IMMUNIZATIONS
- Children and adults with diabetes should receive routinely recommended vaccinations
- All people >=6 months should receive influenza vaccination, especially those with diabetes
- As for pneumococcal disease, PCV13 is recommended for children <2y, PPSV23 for individuals 2-64y, and additional PPSV23 for >65.
- Adults with diabetes 18-59y should receive 2-3 doses of hepatitis B vaccine and, if unvaccinated, consider 3 dosis for those >=60.
ASSESSMENT OF COMORBIDITIES
The ADA discusses here what they call diabetes comorbidities: conditions that are more frequent in diabetes than in age-matched non-diabetic individuals.
- AUTOIMMUNE DISEASES. People with type 1 diabetes should be at the beginning and periodically thereafter screened for autoimmune diseases, including thyroid disease, pernicious anemia and celiac disease.
- CANCER. Diabetes increases risk for liver, pancreas, endometrium, colon/rectum, breast, and bladder cancer. Age- and sex-appropriate screenings as well as measures to reduce modifiable risk factors are encouraged.
- COGNITIVE IMPAIRMENT. Diabetes increases risk for dementia in 73%. In this case, treatment regime should be simplified and hypoglycemia risk avoided if possible. Both chronic hyperglycemia and recurrent hypoglycemia are related to cognitive impairment. In spite of early suggestions, neither nutrition nor statin use are clearly related to cognitive status.
- NONALCOHOLIC FATTY LIVER DISEASE. Obesity and dyslipidemia are associated to NFLD. When suspected (elevated enzymes or suggestive ultrasound) specialized diagnostic assessment should be performed. Weight lose improve NFLD, as well as some medications (pioglitazone, vitamin E, liraglutide, gliflozins) but long term effects are unknown.
- HEPATITIS C is more frequent in diabetes and worsens diabetic control. Its treatment, if effective, improves A1c in 0.45%.
- PANCREATITIS. Pancreatic exocrine dysfunction affect up to half of individuals with diabetes, and they have double risk of acute pancreatitis (AP). After an episode of AP, 1/3 of individuals develop diabetes. In chronic pancreatitis that need pancreatectomy islet autotransplantation should be considered. 1/3 of cases are insulin-free, and it can last up to 10 years.
- FRACTURES. Risk is increased both in type 1 (RR 6.3) and type 2 (RR 1.7) diabetes. In type 1 DM low bone density plays an important role, but not in type 2 DM, where pathophysiology is less clear. In clinical trials, participants with DM had more fractures for any given T-score, FRAX score or age. Nevertheless, there are no specific recommendations to prevent them in diabetes.
- SENSORY IMPAIRMENT. Deafness is more frequent in diabetes, twice as much in NHANES analysis, probably due to neuropathy or vascular disease. Although not mentioned in the document, presence of diabetes and deafness in a family, particularly when maternally inherited, should raise suspiction for MIDD, a mitochondrial disease. Smell, but not taste, is also reduced in diabetes.
- HIV infection on certain therapies (nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors (PI)) may result in diabetes in >5% of cases, and prediabetes in >15%. NRTI affect fat distribution (atrophy and hypertrophy). Diabetes must be screened before initiating or switching antiretroviral therapy, and 3 months thereafter. In case it's detected, manteinance or withdrawal depend on clinical judgement.
- LOW TESTOSTERONE IN MEN. Men with DM have lower testosterone than age-matched controls, but it's unclear whether this is due to obesity. The ADA recommends screening hypogonadism for men with reduced libido or erectile problems, but benefits of treatment are unclear.
- OBSTRUCTIVE SLEEP APNEA. Obese individuals with diabetes have 4-10 higher risk of OSA. Patients with suggestive symptoms (snoring, sleepiness, witnessed apnea) should be screened. Treatment has clear benefits on QoL and blood pressure, less clear on glycemic control.
- PERIODONTAL DISEASE. It's not clear if it's more frequent in diabetes, but it's more severe. People with periodontal disease have more diabetes incidence, and it negatively affects diabetic control, but benefits of its treatment on diabetes are unclear.
There's obviously a very important not mentioned comorbidity: COVID-19 infection. The ADA consensus was published in January and, unlike other, this section has not been so far re-evalated. Surely next year. There are extensive reviews about this topic in many recent publications, for example in The Lancet Diab & Endocrinol
