Numbers to Remember, Important Numbers not to be missed

Numbers to Remember
Usama Ragab Yousif
Zagazig Faculty of Medicine
First Annual ISMA Conference – Mercure Hotel - Ismaliia
Friday, 15/02/2019

Metabolic Syndrome
Criteria for Clinical Diagnosis of the Metabolic Syndrome
Measure Categorical Cut Points
Elevated waist circumference Population- and country-specific definitions
Elevated triglycerides (drug
treatment for elevated
triglycerides)
≥150 mg/dL
Reduced HDL-C <40 mg/dL in males; <50 mg/dL in females
Elevated blood pressure
(antihypertensive drug
treatment)
Systolic ≥130 and/or diastolic ≥85 mm Hg
Elevated fasting glucose (drug
treatment of elevated glucose)
≥100 mg/dL

Blood Glucose
• Normal blood glucose values
Fasting: < 100 mg/dL, fasting is defined
as no caloric intake for at least 8 h.
2hPP: < 140 mg/dL
HbA1C: 5.7%
Diabetes Care 2019 Jan; 42(Supplement 1): S13-S28.

Prediabetes
• Adults of any age who are overweight or
obese (BMI ≥25 kg/m2) and who have one or
more additional risk factors for diabetes.
• For all people, testing should begin at age 45
years.
• If tests are normal, repeat testing carried out
at a minimum of 3-year intervals is reasonable.
• To test for prediabetes and type 2 diabetes,
fasting plasma glucose, 2-h plasma glucose
during 75-g oral glucose tolerance test, and
A1C are equally appropriate.

Prediabetes (cont.)
• For Diagnosis of Prediabetes:
FPG 100 -125 mg/dL (IFG)
2-h PG during 75-g OGTT 140 - 199
mg/dL (IGT)
A1C 5.7–6.4%

Diabetes
• Criteria to diagnose DM
 FPG ≥126 mg/dL (7.0 mmol/L).
 2-h PG ≥200 mg/dL during OGTT; 75-g glucose
 A1C ≥6.5%; method that is NGSP certified and
standardized to the DCCT assay.
 In a patient with classic symptoms of
hyperglycemia or hyperglycemic crisis, a random
plasma glucose ≥200 mg/dL.
In the absence of unequivocal hyperglycemia,
diagnosis requires two abnormal test results from
the same sample or in two separate test samples.

Type 1 DM
• Plasma glucose rather than A1c.
• Diabetic symptoms or hyperglycemic crisis
plus a random plasma glucose ≥200 mg/dL
[11.1 mmol/L]).

Glycemic Targets in DM
• A1c
Twice yearly if stable.
Quarterly if not meeting glycemic goal
A1C <7% (<6.5% - <8%)
Preprandial 80-130 mg/dL
Peak postprandial <180 mg/dL

Glycemic Targets (cont.)
• Blood glucose and A1C targets for children
and adolescents with type 1 diabetes
Blood glucose goal range
Before meals Bedtime/overnight A1C Rationale
90–130 mg/dL 90–150 mg/dL <7.5% A lower goal (<7.0%) is
reasonable if it can be
achieved without
excessive hypoglycemia

Gestational Diabetes
• GDM is diabetes that is first diagnosed in
the 2nd or 3rd trimester of pregnancy that is
not clearly either preexisting type 1 or type
2 diabetes.
• Test for gestational diabetes mellitus at 24–
28 weeks of gestation in pregnant women
not previously known to have diabetes.

Gestational Diabetes (cont.)
• GDM diagnosis can be accomplished with
either of two strategies:
1. “One-step” 75-g OGTT or
2. “Two-step” approach with a 50-g
(nonfasting) screen followed by a 100-g
OGTT for those who screen positive

One Step Strategy
• Perform a 75-g OGTT, with plasma glucose
measurement after overnight fast of at least 8 hours
and at 1 and 2 h, at 24–28 weeks of gestation in women
not previously diagnosed with diabetes.
• The diagnosis of GDM:
 Fasting: 92 mg/dL
 1 h: 180 mg/dL
 2 h: 153 mg/dL

