Transcript Insulin
Science of Diabetes and Diabetes Management as it Relates to Legal Issues and the Need for Accommodations Daniel Lorber, MD, FACP, CDE Linda Siminerio, RN, PhD John Griffin, JD FIGHTING FOR FAIRNESS Session Outline CAUSE/CLASSIFICATIONS COMPLICATIONS CARE CHALLENGES The prevalence of diabetes current estimates - world* Number of people with diabetes: » 177 million (154 million projected) Top 10 countries (number of people with diabetes): » India, China, USA, Indonesia, Russia, Japan, UAE, Pakistan, Brazil, Italy *Source: WHO Global Burden of Disease U.S. Diabetes Facts 20% increase in past 20 years 70% increase in diabetes in 30-39 yr. age range from 1990-1998 1 in 3 children born in 2003 will get diabetes 125,000 in U.S. under the age of 19 Type 2 in children is increasing 14 million lost work days Annual costs -- $132 billion What is Diabetes? Ancient Greek: “Diabetes Mellitus” » Diabetes: Copious Urine » Mellitus: Sweet Lay Definition: » Abnormally High Blood Sugar American Diabetes Association: » Fasting Blood Glucose above 126 mg/dl » Fasting Blood Glucose above 7 mM CLASSIFICATIONS/ CAUSE What is the Cause of High Glucose in Diabetes? Type 1: Failure of the pancreas to make Insulin: cause = autoimmune Type 2: Resistance of the body to Insulin: cause unknown Both of these are areas of active research in the U.S. and internationally What Kinds of Diabetes are There? Type 1 (Juvenile, Insulin-Deficient) » 10% » Under 40 y.o. » Hereditary Type 2 (Adult Onset, Insulin-Resistant) » 90% » Strongly Hereditary » Associated with Overweight Secondary Diabetes » E.g., medications like cortisone; pancreatitis What is the Cause of High Glucose in Diabetes? How is Glucose Regulated? Meet the Cast: Blood Glucose Brain Fat 100 mg/dl Muscle Intestine Pancreas Liver Effects of Eating Food Blood Glucose Brain Fat 100 mg/dl Muscle Intestine Pancreas Liver Effects of Eating Food Blood Glucose Brain Fat 100 mg/dl Glucose 140 mg/dl Intestine Pancreas Muscle Liver Effects of Eating Food Blood Glucose Brain Fat 100 mg/dl Glucose 140 mg/dl Intestine Pancreas (makes Insulin) Muscle Liver Effects of Eating Food Blood Glucose Brain Fat 100 mg/dl Glucose 140 mg/dl Intestine Pancreas (makes Insulin) Muscle Liver Type 1 Diabetes: Food Blood Glucose Brain Fat 100 mg/dl Glucose 500 mg/dl Intestine Pancreas No Islets, No Insulin Muscle Liver BALANCING ACT Insulin and food must stay in balance » The insulin you inject will work whether you eat or not » Timing and amounts of food are important » If you do not eat enough, your blood sugar (glucose) could go LOW » If you eat too much, your blood sugar could go too HIGH » Physical activity will effect your blood sugar level HbA1c and Glucose 5% 6% GOAL Take Action7% 8% 9% 10% 11% 12% - - - 90 120 150 180 210 240 270 300 CARE How Do You Treat Diabetes? Type 1: » Glucose Monitoring (fingersticks) » Insulin Injections or infusion pump therapy (replacement doses) » Meal Plans » Physical Activity How Do You Monitor Blood Glucose Control? Frequent Blood Sugar Measurements » Fingersticks, multiple times each day Hemoglobin A1c (HbA1c) » Quarterly MONITORING Blood Glucose Meters » Small, lightweight and user friendly » Many varieties available » One size does not fit all » No danger to others MONITORING How often? » Some suggestions: • • • • • Before each meal and at bedtime Fasting and two hours after you eat Before and after each meal Once daily before breakfast Fasting and once more during different times of the day • More often if you are ill, exercising, having a low blood sugar, driving. Always individualized for each person with diabetes! BACK MONITORING How to test? » Wash hands with warm soap and water » Dangle fingers » Prick side of finger » Milk your finger to get a good drop of blood » Do not use the same finger over and over for testing URINE TESTING Done to detect ketones » » » » » Ketones are BAD!! Ketones happen mostly in Type 1 diabetes Type 1: test in the presence of persistent hyperglycemia Should test if consistently high or anytime during illness Moderate or large ketones should be reported to physician immediately Urine testing is NOT used to detect glucose levels or as a measure of diabetes control RAPID-ACTING INSULINS HUMALOG AND NOVOLOG » Work very quickly » Starts working in 15 minutes » Peak 1-1 1/2 hours » Clear SHORT-ACTING INSULIN REGULAR » Works quickly » Starts to work in 1/2 hour » Peaks in 2-4 hours » Should be taken 15-30 minutes before a meal » Clear INTERMEDIATE-ACTING INSULINS NPH and LENTE » Work more slowly » Most often taken with oral medicine » Starts to work 1-2 hours after it is given » Peaks in 6-12 hours » Cloudy » Can be mixed with Humalog, Novolog and Regular LONG-ACTING INSULIN ULTRALENTE and LANTUS » Lasts for 24 hours with little or no peak » Usually taken at bed » Ultralente is cloudy » Lantus(Glargine) is clear » Lantus CANNOT be mixed with any other insulin Insulin Delivery Systems Injectors Injection Aids Pen delivery Insulin Pump Other technology Other Delivery Systems Being Explored Closed-loop insulin pumps Lectin-and polymer-bound systems New routes: inhalation, oral, and transdermal Microencapsulation of islet cells Biohybrid artificial pancreas Pump cannula at portal vein (Disetronic) How Do You Treat Diabetes? Type 2: » Careful Diet; Weight Reduction; Glucose Monitoring » Reduce glucose absorption from gut: (alphaglucosidase inhibitors) » Increase Sensitivity of Liver, Muscle to Insulin: (Thiazoladinediones, Metformin) » Stimulate Insulin Secretion: (Sulfonylureas, Repaglinide) » Insulin: large doses » Physical Activity INSULIN INSULIN » Needed to lower blood sugar levels. » Diet alone or diet and oral medicine did not control your blood sugar levels (type 2) » Does NOT mean your diabetes is worse » What your body needs to keep blood sugar in control Kinds of Oral Medicines Sulfonylureas Biguanides Alpha-glucosidase Inhibitors Insulin-sensitizing agents Meglitinides Type 2 Diabetes: Food Blood Glucose Brain Fat 100 mg/dl Glucose 500 mg/dl Pancreas Intestine Liver, Fat, Muscle Resist Insulin Muscle Liver Oral Medicines Medicines can be used alone, with each other or with insulin. Sulfonylureas and meglitinide. Help the pancreas make more insulin. Biguanides and insulin sensitizers Help the insulin to work better Oral Medicines Sulfonylureas Lower pre-meal blood sugar levels Carbohydrate Inhibitors and Meglitinides Lower after meal blood sugar levels SULFONYLUREAS Help pancreas make more insulin Several different types Do not exchange one for another Side effects » Low blood sugar » Weight gain » Upset stomach BIGUANIDES GLUGOPHAGE » Help keep the liver from putting out too much sugar » Help insulin to work better » Lower cholesterol » Do not cause weight gain » Side effects: diarrhea, nausea and loss of appetite » Do NOT take is liver, kidney problems or heart failure ALPHA-GLUCOSIDASE INHIBITORS PRECOSE AND GLYCET » Work in digestive tract » Block enzymes that break down carbohydrates to sugar » Prevent blood sugar from going up after meal » Side Effects: Bloating, gas, diarrhea » Side effects usually go away after a few months INSULIN SENSITIZERS ACTOS AND AVANDIA » Help your body to use insulin better » May take 2-12 weeks to work » Give medicine a fair trial » Monitor liver functions MEGLITINIDES PRANDIN AND STARLIX » Help pancreas make more insulin » Work in response to blood sugar levels » Take before each meal and snack Oral Medicine Most pills should be taken at mealtime Glucotrol (Glipizide) works best if taken 1/2 hour before a meal Prandin should be taken 15 minutes before a meal Precose and Glycet should only be taken with the first bite of food Benefits of Oral Medicine Lower blood sugar will mean you will feel better Remember not a cure for diabetes The Person with Diabetes must Take medicine every day, eat at planned times, eat meals per appropriate diet. Stay in touch with his/her health team Test blood sugar level to see if the medicine is working COMPLICATIONS Acute Chronic Hypoglycemia Sudden Onset Staggering, Poor Coordination Anger, Bad Temper Pale Color Confusion, Disorientation Sudden Hunger Sweating Eventual Stupor or Unconsciousness Hyperglycemia Gradual Onset Drowsiness Extreme Thirst Very Frequent Urination Flushed Skin Vomiting Fruity or Wine-Like Breath Odor Heavy Breathing Eventual Stupor or Unconsciousness Why Do We Care? Chronic Complications: (Years, Decades) Diabetic Nephropathy: Kidney Failure, Dialysis, Kidney Transplant Diabetic Retinopathy: Blindness Diabetic Neuropathy: Numbness, Impotence, GI Probs, and more Accelerated Cardiovascular Disease: Stroke, Heart Attack, Impotence, Peripheral Vascular Disease (Amputations) Are These Chronic Complications Preventable? Absolutely! » Tight Glucose Control Prevents or Delays Complications. Proven Studies “benefits of intensified control” DCCT (type 1) HbA1c = 1.9% Complications in the DCCT Trial showed profound reduction » Retinopathy » Nephropathy » Neuropathy 76% 56% 60% UKPDS (type 2) HbA1c = 0.9% Intensive therapy… reduced overall microvascular complications by 25% and decreased risk of » retinopathy 21% » microalbuminuria 33% Reduction in microvascular complications seen regardless of primary treatment modality for intensive therapy » insulin, sulfonylureas, or metformin HbA1c and Glucose 5% 6% GOAL Take Action7% 8% 9% 10% 11% 12% - - - 90 120 150 180 210 240 270 300 Decision Support ADA Standards of Medical Care A1C Blood pressure Lipids » LDL » Triglycerides » HDL <7% <130/80 mmHg <100 mg/dl <150mg/dl >40mg/dl Dilated eye exams Foot exam (Monofilament) Microalbumin CHALLENGES CHALLENGES at SCHOOL •Meet both the student’s health and educational needs one at the expense of the other •Blood glucose testing: assistance as appropriate, right to carry equipment •Eating: meals, snacks, treat low blood sugar •Medication: assistance as needed per individual child, right to carry, •Field trips •Extra-curricular activities •Treatment of severe low blood sugar •Testing accommodations at WORK •Right to a job for which the person with diabetes is qualified •Individual assessments not blanket bans •Reasonable accommodation for testing, eating other care needs •Access to supplies and equipment •Modified work schedule