I have previously written about the FLECKS as my mnemonic for diabetes care. Today on rounds we reviewed in detail the components of FLECKS.
- Feet – look at the feet for lesions, find tinea pedis and treat it prophylactically, screen for early diabetic neuropathy (either monofilament or tuning fork)
- Lipids – most patients with diabetes should take a statin – in general try to achieve a maximum dose because type II diabetes is a coronary artery disease equivalent – I am not as concerned about the goal LDL, but NCEP says 100. The recent Zetia study provides some caution here.
- Eyes – yearly eye exams because ophthalmologists can decrease the probability of blindness from diabetic retinopathy – I believe the data suggest that we could wait 2 years after a totally normal exam, but that is not current standard of practice
- Control – I have written extensively about this earlier this week – I encourage good control, but refuse to accept a goal of 7 as the standard. Patients receive very little benefit when lowering the HgbA1c from 8 to 7, and they run the risk of side effects of tight control. Some patients can achieve levels less that 7 without resorting to overly complex regimens. We should monitor control, and adjust our medication in the context of patient and their other diseases
- Kidneys – use urine protein/creatinine to screen for early diabetic nephropathy – use ACE-I (maximize dose) to control proteinuria, if they do not control proteinuria, add ARBs. Also control BP tightly (130/80 if possible).
- Shots – yearly influenza, 5 yearly pneumovax, do not forget to keep tetanus up to date in older adults
This list should be considered both for inpatients and outpatients.
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I believe the “q5 yearly Pneumovax” recommendation is out of date:
From Johns Hopkins
Routine revaccination not indicated with the exception of only high-risk groups. This does not include DM (emphasis mine) and asthma not on steroids. COPD and smokers will be added with the next set of CDC guidelines….
High risk groups per the CDC are: functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), HIV infection, leukemia, lymphoma, Hodgkins disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression (e.g., organ or bone marrow transplantation) and those receiving immunosuppressive chemotherapy, including long-term corticosteroids.”
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