Two Step Strategy
• Two-step strategy
Step 1: Perform a 50-g GLT (nonfasting), with plasma glucose
measurement at 1 h, at 24–28 weeks of gestation in women not
previously diagnosed with diabetes.
If the plasma glucose level measured 1 h after the load is ≥130
mg/dL, 135 mg/dL, or 140 mg/dL, proceed to a 100-g OGTT.
Step 2: The 100-g OGTT should be performed when the patient
is fasting.
The diagnosis of GDM is made if at least two* of the following
four plasma glucose levels (measured fasting and 1 h, 2 h, 3 h
during OGTT) are met or exceeded:

• Preconception A1C <6.5% , to reduce the
risk of congenital anomalies, preeclampsia,
macrosomia, and other complications. B

• Ideally, the A1C target in pregnancy is <6%
if this can be achieved without significant
hypoglycemia, but the target may be
relaxed to <7% if necessary to prevent
hypoglycemia. B

• Targets for pregnant women with GDM,
type 1 or type 2 diabetes are as follows:
Fasting <95 mg/dL and either
One-hour postprandial <140 mg/dL or
Two-hour postprandial <120 mg/dL

• Women with GDM should be tested for
persistent diabetes or prediabetes at 4–12
weeks postpartum with a 75-g OGTT using
nonpregnancy criteria.
• screening for the development of diabetes
or prediabetes at least every 3 years.

Hypoglycemia
Level Glycemic criteria/description
Level 1 Glucose <70 mg/dL and glucose ≥54 mg/dL
Level 2 Glucose <54 mg/dL
Level 3 A severe event characterized by altered mental and/or
physical status requiring assistance

Hypoglycemia (cont.)
• Role of 15
15 gm glucose.
15 minutes.
15 gm glucose.

Diabetes in Hospital
• Perform an A1C on all patients with
diabetes or hyperglycemia (blood glucose
>140 mg/dL admitted to the hospital if not
performed in the prior 3 months.

Diabetes in Hospital (cont.)
• Insulin therapy started at a threshold ≥180 mg/dL .
• Once insulin therapy is started, a target glucose
range of 140–180 mg/dL for critically & non
critically ill patients. A
• More stringent goals, such as 110–140 mg/dL, may
be appropriate for selected patients, if this can be
achieved without significant hypoglycemia. C

Perioperative Care
• Target glucose range for the perioperative
period should be 80–180 mg/dL.
• Withhold any other oral hypoglycemic
agents the morning of surgery or procedure
and give 50% of NPH dose or 60–80% doses
of long-acting analog or pump basal insulin.

DKA and HHS
Diabetes Care 2014;37:3124–3131
Total osmolarity: 2 Na + glucose/18 + BUN/2.8
Effective osmolality: 2 Na + glucose/18

Diabetes in Elderly
• Older adults who are otherwise healthy with
few coexisting chronic illnesses and intact
cognitive function and functional status should
have lower glycemic goals (such as A1C <7.5%)
• Those with multiple coexisting chronic
illnesses, cognitive impairment, or functional
dependence should have less stringent
glycemic goals (such as A1C <8.0–8.5%)

Diabetes in Elderly (cont.)
Patient characteristics/health
status
Rationale Reasonable
A1C goal
Fasting or
preprandial
glucose
Bedtime
glucose
Blood
pressure
(mmHg)
Healthy (few coexisting chronic
illnesses, intact cognitive and
functional status)
Longer remaining life
expectancy
<7.5% 90–130 mg/dL 90–150 mg/dL <140/90
Complex/intermediate (multiple
coexisting chronic illnesses or 2+
instrumental ADL impairments or
mild-to-moderate cognitive
impairment)
Intermediate remaining
life expectancy, high
treatment burden,
hypoglycemia
vulnerability, fall risk
<8.0% 90–150 mg/dL 100–180
mg/dL
<140/90
Very complex/poor health (LTC or
end-stage chronic illnesses or
moderate-to-severe cognitive
impairment or 2+ ADL
dependencies)
Limited remaining life
expectancy makes
benefit uncertain
<8.5% 100–180
mg/dL
110–200
mg/dL
<150/90

BMI
• The BMI calculation divides an adult's
weight in kilograms by their height in
metres squared.

