Diabetes Management: Different Treatments for Different Times Faith Pollock, APRN, CNS, CDE

Objectives Verbalize types of diabetes and diagnostic criteria. Discuss the management options for diabetes. Discuss the perioperative management of patients with diabetes.

Number of Americans with Diagnosed Diabetes, 1980-2009 From 1980 through 2009, the number of Americans with diabetes has more than tripled, from 5.6 million to 19.7 million Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey www.cdc.gov Reference Centers for Disease Control and Prevention. Number (in millions) of civilian, non-Institutionalized persons with diagnosed diabetes, United States, 1980–2009. Available at: http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm 3

New Cases of Diagnosed Diabetes About 1.9 million people ages 20 years or older were newly diagnosed with diabetes in 2010, with the largest increase in the 45-64 years age group 20-44 years: 465,000 45-64 years: 1,052,000 ≥65 years: 390,000 Source: 2005-2008 National Health and Nutrition Examination Survey estimates projected to the year 2010 Source: 2005-2008 National Health and Nutrition Examination Survey estimates projected to the year 2010 National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Reference National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 4

Insulin and oral medication 14% Treatment of Diabetes No medication 16% Insulin only 12% Insulin and oral medication 14% Oral medication only 58% Among adults with a diagnosis of diabetes, either type 1 or type 2, 12% take insulin only; 14% take both insulin and oral medication; 58% take oral medication only; and 16% do not take either insulin or oral medication Source: 2007-2009 National Health Interview Survey National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Reference National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 5

Types of Diabetes Type 1 diabetes Type 2 diabetes Others Beta-cell destruction Do NOT make insulin Type 2 diabetes Progressive deficit of insulin secretion Do make insulin, but resistant and decreases over time Others Gestational Chemical or drug induced Disease

Diagnosis of Diabetes A1c Fasting glucose 2-h post OGTT glucose ≥6.5% ≥126 mg/dL ≥200 mg/dL Pre- 5.7–6.4% 100–125 mg/dL 140–199 mg/dL ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9-10; Table 2.1and 2.3

Medications for Diabetes Oral agent 9 categories 5 categories mostly used Non-insulin injectable 2 categories Insulin 5 categories

Oral Medications Biguanides Sulfonylureas i hepatic glucose production metformin Liver Sulfonylureas h insulin secretion glyburide glipizide glimepiride Pancreas

Oral Medications (2) TZDs DPP-4 Inhibitors h insulin sensitivity pioglitazone rosiglitazone Muscle DPP-4 Inhibitors h insulin secretion (with food) i glucagon secretion sitagliptin saxagliptin linagliptin alogliptin Pancreas and Liver

Oral Medications (3) SGLT2 Inhibitors canagliflozin deapagliflozin Blocks glucose reabsorption by the kidney h glucosuria canagliflozin deapagliflozin empagliflozin Kidney

Non-insulin Injectables GLP-1 Receptor Agonists h insulin secretion (with food) i glucagon secretion Slows gastric emptying h satiety exenatide exenatide extended release liraglutide albiglutide dulaglutide

Non-insulin Injectables (2) Amylin Mimetics i glucagon secretion Slows gastric emptying h satiety pramlintide

Insulins Basal Controls glucose when NOT eating

Insulins (2) Short and Rapid-acting To bolus for meals or to correct high glucose

Insulins (3) Mixed (basal and short or rapid-acting)

Insulins Compared to Normal Insulin Profile glargine / determir aspart / lispro / glulisine Regular NPH 100 B L D 80 Insulin 60 40 20 0600 0600 0800 1800 1200 2400 0600 Time of day B=breakfast; L=lunch; D=dinner 17

Components of Insulin Pumps Infusion Set Reservoir (for insulin) Very thin cannula in subcutaneous tissue Picture from diabetes.niddk.nih.gov 18

How Does a Pump Work? Reservoir is filled with rapid acting insulin Infusion set— administers insulin SQ 24 hours/day often placed in the abdomen, thigh or hip/buttock area patient can disconnect pump from the infusion set and reconnect later (exception: disposable pumps) Pump programmed to administer— Basal – continuous rate/hour to maintain glucose control when NOT eating Prandial – bolus per patient for nutrition intake Correction – bolus per patient for high glucose Patient should NOT be disconnected from the pump for more than 1 to 2 hours

Meal Planning with Diabetes

Carbohydrate Foods Fruit and fruit juices Milk and yogurt Starch (bread, rice, potatoes pasta, cereal) Fruit and fruit juices Milk and yogurt Sweets Digested Glucose from Carbohydrate foods Bloodstream 2004 Adapted from International Diabetes Center, Minneapolis

