MD Conference Express ADA 2012 - (Page 26)
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Revisions to Guideline 6: • 6.1: Use of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) for the primary prevention of diabetic kidney disease in normotensive normoalbuminuric patients with diabetes is not recommended (1A) 6.2: Use of an ACE inhibitor or an ARB in normotensive patients with diabetes and albuminuria levels ≥30 mg/g who are at high risk of diabetic kidney disease or its progression is not recommended (2C)
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The guideline objectives include: identifying best practices for recognizing and diagnosing hyperglycemia and diabetes in the hospital setting; identifying appropriate glycemic targets and the rationale for modifying them; understanding how to best reach glycemic targets safely; and recognizing and addressing specific aspects of management (eg, transitions of care and medical nutrition therapy [MNT]). Dr. Umpierrez’s presentation covered the diagnosis and recognition of hyperglycemia and diabetes in the hospital setting (Figure 1). He described the benefits and risks of using HbA1C for diagnosis (ie, values can be altered with several conditions, and analysis should be performed using a method that is certified by the National Glycohemoglobin Standardization program) [Suadek CD et al. JAMA 2006]. Figure 1. Diagnosis and Recognition of Hyperglycemia and Diabetes in the Hospital Setting.
Admission Assess all patients for a history of diabetes Obtain laboratory BG testing on admission
Clinical evidence has failed to provide evidence that ACE inhibitors or ARBs can prevent the development of microalbuminuria in normotensive normoalbuminuric patients, but there are some signs that reninangiotensin system (RAS) blockade may be effective in preventing the development of microalbuminuria in patients with type 2 diabetes. Prof. Bilous cautioned that the majority of the patients in all of the studies were hypertensive. In addition, there were varying levels of blood pressure control among the studies, with the studies achieving the best control being neutral in terms of any preventive effect. What the studies do tell us, Prof. Bilous said, is that “we need to manage blood pressure effectively in patients with type 2 diabetes, and while RAS blockade may be an important part of that blood pressure control, it may not be the RAS blockers per se that reduce albuminuria.”
No history of diabetes BG<140 mg/dL (7.8 mmol/L)
No history of diabetes BG>140 mg/dL
History of diabetes
Managing Hyperglycemia in Hospitalized Patients
Written by Phil Vinall
Initiate POC BG monitoring according to clinical status
Start POC BG monitoring x 24-48 hours Check A1C
BG monitoring
Hyperglycemia occurs frequently in hospitalized patients and affects outcomes, including mortality, inpatient complications, length of stay, and overall hospital costs [Schmeltz LR, Ferrise C. Hosp Pract (Minneap.) 2012]. Observational and randomized controlled studies indicate that improving glycemic control results in lower rates of hospital complications in general medicine and surgery patients [Umpierrez GE et al. J Clin Endocrinol Metab 2012]. Guillermo E. Umpierrez, MD, Emory University School of Medicine, Atlanta, Georgia, USA, reviewed the latest Endocrine Society Clinical Practice Guidelines for the management of hyperglycemia in hospitalized patients in noncritical care settings [Umpierrez GE et al. J Clin Endocrinol Metab 2012].
A1C≥6.5%
Reproduced with permission from G. Umpierrez, MD.
He discussed monitoring of glycemia and glycemic targets (Table 1) in the noncritical care setting (ie, a premeal glucose target of <140 mg/dL [7.8 mmol/L] and a random blood glucose of <180 mg/dL [10.0 mmol/L]) for the majority of patients with noncritical illness [Umpierrez GE et al. J Clin Endocrinol Metab 2012]. He also covered MNT, transition from home to hospital, and pharmacological therapy (eg, scheduled subcutaneous insulin therapy consisting of basal or intermediate-acting insulin given once or twice a day in combination with rapid- or short-acting insulin administered before meals in patients who are eating; Table 2).
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August 2012
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Table of Contents for the Digital Edition of MD Conference Express ADA 2012
MD Conference Express ADA 2012
Contents
ORIGIN Trial Results
New Lessons in Hypertension and Diabetes
Closed-Loop Insulin Therapy in Young Children
The Precocious “AGE’ing” Effect of Type 1 Diabetes in Children
Abatacept in Patients with New-Onset Type 1 Diabetes: One-Year Follow-Up
Explaining the UKPDS Legacy Effect
Insulin and Cancer
Insulin Analogs
Dyslipidemia
Insulin Therapy
Incretin Therapies
Diabetes and Chronic Kidney Disease Guidelines Update
Managing Hyperglycemia in Hospitalized Patients
CVD Prevention and Treatment in Women With Diabetes
China Da Qing Study: Lifestyle Change in Women With IGT Extends Life
Markers of Macrovascular Complications in Pediatric Diabetes
Nonoperative Management of the Infected Diabetic Foot
Diabetic Retinopathy: Changing Prevalence and Severity Require Flexible Interventions
New ADA/EASD Position Statement Endorses a Patient-Centered Approach
MD Conference Express ADA 2012
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