GO! DiabetesCase Studies

Rosita

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)

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

Vital Signs

• Ht. 5 feet 4 inches (162.56 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

Labs

• TG 185

• Total Cholesterol 208

• LDL 122

• HDL 48

• FBG 88, 2 hour (75 gm) glucose challenge WNL

Screening & Diagnosis in PregnancyOvert 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 24-28 wk gestation with 1 abnormal: FBS>= 92, but <126, or

1hr >=180, or

2hr >=153

Metabolic SyndromePARAMETERS 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: +2 OF:

GLUCOSE (mg/dL)

FBS >=100 FBS >=100 FBS >=110,

2hr >=140

HDL (mg/dL) <40 (men)

<50 (women)

<40 (men)

<50 (women)

<40 (men)

<50 (women)

TG (mg/dL) >=150 >=150 >=150

OBESITY (cm) Waist >= 102 (men) or

88cm (women)

HTN (mmHg) >=130/85 >=130/85 >=130/85

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

Metabolic SyndromePatient Education

• Medical Nutrition Therapy (MNT)– carbs, fats, proteins and calories

• Exercise

• Weight management

• Psychosocial and family implications

Medical Nutrition Therapy (MNT) for Rosita

USDA Government

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 about Medications for Rosita?

• Metformin reduced the development of T2DM by 31%

• Recommended by the American Diabetes Association in patients with pre-diabetes

Diabetes Care, Volume 34, Supplement 1, January 2011

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)

Monitoring your Metabolic Patients

• Laboratory– Hgb A1C, FPG or GTT– Lipids

• BP

• Weight

• PE– Dermatology and neuro manifestations

Rosita

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.

Who and When to Screen?

• 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

• 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

(2010) Standards of Medical Care in Diabetes-2010. Diabetes Care, 33, Supplement 1, S14.

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-2010. Diabetes Care, 33, Supplement 1, S4.

Type 1 Vs Type 2: How To Tell Them ApartType 1 Type 2

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 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

Atypical Diabetes

• Type 1.5 or Latent Autoimmune Diabetes in Adults (LADA)

• “Double Diabetes”

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

Co-Morbidities Assessment• Skin exam

– Acanthosis nigricans– MRSA– Fungal infections– Wound care– Skin tags

• Dental exam– Gingivitis– Infection

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

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; 675-682.

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

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-2010. Diabetes Care, 33, Supplement 1, S39.

Sensation Exam

• Monofilament PLUS one of the following:– Vibratory– Pinprick– Ankle reflexes

Diabetes Care, Volume 34, Supplement 1, January 2011, Page S8

Foot Exam Sites

• Fewer sites than 10 years ago…

Lab Surveillance

• A1c

• Lipids

• Microalbumin

Anti-platelet Therapy ADA Guidelines• Recommendations for Aspirin

– ASA 75-162 mg/day for 2o prevention– ASA 75-162 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

Lipids

American Diabetes AssociationLDL <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 ProgramLDL <100 mg/dL

(<70 mg/dL in patients at “highest risk”)Non-HDL <130 mg/dL

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

http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm257884.htm

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

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)

Health Maintenance

• Vaccinations– Influenza– Pneumovax

• Smoking cessation– Counseling– Pharmacotherapy

Diabetes Education

• Diabetes 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

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.

Diabetes Prevention Project (DPP)A randomized clinical trial to prevent Type 2

Diabetes that evaluated the efficacy of 3 treatments

Lifestyle (n=1079, p<0.001) vs. Metformin (n=1073, p<0.001) vs. Placebo (n=1082)

Risk reduction31% by Metformin

58% with modest lifestyle change

sustained for 4 years

Incidence of Diabetes

SOURCE: The DPP Research Group, NEJM, 2002;346:393-403

Diabetes Education Resources

http://www.diabeteseducator.org

/DiabetesEducation/Find.html

http://www.diabetes.org/

http://www.cdc.gov/diabetes/

Patient Education

Who’s responsible?

EVERYONE!

LUNCH TIME

Glycemic Control – Oral Agents

Rosita’s A1C

7.5

How The Body Handles Glucose(Fed State)

MUSCLE

FAT

LIVER PANCREAS

INSULIN

BRAIN

Blood Glucose60-90 mg/dLGlucose

90-140 mg/dL

GLUCAGONGLUCAGON

INSULIN

GLUCAGONAMYLIN

GI TRACT

INSULIN

Pathophysiology of Type 2 Diabetes

MUSCLE

FAT

LIVER PANCREAS

INSULIN

Hyperglycemia

BRAININSULIN

GLUCAGONGLUCAGON

INSULIN

GLUCAGON

INSULIN

AMYLINAMYLIN

GI TRACT

A1C < 7%Premeal ~ 100mg/dL

PPG < 200 mg/dL

Pramlintide Dietary CompositionPortion Control-Glucosidase Inhibitors

Weight LossExerciseTZDs(Metformin)

Insulin SulfonylureasGlinidesIncretin tx

MetforminTZDs

General RulesHyperglycemic 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

Glycemic Goals of Therapy

GoalPremeal 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

Verbal Target~100

<<200

As low as

possible w/o unacceptable adverse

effects

Diabetes Care 2009;32:S6-12

Biguanides: MetforminMechanism 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

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

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 OpinionMelander A. Diabetes 2004;53 Suppl 3:S151

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)

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 theirdoctors of rapid or excessive weight gain

Lebovitz H. Diabetes Metab Rev 2002;18:S23Fonseca V. Am J of Med 2003;115:42S

http://www.natap.org/2011/newsUpdates/052111_07.html

TZDs Lipid Effects and Serious Risks

• Rosiglitazone (Avandia)– +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.

