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Compression Consultations for the
Diabetic Patient
Kimberly Simmons, PharmD, MBAUS Pharmacy Relations Manager
SIGVARIS, Inc.
Adjunct Associate Professor of Pharmacy PracticeMercer University College of Pharmacy and Health Sciences
University of Georgia College of Pharmacy
Program Sponsored by SIGVARIS
Global leader in graduated compression garments for prevention and management
of venous insufficiency/disease
This is commercial program; no CE credits will be This is commercial program; no CE credits will be offered!offered!
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The SIGVARIS Difference…
Double Covered Yarns• Increased durability• Omission of ‘shininess’• Provides for anatomically correct fit• Enhances patient level of comfort
in donning and doffing• Improved patient compliance
Covered spandex
2nd covering(S-twist)
1st covering(Z-twist)
The SIGVARIS Difference…
SIGVARIS offers flexible ready-to-wear sizing options to fit 98.2% 98.2% of the population
while ensuring maximum comfort
and increasing compliance
The SIGVARIS Difference……we work for you & with you to so you can
generate alternative revenue!
Pharmacist managed pharmacy relations department for business support
Healthy leg days Physician detailing Online dealer
locator Distributed dealer
list
Provide complimentary customized & generic marketing materials
Quarterly business reviews
Training & education programs
Do you currently carry and/or consult patients on graduated compression socks or stockings for your patients?
Objectives• Discuss the epidemiology of lower
extremity complications in the diabetic patient
• Discuss graduated compression therapy and it’s uses
• Explain the etiology of lower extremity edema in the diabetic patient
• Describe lower extremity edema management with graduated compression therapy
• Discuss compression consultation points for diabetic patients
Diabetic Patient use of Pharmacy Services
Georgetown University. Center on an Aging Society. Sept. 2002 (5). 1-6. Available at: http://hpi.georgetown.edu/agingsociety/pdfs/rxdrugs.pdf. Accessed 05/03/12.
25.825.8
1 American Diabetes Association. Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011). Available at: http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Accessed 05/03/12
$174 BILLION
1 American Diabetes Association. Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011). Available at: http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Accessed 05/03/12
The old saying “An ounce of prevention is worth a pound of cure” was never as true as it is when preventing amputations!
Factors Leading to Lower Extremity Amputations
• Peripheral neuropathy• Infection
▫Antibodies respond slower to infections secondary to the poor circulation
• Deformity of the feet▫Diabetes can affect the
joints making them stiffer• Vascular disease
▫Poor circulation can affect the body’s ability to heal when damage occurs
Vascular Disease: Arterial & Venous Disease
Venous Disease (PVD)Inadequate return of venous blood from the legs to the heartClinical Symptoms: tired/heavy, achy cramping in the legs; pain worsens when standing and improves with leg elevation and activity
Arterial Disease (PAD)Narrowing of the arteries, commonly the pelvis & legsClinical Symptoms: cramping, pain, tired legs or hip muscles that worsens during walking/activity and subsides with rest
PAD=peripheral arterial disease; PVD=peripheral venous disease
Epidemiology of Vascular Disease
PAD= Peripheral arterial diseaseNational Heart Lung and Blood Institute (NHLBI). Available at: http://www.nhlbi.nih.gov/ Accessed 01/27/11.Society of Interventional Radiology (SIR) Website. 2003. Available at: http://www.scvir.org/patients/varicose-veins/. Accessed 05/28/2009/Vascular Disease Foundation Newsletter. Spring 2005; Volume 5, N2
60% of American suffer from vascular disease and its sequelae More people lose time from work and are
affected by venous disease than from arterial disease
50% of Americans are affected by vein disease
Diabetic patients have a 2-5 times greater risk for developing PAD vs. non-diabetic patients Approx. 1 in 3 diabetic patients >50 years
has concomitant PAD
Veins
60-70%
Arteries
10-12%
102030405060708090
100
0
The venous system contains most of the blood as it moves
through the circulatory system.
Most of the
blood
Perc
en
t D
istr
ibu
tion
Lungs
10-12%
Heart
8-11%
Capillaries
4-5%
Hole’s Human Anatomy and Physiology, 7th Edition, 1996
Audience Response
What etiologic factors directly contribute to the development and progression of venous disease?
