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Definition, Classification and Diagnosis of Diabetes, Predi Definition, Classification and Diagnosis of Diabetes, Predi

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Definition, Classification and Diagnosis of Diabetes, Predi - PPT Presentation

Chapter 3 Ronald Goldenberg Zubin Punthakee Canadian Diabetes Association 2013 Clinical Practice Guidelines Key Messages Screen wisely Diagnose precisely Diagnosis of diabetes can be made with ID: 481098

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Slide1

Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome

Chapter 3Zubin Punthakee MD MSc FRCPC, Ronald Goldenberg MD FRCPC FACE, Pamela Katz MD FRCPC

2018 Clinical Practice GuidelinesSlide2

Disclaimer

All Content contained on this slide deck is the property of Diabetes Canada, its content suppliers or its licensors as the case may be, and is protected by Canadian and international copyright, trademark, and other applicable laws. Diabetes Canada grants personal, limited, revocable, non-transferable and non-exclusive license to access and read content in this slide deck for personal, non-commercial and not-for-profit use only. The slide deck is made available for lawful, personal use only and

not for commercial use

.

The unauthorized reproduction, distribution of this copyrighted work is not permitted.

For

permission to use this slide deck for commercial or any use other than personal, please contact

guidelines@diabetes.ca

Slide3

Key Changes

No change in the diagnostic criteria New information on methods to differentiate between type 1, type 2 and monogenic diabetes in clinical practice

2018

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide4

Classification of Diabetes

Type

Definition

Type 1 diabetes (including LADA form)

Pancreatic beta cell destruction, usually leading to absolute insulin deficiency

Immune mediated

Idiopathic

Type 2 diabetes

May range from predominantly insulin resistance insulin deficiency to a predominantly secretory defect with insulin resistance

Gestational DiabetesGlucose intolerance with onset or first recognition in pregnancyOther typesVariety of uncommon diseases, genetic forms, or diabetes associated with drug use

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide5

*Neonatal diabetes is a form of diabetes with onset <6 months of age, requires genetic testing, and may be amenable to therapy with oral sulfonylurea in place of insulin therapy

Clinical features

Type 1 diabetes

Type 2 diabetes

Monogenic diabetes

Age of onset (yrs)

Most <25

by can occur at any age (but not before the age of 6 months)

Usually >24 but incidence increasing in adolescents, paralleling increasing rate of obesity in children

& adolescentsUsually <25Neonatal diabetes <6 months* WeightUsually thin, but with obesity epidemic, can have overweight or obesity>90% at least overweightSimilar to general populationIslet auto-antibodiesUsually presentAbsentAbsentC-peptideUndetectable/lowNormal/highNormalInsulin production

Absent

Present

Usually present

First line treatment

Insulin

Non-insulin antihyperglycemic agents, gradual dependence on insulin may occurDepends on subtype of MODYFamily history of diabetesInfrequent (5-10%)Frequent (75-90%)Multigenerational, autosomal pattern of inheritanceDKACommonRareRare (except for neonatal diabetes*)

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome

2018Slide6

Diagnosis of Diabetes

FPG ≥7.0 mmol/L

Fasting = no caloric intake for at least 8 hours

or

A1C ≥6.5%

(in adults)

Using a standardized, validated assay in the absence of factors that affect the accuracy of the A1C and not for suspected type 1 diabetes

or

2hPG in a 75 g OGTT ≥11.1 mmol/L

orRandom PG ≥11.1 mmol/LRandom = any time of the day, without regard to the interval since the last meal2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome A1C, glycated hemoglobin; FPG, fasting plasma glucose; PG, plasma glucoseSlide7

Pima Indians

Egyptians

NHANES III

Glycemia and Retinopathy Thresholds

The International Expert Committee.

Diabetes Care

2009; 32:1327-1334.

