Diabetes: Rethinking risk and the Dx that fits

,

Applied Evidence

Diabetes: Rethinking risk and the Dx that fits

J Fam Pract. 2009 May;58(5):248-256

By

Julienne K. Kirk, PharmD, CDE

The USPSTF now calls for screening patients with mild hypertension. A late-onset variant is now in the classification mix. Use these tools and tips to better evaluate patients.

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References

1. Williamson DF, Vinicor F, Bowman BA. Centers of Disease Control and Prevention Primary Prevention Working Group. Primary prevention of type 2 diabetes mellitus by lifestyle intervention: implications for health policy. Ann Intern Med 2004;140:951-957.

2. Centers for Disease Control and Prevention/National Center for Health Statistics. FastStats. Over-weight prevalence. Available at: http://www.cdc.gov/nchs/fastats/overwt.htm. Accessed March 28, 2009.

3. Palmer JP, Hirsch IB. What’s in a name? Diabetes Care. 2003;26:536-538.

4. Centers for Disease Control and Prevention. Health, United States, 2007. Available at: http://www.cdc.gov/nchs/data/hus/hus07.pdf#executivesummary. Accessed October 4, 2008.

5. American Diabetes Association. Clinical practice recommendations 2009. Diabetes Care. 2009;32(suppl 1):S1-S61.

6. National Diabetes Information Clearinghouse. National Institute of Diabetes and Digestive and Kidney Diseases. Am I at risk for type 2 diabetes? Available at: http://diabetes.niddk.nih.gov/DM/pubs/riskfortype2/. Accessed April 10, 2009.

7. US Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults: Recommendations and rationale. Available at: http://www.ahrq.gov/clinic/uspstf08/type2/type2summ.htm. Accessed October 4, 2008.

8. International Diabetes Federation. Backgrounder 1: The IDF consensus worldwide definition of the metabolic syndrome. Brussels, Belgium; 2005.

9. Genuth S, Estman R, Kahn R, et al. American Diabetes Association. Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care. 2003;26(suppl 1):S28-S32.

10. Heikes KE, Eddy DM, Arondekar B, et al. Diabetes risk calculator: a simple tool for detecting undiagnosed diabetes and pre-diabetes. Diabetes Care. 2008;31:1040-1045.

11. Hippisley-Cox J, Coupland C, Robson J, et al. Predicting risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore. BMJ. 2009;338:b880.-

12. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(suppl 1):S3-S68.

13. World Health Organization. Screening for type 2 diabetes. Report of a World Health Organization and International Diabetes Federation meeting. 2003. http://www.who.int/diabetes/publications/en/screening_mnc03.pdf. Accessed October 4, 2008.

14. National Diabetes Information Clearinghouse. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. Available at: http://diabetes.niddk.nih.gov/DM/PUBS/statistics/. Accessed March 27, 2009.

15. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.

16. Eddy DM, Schlessinger L, Khan R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med. 2005;143:251-264.

17. American College of Endocrinology Task Force on Prediabetes. Diagnosis and management of prediabetes in the continuum of hyperglycemia - When do the risks of diabetes begin? Available at: www.aace.com/meetings/consensus/hyperglycemia/hyperglycemia.pdf. Accessed October 4, 2008.

18. SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:1510-1518.

19. Centers for Disease Control and Prevention. CDC’s Diabetes Program-Diabetes Projects-Children and Diabetes. Available at: http://www.cdc.gov/diabetes/projects/cda2.htm. Accessed March 27, 2009.

20. Messiah SE, Arheart KL, Luke B, et al. Relationship between body mass index and metabolic syndrome risk factors among US 8- to 14-year-olds, 1999 to 2002. J Pediatr. 2008;153:215-221.

21. Fowler MJ. Classification of diabetes: not all hyperglycemia is the same. Clin Diabetes. 2007;25:74-76.

22. Kitabachi AE, Umpierrez GE, Murphy MB, et al. Hyperglycemic crises in diabetes. Diabetes Care. 2004;27(suppl):S94-S102.

23. Borg H, Gottsäter A, Landin-Olsson M, et al. High levels of antigen-specific islet antibodies predict future beta-cell failure in patients with onset of diabetes in adult age. J Clin Endocrinol Metab. 2001;86:3032-3238.

24. Sosenko JM, Krischer JP, Palmer JP, et al. A risk score for type 1 diabetes derived from autoantibody-positive participants in the diabetes prevention trial-type 1. Diabetes Care. 2008;31:528-533.

25. Brophy S, Brunt H, Davies H, et al. Interventions for latent autoimmune diabetes (LADA) in adults. Cochrane Data Syst Rev. 2007(3);CD006165.-

26. Appel SJ, Wadas TM, Rosenthal RS, et al. Latent autoimmune diabetes of adulthood (LADA): an often misdiagnosed type of diabetes mellitus. J Am Acad Nurse Pract. 2009;21:156-159.

27. Unger J. Diagnosing and managing latent autoimmune diabetes in adults. Pract Diabet. 2008;27:32-37.

28. Fourlanos S, Varney MD, Tait BD, et al. The rising incidence of type 1 diabetes is accounted for by cases with lower-risk human leukocyte antigen genotypes. Diabetes Care. 2008;31:1546-1549.

