Debra Wood, RN

Do not overdiagnose diabetes, warned Guillermo E. Umpierrez, MD, FACP, a professor of Medicine at Emory University in Atlanta, during a presentation at the American College of Physicians Internal Medicine 2014 annual meeting held in Orlando, FL. He explained that an inappropriate diagnosis will follow the patient and may affect insurance and other options.

Since 2009, HbA1c is one of the tests physicians can use to diagnose diabetes. However, Umpierrez cautioned that other factors can alter HbA1c results. “Look at the fasting glucose,” advised Umpierrez.

He explained how the accepted method of diagnosis has changed over the years, from glucosuria in 1901 to the current guidelines, which include fasting glucose, two-hour postprandial glucose, or a random glucose test. The rationale for using HgA1c as diagnosis criteria involved studies that showed the incidence of retinopathy began to increase in patients with a HgA1c of 6.5%. It’s an easy test to perform, does not require fasting, and is unaffected by illness. Physicians can follow HgA1c over time and adjust therapy accordingly.

The limitations of using HgA1c include its cost, the lack of reliable testing in developing countries, and elevations in certain populations: patients with iron deficiency anemia, older adults, and blacks. HgA1c also cannot be trusted in patients with kidney disease or sickle cell anemia, he said.

Umpierrez declared fasting blood glucose as the best test to screen people. A normal result is less than 100 mg/dL. Subjects at risk are patients with a fasting blood sugar between 100-125 mg/dL or an HgA1c of 6.4%. If the test is greater than 100 mg/dL, he recommended ordering an HgA1c and possibly an oral glucose tolerance test, which is very specific but difficult on the patient.

“Repeat every test twice [before making a diagnosis],” he advised.

With at-risk patients, he advised to first try diet and exercise, with a 5 percent weight loss effective in preventing disease progression. If unsuccessful, metformin can be added, and will usually be more helpful in a younger person. Metformin should not be used to prevent diabetes in patients with a normal fasting blood sugar.

Umpierrez next addressed the pros and cons of intensive glycemic control and informed the internists in the audience that the trend has shifted from accepting glucose levels ranging from 200-300 mg/dL in the 1980s to tight control to the current move toward a middle ground. He discussed three studies showing that tighter control may not reduce heart disease, even though it does reduce microvascular complications. However, “all-cause mortality increased with tight control” in the ACCORD study of 2008.

“It was clearly unexpected, and it’s not clear why,” said Umpierrez, adding that hypoglycemia was associated with risk of death. 

The American College of Physicians recommends keeping HgA1c levels around 7%. The American Diabetes Association guidelines range from less than 6% to more than 8%, depending on a variety of factors including attitude, risk of hypoglycemia, duration of time with the disease, age, co-morbidities, vascular complications, and resources.

“The goal is individualization of care,” Umpierrez said.

Umpierrez recommended aiming for an HgA1c of around 7%, no higher than 8%, except in patients with dementia who have a greater risk of hypoglycemia. If the patient takes only a medication not associated with hypoglycemia, such as metformin, the goal can be lower than 7%.

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Clinicians should consider a patient's risk of hypoglycemia, the duration of time with the disease, age, comorbidities, vascular complications, and other factors when setting treatment goals. 

Setting A1c Goals for Patients with Diabetes Depends on a Variety of Factors

With state-of-the-art treatment regimens for hepatitis C becoming more effective and easier to administer and monitor, care delivery will shift away from specialists to include more involvement by prima ry care physicians.

“The disease is moving swiftly into the arena of internists,” said Norah A. Terrault, MD, MPH, FACP, a professor of medicine and director of the Viral Hepatitis Center at the University of California, San Francisco, during a presentation at the American College of Physicians Internal Medicine 2014 annual meeting held in Orlando, FL.

About 65 percent of people infected with the hepatitis B and 75 percent of those infected with hepatitis C virus do not know it. Screening guidelines recently changed for both diseases. For hepatitis B, all people born in countries with a high prevalence of the disease (a HBsAg prevalence of equal to or greater than 2 percent) should be screened, as should anyone born in the United States who was not vaccinated as an infant with a parent born in regions with a HBV endemicity of equal to or greater than 8 percent.

“You need to understand where it is prevalent in the world,” in order to guide your screening decisions, Terrault said.

Additional people screened include injection-drug users, men who have sex with men, immunosuppressed people, those with elevated liver function tests, hemodialysis patients, organ donors, and partners of patients with the disease.

Screening guidelines for hepatitis C changed from only those with risk factors to include all people born between 1945 and 1965. They may have been infected years ago due to lifestyle experimentation, meaning they may have been infected for nearly 40 years, she said. 