Threshold levels for the development of retinopathy are similar in all 3 populations:

FPG ≥7.0 mmol/L

2hPG ≥11.1 mmol/L A1C ≥6.5%FPG2hPGHbA1c70-89-93-97-100-105-116-109-136-226-364-244-

185-

156-

138-

126-

116-

106-94-38-3.4-4.8-5.0-5.2-5.3-5.5-5.7-6.0-6.7-HbA1c (%)2hPG (mg/dl)FPG (mg/dl)Retinopathy (%)9.5-15

10

5

0

FPG

2hPG

HbA1c

57-

79-

84-

89-

93-

99-

130-

108-

178-

258-

386-

304-

218-

155-

125-

110-

99-

90-

80-

39-

2.2-

4.7-

4.9-

5.1-

5.4-

5.6-

6.0-

6.9-

8.5-

HbA1c (%)

2hPG (mg/dl)

FPG (mg/dl)

Retinopathy (%)

10.3-

50

20

10

0

40

30

FPG

2hPG

HbA1c

42-

87-

90-

93-

96-

98-

104-

101-

109-

120-

195-

154-

133-

120-

112-

102-

94-

86-

75-

34-

3.3-

4.9-

5.1-

5.2-

5.4-

5.5-

5.6-

5.7-

5.9-

HbA1c (%)

2hPG (mg/dl)

FPG (mg/dl)

Retinopathy (%)

6.2-

15

10

5

0

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome

A1C, glycated hemoglobin; FPG, fasting plasma glucose; PG, plasma glucoseSlide8

DETECT-2: A1C ≥6.5% Threshold for Retinopathy

Colagiuri S et al.

Diabetes Care 2011

; 34:145-150.

Any retinopathy

≥ moderate NPDR

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

9.5

15.0+

10.0

10.5

11.0

11.5

12.0

12.5

13.0

13.5

14.0

14.5

45

40

35

30

25

20

15

Prevalence (%)

FPG by 0.5 mmol/L intervals

4.0

5.0

6.0

7.0

8.0

9.0

18.0+

12.0

11.0

13.0

10.0

14.0

15.0

16.0

17.0

Prevalence (%)

2hPG by 0.5 mmol/L intervals

45

40

35

30

25

20

15

10

4.0

5.5

6.0

6.5

7.0

7.5

12.0+

9.0

8.5

9.5

8.0

10.0

10.5

11.0

11.5

Prevalence (%)

HbA1c by 0.5% intervals

5.0

4.5

5

0

45

40

35

30

25

20

15

10

5

0

5

0

10

A1C, glycated hemoglobin; FPG, fasting plasma glucose; PG, plasma glucoseSlide9

Confirmatory test required

In the absence of symptomatic hyperglycemia, if a single lab test result is in the diabetes range, a

repeat confirmatory lab test

(FPG, A1C, 2hPG in a 75 g OGTT) must be done on another day

Repeat the same test

(in a timely fashion) to confirm

But a random PG in the diabetes range in an asymptomatic individual should be confirmed with an alternate test

If

results of two different tests

are available and both are above the diagnostic thresholds, the diagnosis of diabetes is confirmed2hPG, 2-hour plasma glucose; AlC, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose.2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide10

Confirmatory test NOT required

In the case of

symptomatic hyperglycemia

, the diagnosis has been made and a confirmatory test is not required before treatment is initiated.

To avoid rapid metabolic deterioration in individuals in whom

type 1 diabetes is likely

(younger or lean or symptomatic hyperglycemia, especially with ketonuria or ketonemia), the initiation of treatment should not be delayed in order to complete confirmatory testing

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome

2hPG,

2-hour plasma glucose; AlC, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose.Slide11

Considerations when using A1C for Diagnosis

Need validated standardized assayRepeat confirmatory test on another dayRecognize conditions leading to misleading A1CA1C is not used for diagnosis in children, adolescents (as the sole diagnostic test), pregnant women as part of routine screening for gestational diabetes, those with cystic fibrosis or those with suspected type 1 diabetes

