Transcript No Slide Title

Guidelines for Diabetes Management
September 20, 2012
Margaret Pochay RD CDE
How Food is Digested
1. Food enters
stomach
4. Pancreas
releases insulin
5. Insulin unlocks
receptors
6. Glucose
enters cell
3. Glucose enters
bloodstream
2. Food is converted
into glucose
Diabetes
Body lacks insulin or is unable
to use insulin effectively
Pancreas
Muscle and
Fat Cells
Cannot Produce
Enough Insulin
Cannot Use
Insulin
Effectively
Insulin Resistance
Related Conditions
Type 2 Diabetes
Cardiovascular
Disease
Insulin
Resistance
High
Blood Fats
Impaired Glucose
Tolerance
Obesity
High Blood
Pressure
Complications of Diabetes
End-Stage
Kidney Disease:
17x
Stroke: 2-6x
Retinopathy: 25x
Foot/Leg
Amputations:
5x
Heart Disease: 2-4x
Results from Diabetes Studies
Good Diabetes Management results in
• REDUCED microvascular disease
– eye disease
– kidney disease
– neuropathy
• REDUCED macrovascular disease
– heart disease
– stroke
United Kingdom Prospective Diabetes
Study (UKPDS)
Change
in HbA1C
Microvascular
Complications
0
0
-1
-5
-2
- 0.9%
- 25%
-10
-3
-15
-4
-20
-5
-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
Key Numbers in Diabetes Control
• Daily Blood Glucose
• A1C (2-3 month glucose levels)
• Lipids (Blood Fats)
• Blood Pressure (Hypertension)
• Urine Protein (Microalbuminuria)
Targets for Glucose Control
Type 1 and Type 2 Diabetes
Fasting/Pre-meal glucose
70-130 mg/dL
Post-meal glucose
<180 mg/dL
2 hr. after start of meal
Bedtime glucose
100-140 mg/dL
A1C
<7.0%
Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2003
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
HbA1c and Self-Monitoring Results
HbA1c
4%
5%
6%
7%
8%
9%
10%
11%
12%
13%
60
90
120
150
Blood
Glucose
(mg/dl)
180
210
240
270
300
330
Targets for Lipids, Blood Pressure and
Microalbumin
LDL
cholesterol
(mg/dL)
Lipids (Blood Fats) 100
HDL
cholesterol
(mg/dL)
Total
cholesterol
(mg/dL)
Triglycerides
(mg/dL)
>60
<200
<150
Blood Pressure <130/80 mmHg
<30 mg/24 h or
<20 µg/min on a timed specimen or
Microalbumin <30 mg/g creatinine on a random sample
Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2001.
Medications
Insulin
Supplements body’s own insulin
Sulfonylureas
Meglitinides
Pancreas -- stimulates insulin
production
Metformin
DPP4 inhibitor
Thiazolidinediones
Alpha-glucosidase
inhibitors
Liver -- decreases glucose release
Fat/Muscle -- increases insulin
sensitivity
Reduces breakdown of GLP1
Fat/Muscle -- increases insulin
sensitivity
Intestine -- slows carbohydrate
metabolism
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
Preparations
Peak (hr)
Duration of
Action (hr)
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
Lispro/Aspart/Glulisine
Onset of
Action
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
Fear of injections
Fear of hypoglycemia
Fear of weight gain
Solutions
Syringes, pens, and
needles vastly improved
Low rate of severe
hypoglycemia in DM2
Glucose control is more
important than mild-tomoderate weight gain
• How:
Injecting insulin
– Insulin pen
– Syringe filled from a bottle of insulin
– Insulin pump
• Where:
– Abdomen
– Thighs
– Backs of the upper arms
Pen Delivery of Insulin
•Encourages multipledose 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
Summary
• Pathophysiology important part of
educationg patients with diabetes
• 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