1. GO! Diabetes Case Studies
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<?xml version="1.0"?><AllQuestions><Question><slideID>ec55511e44df43b6a0e10e79add70895</slideID><slideType>Q&A_QSlide</slideType><questionText>What percent of weight loss will have a significant reduction in the incidence of diabetes at the end of four years?</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><slideType>Q&A_QSlide</slideType><questionText>Which of the following is NOT an indication for screening for diabetes?</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>dffc430ffb534fb1953a13bd24d92893</slideID><slideType>Q&A_QSlide</slideType><questionText>Patients with Diabetes and Subsequent Limb Amputation Have a 5-year Mortality Rate of Nearly 80%.</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>45d239a6aa e702d42d3d325</slideID><slideType>Q&A_QSlide</slideType><questionText>Which of the following is NOT a contraindication of continuing metformin?</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><slideType>Q&A_QSlide</slideType><questionText>Which of the Following Medications Reach Maximum Therapeutic Effect at ½ the Maximal Dose?</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>5d944a a acf7d84ad4</slideID><slideType>Q&A_QSlide</slideType><questionText>Which of the following should be tapered and discontinued with replacement insulin? </questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><slideType>Q&A_QSlide</slideType><questionText>Which is NOT a 15 Gram Carbohydrate Choice?</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question></AllQuestions>
<?xml version="1.0"?><AllAnswers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>0</answerID><answerText>Dyslipidemia </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>1</answerID><answerText>Hypertension</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>2</answerID><answerText>High risk ethnicity </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>3</answerID><answerText>Age 40</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>4</answerID><answerText>All of the above are appropriate indicators</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa e702d42d3d325</slideID><answerID>0</answerID><answerText>Congestive Heart Failure</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa e702d42d3d325</slideID><answerID>1</answerID><answerText>Renal Insufficiency</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa e702d42d3d325</slideID><answerID>2</answerID><answerText>Hepatic insufficiency </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa e702d42d3d325</slideID><answerID>3</answerID><answerText>IV contrast administration </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa e702d42d3d325</slideID><answerID>4</answerID><answerText>All of the Above</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a a acf7d84ad4</slideID><answerID>0</answerID><answerText>Metformin</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a a acf7d84ad4</slideID><answerID>1</answerID><answerText>Glyburide</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a a acf7d84ad4</slideID><answerID>2</answerID><answerText>Sitagliptin</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a a acf7d84ad4</slideID><answerID>3</answerID><answerText>Acarbose</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>dffc430ffb534fb1953a13bd24d92893</slideID><answerID>0</answerID><answerText>True</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>dffc430ffb534fb1953a13bd24d92893</slideID><answerID>1</answerID><answerText>False</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>ec55511e44df43b6a0e10e79add70895</slideID><answerID>0</answerID><answerText>5-10%</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>ec55511e44df43b6a0e10e79add70895</slideID><answerID>1</answerID><answerText>15-20%</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>ec55511e44df43b6a0e10e79add70895</slideID><answerID>2</answerID><answerText>At least 25%</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>0</answerID><answerText>½ cup of juice</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>1</answerID><answerText>2 Tbsp raisins</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>2</answerID><answerText>7 saltine crackers</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>3</answerID><answerText>1 oz soft granola bar with raisins</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>0</answerID><answerText>Metformin</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>1</answerID><answerText>Acarbose </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>2</answerID><answerText>Sulfonylurea </answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>3</answerID><answerText>All of the Above</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers></AllAnswers>
GO! Diabetes Case Studies

2. Rosita

3. Case #1
Rosita is an 18 year old Hispanic female who is a new mother. She presents for postpartum care 6 weeks after the birth of a 9 lb. 2 oz. boy
She was diagnosed with GDM based on her 2 hour glucose challenge at 26 weeks gestation (results FBS 90, 1 hour 179, 2 hour 158)

4. Rosita’s History Her original screening HbA1c was 5.4
GDM was adequately controlled with MNT as evidenced by consistent FBS <95 with 2 hour PP <120 with home glucose monitoring
She is breastfeeding, desires contraceptives and otherwise has no additional concerns

5. Vital Signs
Ht. 5 feet 4 inches ( cm), Wt 190 lbs. (86.18 kg.), BMI 32.6 kg/m2, afebrile and BP 114/61
Waist circumference: 38 inches
PE: Obese, lactating female with normal eye, CV, neuro, monofilament, skin and GYN exam
RE: abd circumference, generally we consider abnormal if >=40 inches (male), >=35 inches (female)
For South Asia, Japanese and Chinese patients, waist ≥90 cm (men) or ≥80 cm (women).

6. Labs TG 185 Total Cholesterol 208 LDL 122 HDL 48
FBG 88, 2 hour (75 gm) glucose challenge WNL
According to the 2011 guidelines, we should continue to screen all women with GDM for persistent diabetes 6-12 wks postpartum. These women should have lifelong screening for the development of diabetes or prediabetes at least once q3yrs. Diabetes Care, Vol 34, Supplement 1, January 2011.

7. Screening & Diagnosis in Pregnancy
Overt Diabetes
FPG>=126, or
A1C>=6.5, or
Random glucose>=200, confirmed by FPG or A1C
Gestational Diabetes
FPG >= 92 mg/dL, but < 126 at any gestational age, or
75 gm 2hr GTT at wk gestation with 1 abnormal: FBS>= 92, but <126, or
1hr >=180, or
2hr >=153
In Jan 2011, recommendations were made for the use of New terminology and testing and diagnostic criteria for diabetes in pregnancy. This was based on a large study, HAPO (Hyperglycemia and Adverse Pregnancy Outcome), which evaluated >23,000 pregnancies using a 75gm 2hr GTT. They found a continuum of increasing risk of adverse outcome as each of the 3 plasma glucose values increased. These adverse outcomes included MACROSOMIA, CSECTION, NEONATAL HYPOGLYCEMIA, CORD BLOOD C-PEPTIDE ELEVATIONS and PREECLAMPSIA. As a result, the IADPSG (International Assoc of Diabetes and Pregnancy Study Group), which is an international consensus group with reps from multiple OB and DM organizations, recommended new HAPO-based diagnostic testing and criteria for diabetes in pregnancy. In addition, they suggested changing terminology from current “PREEXISTING” and “GDM A1, A2, B”, etc… to “Overt vs. Gestational Diabetes”. ADA has endorsed this, though ACOG has not taken a position on the proposed change.
According to these guidelines, we should screen for overt DM at 1st prenatal visit in women with risk factors (just as before) but using the standard diagnostic criteria, then use a 75gm 2 hr GTT (as opposed to the 1hr screen) at 24-28wks in all women not known to have DM. Only 1 abnormal is required for dx (thus will increase prevalence). Under this new system, …

