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Figure 1. DM 2 diagnostic algorithm and screening Clinical suspicion Polyuria / Polydipsia Asthenia Weight loss Ketonuria Casuall plasma glucose (without prior fasting) Annual screening Population with risk factors: BMI > 30 DM antecedents in fi rst-degree relatives HBP Dislypemia Prior Impaired Fasting Glucose or Impaired Glucose Tolerance (IGT) Gestational diabetes High risk ethnic groups (Central American, Asian, etc.) Temporal screening every three years at the health centre General population > 45 years > 200 mg/dl DM 2 diagnosis FASTING PLASMA GLUCOSE 126 mg/dl Repeat FPG 75 g glucose OGTT Repeat FPG 110-125 mg/dl a 200 mg/dl >126 mg/dl Repeat OGTT NORMAL Impaired Plasma Glucose Impaired Glucose Tolerance >200 mg/dl DIABETES a WHO / IDF Criteria 2006. b Indicated in case of suspicion of diabetes with normal basal glycaemias and in some cases of patients with repeated Altered Basal Glycaemias, especially among the elderly and female population. OGTT: Oral Glucose Tolerance Test; FPG: Fasting Plasma Glucose; IFG: Impaired Fasting Glucose ; IGT: Impaired Glucose Tolerance. 5.4. DM 2 screening There is no evidence to support DM 2 universal screening. It is worth highlighting that the best evidence to support screening is that provided by randomized clinical trials (RCTs) where the intervention performed is the screening and the result variables are the fall of the morbimortality rates attributed to the condition to be screened. If these are not available, screening can be justified by indirect evidence which shows the existence of effective interventions for the disease to be screened. At a lower evidence level, an increase in the risk to develop the disease in different groups at risk may justify the screening. The Systematic Reviews taken into consideration recommend screening in groups at risk though they disagree in the classification of these groups. The US Preventive Services Task Force (61; 69) recommends screening in hypertensive patients and those suffering from dyslipidemia. Recent research carried out in the UK extends the screening indications to obesity (62). Different national initiatives agree on the recommendation to develop a screening in other groups at risk in addition to those already mentioned: adults over 45 years old, within a cardiovascular preventive structured activity program; diabetes antecedents in first degree relatives; prior Impaired Fasting Glucose or Impaired Glucose Tolerance diagnosis, SR of RCT 1+ CPG and Expert opinion 4 44 CLINICAL PRACTICE GUIDELINES IN THE NHS
and certain ethnic groups (Asian, Central American, etc.) (1; 2; 63). The screening frequency is determined by consensus; screening is recommended every three years for people over 45 years old and on an annual basis for patients suffering from other risk factors (hypertension, dyslipidemia, pre-diabetic stages, etc.) (64). As regards the screening technique, the reviews and Clinical Practice Guidelines analysed recommend fasting plasma glucose. Determination through capillary glucose in total blood, could simplify the diagnosis. Although there are multiple studies published on capillary glucose on the diagnosis of diabetes (65- 68), none of them complies with the quality standards demanded for a study on diagnostic tests, therefore the located evidence does allow its recommendation for this purpose. CPG 4 Evidence summary 1+ Diabetes universal screening is not cost-effective (61; 62; 69). Recommendations D C An annual diabetes screening is recommended through fasting plasma glucosein the population at risk, defined by hypertension, hyperlidemia, obesity, gestational diabetes or obstetric pathology (macrosomia, repeated miscarriages, malformations), Impaired Fasing Glucose and Impaired Glucose Tolerance at any age; and every three years in patients aged 45 or over, within a cardiovascular preventive structured program. Capillary glucose in total blood cannot be recommended as a diagnostic test in the population groups at risk. CLINICAL PRACTICE GUIDELINE ON TYPE 2 DIABETES 45
Page 1: Clinical Practice Guideline on type
Page 4 and 5: A bibliographic record of this work
Page 7 and 8: Table of Contents Presentation 9 Au
Page 9 and 10: 11. Diabetic foot. Assessment, prev
Page 11: Presentation Care practice is becom
Page 14 and 15: Other collaborations Rosa Rico Itur
Page 16 and 17: 13. Which drug combination strategi
Page 19 and 20: Summary of recommendations Defi nit
Page 21 and 22: D CPG B B B B A daily single dose
Page 23 and 24: A B CPG Hypertense patients with DM
Page 25 and 26: Treatment for diabetic foot ulcers