Metabolic Surgery
• Metabolic surgery should be recommended as an option to
treat type 2 diabetes in appropriate surgical candidates with
BMI ≥40 kg/m2 and in adults with BMI 35.0–39.9 kg/m2 who do
not achieve durable weight loss and improvement in
comorbidities (including hyperglycemia) with reasonable
nonsurgical methods. A
• Metabolic surgery may be considered as an option for adults
with type 2 diabetes and BMI 30.0–34.9 kg/m2 who do not
achieve durable weight loss and improvement in comorbidities
(including hyperglycemia) with reasonable nonsurgical
methods. A

Metabolic Surgery
Treatment BMI category (kg/m2)
25.0–26.9 27.0–29.9 30.0–34.9 35.0–39.9 ≥40
Diet, physical activity,
and behavioral
therapy
+ + + + +
Pharmacotherapy + + + +
Metabolic surgery +
May be
considered
+
should be
recommend
ed if
+
should be
recommend
ed

Hypertension
Hypertension. 2017;71:e13–e115
Was Classified as
prehypertension in
previous guidelines
Stage 1: 140-159 SBP & 90-99 DBP
Stage 2: ≥160 SBP & ≥100 DBP

Hypertension (cont.)
• For adults with confirmed hypertension and
known CVD or 10-year ASCVD event risk of
10% or higher a BP target of less than 130/80
mm Hg is recommended.
• For adults with confirmed hypertension,
without additional markers of increased CVD
risk, a BP target of less than 130/80 mm Hg
may be reasonable.

• Adults with hypertension and CKD (and after
kidney transplantation) should be treated to a
BP goal of less than 130/80 mm Hg.
• In adults with DM and hypertension,
antihypertensive drug treatment should be
initiated at a BP of 130/80 mm Hg or higher
with a treatment goal of less than 130/80 mm
Hg.

• In pregnant patients with diabetes and preexisting
hypertension who are treated with antihypertensive
therapy, blood pressure targets of 120–160/80–105
mmHg are suggested.
• Resistant hypertension is defined as blood pressure
≥140/90 mmHg despite a therapeutic strategy that
includes appropriate lifestyle management plus a
diuretic and two other antihypertensive drugs
belonging to different classes at adequate doses.

• Resistant hypertension is defined as blood pressure
(BP) >140/90 mmHg treated with ≥3
antihypertensive medications, including a diuretic,
if tolerated.
• Refractory hypertension is defined as BP >140/90
mmHg with use of ≥5 different antihypertensive
medications, including a diuretic and a
mineralocorticoid receptor antagonist (MRA) has
been applied inconsistently.
J Nat Sci. 2017 Sep;3(9). pii: e430.

Hypertension and DM
• Patients found to have elevated blood pressure (≥140/90
mmHg) should have blood pressure confirmed using multiple
readings, including measurements on a separate day. B
• For individuals with diabetes and hypertension at higher
cardiovascular risk (existing ASCVD or 10-year ASCVD risk
>15%), a blood pressure target of <130/80 mmHg may be
appropriate, if it can be safely attained. C
• For individuals with diabetes and hypertension at lower risk for
cardiovascular disease (10-year ASCVD <15%), treat to a blood
pressure target of <140/90 mmHg. A

Lipid Disorders
• In adults not taking statins or other lipid-lowering
therapy, it is reasonable to obtain a lipid profile at the
time of diabetes diagnosis, at an initial medical
evaluation, and every 5 years thereafter if under the
age of 40 years, or more frequently if indicated. E
• Obtain a lipid profile at initiation of statins or other
lipid-lowering therapy, 4–12 weeks after initiation or a
change in dose, and annually thereafter as it may help
to monitor the response to therapy and inform
medication adherence. E

