Liječenje oboljelih od šećerne bolesti značajan je izazov liječnicima obiteljske medicine s obzirom na multimorbiditet i prisutni komobriditet oboljelih kao i na vrijeme koje se realno može posvetiti pojedinom oboljelom. Iako kliničke smjernice ne mogu zamijeniti individualnu liječničku prosudbu u razvoju plana liječenja za pojedinog bolesnika, one su korisna vodilja na tom putu. Donosimo vam dio zanimljivog članka objavljenog na Medscape Education Diabetes & Endocrinology o izazovu sveobuhvatne skrbi za oboljele od šećerne bolesti.

From Medscape Education Diabetes & Endocrinology
Comprehensive Diabetes Care — Are You Up to the Challenge?

Eugene E. Wright, Jr, MD

Introduction

Diabetes has reached epidemic proportions in the United States, occurring in nearly 8% of the population, and of the 24 million Americans diagnosed with diabetes, the overwhelming majority have type 2 diabetes mellitus (T2DM). Its prevalence has doubled over the past 2 decades, and this trajectory is expected to continue due to the increasing frequency of obesity in the United States. The presence of diabetes significantly increases the risk for microvascular consequences including diabetic retinopathy, nephropathy, and neuropathy, as well as macrovascular consequences that include coronary heart disease, stroke, and death. Diabetes typically co-occurs with a range of other cardiometabolic conditions including central obesity, hyperlipidemia, and hypertension. This results in highly complex clinical care scenarios that require attention to issues beyond glycemic control alone. There is a significant body of evidence supporting a range of testing protocols and interventions in patients with diabetes that can vastly reduce disease burden and prevent potentially disastrous consequences for patients. These have been summarized in clinical practice guidelines from numerous organizations.

It is estimated that if each patient with diabetes received the same care as those who are members of top healthcare plans, up to 9600 diabetes-related deaths and 14,000 myocardial infarctions, amputations, and strokes could be prevented annually in the United States. Among older Medicare beneficiaries, adherence to recommended screening and monitoring guidelines (eg, A1c testing, lipid panels, urinalysis, eye examinations) reduced hospitalization rates and vascular, renal, and other complications. However, studies have demonstrated that few patients with diabetes in the United States receive evidence-based comprehensive care. The Centers for Disease Control and Prevention have found that < 5% of patients with diabetes receive care that is in line with American Diabetes Association (ADA) guidelines.

There are many clinician and patient barriers that may prevent guideline-based comprehensive diabetes care. It is well established that many patients with diabetes do not adhere to treatment plans due to socioeconomic, psychological, interpersonal, and treatment-related factors as well as lack of education. Issues affecting healthcare providers include lack of consensus among major diabetes organizations, lack of clinician knowledge of guidelines, underutilization of the extended diabetes care team, and perhaps most importantly, time and resource limitations. This program will review and summarize key issues in comprehensive diabetes care with the goal of simplifying and improving the implementation of evidence-based care measures.

Use of A1c in Diabetes

There are multiple ways to measure blood glucose levels in patients with diabetes, and each plays an important role. Whereas FPG indicates a blood glucose level at a given time, A1c is a measure that reflects overall glucose tolerance over the previous 8-12 weeks, which adds important data to a single FPG level. An additional advantage of A1c testing is that it does not require an 8-hour fast, unlike FPG and the oral glucose tolerance test, which removes a barrier to same-day testing in patients who did not fast before their office visit. Blood glucose self-monitoring is another method that plays an important role in assessing ongoing diabetes control because it provides data on when hyperglycemic or hypoglycemic conditions exist and what precipitates them, which can help in individualizing treatment regimens.

A1c was not historically used to diagnose diabetes; however, a 2009 international consensus statement recommended its use (standardized and aligned with the Diabetes Control and Complications Trial/UKPDS assay) as a diagnostic criterion. The ADA has now endorsed this criterion for the diagnosis of diabetes; the recommended cutoff point for diagnosis is an A1c level ≥ 6.5% with repeat confirmation.

The ADA also recommends use of A1c on an ongoing basis to assess the overall picture of a patient’s glycemic levels for the previous 2-3 months.[4] This should be done at 8- to 12-week intervals in patients who are not at A1c goal so that their treatment can be intensified until stable blood glucose control is attained (Figure 1). It would not be appropriate to measure A1c more frequently than once every 8-12 weeks because changes in overall glucose tolerance would not be evident at shorter intervals.