Page 27: 1. Introduction Effective care for
Page 31 and 32: 3. Methodology Methodology. Evidenc
Page 33 and 34: 4. Epidemiology and sanitary impact
Page 35: However, the quality of the assista
Page 38 and 39: 5.2. Risk factors for the developme
Page 40 and 41: 5.2.8. Diet and alcohol Type of die
Page 42 and 43: 5.2.12. Heart failure The associati
Page 44 and 45: The ADA does not recommend it for c
Page 48 and 49: 46 CLINICAL PRACTICE GUIDELINES IN
Page 50 and 51: 6.1. Impaired Fating Glucoseucose (
Page 52 and 53: 1++ An intensive intervention on li
Page 54 and 55: Different SRs (81-84) have assessed
Page 56 and 57: 7.1.4. Other dietary interventions
Page 58 and 59: Exchange system This system is base
Page 60 and 61: duration and intensity). Performing
Page 62 and 63: [RR 0.75 (CI 95%: 0.60-0.93)], and
Page 64 and 65: The optimum dose in most patients i
Page 66 and 67: without heart failure. In this stud
Page 68 and 69: B B B B Metillinides can play a ro
Page 70 and 71: Recommendations B A A B B B B When
Page 72 and 73: 8.2. Insulin therapy 8.2.1. Associa
Page 74 and 75: Slow-acting insulin analogues vs. N
Page 77 and 78: 9. Screening and treatment of macro
Page 79 and 80: The validity and applicability of a
Page 81 and 82: The RCTs and the meta-analysis are
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Page 85 and 86: 9.5.2. Pharmacological treatment of
Page 87: Recommendations B/D A B CPG Patient
Page 90 and 91: incidence was 0.3% after the first
Page 92 and 93: it is believed that microalbuminuri
Page 94 and 95: Summary of evidence 1++ In hyperten
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An SR on drugs to treat diabetic ne
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(241), the response rate to placebo
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11. Diabetic foot. Assessment, prev
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11.2.2. Peripheral arterial disease
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11.4. Other preventive measures The
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B D CPG B Diabetic foot screening m
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11.5.4. Antibiotic treatment for in
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2+ The culture has a limited value
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• Promote healthy lifestyles: die
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In another recent RCT (289), sMBG w
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12.3. Contents and methods of an ed
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Assessment of self-management recor
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13.4. Referral criteria to medical
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Appendices Appendix 1. Levels of Ev
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Appendix 2. DM 2 diet Estimating ca
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CLINICAL PRACTICE GUIDELINE ON TYPE
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GPL-1 Analogues Biguanides Glitazon
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Devices FLEXPEN (Novo Nordisk): OPT
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Treatment for an unconscious patien
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Appendix 6. Assessment of macro- an
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Appendix 8. Use of monofilament Mon
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Indicators of final outcomes • Nu
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Impaired Glucose Tolerance (IGT): I
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IGT INSIGHT Trial IV LDL LH LIFE Tr
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Bibliography 1. Estrategia en diabe
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33. Iso H, Date C, Wakai K, Fukui M
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64. Screening for type 2 diabetes.
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97. Thomas DE, Elliott EJ, Naughton
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129. Lincoff AM, Wolski K, Nicholls
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157. Natarajan S, Liao Y, Cao G, Li
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185. de GG. Low-dose aspirin and vi
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214. Rahman M, Pressel S, Davis BR,
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245. NZGG. Management of type 2 dia
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279. Norris SL, Nichols PJ, Caspers
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