Essay Elements:

• One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
• Brief introduction of the case
• Identification of the main diagnosis with supporting rationale
• Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
• Diagnostic plan with supporting rationale or references
• A specific treatment plan supported by recent clinical guidelines
• Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.

PATIENT DASHBOARD

PATIENT DASHBOARD

Name: Maria Sanchez

• Age: 57
• Sex assigned at birth: female
• Gender identity: female
• Pronouns: she/her/hers
• Language for medical communication: English; prefers written materials in Spanish

INTRODUCTION

TEACHING

You are working in Dr. Wilson's family medicine clinic. He asks you to see Maria Sanchez, a patient who has diabetes and who is new to the practice.

He instructs you, "Take a medical history, which includes the relevant information for a comprehensive diabetes visit. Remember, diabetes care is complex and includes many issues beyond controlling blood sugar. It is also becoming more common - over 10% of the US population has diabetes (the vast majority being type 2), and the CDC estimates that about a fifth of adults are undiagnosed.

TEACHING POINT

Comprehensive Annual Diabetes Visit

The American Diabetes Association (ADA) provides standards of care for diabetes management that are updated annually and can be downloaded to a smartphone.

Goals during an initial medical visit for diabetes care:

• Confirm the diagnosis and classify diabetes.
• Evaluate for diabetes complications, potential comorbid conditions, and overall health status.
• Identify care partners and support system.
• Assess social determinants of health and structural barriers to optimal health and health care.
• Review previous treatment and risk factor management in people with established diabetes.
• Begin engagement with the person with diabetes in the formulation of a care management plan including initial goals of care.
• Develop a plan for continuing care.

See the American Diabetes Association's "Components of the comprehensive diabetes medical evaluation at initial, follow-up, and annual visits": Table 4.1

FEATURES OF THE EMR

TEACHING

You ask, "How do you remember all that needs to be done at each visit?"

Dr. Wilson acknowledges that remembering all that is recommended in the visit can be challenging. He opens a template within the electronic medical record (EMR) that outlines the appropriate goals for a diabetes visit. "Using the EMR template increases the likelihood that we will provide Ms. Sanchez with the recommended care."

He continues, "I also use the EMR to evaluate how I am taking care of my entire patient population. Four months ago, I introduced a program in our practice to increase the initiation of insulin in our patients with type 2 diabetes whose glucose control is not optimal. Last week, I generated a report to assess our progress. The percentage of my patients with an A1C less than or around 7% had increased from 65% to 77%."

Dr. Wilson concludes, "EMRs are great, but they won't solve all our problems in taking care of patients. They can sometimes get in the way of effective patient-clinician interaction so it is worth considering how best to use the EMR to support your patient. Don't spend all your time interacting with the computer. Your patient is your best source of information!"

TEACHING POINT

Electronic Medical Record

An electronic medical record system:

• Offers templates and care gap checklists that can increase the likelihood that patients will receive recommended care.
• May improve the quality of care by allowing increased patient participation and care coordination.
• Provides tools to improve patient care across an entire population.
• Allows documentation of improved performance, which may increase reimbursements by some insurers.
• Can limit direct communication between the clinician and patient as well as contribute to burnout

CHRONIC COMPLICATIONS OF DM

TEACHING

Dr. Wilson asks you how you might remember your plan for a diabetes visit if you did not have an EMR template to prompt you. "Let's think about the pathophysiology of diabetes and its complications, and use this knowledge to create our agenda."

TEACHING POINT

Pathophysiology of Diabetes

Type 1 diabetes mellitus

The pancreas is damaged through autoimmune inflammation leading to the destruction of the beta cells. The loss of beta cells leads to the complete inability to produce insulin (immunologic etiology).

Type 2 diabetes mellitus

The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell insulin secretion may initially compensate, but over time beta cells fail.

Chronic complications

Both types of diabetes can result in the same complications. High blood glucose eventually affects blood vessels, and therefore organs throughout the entire body. Complications are typically considered to be either macrovascular (cardiovascular and cerebrovascular disease) or microvascular (retinopathy, neuropathy, nephropathy).

Remember: Hypertension, which is common in patients with diabetes, can make vascular disease much worse.

