CORE: Diabetes

Goal: Review factors, diagnose, treatment, and monitoring of type 2 diabetes mellitus

Objectives:

1. What are the risk factors for diabetes mellitus?

2. Discuss how to make diagnosis of diabetes mellitus

3. Discuss management of diabetes mellitus, both with non-insulin and insulin agents, as well as appropriate lab monitoring

4. Build diabetes resources, including smartphrases and order preference lists, into Epic

Case 1: Non-insulin agents

Metta Formin is a 42 year old male with no past medical history who presents for an annual physical. His BMI is 35 and he smokes 1 ppd of cigarettes. He notes that his parents both suffered from diabetes and he’s wondering if he should be worried that he has it.

• What are risk factors for diabetes mellitus?

• How do you make the diagnosis of diabetes mellitus? What labs should you consider ordering for further evaluation?

You order labs for Metta - his HbA1c is 8%, fasting lipids with TC 220, LDL 130 otherwise normal, blood glucose 250 otherwise normal CMP, normal microalbumin/creatinine ratio. You invite him back to the office to talk about next steps.

• What are lifestyle changes that you would recommend for Metta?

• What kinds of pharmacological therapy would you recommend for Metta? If he continues to be uncontrolled after 3 months of this initial medication, what would you recommend? What other medications other than the first answer for glycemic control would you recommend? What are pertinent side effects to watch out for with each specific medication or class of drug?

• How often should you see Metta in clinic? What labs should you order for monitoring and how often? What other health screening does he need?

Case 2: Insulin titration

Kandi Corn is a 45 year old female who presents with polyuria, polydipsia, and unintentional weight loss of 10 lbs in the past 4 weeks. She is worried about diabetes based on some ads she’s seen on TV. Her BMI is 32, and her BP in clinic is 120/80. Labs show an HbA1c of 11, BMP with glucose 350 but otherwise normal, normal microalbumin/creatinine ratio, normal lipid panel. She is interested in next steps in management.

• What medications would you recommend starting for glycemic control?

• How do you calculate recommended insulin dose to (both when initiating insulin and for maximum levels)?

• If her weight is 60 kg, what would her starting dose of insulin and estimated max dose of insulin be (short-acting and long-acting)?

• What counseling would you give regarding checking blood sugars and hypoglycemia?

Resources:

JAMA article - Metfomin in 2019

Apps: ADA Standards of Care, AACE/ACE

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