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1 GO! Diabetes Case Studies
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<?xml version="1.0"?><AllResponses /> <?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 “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

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


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 Choices
BG 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


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

109 Drug Levels With Impaired Renal Function

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).

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