1. Guidelines for Diabetes Management September 20, 2012 Margaret Pochay RD CDE

2. How Food is Digested 1. Food enters stomach 5. Insulin unlocks receptors 4. Pancreas releases insulin 2. Food is converted into glucose 3. Glucose enters bloodstream 6. Glucose enters cell

3. Pancreas Cannot Produce Enough Insulin Body lacks insulin or is unable to use insulin effectively Diabetes Muscle and Fat Cells Cannot Use Insulin Effectively

4. Cardiovascular Disease Type 2 Diabetes High Blood Pressure Obesity High Blood Fats Impaired Glucose Tolerance Insulin Resistance Related Conditions Insulin Resistance

5. Retinopathy: 25x Complications of Diabetes End-Stage Kidney Disease: 17x Heart Disease: 2-4x Foot/Leg Amputations: 5x Stroke: 2-6x

6. Good Diabetes Management results in REDUCED macrovascular disease –heart disease –stroke Results from Diabetes Studies REDUCED microvascular disease –eye disease –kidney disease –neuropathy

7. Change in HbA 1C Microvascular Complications 0 -2 -3 -4 -5 United Kingdom Prospective Diabetes Study (UKPDS) 0 - 5 -10 -15 -20 -25 - 0.9% - 25% 1% Decrease in HbA 1c = 25% Decrease in Microvascular Risk!

8. Guidelines for Diabetes Management http://care.diabetesjournals.org/content/35/ Supplement_1/S11.full.pdf+html Diagnostic criteria, standards of care, treatment goals, nutrition guidelines, diabetes self management guidelines, preventing complications

9. Daily Blood Glucose A1C (2-3 month glucose levels) Lipids (Blood Fats) Blood Pressure (Hypertension) Urine Protein (Microalbuminuria) Key Numbers in Diabetes Control Daily Blood Glucose

10. Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2003 Targets for Glucose Control Type 1 and Type 2 Diabetes Fasting/Pre-meal glucose Post-meal glucose 2 hr. after start of meal Bedtime glucose A1C 70-130 mg/dL <180 mg/dL 100-140 mg/dL <7.0%

11. Checking your blood sugar Why: –Checking your blood sugar yourself is often the best way to be sure your diabetes is under control. It tells you: If your insulin or other diabetes medicine is working How physical activity and the foods you eat affect your blood sugar Based on your care plan, you may want to test when: –You wake up –Before meals or large snacks –1 or 2 hours after meals or large snacks –Before and 15 minutes after physical activity

12. 8% 180 9% 210 10% 240 11% 270 12% 300 13% 330 4% 60 5% 90 6% 120 HbA 1c Blood Glucose (mg/dl) HbA 1c and Self-Monitoring Results 7% 150

13. Targets for Lipids, Blood Pressure and Microalbumin Lipids (Blood Fats) Blood Pressure Microalbumin LDL cholesterol (mg/dL)  100 Triglycerides (mg/dL) <150 HDL cholesterol (mg/dL) >60 <130/80 mmHg Total cholesterol (mg/dL) <200 <30 mg/24 h or <20 µg/min on a timed specimen or <30 mg/g creatinine on a random sample Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2001.

14. Pancreas -- stimulates insulin production Liver -- decreases glucose release Fat/Muscle -- increases insulin sensitivity Reduces breakdown of GLP1 Intestine -- slows carbohydrate metabolism Medications Insulin Sulfonylureas Meglitinides Metformin DPP4 inhibitor Thiazolidinediones Alpha-glucosidase inhibitors Supplements body’s own insulin

15. Exenatide (Byetta, Bydureon) and Victoza GLP-1 agonist or incretin mimetic Synthetic version of salivary protein found in the Gila monster

16. Indications for Insulin in T2DM Newly diagnosed symptomatic type 2 pts with severe hyperglycemia Poor glucose control despite max doses of OA Intercurrent illness (MI, infection, surgery) Pregnancy Renal/Hepatic Disease Allergies to OA

17. What are the different types of insulin? Rapid-acting: –Controls blood sugar surges at mealtime Long-acting: –Controls blood sugar between meals and during sleep Premixed: –Combines rapid-acting and intermediate-acting insulin –Controls blood sugar at mealtime and all day and night

18. Comparison of Human Insulins and Analogs Insulin Onset ofDuration of Preparations Action Peak (hr)Action (hr) Lispro/Aspart/Glulisine 5–15 min1–2 4–5 Regular Human 30–60 min2–4 6–10 Human NPH ® 2–3 hr6–10 10–20 Glargine/Detemir 1-2 hr flat~24 Mixes5-15 min 1-2 & 6-10 10-20 Time course of action of any insulin can vary in different people, or at different times in the same person; thus, time periods indicated here should be considered general guidelines only

19. Dosing Insulin Individual needs to be considered Type 2 Diabetes: Basal Insulin start 10units change by 3 units every 3 days fasting blood glucose 130 Meal time insulin calculate insulin to carb ratio rapid acting divide 500 by total daily insulin dose. Titrate depending on post meal blood glucose

20. Dosing Insulin type 1 diabetes.5 unit of insulin per kg body weight 50% insulin basal insulin (goal FBS 70-130 1 unit of fast acting insulin per 15gm carbohydrate to be eaten (goal post prandial <180) Correction also calculated (ex: 1 unit for every 50 points glucose above or below goal)

21. Barriers to Insulin Use: Patient Issues BarriersSolutions Fear of injectionsSyringes, pens, and needles vastly improved Fear of hypoglycemiaLow rate of severe hypoglycemia in DM2 Fear of weight gain Glucose control is more important than mild-to- moderate weight gain

22. Injecting insulin How: –Insulin pen –Syringe filled from a bottle of insulin –Insulin pump Where: –Abdomen –Thighs –Backs of the upper arms

23. Pen Delivery of Insulin Encourages multiple- dose insulin therapy Adds convenience Enhances flexibility in schedule Reduces insulin waste May improve accuracy of correct dosage delivery

24. Patient Education Issues Insulin Administration –Abdomen preferred injection site –Rapid acting insulins within 15 min before meals; regular insulin 30 min before meals When to self-monitor blood glucose –3-4 times per day (pre-meals) –Intermittent 1–2 hours postmeal to adjust analog How to recognize and treat hypoglycemia and hyperglycemia

25. Good control involves proper use of lifestyle tools and medications Regular and frequent monitoring of all aspects of diabetes is essential to good control Diabetes is a self managed disease Summary Pathophysiology important part of educationg patients with diabetes