Question

Dr. Wilson asks you: Which of the following are common long-term complications of type 2 diabetes?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Cerebrovascular disease
• B. Coronary heart disease
• E. Nephropathy
• F. Neuropathy
• H. Retinopathy
• Diabetes:Common Long-term Complications
• Macrovascular: Atherosclerotic cardiovascular disease, including coronary heart disease, cerebrovascular disease, and peripheral arterial diseasePeople with diabetes are two to four times more likely to have heart disease or stroke than people without diabetes. Patients with diabetes who have a myocardial infarction have worse outcomes than patients without diabetes, and a diagnosis of diabetes is considered equivalent in risk to having had a previous myocardial infarction. Management of the cardiovascular risk factors so commonly found alongside diabetes is therefore essential in preventing morbidity and mortality.The American College of Cardiology/American Heart Association ASCVD risk calculator(Risk Estimator Plus) can be a useful tool to estimate 10-year ASCVD risk and includes:
• • Age (options between 20-79)
  • Sex (options of male and female)
  • Race (options of White, Black, and other)
  • Blood Pressure (Systolic and Diastolic)
  • Cholesterol (Total, HDL, LDL)
  • Diabetes (Yes/No)
  • Smoking (current, former, never)
  • Treatment for hypertension (Yes/No)
  • On a statin (Yes/No)
  • On aspirin (Yes/No)
  Of note, this calculator includes a field for race, which may or may not provide more accurate estimates of risk in any given individual. It is important to remember that race is a poor substitute for the diversity of human backgrounds, and race alone does not confer increased risk for disease; rather, race can serve as a marker for structural issues (such as racism) that themselves may confer that increased risk.Microvascular:RetinopathyDiabetes is the most common cause of new cases of blindness among adults aged 18-64 years. Factors associated with diabetic retinopathy include higher hemoglobin A1C levels, a longer duration of diabetes, insulin use, dyslipidemia, nephropathy, and higher systolic blood pressure. Achieving optimal glycemic control can prevent or delay the onset and progression of diabetic retinopathy. Optimizing blood pressure and lipid control can also slow the progression of diabetic retinopathy.NeuropathyNeuropathy is a heterogeneous condition that is associated with nerve pathology. Diabetic peripheral neuropathy can affect nearly 50% of adults with diabetes and can put patients at risk for pain, foot ulcers, and lower limb amputation. The condition is a diagnosis of exclusion (other neuropathies may be present in people with diabetes and may be treatable). It may be asymptomatic, but if not recognized, patients are still at risk for injury. Glycemic control can prevent some neuropathies in type 1 diabetes, and may slow its progression in type 2 diabetes, but does not reverse neuronal loss.NephropathyNephropathy is common: 20-40% of people with diabetes develop diabetic nephropathy, which is a primary cause of renal failure. Treatment includes optimizing glycemic and blood pressure control in all patients, and the use of medications in certain patients to reduce the progression of chronic kidney disease.

Dr. Wilson asks you about acute problems related to diabetes.

TEACHING POINT

Acute Diabetic Decompensations

Type 1 diabetes

In patients with type 1 diabetes, without sufficient insulin, blood sugar runs high, and diabetic ketoacidosis (DKA) can develop.

Type 2 diabetes

Patients with type 2 diabetes with hyperglycemia more often develop hyperosmolar hyperglycemic state (HHS). Patients with type 2 diabetes can also develop DKA because, over time, pancreatic function dwindles. If insulin deficiency is severe enough, a patient with type 2 diabetes may produce ketones as seen in DKA.

Question

Which of the following statements are true regarding hyperosmolar hyperglycemic state (HHS)?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Dehydration is a common finding.
• B. Ketones are absent or mildly elevated.
• D. Plasma glucose levels are commonly > 600 mg/dL.

Answer Comment

The correct answers are A, B, and D.

For more information about HHS and how it is distinguished from DKA, see the Teaching Point below.

TEACHING POINT

Hyperosmolar Hyperglycemic State (HHS) versus Diabetic Ketoacidosis (DKA)

Both HHS and DKA are life-threatening conditions that require prompt management.

Physical findings of HHS:

HHS is characterized by severe dehydration. A profound fluid deficit is usually present, in excess of 9 L on average in adults. Serum osmolality usually exceeds 320 mOsm/kg. Fluid replacement is a key component of treatment.

Precipitants of HHS:

Infections such as pneumonia and urinary tract infections, accompanied by decreased fluid intake, are the most common underlying causes of HHS. Other acute conditions, such as stroke, MI, or pulmonary embolism, may also precipitate HHS.

PATIENT INTRODUCTION AND HISTORY

HISTORY

You enter the exam room and introduce yourself, explaining your role as a student.

You read the nurse's note on the encounter form:

Ms. Sanchez is a 57-year-old with diabetes and hypertension. She is tired, has increased frequency of urination, and burning in her feet. Her PHQ-2 screening for depression is negative.

Approach to the comprehensive diabetes visit history

"What brought you in today?"

"I've had burning and stabbing pains in my feet for the last four months, but it has gotten worse in the last two weeks. It happens every day but seems worse at night. I have some tingling in my fingertips as well, but not all the time. I have also been going to the restroom more often, around eight times in the day and twice at night. It is making it harder to get my work done. And I have diabetes, so I am sure it is time to get that checked again."

You ask about dysuria, back pain, and fever, and she does not have these symptoms.

"How were you first diagnosed with diabetes?"

"At 49, I had a lot of urination, and I was drinking water all the time. My sister has diabetes also. She told me to go to the doctor."

"Have you ever been hospitalized related to your diabetes?"

"No."

"Have you had any problems caused by diabetes?"

She does not think she has any problem with her kidneys or heart. She reports no sores or infection in her feet and no history of stroke. When you ask about problems with her eyes, she says her vision has been a little blurry. She was told a few years ago that her blood pressure was high and to try to diet and exercise for that.

"When was your last visit to the dentist?"

"About three years ago."

"How has your diabetes been treated?"

"I took metformin for four years. Last year, they gave me glipizide also. I take both two times every day."

She adds, "I lost my glucometer when I moved to the area eight months ago. I haven't been able to monitor my blood sugar or blood pressure at home."

"What do you eat in a typical day?"

"I do not always have time to eat breakfast. For lunch, I get something fast, either a burger and fries or sometimes pizza. For dinner, we cook at home—rice and beans, chicken or pork, some vegetables—I love cooking with my family.

She continues, "I drink four to five sodas and iced teas a day; the caffeine helps me get my work done."

"Tell me about your exercise."

