Cancer and Diabetes 2017 · Promote healthy diet, physical activity and weight management....

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Diabetes and CancerA Case Study Approach

Beverly Thomassian, RN, MPH, BC‐ADM, CDEPresident, Diabetes Education Services

Objectives• Discuss the relationship between cancer and

hyperglycemia

• State 3 strategies and benefits of normalizing glucose levels.

• Using a case study approach, discuss strategies to improve glucose levels while maintaining quality of life.

Links

Cancer is the 2nd leading cause of death in U.S.

Diabetes is the 7th leading cause of death

Cancer and diabetes diagnosed within the same individual more frequently than would be expected, even after adjusting for age.


Risk Factors Common to Both Diseases

Aging

Obesity

Diet

Physical inactivity

Ethnicity

Alcohol (more than 2 drinks a day)

Smoking

Biologic links incompletely understood

Obesity associated with increased cancer risk in 11 sites

esophageal adenocarcinoma multiple myeloma cancers of the gastric cardia colon (in men) rectum (in men) biliary tract system pancreas breast (postmenopausal) endometrium (premenopausal) Ovary Kidney

An meta review of 12 studies, determined an association between obesity (BMI 30+) and 11 cancer sites. BMJ. Published online February 28, 2017

Possible Mechanisms for a Direct Link

Hyperinsulinemia

Hyperglycemia

Inflammation


Type 1 and Cancer Rates of stomach, liver, pancreatic and kidney cancer increased in both men and women

Rate of cancer doubled during first year of diagnosis Then feel back to population levels after that

Both type 1 and type 2 have increased risk of cancer, but type 1s a little less

Type 1 and Cancer – Risk compared to general population

Increased Risk Decreased Risk

Stomach

Liver

Kidney

Pancreatic

Endometrial

Breast

Prostate

Due to hormone levelsMore frequent doctor visits?

Diabetologia, published online Feb. 29, 2016

Type 2 Diabetes and Cancer People with prediabetes and type 2 Two fold higher risk for cancers of Liver

Pancreas

Endometrium

1.2 to 1.5 fold risk of cancers of Colon

Breast

Bladder.

Lower risk of prostate cancer

Diabetes and Cancer: A Consensus Report Cancer J Clinic 2010Joint statement American Cancer Society and American Diabetes Assoc


What Can Health Professionals Do? Promote healthy diet, physical activity and weight management.

Encourage appropriate screening for cancer and to report any symptoms

Studies indicate that metformin may decrease cancer risk

Focus on prevention of diabetes

Focus on Modifiable Risk Factors Try to lose weight (if overwt or obese)

Eat less meat, more fiber, whole foods

Get active ‐ reduces risk of colon, post‐menopausal breast and endometrial cancer.

Quit smoking

Review alcohol intake


Mrs. RT 67 years History of Pancreas and Colon Cancer, Stroke and Cardiac Stent. Liver cancer discovered.

A1c, 7.7%, BMI 28, Walks 5 miles daily, eats high fiber diet, GFR > 60

Diabetes Meds Victoza 1.8mg daily (2 years)

Glipizide 40mg daily

Metformin 1000mg BID

Lantus 20 units at night

What Should We Assess?

Assessment Areas Blood Glucose levels

Weight – Current/ recent Past

Eating habits

Level of activity

Diabetes Medications

Kidney / Liver function – affect medication choices

Chemo regimen / steroid or no steroid?

Self‐Care and Social support

Individualize Glucose Goals*

Before meals 80‐130

2 hrs after meals < 180

A1c < 7%

Individualized based on Patients goals

Risk of hypoglycemia

Complexity of medication regimen

Life expectancy


Monitoring GlucoseCost should match the benefit

Consider:• Degree of hyperglycemia and

• Intensity of medication management

• Patient limitations

• BG highest after lunch and dinner

• BG trends down overnight

• How will this information affect treatment adjustments

• How patient is feeling

Weight and Food Goal – maintain weight

and physical health

Strategies Evaluate Carb and caloric intake, consult RD

Identify favorite, desired foods

Maximize nourishment to protect gut bacteria, especially in presence of antibiotics, diarrhea Encourage nutrient and calorie rich, high fiber foods

Yogurt, buttermilk, Kefir can be considered if pt not severely immunocompromised. Check with MD

Not time to cut back on caloric intake – Adjust meds to cover food

Other Considerations

Keep as active as realistic, consider strength training, gentle yoga, meditation

Rest – sleep is vital for healing and restoration. Will also improve blood glucose levels

Quit Smoking

Limit alcohol


Mrs. RT 67 years History of Pancreas and Colon Cancer, Stroke and Cardiac Stent. Liver cancer discovered.