Preoperative Assessment A detailed history of diabetes therapy is essential to guide the practitioner in preoperative instructions medication therapy characteristics of the surgery when the patient must stop eating prior to the procedure timing of the procedure duration of the procedure

Clinic Assessment Type of diabetes type 1 patients CANNOT be without insulin Does patient reliably glucose monitor A1c How well has the patient been controlling glucose? Should elective surgery be postponed? Comorbidity risk Wound healing Risk of infection

Estimated Average Blood Glucose (mg/dL) over 3 to 4 months A1c 97 126 154 183 212 240 269 298 326 10 6 7 8 9 5 11 12 13 A1C (Percent) Estimated Average Blood Glucose (mg/dL) over 3 to 4 months Normal 4 to 6%

Clinic Assessment (2) Hypoglycemia Symptomatic of hypoglycemia? At what glucose level is patient symptomatic? When does hypoglycemia usually occur? Hypoglycemia is defined by the American Diabetes Association as a blood glucose less than 70 mg/dL. Some patients have symptoms at higher glucose levels.

Obtain dose and specific timing Clinic Assessment Oral diabetes medication Insulin Hypoglycemic injectables Inhalable insulin Obtain dose and specific timing

Pre-Surgery Medication Guidelines Oral Diabetes Medications Guidelines See List Below Hold dose(s) the day of procedure. metformin glyburide, glipizide, glimepiride sitagliptin, saxagliptin, linagliptin, alogliptin, vildagliptin canagliflozin, dapagliflozin, empagliflozin pioglitazone, rosiglitazone acarbose, miglitol repaglinide, nateglinide combinations of these drugs

Pre-Surgery Medication Guidelines (2) Insulin Guidelines Rapid-acting or short-acting (Regular, lispro, aspart, glulisine) Hold scheduled mealtime dose the day of procedure. If using sliding (correction) scale insulin, dose according to scale to correct elevated glucoses. Long-acting (glargine, detemir) If taking ONLY glargine or detemir: Take 75% of usual dose evening before procedure. Take 75% of usual morning dose day of procedure. If taking glargine or determir with meal time insulin: Take usual dose evening before procedure. Intermediate (NPH) Take 50% of usual morning dose day of procedure.

Pre-Surgery Medication Guidelines (3) Insulin Guidelines Mixed Insulin: (70/30, 75/25, 50/50) Take usual dose evening before procedure. Hold dose day of procedure. Recommend contacting the patient’s provider for further orders. Insulin Concentrated: R-U-500 Take 50% usual dose evening before procedure. Insulin Pumps Continue BASAL rate only. Decrease BASAL rate by 25% the day of procedure. Instruct patient to bring extra pump supplies to the procedure. Inhalable Insulin: Afreeza ® Hold scheduled mealtime dose day of procedure.

Pre-Surgery Medication Guidelines (4) Hypoglycemic Injectables Guidelines albiglutide dulaglutide exenatide, exenatide XR liraglutide pramlintide Hold dose(s) day of procedure.

Pre-Surgery Glucose Management OUTPATIENTS Monitor glucose morning of procedure and every 4 hours until procedure Correct HYPERglycemia per usual routine if using sliding (correction) scale insulin For symptoms of HYPOglycemia or blood glucose <100 mg/dL, drink 4 oz of CLEAR fruit juice. Then monitor glucose every 15 minutes. Repeat treatment until glucose >100 mg/dL. Hospital or procedure areas will manage glucose upon arrival.

Pre-Surgery Glucose Management (2) INPATIENTS Monitor glucose prior to procedure Correct HYPERglycemia per sliding (correction) scale insulin or per physician order Follow HYPOglycemia protocol if needed Preoperative nursing will manage glucose per Anesthesia orders after arrival to surgical area

Hyperglycemia Pre-Surgery Causes Inappropriate discontinuation of diabetes medication History of poor glucose control Stress hyperglycemia When to post-pone surgery Acute complications of hyperglycemia Dehydration Ketoacidosis Hyperosmolar nonketotic state

Hypoglycemia Pre-Surgery Hypoglycemia is defined by the American Diabetes Association as a blood glucose less than 70 mg/dL. Some patients have symptoms at higher glucose levels. Follow hypoglycemia protocol D50 IV Dextrose containing IV fluids

Intra and Post-Operative Management Glucose goal Patient outcomes Insulin therapy Insulin pumps

Intraoperative Glucose Goal Patients with well controlled glucose 100-180 mg/dL 120-180 mg/dL for coronary bypass surgery Patient with poorly controlled glucose Preop glucose baseline Symptomatic of hypoglycemia at normal glucose Increased oxidative stress with glucose reduction

Postoperative Outcomes Retrospective study in 55,408 noncardiac surgeries Higher rates of postoperative infection were associated with a mean 24 hour postoperative serum glucose concentrations of 150 mg/dL or higher King, J.T., et. al. (2011). Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Annals of Surgery. 253(1), 158-165.

