Presentation on theme: "Susan Alexander, DNP, CNS, CRNP, BC- ADM College of Nursing University of Alabama in Huntsville Clinical Affiliation: Outpatient Diabetes Self-Management."— Presentation transcript:
Susan Alexander, DNP, CNS, CRNP, BC- ADM College of Nursing University of Alabama in Huntsville Clinical Affiliation: Outpatient Diabetes Self-Management Education Crestwood Medical Center Huntsville, AL
Describe factors associated with worsening of DM control in the patient with pre-TXP DM. Describe risk factors associated with development of DM in the post-TXP patient Discuss management strategies for optimization of DM control in the post-TXP patient.
Diabetes Mellitus: Heterogeneous Condition With Hyperglycemia and Common Complications Insulin Deficiency: Relative or Absolute
Diabetes occurs post transplant at rate of: 9% at 3 months 16% at 12 months 24% at 36 months Risk factors: Age >40-45, Obesity, AA and Hispanic Race, Family History, Hepatitis C and CMV, Polycystic kidneys Post-transplant Diabetes Mellitus in Renal Transplant Recipiants. Tobin, G et al, UpToDate, May 31, 2008.
Calcineurin Inhibitors Reversible islet cell toxicity, (tacrolimus) Glucocorticoids are insulin antagonists that insulin resistance, hepatic glucose production and inhibit glucose transport into cells Screening for Diabetes: -Monitor blood sugar prior to transplant -Monitor blood sugar post transplant with FBS weekly X4, recheck in 3 months, 6 months and annually thereafter Post-transplant Diabetes Mellitus in Renal Transplant Recipients. Tobin, G et al, UpToDate, May 31, 2008.
Fat Adapted from Kruszynska YT, et al. J Invest Med. 1996;44:413-428. Henry RR. Ann Intern Med. 1996;124:97-103. Liver Pancreas Peripheral Tissues (Skeletal Muscle and Adipose Tissue) Glucose Insulin Resistance Increased Glucose Production Impaired Insulin Secretion Hyperglycemia in Type 2 Diabetes
Type 1: -Steroids increase insulin requirement and dose -Insulin dose will increase from ESRD to having a working kidney Type 2 -Cannot use all oral agents -Usually require insulin -Insulin and/or oral agent dose will increase from ESRD to having a working kidney
Large blood vessel disease MI, stroke, peripheral artery disease and LE amputation Small vessel disease retinopathy/vision loss and blindness, kidney damage/renal failure Neuropathy with pain, loss of protective sensation
Hyperglycemia Severe hyperglycemia (BG>250) Does improving glycemic control relate to improved outcomes for patients? Medical ICU, CV surgery and general surgery patients have higher risk of death if hyperglycemia is present.
Medications Food intake Tests and procedures Prior history Nutritional status Inzucchi, S. N Engl J Med 2006;355:1903-11
IV insulin infusion Hourly BG monitoring Transition to subcutaneous Overlap IV and subcutaneous Insulin Type 2 DM with <2u/h Inzucchi, S. N Engl J Med 2006;355:1903-11
Before meals: - Regular insulin (R) - Rapid-actingAnalog Correction Dose: insulin sensitive/resistant Adjust dose based on BG before lunch, supper or HS Inzucchi, S. N Engl J Med 2006;355:1903-11
ADA: ICU target = As close to 110 as possible and <180. General med. target = 90-130 and <180 after meals. ACE: ICU target = <110. General med. Target = <110 with max of 180. Guidelines are controversial, not based on clinical data from non-ICU patients. Inzucchi, S. N Engl J Med 2006;355:1903-11
No Food Intake: Give IV infusion or basal insulin qd or bid + regular or rapid acting analog q 6h based on blood glucose. Continuous Enteral Feeding: Basal insulin + correction dose q 6h. If feeding interrupted, give IV glucose to prevent hypoglycemia. Total Parenteral Nutrition: Add regular insulin to IV bag and titrate dose in increments of 5-10u/liter. Reassess insulin requirement with any change in nutritional status. Inzucchi, S. N Engl J Med 2006;355:1903-11
Medical and surgical ICU targets: Suggest <140 and consider <110 IV insulin allows more rapid titration and absorption in critically ill Non critically ill target: 90-150 pre meals Adjust dose q 1-2 days to optimize glycemic control ASAP Inzucchi, S. N Engl J Med 2006;355:1903-11
Before making insulin adjustment, consider factors that can cause hyperglycemia: -Missed insulin doses -Snacking -Infection -BG testing and/or insulin administration after versus before meals Frequent monitoring and dose adjustment is essential. Adjust dose based on fingerstick BG before each meal and HS. Transition to out patient regimen requires education of patient and a manageable regimen.