A.Incompetent valvesB.High blood pressureC.Improper venous returnD.A and BE.All of the above
Physiology of the Normal Venous Circulation: Competent Valves
Valve Open Pumps blood against gravity towards heart
Valve Closed Inhibits gravitational reflux of
pumped blood
Physiology of the Normal Venous Circulation: Incompetent Valves
Vein Wall InjuryVein Wall Injury
↑↑
Venous Venous HypertensionHypertension
↑↑
Damaged ValvesDamaged Valves
Sources of Venous Return
•Calf muscle (2nd heart)•External foot pump•Arterial pressure•Abdominal/intrathoracic
pressure
Examples of Vein Disease Complications
Telangiectasia(spider veins)
Varicose Veins
Deep Vein Thrombosis
Lipodermatosclerosis
Superficial Phlebitis
Examples of Vein Disease Complications
Leg EdemaVenous Hypertension
Chronic Venous Insufficiency
Venous Ulcers
• Lower extremity edema is a common clinical finding in diabetic patients▫ Graduated compression therapy is the standard
treatment for edema▫ Graduated compression therapy is a precaution in
diabetic patients because of concomitant arterial disease
• Lack of reliable measures to objectively quantify edema makes it difficult to assess it’s prevalence in diabetic patients
• Edema in diabetics is difficult to isolate and may have multiple etiologies▫ Edema may be attributable to anti-diabeties meds
such as: Actos, Avandia, ACTOplus met, Byetta
Lower Extremity Edema:A Complication of Poor Circulation
Brodovicz KG, et al. Clin Med Res. 2009;7(1-2):21-31.Fries R. MMW Fortschr Med. 2004;146(16):39-41.Powell AA, et al. Am Fam Physician. 1997;55(5):1721-6.
Safety and Efficacy of Mild Compression (18-25mmHg) Therapy in
Patients with Diabetes and Lower Extremity Edema
Wu SC, Crews RT, Najafi B, et al. J Diabetes Sci Technol 2012 Vol 6 Issue 3• 4-week pilot study
• N=18▫ Diabetes▫ Lower extremity edema of the leg, foot, and ankle▫ Ankle-brachial index (ABI) >0.6
• Assess whether diabetic compression socks* can reduce LE edema in diabetic patients without compromising vascularity
• Mild graduated compression socks (18-25mmHg) decreased swelling in diabetic patients with LE edema without compromising vascularity
LE=lower extremity
Defining Anti-embolisms (TEDs)“TEDS are for BEDS”“TEDS are for BEDS”
Anti-embolismsTherapeutic Compression Ranges: 18-8mmHg,
20-10mmHgUtilized in the hospital or nursing home setting For bed-ridden patients
Class A (8-15mmHg) compression reflects the standard in some countries but there is insufficient clinical evidence to support it’s use in practice. (European Prestandard, 2001)TEDS=Thromboembolic Deterrent Stockings
Anti-embolismsIndicated for prevention of
thromboembolisms in recumbent patientsrecumbent patients
Defining Graduated Compression Therapy“Stockings are for Walking”“Stockings are for Walking”
20 - 40%
50 - 80%
100%
Pictures obtained from http://www.newlook.com.sg/tedantiembolismstockings.asp. Accessed 09/02/10.
• Compression therapy is the application of controlled graduated external pressure to the limb to reduce venous pressure within the limb.
• Strongest at the ankle and decreasing in the proximal direction
• To be effective, must fit over the calf• Require measurement, fitting,
and patient counseling by a certified and trained compression specialist
Audience ResponseHow do you know what level of compression pressure is appropriate for the patient?
A.Physician prescriptionB.Patient requestC.Assessment of venous complicationsD.A and B onlyE.All of the above
Graduated Compression Indications
There is insufficient clinical evidence to support the clinical efficacy of compression pressures <15mmHg to support ambulatory patients. (European Prestandard, 2001)
Shoe Size Precisely Measured
15-20mmHg 18-25mmHg 20-30mmHg 30-40mmHg 40+mmHg
• Tired, achy legs• Occupational or
evening edema• Leg discomfort
from prolonged standing/sitting
• Preventing pregnancy varicosities &swelling
• Predisposed risk• Reduce travel
swelling• Prevention of
traveler’s thrombosis
• Lower extremity edema in diabetic patients without contraindications and ABI >0.6
• Heavy, fatigued, aching legs
• Mild edema in lower extremities
• Mild varicosities w/ minimal edema
• Mild varicosities & pregnancy edema
• Post-procedure of small veins
• DVT prevention or management
• Moderate varicosities w/ mild-moderate edema ± pregnancy
• Post-procedure of larger veins
• CEAP C3, C4, C5, C6
• Recurrent or active venous ulceration
• DVT prevention or management
• DVT or PTS treatment
• Severe varicosities
• Severe edema• CEAP C4, C5,
C6• Recurrent
venous ulceration
• Severe post traumatic, fracture edema
• Severe PTS
A simple change of socks!!!A simple change of socks!!!