She is physically active during the day at her work. She does not engage in any planned exercise outside of work.

"What types of things do you do to take care of your diabetes?"

"The nurse at my previous doctor's office showed me how to use the machine to check my blood sugar and gave me a book about diabetes. It was in English. I did not read it."

When you tell her that her chart at this office includes a note about preferring written materials in Spanish, Ms. Sanchez says that she was pleased that the intake form included that question. "No one has ever asked me that before, and I do find it easier to review things later in Spanish.

REVIEWING PAST HISTORY AND ROS

HISTORY

"What do you think might be causing the symptoms you are having now?"

"I think all the standing I do at work may be making my feet burn. So I try to keep my feet up when I can, and not do any extra walking. I wonder if I am urinating more because I am drinking more, which feels like when I first got diabetes."

"Why do you think your diabetes started when it did?"

"Eight years ago, my daughter was expecting her third child. She lost the baby and I took care of her during that very sad time. I think my worry probably caused my weight loss and sickness. Then, last year when my husband died, I think my loneliness probably made my diabetes worse."

You express concern that Ms. Sanchez has experienced so many major stressors in her life, and agree that stressors can have a significant impact on health. Together with her, you review the results of her PHQ-2, and she tells you that she is feeling better now than she did 6 months ago, though is still grieving. You also acknowledge that her burning feet are a barrier to her ability to be physically active and exercise. You make a note to recommend a diabetes education visit when you present the information to Dr. Wilson.

You continue to obtain the following history:

Past medical history:

Type 2 diabetes mellitus and hypertension. Gravida 3 Para 3; birth weights were 8.5 lbs., 10 lbs., 9.5 lbs. In her second and third pregnancies, she was treated for gestational diabetes. No hospitalizations, no surgeries.

Social history:

Ms. Sanchez moved from Puerto Rico with her husband when she was 20. Her three children are grown and live in different parts of the U.S. After her husband had a stroke two years ago, she cared for him for a year before he died. Due to loneliness and increasing financial pressures, she moved here to live with her sister eight months ago. She works as a medical assistant. She completed high school and speaks English fluently, preferring to read in Spanish.

She does not smoke. She drinks an 8 oz. glass of wine about twice a month and on special occasions. She does not use any other substances.

She attends mass at a Catholic church twice a week and appreciates the support from this community. She has health insurance through her work.

Medications:

Metformin (Glucophage) 1,000 mg PO twice a day

Glipizide (Glucotrol) 5 mg PO twice a day

Review of Systems:

General:

Increased appetite, weight gain of 15 lbs over the last year. Increasing fatigue in the last three to four weeks. Sleeps well, roughly seven hours per night, no excessive snoring.

Eyes:

Increasingly blurred vision over two months, worse in the afternoon.

Cardiac:

No chest pressure or pain at rest or with exertion. No shortness of breath.

Genitourinary:

Increased urinary frequency over two to three weeks. No burning with urination.

Extremities:

Burning, tingling, and at times stabbing pains in both feet for the last four months, occurs daily but seems worse at night. Some tingling in fingertips as well, but intermittent.

Psychiatric:

No depressed mood, no anhedonia.

You thank Ms. Sanchez and explain that you are going to talk with Dr. Wilson and then you will both return to talk some more and perform a physical exam.

SCREENING FOR AND DIAGNOSIS OF DIABETES

TESTING

You present a focused history to Dr. Wilson. You and Dr. Wilson discuss the diagnostic criteria that would lead to a diagnosis such as Ms. Sanchez's. You also review who should be screened for diabetes.

See the associated reference ranges in conventional and SI units.

TEACHING POINT

Screening Recommendations for Type 2 Diabetes

American Diabetes Association Recommendations

1. Screening should begin at age 35 for all people. If results are normal, testing should be repeated at a minimum of three-year intervals, or sooner if risk status changes.

2. Screening should begin earlier in adults with risk factors (e.g., overweight or obese, first-degree relative with diabetes, history of gestational diabetes). If results are normal, testing should be repeated at a minimum of three-year intervals, or sooner if risk status changes.

3. Patients with prediabetes (A1C ≥ 5.7%, impaired glucose tolerance (two-hour plasma glucose > 140 mg/dL following a 75 gram glucose load) should be tested annually.

4. People who have gestational diabetes during pregnancy should be screened for prediabetes and diabetes between four and 12 weeks postpartum, and routinely thereafter.

United States Preventive Services Task Force (USPSTF) Recommendations

• Screen for prediabetes and type 2 diabetes in adults aged 35 to 70 years whose weight is in the overweight or obesity category. Patients with prediabetes should be offered or referred to effective preventive interventions.
• The USPSTF also recommends that clinicians should consider screening at an earlier age in people with certain risk factors: family history of diabetes, personal history of gestational diabetes, or personal history of polycystic ovarian syndrome.

• A note on Race:
• Both the ADA and the USPSTF recommend screening at a lower BMI in Asian American persons. According to the USPSTF, "data suggest that a BMI of 23 or greater may be an appropriate cut point in Asian American persons, because a difference in body fat composition in Asian persons results in underestimation of risk based on BMI thresholds used to define overweight in the US."

Both groups also recommend that earlier screening should be considered in people from groups who are disproportionately affected by type 2 diabetes (American Indian/Alaska Native, Asian American, Black, Hispanic/Latino, or Native Hawaiian/Pacific Islander). It is important to keep in mind that race/ethnicity alone are not causal factors in the development of diabetes, rather, race/ethnicity may be serving as proxies for the social and structural factors that impact the health of different groups of people.