8. Metabolic Syndrome PARAMETERS NCEP / ATP 3 2005 IDF 2005 AACE 2003
REQUIRED
Waist >= 94 (men) or 80cm (women)
HR for insulin resistance OR BMI >25 OR Waist >= 102 (men) or 88cm (women)
# ABNORMALS
>=3 OF:
+2 OF:
GLUCOSE (mg/dL)
FBS >=100
FBS >=110,
2hr >=140
HDL (mg/dL)
<40 (men)
<50 (women)
TG (mg/dL)
>=150
OBESITY (cm)
Waist >= 102 (men) or
88cm (women)
HTN (mmHg)
>=130/85
IDF alone requires abd obesity (others include as option in dx)
High risk of being insulin resistant is indicated by the presence of at least one of the following: diagnosis of CVD, hypertension, polycystic ovary syndrome, non-alcoholic fatty liver disease or acanthosis nigricans; family history of Type 2 diabetes, hypertension of CVD; history of gestational diabetes or glucose intolerance; nonwhite ethnicity; sedentary lifestyle; age 40 years, treatment for lipids, BP, or low HDL. Adapted from: Meigs, James. Metabolic syndrome and the risk for type 2 diabetes. Expert Rev Endocrine Metab. 2006; 1:57. Table 1.
NCEP: National Cholesterol Education Program; IDF: International Diabetes Federation; AACE: American Association of Clinical Endocrinologists

9. Risk Factors for Diabetes in Pregnancy
Obesity
Family history (Type 2 DM)
Specific ethnic groups
Female
Conditions associated with insulin resistance
Other risk factors in pregnancy
Ethnicity: Native American, African American, Asian-American, Hispanic-American, pacific Islander..
In pregnancy: risk factors include: FH DM in 1st degree relatives, Pre pregnancy wt >110% ideal body wt or BMI >30 kg/m2, or significant wt gain in early adulthood/ between pregnancies, Age >25, prior macrosomic infant (>9#), personal hx abnormal GTT, prior unexplained perinatal loss or birth of a malformed child, maternal BW > 9# or < 6 #, Glycosuria at intake, PCO, current use of steroids, HTN (essential or pregnancy-related).

10. Metabolic Syndrome Patient Education
Medical Nutrition Therapy (MNT)
carbs, fats, proteins and calories
Exercise
Weight management
Psychosocial and family implications
Most patients with the metabolic syndrome are overweight, and weight reduction, which improves insulin sensitivity, is an important outcome goal of any diet. In general, it is agreed that The Mediterranean diet may be beneficial. In a study comparing the Mediterranean diet (high in fruits, vegetables, nuts, whole grains, and olive oil) with a low-fat prudent diet, subjects in the Mediterranean diet group had greater weight loss, lower blood pressure, improved lipid profiles, improved insulin resistance, and lower levels of markers of inflammation and endothelial.
A diet that is low in glycemic index/glycemic load, replacing refined grains with whole grains, fruits and vegetables, and eliminating high-glycemic beverages, may be particularly beneficial for patients with the metabolic syndrome.
Exercise — Exercise may be beneficial beyond its effect on weight loss by more selectively removing abdominal fat, at least in women. Current physical activity guidelines recommend a daily minimum of 30 minutes of moderate-intensity (such as brisk walking) physical activity. Increasing the level of physical activity appears to further enhance the beneficial effect.

11. Medical Nutrition Therapy (MNT) for Rosita
Usda.gov “plate method” visual, (preventive) is a good visual for pts at risk for progression to DM. Carb counts too complex at this stage. There is wonderful pt education at this site. Emphasis for Rosita at this time is:
Balancing Calories   ● Enjoy your food, but eat less.   ● Avoid oversized portions.    
Foods to Increase   ● Make half your plate fruits and vegetables.   ● Make at least half your grains whole grains.   ● Switch to fat-free or low-fat (1%) milk.    
Foods to Reduce   ● Compare sodium in foods like soup, bread, and frozen meals ― and choose the foods with lower numbers.   ● Drink water instead of sugary drinks
USDA Government

12. Metabolic Syndrome Management
5-10% weight loss yields a 58% reduction in the incidence of diabetes at the end of four years
What community resources have benefited your patients?
What can you do to help your pt decrease risk of progression to DM?
A 5-10% weight loss yields a 58% reduction in the incidence of diabetes at the end of four years. How can we help our pts win? Mention family dynamics in the metabolic pt….
Expound on exercise guidelines 2011, what about bariatric programs, psychosocial support for challenges of making change…
Ask: ?Do you have community resources available to your pts? If so, have they been beneficial? Which ones are the most helpful in the care of your DM pts?
Other resources (links)

13. What about Medications for Rosita?
Metformin reduced the development of T2DM by 31%
Recommended by the American Diabetes Association in patients with pre-diabetes
Prevention of type 2 diabetes — clinical trials have shown that lifestyle modifications in AT RISK populations can substantially reduce the risk of development of type 2 diabetes and the levels of risk factors for CVD in patients at increased risk. As for reduction of risk specifically in pts with IFG and IGT, Lifestyle modification is the most effective strategy, but it is difficult to
implement and maintain for many pts. An estimated 40–50% of IGT subjects progress toT2DM despite weight loss over time.
Pharmacological intervention with medications that reverse known pathophysiological abnormalities (B-cell dysfunction and insulin resistance) uniformly prevents IGT progression to
T2DM. Thiazolidinediones reduce IGT conversion to diabetes by approximately 50–70%. Metformin in the U.S. Diabetes Prevention Program reduced the development of T2DM by 31% and
has been recommended by the American Diabetes Association. Because glucagon-like peptide-1 analogs augment insulin secretion, preserve-cell function, and promote weight loss, they may be
efficacious in preventing IGT progression to T2DM. (J Clin Endocrinol Metab 96: 2354–2366, 2011)
Diabetes Care, Volume 34, Supplement 1, January 2011 13

14. Bottom Line…
Pharmacological intervention with a variety of agents reduces the rate of conversion of IGT/ IFG to T2DM, but Therapeutic Lifestyle Change (TLC) remains the mainstay of rx.
For metabolic syndrome without coexistent prediabetes, routine pharmacoprevention for DM is not recommended at this time.
(DeFronzo, J Clin Endocrinol Metab 96: 2354–2366, 2011)

15. Monitoring your Metabolic Patients
Laboratory
Hgb A1C, FPG or GTT
Lipids BP
Weight PE
Dermatology and neuro manifestations
Screening for development of DM in your at risk pts can be accomplished with A1C, FPG, or performance of 2hr GTT. This should be done annually. If pt has not fasted overnight, A1C is preferred. Abnormal results should be confirmed with by repeat testing on another day, or performing a different test. Treat cardiovascular risks if they persist despite TLCs.
What are BP goals for Rosita? Lipid goals? Wt reduction goals?