Postoperative Outcomes (2) Perioperative hyperglycemia (>180 mg/dL) was associated with adverse outcomes in general surgery patients with and without diabetes (11, 633) Reoperative interventions Infections Death Patients with hyperglycemia on the day of surgery who received insulin (with or without diabetes) had no significant increase in these adverse outcomes Kwon, S., et. al. (2012). Importance of perioperative glycemic control in general surgery: A report from the Surgical Care and Outcomes Assessment Program. Ann Surgery, 257(1), 8-14.

Glucose Control with Insulin Subcutaneous Rapid or short acting Short acting preferred (aspart, lispro, glulisine) Injection before and/or after surgery Not often during surgery IV insulin IV push Insulin pump (continuous subcutaneous insulin infusion-CSII) Insulin infusion Major surgeries Replace insulin pump

Insulin Pump Therapy or CSII Insulin pumps are a SAFETY concern perioperatively Several different models available With tubing, without tubing, wireless, disposable Continuous glucose sensor Cannot be exposed to MRI, CT scans and X-rays Basal rate may not be accurate when patient NPO Patient not alert to self-manage! There are NO standardized guidelines!

CSII Perioperative Guidelines Abbott NW Hospital task team developed Clinical specialist, anesthesia, managers, pharmacy, nursing, medical safety officer CSII may be considered— For surgical procedures 2 hours or less of actual scheduled OR time If the infusion site is not located in the operative area If glucose <300 mg/dL If there will be no MRI, CT scan or X-rays

CSII Perioperative Guidelines (2) Preoperative Metered glucose within 60 minutes of arrival RN contacts Diabetes CNS or hospitalist for assessment Decision made if CSII or alternative insulin plan Close relationship with Anesthesia Diabetes CNS or hospitalist documents recommendations

CSII Perioperative Guidelines (3) Intraoperative CSII if meets criteria Basal rate (may be reduced) CSII disconnected for short procedures with radiology May give bolus dose of insulin via pump before disconnect Insulin infusion Procedures >2 hours Major surgery Expect high doses of pain meds post op Initiation rate determined by Diabetes CNS or hospitalist Metered glucose every 1 hour

CSII Perioperative Guidelines (4) Postoperative Metered glucose upon arrival to recovery RN contacts Diabetes CNS or hospitalist Decision made if— Safe to discharge home for ambulatory patients Safe to continue CSII Will continue insulin infusion Inpatient policies and protocols implemented CSII Insulin infusion

Summary Know the type of diabetes for which your patient has been diagnosed Assess glucoses regularly perioperatively Know what medication your patient takes for glucose management What medication and dose was taken evening prior and the day of surgery Assess if your patient has experienced hypoglycemia overnight prior and the day of surgery If your patient uses a CSII, collaborate with the perioperative team for safe use with surgery

Questions

References Abdelmalak, B., et al. (2012). Perioperative glycemic management in insulin pump patients undergoing noncardiac surgery. Current Pharmaceutical Design.18, 6204-6214. Boyle, M. E., et.al. (2012). Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period. Journal of Diabetes Science and Technology. 6(1), 184-190. Desai, S. P., et. al. (2012). Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized control trial. The Journal of Thoracic and Cardiovascular Surgery, 143, 318-325. Joshi, G. P., et. al. (2010). Society for ambulatory anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesthesia Analg, 111, 1378-87. King, J.T., et. al. (2011). Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Annals of Surgery. 253(1), 158-165. Kwon, S., et. al. (2012). Importance of perioperative glycemic control in general surgery: A report from the Surgical Care and Outcomes Assessment Program. Ann Surgery, 257(1), 8-14. Micromedex Solutions. (2015). Drug reference library. Retrieved February 6, 2015, from http://www.micromedexsolutions.com Smiley DD, Umpierrez GE. (2006). Perioperative glucose control in the diabetic or non diabetic patient. South Med J. 99:580. UpToDate. (2013). Perioperative management of diabetes mellitus. Retrieved September 20, 2013, from http://www.uptodate.com/contents/perioperative-management-of-diabetes-mellitus.