Continuing Medical Education (CME)

Management of Type 2 Diabetes Mellitus

Introduction to this self-study CME activity

Purpose

Studies demonstrate that morbidity due to complications of diabetes can be reduced through prevention, detection, and management.  This self-study provides practical guidance to clinicians about routine screening and prevention efforts for cardiovascular risk factors (hypertension, hyperlipidemia, tobacco use) and for microvascular disease (retinopathy, nephropathy, neuropathy.  Management of risk factors, complications, and glycemis is organized into specific care activities to be performed at each regular diabetes visit, every 3 to 6 months, and annually.  Key recommendations for care are summarized at the beginning of the guideline.

New information in this revision: 

BP control.  Controlling blood pressure has the most impact on decreasing morbidity and mortality in patients with diabetes melitus.  Target blood pressures remain less than 135/80 mmHg.  Table 3 (new) presents a treatment algorithm for the sequential addition of medications until blood pressure is controlled. 

Statins.  Patients age 40 and older with type 2 diabetes should be on moderate doses of statins.  Even those with initial LDL-C levels under 100 mg/dL receive substantial benefit.  The UMHS preferred generic statin and its moderate dose level is simvastatin 40 mg/d.  For patients with LDL-C levels greater than 100 mg/dL on this therapy, higher doses of generic (e.g., simvastatin 80 mg) or brand name statins (e.g., atorvastatin or rosuvastatin) may be indicated.  Do not use high-dose simvastatin if patients have severe renal insufficiency. Statins are optional for patients younger than 40 given their marginal cost-effectiveness.

Blood sugar control.  Generic metformin is the preferred initial oral hypoglycemic medication for patients with a normal Glomerular Filtration Rate; Sulfonylureas (eg., glipizide, glyburide) are preferred for those with contraindications to metformin. The short-term fasting glucose goal is less than 130 mg/dL and the long-term goal is a hemoblobin A1c under 7%.  The treatment algorithm for the sequential addition of medications to achieve glycemic control has been extensively revised (Table 6). 

Eye exam.  A dilated retinal exam should be performed by an eye care specialist every 2 years if previous eye exam was normal, otherwise annually or more frequently as recommended by the eye care provider. 

Urine albumin testing.  Patients who are being treated with an Angiotensin Converting Enzyme Inhibitor (ACE-I) or an Angiotensin II Receptor Blocker (ARB) no longer require annual urine albumin testing.

Audience

This self-study activity is appropriate for primary care clinicians and other health care providers providing care for adults with type 2 diabetes.

Authors

Team Leader
	Sandeep Vijan , MD General Internal Medicine
Team Members
	Hae Mi Choe, PharmD College of Pharmacy Steven J. Bernstein, MD, MPH General Internal Medicine William H. Herman, MD Endrocinology & Metabolism Robert W. Lash, MD Endrocinology & Metabolism Martha M. Funnell, MS, RN Diabetes Research & Training Center R. Van Harrison, PhD Medical Education Denise Campbell-Scherer, MD, PhD Family Medicine
Author Disclosures
	Team Member Relationship Company Steven J. Bernstein, MD, MPH (None)   Denise Campbell-Scherer, MD, PhD (None)   Hae Mi Choe, PharmD (None) Martha M. Funnell, MS, RN Consultant Eli Lilly, Home Diagnostics Inc, Novo Nordisk R. Van Harrison, PhD (None) William H. Herman, MD Consultant Aventis Eli Lilly GlaxoSmithKline Merck Sanofi-Aventis Takeda Robert W. Lash, MD (None)   Sandeep Vijan, MD (None)

Other Acknowledgements

UMHS Guidelines Oversight Team: William E. Chavey, MD R. Van Harrison, PhD Connie J. Standiford, MD Literature search services: Taubman Medical Library Production of Internet format and web site maintenance: Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this educational activity for a maximum of 1 AMA/PRA Category 1 Credits™.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

This CME activity was prepared for release in July 2007. CME credit may be awarded for a maximum of three years from its release date, specifically from July 2007 through June 2010. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

Method of Participation

1. View the web pages. You may print the self-study text to read off-line.
2. Complete the on-line learning assessment test.  It will be electronically scored and the correct answers returned immediately for your review.
3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
4. Print the certificate of participation for your personal records.

 

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