History and Physical.
A1C goal for this patient:______
Last HbA1c (needed q3-6mo) was_____
Will screen for Vitamin B12 deficiency annually in patients on Metformin.
Last annual dilated retinal exam was____
Last annual diabetic foot exam was____
Last annual microalbuminuria screening with spot urine albumin/creatinine ratio was_____
Last annual eGFR, BUN / Cr was____
The patient has had diabetes since _____
Treatment
Moderate glycemic control in older adults.
BP goal 140/90
Diet, exercise, behavior modification, weight loss.
1st line Rx: Metformin, if no contraindication.
2nd line Rx: See Diabetes Treatment Algorithm from ADA 2016.
ACE-I / ARB for renoprotection
Statins (beneficial in DM pts even w/o overt CAD)
ASA according to USPTF.
CV risk stratification: Will evaluate for other cardiovascular risk factors.
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For Obesity, see here.
Pearls & Related Links
- “Do not medicate to achieve tight glycemic control in older adults. Moderate control is generally better.” (AFP 2018)
- ? Strict glycemic control b/c microvascular & macrovascular complications are decreased by a strict glycemic control in both DM1 and DM2.
- Diabetes Care Standing Orders, from the Kentucky Diabetes Network.
- Diabetes Flow Sheet, from Indiana University.
- CDC (2016) Guidelines for using Metformin in Diabetic Patients.
- Initiating Insulin therapy in type 2 Diabetes mellitus **
- Initiating and Adjusting Insulin Therapy for Type II Diabetics.
- Diabetes, Insulin Management.
- Writing Prescription for Insulin, Needles, Lancets, Syringes, Monitors, etc.
- Insulin Syringe Sizes: How to choose the right size for your situation.
- Diabetes Drugs and their classes.
- Diabetes complications.
- Diabetes Type I Vs. Type II.
- Insulin Drip for DKA.
- Low Carb, High Fat (LCHF) Diet.
- Microalbuminuria: goal <30mg/g. If positive will repeat for a total of three times. 2 out of 3 positive will diagnose microalbuminuria.
Need to check eGFR at least annually in all patients taking metformin. In patients at increased risk for the development of renal impairment such as the elderly, renal function should be assessed more frequently. - Check out the algorithm for mono, dual, and triple therapy with oral agents before moving to injectables. See below
- http://care.diabetesjournals.org/content/39/Supplement_1/S52
References / Sources
Am Fam Physician. 2018 Jan 1;97(1):29-37. Type 2 Diabetes Mellitus: Outpatient Insulin Management. https://www.aafp.org/afp/2018/0101/p29.html
Diabetes global disease burden. http://www.idf.org/sites/default/files/Media-Information-Pack.pdf