Use of A1c in Diabetes Monitoring: Benefits, Barriers, and Strategies

Timely screening and diagnosis of T2DM and tight, stable blood glucose control can significantly reduce the risk for and/or delay the onset of diabetes complications. Patients with diabetes who achieve and maintain near-normal A1c levels can gain an average of an extra 5 years of life, 8 years of sight, and 6 years free from kidney disease.

In a study of individuals 67 years of age and older who had T2DM, those who received at least 2 A1c tests per year had a significant 29% reduction in macrovascular complications, a 29% reduction in atherosclerotic heart disease, and a 23% reduction in chronic kidney disease or end-stage kidney disease in the 4-year follow-up period. Achieving A1c control also improves patient quality of life and leads to increased work productivity and decreased healthcare use. In contrast, patients with poor diabetes control continue to have increased risks for complications, decreased functional ability and cognitive function, and poor quality of life.

Although regular A1c screening is clearly an important aspect of diabetes care, data from the National Committee for Quality Assurance (NCQA) suggest that as many as 35% of patients with diabetes who are on Medicare do not receive ≥ 1 A1c test per year. A study that administered a questionnaire to adults who were members of a regional managed care plan found that one third of the respondents with diabetes did not receive recommended A1c screening; primary barriers included lack of patient awareness that the test is recommended (49%), not informed of the need for the test by their physician (38%), never heard of the A1c test (33%), and not seen regularly by their physicians (19%). Other studies have reported even lower rates of A1c testing in routine practice. In a study of older patients with diabetes, only 27.1% received recommended A1c screening.

Use of A1c in Diabetes Monitoring: Identifying a Target

Although there is some controversy regarding optimal A1c goal, there is no question that A1c is the key glycemic variable to be monitored in patients with diabetes. The ADA recommends a target A1c < 7.0% for most adults with diabetes, whereas the American Association of Clinical Endocrinology/American College of Endocrinology (AACE/ACE) consensus panel recommends an A1c goal of ≤ 6.5%. Results from trials such as ACCORD, ADVANCE, and VADT raised further questions regarding optimal A1c targets and elevated concerns about the potential adverse impact of severe hypoglycemic episodes with intensive antihyperglycemic treatment.

Summary of Glycemic Recommendations for Non-Pregnant Adults With Diabetes

A1C < 7.0%a
Preprandial capillary plasma glucose 70-130 mg/dL (3.9-7.2 mmol/L)
Peak postprandial capillary plasma glucoseb < 180 mg/dL (< 10.0 mmol/L)
Key concepts in setting glycemic goals:

  • A1C is the primary target for glycemic control
  • Goals should be individualized based on:
    • Duration of diabetes
    • Age/life expectancy
    • Comorbid conditions
    • Known cardiovascular disease or advanced microvascular complications
    • Hypoglycemia unawareness
    • Individual patient considerations

More or less stringent glycemic goals may be appropriate for individual patients
Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals
a. Referenced to a nondiabetic range of 4.0%-6.0% using a Diabetes Control and Complications Trial (DCCT)-based assay
b. Postprandial glucose measurements should be made 1-2 hours after the beginning of the meal, generally peak level in patients with diabetes
From http://www.guideline.gov/content.aspx?id=15687

Most experts agree that A1c goals should be individualized based on a patient’s overall health — targeting an A1c level as close to “normal” as possible would be appropriate for younger, relatively healthy patients with diabetes, whereas a more conservative A1c target in the range of high 6% to low 7% would be appropriate in patients with factors such as history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, and long duration of diabetes.

The Importance of LDL-C Screening in Individuals With Diabetes

Glycemic control is obviously a key priority in the treatment of patients with diabetes. However, diabetes rarely exists without comorbid cardiometabolic conditions including hyperlipidemia, hypertension, and central obesity. Many patients with diabetes display the cardiometabolic syndrome, which signals an increased risk for cardiovascular events and a need for intensive risk reduction.