Ethnicity and age can affect A1C results

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide12

Recognize pitfalls of A1C: conditions that can affect value

Factors affecting A1C

Increased A1C

Decreased A1C

Variable Change in A1C

Erythropoiesis

B12/Fe deficiency Decreased erythropoiesis

Use of EPO, Fe, or B12

Reticulocytosis

Chronic liver Dx

Altered hemoglobin

Fetal hemoglobin Hemoglobinopathies Methemoglobin

Altered glycation

Chronic renal failure

↓↓erythrocyte pH

ASA, vitamin C/E

Hemoglobinopathies

↑ erythrocyte pH

Erythrocyte destruction

Splenectomy

Hemoglobinopathies

Chronic renal failure

Splenomegaly

Rheumatoid arthritis

HAART meds, Ribavirin

Dapsone

Assays

Hyperbilirubinemia

Carbamylated Hb

ETOH

Chronic opiates

Hypertriglyceridemia

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide13

Pros and Cons of Diagnostic Tests

Test

Advantages

Disadvantages

FPG

Established standard

Fast and easy

Single Sample

Sample not stable

Day-to-day variabilityInconvenient to fastGlucose homeostasis in single time point2hPG in 75 g OGTTEstablished standardSample not stableDay-to-day variabilityInconvenient, UnpalatableCost

A1C

Convenient

Single sample

Low day-to-day variability

Reflects long term glucose

$$$Affected by medical conditions, aging, ethnicityStandardized, validated assay requiredNot applicable to every patient type 2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome A1C, glycated hemoglobin; FPG, fasting plasma glucose; PG, plasma glucoseSlide14

Dealing with discordance in results

Many people identified as having diabetes using A1C will not be identified as having diabetes by traditional glucose criteria, and vice versa.

When results of more than one test are available (FPG, A1C, 2hPG in a 75-g OGTT) and the results are discordant, the test whose result is above diagnostic cut-point should be repeated, and the diagnosis made on basis of the repeat test.

FPG

2hPG

A1C

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome

A1C, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucoseSlide15

Diagnosis of prediabetes

Tests

Result

Prediabetes category

Fasting plasma glucose (mmol/L)

6.1-6.9

IFG

2h PG

in a 75g OGTT (mmol/L)

7.8-11.0 IGTA1C (%)6.0-6.4Prediabetes2hPG, 2-hour plasma glucose; AlC, glycated  hemoglobin; FPG, fasting plasma glucose; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; OGTT, oral glucose tolerance test.2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide16

A1C Level and Future Risk of Diabetes: Systematic Review

A1C Category (%)

5-year incidence of diabetes

5.0-5.5

<5 to 9%

5.5-6.0

9 to 25%

6.0-6.5

25 to 50%

Zhang X et al. Diabetes Care. 2010;33:1665-1673.A1C, glycated hemoglobin2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide17

Definition of Metabolic Syndrome

 

Measure

Categorical thresholds

Elevated waist circumference (population/country specific)

Canada, United States of America

Middle Eastern, Sub-Saharan African, Mediterranean, Europids

Asians, Japanese, South and Central Americans

Men

Women≥102 cm

≥94 cm

≥90 cm

≥88 cm

≥80 cm

≥80 cm

Elevated TG (drug treatment for elevated TG is an alternate indicator†)≥1.7 mmol/L

Reduced HDL-C (drug treatment for reduced HDL-C is an alternate indicator†)

<1.0 mmol/L in males; <1.3 mmol/L in females

Elevated BP (antihypertensive drug treatment in a person with a history of hypertension is an alternate indicator)

systolic ≥130 mmHg or diastolic ≥85 mmHg

Elevated FPG (drug treatment of elevated glucose is an alternate indicator)

≥5.6 mmol/L

Adapted from: Alberti KG, et al.

