Diagnosing Diabetes

The ADA guidelines for diagnosing diabetes are not always straight forward—there is a barrage of random numbers to memorize. See if this handout which has an easy pneumonic that I made up for the residents helps to ease some of the pain. Also I have included a handout explaining how to use the Homeostatis Model Assessment (HOMA) to determine whether a diabetic patient has an insulin production problem, a peripheral resistance problem, or both. (NOTE: Don't click on the image below since it will only give you a low quality image; click instead on the "this handout" link above).

Finally, I want to give Dr. George Guthrie profuse thanks for his help in putting together these handouts, and for lending his expertise at the 2012 AAFP Scientific Assembly. Thanks George, you are a blessing. He also added feet and toes and eyes to the pneumonic (to help us remember to do our diabetic feet exams and eye exams). Cool!

The difference between glyburide and glipizide?

Both medications are common sulfonylureas use to treat type II diabetes. However, glipizide has a shorter half-life compared to glyburide (12 hours versus 22 hours). And glipizide has a lower incidence of hypoglycemia. Although the pharmaceutical companies want us to prescribe their newer oral agents (which are not part of the ADA guidelines), sulfonylureas like glipizide are considered "well validated" and "Tier I" medications for the treatment of type II diabetes (after metformin).

REVISIT: Glycohemaglobin and Average Plasma Glucose

In a previous post, we discussed a quick tip to calculate the A1C, here is an EVEN QUICKER tip provided by Dr. Eddie Needham (in which Dr. Carlos Dumois started the entire discussion):

Ave Glucose = (A1C — 2) x 30

So a patient with an A1C of 10 would have an average glucose = (10 — 2) x 30. Or 240. Simple awesomeness. 

The Miracle of Insulin

Have you ever stopped to wonder what a miracle insulin is? Before 1922, the death rate from type I diabetes was 100%. It wasn't until 1922 when Frederick Banting discovered insulin that hope arrived. Can you imagine that? 1922! That was not that long ago!

As doctors, we take insulin for granted. Right now, I'm going through the book The Discovery of Insulin by Michael Bliss. It's a great read! Full of suspense and intrigue! It's amazing how far we have come since the early days of Frederick Banting's discovery.

Encouragement is Sometimes the Best Medicine

I have a patient who we recently diagnosed with diabetes. During our visits, I have tried to explain the importance of reducing simple carbs in his diet, but I don't think that he ever "got it." At our last visit, I noticed that he lost 30 pounds over the past 3 months (and I didn't need a scale to tell me that). He was proud of the progress that he had made with he weight and his improved diabetic control. When I asked him how he did it, he told me that he was eating a lot of rice. At that moment, the thought briefly entered my mind of discussing carbs again. But you know what? I didn't say a word! That day was not the right time for that discussion? He was doing well, losing weight, and his glycemic control had improved. That day was the time for simple encouragement. That day was the time to celebrate his success.

Renal Insufficiency and Metformin

Because of concerns of lactic acidosis (and subsequent high risk of mortality), metformin should not be used in patients with renal failure or severe renal insufficiency. When I get lab results back showing an elevated creatine, I have made it a habit to check 1) what the last creatine was, and 2) if the patient is currently taking metformin.

Glycohemaglobin and Average Plasma Glucose

A glycohemaglobin of 6% correlates with an average plasma glucose of about 120. And every 1% increase in glycohemaglobin will cause approximately a 30 point rise in the average plasma glucose. So if we charted it out, it would look something like this:

Just remember 120 at 6%. And 30 rise with every 1%. Remember that these are just rough estimates (and they are probably on the conservative side).

ACE Inhibitors and Birth Defects

As family doctors are diagnosing diabetes and hypertension earlier and earlier, the use of ACE Inhibitors in younger patients is becoming more common. However, it is good to be reminded that ACE Inhibitor may be associated with an increased risk of birth defects (and currently this is a black-boxed warning). For woman of childbearing age, options other than ACE Inhibitors should be considered. So when we get that fax from the insurance company urging us to start an ACE Inhibitor for our young, diabetic, female patient, we should feel free to tell them to bugger off.

Asprin use in Diabetic Patients

Hmmmmm... It looks like aspirin use in diabetic patients is not as "cut and dry" as we once thought. But still, most of my diabetic patients seem to meet the criteria since they are typically older patients with multiple risk factors for cardiovascular events:

The organizations state that only men older than 50 and women older than 60 who have one or more additional major risk factors should be treated with aspirin for primary prevention of cardiovascular events.