TPN

Diagnosis

A diagnosis of diabetes can be accomplished through any one of the following three criteria:

Symptoms plus elevated casual plasma glucose

Symptoms of diabetes plus casual plasma glucose ≥200 mg/dL

Elevated fasting plasma glucose

Fasting plasma glucose levels ≥126 mg/dL (or 7.0 mmol/L)

Elevated OGTT glucose level

A 2-hour reading during a “75 gram oral glucose tolerance test” with a glucose level of ≥200 mg/dL

Treatment Strategies

Treatment strategies are aimed at plasma glucose control and the prevention of complications often associated with diabetes. In the case of prediabetes, treatment strategies are aimed at reducing the risk for progression to type 2 diabetes. A stepped plan for treatment will include efforts in patient education, diet modification, improved physical activity, and medications according to need. This section will provide an overview for each of these treatment modalities.

New treatment guidelines are based on a better understanding of the relationship between biochemical tests. Fasting plasma glucose levels (or FPG) contribute more to higher hemoglobin A1c levels, while postprandial levels contribute less; and FPG contributes less than postprandial levels to lower HbA1c levels. For instance, in patients with HbA1c >10.2%, the fasting glucose levels contribute 70% of the value. If the HbA1c is less than 7.3%, the fasting glucose levels contribute only 30%. When HbA1c levels are between 7.3% and 8.4%, the contributions of FPG and postprandial levels are about the same. This suggests that in cases of high HbA1c levels, efforts should be concentrated in achieving FPG control. If there are lower HbA1c levels, efforts can be concentrated on post-meal glucose control. The AACE guidelines suggest addressing both issues simultaneously to assure best results.

There is strong evidence to support the aggressive implementation of therapies once a diagnosis of type 2 diabetes is received.

The ongoing management of diabetes requires patient involvement and control. Patients who are equipped with education on the disease and appropriate self-management guidelines are more likely to achieve glucose control and be able to reduce associated complications.[i][ii] Support systems with diabetes educators are essential to the maintenance of self-management behaviors and can reduce the requirement for pharmacologic therapies. Self-monitoring of blood glucose (or SMBG) is the primary feedback mechanism that allows patients and their caregivers to adjust therapies. Less emphasis has been put on monitoring glucose in urine because the results may reflect a delay in the effect of high blood glucose and have not been well correlated with improved control. However, ketone levels may be monitored in cases of very high glucose levels.

Education Associated with improved glucose control and reduced complications Support systems Self-monitoring of blood glucose (SMBG)

[i] Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005;CD003417.

[ii] Warsi A, Wang PS, LaValley MP, Avorn J, Solomon DH. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med. 2004;164:1641-1649.