NR 601 Week 6 Quiz Review of
Week 5 Diabetes
NR 601: Week 6 Quiz Review
Week 5
Diabetes
· ADA screening recommendations: when to screen to repeat screens based on findings
Recommendations
Screening for type 2 diabetes with an informal assessment of risk factors or validated tools should be
considered in asymptomatic adults. B
Testing for type 2 diabetes in asymptomatic people should be considered in adults of any age who are
over- weight or obese (BMI >25 kg/m2 or $23 kg/m2 in Asian Americans) and who have one or more
additional risk factors for diabetes. B
For all people, testing should be- gin at age 45 years. B
If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable. C
To test for type 2 diabetes, fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance
test, and A1C are equally appropriate. B
In patients with diabetes, identify and treat other cardiovascular disease risk factors.
Updated recommendations emphasize that testing for prediabetes and type 2 diabetes should be
considered in children and adolescents younger than 18 years of age who are overweight or obese (BMI
>85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height),
and have one or more additional risk factors for diabetes such as (1) maternal history of diabetes or
gestational diabetes during the child’s gestation; (2) family history of type 2 diabetes in first- or second-
degree relative; (3) race/ethnicity (Native American, African American, Latino, Asian American, Pacific
Islander; and/or (4) signs of insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-
DIAGNOSTIC TESTS FOR DIABETES
Diabetes may be diagnosed based on plasma glucose criteria, either the fasting plasma glucose (FPG) or
the 2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT) or A1C criteria
(1,6) (Table 2.2).
FPG, 2-h PG after 75-g OGTT, and A1C are equally appropriate for diagnostic testing. It should be noted
that the tests do not necessarily detect diabetes in the same individuals. The efficacy of
interventions for primary prevention of type 2 diabetes (7,8) has primarily been demonstrated among
individuals with impaired glucose tolerance (IGT), not for individuals with isolated impaired fasting glucose
(IFG) or for those with prediabetes defined by A1C criteria.
The same tests may be used to screen for and diagnose diabetes and to detect individuals with
prediabetes. Diabetes may be identified anywhere along the spectrum of clinical scenarios: in seemingly
low-risk individuals who happen to have glucose testing, in individuals tested based on diabetes risk
assessment, and in symptomatic patients.
Fasting and 2-Hour Plasma Glucose
The FPG and 2-h PG may be used to diagnose diabetes (Table 2.2). The concordance between the FPG
and 2-h PG tests is imperfect, as is the concordance be- tween A1C and either glucose-based test.
Numerous studies have confirmed that, compared with FPG and A1C cut points, the 2-h PG value
diagnoses more people with diabetes.
A1C
The A1C test should be performed using a method that is certified by the NGSP (www.ngsp.org) and
standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference as- say.
,Although point-of-care A1C assays may be NGSP certified, proficiency testing is not mandated for
performing the test, so use of point-of-care assays for diagnostic purposes is not recommended but may
be considered in the future if proficiency testing is performed and documented.
The A1C has several advantages com- pared with the FPG and OGTT, including greater convenience
(fasting not required), greater preanalytical stability, and less day-to-day perturbations during stress and
illness. However, these
advantages may be offset by the lower sensitivity of A1C at the designated cut point, greater cost, limited
availability of A1C testing in certain regions of the developing world, and the imperfect correlation
between A1C and average glucose in certain individuals. National Health and Nutrition Examination
Survey (NHANES) data indicate that an A1C cut point of $6.5% (48 mmol/mol) identifies one-third fewer
cases of undiagnosed diabetes than a fasting glucose cut point of $126 mg/dL (7.0 mmol/L) (9).
When using A1C to diagnose diabetes, it is important to recognize that A1C is an indirect measure of
average blood glucose levels and to take other factors into consideration that may impact hemoglobin
glycation independently of glycemia including age, race/ethnicity, and anemia/ hemoglobinopathies.
Confirming the Diagnosis
Unless 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 [11.1 mmol/L]), a second test is required for
confirmation. It is recommended that the same test be repeated without delay using a new blood sample
for confirmation because there will be a greater likelihood of concurrence. For ex- ample, if the A1C is
7.0% (53 mmol/mol) and a repeat result is 6.8% (51 mmol/mol), the diagnosis of diabetes is confirmed. If
two different tests (such as A1C and FPG) are both above the diagnostic threshold, this also confirms the
diagnosis. On the other hand, if a patient has discordant results from two different tests, then the test
result that is above the diagnostic cut point should be repeated. The diagnosis is made on the basis of the
confirmed test. For example, if a patient meets the diabetes criterion of the A1C (two results $6.5% [48
mmol/mol]) but not
FPG (,126 mg/dL [7.0 mmol/L]), that person should nevertheless be considered to have diabetes.