Lipid Disorders (cont.)
Age ASCVD or 10-
year ASCVD
risk >20%
Recommended statin intensity and
combination treatment
<40 years No None*
Yes High
• In patients with ASCVD, if LDL cholesterol ≥70 mg/dL
despite maximally tolerated statin dose, consider adding
additional LDL-lowering therapy (such as ezetimibe or PCSK9
inhibitor)
≥40 years No Moderate
Yes High
• In patients with ASCVD, if LDL cholesterol ≥70 mg/dL
despite maximally tolerated statin dose, consider adding
additional LDL-lowering therapy (such as ezetimibe or PCSK9
inhibitor)

https://www.acc.org/latest-in-cardiology/articles/2018/04/24/08/56/major-dyslipidemia-guidelines-and-their-discrepancies
ACC/AHA CCS ESC/EAS USPSTF
Threshold to
recommend
treatment
a) Age 40-75: if
risk ≥ 7.5%
b) Age ≥ 21: if
LDL-C ≥ 190
a) Age 40-75: if
risk ≥ 20%
b) Any age and
LDL-C ≥ 193
a) Age 40-65:
if risk 5-10%
and LDL-C ≥
100
b) Risk ≥ 10%
and LDL-C ≥ 70
Age 40-75: risk ≥
10% and one
other
atherosclerotic
cardiovascular
disease risk
factor
Recommended
treatment in
addition to
lifestyle
a) Risk ≥ 7.5%:
moderate or high
intensity
b) Risk > 5%
but < 7.5%:
moderate
intensity
Target ≥ 50%
reduction or LDL-
C < 77
Maximally
tolerated statin
dose to achieve
target treatment
goal
a) Risk > 10%:
low-moderate
dose
b) Risk 7.5-10%:
low-moderate
dose for select
patients

https://www.acc.org/latest-in-cardiology/articles/2018/04/24/08/56/major-dyslipidemia-guidelines-and-their-discrepancies
ACC/AHA CCS ESC/EAS USPSTF
Secondary prevention
Recommended
treatment in
addition to
lifestyle
a) Age ≤ 75:
high-intensity
statin
b) If age > 75,
contraindications
or safety
concerns:
moderate-
intensity statin
a) Target LDL-C
< 77 or ≥ 50%
reduction
b) If LDL-C ≥
193, reduce by ≥
50%
Maximally
tolerated statin
dose to achieve
target treatment
goal
Not covered

High-intensity statin therapy
(lowers LDL cholesterol by
≥50%)
Moderate-intensity statin
therapy (lowers LDL
cholesterol by 30–50%)
Atorvastatin 40–80 mg
Rosuvastatin 20–40 mg
Atorvastatin 10–20 mg
Rosuvastatin 5–10 mg
Simvastatin 20–40 mg
Pravastatin 40–80 mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Pitavastatin 2–4 mg

Journal of the American College of Cardiology (2018): 25709.

Uric Acid Disorders
• Male: 3.5 – 7.2 mg/dL
• Non Pregnant Female: 2.5 – 5.6 mg/dL
• Pregnant2:
 2 - 4.2 mg/dL
 2.4 - 4.9 mg/dL
 3.1 - 6.3 mg/dL
1- Gomella L, Haist S. Laboratory Diagnosis: Chemistry, Immunology, Serology. Clinician's Pocket Reference: The Scut Monkey. 11th ed. New
York, NY: McGraw-Hill; 2007. 2- Obstet Gynecol. 2009 Dec;114(6):1326-31.
Hyperuricemia, which is variably defined as a serum
urate level greater than either 6.8 or 7.0 mg/dl

Uric Acid Disorders (cont.)
• Targets in treatment of gout:
 For patients on ULT, SUA level should be monitored
and maintained to <6 mg/dL (360 µmol/L).
 A lower SUA target (<5 mg/dL; 300 µmol/L) to
facilitate faster dissolution of crystals is
recommended for patients with severe gout (tophi,
chronic arthropathy, frequent attacks) until total
crystal dissolution and resolution of gout.
 SUA level <3 mg/dL is not recommended in the
long term.
Richette, P., et al. "2016 updated EULAR evidence-based recommendations for the management of gout." Annals of the rheumatic
diseases 76.1 (2017): 29-42.