“If we identify 800,000 infected people and treat, we will prevent liver cancer and cirrhosis,” Terrault said. “We need to find them now to get them care to prevent downstream complications. Timing is critical.”

Goals are to reduce the risk of chronic infection and transmission to others. The hepatitis B vaccine is the most important intervention in the prevention of hepatitis B, but no vaccine for hepatitis C exists, she said. With the hepatitis B vaccine, pre-vaccination testing is recommended. Post-vaccination testing is indicated only for high-risk patients at one to two months after the last dose. If the desired titer is not reached, a second course can be given. Booster shots are not recommended

Whether treating hepatitis B or C, prevention of the progression to cirrhosis involves reducing risk with abstinence from alcohol and cannabis and maintaining an ideal body weight.

Terrault emphasized the importance of staging cirrhosis, because patients remain at risk of liver decompensation. Staging provides guidance for when to treat the infected patient. Noninvasive tests are the first step. “We can make the diagnosis short of a biopsy,” she said.

A platelet count of less than 140,000 platelets per microliter of blood indicates the patient may have cirrhosis. Other tests include the Fibrotest (or FibroScore) and the APRI or F1B4, which are two markers for fibrosis that can be calculated at the bedside.

“The tests perform best at the extremes and are not perfect,” she said. “They give an estimate.”

If the blood testing indicates cirrhosis, do more testing to confirm or eliminate the diagnosis, she recommended. That may include transient elastography, which uses sound waves to assess liver stiffness.

Patients with chronic hepatitis B are more difficult to manage and need ongoing monitoring, Terrault said. Patients who are immune inactive or immune tolerant do not require treatment, only those who are immune active, with an increased ALT and HBVDNA. Peginterferon, tenofovir, and entecavir are first-line drugs. Patients are not cured only controlled.

Hepatitis C, on the other hand, can be cured in most people. The goal is to suppress the virus long term, which will lead to improved liver enzymes and a seroconversion.

Treatment regimens depend on genotype. Some genotypes still require interferon as part of the drug regimen, but interferon-free combinations have shown great promise in clinical trials and are expected to be available within a year.

“Our options for treatment continue to improve,” Terrault concluded. “It’s only going to get better.”

With state-of-the-art treatment regimens for hepatitis C becoming more effective and easier to administer and monitor, care delivery will shift away from specialists to include more involvement by primary care physicians. 

Screening and Management of Hepatitis C in the Wake of New Guidelines and Treatments

How important are lifestyle modifications in reducing cardiovascular events in patients with type 2 diabetes? Are higher glucose levels associated with dementia? Is bariatric surgery effective in severe obesity? What is the role of diabetes in bariatric surgery?

Hossein Gharib, MD, MACP, professor of medicine at the Mayo Clinic College of Medicine in Rochester, MN, answered these and other endocrine-focused questions during a journal article review session at the American College of Physicians Internal Medicine 2014 annual meeting held in Orlando, FL.

In a randomized, multicenter trial examining whether lifestyle changes favorably affected cardiovascular morbidity and mortality, researchers followed overweight, diabetic patients for 10 years, monitoring weight, waste circumference, physical fitness, and glycated hemoglobin and found the intervention group achieved a 7 percent or greater loss and improvements in physical fitness and HbA1c. Cardiovascular events were not improved and the study was discontinued early.

“Lifestyle modification is still useful. Complications are less,” Gharib said. “Lifestyle changes cause no harm, offer modest benefit, and should be pursued” for overweight patients with diabetes.

A prospective, community-based cohort study with 2,067 participants who did not have dementia suggested higher glucose levels are a risk factor for dementia even in people without diabetes. Participants with a mean age of 76 years were followed for a median of 6.8 years; 524 of them developed dementia.

Studies like this demonstrate “there is a need to evaluate and carefully monitor hyperglycemia in the elderly,” Gharib said.

A multicenter, observational cohort study investigated medium-term outcomes for and complications of bariatric surgery in the severely obese, a term Gharib prefers to “morbidly obese,” which patients find offensive. Researchers followed for three years 1,737 patients who underwent a Roux-en-Y gastric bypass (RYGB) and 610 who had a laparoscopic gastric banding (LAGB).

The three-year median weight loss after the RYGB was 31.5 percent; after LAGB it was 16 percent. Partial diabetes remission was achieved in 67.5 percent of the RYGB cohort and in 28.6 percent in the LAGB group. Dyslipidemia resolved in 62 percent of the RYGB group and 27 percent of the banding group.

“Roux-en-Y is a more dramatic surgery and more effective,” Gharib said.

Adverse effects and the need for additional operations were common. However, overall, the treatment was satisfying and will be the subject of more studies, Gharib predicted.

