5.      Special Aspects of Diabetes Care        

Antiplatelet Therapy - Aspirin has been used as a primary and secondary prevention strategy to prevent cardiovascular events.  Men and women with diabetes have a 2-4 fold increase in risk of dying from complications of cardiovascular disease (CVD).  Aspirin in doses of 162-325 mg/day is recommended for patients with diabetes. Aspirin should not be used in patients under 21 years of age because of the risk of Reye's syndrome. 

Strongly consider aspirin therapy (or other antiplatelet therapy) as a primary prevention strategy in high risk men and women age 30 and above with diabetes. This includes individuals with family history of CVD, cigarette smoking, hypertension, obesity, albuminuria and dyslipidemia.  

Use aspirin therapy (or other antiplatelet therapy) as a secondary prevention strategy in diabetic men and women who have evidence of large vessel disease, such as history of MI, stroke, peripheral vascular disease, claudication or angina.  

Clopidogrel (Plavix) is another anti-platelet therapy known to reduce CVD in people with diabetes. Consider using this medication as an alternative to aspirin therapy if patient has significant GI intolerance or true aspirin allergy.  Studies show similar if not better efficacy when compared to aspirin. Ticlopidine is another option but has been shown to have less efficacy than aspirin and requires more intensive monitoring.

Tobacco Use - Current tobacco use should be documented and a referral made to a program for cessation of tobacco use.

Distinguishing Type 1 from Type 2 Diabetes - Distinguishing adult onset latent type I diabetes from type 2 diabetes is not always straightforward.  Several laboratory studies may be helpful when the diagnosis is not clear clinically: C-peptide, the other half of pro-insulin, can evaluate a patient's endogenous insulin secretion and measuring autoantibodies, GADA and ICA (antibodies to glutamic acid decarboxylase and islet cells) can detect an underlying autoimmune process. These tests can be useful in at least three clinical situations, such as:  

1.         Solving a clinical problem about using oral agents vs. insulin.

2.         Evaluating a patient with a history of ketoacidosis when stable (useful in setting of ETOH,
                        acidosis, and diabetes to determine ongoing need for insulin).

3.         Evaluating a patient who is non-ketotic off of insulin, but who has few or none of the components
                        of the metabolic syndrome.