Pearls from the "Management of Diabetes and its Complications" Conference

May 7 & 8, 2004, Saskatoon, Saskatchewan
From a presentation by Dr. Joanne Kappel

KEY THOUGHTS TO REMEMBER IN MANAGING DIABETES:

1. Think early and think upstream:

Complications of diabetes (especially with Type 2) begin to develop as soon as the disease appears, not at the time of diagnosis. Be alert for changes that may signal diabetes in your patient. As soon as Type 2 diabetes is diagnosed, a complete diabetes complication assessment should be performed.

2. There is no place for complacency:

The best outcomes are the result of active management by patient, physician and diabetic education staff.

3. Control is more than just sugars:

Both macrovascular and microvascular complications must be part of the overall management strategy. Macrovascular complications include: hypertension, dylipidemias, and nephropathy. Microvascular complications include: retinopathy, neuropathy and foot care.

4. "Its not that people are unwilling to change. Its that people are unwilling to BE changed":

Unless patients are active participants in the management of their disease, physicians can do little. Help the patient to build problem-solving skills. Remember the patient is the one who delivers the care and they often have personal goals, values and expertise that must be validated, valued and used.

5. You can't teach people everything they need to know. The best you can do is to put them where they can find what they need:

Know your local and referral resources, encourage patients in self-directed learning about their disease. You may not know all that they need to know and may learn a lot from your patients.

6. The Ark was built by amateurs. The Titanic was built by professionals. Which one sank?

Recommended Targets For Glycemic Control

	A1C (%)	FPG/preprandial PG (mmol/l)	2-hour postprandial PG (mmol/l)
Target for most patients	<= 7.0	4.0 – 7.0	5.0 – 10.0
Normal Range (considered for patients in whom it can be achieved safely)	<= 6.0	4.0 – 6.0	5.0 – 8.0

A1C = glycosylated hemoglobin
FPG = fasting plasma glucose

Recommended Targets For Physical Activity And Nutrition Therapy

Physical Activity	2.5 hours of moderate intensity exercise each week, spread over 3 nonconsecutive days. Resistance exercises 3 times per week
Nutrition Therapy	Dieting alone is not enough for long-term weight loss. Modest weight loss (5-10%) improves lipid profile, insulin sensitivity, BP by 10 mmHg and overall mortality by 25%. Carbohydrate counting is important in basal/bolus insulin regimen.

Pharmacological Management – Need For Action
Lifestyle Counselling At All Levels

PARAMETER	TARGET	HOW
Blood Pressure	130/80 mmHg	ACE, Diuretic, ARB, BB, CCB
Lipids	LDL <= 2.5 mmol/l	Statin, Fibrate, Ezetimibe
Antiplatelet therapy	Yes	ASA
Smoking	None	Whatever it takes
Kidneys	ACR falling or normal, CrCl stable	ACE, ARB
Retinopathy	Annual screening	Optometrist, ophthalmologist
Neuropathy	Annual screening	Monofilament
Feet	Daily inspection	Patient, family, health care provider