Since all the tests have preanalytic and analytic variability, it is possible that an abnormal result (i.e.,
above the diagnostic threshold), when repeated, will produce a value below the diagnostic cut point. This
scenario is likely for FPG and 2-h PG if the glucose samples remain at room temperature and are not
centrifuged promptly. Because of the potential for preanalytic variability, it is critical that samples for
plasma glucose be spun and separated immediately after they are drawn. If patients have test results
near the margins of the diagnostic threshold, the health care professional should follow the patient closely
and repeat the test in 3–6 months.
Description
In 1997 and 2003, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (17,18)
recognized a group of individuals whose glucose levels did not meet the criteria for diabetes but were too
high to be considered nor- mal. “Prediabetes” is the term used for individuals with IFG and/or IGT and/or
A1C 5.7–6.4% (39–47 mmol/mol). Pre- diabetes should not be viewed as a clinical entity in its own right
but rather as an increased risk for diabetes (Table 2.3) and cardiovascular disease (CVD). Prediabetes is
associated with obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides
and/or low HDL cholesterol, and hypertension.
Diagnosis
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (17,18) defined IFG as
FPG levels be- tween 100 and 125 mg/dL (between 5.6 and 6.9 mmol/L) and IGT as 2-h PG after 75-g
, OGTT levels between 140 and 199 mg/dL (between 7.8 and 11.0 mmol/L). It should be noted that the
World Health Organization (WHO) and numerous other diabetes organizations define the IFG cutoff at
110 mg/dL (6.1 mmol/L).
As with the glucose measures, several prospective studies that used A1C to predict the progression to
diabetes as defined by A1C criteria demonstrated a strong, continuous association between A1C and
subsequent diabetes. In a systematic review of 44,203 individuals from 16 cohort studies with a follow-up
interval averaging 5.6 years (range 2.8– 12 years), those with A1C between 5.5 and 6.0% (between 37
and 42 mmol/mol) had a substantially increased risk of diabetes (5-year incidence from 9 to 25%). An
A1C range of 6.0–6.5% (42–48 mmol/mol) had a 5-year risk of developing diabetes between 25 and 50%
and a relative risk 20 times higher compared with A1C of 5.0% (31 mmol/mol) (19). In a community-
based study of African American and non-Hispanic white adults without diabetes, baseline A1C was a
stronger predictor of subsequent diabetes and cardiovascular events than fasting glucose (20). Other
analyses suggest that A1C of 5.7% (39 mmol/mol) or higher is associated with a diabetes risk similar to
that of the high-risk participants in the Diabetes Prevention Program (DPP) (21), and A1C at baseline was
a strong predictor of the development of glucose- defined diabetes during the DPP and its follow-up (22).
Hence, it is reasonable to consider an A1C range of 5.7–6.4% (39–47 mmol/mol) as identifying individuals
with prediabetes. Similar to those with IFG and/or IGT, individuals with A1C of 5.7–6.4% (39– 47
mmol/mol) should be informed of their increased risk for diabetes and CVD and counseled about effective
strategies to lower their risks (see Section 5 “Prevention or Delay of Type 2 Diabetes”). Similar to glucose
measurements, the continuum of risk is curvilinear, so as A1C rises, the diabetes risk rises
disproportionately (19). Aggressive interventions and vigilant follow-up should be pursued for those
considered at very high risk (e.g., those with A1C .6.0% [42 mmol/mol]).
· Guideline recommendations to start medications
recommendations
A complete medical evaluation should be performed at the initial visit to
- Confirm the diagnosis and classify diabetes.
- Detect diabetes complications and potential comorbid conditions.
- Review previous treatment and risk factor control in patients with established diabetes.
- Begin patient engagement in the formulation of a care management plan.
- Develop a plan for continuing care.
Recommendations
- Provide routine vaccinations for children and adults with diabetes according to age-related
recommendations. C
- Annual vaccination against influenza is recommended for all persons with diabetes $6 months of age.
- Vaccination against pneumonia is recommended for all people with diabetes 2 through 64 years of age
with pneumococcal polysaccharide vaccine (PPSV23). At age $65 years, administer the pneumococcal
conjugate vaccine (PCV13) at least 1 year after vaccination with PPSV23, followed by another dose of
vaccine PPSV23 at least 1 year after PCV13 and at least 5 years after the last dose of PPSV23.
- Administer 3-dose series of hepatitis B vaccine to unvaccinated adults with diabetes who are age 19–59
years.
- Consider administering 3-dose series of hepatitis B vaccine to un- vaccinated adults with diabetes who
are age $60 years.
First line medication options and medication side effects