Why are graduated compression garments sized and measured to precisely fit patients?
Graduated compression therapy is “Medicine you
Wear”
What compression consultation would you offer this
diabetic patient presenting to your pharmacy?
“Your labs show you have diabetes. I know your legs hurt
but you need to exercise to improve your circulation, and start Actoplus met!”
Selecting the ‘Right’ Diabetic Compression Sock • Promotes circulation• Fiber blend of cotton, acrylic, nylon, and elastic
▫Regular 100% wool or cotton socks are too tight on the foot, reduce circulation, and are not cool and do not keep the foot dry
• Cushioned▫Regular socks do not provide comfort and protection
• Flat seams▫Coarse seams on regular socks rub the foot and .
cause blisters and calluses to emerge
Feldman CB, et al. Diabetes Spectrum.14(2), 59-613Herring KM, et al. J Amer Pod Med Assn. 80, 63-70.
Diabetic Compression Sock Target Patient Population
•Pre-diabetic•Newly diagnosed•Edema•Gestational diabetes•No neuropathy•ABI >0.6 without
claudication
Diabetic patients a more likely to exercise when their legs feel good!
Key Benefits: •Clinically proven to reduce swelling and improve circulation•American Podiatric Medical Association (APMA) Seal of Approval•Non-binding calf band•Flat toe seam•Extra padding on foot•DriRelease fiber blend for moisture wicking, odor control, and softness•Latex free•True graduated compression
Compression Level: 18-25mmHgStyle(s): Over the Calf Color(s): White Retail Price: $30-40
Diabetic Compression Sock
Diabetic-friendly Compression Sock
Key Benefits: •Diabetic-friendly •Non-binding calf band•Flat toe seam•Extra padding on foot•DriRelease fiber blend for moisture wicking, odor control, and softness•Latex free•True graduated compression
Compression Level: 15-20mmHg & 20-30mmHgStyle(s): Over the Calf Color(s): White & BlackShoe size, ankle & calf measurementsRetail Price: $30-60
15-20mmHg
20-30mmHg
Cushioned Cotton
Compression Consultation Points for the Diabetic Patient
• Avoid diabetic compression socks upon development of:▫ Severe arterial insufficiency ▫ Intermittent claudication▫ Ischemia▫ Weeping wounds▫ Uncontrolled CHF
• Seek physician consultation and approval to wear diabetic compression socks if neuropathy presents
• Remove socks if they cause persistent pain to lower extremities and pain does not improve with activity
Compression Consultation Points for the Diabetic Patient
• Put on diabetic compression socks daily upon waking & remove at bedtime
• Launder socks every night in a mild washing detergent
• Diabetic compression socks will decrease LE edema & improve circulation to help legs & feet feel better
• Moisturize feet daily before & after sock application with a foot cream to minimize dry, cracked skin
Compression Consultation Points for the Diabetic Patient
•When donning and doffing stockings, it’s best to wear gloves.
•To don, do not bunch the garment like ordinary socks.
•Use the ‘pull-on’ or ‘sock-puppet’ method to don graduated compression garments.
•To doff the garment, pull off like a banana.
Foot Care Consultation Points
• Wash feet daily with luke warm water• Dry feet and between toes well• Keep skin supple with moisturizing
lotion• Use soft socks or stockings, which
must neither be too big or small• Avoid walking bare-foot• Examine shoes daily for
abnormalities/defects• A brisk walk daily stimulates
circulation and makes patient feel better
Palaian S, et al. The Internet Journal of Pharmacology. 2005 Volume 4 Number 1. Available at: http://www.ispub.com/journal/the-internet-journal-of-pharmacology/volume-4-number-1/role-of-pharmacist-in-counseling-diabetes-patients.html. Accessed 05/04/12.
Questions & Discussion
SIGVARIS Graduated Compression Socks …
“It’s Medicine you Wear”
Thank You for Attending!
Kimberly Simmons, PharmD, MBAUS Pharmacy Relations Manager
SIGVARIS [email protected]
770-632-2571 (office)770-632-2973 (fax)