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Finding the Sweet Spot: DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) Belinda Setters,

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Presentation on theme: "Finding the Sweet Spot: DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) Belinda Setters,"— Presentation transcript:

1 Finding the Sweet Spot: DM II treatment in post acute rehabilitation (& a few crumbs for granny – the key to treating DM II in frail elders) Belinda Setters, MD, MS, AGSF March 6, 2014 Kentucky Cardiopulmonary Rehab Symposium

2 The Sweet Spot: DM II treatment update Disclosures Acting Associate Chief of Staff, Geriatrics & Extended Care Director, Acute Care for Elders & Transitional Care Programs Robley Rex VAMC, Louisville, Ky Associate Clinical Professor University of Louisville Depts. of Internal and Family & Geriatric Medicine No financial (or other) incentives, stock or compensation

3 The Sweet Spot: DM II treatment update Learning Objectives Review updated guidelines for DM II treatment Identify pitfalls of treatment in post acute (rehabilitation) care Understand unique features of elderly patients that complicate treatment Understand the importance of individualized care

4 The Sweet Spot: DM II treatment update Just the stats m’am million diabetics (all ages) = 8.3% of population > 65 yo, increases to 27% of population (10.9 million) o 7 million undx patients DM II associated with 2 x higher disability 42% of persons > 65 yo have at least one disability o = 14 million people American Diabetes Association: CDC: NIH:

5 The Sweet Spot: DM II treatment update

6 From Dr. Samuel E. Dagogo-Jack:

7 The Sweet Spot: DM II treatment update

8

9 Treatment goals... Fasting blood glucose < 140 mg Hemoglobin A 1 C < 7 If can push to get better #s, without side effects (hypoglycemia), then ok to do so in adult patients Post acute care (“rehabilitation”) guidelines follow those of non-critical care acute recommendations J Clin Endocrinol Metab 2012, 97(1):16-38

10 The Sweet Spot: DM II treatment update Treatment goals... Short term concerns Minimize adverse effects of high glucose o Wound healing & infection o Confusion/MS change o Fatigue = decr. participation in therapy o Falls Minimize HYPOglycemia Minimize “pill burden” Transition patient to home

11 The Sweet Spot: DM II treatment update Treatment goals... Options. Glucose >140 DX: DM II Current RXAdjust RX No DM II Monitor BS hrs d/c monitoring ( --) ( + )

12 The Sweet Spot: DM II treatment update Recommended therapy: Insulin Long Acting Insulin (Daily) Short Acting Insulin (with Meals) Intermediate acting (Twice Daily) OR

13 The Sweet Spot: DM II treatment update Insulin types ActionOnsetPeakDurationNameBrand Rapid15 min1 hr2-4 hrsGlucine Lispro Aspart Apidra Humalog Novolog Regular / “short” 30 min2 hrs3-6 hrsLispro R Novolin R Humalog R Novolgo R Intermediate2 -4 hrs4-12 hours12-14 hrsNPHHumulin N Novulin N Longhrs (aprox 6) None24 hrsDetemir Glargine Levemir Lantus

14 The Sweet Spot: DM II treatment update Insulin types..... “the slide” Sliding Scale Insulin o Good for short term coverage to adjust long acting insulins o Should not be used as a substitute for long acting or short/regular insulin regimen. diabetesmanager.pbworks.com

15 The Sweet Spot: DM II treatment update

16 Oral agents

17 ClassPharmLimitationsNameBrand SulfonylureasStimulates pancreas to release insulin Hypoglycemia CV risks Liver/renal Glimeprimide Glyburide Glipizide Gliclazide Amaryl Micronase Gluctorol Diamicron BiguanideReduces glucose production Lactic acidosisMetforminGlucophage Alpha-glucosidase inhibitor Reduces glucose absorption GI side effects / take with meals Acarbase Miglitol Voglibose Precose, Glucobay Glyset Basen ThiazolidinedioneReduces insulin resistance Edema Heart failure Wt gain Liver fxn Rosiglitazone Pioglitazone Avandia Actos Prandial glucose regulators Incr. insulin secretion HypoglycemiaRepaglinide Nateglinide Prandin Starlix Incretin mimeticsIncr. insulin sensitivity hypoglycemia, Fatigue, anorexia Pramlinitide Sitagliptin Exenatide Symlin Januvia Byetta

18 The Sweet Spot: DM II treatment update Nutrition therapy Rec: “Consistent Carb” diet + Education & Accountability Exercise Therapy, activities, walking American Diabetes Association:

19 The Sweet Spot: DM II treatment update Control Vascular Risk Factors o Tobacco cessation o Nutrition o Weight Loss o HTN management o HLD management / statins o Anti-inflammatory therapies o Mental & physical activity

20 The Sweet Spot: DM II in elders Treatment Considerations Micro-vascular Injury (in Years) Macro-vascular Injuries (in Years) Control of -- Glucose8-- Blood Pressure2-33 Cholesterol--3-6 ( CHF/AGS, presented at AGS Symposium, May 2003 )

21 The Sweet Spot: DM II in elders

22 The Sweet Spot: DM II treatment update DM in The Elderly: Unique Concerns o Erratic eating (or dependency on being fed) o Inability to report symptoms (dementia, vague symptoms) o Polypharmacy: multiple meds – competition for clearance o Slowed metabolism / impaired clearance o Shift in water-fat body content o Low reserve, can’t respond to hypoglycemia Med Care 2006 Apr;44(4):373-7 JAMA 2006 Oct 18;296(15): J Am Coll Cardiol 2009 Jan 20;53(3):

23 The Sweet Spot: DM II treatment updates DM in Elders: Frailty o Loss of functional reserve o Slowed response to stress / pathologic illness o Multisystem organ involvement o Estimated prognosis (life expectancy)1-2 years Lancet 2013; 381(9868): JAGS 2006; 54(6): Clin Geriatr Med 2011; 27(1): 1-15.

24 The Sweet Spot: DM II treatment updates DM in Elders: Frailty Philosophy, Ethics, and Humanities in Medicine :3 doi: /

25 The Sweet Spot: DM II in elders Treatment Considerations Hemoglobin A1C < 7 o Mean plasma glucose 154 mg/dl (2-3 months) o Healthy adults with > 10 year life expectancy Hemoglobin A1C between 7 – 8.5 o Mean plasma glucose 180 mg/dl (2-3 months) o Adults with limited life expectancy, history of severe hypoglycemia, or advanced micro-vascular or macro-vascular disease DIABETES CARE, 2013; 36(1): S11-S66

26 The Sweet Spot: DM II in elders Treatment Considerations Blood Pressure & Lipid Goals Blood pressure < 140/80 LDL < 100 mg/dl or 70 with CVD HDL > 40 mg/dl Triglycerides < 150 mg/dl DIABETES CARE, 2013; 36(1): S11-S66

27 The Sweet Spot: DM II in elders The “Sweet Spot” for Frail Elders J Am Geriatr Soc 60:1215–1221, 2012.

28 The Sweet Spot: DM II in elders Other thoughts: Hypoglycemia 2 episodes = 80% increased risk for Dementia development 3 episodes = 94% increased risk for dementia development

29 The Sweet Spot: DM II in elders Other thoughts Life Expectancy o Changes w/ comorbidity o Changes w/ frailty Goals of Care o Pt Preferences

30 The Sweet Spot: DM II treatment update Wrap up Blood glucose < 140 or Hg A 1 C < 7 Control vascular, other risk factors Consider QOL, pt preferences/GOC & life expectancy For most elders, especially frail elders, A1C = 8 is target 8 at 80 honey!

31 Geriatrics & Extended Care


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