29. Radtke MA, Midthjell K, Nilsen TI, et al. Heterogeneity of patients with latent autoimmune diabetes in adults: linkage to autoimmunity is apparent only in those with perceived need for insulin treatment: results from the Nord-Trondelag Health (HUNT) study. Diabetes Care. 2009;32:245-250.

30. American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Obstetrics. Clinical Management Guidelines for ObstetricianGynecologists Number 30, September 2001 (Replaces Technical Bulletin Number 200, December 1994): Gestational diabetes. Obstet Gynecol. 2001;98:525-538.

31. Danilenko-Dixon DR, Van Winter JT, Nelson RL, et al. Universal versus selective gestational diabetes screening: application of 1997 American Diabetes Association recommendations. Am J Obstet Gynecol. 1997;81:798-802.

32. Cosson E, Benchimol M, Carbillon L, et al. Universal rather than selective screening for gestational diabetes mellitus may improve fetal outcomes. Diabetes Metab. 2006;32:140-146.

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34. Holt RI. The Hyperglycemia and Adverse Pregnancy Outcomes trial: answers but still more questions about the management of gestational diabetes. Diabet Med. 2008;25:1013-1014.

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Practice recommendations

Routinely screen adult patients with a sustained blood pressure >135/80 mm Hg for type 2 diabetes (SOR: B).
Closely monitor pregnant women with 1 or more elevated glucose test results; although a diagnosis of gestational diabetes mellitus (GDM) requires 2 or more abnormal values, even 1 may be associated with a higher risk of adverse outcomes (SOR: C).
Include latent autoimmune diabetes in adults (LADA), a progressive form of type 1 with a slower onset, in the differential diagnosis for symptomatic patients who don’t fit the classic patterns for type 1 or type 2 diabetes (SOR: B).

Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

The youngest Americans—those born in the year 2000 or thereafter—have more than a 1 in 3 lifetime risk of developing diabetes, according to the Centers for Disease Control and Prevention.¹ That estimate, coupled with the fact that more than 2 out of 3 adults and 1 in 6 children between the ages of 2 and 19 years are overweight,² would seem to indicate a need for widespread diabetes screening. But limited health care resources, a lack of evidence that mass screening improves outcomes, and differences among leading medical associations about whom and when to screen argue against it.

FAST TRACK

The USPSTF recommends screening asymptomatic adults whose blood pressure is >135/80 mm Hg for type 2 diabetes, regardless of lipid profile.

At the same time, widespread obesity is making the presentation of hyperglycemia more complex and the forms of diabetes harder to classify. Many cases don’t follow the classic patterns, in which type 1 (formerly called juvenile diabetes) virtually always emerges in childhood and type 2 (previously known as adult-onset diabetes) is strictly an adult disease. Our evolving understanding of diabetes has led researchers to focus on prediabetes (defined as impaired fasting glucose, impaired glucose tolerance, or both) and latent autoimmune diabetes in adults (LADA), a recently reported type 1 variant that some have labeled type 1.5.³

In the face of growing complexity, the US Preventive Services Task Force (USPSTF) last year upgraded its recommendation for screening for type 2 diabetes, and researchers have developed new risk calculation tools. We’ve taken a look at the changing clinical landscape and sorted through the latest evidence to help you make sense of the latest risk and diagnostic developments in diabetes care.

Screening for type 2: A look at guidelines

Type 2 diabetes accounts for approximately 90% of the cases you’ll see.^1,4,5 The American Diabetes Association (ADA) calls for routine screening, starting at 45 years of age and continuing every 3 years thereafter in the absence of risk. But for those who are overweight or obese and have 1 or more additional risk factors, screening is recommended at any age.⁵ In addition to a body mass index (BMI) ≥25, risks include physical inactivity, a first-degree relative with type 2 diabetes, blood pressure >135/80 mm Hg (or controlled with an antihypertensive), high-density lipoproteins (HDL) <35 mg/dL, triglycerides >250 mg/dL, polycystic ovary syndrome, impaired glucose tolerance or impaired fasting glucose, and acanthosis nigricans, a pigmented thickening of the skin folds of the neck (TABLE).^6,7 Patients with the metabolic syndrome—abdominal obesity (defined as a waist circumference of >40” in men and >35” in women) and ≥2 of the following: raised triglyceride levels, elevated blood pressure, elevated fasting plasma glucose, and reduced HDL cholesterol—are at especially high risk of both cardiovascular disease and type 2 diabetes.⁸

FAST TRACK

Prediabetes increases the risk of developing type 2 diabetes by an estimated 30% over a 4-year period.

The ADA screening recommendations, however, are not based on prospective outcome studies, nor are they widely followed. Until recently, the USPSTF only recommended screening adults with hypertension and hyperlipidemia.

In 2008, after an assessment of new findings and research updates, the USPSTF revised its recommendation: The task force now calls for screening asymptomatic adults with sustained blood pressure >135/80 mm Hg—regardless of lipid profile.⁷ For patients with diabetes and hypertension, the USPSTF concluded, evidence shows that early intervention—including lowering blood pressure below conventional targets—can prevent long-term adverse outcomes of diabetes and reduce the risk of cardiovascular events.