Introduction

Diabetes is a chronic illness that requires continuing medical care and education. Patient compliance and self care are critical factors in appropriate management of the illness. The ultimate goal of the long term management process is prevention of acute and chronic complications of the disease through glycemic control defined as HbA1c of 7%.

Diagnosis:
The diagnosis of diabetes mellitus is established by the following criteria:

1. Fasting plasma glucose >140 mg/dl on at least two occasions.

2. Fasting plasma glucose >140 mg/dl and 2-hour plasma glucose >200 mg/dl with one intervening value >200 mg/dl following a 75 mg glucose load.

3. Plasma glucose >200 mg/dl and classic symptoms of diabetes including polydipsia, polyuria, polyphagia, and weight loss.

Evaluation of Newly Diagnosed Diabetes:

1. Determination of the type of diabetes mellitus should be made.

• Type 1 diabetes is characterized by sudden onset, earlier age of onset, and absolute insulin deficiency.
• Type 2 diabetes is characterized by a more gradual onset, later age of onset, and insulin resistance.

2. Complete physical exam and medical evaluation should be performed at the time of diagnosis of diabetes. Important components of this exam which should be specifically documented include:

• Medical history including vascular or neurologic symptoms
• Social history, including smoking, ethanol use, exercise, and diet
• Height and weight (specifically evaluate for obesity)
• Blood pressure
• Dilated eye exam (by optometry or ophthalmology)
• Dentition
• Skin examination
• Thyroid exam
• Cardiovascular exam
• Peripheral pulses
• Foot exam -- Podiatry referral if any abnormalities
• Neuro exam including pinprick and vibratory sensation

3. Initial Lab evaluation should include:

• Plasma glucose at every visit until the patient's diabetes has stabilized
• Glycosylated hemoglobin
• Home glucose checks (may not be needed in type 2 diabetes)
• Fasting lipid profile
• Serum creatinine
• Urinary albumin (consider a microalbumin/creatinine level, which is more accurate)
• Urinalysis
• Thyroid function (TSH)

4. At the time of diagnosis the patient should receive in-depth teaching in the following areas:

• Diabetic diet
• Understanding and managing diabetes
• Home glucose monitoring
• Diabetic foot care

Goals of Therapy:

1. The goal of treatment of diabetes is to:

• Maintain blood glucose levels at near normal levels. For most patients that is between 80 to 120 mg per dl before meals and between 100 to 140 mg per dl at bedtime. Glycohemoglobin levels should generally be less than 7.0.
• In elderly or chronically ill patients this level of control may not be appropriate. A more realistic goal for these patients is to keep the glycohemoglobin level below 8.0.
• These goals may not be met in patients who have problems with recurrent or severe hypoglycemia or poor patient compliance.

2. If a diabetic patient has a glycohemoglobin level exceeding 8.0, physician action to improve control is suggested. For elderly or chronically ill patients, actions should generally be taken if the glycohemoglobin exceeds 9.0.

3. In order to meet these goals, most patients will require:

• Self-monitoring of glucose levels at home
• Careful meal planning
• Regular exercise
• Multiple daily injections of insulin (if type 1 diabetes)
• Oral agents or insulin in diabetics who fail to respond to diet alone
• Instruction in the prevention/ treatment of hypoglycemia
• Ongoing and continuous reinforcement and education from clinicians
• Periodic assessment of treatment goals

Follow-up Care:

1. At least quarterly the patient should have an assessment of diabetic control.

2. Periodic follow-up visits should be timed to meet the medical needs of the member. In general, after diabetic control has been established and the member's medical condition is clearly stable:

• Type 1 and insulin dependent type 2 diabetics should be seen at least quarterly with a glycohemoglobin level.
• Type 2 diabetics (non-insulin dependent) should be seen at least semiannually with a glycohemoglobin level.
• An annual comprehensive exam and evaluation can be considered one of these visits.

3. Periodic follow-up exams should include the following:

• Blood pressure
• Weight
• Assessment of control. If control is not meeting the goals of treatment, an action plan should be developed, discussed with the patient, and documented in the medical record.

4. Complete medical exam and evaluation should be performed annually for all diabetics. Important components of this exam which should be specifically documented include:

• Medical history including vascular or neurologic symptoms
• Weight (and height if not previously recorded)
• Body frame size (small, medium, large)
• Blood pressure
• Visual symptoms
• Dentition
• Skin examination (including insulin injection sites)
• Thyroid exam Cardiovascular exam
• Peripheral pulses
• Foot exam (be specific with documentation)
• Neuro exam (including pinprick and vibratory sensation)

5. Laboratory evaluation of diabetes should include:

• TSH (periodically based on initial value)
• Plasma glucose (preferably via home glucose monitoring records)
• Glycohemoglobin (minimum quarterly for insulin dependent and twice yearly for non-insulin dependent)
• Urinalysis (annually)
• Microalbuminuria or Microalbumin/creatinine level (annually)
• Serum creatinine (annually)
• Lipid profile (annually)

6. An annual, dilated eye examination should be performed on all patients (except patients under age 30, who should begin these exams within five years after they are diagnosed).

7. A baseline ECG should be obtained on all diabetics if they are 40 years of age or over.

Special Considerations:

1. Diabetics should receive influenza and pneumococcal immunizations.

2. Smoking in diabetic patients is a special concern due to the higher incidence of peripheral and coronary arterial vascular disease in these patients. A provider recommendation to stop smoking should be documented and reinforced on a regular basis (at least annually).

3. Use of an ACE inhibitor is recommended in the primary treatment of hypertension in diabetics who have microalbuminuria or overt nephropathy. Patients with diabetes and evidence of microalbuinuria or overt albuminuria shoud be considered for therapy with an ACE inhibitor even if normotensive.

4. For adult diabetic patients with hypertension, the primary goal of therapy should be to decrease blood pressure to < 130/85. For isolated systolic hypertension 160 mmHg, the short-term goal is a reduction of 20 mmHg. If achieved and well-tolerated, further lowering to 140 mmHg may be appropriate.

5. Gestational diabetes requires intensive management. This guideline does not address the management of gestational diabetes.

6. Referral to a physician experienced in the care of diabetic renal disease should be considered when the serum creatinine has risen to 2.0 mg/dL in males or 1.5 mg/dL in females.

References
ADA Position Statement: Standards of Medical Care for Patients With Diabetes Mellitus, Diabetes Care 17:616, 1994.
Diabetes Control and Complications Trial Research Group (DCCT): The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl. J Med 329;977, 1993.
Monitoring diabetes Mellitus. In Therapy for Diabetes Mellitus and Related Disorders. American Diabetes Association, 1994, pg. 86-91.
Diabetes Care 1999 Jan; 22 (Supp 1): S32-S41