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