Circulation

2009;120:1640

† Commonly used drugs for elevated TG and reduced HDL-C are fibrates and nicotinic acid. A person taking one of these drugs can be presumed to have high TG and reduced HDL-C. High-dose omega-3 fatty acids presumes high TGSlide18

Recommendation 1

Diabetes should be diagnosed by any of the following criteria:FPG ≥7.0 mmol/L [Grade B, Level 2]A1C ≥6.5% (for use in adults in the absence of factors that affect the accuracy of A1C and not for use in those with suspected type 1 diabetes) [Grade B, Level 2]

2hPG in a 75 g OGTT ≥11.1 mmol/L

[Grade B, Level 2]

Random PG ≥11.1 mmol/L

[Grade D, Consensus]

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide19

Recommendation 1 cont’d

In the presence of symptoms of hyperglycemia, a single test result in the diabetes range is sufficient to make the diagnosis of diabetes. In the absence of symptoms of hyperglycemia

, if a single laboratory test result is in the diabetes range, a

repeat confirmatory

laboratory test (FPG, A1C, 2hPG in a 75 g OGTT) must be done on another day

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide20

Recommendation 1 cont’d

It is preferable that the same test be repeated (in a timely fashion) for confirmation, but a random PG in the diabetes range in an asymptomatic individual should be confirmed with an alternate test. If results of two different tests are available and both are above the diagnostic cut-points, the diagnosis of

diabetes is confirmed

[Grade D, Consensus]

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide21

To avoid rapid metabolic deterioration in individuals in whom

type 1 diabetes is likely (younger or lean or symptomatic hyperglycemia, especially with ketonuria or ketonemia), the initiation of treatment should not be delayed in order to complete confirmatory testing [Grade D, Consensus]

Recommendation 1 cont’d

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide22

Recommendation 2

2. Prediabetes (defined as a state which places individuals at high risk of developing diabetes and its complications) is diagnosed by any of the following criteria:IFG (FPG 6.1-6.9 mmol/L) [Grade A, Level 1]IGT (2hPG in a 75 g OGTT 7.8-11.0 mmol/L) [Grade A, Level 1]

A1C 6.0%-6.4%

(for use in adults in the absence of factors that affect the accuracy of A1C and not for use in suspected type 1 diabetes)

[Grade B, Level 2]

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide23

Key Messages

The chronic hyperglycemia of diabetes is associated with significant long-term microvascular and CV complicationsA FPG of ≥7.0 mmol/L, a 2hPG value in a 75 g OGTT of ≥11.1 mmol/L or an A1C of  ≥6.5% can predict the development of retinopathy. This permits the diagnosis of diabetes to be made on the basis of each of these parameters

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide24

Key Messages

The term "prediabetes" refers to impaired fasting glucose, impaired glucose tolerance or an A1C of 6.0% to 6.4%, each of which places individuals at increased risk of developing diabetes and its complications

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide25

Key Messages for People with Diabetes

There are two main types of diabetes. Type 1 diabetes occurs when the pancreas is unable to produce insulin. Type 2 diabetes occurs when the pancreas does not produce enough insulin or when the body does not effectively use the insulin that is producedGestational diabetes is a type of diabetes that is first recognized or begins during pregnancy

Monogenic

diabetes is a rare disorder caused by genetic defects of beta cell function

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide26

Key Messages for People with Diabetes

Prediabetes refers to blood glucose levels that are higher than normal, but not yet high enough to be diagnosed as type 2 diabetes. Although not everyone with prediabetes will develop type 2 diabetes, many people willYou should discuss the type of diabetes you have with your diabetes health-care teamThere are several types of blood tests that can be done to determine if a person has diabetes and, in most cases, a confirmatory blood test is required to be sure

2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome Slide27

Visit guidelines.diabetes.ca

Slide28

Or download the AppSlide29

Diabetes Canada Clinical Practice Guidelines

http://guidelines.diabetes.ca – for health-care providers

1-800-BANTING (226-8464)

http://diabetes.ca

– for people with diabetes