Diabetes

Introduction to this self-study CME activity

Purpose

Studies demonstrate that morbidity due to complications of diabetes can be reduced through prevention, detection, and management.  This self-study provides practical guidance to clinicians about routine screening and prevention efforts for cardiovascular risk factors (hypertension, hyperlipidemia, tobacco use) and for microvascular disease (retinopathy, nephropathy, neuropathy.  Management of glycemic control, risk factors, and complications is organized into specific care activities to be performed at each regular diabetes visit, every 3 to 6 months, and annually.  Key recommendations for care are summarized at the beginning of the guideline.  Participants in this self-study CME activity will gain a systematic overview of care for diabetes and be able to provide systematic care for diabetes and to help prevent or delay its complications. 

 

New information in this revision: 

Screening for diabetes. Although little evidence is available on screening for diabetes, screening should be considered every 3 years beginning at age 45 or annually at any age if BMI ≥ 25 kg/m2, history of hypertension, gestational diabetes, or other risk factors.

A1c for diagnosis.  An option for diagnosing diabetes is hemaglobin A1c:  6.5% or greater is diagnostic, 5.7% -6.4% is considered pre-diabetes. (See Table 1 for diagnostic tests and values.) 

New medications for glycemic control.  Several new drugs (and drug cautions) have been released, particularly for second line therapy after metformin. 

BP target.  A reasonable clinical target is 135/80 mmHg.  Mortality increases when patients with diabetes have a diastolic blood pressure below 70 mmHg.  More aggressive control may be warranted in patients with renal disease. The HEDIS measure for BP in diabetes is <140/90 mmHg.  The clinical target of 135/80 mmHg helps assure patients are under the measurement maximum and recognizes the potential clinical benefit of somewhat lower levels.

Prescribe “statin for all” patients with diabetes including those patients over > 40 years old with LDL < 100 mg/dl.  Check baseline LFTS and if normal, no further monitoring is required. If baseline LFTs are mildly abnormal (over upper limit of normal but < 5 X upper limit of normal): monitor LFTs during first 6 months of statin treatment for stability. Abnormal baseline liver biochemistries can frequently improve with statin therapy.

Hepatitis B vaccination.  Vaccinate patients with diabetes ages 19-59 years as soon as feasbile after diabetes is diagnosed.  Risk is increased primarily due to sharing inadequately cleaned blood glucose monitors (e.g., in healthcare settings, households, worksite clinics, schools and camps). Consider vaccinating those aged ≥ 60 based on likelihood of acquiring HBV infection.

Measures of clinical care quality.  National and regional third-party payors measure 13 aspects of care for patients with diabetes related to payment based on quality of care.  See “Measures of Performance.”

Objectives

Participants in this CME activity will understand and be able to implement evidence-based cost-effective clinical strategies for the diagnosis and treatment of type 2 diabetes in adults.

Audience

This self-study activity is appropriate for primary care clinicians and other health care providers providing care for adults with type 2 diabetes.

Authors

Team Leaders

  • Connie J Standiford, MD
    General Internal Medicine
  • Sandeep Vijan, MD
    General Internal Medicine

Team Members

  • Hae Mi Choe, PharmD
    College of Pharmacy
  • R Van Harrison, PhD
    Medical Education
  • Caroline R Richardson, MD
    Family Medicine
  • Jennifer A Wyckoff, MD
    Metabolism, Endocrinology & Diabetes

Consultants

  • Martha M Funnell, MS, RN, CDE
    Diabetes Research and Training Center
  • William H Herman, MD
    Metabolism, Endocrine & Diabetes

Author Disclosures

Neither the team lead, the team members, nor the consultants have financial relationships with commercial companies whose products are discussed in this CME activity.
Hae Mi Choe, PharmD
None
Martha M. Funnell, MS, RN, CDE
Advisory Boards
Boehringer Ingelheim, Bristol-Myers Squibb/ AstraZeneca, Halozyme Thera-peutics, Eli Lilly, Animas/ Lifescan, Hygeia Inc, Intuity Medical
R. Van Harrison, PhD
None
William H. Herman, MD, MPH
Consultant
Cebix, Genentech, McKinsey & Co., Sanofi-Adventis, VeraLight
Caroline R. Richardson, MD
None
Connie J. Standiford, MD
None
Sandeep Vijan, MD
None
Jennifer A. Wycoff, MD
None

Other Acknowledgements

UMHS Guidelines Oversight Team

  • Connie J. Standiford, MD
  • Grant Greenberg, MD, MA, MHSA
  • R. Van Harrison, PhD

Literature Search Services

  • Taubman Medical Library

Production of Internet Format and Website Maintenance

  • Ellen Patrick, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was released in October 2012, with credit available through September 2015. The activity was most recently reviewed for currency of content in July 2017 and availability of credit extended through February 2020. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

 

Method of Participation

  1. View the web pages. You may print the self-study text to read off-line.
  2. Complete the on-line learning assessment test with a score of 70% or higher.  After you initially take the test, the test will be immediately electronically scored. 
    If fewer than 70% of the questions are answered correctly, the questions that were not answered correctly will be noted in red.  Review the CME content related to those topics and retake the test.
    If 70% or more of the questions are answered correctly, the correct and incorrect answers for all questions will be shown along with explanations of the basis for the correct answer.  The link to register and receive credit is shown at the end of the items and explanations. 
  3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
  4. Print the certificate of participation for your personal records.