Type 2 Diabetes: What Busy PCPs Need to Know

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For those of you who have been in practice for a while and find that increasing numbers of your patients have diabetes, you are not imagining it. In their most recent Diabetse Report Card published in 2014, the CDC reported that over the past 32 years the number of adults with diabetes has nearly quadrupled to 21.3 million.¹ The report further states that there are 1.7 million new cases diagnosed annually with a predicted prevalence of one in every three adults by 2050.¹ The estimated healthcare costs are just as staggering with a projected $176 billion in direct medical costs and $69 billion in indirect costs due to lost productivity, disability, and premature death.¹ As “front line” physicians it is nothing short of imperative that we initiate preventive measures, make timely diagnoses, and employ optimal medical management for each of our patients with T2DM.

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Protracted prequel

The prequel to the diagnosis of T2DM can span years to decades and begins with insulin resistance. As insulin resistance worsens, pancreatic beta cells are initially able to compensate by increasing insulin levels, resulting in hyperinsulinemia.² This compensatory mechanism can maintain blood glucose levels within the normal range for up to several years but the consequence impaired glucose tolerance, most notably manifested as mild postprandial hyperglycemia.² By the time diabetes is diagnosed, it is estimated the approximately 50% of beta cell function has been lost.³ It should come as no surprise then that at the time of diagnosis more than 20% of patients will have chronic macro- and/or microvascular complications.

Without a doubt, this is a challenging patient population to effectively treat. Conceptually, we know that if our obese patients could lose weight, their diabetes could often be managed by nutrition and lifestyle alone; and yet what we are asking patients to do in order to control their disease is not simply to “lose weight;” we are asking them to essentially change everything from their food preferences to their day-to-day lifestyle habits. And this is often how we as clinicians, most often unknowingly, start with the very best of intentions yet slump into that state of medical limbo called clinical inertia.

Next: Meet Mrs Davis

(Image: beta cells on surfact of pancreas)

Meet Mrs Davis. Over the next four weeks, we are going to focus on our patient Mrs Davis. You probably already recognize her:

Her blood pressure at today’s visit is 134/80, BMI is 34, most recent HgbA1c (A1c) 7.8, and most recent LDL-cholesterol is 108 mg/dL. She states that she has a blood glucose meter but she left it at home.

Where do you go from here? 

 ^► What is the optimal approach to patients such as Mrs. Davis? 
 ^► Are there simple guidelines or tools available to practitioners to help optimize disease management?
 ^► What about treatment algorithms?
 ^► Is home glucose monitoring data really that useful to clinicians? 
 ^► And if so, what are some key elements of interpreting home blood sugars?

In this Special Report, we will explore these questions and more to help you optimize your treatment plan and time in the office with this most challenging patient population.

First up: a T2DM multiple-choice pretest aimed at primary care physicians. The questions will be answered in upcoming segments of this Special Report.

Continue to Type 2 Diabetes Special Report Pretest

TYPE 2 DIABETES: PRE-TEST

Take our short pretest to see what you know about diagnosis and management of type 2 diabetes and common comorbidities.

You’ll see these questions again after the final installment of the report, so you might want to take notes to help you assess how much you have learned after reading it.

Question 1:

Answer and Question #2 on Next Page »

The correct answer is A. Yes, appropriate treatment strategies can help prevent or delay T2DM.

Question 2.

Answer and Question #3 on Next Page »

The correct answer is D. HDL-cholesterol > 60 mg/dL

Question 3.

Answer and Question #4 on Next Page »

The correct answer is C. A1c ≤ 7

Question 4.

Answer and Question #5 on Next Page »

The correct answer is C. Nutrition, physical activity, sleep, behavioral support, smoking cessation

Question 5.

Answer and Question #6 on Next Page »

The correct answer is C. Hypertension

Question 6.

Answer and Question #7 on Next Page »

The correct answer is D. 140/90 mm Hg

Question 7.

Answer and Question #8 on Next Page »

The correct answer is A. Nutrition and lifestyle therapy

Question 8.

Answer and Question #9 on Next Page »

The correct answer is A. Metformin

Question 9.

Answer and Question #10 on Next Page »

The correct answer is B. For patients who are on dual or triple oral therapy and A1c remains > 7.5, basal insulin should be considered.

Question 10.

Answer on Next Page »

The correct answer is A. When pre-meal blood sugars are not at goal.

Continue to Part 2. Type 2 Diabetes Back to Basics: Clinical Suspicion and Diagnosis

References:

• Centers for Disease Control and Prevention. Diabetes Report Card 2014. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2015. www.cdc.gov/diabetes/library/reports/congress.html
•  Ramlo-Halsted BA, Edelman SV. The natural history of type 2 diabetes: practical points to consider in developing preventing and treatment strategies. Clinical Diabetes 2000; 18(2). http://journal.diabetes.org/clinicaldiabetes/v18n22000/pg80.htm
• Gallwitz B. The fate of beta cells in type 2 diabets and the possible role of pharmacological interventions. Rev Diabet Stud. 2006;3:208–216.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1828283/