16. Rosita

17. Case #2
Rosita, a 50 year-old obese female patient presents with blurred vision for several days, weight loss, and feeling tired all the time.

18. Who and When to Screen?
Starting at age 45, a fasting blood glucose every three years
Obesity (specifically abdominal) has one of the highest associations with insulin resistance
Earlier/more frequent screening if BMI >25, AND a
Family history
Dyslipidemia
HTN
GDM or baby >9lb
Women with PCOS
High risk ethnicity
Vascular disease
Prior glucose elevation
Hx or exam findings
Physical inactivity
*However, USPSTF has stated that current evidence is insufficient to assess the balance of benefits and harms of screening asymptomatic adults with untreated BP< 135/80.
(Ref: USPSTF: Type 2 Diabetes American Family Physician; Nov 2009; vol 80 no 10: 1138.)
(2010) Standards of Medical Care in Diabetes Diabetes Care, 33, Supplement 1, S14.

19. Diagnosis FPG ≥ to 126 HbA1C ≥ to 6.5%
2-hour OGTT using 75gm glucose load
Random plasma glucose ≥ 200 in a patient with symptoms and signs of hyperglycemia
(2010) Executive Summary: Standards of Medical Care in Diabetes Diabetes Care, 33, Supplement 1, S4.

20. Type 1 Vs Type 2: How To Tell Them Apart
Treatment
Always insulin; 4+ shots
Pills  Insulin
Age at Onset
10% of adults w/ new dx
50% of children w/ new dx
Weight
~20% obese
~10% thin
Family History
10% w/ a close relative
>50% w/ a close relative
DKA
Can happen
Blood Glucose
More variable; big hypo’s
More stable; milder hypo’s
Thyroid Disease
Often
Sometimes
Antibodies
Usually (Anti-GAD)
Not usually
C-peptide
Early: low nl; Late: ~0
Early: high nl; Late: low nl

21. Atypical Diabetes
Type 1.5 or Latent Autoimmune Diabetes in Adults (LADA)
“Double Diabetes”
A misdiagnosis is easy to make when the person is older and responds well at first to treatment with oral medications. If someone does not clearly fit the model for Type 1, they may be mistakenly placed on oral agents even though limited capacity for insulin production remains. The immune system's slower and more selective attack on the beta cells allows these cells to function to a high degree for a few years. On average, insulin is required in half of those with Type 1.5 diabetes within four years of diagnosis, compared to over ten years in those with true Type 2 (Endocrine Practice, v7 n5, Sept/Oct 2001, pgs ).
It is possible for a patient with Type 1 diabetes to develop Type 2 secondary to the same risk factors as others that meet metabolic syndrome criteria.

22. Co-Morbidities Assessment
Screen for depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self management is poor1.
Bariatric surgery may be considered for adults with BMI >35 and Type 2 DM1
1Diabetes Care, volume 34, Supplement 1 January 2011 pg S5-S6

23. Co-Morbidities Assessment
Skin exam
Acanthosis nigricans
MRSA
Fungal infections
Wound care
Skin tags
Dental exam
Gingivitis
Infection

24. Eye Care
Diabetic retinopathy (DR) is the leading preventable cause of blindness
Prevalence of DR increases with duration of diabetes (100% Type 1, 60% Type 2 after 20 years)
Of all recommendations, eye screening is the least likely to get done

25. Reasons to Look at Feet
Up to 70% of diabetics eventually develop a neuropathy
Up to 15%* develop foot ulcers
More than half of the foot ulcers become infected at some point
*The Semmes Weinstein Monofilament Exam as a screening tool for Diabetic peripheral neuropathy Journal of Vascular Surgery; Sept 2009;

26. The real morbidity… 10-20% of infected ulcers lead to amputation
More than 50% of nontraumatic lower limb amputations are due to diabetic foot ulcers
One amputation increases the likelihood of another

27. Foot Surveillance Examine the feet at every visit
Annual comprehensive evaluation
Sensation
Pulses
Skin condition (ulcers, hair, nails)
Anatomic deformities
Shoe evaluation
Consider ABI age >50 and <50 if other risk factors for PAD
(2010) Standards of Medical Care in Diabetes Diabetes Care, 33, Supplement 1, S39.

28. Sensation Exam Monofilament PLUS one of the following: Vibratory
Pinprick
Ankle reflexes
Diabetes Care, Volume 34, Supplement 1, January 2011, Page S8

29. Foot Exam Sites Fewer sites than 10 years ago…
The areas must be tested randomly over sites prone to skin breakdown. The 3 site per foot testing is sufficiently sensitive (93%) and more efficient than prior recommendations. It is important to avoid performing the test rhythmically, hence giving the patient clues as you go. Heavily callused areas should be avoided. The most conservative approach is to use 1 insensate site as the threshold for a positive test for peripheral neuropathy with loss of protective sensation.

30. Lab Surveillance
A1c
Lipids
Microalbumin

31. Anti-platelet Therapy ADA Guidelines
Recommendations for Aspirin
ASA mg/day for 2o prevention
ASA mg/day for 1o prevention
Age > 50 in men and > 60 in women with at least one risk factor
Consider in any age with multiple CV risk factors
Not recommended ages < 21 (Reye’s syndrome)
Clopidogrel 75 mg/day
Very high risk diabetics; intolerance to ASA

32. American Diabetes Association National Cholesterol Education Program
Lipids
American Diabetes Association
LDL <100 mg/dL
(<70 mg/dL in patients at “highest risk”)
HDL >40 mg/dL (>50 mg/dL in females)
TG <150 mg/dL
National Cholesterol Education Program
LDL <100 mg/dL
(<70 mg/dL in patients at “highest risk”)
Non-HDL <130 mg/dL

33. ADA Guidelines Dyslipidemia
Fasting lipid profile annually
Simvastatin 80 mg/day warning
Without overt CVD
LDL<100
At age 40 start on statin regardless of LDL to reduce LDL 30-40%
With overt CVD
Start statin to reduce LDL 30-40%
LDL<70 is an option
Normalizing triglycerides and raising HDL with fibrates reduces CV events
The Food and Drug Administration is recommending that the use of drugs containing 80 mg of simvastatin—the highest approved dose of the popular cholesterol-lowering statin—be sharply curtailed because of the risk of muscle injury.