Insulin NPH QD or BID 0.2-0.3 u/kg/day or 50% of IV insulin dose Insulin Detemir QD or BID 0.2-0.3 u/kg/day or 50% of IV insulin dose Insulin Glargine Q day 0.2u/kg/day or 50% of IV insulin dose
Regular, Lispro, Aspart, Glulisine 0.20 units/kg/meal or 50% of IV insulin dose type 2 Diabetes 0.30 units/kg/meal or 50% of IV insulin dose High Steroid Dose Consistent carb intake across meals (45-60 grams/meal) to avoid hypo- and hyperglycemia Adjust each dose by 10-20 % q 1-2 days until pre- meal BG is in target
NormalGoal HbA1c4-6%<7% * Pre-prandial Blood Sugar 70-100 mg/dl90-130 mg/dl (70-120) Post-prandial Blood sugar <140 mg/dl<180 mg/dl (<160) Diabetes Care 29:S4-S42, 2006 * As close to 6.0% as possible ADA Recommendation: Check A1c at least 2 x/yr if in target and stable; q 3 months if therapy has changed or not meeting goals. Diabetes Care 29:S4- S42, 2006
Provides vital data for clinical decision making Provides patient with accountability and feedback about his/her behavior Advise patient about: -Appropriate meter -When to test -How to record results -How to interpret and respond to results -Insurance/financial issues, prescription required for reimbursement
Set small, reasonable goals: Something is better than nothing Long term goal: Aerobic activity 30 minutes per day, 5 days per week, 1-3 sessions per day; resistance/strength training 3x/week
Chair exercises Strength training Water exercise
2896 adults with DM interviewed from 1990-1991 Outcomes: All cause and CVD mortality over 8- years RESULTS: Walking 17-minutes/day 39% in all cause mortality; 34% in CVD Walking 30 minutes/day 46% all cause mortality; 47% in CVD Arch Intern Med. 2003 Jun 23;163(12):1440-7.
Ingestion of food Pancreas 2,3 β -cells α -cells Release of gut hormones — Incretins 1,2 insulin from beta cells (GLP-1 and GIP) Glucose-dependent Glucose uptake by muscles Glucose production by liver Blood glucose Glucagon from alpha cells (GLP-1) Glucose dependent Active incretins physiologically regulate glucose by modulating insulin secretion in a glucose- dependent manner. GLP-1 also modulates glucagon secretion in a glucose-dependent manner. GI tract Active GLP-1 & GIP Inactive GLP-1 and GIP DPP-4 Enzyme 2,4 1. Kieffer TJ, Habener JF. Endocr Rev. 1999;20:876–913. 3. Drucker DJ. Diabetes Care. 2003;26:2929–2940. 2. Ahrén B. Curr Diab Rep. 2003;2:365–372. 4. Holst JJ. Diabetes Metab Res Rev. 2002;18:430–441.
Treatment of type 2 diabetes in patients on metformin or sulfonylurea and not taking insulin Byetta 5 mcg bid x 1 month, the 10 mcg bid within 1 hour of meal Liraglutide 0.6 mg per day for one week, then 1.2 mg daily with max. dose ofto 1.8 mg (2).
Stimulates first phase insulin release by pancreas when glucose levels are elevated Reduces glucagon secretion Slows Gastric Emptying (gastric emptying is accelerated in diabetes) Reduces caloric intake by promoting satiety
Symlin =synthetic Amylin. Amylin is co-secreted with insulin by pancreatic beta cells in response to food intake. Reduces Postprandial Glucagon Postprandial Glucagon is Excessive and Not Corrected by Exogenous Insulin in Diabetes Slows Gastric Emptying Gastric Emptying Is Accelerated in Diabetes Reduces Caloric Intake by promoting satiety *** Slowed gastric emptying will effect immunosuppressive drug levels ***
Described by duration of action - Absorption -Clearance Maintenance Insulin (Basal) -Dose effectiveness evident in fasting blood glucose -Dose is based on body mass and insulin sensitivity Meal Insulin -Impacts post prandial blood glucose -Dose based on meal timing and size, insulin sensitivity
0 20 40 60 80 100 7:009:00 11:0013:0015:0017:0019:0021:0023:00 3:007:00 9:00 11:0015:0019:00 23:00 3:00 7:00 Serum insulin concentration ( U/mL) Breakfast Lunch Dinner Fasting Insulin is normally produced endogenously at a constant (i.e., basal) rate of 0.5 - 1.0 units/hour as well as in response to increases in blood glucose concentration after a meal.
TypeGeneric/ Brand Name OnsetPeakDuration RAPID ACTING Glulisine/Apidra Lispro/Humalog Aspart/Novolog 5-15 Min. 1-2 Hours 3-4 Hours 4 Hours 4-6 Hours Short ActingRegular/Humulin R, Novolin R ½-1 hour2-3 hours4-8 hours
TypeGeneric/ Brand Name OnsetPeakDuration Intermediate Acting NPH/ Humulin N Novolin N Reli-on N 1-1.5 Hours4-12 Hours 18-25 Hours Long ActingGlargine/Lantus Detemir/Levemir 4-6 Hours 1-2 Hours 4-12 Hours 1-7 Hours 24+ Hours 6-23 Hours
Basal Insulin – NPH, Levemir, Lantus 50% of daily needs Suppresses glucose production between meals and overnight Bolus Insulin (Mealtime or Prandial) Novolog, Humalog, Apridra Regular Limits hyperglycemia after meals Immediate rise and sharp peak at 1 to 1½ hour 10% to 20% of total daily insulin requirement at each meal
Humalog/Novolog 10ml Humalog/Novolog cartridges 15ml Lantus 10ml vial Hum/Novo R,N, 10ml vial Hum/Novo, R, N Pen, cartridges 15ml $112.00 $225.00 $107.99 $47-64.00 Walmart $20.00 $130-150.00 * 1 vial = 30-day supply if using <33u per day ** 5 pens of 3ml each = 15ml, 1500 units
Fluctuating prednisone dose requires frequent monitoring of blood sugar and flexibility in insulin and/or oral medication dosing Prednisone will increase appetite Insulin or oral medication doses will increase after kidney transplant
Adjust dose and number of injections based on home capillary glucose readings Monitor in 1-2 week intervals Steroid-induced hyperglycemia is less severe when dose is < 10mg/day Prednisone dosed in morning elevated lunch and suppertime glucose, minimally elevated FBG
Continuous, automatic monitoring of glucose in the subcutaneous tissue