Any 3 of the following 5 criteria constitutes the diagnosis of cardiometabolic syndrome:
Elevated waist circumference ≥ 102 cm (40 inches) in men and ≥ 88 cm (35 inches) in women;
Elevated triglycerides ≥ 150 mg/dL (1.7 mmol/L) or on drug treatment for elevated triglycerides;
Reduced HDL-C < 40 mg/dL (0.9 mmol/L) in men and < 50 mg/dL (1.1 mmol/L) in women or on drug treatment for reduced HDL-C;
Elevated blood pressure ≥ 130 mm Hg systolic blood pressure or ≥ 85 mm Hg diastolic blood pressure or on antihypertensive drug treatment in a patient with a history of hypertension; or
Elevated fasting glucose ≥ 100 mg/dL or on drug treatment for elevated glucose.
Because individuals with diabetes are already at elevated cardiometabolic risk, they require a global approach to risk reduction and comprehensive care. Therefore, targets for other risk factors are generally lower for people with diabetes than for the general population, including:
Total cholesterol: < 200 mg/dL;
LDL-C: < 100 mg/dL, or < 70 mg/dL in established coronary artery disease;
HDL-C: > 40 mg/dL in men, > 50 mg/dL in women; and
Triglycerides < 150 mg/dL.
LDL-C levels have been shown to be both a strong predictor of cardiovascular events and an important target for lipid-lowering therapy.[22,26,27] This is underscored by a study of Medicare claims that found patients without a lipid profile had a 2.3-fold higher cardiovascular mortality rate than those with ≥ 2 lipid profiles. Therefore, regular LDL-C screening is a critical priority in patients with diabetes. The ADA recommends that a fasting lipid panel be performed in individuals with diabetes at least annually in most cases.

As with A1c levels, current clinical practice is not optimal with regard to lipid profile screening. According to the NCQA, up to 41% of all patients on Medicare do not receive lipid screening at least once every 2 years. Among individuals with diabetes, 15% of those in commercial plans, 14% of those in Medicare, and 26% of those in Medicaid did not receive LDL-C screening in 2008. There are important healthcare disparities in this area, with white individuals being 1.6-fold more likely to receive lipid screening than black individuals. The most frequent identified reason for failure to follow lipid testing guidelines is that the need to test was overlooked.

Hypertension and Nephropathy:
Recommendations for Screening
Uncontrolled hypertension is a major risk factor for both cardiovascular disease and microvascular complications as well as an important reversible cause of kidney dysfunction. This is particularly important in the diabetes care setting, since diabetes (specifically, diabetic nephropathy) is the leading cause of end-stage renal disease.

Blood pressure recommendations from the ADA for individuals with diabetes include:

Blood pressure should be measured at every routine diabetes visit. Those with systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure ≥ 80 mm Hg should have a repeat measurement on a separate day for confirmation;
Patients with diabetes should be treated to attain a systolic blood pressure < 130 mm Hg; and
Patients with diabetes should be treated to attain a diastolic blood pressure < 80 mm Hg.
Diabetic nephropathy occurs in 20%-40% of patients with diabetes, but it can be detected in its earliest stages via regular screening. Microalbuminuria (ie, albuminuria in the range of 30-299 mg/24 hours) has been shown to be an early marker for the development of nephropathy, and is also a well-established marker of increased global cardiovascular risk.
Screening recommendations include:
Annual testing of urine albumin excretion in patients with type 1 diabetes with duration ≥ 5 years and in all patients with T2DM starting at diagnosis; and
Annual measurement of serum creatinine in all adults with diabetes regardless of the degree of urine albumin excretion; this should be used to estimate glomerular filtration rate.

Diabetic retinopathy, a microvascular complication of T1DM and T2DM, is the most common cause of new blindness in adults, and the leading cause of blindness in adults aged 25 to 74; prevalence is strongly associated with duration of diabetes. Early detection and treatment are key to preserving vision, because it is typically asymptomatic until it is advanced.
Recommended screening practices include:
Initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after onset of T1DM in individuals aged ≥ 10 years;
Initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after diagnosis of T2DM; and subsequent examinations should be repeated annually for patients with T1DM and T2DM.
Although optimal glycemic and blood pressure control and, in some cases, laser and surgical treatment, can prevent progression of diabetic retinopathy and vision loss, only 35%-55% of individuals with diabetes get the recommended dilated exam each year; this is regardless of type of insurance or socioeconomic/educational level. This is troubling, because while further deterioration of sight is preventable, there is currently no treatment that can restore lost vision.
Major barriers to the use of yearly eye examinations include both clinician and patient factors. Providers may perceive this as a low priority given the multiple health problems in their patients with diabetes, and may not have an effective way to track data such as the date of the patient’s last ophthalmology appointment or the eyecare professional’s recommended follow-up schedule. Providers also frequently assume that it is the patient’s responsibility to follow through in scheduling the examination, and generally do not provide a reason for the requested examination to the eye specialist. Patients may fail to follow through with eye examinations due to lack of understanding of the potential consequences, fear of discovering a problem, and reluctance to make an appointment that may require time off from work.
Strategies to improve diabetic retinopathy screening include patient education; use of flow sheets, patient registries, electronic medical records, and other tracking systems; and having nurses, diabetes educators, or office staff follow up with patients. Improved communication between the eyecare professional and the primary care provider is another important strategy to improve guideline adherence; to that end, Sinclair and Delvecchio propose specific roles for the primary care provider and eyecare professional, and have created a standardized form to improve coordination of care.

