrogen (BUN), glomerular filtration rate (GFR). lipid panel, urinalysis, and urine for albuminuria. Additional tests may be needed if complications develop.

Consultation/Referral

A.Refer to the physician if the patient experiences the following:

1.Diabetic ketoacidosis.

2.Severe or frequent hypoglycemia that is unresponsive to conventional pharmaceutical therapy.

3.Hyperosmolar hyperglycemic nonketotic syndrome.

4.Pregnancy.

5.Symptoms from an acute complication related to retinopathy.

6.Nephropathy develops 35% to 45% of the time in type 1 and 20% of the time in type 2 diabetes; it is the leading disease requiring kidney dialysis.

7.Neuropathy: 60% to 70% of patients experience impaired sensation or pain in feet/hands, or carpal tunnel syndrome; over half of all amputations of lower extremities are related to diabetes. All patients should be screened for neuropathy at the diagnosis of type 2 diabetes and at 5 years after the diagnosis of type 1 diabetes, and then annually. Early diagnosis is imperative to prevent nerve damage from occurring. Tight control of the blood glucose levels can slow down the progression of nerve damage but cannot reverse neuronal loss. The pain experienced with neuropathy can be treated with oral medications. Pregabalin and duloxetine are both FDA-approved for neuropathic pain. Other medications that may be used include opioids such as tramadol or morphine, along with venlafaxine, amitriptyline, gabapentin, or valproate.

8.Persistent uncontrolled diabetes.

Individual Considerations

A.Pregnancy/preconceptual:

1.Women considering pregnancy should be switched to insulin before conception and during pregnancy:

a.Fetal anomalies increase proportionally with uncontrolled diabetes.

b.HgbA1c goal prior to conception is less than 7%.

c.Gestational diabetes screening may be completed by performing the one-step 2-hour 75 gm OGTT or a two-step approach with 1-hour 50 g nonfasting Glucola followed by a 3-hour 100 g OGTT for patients who test positive for the 1-hour screening.

2.Hypertensive medications may need to be changed if considering pregnancy because ACE inhibitors, beta blockers, and diuretics are contraindicated during pregnancy.

3.Increased monitoring of blood glucose is necessary during pregnancy.

B.Adults:

1.American College of Physicians (ACP) guidance statement (2018) recommended:

a.Clinicians personalize glycemic control in patients with type 2 diabetes and discuss benefits/harms of pharmacotherapy, patient’s preferences, patient’s life expectancy and general health, treatment burden, and cost of care.

b.HgbA1C level aims between 7% and 8% in most patients with type 2 diabetes. (Note: American Diabetes Association does align recommendations with ACP and recommends to continue the guideline of a HgbA1C target as less than 7%.)

c.Deintensify pharmacologic therapy in patients with type 2 diabetes who achieve HgbA1C less than 6.5%.

C.Geriatrics:

1.Rates of major morbidity, including amputation, myocardial infarction (MI), blindness, end-stage renal disease (ESRD), and death is much higher in those patients diagnosed with diabetes that are over 65 years of age. Complications for patients with diabetes increase at 75 years and older.

2.Diabetes is associated with the emergence/worsening of the following geriatric syndromes: Cognitive dysfunction, functional impairment, falls and fractures, depression, and visual and hearing impairment. There is also strong evidence to indicate that adults with diabetes aged 65 years and older are a high priority population for depression screening and treatment.

3.Elderly patients are sensitive to fluctuating blood glucose (severe highs and lows). Treat elderly patients with type 2 diabetes cautiously to minimize hyperglycemia. However, monitor for over-treatment from oral/insulin treatments and high carbohydrate eating (snacks and food and drink cravings).

4.Carefully monitor the HgbA1c of patients with a life expectancy less than 10 years due to advanced age (80 years or older); those residing in a long-term care facility; or those with chronic conditions (dementia, cancer, ESRD, chronic obstructive pulmonary disease [COPD], or congestive heart failure [CHF]) secondary to the harms outweighing the benefits to this population.

5.Glucose testing and treatment for geriatric patients:

a.Liberalization of control: Functional and cognitive status is an important consideration when determining goals for glycemic control in the older adult:

i.Functional and cognitively intact older adults with long life expectancy should have care and goals similar to those for younger diabetics.

ii.Glycemic goals may be relaxed based in selected individuals, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided.

iii.The HbA1C goal for healthy adults over age 65 is less than 7.5%.

iv.The HbA1C goal for older adults who have medical and functional comorbidities, are frail, and have a life expectancy less than 10 years is 8.0% or less.

v.The old–old, those over 85 years of age can be allowed to have a HbA1C up to 8.5% as long as this preserves quality of life and avoids the complications of hypoglycemia (Kirkman et al., 2012).

b.Falsely high HbA1C: May result from increased age of red cells when turnover/production is low, as in iron or nutrient deficiency anemia, or asplenia.

c.Falsely low HbA1C: May result from more rapid cell turnover as in hemolysis, or in repletion of iron or other nutrients as red cell production is increased.

d.Chronic kidney disease can both falsely lower and raise the HbA1C.

6.Treatment considerations:

a.Metformin is first-line therapy, however it is contraindicated in patients with renal insufficiency (creatinine clearance [CrCl] <30) or significant heart failure.

b.Avoid sulfonylureas: They cause hypoglycemia. Glyburide is contraindicated in older adults

c.GLP-1 receptor agonists and DPP-4 inhibitors may be an option if metformin is inadequate, but costs are often higher

d.Treat other cardiovascular risk factors:

i.HTN treatment is indicated for all older diabetics.

7.American Diabetes Association recommends:

a.Individualized screening be implemented periodically for diabetes diagnosis or diabetic complications in adults older than 65 years. A full assessment of medical, psychological, functional, and social domains would provide a framework to determine individualized targets and decisions.

b.Consider revisiting self-management capabilities for the geriatric population and evaluating for any limitations in activities of daily living (ADLs).

c.Aspirin and lipid-lowering agents may benefit geriatric patients whose health presentation suggests longer life expectancies.

d.For a palliative/hospice geriatric patient, consider hydration and discontinuation of all oral diabetic agents, except a low-dose basal insulin for type 1 diabetes patients.

e.Beers Criteria:

i.Glyburide and chlorpropamide may increase the risk of hypoglycemia in the geriatric patient. An alternative would be glipizide.

ii.Insulin must be meticulously titrated to avoid severe rebound hypoglycemia. The sole use of sliding scale insulin (SSI) should be avoided because it is often difficult for older adults to manage multiple tests and injections, and SSI carries a higher risk of hypoglycemia without improvement in hyperglycemia management. SSI may be used in the short term for acute illness, or in titration of basal insulin, or when rapid-acting insulin is used as correction insulin in conjunction with scheduled insulin.

iii.Pioglitazone and rosiglitazone tend to increase fluid retention and worsen heart failure in geriatrics.