TEACHING POINT

Diagnostic Criteria for Diabetes Mellitus

The diagnosis requires two abnormal glucose test results from the same sample, or two abnormal tests measured at different times.

1. A fasting plasma glucose of greater than or equal to 126 mg/dL. Fasting is defined as no caloric intake for at least eight hours.
2. A hemoglobin A1C greater than or equal to 6.5%.
3. Two-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT).

Two test results are not needed if there is a clear clinical diagnosis (e.g., patient in a hyperglycemic crisis or with classic symptoms of hyperglycemia, and a random plasma glucose ≥ 200 mg/dL).

PREVALENCE OF DIABETES

TEACHING

You remark that "Ms. Sanchez has many risk factors for diabetes. She is overweight (BMI of 29) and had gestational diabetes in two of her pregnancies. She has a sister with diabetes, and she identifies as Latina, so she is part of a population that is disproportionately affected by diabetes, likely due to social and structural determinants of health in the US. I wonder how long she actually had diabetes or pre-diabetes before being diagnosed."

Dr. Wilson answers, "There is evidence that by identifying patients with prediabetes, we may be able to prevent or delay the onset of diabetes with intensive lifestyle modifications. This program is a nice resource for patients at risk for diabetes who are trying to prevent it from developing."

TEACHING POINT

Prediabetes

It is estimated that 38% of the US adult population has prediabetes, which is defined as the presence of either impaired fasting glucose (fasting glucose 100—125 mg/dl) or impaired glucose tolerance (2 hr values of oral glucose tolerance testing 140—199 mg/dl). Progression to type 2 diabetes can be delayed or prevented with lifestyle modification, and to a lesser degree with medication.

The Diabetes Prevention Program (DPP) is an intensive lifestyle modification program authorized by Congress and supported by the Centers for Disease Control. In a five-year study comparing it to diet/exercise information and 850 mg of metformin twice a day, intensive lifestyle modification resulted in a 58% reduction in risk for type 2 diabetes or a delay of about 11 years. The metformin group showed a 31% reduction in risk and over 15 years of follow-up, certain groups were identified as having the most benefit from metformin: those with a higher baseline fasting glucose (≥ 110 mg/dL versus 95–109 mg/dL), those with a higher A1C (6.0–6.4% versus < 6.0%), and people with a history of gestational diabetes.

PLANNING A FOCUSED PHYSICAL EXAM

TEACHING

You and Dr. Wilson review Ms. Sanchez's vital signs.

Vital signs:

• Temperature is 37 C (98.6 F)
• Pulse is 74 beats/minute
• Respiratory rate is 12 breaths/minute
• Blood pressure is 154/90 mmHg
• Weight is 82 kg (181 lbs)
• Height is 168 cm (66 in)
• Body mass index is 29 kg/m2

Based on her history of elevated blood pressure and the measurement today, Ms. Sanchez meets the criteria for stage 2 hypertension.

Dr. Wilson asks you what portions of the physical you would like to focus on. You respond, "Since Ms. Sanchez has both diabetes and hypertension and she also has some visual changes, I would examine her eyes for retinopathy."

Dr. Wilson tells you, "We won't dilate Ms. Sanchez's eyes today, but we will examine her eyes and refer her to an ophthalmologist for a fundoscopic exam. What else?"

"I would examine her heart, and check her feet."

TEACHING POINT

Diabetic Retinopathy

Since retinopathy is asymptomatic during its initial course, and early treatment can help reduce vision loss, it is important to identify and treat early with a comprehensive fundoscopic exam. This should happen annually, with an eye care professional.

In severe, non-proliferative retinopathy, look for the following findings on a fundoscopic exam:

• Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction.
• Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages.
• Microaneurysms are more punctate dark lesions that indicate vascular dilatation.

Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia.

Question

Which of the following elements may comprise a comprehensive foot examination for a diabetes patient?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Assess the skin for color changes, hair loss, and scaling
• C. Evaluate the feet for sensation to vibration
• D. Inspect the feet for abrasion, callus formation, ulceration, and infection
• E. Inspect the feet for bony abnormalities
• F. Palpate dorsalis pedis and posterior tibial pulses bilaterally

Annual Foot Exam for Patients with Diabetes

The American Diabetes Association recommends that all patients with diabetes have an annual foot exam to assess risk for ulcerations and amputations. Those with evidence of sensory loss, or prior ulceration or amputation, should have their feet inspected at every visit.

Foot ulceration is the result of impaired sensation (distal symmetric polyneuropathy) and impaired perfusion (diabetes vasculopathy and peripheral vascular disease), both of which are independent, strong risk factors for foot ulceration and amputation.

The early recognition and appropriate management of neuropathy in a patient with diabetes is important because:

1. Up to 50% of diabetic peripheral neuropathy (DPN) may be asymptomatic but leave patients at risk of foot ulceration.
2. Nondiabetic neuropathies may be present in patients with diabetes and may be treatable.
3. While specific treatment for the underlying nerve damage is currently not available—other than improved glycemic control, which may slow progression but not reverse neuronal loss—effective symptomatic treatments are available for some manifestations of DPN.
4. Specialized footwear can help prevent plantar foot ulceration recurrence or worsening.