The Importance of Foot and Lower-Extremity Examinations in Diabetes

Diabetic neuropathy is the most common complication of diabetes, and along with nephropathy and retinopathy, it is an important microvascular manifestation of the disease. Neuropathy will develop in approximately half of all patients with diabetes, and the most common presentation is diabetic peripheral neuropathy (DPN) with symptoms originating in the lower extremities.
DPN varies widely in its presentation, with up to half of patients being asymptomatic. This underscores the importance of regular screening and early recognition, because asymptomatic patients are at increased risk for insensate injury to their feet and other complications. Common signs and symptoms of DPN include loss of protective sensation, pain, numbness, attenuated reflexes, and symmetric foot ulcers.

Among the potential complications of DPN are ulcerations, lower-extremity infection, and amputation. One study showed that the cumulative risk for lower-extremity amputation 25 years after diagnosis of DM is 11%, and compared with nondiabetic individuals, patients with T2DM have a nearly 12-fold increased risk for below-knee amputation.

Along with blindness, amputation is one of the most feared complications of diabetes. Fortunately, DPN is relatively easy to detect with regular screening. The American College of Foot and Ankle Surgeons recommends that all patients with diabetes should have their feet checked at every visit to a healthcare provider. This includes thorough inspection of the feet, including the interdigital spaces and nails, for abrasions, cuts, cracks, fissures, or ulcerations.

In addition, all patients with diabetes should have a comprehensive lower-extremity examination upon diagnosis and yearly thereafter.

This should consist of:

  • Checking pedal pulses and ankle reflexes;
  • Inquiring whether the patient has pain, loss of sensation, or pins-and-needles sensation in the limbs;
  • Thorough evaluation of both feet, including interdigital spaces and nails;
  • Examination of shoes for wear;
  • Testing for loss of protective sensation:
  • Monofilament
  • Vibration
  • Pinprick.

Foot and Lower-Extremity Examinations: Follow-up, Barriers, and Strategies
In most cases, a diagnosis of DPN can be made based on a detailed patient history and the presence of at least 2 signs/symptoms of peripheral nerve dysfunction, and most cases can be managed by primary care providers through patient education, symptomatic treatment, and optimization of glycemic control. Individuals with diabetes should be instructed to check their feet daily for any abrasions, ulcerations, or other injuries, and contact their provider promptly if they do not resolve with reasonable self-care measures. Patients should be referred to a podiatrist if they have nonhealing open foot wounds or other atypical features if pedal pulses are palpable, and to a vascular specialist if pulses are nonpalpable. Appropriate use of foot examinations can prevent some of the most feared complications of diabetes; yet, they are dramatically underused in clinical practice. Various studies have reported annual rates of foot examinations from < 6% to 67% in different settings. Important barriers include lack of clinician awareness regarding optimal frequency and procedures for screening, as well as limited time for examinations. Strategies to improve rates of screening include the use of tracking systems such as patient registries, flagging charts of patients with diabetes, or flow sheets; as well as simple office practices such as posting signs in examination rooms instructing patients with diabetes to remove socks and shoes at each visit, or asking an office assistant to do so for patients whose charts are flagged as diabetic.

Conclusion

Taking simple but organized steps to implement these recommendations and improve the process of care for patients with diabetes forms the foundation for a clinical quality improvement program. There are several resources to aid clinicians in improving comprehensive diabetes care.

The American Academy of Family Physicians Website (www.aafp.org) also provides useful quality improvement tools and resources, including patient registry tools, links to pay-for-performance programs and criteria for performance measures, and practical resources to improve practice efficiencies. The Agency for Healthcare Research and Quality Bridges to Excellence program (www.bridgestoexcellence.org) provides 2 incentive programs for higher-quality diabetes care.

Attaining optimal glycemic control in itself provides challenges to clinicians who treat patients with diabetes, but providing comprehensive care to these individuals requires a much broader focus on preventing common consequences of chronic diabetes.

Implementing routine testing protocols including A1c, LDL-C, urine albumin, and serum creatinine testing; eye, foot, and lower-extremity examinations; and blood pressure measurement can vastly improve the health of patients with diabetes by allowing healthcare providers to recognize and address problems before they lead to devastating consequences.

Supported by an independent educational grant from Eli Lilly & Co.