Guidelines for Diabetes Management
September 20, 2012
Margaret Pochay RD CDE
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
Pancreas
Cannot Produce Enough Insulin
Body lacks insulin or is unable to use insulin effectively
Diabetes
Muscle and Fat Cells
Cannot Use Insulin
Effectively
Cardiovascular Disease
Type 2 Diabetes
High Blood Pressure
ObesityHigh Blood Fats
Impaired Glucose Tolerance
Insulin ResistanceRelated Conditions
InsulinResistance
Retinopathy: 25x
Complications of Diabetes
End-Stage Kidney Disease:
17x
Heart Disease: 2-4x
Foot/Leg Amputations:
5x
Stroke: 2-6x
Good Diabetes Management results in
• REDUCED macrovascular disease – heart disease– stroke
Results from Diabetes Studies
• REDUCED microvascular disease– eye disease– kidney disease– neuropathy
Changein HbA1C
Microvascular Complications
0
-1
-2
-3
-4
-5
United Kingdom Prospective Diabetes Study (UKPDS)
0
- 5
-10
-15
-20
-25
- 0.9%
- 25%
1% Decrease in HbA1c = 25% Decrease in Microvascular Risk!
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
• 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
Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2003
Targets for Glucose ControlType 1 and Type 2 Diabetes
Fasting/Pre-meal glucose
Post-meal glucose2 hr. after start of meal
Bedtime glucose
A1C
70-130 mg/dL
<180 mg/dL
100-140 mg/dL
<7.0%
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
8% 180
9% 210
10% 240
11% 270
12% 300
13% 330
4% 60
5% 90
6% 120
HbA1cBlood Glucose(mg/dl)
HbA1c and Self-Monitoring Results
7% 150
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.
Pancreas -- stimulates insulin production
Liver -- decreases glucose release
Fat/Muscle -- increases insulin sensitivity
Fat/Muscle -- increases insulin sensitivity
Reduces breakdown of GLP1
Intestine -- slows carbohydrate metabolism
Medications
Insulin
SulfonylureasMeglitinides
Metformin
DPP4 inhibitorThiazolidinediones
Alpha-glucosidase inhibitors
Supplements body’s own insulin
Exenatide (Byetta, Bydureon) and Victoza
•GLP-1 agonist or incretin mimetic
•Synthetic version of salivary protein found in the Gila monster
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
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
Comparison of Human Insulins and Analogs
Insulin Onset of Duration ofPreparations Action Peak (hr) Action (hr)
Lispro/Aspart/Glulisine 5–15 min 1–2 4–5
Regular Human 30–60 min 2–4 6–10
Human NPH ® 2–3 hr 6–10 10–20
Glargine/Detemir 1-2 hr flat ~24
Mixes 5-15 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
Dosing Insulin
• Individual needs to be considered• Type 2 Diabetes: Basal Insulin start 10units
change by 3 units every 3 days fasting blood glucose <70 or >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
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)
Barriers to Insulin Use: Patient Issues
Barriers Solutions
Fear of injections Syringes, pens, and needles vastly improved
Fear of hypoglycemia Low rate of severe hypoglycemia in DM2
Fear of weight gain Glucose control is more important than mild-to- moderate weight gain
Injecting insulin• How:
– Insulin pen– Syringe filled from a bottle of insulin– Insulin pump
• Where:– Abdomen – Thighs– Backs of the upper arms
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
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
• 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