The foot exam should include:

• Testing for loss of protective sensation with a 10-gram monofilament PLUS any one of the following:

• Vibration using a 128-Hz tuning fork
• Pinprick sensation
• Temperature
• Ankle reflexes

• Assessment of pedal pulses (dorsalis pedis and posterior tibial arteries). Assessing the arterial supply to the lower limbs and feet is essential in the evaluation for peripheral vascular disease, the strongest risk factor for delayed ulcer healing and amputation. Patients with symptoms of claudication or with decreased pedal pulses should be referred for ankle-brachial indexes.
• Inspection: Skin changes such as hair loss and color changes may signal vascular insufficiency. Since foot ulceration is usually caused by breaks in the skin due to accidental trauma or poorly fitted footwear, feet should be inspected for breaks in the skin, pressure calluses, existing ulceration, infection, and bony abnormalities that can lead to abnormal pressure distribution. The patient's footwear should also be inspected for abnormal patterns of wear and appropriate sizing.

PHYSICAL EXAM

PHYSICAL EXAM

You and Dr. Wilson go to Ms. Sanchez's exam room, greet her, and then perform the physical examination together.

Eyes: Normal red reflex. Normal disc size and color with sharp edges. No obvious AV nicking or exudates noted.

Neck: No jugular venous distention (JVD). Thyroid nontender, not enlarged, no masses.

Cardiovascular: Normal S1 and S2; no murmurs, rubs, or gallops. No carotid bruits.

Lungs: Normal respiratory movements and clear to auscultation bilaterally.

Abdomen: Soft, nontender, nondistended, no masses. Liver not enlarged.

Skin: Hyperpigmented velvet-like plaques on the posterior neck and axilla bilaterally.

Feet: Cool, dry, thin skin. No abrasions or ulcers present. Bilateral callus formation on the medial side of the great toes. Normal bony structure. Nails are thick and long. Dorsalis pedis and posterior tibial pulses are both 3 out of 4 in strength bilaterally. Moderately impaired vibratory sensation bilaterally. Diminished sensation to monofilament testing in 3/4 sites tested on each foot. No edema. The patient's shoes are worn and stretched around the great toes, and appear small in size when compared to her feet.

ORDERING LAB WORK

TESTING

After you and Dr. Wilson complete the exam, you excuse yourselves from the room. You ask Ms. Sanchez to change back into her clothes while you are gone.

Question

In the hallway, Dr. Wilson asks, "Since Ms. Sanchez has not been seen for her diabetes for over a year, which of the following tests are appropriate to order?"

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• B. Lipid profile (total cholesterol, LDL- and HDL-cholesterol and triglycerides)
• D. Hemoglobin A1C
• E. Liver enzyme tests (LFTs)
• F. Serum B12 levels
• G. Serum creatinine and calculated GFR
• H. Spot urine albumin/creatinine ratioRecommended Diabetes Follow-Up Laboratory StudiesSee Table 4.1 - Components of the comprehensive diabetes medical evaluation at initial, follow-up, and annual visits, from the 2022 ADA Standards of Medical Care in Diabetes.Lab tests at a diabetes follow-up visit are ordered to monitor diabetic control and any side effects of treatment, and to assess for complications and co-existing conditions.Diabetic control is monitored via the hemoglobin A1C. The A1C is a measurement of glycosylated hemoglobin and represents plasma glucose concentrations over a four- to-12-week period of time. Follow-up testing is recommended at least two times a year in patients who are stable and whose A1C is less than 7; it should be performed quarterly in patients when treatment is changing or if A1C is > 7. Point-of-care testing for A1C provides the opportunity for timely (during the visit) treatment changes.Measuring a fingerstick blood glucose is indicated if a patient acutely endorses symptoms of hyperglycemia or hypoglycemia at the time of the visit. Otherwise, this measurement does not provide more useful information about glycemic control than can be obtained from an A1C.Screening for and monitoring diabetic nephropathy is recommended at diagnosis and annually. In addition, many diabetes medications are excreted through the kidneys and require monitoring to avoid drug toxicity (e.g., metformin, which can cause metabolic acidosis). The spot urine albumin-to-creatinine ratio screens for microalbuminuria. In patients with urinary albumin > 30 mg/g creatinine and/or an eGFR < 60 mL/min/1.73 m2, consider monitoring twice annually. (24-hour or timed urine collections are difficult to obtain and add little to the spot urine measurements).The serum creatinine and calculated GFR are used to monitor or stage chronic kidney disease. Automatic calculators directly calculate the GFR from the serum creatinine level. Of note, these calculators include race (Black versus non-Black), which has come into question given that this oversimplifies diversity within and among racial groups, and may contribute to systemic racism in medicine. New eGFR equations that do not incorporate race, but do incorporate cystatin C (a marker of endogenous filtration), as well as creatinine, may be more accurate as well as more inclusive, and less likely to perpetuate bias.During clinical trials, up to 7% of patients taking metformin developed asymptomatic subnormal serum vitamin B12 levels. In patients taking metformin, especially in the setting of neuropathy, B12 levels are recommended.Screening patients with type 1 diabetes (but not type 2) for autoimmune thyroid disease is recommended.It is recommended to obtain a lipid profile annually and after the initiation or dose changes of medications that affect the lipid profile (including some blood pressure and diabetes medications, as well as lipid-lowering agents).Diabetes is associated with the development of nonalcoholic fatty liver disease, which can include nonalcoholic steatohepatitis, liver fibrosis, cirrhosis, and hepatocellular carcinoma. Therefore, it is recommended to check liver enzyme tests (traditionally known as LFTs) at the initial visit and annually.