34. ADA Guidelines Dyslipidemia
High LDL, High triglycerides, Low HDL
Consider statin + fibric acid
Remember the increased risk of rhabdomyolysis
Consider statin + niacin
Remember niacin can increase glucose levels
moderate doses = mild changes in glycemia

35. ADA Guidelines - 2011 Hypertension control individualized
for most 130/80 is ideal
Glycemic control individualized
for most < 7% is ideal
Nephropathy management
Table included for diagnosis and surveillance
Advances CKD management guidelines (modified from NKF)
Chronic health care delivery systems restructuring paramount (NDEP resources)

36. Health Maintenance Vaccinations Smoking cessation Influenza Pneumovax
Counseling
Pharmacotherapy

37. Diabetes Education Diabetes education Goals of education
is a collaborative process
develop knowledge and skills needed to change behavior
successfully self-manage the disease and its related conditions
Goals of education
improve health
better quality of life
reduce the need for costly healthcare
Diabetes Educators
Prepared in diabetes knowledge
Use principles of teaching, learning, and counseling
Behavior change for successful self-management

38. Value of the Diabetes Educator: Summary of Findings
People with diabetes education:
Save money and have better outcomes.
Are more likely to adhere to recommendations for screening/HEDIS measures.
Are younger, more likely to be female, located in more affluent areas, have lower clinical risk, higher adherence to diabetes care recommendations and lower average costs.
Physicians and patients exhibit high variation in their use of diabetes education.

39. modest lifestyle change
Diabetes Prevention Project (DPP) A randomized clinical trial to prevent Type 2 Diabetes that evaluated the efficacy of 3 treatments
Incidence of Diabetes
Risk reduction
31% by Metformin
58% with
modest lifestyle change
sustained for 4 years
Lifestyle (n=1079, p<0.001) vs. Metformin (n=1073, p<0.001) vs. Placebo (n=1082)
SOURCE: The DPP Research Group, NEJM, 2002;346:

41. Diabetes Education Resources
/DiabetesEducation/Find.html

42. EVERYONE! Patient Education Who’s responsible?
Role of health care team
Patient and family
Office staff
Nursing
PAs/NPs
Physicians
Dietitian
Diabetes Educator
Mental Health Provider

43. LUNCH TIME

44. Glycemic Control – Oral Agents

45. Rosita’s A1C
7.5

46. How The Body Handles Glucose
(Fed State)
LIVER
PANCREAS
GLUCAGON
GLUCAGON
GLUCAGON
AMYLIN
INSULIN
BRAIN
INSULIN
Blood Glucose
60-90 mg/dL
Glucose
mg/dL
The major metabolic defects that are present in type 2 diabetes mellitus which lead to glucose elevation are: decreased glucose transport and utilization at the level of muscle and adipose tissue, increased glucose production by the liver and relatively decreased insulin secretion by the pancreas. Added to this abnormal flux is any dietary carbohydrate which is absorbed as glucose or converted to glucose during the absorption or postabsorptive process.
The oldest agents used to treat what we now recognize as type 2 diabetes and which stimulate increased pancreatic insulin secretion include the sulfonylureas. More recently, repaglinide, a meglitinide, has been added to the available agents that stimulate increased pancreatic insulin secretion. Insulin administration, the oldest pharmacologic therapy for diabetes is also a choice to increase circulating insulin levels in response to a failing beta-cell function. Biguanides increase the sensitivity of the liver to circulating insulin, thereby participating in a reduction in the level of excess glucose produced by that organ in type 2 diabetes.
PPAR-g activators act at a number of sites to lower blood glucose levels. They also improve insulin sensitivity at the level of the liver, thereby decreasing the excess glucose production by that organ. But they are more commonly recognized for their action in increasing insulin sensitivity in muscle and adipose tissue peripherally. By improving this sensitivity, they allow for improvement in the utilization of glucose by these organs. It should be noted that Biguanides, in high doses, also have some mild effect on increasing peripheral glucose utilization. To decrease the rapid influx of carbohydrate from ingested food, alpha-glucosidase inhibitors are used to slow the digestion of starches and the absorption of glucose and several other sugars.
FAT
GI TRACT
MUSCLE

47. Pathophysiology of Type 2 Diabetes
AMYLIN
AMYLIN
LIVER
PANCREAS
Metformin
TZDs
INSULIN
GLUCAGON
INSULIN
GLUCAGON
GLUCAGON
INSULIN
Insulin
Sulfonylureas
Glinides
Incretin tx
BRAIN
INSULIN
INSULIN
Hyperglycemia
A1C < 7%
Premeal ~ 100mg/dL
PPG < 200 mg/dL
FAT
The major metabolic defects that are present in type 2 diabetes mellitus which lead to glucose elevation are: decreased glucose transport and utilization at the level of muscle and adipose tissue, increased glucose production by the liver and relatively decreased insulin secretion by the pancreas. Added to this abnormal flux is any dietary carbohydrate which is absorbed as glucose or converted to glucose during the absorption or postabsorptive process.
The oldest agents used to treat what we now recognize as type 2 diabetes and which stimulate increased pancreatic insulin secretion include the sulfonylureas. More recently, repaglinide, a meglitinide, has been added to the available agents that stimulate increased pancreatic insulin secretion. Insulin administration, the oldest pharmacologic therapy for diabetes is also a choice to increase circulating insulin levels in response to a failing beta-cell function. Biguanides increase the sensitivity of the liver to circulating insulin, thereby participating in a reduction in the level of excess glucose produced by that organ in type 2 diabetes.
PPAR-g activators act at a number of sites to lower blood glucose levels. They also improve insulin sensitivity at the level of the liver, thereby decreasing the excess glucose production by that organ. But they are more commonly recognized for their action in increasing insulin sensitivity in muscle and adipose tissue peripherally. By improving this sensitivity, they allow for improvement in the utilization of glucose by these organs. It should be noted that Biguanides, in high doses, also have some mild effect on increasing peripheral glucose utilization. To decrease the rapid influx of carbohydrate from ingested food, alpha-glucosidase inhibitors are used to slow the digestion of starches and the absorption of glucose and several other sugars.
Weight Loss
Exercise
TZDs
(Metformin)
GI TRACT
Pramlintide
Dietary Composition
Portion Control
-Glucosidase Inhibitors
MUSCLE

48. General Rules Hyperglycemic Therapy
Normalize fasting glucose levels first
Many patients will achieve glycemic targets
When to target postprandial glucose levels?
Pre-prandial values are at goal
A1C levels are not met
Measure 1-2 hours after beginning of the meal
Glucose are generally at their peak
Many type 2 diabetics will meet their target A1C with normalization of their fasting glucose. Later in the course of the disease post prandial hyperglycemia becomes more problematic and their A1C targets won’t be met unless they improve their postprandial glucose levels. This can be accomplished by sulfonylureas, Glinides, mealtime insulin.