Chronic Kidney Disease (CKD)
• Kidney damage for ≥3 months, as defined by structural
or functional abnormalities of the kidney, with or
without decreased GFR, that can lead to decreased GFR,
manifest by either:
 Pathologic abnormalities; or
 Markers of kidney damage, including abnormalities
in the composition of the blood or urine, or
abnormalities in imaging tests
• GFR <60 mL/min/1.73 m2 for ≥3 months, with or
without kidney damage
Inker, Lesley A., et al. "KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of
CKD." American Journal of Kidney Diseases63.5 (2014): 713-735.

Chronic Kidney Disease (CKD) (cont.)
• We recommend that CKD is classified based
on cause, GFR category and albuminuria
category (CGA).
Inker, Lesley A., et al. "KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of
CKD." American Journal of Kidney Diseases63.5 (2014): 713-735.

Diabetic Nephropathy
• Spectrum of Diabetic Kidney Disease.
• Diabetic nephropathy is a clinical syndrome
characterized by the following:
 Persistent albuminuria (>300 mg/d or >200
μg/min) that is confirmed on at least 2 occasions
3-6 months apart.
 Progressive decline in the glomerular filtration
rate (GFR).
 Elevated arterial blood pressure.
Tang SC, Chan GC, Lai KN. Recent advances in managing and understanding diabetic nephropathy. F1000Res. 2016. 5

Diabetic Nephropathy (cont.)
Tang SC, Chan GC, Lai KN. Recent advances in managing and understanding diabetic nephropathy. F1000Res. 2016. 5

Diabetic Nephropathy (cont.)
Mogensen CE, Christensen CK, Vittinghus E. Diabetes. 1983 May;32 Suppl 2:64-78.

Thyroid disorders
• Although laboratories vary, most report a
normal TSH reference range between 0.4-
0.5 mU/L on the lower end and 4-5.5 mU/L
on the upper end of the range.
Mogensen CE, Christensen CK, Vittinghus E. Diabetes. 1983 May;32 Suppl 2:64-78.

TSH in pregnancy
• For long time, TSH upper reference limit of 2.5 mU/L in
the first trimester and 3.0 mU/L in the second and third
trimesters was recommended1.
• When possible, population-based trimester-specific
reference ranges for serum TSH should be defined
through assessment of local population data
representative of a health care provider's practice.
Reference range determinations should only include
pregnant women with no known thyroid disease,
optimal iodine intake, and negative TPOAb status2.
Alexander, Pearce, et al., Thyroid. March 2017, 27(3): 315-389. doi:10.1089/thy.2016.0457.

TSH in pregnancy (cont.)
• In case of hypothyroid or subclinical
hypothyroidism, the goal of treatment is to achieve
a TSH concentration <2.5 mU/L.
• In parallel to the treatment of hypothyroidism in a
general population, it is reasonable to target a TSH
in the lower half of the trimester-specific reference
range. When this is not available, it is reasonable to
target maternal TSH concentrations below
2.5 mU/L.
Alexander, Pearce, et al., Thyroid. March 2017, 27(3): 315-389. doi:10.1089/thy.2016.0457.

Waist Circumference
Int J Med. Public Health. 2016; 6(2): 69-72

WHR and WR
• Harmonized Defnition (2009)
Circulation. 2009;120(16):1640-5.

Metabolic Syndrome
Criteria for Clinical Diagnosis of the Metabolic Syndrome
Measure Categorical Cut Points
Elevated waist circumference
Population- and country-specific definitions
Elevated triglycerides (drug
treatment for elevated triglycerides is
an alternate indicator)
≥150 mg/dL (1.7 mmol/L)
Reduced HDL-C (drug treatment for
reduced HDL-C is an alternate
indicator)
<40 mg/dL (1.0 mmol/L) in males; <50 mg/dL
(1.3 mmol/L) in females
Elevated blood pressure
(antihypertensive drug treatment in a
patient with a history of hypertension
is an alternate indicator)
Systolic ≥130 and/or diastolic ≥85 mm Hg
Elevated fasting glucose (drug
treatment of elevated glucose is an
alternate indicator)
≥100 mg/dL

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