Diabetes/Prediabetes

MMC Simple Diabetes Treatment Algorithm
Clinical Goals

Ideal Blood Sugar Goals: Fasting Blood Sugars < 130. 2hr Postprandial Blood Sugars < 180. BP < 130/80 (Start with ACE or ARB and will likely need multiple medications). Urine Microalb 1x/yr. Statin for all patients > 40 y/o unless contraindicated. Yearly complete foot exam and eye exam. IF check chol, goals are LDL < 70-100, HDL > 40, TG < 200. Baseline EKG. Aspirin if CAD/Stroke. Healthy Eating, Regular Exercise (30 min/day+), Sustainable Weight Loss 5-7%. Ask about CV symptoms, and check weight, feet/peripheral pulses every visit. Quit Smoking!

Step 1 for all patients for glycemic control

Note

Emphasize lifestyle changes and send to diabetes and nutrition classes

Start with Metformin and titrate to 1g BID (500mg BID if eGFR 30-60) Take with meals to minimize GI side effects

Note

If patient has severely elevated blood sugar at time of diagnosis, it may by necessary to start with insulin therapy (can often wean off in 1-2 months in early DM2).

Step 2 if not at glycemic goals when recheck blood sugars or HbA1c

ADD Sulfonylurea but beware hypoglycemia and long term metabolic consequences (weight gain, lipids, beta cell function).

AND/OR

ADD Pioglitazone (Actos) unless contraindicated (CHF) and titrate to max 45mg QD. Consider Spironolactone unless contraindicated to avoid/treat edema (25mgQD)

Step 3 if not at glycemic goals when recheck blood sugars or HbA1c

Note

ADD once daily insulin, NPH or Glargine (usually start at 10units QD) and titrate to fasting AM blood sugar < 130 and/or HbA1c < 7.

Step 4 if not at glycemic goals when recheck blood sugars or HbA1c

ADD short acting insulin with meal(s) by following 2hr postprandial blood sugars and titrating to 2hr postprandial blood sugar < 180 and HbA1c <7 (Stop Sulfonylurea).

OR

Change to Insulin Mix 70/30 BID or TID and titrate as above

*Sulfonylureas can cause severe hypoglycemia. Sulfonylureas and Pioglitazone can cause weight gain and increased cholesterol.

1. Background/Cultural Points:

   Diabetes is an increasingly common disease in Cambodia, due primarily to genetic predisposition, low birth weights, and the high non-whole-grain (white) rice diet. Alcohol intake and obesity also contribute. Diabetes often presents classically (Polyuria, etc), but often presents at MMC as a patient’s-presumed-diagnosis based on a “high” random blood glucose test at a rural lab.

2. Work-Up/Diagnosis & Lab:

   1. Make the diagnosis according to WHO criteria (HbA1c >= 6.5, FPG >/= 126 mg/dL or 7.00 mmol/L; 2h-PPG >/= 200 mg/dL or 11.10 mmol/L)
   2. Other labs: U/A is important to detect evidence of renal damage; ALT and Creatinine may be ordered to help determine best medication option and as baseline (Private lab acceptable)
   3. If fatigue is the presenting complaint, consider Hematocrit (in-house) and TSH (Pasteur Institute only) evaluations, etc.
   4. Consider: EKG if co-morbidities

3. Management/Education/Treatment:

   1. Patient Education:

      1. Explain the disease and its chronicity (incurable) to the patient.
      2. Teach the patient about the goal of treatment, prevention of complications
      3. Review Lifestyle Modifications: Weight Loss, Diet (Decrease Fat/Alcohol intake, decrease calories including decrease of white rice intake/substitute for brown rice); Increase physical activity. Diet – explain to patients that they may and should eat foods from ALL food groups, including fruits (Many Cambodians think DM2 management requires avoidance of fruits).
      4. Give patient DM2 Patient Information single page handout

   2. Glucose Management Medications:

      1. If not contraindicated, Metformin is first-line (start low-dose to reduce nausea, and warn patient of initial SE)(Max: 500mg-850mg BID). Unless patient is clinically suspicious for Renal or Liver Failure, begin empiric treatment and order Creatinine as baseline (to review at follow up)
      2. Sulfonylureas (EG, glipizide) or Thiazolidinediones (EG, Pioglitazone) are also available in Cambodia; the former is cheaper, but causes weight gain and typically is effective for only 5-10 years. The latter is costly; SE: fluid retention, hepatic disease
      3. Insulin: difficult to procure in Cambodia; use as needed if resources allow
      4. Goal: Per WHO, A1C <6.5% is target (eAG = 140 mg/dL); however, the risks of tight control in this population may outweigh the benefits – it may therefore be reasonable to have a goal of A1C <7.0% (eAG = 154 mg/dL) or higher.

   3. Other interventions/goals:

      1. Smoking & Alcohol cessation
      2. Tight blood pressure control (<130/80); ACEI = first-line; otherwise, consider HCTZ or Atenolol/Propranolol.
      3. ACEI (Enalapril 5-10mg QD) if proteinuria on U/A; otherwise, especially for rural patients, defer start of ACEI (Rationale: unlikely to be sustained by rural Cambodians; difficulty to monitor Cr/K). Monitor Cr/K q6-12 mos.
      4. Aspirin (ASA) low dose (325mg ¼ tab) if CAD risks additional to DM2 (Rationale: many Cambodians do not tolerate aspirin’s GI SE well; no coated version available; therefore, reasonable to defer ASA unless CAD risks significant (including age>40))
      5. Visual Acuity check in-house and fundoscopy (dilated exam per HCP skill); referral to Optometry for dilated-eye exam near time of diagnosis (if not done in-house)
      6. Counsel regarding foot care (wash and check daily; wear good fitting shoes with socks if able to afford)
      7. Vaccinations – advise annual flu, Pneumococcus (Age >65); not available at MMC
      8. Counsel women of child-bearing age regarding pregnancy (offer OCP; Metformin = Cat B)
      9. Home Glucose Monitoring is available at some pharmacies, but usually cost- prohibitive; therefore, may advise patients to check FPG weekly or monthly at a local lab, and return to MMC right away if FPG >

   4. Follow-Up:

      1. 1 month f/u after initial diagnosis is reasonable (3 months if RPG <250-300 and patient from remote location); goal is every 6-12 month follow up.
      2. “Tight glycemic control” is goal, but without close monitoring, MMC goal is “looser” to avoid hypoglycemia and ensure reasonably sustainable regimen. FPG goal is <130 mg/dL or <7.22 mmol/L; Do NOT use HgbA1C unless NEEDED for clarification.
      3. At every 6-12 month follow-up, consider: FPG, U/A, Fundoscopy, Skin/Foot exam, Cr/K if indicated.