49. Glycemic Goals of Therapy
Verbal Target
~100
<<200
As low as
possible w/o unacceptable adverse effects
Goal
Premeal plasma glucose (mg/dL)
2-h postprandial plasma glucose
A1C
ADA
90-130
<180*
<7%**
ACE
<110
<140
<6.5%
* Evaluation and treatment of postprandial glucose may be useful in the setting of suspected postprandial hyperglycemia, with the use of agents targeting postprandial hyperglycemia and for suspected hypoglycemia
** More stringent glycemic goals (i.e. a normal A1C, <6%) may further reduce complications at the cost of increased risk of hypoglycemia
There has been no change in these recommendations.
Diabetes Care 2009;32:S6-12

50. Biguanides: Metformin
Mechanism of action
Reduces hepatic glucose production
Depends upon presence of insulin
Safety and efficacy
Decreases A1C 1-2%
Adverse effects: diarrhea and nausea; main risk: lactic acidosis
Discontinuation rate 5%
Contraindications: renal, cardiac, hepatic insufficiency; IV contrast
No direct effect on kidney
Dosing
Initial dose: 500 mg once a day; dosing: usually BID
Maximum effective dose: 2,000 mg per day
Titration frequency: week(s) to months
Alternate formulations: “XR” and combinations

51. Insulin Secretagogues: Sulfonylureas (SFU) and “Glinides”
Mechanism of action
Stimulate basal and postprandial insulin secretion
Require functioning beta cells (no effect on beta cell dysfunction)
Work quickly
Safety and efficacy
Decrease A1C approximately 1-2%
Lower fasting glucose 20%
Adverse events: weight gain, allergy (rare); main risk, hypoglycemia
Dosing
Initial dose: 1/8 to 1/4 maximum dose; dosing: 1-2 times/day (SFU), 3 times/day (Glinides)
Maximum effective dose: 1/2 maximum (full dose with nateglinide)
Titration frequency: day(s) to weeks

52. Preferred Sulfonylureas
All available as generic agents
Glipizide ER 5-20 mg once per day
Once daily, flat profile, low plasma levels resulting in a low risk of weight gain and hypoglycemia
Glipizide 2.5 to 20 mg twice a day
Twice daily. Half-life 2-4 hours, peaks in 2-3 hours. By taking it once a day at low dose it stimulates insulin secretion for 6-12 hours
Glimepiride 1-8 mg per day
Once daily. Half-life 9 hours, peak action for 4 hours. Special utility like with glipizide but with longer half-life
Buse J. Personal Opinion
Melander A. Diabetes 2004;53 Suppl 3:S151

53. Thiazolidinediones (TZD’s or Glitazones): Pioglitazone and Rosiglitazone
Mechanism of action
Enhance insulin sensitivity in muscle, adipose tissue
Inhibit hepatic gluconeogenesis
Reduced rate of beta cell dysfunction
Safety and efficacy
Decrease A1C 1-2%
Adverse events: edema, weight gain, anemia; more serious risk: liver failure
Dosing
Initial dose (monotherapy): 1/2 to 2/3 maximum; dosing,1-2 x/day
Maximum effective dose: maximum dose
Titration frequency: weeks to month(s)
Patients with type 2 diabetes may face an increased fracture risk when treated with thiazolidinedione (TZD) drugs, data from a large observational study suggest. Use of rosiglitazone (Avandia) or pioglitazone (Actos) was 70% more common among postmenopausal women with diabetes and a history of fractures, compared with a matched control group without fractures. Among diabetic men with a history of fractures, concurrent use of a TZD and a loop diuretic was more than three times as common as in similar men with no history of fractures.
Fracture risk was associated with TZD dose, but the risk was similar for rosiglitazone and pioglitazone, suggesting a class effect, William Herman, MD, of the University of Michigan in Ann Arbor, and co-authors wrote in an article published online in the Journal of Clinical Endocrinology and Metabolism.

54. TZDs: Weight Gain and Edema
Derived from an increase in body fat and possibly increased fluid retention
Severity appears to be proportional to level of glycemic control achieved
Not inevitable and diet helps
Accentuated by combination with Secretagogues or insulin
Usually mild to moderate and well tolerated
Patients should be instructed to inform their
doctors of rapid or excessive weight gain
Lebovitz H. Diabetes Metab Rev 2002;18:S23
Fonseca V. Am J of Med 2003;115:42S

55. TZDs Lipid Effects and Serious Risks
Rosiglitazone (Avandia)
+LDL
+HDL
+Triglycerides
Pioglitazone (Actos)
+LDL
+HDL
-Triglycerides
Rosiglitazone – Black box warning for CHF and ischemic heart disease; warnings about increased fracture risk in women
Pioglitzaone – Black box warning for CHF and warning about increase fracture risk. No evidence to suggest increased ischemic heart disease. There is a potential increased risk of bladder cancer with long term use.
DIABETES CARE, VOLUME 34, APRIL 2011
“When we examined the association between bladder cancer incidence and increasing levels of pioglitazone exposure (Table 2), the risk of bladder cancer slightly increased with increasing dose and duration of pioglitazone use. After adjustment for only age and sex, the risk of bladder cancer was 30% higher among those whose duration of pioglitazone therapy was months (HR 1.3 [95% CI ]) and 50% higher among those with >24 months of expo- sure (1.5 [ ]) than that among never users of pioglitazone.”

56. AHA/ADA Consensus Statement for TZDs
Not recommended for patients with NY Heart Association class III or IV heart failure
TZDs alone, or particularly in combination with insulin, may cause fluid retention which can lead to heart failure
Incidence of CHF <1% with TZD monotherapy
Increased to 2%-3% in combination with insulin
Patients should be observed for signs and symptoms of heart failure
TZDs should be discontinued if any deterioration in cardiac status occurs
February 2010
A joint science advisory statement issued by the American Heart Association (AHA) and the American College of Cardiology (ACC) warn about the use of thiazolidinediones (TZDs) as a treatment for diabetes after a report from the U.S. Senate Finance Committee outlined the drug's potential to cause adverse cardiac events. According to the statement, limited research currently exists regarding the safety and efficacy of TZDs such as pioglitazone (Actos, Takeda) or rosiglitazone (Avandia, GlaxoSmithKline). According to the AHA/ACC, these drugs may have the potential to increase heart risks in diabetes patients. "Research is ongoing and more is needed to understand which agents, including TZDs, work best for diabetes control," said Clyde Yancy, MD, president of AHA. The advisory suggested that Metformin, a glucose-lowering medication, be the first drug of choice for diabetic patients. The advisory said that if a TZD is considered as treatment, it should be used with caveats and not with the expectation to lower the risk of heart attack or stroke in patients. Although the advisory said that there is not enough data to clinically support the use of TZDs, the joint statement advises clinicians to consider keeping patients currently taking a TZD on the drug if they have achieved HbA1c control.
Nesto RW et al. Diabetes Care 2004;27:256

