Presentation on theme: "GO! Diabetes Case Studies. Rosita Case #1 Rosita is an 18 year old Hispanic female who is a new mother. She presents for postpartum care 6 weeks after."— Presentation transcript:
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)
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
Vital Signs Ht. 5 feet 4 inches (162.56 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
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 24-28 wk gestation with 1 abnormal: FBS>= 92, but <126, or 1hr >=180, or 2hr >=153
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
Metabolic Syndrome Patient Education Medical Nutrition Therapy (MNT) –carbs, fats, proteins and calories Exercise Weight management Psychosocial and family implications
Medical Nutrition Therapy (MNT) for Rosita USDA Government
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 about Medications for Rosita? Metformin reduced the development of T2DM by 31% Recommended by the American Diabetes Association in patients with pre-diabetes Diabetes Care, Volume 34, Supplement 1, January 2011
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)
Monitoring your Metabolic Patients Laboratory –Hgb A1C, FPG or GTT –Lipids BP Weight PE –Dermatology and neuro manifestations
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.
Who and When to Screen? 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 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 (2010) Standards of Medical Care in Diabetes-2010. Diabetes Care, 33, Supplement 1, S14.
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- 2010. Diabetes Care, 33, Supplement 1, S4.
Type 1 Vs Type 2: How To Tell Them Apart Type 1Type 2 TreatmentAlways insulin; 4+ shots Pills Insulin Age at Onset10% of adults w/ new dx50% of children w/ new dx Weight~20% obese~10% thin Family History10% w/ a close relative>50% w/ a close relative DKACan happen Blood GlucoseMore variable; big hypo’sMore stable; milder hypo’s Thyroid DiseaseOftenSometimes AntibodiesUsually (Anti-GAD)Not usually C-peptideEarly: low nl; Late: ~0Early: high nl; Late: low nl
Atypical Diabetes Type 1.5 or Latent Autoimmune Diabetes in Adults (LADA) “Double Diabetes”
Co-Morbidities Assessment Screen for depression and diabetes- related distress, anxiety, eating disorders, and cognitive impairment when self management is poor 1. Bariatric surgery may be considered for adults with BMI >35 and Type 2 DM 1 1 Diabetes Care, volume 34, Supplement 1 January 2011 pg S5-S6
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
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; 675-682.
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
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-2010. Diabetes Care, 33, Supplement 1, S39.
Sensation Exam Monofilament PLUS one of the following: –Vibratory –Pinprick – Ankle reflexes Diabetes Care, Volume 34, Supplement 1, January 2011, Page S8
Anti-platelet Therapy ADA Guidelines Recommendations for Aspirin –ASA 75-162 mg/day for 2 o prevention –ASA 75-162 mg/day for 1 o 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
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
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 http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm257884.htm
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
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)
Health Maintenance Vaccinations –Influenza –Pneumovax Smoking cessation –Counseling –Pharmacotherapy
Diabetes Education Diabetes 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
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.
Diabetes Prevention Project (DPP) A randomized clinical trial to prevent Type 2 Diabetes that evaluated the efficacy of 3 treatments Lifestyle (n=1079, p<0.001) vs. Metformin (n=1073, p<0.001) vs. Placebo (n=1082) Risk reduction 31% by Metformin 58% with modest lifestyle change sustained for 4 years Incidence of Diabetes SOURCE: The DPP Research Group, NEJM, 2002;346:393-403
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
Glycemic Goals of Therapy 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 Verbal Target ~100 <<200 As low as possible w/o unacceptable adverse effects Diabetes Care 2009;32:S6-12
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
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
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
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)
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
http://www.natap.org/2011/newsUpdates/052111_07.html TZDs Lipid Effects and Serious Risks Rosiglitazone (Avandia) –+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. Pioglitazone (Actos) –+LDL –+HDL –-Triglycerides
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 Nesto RW et al. Diabetes Care 2004;27:256
Alpha-Glucosidase Inhibitors: Acarbose And Miglitol Mechanism of action –Delay absorption of carbohydrates –Depend upon postprandial hyperglycemia Safety and efficacy –Decrease A1C 0.5-1% –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
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
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 effects 2 Glucose-lowering effects of a sulfonylurea plateau at half the maximum recommended dose 3 1.Garber AJ et al. Am J Med 1997;103:491 2.Nesto RW et al. Diabetes Care 2004;27:256 3.Stenman S et al. Ann Intern Med 1993;118:169
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???