Gharib prefers the name “metabolic surgery” for the procedures, because it reduces weight, causes diabetes remission, and improves hyperlipidemia.

In a multinational, randomized controlled trial involving 120 patients with diabetes mellitus and a body mass index ranging from 30 to 39.9, all patients underwent lifestyle modification and intensive medical management. Half of the patients were randomized to receive a RYGB. Researchers compared HbA1c levels, LDL cholesterol, and systolic blood pressure.

“The data shows better results after Roux-en-Y,” Gharib said. “HbA1c improved, and there was a significant weight reduction.”

However, the surgical group experienced a higher complication rate, and one patient became disabled as a result of a brain injury.

“The long-term safety and efficacy needs to be determined,” Gharib said. “Surgical treatment for diabetes seems to be an evolving process.”

Diabetic surgery seems to work, he added, but should serve as an adjunct to intensive medical management, not replace it. The surgery can be offered to moderately obese patients with type 2 diabetes.

“The results are somewhat encouraging, and the study is noteworthy,” Gharib concluded.

Several studies have shown good results with Roux-en-Y gastric bypass and laparoscopic gastric banding when combined with lifestyle modifications in severely overweight patients with type 2 diabetes.

What is the Role of Surgery in the Management of Patients with Diabetes?

Once confirmation of an asthma diagnosis is made, most primary care physicians can manage the condition and need refer only challenging cases to a pulmonologist.

“Most asthma is manageable and not difficult to control,” said Sola Olopade, MD, MPH, FACP, FCCP, professor of Medicine at The University of Chicago, during a presentation at the American College of Physicians Internal Medicine 2014 annual meeting held in Orlando, FL.

“It’s important to take a very good and detailed history,” Olopade added. “Every patient is different.”

Olopade encouraged physicians to ask about occupational exposures to irritants; the use of medications, including aspirin and other anti-inflammatory drugs and antihypertensives; and household pets, including birds, which patients often forget to mention.

“Most patients are poorly controlled, because [they] haven’t identified the factor making the asthma worse,” he said.

Following the history, he suggested obtaining spirometry. A methacholine challenge test may be helpful, except with anticipated exercise-induced asthma. The best way to check for exercise-induced asthma is to assess FEV1 (forced expiratory volume in 1 second) 20 minutes into the exercise session.

When monitoring effectiveness of therapy, Olopade said he pays the most attention to nighttime symptoms. If the patient does not respond to asthma therapy, extrapulmonary conditions, such as gastroesophageal reflux disease or rhinitis, should be considered and treated. Physicians should also treat sleep apnea, which can worsen asthma symptoms.

For patients who continue to worsen despite initial treatment, Olopade encouraged the audience to explore what might be making symptoms worse and not simply to increase the level of treatment. He advised that they delve into the patient’s history to determine what might contribute, and offer suggestions for mitigation; for instance, patients may need professional help to rid a home of mold.

For patients with moderately severe asthma, he suggested trying the long-acting muscarinic receptor antagonist tiotropium, in conjunction with inhaled corticosteroids.

“Asthma symptoms and pulmonary function can be well controlled by the addition of tiotropium as an alternative to salmeterol,” Olopade said. “The effectiveness is comparable.”

The anti-IgE medication Xolair makes physiologic sense and can mitigate the allergic mechanism that drives asthma and prevents exacerbations, he said. However, he recommended reserving it for people with severe allergic asthma uncontrolled on aggressive standard treatment and who frequently need steroid bursts, those with an elevated IgE level, and patients who are steroid dependent.

“Don’t use it as an early intervention,” he advised.

Bronchial thermoplasty, in which the smooth muscle in the airway is burned during bronchoscopy, has been effective in improving symptoms of moderate to severe asthma. Adverse events, such as mucous plugs are manageable. Studies have shown improvement in asthma control and quality of life but not in improvement to peak flow and FEV1.

“The fact is, just because we can do it, doesn’t mean we should do it for everyone,” Olopade cautioned.

Olopade also discussed management of chronic obstructive pulmonary disease (COPD). Goals include reducing symptoms, improving exercise tolerance and health status. In addition, physicians are focusing more on patients’ quality of life and reducing the risk of exacerbations, which means decreasing exposure to risk factors, such as smoking. Taking care of a patient who continues to smoke presents a challenge for physicians, he said, recommending smoking cessation programs. Pulmonary rehabilitation proves helpful for many patients.

Roflumilast works well as an adjuvant therapy in patients with severe COPD and chronic bronchitis who can tolerate it. He said it should not be the default medication for all patients. Gastrointestinal side effects, with associated significant weight loss and loss of muscle mass, hinder its successful use.

Debra Wood, RN

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