A1c, 7.7%, BMI 28, Walks 5 miles daily, eats high fiber diet, GFR > 60, BMI 80 kg

Diabetes Meds Victoza 1.8mg daily (2 years)





Assessment Areas Blood Glucose/ A1c levels


Eating habits

Level of activity





Metformin – New GFR Guidelines

Biguanide derived from:Goat’s Rue Galega officinalis,French Lilac


Metformin and Cancer Metformin:Research suggests it can lower the risk of developing cancer and improves survival in people with cancer. An ongoing clinical trial is testing metformin as a breast cancer treatment in people without type 2 diabetes.


Mrs. RT 67 yrs, A1c 7.7% Started chemotherapy and daily prednisone.

How will these new therapies affect BG?

Needed adjustments, additions to medications? Victoza 1.8mg daily (2 years)




The Problem with Cancer + Hyperglycemia:

Increased risk of infection in an already immuno‐compromised patient

Increased weight loss

Fatigue

Dehydration / lack of sleep

Depression

How to Manage Steroid Diabetes in the Pt w/ CancerOyer et al Supportive Oncology, v4/#9 Oct 2006

Benefits of Glucose Control Patient feels better / more energy

Better outcomes

Less infection

Focus on feeling better right now, not on preventing long term complications.


Steroids Impact on BG What we know Steroids cause insulin resistance

Most notable after lunch and dinner

Need bolus insulin at lunch/dinner

Can also try 70/30 in am

Oral agents alone, usually won’t work

Decadron causes highest blood glucose levels

BG trends down through night Give basal insulin in am

Avoid basal at night

Assess kidney function/eating habits

Plan for Mrs. RT What blood glucose goal and strategies

BG goals 100‐ 180

Food

Activity

Medication Adjustments or addition? Victoza 1.8mg daily (2 years)




Medication Adjustments / addition?

Victoza 1.8mg daily Continue unless wt loss

Glipizide 40mg daily Continue unless hypo

Metformin 1000mg BID Continue, keep eye on kidney

function

Lantus 20 units at night Move to am, may need increased

dose

Consider adding 3‐10 units bolus insulin at breakfast and lunch

Consider switching to am 70/30

Insulin Action Teams


Next Steps – Switch from 20 units basal to 70/30 Insulin

Switch to 70/30 Insulin

Usually, take current dose and give 2/3 in am and 1/3 in pm.

In this case, since we don’t want to cause nocturnal hypo, give 20 units in am 14 units basal + 6 units bolus

Can always add pre dinner if needed.

Basal Bolus TherapyInsulin Dosing Strategy

50/50 Rule

0.5‐1.0 units/kg day(.5 units/kg most common)

Basal = 50% of total

Glargine Q day

NPH or Detemir BID

Bolus = 50% of total

usually divided into 3 meals

Example

Wt 50kg x 0.5 = 25 units of insulin/day

Basal dose: 13 units

Glargine 13 units Q day

NPH/Detemir 6u BID

Bolus dose: 12 units

4 units NovoLog, Apidra, Reg, Humalog each meal


Intensive Diabetes TherapyInsulin Dosing Strategy

50/50 Rule


Basal = 50% of total Glargine Q day

NPH or Detemir BID

Bolus = 50% of totalusually divided into 3 meals

Example – You Try

Wt 80 kg x 0.5 = ___ units of insulin/day

Basal dose: ____ unitsGlargine ____ units QD

NPH/Detemir ____ BID

Bolus dose: ____ units___units NovoLog, ApidraHumalog each meal

Intensive Diabetes TherapyInsulin Dosing Strategy

50/50 Rule


Basal = 50% of total Glargine Q day

NPH or Detemir BID

Bolus = 50% of totalusually divided into 3 meals

Example – You Try

Wt 80 kg x 0.5 = 40 units of insulin/day

Basal dose: 20 unitsGlargine 20 units QD

NPH/Detemir 10 BID

Bolus dose: 20 units6+ 7+ 7units NovoLog, ApidraHumalog, REg each meal

Correction Bolus for SteroidsRapid/Fast Acting Insulin (1 unit:50 mg/dl>150)