57. Alpha-Glucosidase Inhibitors: Acarbose And Miglitol
Mechanism of action
Delay absorption of carbohydrates
Depend upon postprandial hyperglycemia
Safety and efficacy
Decrease A1C %
Adverse events: flatulence; main risk: rare liver enzyme elevation
Dosing
Initial dose: 1/4 maximum once daily; dosing: 3 times daily
Maximum effective dose: 1/2 maximum dose
Titration frequency: week(s) to months

58. Incretin-Based Therapies
PROS
Preserve beta cell function
Weight loss (GLP-1 mimetics: Victoza and Byetta)
Less hypoglycemia risk vs. insulin and Secretagogues
Enhanced postprandial glucose control
CONS
Expensive
GI (nausea)
May exacerbate renal failure
Concern for pancreatitis and thyroid tumors
Liraglutide (Victoza) should not be used in patients with MEN-2, or with personal or FH of thyroid cancer.
Exenatide (Byetta) should be avoided in patients with severe kidney disease.
Patients on sitagliptin (Januvia) should be monitored for the development of pancreatitis.

59. Key Points to Consider for Therapy
Maximal benefits of Metformin are observed at the recommended daily dose of 2000 mg (1 g BID)1
Thiazolidinediones should be started at low doses and slowly increased to minimize side effects2
Glucose-lowering effects of a sulfonylurea plateau at half the maximum recommended dose3
Garber AJ et al. Am J Med 1997;103:491
Nesto RW et al. Diabetes Care 2004;27:256
Stenman S et al. Ann Intern Med 1993;118:169

60. Rosita

61. Case #3
Rosita is now 60 years old and has been diagnosed with Type 2 DM since the age of 50. Her treatment regimen included diet, exercise and oral medications with which she has been intermittently adherent (lisinopril, metformin and sitagliptin).
Over the past two years, Rosita has been working more and exercising less and her last visit to her PMD was 18 months ago.
How do I know my patient does not already have cardiovascular disease???

62. Risk factors for CV Disease
Male age >45 and female Age >55
Current cigarette smoking
Hypertension
HDL <40
Family history of CV disease-Definite MI or sudden death in male first degree relative <55 or female first degree relative < 65
HDL >60 counts as a negative risk factor

63. Coronary Heart Disease Risk Equivalents
Symptomatic Carotid Artery Disease
Abdominal Aortic Aneurysm
Peripheral Vascular Disease
In ATP III, Diabetes is considered a CHD Equivalent

64. Screening for CV Disease
In asymptomatic pts, routine screening for CAD is not recommended as it does not improve outcomes as long as risk factors are treated.
Diabetes Care, volume 34, Supplement 1 January 2011 pg S7

65. Screening for CV Disease
ACC/AHA – persons with multiple risk factors (including patients with T2DM) =IIb indication (usefulness/efficacy not well established by evidence/opinion).
ADA –Stress testing in abnormal ECG (ST-T abnormalities, ischemia, or infarction), and ≥2 risk factors.
Before exercise-Both the ACC/AHA and the ADA recommend that an exercise stress test be performed (ACC/AHA guidelines as a class IIa indication, weight of evidence/opinion is in favor of usefulness/efficacy)
(accessed Aug 11, 2011)

66. Rosita’s A1C…..
9.1

67. Management Options
Medications-maximizing orals and considering injectables
Lifestyle-including exercise and diet

68. Beta Cell Function Declines UKPDS Data
Beta cell function declines with time
5-10% failure per year
Eventually Insulin Needed
In the UKPDS there was a glycemic difference attained from the outset of the trial. The difference wasn’t as large as the DCCT. In the trial, both groups worsened. Many experts estimate the production of insulin in type 2 diabetics declines 50% every 5 years. This slide demonstrates how control deteriorates over time in type 2 diabetics requiring the addition of therapies including insulin.

69. 63% of Patients with Diabetes are Not at ADA A1C Goal <7%
Adults aged years with previously diagnosed diabetes who participated in the interview and examination components of the National Health And Nutrition Examination Survey (NHANES),
37.2%
>8%
63%
7%
7.8%
25.8%
37.0%
17.0%
12.4%
A1C
% of Subjects
n=404
Review of data from the Third National Health and Nutrition Examination Survey ( ). Nearly 2/3 of patients in this survey were not reaching recommended A1C Goal of < 7%. NHANES is administered by a CDC agency – the National Center for Health Statistics (NCHS)
Saydah SH et al. JAMA 2004;291:335

70. Challenges with Achieving Target A1C Values
Late diagnosis and initiation of therapy
Therapeutic inertia
Lack of effective lifestyle intervention
Secondary failure
Adverse events associated with antihyperglycemic therapies
Complexity of care
Role of postprandial glucose in failure

71. Insulin Therapy
ACE and AACE recommend insulin when: initial A1C is >9, DM is uncontrolled >7 despite optimal oral meds
Not contraindicated at any time
Fasting glucose > 250mg/dl
Random glucose >300mg/dl
Polyuria, polydipsia, weight loss, ketones
Petznick, Allison. Insulin Management of Type 2 DM. American Family Physician. July 2011 Volume 84 (2);

72. What are some common patient concerns when transitioning to insulin?

73. Common Patient Concerns when Transitioning to Insulin
Fear of needles or pain from injections
Fear of hypoglycemia
Weight gain
Fear of needles or pain from injections
Describe/show very fine needles
Offer insulin pens or other devices that hide the needle from view or may be less painful
Point out that injections are less painful the SMBG tests
Psychological counseling when needed
Fear of hypoglycemia
Discuss insulin action times and minimal potential for hypoglycemia
Describe difference in risks for hypoglycemia between multiple and once a day injections
Describe prevention and treatment of hypoglycemia
Weight gain
Educate about strategies to minimize weight gain
Funnel M. Self-management Support for Insulin Therapy in Type 2 Diabetes. The Diabetes Educator 2004;30:274

74. Common Concerns When Transitioning To Insulin
Adverse impact on lifestyle; inconvenient; loss of personal freedom and independence
Belief that insulin means diabetes is worse or more serious disease
Insulin as a personal failure
Insulin causes complications
Treated differently by family members
Adverse impact on lifestyle; inconvenient; loss of personal freedom and independence
Discuss intensifying as a way to increase flexibility
Use once daily insulin
Offer available resources and support
Belief that insulin means diabetes is worse or more serious disease.
Review all treatment options as a progression from the inception of education's.
Explain how insulin is a logical step in the progression as it related to insulin resistance and beta cell failure.
Insulin as a personal failure
Teach initially and review that beta-cell failure is progressive.
Avoid statements such as “You failed oral agents”. Reframe as “oral agents have failed you”.
Avoid using insulin as a threat to encourage weight loss and activity.
Funnel M. Self-management support for insulin therapy in type 2 diabetes. The Diabetes Educator 2004;30:274

75. What are your concerns when transitioning a patient to insulin?

76. Insulin Initiation Provider Concerns
Which insulin?
How much?
How do I adjust?
How do I teach?
How often do I change dosages?