MEANINGFUL MANAGEMENT

MANAGEMENT

in Dr. Wilson's practice, patients are asked to have preliminary lab work completed before their first visit. Since Ms. Sanchez was able to do this, her results are available in the EMR. "It is helpful to have the lab results available at the time of the visit, so we can better collaborate with the patient in the treatment plan. When the patient is involved in the management, we are more likely to be successful working together.”

While you are going over the labs, Dr. Wilson offers a framework for guiding treatment decisions. "It is important to look at treatment from the patient's perspective. For example, strong evidence may exist that a specific drug can lower a lab value to optimal levels. What you really want is evidence linking this improved lab value to outcomes that really matter."

He asks,

"What are some outcomes that you think really matter to patients?"

"Well, reducing myocardial infarction and stroke, blindness, and of course, mortality, would be important. It is easy to assume that bringing abnormal lab values into the normal range automatically means improved outcomes. But I guess that may not always be the case.

Which of the following interventions has evidence of improving patient-oriented cardiovascular disease outcomes for patients with diabetes?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Adding a high-intensity statin for patients 40—75 yrs old with LDL-c > 70 mg/dL and ≥ 7.5% estimated 10-year ASCVD risk
• B. Adding a moderate-intensity statin for patients 40—75 yrs old with LDL-c > 70 mg/dl
• E. Lowering blood pressure in patients with blood pressure > 140/90 mmHg
• G. Treating patients with dyslipidemia with diet and exercise
• H. Using aspirin as secondary prevention in patients with diabetes and a history of CVD

Management of Specific ASCVD Risk Factors

Atherosclerotic cardiovascular disease, or ASCVD is the leading cause of death in patients with diabetes. People with diabetes are two to four times more likely to have heart disease or stroke than people without diabetes. Myocardial infarction in people with diabetes leads to worse outcomes than in people without diabetes, and a diagnosis of diabetes is considered equivalent in risk to having had a previous myocardial infarction. Management of the cardiovascular risk factors so commonly present in people with diabetes is essential in preventing morbidity and mortality.

SMOKING CESSATION:

Advise all patients not to use cigarettes and other tobacco products or e-cigarettes.

Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care.

Advising all patients to cut back on their smoking has not been shown to improve cardiovascular outcomes; rather, patients should be advised not to use tobacco products. A number of large randomized clinical trials have demonstrated the efficacy and cost-effectiveness of smoking cessation counseling in changing smoking behavior, and there is evidence that people with diabetes who quit smoking are able to better manage their blood sugar.

Hypertension:

Blood pressure goals should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences. According to the ADA, the treatment goal should be <130/80 mmHg, if it can be safely obtained.

Lifestyle recommendations for reducing blood pressure include reducing sodium and increasing potassium intake, moderating alcohol intake, smoking cessation, and increasing physical activity.

All first-line classes of anti-hypertensive (thiazides, ACE inhibitors, angiotensin receptor blockers (ARBs), or calcium channel blockers) are useful and effective medications for patients with diabetes. For patients with known coronary artery disease and/or an elevated urinary albumin/creatinine ratio, an ACE inhibitor or ARB is recommended by the ADA as first-line therapy.

Dyslipidemia:

Abundant evidence supports the use of statins in the prevention of cardiovascular morbidity and mortality in patients with diabetes. Measurement of a lipid profile is recommended at the time of diagnosis of diabetes and then annually.

The American College of Cardiology and American Heart Association (ACC/AHA) and the ADA make the following medication-specific recommendations for managing hyperlipidemia in people with diabetes:

• Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age, and a high-intensity statin should be considered on the basis of risk assessment.
• High-intensity statin therapy is reasonable for adults 40 to 75 years of age with multiple ASCVD risk factors.
• A statin should be considered in adults 20-39 years of age whose diabetes has the following characteristics:
  • long duration (> 10 years for type 2)
  • albuminuria
  • eGFR <60
  • retinopathy
  • neuropathy
  • ABI < 0.9
• Statin therapy should be continued in adults older than 75 already on a statin; in those who are not, initiating a statin could be reasonable after a discussion of potential benefits and risks.
• Ezetimibe may be added to maximally tolerated statin therapy in adults whose ASCVD risk ≥ 20%.

Lifestyle therapy to improve the lipid profile and reduce the risk of developing ASCVD in patients with diabetes mellitus is also important. The ADA recommends focusing on weight loss (if indicated); application of a Mediterranean style or Dietary Approaches to Stop Hypertension (DASH) eating pattern; reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity.

Aspirin:

Aspirin is effective in reducing cardiovascular morbidity and mortality in patients with previous MI or stroke (secondary prevention). For patients with no previous cardiovascular events (primary prevention), the net benefit is not as evident.

Aspirin therapy for primary prevention can be discussed with a patient through a process of shared decision-making, weighing the potential cardiovascular benefits (generally small) with the risk of bleeding. According to the USPSTF (2022), the decision to initiate low-dose aspirin for the primary prevention of CVD in adults aged 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one.

The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older (Grade D).