Less than 70 - 1 unit70-150 mg/dl 0 units

151-200 mg/dl 1 unit

201-250 mg/dl 2 units




- 1 unit1 units

2 unit

3 units

4 units

5 units

6 units

30 mg Pred 45 mg Pred


Hypoglycemia Caution

If lowering steroid dose, down regulate diabetes meds/insulin

If pt loses weight, diabetes meds may need dose reduction

Poor kidney function increases hypo risk

Assess for nocturnal hypo Headache, vivid dreams, sweats

Mr. LR 73 yrs

Being treated for Lymphoma

Finished with chemo now – planning stem cell transplant

A1c, 6.1 to 6.5%, BMI 26, GFR > 60

Diabetes Meds Dapagliflozin (Farxiga)


Januvia 100mg daily


Assessment Areas Blood Glucose / A1c levels


Eating habits

Level of activity






Diabetes Meds Associated with Cancer Warning

GLP‐1 Receptor Agonists (long acting) Caution regarding medullary thyroid tumor

Pancreatitis

Actos (pioglitazone) may increase bladder cancer risk

Farxiga (Dapaglifozin) Do not use in patients at risk of bladder cancer

Mr. LR 73 yrs Being treated for Lymphoma

Diabetes Meds Dapagliflozin (Farxiga)


Januvia 100mg daily

Medication Adjustments Dapagliflozin (Farxiga)

Change to Empagliflozin

Metformin 1000mg BID Continue – keep on on body weight, appetite

Januvia 100mg daily Can cause sudden severe joint pain. Monitor closely

Have pt contact you if steroids started


Mr. Carter – 83 yrs youngDiagnosed w/ Leukemia

Medical situation Diabetes 11 years, usually controlled on oral medications

Glipizide 40 mg daily

A1c usually less than 6.5%. Now 7.6%

GFR >60

On prednisone taper

Blood transfusions every 2 weeks

5’11 – weighs 182 (has lost 10 lbs over past 6 months, but is holding now)

Mr. Carter – 83 yrs youngSocial Situation Social Situation Lost wife 3 months ago

Lives alone – very active

Rates his health as good to excellent

Has extensive social network

Tells you “I am worried about my blood sugars and want to get them down”.


Assessment Areas Blood Glucose / A1c levels


Eating habits

Level of activity






A1c Test Measures glycation of RBC’s over 2‐3 months

Weighted mean (50% preceding month)

Each 1% ~ 29mg/dl

Accuracy: affected by some anemias, hemoglobinopathies, blood transfusion

A measurement of glucose in fasting and postprandial states

Fructosamine Test – Just in case The level of fructosamine in the blood is a reflection of glucose levels over the previous 2‐3 weeks – Can be used to eval: Effects of rapid changes in diabetes treatment

Diabetes control during pregnancy – to help monitor and accommodate shifting glucose, insulin, or other medication requirements.

Glucose control for pts with shortened RBC life span –such as anemia or blood loss. In these situations, A1c result is falsely low.

Abnormal forms of hemoglobin such as in sickle cell anemia.

Plan for Mr. Carter – 83 yrs young Medical situation Glipizide 40 mg daily A1c usually less than 6.5%. Now 7.6%

GFR >60 On prednisone taper Blood transfusions every 2 weeks

5’11 – weighs 182 (has lost 10 lbs over past 6 months, but is holding now)

Action Glipizide 40 mg daily

Continue

Add Metformin XR 500mg daily and gradually increase

Use daily BG levels and fructosamine to determine control

Monitor body weight

Provide hypo info

Plan to meet his lifestyle


In Conclusion Patients with diabetes are more likely to get certain cancers

Cancer treatments are improving

Glucose control improves quality of life

Through careful thought and consideration, we can help patients get to the best health possible.

Thank You Thanks for joining us!

Please let us know if wecan be of more service to you.

www.DiabetesEdUniversity.net

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Cancer and Diabetes 2017 · Promote healthy diet, physical activity and weight management....

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