From the ACP Diabetes Care Guide

Persons with diabetes are at increased risk for macrovascular disease; microvascular disease, including retinopathy and nephropathy; peripheral and autonomic neuropathies; and lower extremity disease.

• Diabetic retinopathy is the leading cause of noncongenital blindness among adults.
• Diabetes is the most common cause of endstage kidney disease in the United States, especially among Native American, Hispanic, and African American persons. One quarter to one third of patients with type 1 or type 2 diabetes develop some degree of nephropathy.
• Diabetes doubles the risk for cardiovascular disease in men and triples it in women (data from the Multiple Risk Factor Intervention Trial [MRFIT]).
• Patients with diabetes are several-fold more likely to have peripheral arterial disease than patients without diabetes.
• Peripheral arterial disease and foot ulcers in patients with diabetes account for two thirds of all nontraumatic amputations performed in the United States.

Screening for and prevention of these complications are fundamental to the care of patients with diabetes and are important components of quality of care initiatives for diabetes.

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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ACP Summer Session was a two-day event that covered key topics and management strategies in the areas of cardiology, diabetes, pulmonary diseases, and neurological diseases. ACP Summer Session was held in Orlando, Florida on August 7-8, 2009 and in San Francisco, California on August 14-15, 2009. The following audio recordings with synchronized slides and course handouts are from the Orlando meeting and are available free to ACP members.

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Diabetic neuropathy has many manifestations because injury occurs to sensory, motor, and autonomic nerves. The most common presentation is the loss of sensation in a “stocking-glove” distribution, associated with paresthesias or painful dysesthesia. Loss of sensation in the lower extremities is also a major factor in the development of foot ulcerations.

Less commonly, acute mononeuropathies may involve either cranial or peripheral nerves, and sometimes even entire spinal nerve roots (radiculopathy). The latter may have perplexing clinical presentations that mimic the pain associated with acute myocardial infarction, acute cholelithiasis, or nephrolithiasis.

Autonomic neuropathy presents as erectile dysfunction in men, and orthostatic hypotension, gastroparesis, diabetic diarrhea, and atonic bladder.

Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.

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Psychological issues may interfere with type 1 diabetes management tasks such as insulin injections, diet and exercise. To find out whether psychological therapy could improve diabetes management, researchers assigned 344 patients to either regular care, cognitive behavioral therapy or a combination of nurse-delivered cognitive behavioral therapy and motivational enhancement therapy (brief counseling that focuses on self-motivation). Researchers collected information on change in blood sugar levels, low blood sugar episodes, depression, quality of life, diabetes self-care activities and weight for one year. Patients who received both psychological therapies fared the best, having a greater decrease in blood sugar levels than patients who received usual care. However, the changes were small and this study cannot determine whether they would persist beyond 12 months.

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Question
In patients with poorly controlled type 2 diabetes, how does intensive glucose control compare with standard control for reducing cardiovascular (CV) events?

Conclusion
Intensive glucose control and standard control did not differ for reducing cardiovascular events or death in patients with poorly controlled type 2 diabetes.

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Question
In type 2 diabetes, does intensive glucose control prevent adverse outcomes more than standard glucose control?

Conclusion
Compared with standard glucose control in type 2 diabetes, intensive glucose control with gliclazide and other drugs had no effect on macrovascular events, prevented new or worsening albuminuria, but led to greater hypoglycemia.

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Question
In patients with type 2 diabetes and cardiovascular disease or risk factors, does intensive glucose control prevent cardiovascular events more than standard glucose control?

Conclusion
In patients with type 2 diabetes and cardiovascular disease or risk factors, intensive glucose control increased mortality and did not prevent cardiovascular events more than standard glucose control.

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Question
In adults with diabetes, how effective are treatments for painful diabetic neuropathy?

Conclusion
Tricyclic antidepressants, traditional anticonvulsants, newer-generation anticonvulsants, opioids, duloxetine, and capsaicin cream are effective short-term treatments for painful diabetic neuropathy in adults, although side effects may result in discontinuation of treatment.

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Question
In patients with type 2 diabetes, does pioglitazone reduce cardiovascular events, other adverse events, and mortality or improve health-related quality of life?

Conclusions
Based on 1 randomized trial, pioglitazone does not reduce risk for mortality or cardiovascular events in patients with type 2 diabetes. Some evidence exists that pioglitazone increases risk for such adverse events as weight gain, decrease in hemoglobin level, and edema.

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Question
In patients with chronic noncancer pain (CNCP), are opioids more effective than placebo or other analgesics for relieving pain and improving functional outcomes?

Conclusions
In patients with chronic noncancer pain, weak and strong opioids are more effective than placebo for relieving pain and improving functional outcomes, although they are less effective than other analgesics for improving functional outcomes. Strong opioids are more effective than other analgesics for relieving pain.

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