77. Potential Insulin Regimens
Insulin pump Physiologic/COMPLEX/Flexible
Multiple daily injections
Free mixing - twice daily
Pre-mixed - twice daily
Basal only SIMPLE/Inflexible
Presenter reviews options for insulin initiation.
How do we balance simplicity and flexibility to achieve glycemic control?

78. Insulin Initiation Answers to Provider Concerns
Normalize the fasting glucose
Fasting FSBS
Once Daily Options
Start 10 units or 0.2 u/kg
Basal Insulin (glargine or detemir)
NPH (bedtime)
Premixed before dinner
Increase 2-3 units every 3 days prn to reach target of fasting
Decrease 3 units for fasting < 70

79. Once Daily Insulin Options Basals vs. NPH vs. Premixed
INSULIN TYPE
ADVANTAGES
DISADVANTAGES
Glargine
Peakless, less hypoglycemia, less wt gain; simple
Cost; can’t mix; no meal time coverage
Detemir
Less wt gain, less hypoglycemia; simple
Cost, shorter duration than glargine; can’t mix, basal only
Pre Mixed 70/30 or 75/25
Covers meal time and basal; easy transition to bid
More hypoglycemia and weight gain than basals
NPH
Less expensive
More hypoglycemia than basals

80. Analogue vs. Human
No difference in glycemic control but slightly decreased hypoglycemia with analogue
Petznick, Allison. Insulin Management of Type 2 DM. American Family Physician. Volume 84 (2);

81. Insulin therapy
Augmentation –use of either basal or bolus with partial beta-cell failure. Basal regimen may offer slight benefit with fewer adverse side effects vs.. premixed or bolus. Dose is 0.3 u/ kg/day
Replacement- use of basal and bolus insulin when beta cell function is absent. Includes basal, bolus, correction, and premixed insulin. Dose is 0.6 u/kg/day. Fifty percent given as basal and fifty percent given as bolus in divided doses
1Petznick, Allison. Insulin Management of Type 2 DM. Am. Fam. Physician. July 2011 Vol. 84 (2);

82. Oral Meds When Starting Insulin
Metformin
Continue unless contraindicated
Reduces CV risk in overweight Type 2 DM pts
Sulfonylureas
Continue with basals generally
Stop if using large doses of insulin
Stop if using premixed insulin
TZDs
Proceed with caution
Exacerbates weight gain and edema

83. Oral Meds When Starting Insulin-Pearls
Secretagogues should be tapered and discontinued
Sitagliptin is currently only incretin based therapy approved for use with insulin
-algorithm for type 2 DM
Petznick, Allison. Insulin Management of Type 2 DM. American Family Physician. Volume 84 (2);

84. Carbohydrate Counting
Technique based on the concept that most meal-related glucose increase is due to the carbohydrate content
Patients count either:
Carbohydrate choices (milk, fruit, breads, sweets, starchy vegetables) OR
Grams of “total carbohydrates” on food label

85. Carbohydrate Counting
Providers prescribe insulin-to-carbohydrate ratio
Start with 1 unit per choice or 1 unit per 15 grams
Typical dose is 2-4 units per choice in type 2 diabetes
Titrate based on postprandial glucose monitoring
Generally, start with glulisine/ lispro/ aspart administered just before meals

86. Causes of Hypoglycemia
Incorrect amount of insulin/oral agents
Skipped or delayed meal/snack
Carbohydrate intake less than normal
Alcohol intake without food
Exercise without insulin/food adjustment
Not re-testing 1 to 2 hours after hypoglycemia treatment if meal or snack is not eaten

87. Treatment of Hypoglycemia
Definition of hypoglycemia: Plasma glucose <70 mg/dL
Symptoms may or may not be present
Sweaty, cold, unable to concentrate, dizzy
Treatment
Treat with 15 g carbohydrate; wait 15 minutes; test BG, if BG not >70 mg/dL, treat again
All carbohydrates raise blood glucose
On average, 15 g of glucose can increase BG from 60 to ~110 mg/dL (50mg/dL) over ~40 minutes
BG starts to fall at 60 minutes and reaches previous treatment level at 2 hours
Cryer et al. Diabetes Care 2003;26:1902

88. 15 Gram Carbohydrate ChoicesBG
½ cup juice or 2Tbsp raisins or 7 saltines =
Glucose Increase
~50 mg/dL
or 6-8 hard candies =
Instruct patients on insulin therapy (or on insulin Secretagogues) to carry source of carbohydrate that is convenient, readily available, easily and quickly consumed and doesn’t spoil

89. Treatment of Hypoglycemia
Hypoglycemia increases gastric emptying from ~50 minutes to ~25 minutes; emptying rates of solid foods and liquids are the same
Adding protein to carbohydrate does not help in the treatment and does not prevent subsequent hypoglycemia
Schvarcz et al. Diabetic Med 1993;10:660
Gray et al. J Clin Endocrinol Metab 1996;81:1508

90. Treatment of Severe Hypoglycemia
Definition: Requires assistance to treat
Inject glucagon with loss of consciousness or seizure
Administered by another person
May be given intramuscular or subcutaneous
Standard dose
1.0 mg for adults; 0.5 mg for children under 5 yrs
Prescription is required
Precautions
May cause nausea/vomiting/headache
Call 911

91. Hypoglycemia Prevention
Instruct patients to…
Follow food and insulin plan
Test blood glucose daily
Carry carbohydrate
Wear medical identification
Teach others how to inject glucagon

92. Continuous Glucose Monitoring
CGM and intensive insulin regimens can be useful to lower A1C in selected adults >25 YOA
CGM may also help in children, teens and younger adults although evidence is less strong
CGM may be supplemental tool for those with hypoglycemia unawareness and/or frequent hypoglycemic episodes1.
Reliability concerns do not eliminate need for SMBG
Effectiveness on glycemic control has not been established
1Diabetes Care, volume 34, Supplement 1 January 2011 pg S4.