• Pioglitazone (Actos)

– +LDL

– +HDL

– -Triglycerides

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

Nesto RW et al. Diabetes Care 2004;27:256

Alpha-Glucosidase Inhibitors: Acarbose And Miglitol

Mechanism of action

– Delay absorption of carbohydrates

– Depend upon postprandial hyperglycemia

Safety and efficacy

– Decrease A1C 0.5-1%

– 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

Incretin-Based Therapies

PROSPreserve beta cell functionWeight loss (GLP-1 mimetics: Victoza and Byetta)Less hypoglycemia risk vs. insulin and SecretagoguesEnhanced postprandial glucose control

CONSExpensiveGI (nausea)May exacerbate renal failureConcern for pancreatitis and thyroid tumors

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

1.Garber AJ et al. Am J Med 1997;103:4912.Nesto RW et al. Diabetes Care 2004;27:256 3.Stenman S et al. Ann Intern Med 1993;118:169

Rosita

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???

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

http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf

Coronary Heart Disease Risk Equivalents

• Symptomatic Carotid Artery Disease

• Abdominal Aortic Aneurysm

• Peripheral Vascular Disease

• In ATP III, Diabetes is considered a CHD Equivalent

http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf

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

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)

http://circ.ahajournals.org/content/119/25/3244.full?sid=74e4098a-f84a-4abd-ad60-647a7da0ca9f. (accessed Aug 11, 2011)

Rosita’s A1C…..

9.1

Management Options

• Medications-maximizing orals and considering injectables

• Lifestyle-including exercise and diet

Beta Cell Function DeclinesUKPDS Data

• Beta cell function declines with time

• 5-10% failure per year

• Eventually Insulin Needed

63% of Patients with Diabetes are Not at ADA A1C Goal <7%

0

20

40

60

80

100

>10%

>9%

>8%

7-8%

<7%

37.2%>8%63%

7%

7.8%

25.8%

37.0%

17.0%

12.4%

% of Subjects

n=404

A1C

Adults aged 20-74 years with previously diagnosed diabetes who participated in the interview and examination components of the National Health And Nutrition Examination Survey (NHANES), 1999-2000

Saydah SH et al. JAMA 2004;291:335

Challenges with AchievingTarget A1C Values

• Challenges• 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

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); 183-189.

What are some common patient concerns when transitioning to insulin?

Common Patient Concerns when Transitioning to Insulin

• Fear of needles or pain from injections

• Fear of hypoglycemia

• Weight gain

Funnel M. Self-management Support for Insulin Therapy in Type 2 Diabetes. The Diabetes Educator 2004;30:274

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

Funnel M. Self-management support for insulin therapy in type 2 diabetes. The Diabetes Educator 2004;30:274

What are your concerns when transitioning a patient to

insulin?

Insulin InitiationProvider Concerns

• Which insulin?

• How much?

• How do I adjust?

• How do I teach?

• How often do I change dosages?

Potential Insulin Regimens

Insulin pump Physiologic/COMPLEX/Flexible

Multiple daily injections

Free mixing - twice daily

Pre-mixed - twice daily

Basal only SIMPLE/Inflexible

How do we balance simplicity and flexibility to achieve glycemic control?

Insulin InitiationAnswers to Provider Concerns

• Normalize the fasting glucose– Fasting FSBS 70-130– 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 70-130 fasting

• Decrease 3 units for fasting < 70

Once Daily Insulin OptionsBasals 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

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); 183-189.

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); 183-189.

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

Oral Meds When Starting Insulin-Pearls

• Secretagogues should be tapered and discontinued

• Sitagliptin is currently only incretin based therapy approved for use with insulin

• http://care.diabetesjournals.org/content/32/1/193/F2.expansion.html -algorithm for type 2 DM

Petznick, Allison. Insulin Management of Type 2 DM. American Family Physician. Volume 84 (2); 183-189

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

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

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

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

15 Gram Carbohydrate Choices

½ cup juice or 2Tbsp raisins or 7 saltines = Glucose Increase

~50 mg/dL

BG

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

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;10:660Gray et al. J Clin Endocrinol Metab 1996;81:1508

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

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

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.

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

http://clinical.diabetesjournals.org/content/25/2/50.full.Accessed August 31, 2011.

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 $2000-3000 per year)

http://clinical.diabetesjournals.org/content/25/2/50.full Accessed August 31, 2011.

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

http://clinical.diabetesjournals.org/content/25/2/50.full Accessed August 31, 2011

Management of Diabetes in the Hospitalized Patient

• Critically Ill: Insulin treatment for persistent BG >180 to maintain a range of 140-180 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.

Rosita

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

• 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

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

SOUND FAMILIAR?

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

Incident Counts & Adjusted Rates, By Primary Diagnosis of ESRD

Early Treatment Makes a Difference

Brenner, et al., 2001

CategorySpot urine collection albumin/

creatinine (microgram/mg creatinine)

Normal <30

Microalbuminuria 30-299

Macroalbuminuria (clinical)

>/= 300

Definitions of Abnormalities In Albumin Excretion

Screening for Chronic Kidney DiseaseIn 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

Diabetes Care, Volume 34, Supplement 1, January 2011, Page S34

Stage 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

Stages Chronic Kidney Disease

Drug Levels With Impaired Renal Function

Drug Level

Time

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

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

Meta-AnalysesDiabetes Care, Volume 34, Supplement 1, January 2011, Page S33

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

WHO -HCT team. World Health Organization. Adherence to Long Term Therapies: Evidence for Action. (2003).