For people with diabetes, the American Diabetes Association (ADA) recommends:

• Considering aspirin therapy as a primary prevention strategy for those who are at increased cardiovascular risk, after a discussion with the patient on the benefits versus risk.
• Aspirin should be used as a secondary prevention strategy in those with a history of ASCVD.

Glycemic control:

Lowering A1C to < 7% has been shown to prevent microvascular disease (retinopathy and nephropathy). Whether this level of glycemic control prevents macrovascular disease has been less clear. A meta-analysis of 5 randomized controlled trials of intensive (A1C of 6–6.5) versus standard (A1C of 7%) glycemic control showed a significant reduction in fatal and non-fatal myocardial infarctions but failed to show a decrease in stroke or all-cause mortality. Another randomized trial of intensive glycemic control found no benefit for preventing CVD over five years but found an increase in all-cause mortality. Notably, more stringent glucose control confers a greater risk of hypoglycemia.

Current ADA guidelines recommend an A1C goal for the majority of nonpregnant adults of less than 7%, though more or less stringent goals may be appropriate for individual patients if achieved without significant hypoglycemia or adverse events.

Other organizations interpret the evidence differently. For example, the American College of Physicians (ACP) recommends an A1C goal between 7% and 8% for most patients.

Using the Pooled Cohort Equations risk calculator, you estimate Ms. Sanchez's ten-year ASCVD risk at 11.4%. (Of note, depending on whether you input her race as “white,” “African American,” or “other,” her risk varies between 11.4% and 26.2%, which provides an example of the potential issues with race-based calculators, as described previously). In either case, she would likely benefit from lifestyle treatment and high-intensity statin therapy to prevent ASCVD. A discussion about the potential risks and benefits of aspirin therapy would also be warranted.MAKING A TREATMENT PLAN

THERAPEUTICS

You have several ideas you would like to discuss regarding a treatment plan.

You tell Dr. Wilson, "Ms. Sanchez does not smoke, otherwise helping her quit completely would be really important. If her blood pressure recheck remains high, I think we should start an antihypertensive medication. I think we should also add a high-intensity statin. But, very importantly, diet and exercise may result in some weight loss and could play a major role in improving her lipids as well as her glucose control. I think we should also talk about aspirin, even though it has risks.”

"That is a great plan so far if she agrees. What about glycemic control?" asks Dr. Wilson.

"Well, I know her A1C is way too high, and that puts her at risk for many microvascular complications. She is on two medications. I’m not sure what should come next, but probably insulin or another injectable medication.

Dr. Wilson says, "Understanding the various medications for diabetes can help us make this decision."

TEACHING POINT

Additional Medications for Type 2 Diabetes

There are a number of additional pharmacologic therapies for glycemic control, including insulin. The selection of these agents depends in large part on the individual patient's level of glycemic elevation, medical comorbidities (such as obesity, cardiovascular disease, chronic renal disease, etc.), as well as cost and patient preference.

In patients on a single oral agent whose A1c is within one percentage point of goal, adding another oral agent or non-insulin injectable should be considered. A meta-analysis found that for each non-insulin agent added from a different class, the A1c could be expected to decrease 0.9-1.1%.

Information about the different types of insulin used to manage diabetes can be found by selecting the link.

When insulin is used, typically a basal insulin such as glargine or detemir is initiated first, with continuation of one or more oral medications (usually metformin, unless there is a contraindication). The regimen is then escalated until the A1c goal is attained.

For an approach to the many types of anti-diabetic agents and the patient-specific factors that may be considered in medication selection, refer to figure 9.3 and 9.4 from the 2024 ADA guidelines.

BARRIERS TO TREATMENT

MANAGEMENT

You state, "It sounds like a GLP-1 agonist or SGLT 2 inhibitor would be best given her cardiovascular risk—if her hemoglobin A1C was a little higher I think she would need to start insulin. She does have symptoms of hyperglycemia, so that could be a reason to start insulin. Either way, I guess we failed to avoid the 'shots.'”

Dr. Wilson says, "It's common for both patients and their clinicians to have the view that requiring an injectable medication is a personal failure. Motivating patients to adhere to treatment plans in hope of 'avoiding insulin or another injectable medication' is, in essence, setting patients up for failure. It is part of the natural progression of type 2 diabetes that beta-cell function declines, and patients often need additional medication. It is important for us to share this so that patients do not view initiation of insulin or an injectable medication as a personal failure. If we are able to help Ms. Sanchez with better glucose control by developing a treatment plan that works for her, we may be able to reduce or eliminate her medication needs in the future.”

TEACHING POINT

Barriers to Pharmacologic Treatment

Barriers to injectable therapy:

• Mindset that injectable therapy is a medication of last resort and that initiating it equals failure. This is not true. Remember that good glucose control is more important than the means used to achieve it.

• Patient fear of injecting medication with a needle. Most patients are surprised at how easy administering injectable therapy is and often share that it is less painful than fingerstick glucose monitoring.

• Physical limitations regarding drawing up injectable therapy. Presents a challenge for some patients due to vision impairment or dexterity issues; pens make it easier to "draw up" the correct amount of medication.

• Patient's perception that insulin or other injectable medications actually cause the comorbidities associated with diabetes. Some patients have family members or friends with diabetes who were placed on insulin late in the progression of their disease. When complications occurred, insulin could be seen as responsible for poor outcomes.