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 http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf
Coronary Heart Disease Risk Equivalents Symptomatic Carotid Artery Disease Abdominal Aortic Aneurysm Peripheral Vascular Disease In ATP III, Diabetes is considered a CHD Equivalent http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf
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
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) http://circ.ahajournals.org/content/119/25/3244.full?sid=74e4098a- f84a-4abd-ad60-647a7da0ca9f. (accessed Aug 11, 2011)
Management Options Medications-maximizing orals and considering injectables Lifestyle-including exercise and diet
Beta Cell Function Declines UKPDS Data Beta cell function declines with time 5-10% failure per year Eventually Insulin Needed
63% of Patients with Diabetes are Not at ADA A1C Goal <7% 37.2% >8% 63% 7% 7.8% 25.8% 37.0% 17.0% 12.4% % of Subjects n=404 A1C Adults aged 20-74 years with previously diagnosed diabetes who participated in the interview and examination components of the National Health And Nutrition Examination Survey (NHANES), 1999-2000 Saydah SH et al. JAMA 2004;291:335
Challenges with Achieving Target A1C Values Challenges 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
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); 183-189.
What are some common patient concerns when transitioning to insulin?
Common Patient Concerns when Transitioning to Insulin Fear of needles or pain from injections Fear of hypoglycemia Weight gain Funnel M. Self-management Support for Insulin Therapy in Type 2 Diabetes. The Diabetes Educator 2004;30:274
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 Funnel M. Self-management support for insulin therapy in type 2 diabetes. The Diabetes Educator 2004;30:274
What are your concerns when transitioning a patient to insulin?
Insulin Initiation Provider Concerns Which insulin? How much? How do I adjust? How do I teach? How often do I change dosages?
Potential Insulin Regimens Insulin pump Physiologic/COMPLEX/Flexible Multiple daily injections Free mixing - twice daily Pre-mixed - twice daily Basal only SIMPLE/Inflexible How do we balance simplicity and flexibility to achieve glycemic control?
Insulin Initiation Answers to Provider Concerns Normalize the fasting glucose –Fasting FSBS 70-130 –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 70-130 fasting Decrease 3 units for fasting < 70
Once Daily Insulin Options Basals vs. NPH vs. Premixed INSULIN TYPEADVANTAGESDISADVANTAGES GlarginePeakless, less hypoglycemia, less wt gain; simple Cost; can’t mix; no meal time coverage DetemirLess 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 NPHLess expensiveMore hypoglycemia than basals
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); 183-189.
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 1 Petznick, Allison. Insulin Management of Type 2 DM. Am. Fam. Physician. July 2011 Vol. 84 (2); 183-189.
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
Oral Meds When Starting Insulin-Pearls Secretagogues should be tapered and discontinued Sitagliptin is currently only incretin based therapy approved for use with insulin http://care.diabetesjournals.org/content/32/ 1/193/F2.expansion.html -algorithm for type 2 DM Petznick, Allison. Insulin Management of Type 2 DM. American Family Physician. Volume 84 (2); 183-189
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
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
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
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
15 Gram Carbohydrate Choices ½ cup juice or 2Tbsp raisins or 7 saltines = Glucose Increase ~50 mg/dL BG 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
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
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
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
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 episodes 1. Reliability concerns do not eliminate need for SMBG Effectiveness on glycemic control has not been established 1 Diabetes Care, volume 34, Supplement 1 January 2011 pg S4.
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 http://clinical.diabetesjournals.org/content/25/2/50.full. Accessed August 31, 2011.
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 $2000-3000 per year) http://clinical.diabetesjournals.org/content/25/2/50.full Accessed August 31, 2011.
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 http://clinical.diabetesjournals.org/content/25/2/50.full Accessed August 31, 2011
Management of Diabetes in the Hospitalized Patient Critically Ill: Insulin treatment for persistent BG >180 to maintain a range of 140-180 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.
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
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
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
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
Incident Counts & Adjusted Rates, By Primary Diagnosis of ESRD
Early Treatment Makes a Difference Brenner, et al., 2001
Category Spot urine collection albumin/ creatinine (microgram/mg creatinine) Normal <30 Microalbuminuria30-299 Macroalbuminuria (clinical) >/= 300 Definitions of Abnormalities In Albumin Excretion
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 Diabetes Care, Volume 34, Supplement 1, January 2011, Page S34
StageDescriptionGFR 1 Kidney damage with normal or inc. GFR >=90 2 Kidney damage with mild decrease in GFR 60-89 3Moderate decrease in GFR 30-59 4Severe decrease in GFR15-29 5Kidney failure<15 or dialysis Stages Chronic Kidney Disease
Drug Levels with Normal Renal Function Drug Level Time
Drug Levels With Impaired Renal Function Drug Level Time
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
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 Meta-Analyses Diabetes Care, Volume 34, Supplement 1, January 2011, Page S33
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
WHO -HCT team. World Health Organization. Adherence to Long Term Therapies: Evidence for Action. (2003).