93. Key Attributes of Good Candidate for Insulin Pump
Patients must be able to:
Learn and apply basic diabetes self management skills
Learn and apply advanced diabetes self management skills
Learn to operate an insulin pump
Follow their prescribed regimens
Accessed August 31, 2011.

94. Key Attributes of Good Candidate for Insulin Pump
Patients must be able to:
Learn and apply troubleshooting skills
Meet with their healthcare team as scheduled
Pay for their insulin, insulin pump, glucose monitoring device and all disposables ($6500 initially and $ per year)
Accessed August 31, 2011 .

95. Insulin Pumps Used by Adolescents-often with a Behavior contract
Pre-pump training to include basic diabetes management and basal bolus training
Start up training-up to two days
Maintenance and expansion of competencies
Accessed August 31, 2011

96. Management of Diabetes in the Hospitalized Patient
Critically Ill: Insulin treatment for persistent BG >180 to maintain a range of mg/dl
Non-critically ill: No clear evidence. Pre-meal goal of <140mg/dl and random BG of <180 mg/dl if treated with insulin
More stringent goals in pts with previous tight control and less stringent goals in pts with multiple co morbidities
Diabetes Care, volume 34, Supplement 1 January 2011 pg S9.

97. Rosita

98. Case #4 Rosita is now 80, living in a multigenerational household
Her daughter Maria cares for her great grandchildren while granddaughter and son-in-law work
Rosita has her own room near a bathroom

99. Rosita’s daughter prepares all meals, administers medications, and assists with transportation to her many doctor visits including her:
family physician -ophthalmologist
cardiologist - orthopedic surgeon
nephrologist - neurologist

100. Rosita’s Meds and Labs
Medications: lisinopril, furosemide, acetaminophen, aspirin, glargine, insulin aspart, statin, carvedilol, gabapentin, colace, metamucil, glucosamine chondroitin, ginko biloba
Her last HbA1c was 8.1
LDL 105
Creatinine 3.2
MMSE 21

101. SOUND FAMILIAR?

102. Individualize Treatment Goals
Patients who are functionally and cognitively intact should be treated with same goals as younger patients
Glycemic goals may be relaxed and individualized to avoid symptoms of hyper and hypoglycemia
CV treatment goals are based on quality of life and life expectancy
Continue to screen for complications that would lead to functional impairment

103. Incident Counts & Adjusted Rates, By Primary Diagnosis of ESRD
Diabetes is the most rapidly rising cause of ESRD, but the hypertension rate also continues to rise.

104. Early Treatment Makes a Difference
Diagnosing CKD at an early stage can add 2 or more years of ESRD-free survival. In some patients ESRD may actually be prevented. Careful attention to classic cardiovascular risk factors, especially smoking cessation and lipids, is also important to prevent premature cardiovascular death.
Brenner, et al., 2001

105. Definitions of Abnormalities In Albumin Excretion
Category
Spot urine collection albumin/ creatinine (microgram/mg creatinine)
Normal
<30
Microalbuminuria
30-299
Macroalbuminuria (clinical)
>/= 300

106. Screening for Chronic Kidney Disease
In individuals with diabetes with initial
microalbuminuria detected:
Spot urine albumin to creatinine ratio (on 2 out of 3 occasions over 3-6 months)
Affected by exercise, infection, fever, CHF, marked hyperglycemia
Measure serum creatinine, estimate the GFR and stage the level of CKD
Three major points that should be made:
(1) 24- hour urine collections are not needed. They are not only cumbersome but may be even less accurate, at least for clearance/GFR than the equation. Spot urine for albuminuria is just as good as the collection.
(2) A calculator with the MDRD equation is at the NKDEP website and a downloadable version is available.
(3) The frequency of testing once a year is the consensus for diabetes and is the ADA guideline, but for the other risk groups (hypertension and family member with CKD) no evidence guidelines exist. Testing should be regular but some interval longer than that for diabetes - say 3 years - seems reasonable so long as the test remains normal.
Diabetes Care, Volume 34, Supplement 1, January 2011, Page S34

107. Stages Chronic Kidney Disease
Description
GFR 1
Kidney damage with normal or inc. GFR
>=90 2
Kidney damage with mild decrease in GFR
60-89 3
Moderate decrease in GFR
30-59 4
Severe decrease in GFR
15-29 5
Kidney failure
<15 or dialysis

108. Drug Levels with Normal Renal Function
Time

109. Drug Levels With Impaired Renal Function
Time

110. Age-Related Pharmacokinetic Changes
Absorption
Decreased gut motility
Decreased secretion of digestive enzymes
Distribution
Increased total body fat
Decreased muscle mass
Decreased total body water
Metabolism
Decreased ability of the liver to metabolize
Elimination
Decreased creatinine clearance due to age
The ability of the liver to metabolize many substances decreases with aging.
Thus, some drugs are not inactivated as quickly in older people as they are in younger people.
As a result, a drug dose that would not have side effects in younger people may cause dose-related side effects in older people.
Also, the liver's ability to withstand stress decreases. Thus, substances that are toxic to the liver can cause more damage in older people than in younger people.
Repair of damaged liver cells is also slower in older people.

111. Treatment to Prevent Progression of CKD to Kidney Failure
Intensive glycemic control lessens progression from microalbuminuria in type 1 diabetes
Anti-hypertensive therapy with ACE inhibitors lessens proteinuria and progression
Low protein diets in later stages of CKD may improve function
Several therapies have been proven effective over the last 10 years. While not all people with CKD can have their disease process completely halted, significant slowing can be achieved and arrest of the process may be possible in some.
Diabetes Care, Volume 34, Supplement 1, January 2011, Page S33
Meta-Analyses

112. Medication Safety in Seniors
Lower doses should be used initially
Upward titration at a slower rate
Start Low-Go Slow-Check Creatinine Clearance!
Have a high level of suspicion for drug SE
Establish a routine for drug monitoring
Consult with Clinical pharmacist

113. According to WHO, there are 5 interacting factors of adherence:
Social/economic: affordability, access(transportation), illiteracy, social support networks, cultural and religious beliefs
Therapy related: Complexity of treatment, which we’ll talk more about
Patient related: Knowledge, beliefs, perceptions, expectations (immediacy of benefits of therapy)
Condition-related: severity of symptoms, level of disability (physical, psychological)
Healthcare team, system-related: patient-provider relationship, knowledge and training of healthcare providers
WHO -HCT team. World Health Organization. Adherence to Long Term Therapies: Evidence for Action. (2003).