Overall barriers:

• Physicians may lack the time and support staff to educate patients. Initial and ongoing education about administering, storing, and dosing medications, monitoring blood glucose, diet, exercise, and more is important. Programs such as the Diabetes Prevention Program and partners such as Community Health Workers and Diabetes Educators can help with this effort.

• Cost for diabetes medicine has increased, which can be challenging for many patients. Clinicians can partner with pharmacists to help ensure that prescribed medications are cost-effective, and can work with insurance companies to address coverage issues.
• Social determinants of health (SDOH) impact care and outcomes. Screening for SDOH (for example, access to healthy food and places to exercise)), referrals and assistance to access community services, and partnership with community organizations are all important steps to address the structural issues that impact health outcomes. Many health care systems are utilizing electronic health records to capture SDOH data and identify patients who would benefit from additional support.

PARTNERING WITH PATIENTS FOR MANAGEMENT

CARE DISCUSSION

You and Dr. Wilson return to talk with Ms. Sanchez and discuss that her symptoms are likely manifestations of her high blood sugar.

Dr. Wilson asks,

"What concerns you most about your diabetes, Ms. Sanchez?"

"I worry that I will not be able to work or help my sister and her family. It is very important that I help them—they have done so much to support me," Ms. Sanchez replies.

You discuss a plan for partnering with her to minimize the complications of her disease and maximize her ability to contribute to her family. You ask her how she would feel about taking some additional medications:

• Lisinopril 5 mg PO daily
• Atorvastatin 80 mg PO nightly
• Dulaglutide injection 0.75 mg once a week

You explain that the first two medications are not for diabetes, but will help with her high blood pressure and her cholesterol, and will help prevent cardiovascular problems that are common in people with diabetes. She does not think it will be hard for her to add these medications.

You also ask her if she would like to learn more about diabetes. She chooses to attend a group visit at the practice later that week. She asks if her sister can accompany her and you agree that this would be a great way for her and her sister to support one another.

Next, Dr. Wilson shares that her A1C is 9.5% and that, according to guidelines from the American College of Physicians, the goal is between 7% and 8%.

He also tells you, "I've chosen to follow the ACP guidelines, because I think they have a more patient-centered approach than the ADA guidelines, which have a more stringent A1C goal."

He continues, "Lowering your blood sugar can help prevent the complications of diabetes. We’ll talk in the group more about the diets that have been shown to help with diabetes, and how people manage these, especially when they’re busy. You are taking some medicines now that are helping, but at this point in time, they are not doing enough, and I think we should change your diabetes medications. This is common, and you’ll meet others in the group who have had the same thing happen.”

DISCUSSING IMMUNIZATIONS AND REFERRALS

CARE DISCUSSION

Before the visit concludes, you review recommended vaccines with Ms. Sanchez and she decides to receive them today. You also provide her with some written information in Spanish about basic diabetes care. You let her know that the practice will arrange a visit with an eye doctor, and you also briefly discuss the importance of dental care and foot care. At the end of the visit, the diabetes educator meets briefly with Ms. Sanchez, giving her more information about the group visit.

TEACHING POINT

Vaccines Recommended for Patients with Diabetes

• Influenza and COVID vaccines are recommended annually, because people with diabetes are a group at high risk of severe illness. People with diabetes are advised not to receive the live attenuated influenza vaccine.
• Adults older than 60 with diabetes are at high risk of RSV disease, so are likely to benefit from the RSV vaccine.
• Pneumococcal vaccine is recommended for adults with diabetes who are between 19-64 years of age. One dose of PCV15 or one dose of PCV20 can be given. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose.
• Hepatitis B vaccine is recommended for patients with diabetes who are younger than 60 (older patients should discuss the vaccine with their healthcare provider). There is evidence that patients with diabetes are at increased risk for developing hepatitis B, perhaps due to the frequent use of needles for injectable medications and glucometers.
• Ensuring that all other age-group recommended vaccinations rare up to date is also important.

TEACHING POINT

Importance of Dental Care for Patients with Diabetes

When diabetes is not well controlled, high glucose levels in saliva may help bacteria that attack tooth enamel thrive. Going to the dentist regularly and brushing and flossing teeth helps remove decay-causing plaque, which can result in cavities and gum disease. Gum diseases and oral infections appear to be more frequent and more severe due to immunosuppression among people with diabetes.

Additionally, periodontal disease can increase the risk of cardiovascular disease.

TEACHING POINT

Team-Based Care for Patients with Diabetes

People with diabetes should receive medical care from a team that includes clinicians, nurses, dietitians and nutritionists, pharmacists, diabetes health educators, mental health professionals, and community health workers. It can be challenging to offer everything that a patient needs to effectively manage their diabetes within the context of office visits. Each patient should develop an individualized plan using the combination of resources that works best for them.

Group medical visits are a model of outpatient care that combines medical care, patient education, and patient empowerment in a group setting. Group visits for patients with diabetes have been shown to improve quality measures, empower patients around self-management goals, improve patient satisfaction, and develop support and community. Some studies have shown reductions in hospitalizations and vistis to the Emergency Department. Group visits can be challenging to set up, however, many resources exist to help implement group visits in terms of logistics, billing, and educational materials

OPHTHALMOLOGY REFERRAL

MANAGEMENT

With the help of the referral coordinator in the office, you complete the referral for an ophthalmology evaluation. You include pertinent patient information and a clear request to be addressed by the consultant. You also send a summary that includes the past medical history, medication list, allergies, relevant lab tests, and insurance information.