Routine Preventive Care

Trinidad and Tobago Specific Information

Trinidad and Tobago Information Author: Claude Khan, BSc, MBBS, MRCGP, MSc and Nancyellen Brennan FNP, CDE

Diabetes guidelines developed in 2006 under auspices of Pan American Health Organization (PAHO) and Caribbean Health Research Council (CHRC).
Guidelines for frequency of testing: HbA1c (every 3-6 months), urine microalbumin (annually), fasting lipid profile (annually)
Goal HbA1c < 6.5 %
Goal blood pressure <130/80 mmHg; with nephropathy <125/75 mmHg
Goal lipids: LDL<70 mg/dL, HDL>40 mg/dL (no difference for male or female), fasting triglycerides <150 mg/dL
Recommend regular aerobic activity 30-60 minutes a day, five times a week.
Adherence to guidelines may be influenced by both provider and patient inertia.
A frequent barrier to achieving guidelines is resource availability (i.e. lab reagents are difficult to obtain and not always available in the public sector).
Glucometer test strips available through the Chronic Disease Assistance Program (CDAP) for people on insulin since 2008, in order to help patients attain glucose targets.

EPIDEMIOLOGY

Modification of multiple risk factors (glycemic control, high blood pressure, dyslipidemia, aspirin therapy, and smoking cessation) decreases mortality by 46%, cardiovascular disease death and events by 57 and 59%, respectively, and microvascular complications by 55% relative to conventional therapy among individuals with diabetes (Gaede).

Influenza and pneumococcal pneumonia associated with higher mortality rates in diabetes

Periodontal disease frequently complicates diabetes and may worsen glycemic control.

Diabetes associated with increased risk of cancer including that for breast (RR 1.2) and colon cancer (RR 1.3) and is associated with increased all-cause mortality in cancer patients (RR 1.4).

DIAGNOSIS

Hemoglobin A1c: every 3 months if therapy changed or patient not at goal. Every 6 months in patients with stable control. Self-monitoring of blood glucose: at least 3 times a day for individuals on multiple insulin injections or insulin pump therapy; less frequently for other patients to help guide therapy. Continuous glucose monitoring: may be useful in type 1 diabetes.

Blood pressure: each routine diabetes visit

Fasting lipid profile: at least annually

Urine albumin excretion: annually (i.e. spot urine albumin-to-creatinine ratio) for individuals with type 1 diabetes and >5 years duration or type 2 diabetes beginning at diagnosis. Annual serum creatinine to estimate glomerular filtration rate

Ophthalmologic evaluation: annually beginning 5 years after type 1 diagnosis and at initial type 2 diagnosis

Foot examination annually for: 1) distal symmetric polyneuropathy: pinprick sensation, vibration sense, Achilles reflexes, monofilament testing; 2) peripheral arterial disease: evaluation for claudication, examination of distal pulses (i.e. dorsalis pedis or posterior tibial).

Autonomic neuropathy evaluation annually by history and physical

Screen for depression, anxiety, and dementia at routine diabetes visits especially if concerned about adherence.

Age-appropriate cancer screening per United States Preventive Services Task Force (http://www.ahrq.gov/CLINIC/uspstfix.htm)

Evaluate estimated 10-year cardiovascular disease risk at routine visits (Framingham equations, http://hp2010.nhlbihin.net/atpIII/calculator.asp?usertype=prof, Accessed April 19, 2010).

SIGNS AND SYMPTOMS

HEENT: hearing loss, visual acuity, diplopia, scotomata, blurry vision

Cardiovascular: chest pain, exercise intolerance, heart palpitations, numbness, tingling, weakness, intermittent claudication

GI: constipation, nausea

GU: erectile dysfunction, bladder dysfunction, urinary tract infections, incontinence

Extremities: foot ulcers, hand/foot pain, numbness, tingling

Orthostatic hypotension: decrease in systolic blood pressure of more than 20 mmHg or decrease in diastolic blood pressure of more than 10 mmHg upon standing from seated position; this may indicate autonomic dysfunction but may be related to medication (e.g., diuretics) as well (JNC 7)

CLINICAL TREATMENT

Glycemic control (goal A1c <7%): to decrease risk of microvascular and macrovascular complications of diabetes. Medications should be intensively escalated until goal A1c reached (see modules on sequencing therapies in type 2 diabetes and insulin treatment in type 1 diabetes).

Lifestyle recommendations: 1) physical activity: hyper- or hypoglycemia, diabetic retinopathy, and diabetic neuropathy may limit physical activity; and 2) diet

Lipid control (goal LDL-cholesterol <100 mg/dl, or <70 mg/dl in patients at very high risk for coronary events): regardless of lipid profile, HMG CoA reductase inhibitors (statins) recommended if patient has known cardiovascular disease or is > 40 years of age and has >1 risk factor for cardiovascular disease

Hypertension (goal blood pressure <130/80); measurements above this value warrant further evaluation and management

ACE inhibitor: recommended for patients with: 1) known cardiovascular disease; 2) micro- or macroalbuminuria (ACE inhibitor or ARB acceptable)

Beta blocker: recommended for patients with prior myocardial infarction for at least 2 years after event

Smoking cessation: for cardiovascular disease prevention; offer treatment to facilitate smoking cessation. Counsel patients following the 5 A's model: Ask, Advise, Assess, Assist, Arrange. Pharmacologic agents include nicotine replacement, bupropion, and varenicline (www.surgeongeneral.gov/tobacco).

Aspirin (75-162 mg/day): for primary or secondary prevention of cardiovascular disease. Primary prevention indication: 10-year cardiovascular disease (CVD) risk >10% in the absence of elevated risk of bleeding (typically, men >50 years women >60 years (women) with an additional risk factor (hypertension, family history, dyslipidemia, microalbuminuria, family history of premature CVD, or smoking). Consideration of aspirin in those without CVD but at intermediate 10-year risk (5-10%). Aspirin is not recommended for primary prevention for low-risk patients without CVD (e.g., no risk factors, 10-year risk <5%). Secondary prevention indications: patients with CVD. Consider clopidogrel if aspirin allergy present.

Foot care: referral to podiatrist if patient smokes, has neurologic deficit, or prior foot disease

Vaccinations: pneumococcal and influenza vaccinations as recommended

EXPERT COMMENTS

Routine care of the patient with diabetes should be multidisciplinary and include the patient, family members, physicians, nurses, dieticians, and other health care professionals in the management plan.

Routine preventive care, when effectively implemented, can delay the development of complications and preserve quality-of-life for individuals with diabetes.

Recommendations have been updated to narrow the group of patients with diabetes for whom aspirin for primary prevention of CVD is recommended based on estimated CVD risk (Pignone). Multiple CVD risk prediction tools are available for diabetes (http://www.dtu.ox.ac.uk/riskengine/index.php, http://www.aricnews.net/riskcalc/html/RC1.html, http://www.diabetes.org/living-with-diabetes/complications/diabetes-phd/) as seen in the American Diabetes Association position statement.

Basis for Recommendations

American Diabetes Association; Standards of medical care in diabetes--2010.; Diabetes Care; 2010; Vol. 33 Suppl 1; pp. S11-61;
ISSN: 1935-5548;
PUBMED: 20042772
Rating: Basis for recommendation
Comments:Summary of American Diabetes Association recommendations for routine preventive care.