Diabetes and Primary Care so0me what old but good

nDiabetes and Primary Care

nVirginia G. Miller, PhD, RN, CS, FNP

nPrimary Care –
Caring for People with Diabetes:
Objectives

nExplain current terminology regarding categories of diabetes.

n

nDescribe lab tests used to diagnose diabetes.

n

nIdentify current diagnostic criteria for diabetes.

n

nDiscuss treatment protocols for persons with diabetes.

n

nBe aware of some innovations in the treatment of diabetes

nSo…What's the Problem??

n34% of the adult population in the US is overweight (BMI = 25.0-29.9)

nAn additional 27% is obese (BMI > 30)

n17 million in US have DM ( -- half are unaware).

n

n120 million worldwide have DM.

n

n300 million will have DM worldwide by 2025 (estimated by the WHO).

n

nDetermining Weight Status

nThe Type 2 Diabetes Epidemic

nDiabetes – Facts & Statistics                                                         5

n90-95% of all diabetes is DMT2*.

n5-10% of all diabetes is DMT1†.

nPrevalence of DMT2 in the US has tripled in last 30 years, primarily due to an increase in obesity.

*Previously called "Adult-Onset DM" or "NIDDM"

†Previously called "Juvenile-Onset DM" or "IDDM"

nHave you seen this woman???

nHow about any of these????

nDiabetes – Facts & Statistics (cont.)

nIncidence of DMT2 is increasing –

namong children & adolescents in the US

nin a direct relationship w/ the ↑ in overweight & obesity among this population (and adults) 

n

nIndividuals w/ “pre-diabetes” have a substantially higher risk of CV disease & death than those w/o

n

nIsn't a "chubby" baby a "healthy" baby?
                                                          10

nIsn't a "plump" kid a "healthy" kid?

nChildhood Obesity

n1999, 13% of children aged 6 to 11 years & 14% of adolescents aged 12 to 19 years in the US were overweight (CDC, 2000).

nThis prevalence has nearly tripled for adolescents in the past two decades.

n"Childhood obesity is at epidemic levels in the US" (US Surgeon General).

nChildhood Obesity

nThe largest increase in pediatric and adolescent obesity has been in certain ethnic populations including African American females, Mexican Hispanics and Native American Indians.
 

nSome of the studies report that 70% of overweight children aged 10 to 13 years will be overweight and obese as adults.  This statistic increases to 80% if one or both parents are overweight or obese.

n

nLeads to (among other problems) DMT2.

nEconomic Impact of DM

nPer capita annual costs of health care for people w/ DM rose from $10,071 in 1997 to $13,243 in 2002

nThis reflects an increase of > 30%, and these data (and the data above) are at least four years old.  Do you think the numbers have declined since 2004?

nHealth care for people w/o DM was ~ $2,560 in 2002.

nKEY FINDINGS: 2013

n$14,999 Per capita spending for individuals with diabetes

n$4,305 Per capita spending for individuals without diabetes

n $1,922 Out-of-pocket spending per capita for individuals with diabetes

n$738 Out-of-pocket spending per capita for individuals without diabetes

nDirect Costs of DM (2002)
15

n

n~ $91.8 billion – 19% of total personal health care expenditures.  Big money items:

nGlucose strips

nMedications

nPreventive/screening checkups

nLab work

n

n~ $40.3 billion spent for in-pt. care, & $13.8 billion for NH care.

nEconomic Impact of DM

n$15,456 Per capita spending for children (ages 0–18) with diabetes

n $16,889 Per capita spending for preMedicare adults (ages 55–64) with diabetes

n$1,361 2013 year-over-year increase in per capita spending for children with diabetes

n$604 2013 year-over-year increase in per capita spending for pre-Medicare adults with diabetes

nIndirect Costs of DM (2002*)

nIndirect costs of diabetes ~ $39.8 billion

n

nDM accounted for a loss of nearly 88 million days due to disability

n

n176, 000 cases of permanent disability were caused by DM – cost of $7.5 billion

   *This was in 2002.  Any reason to believe costs have declined since then?

nCriteria for the Diagnosis of Diabetes (ADA, 2006)

n1. Symptoms of diabetes plus casual plasma glucose > 200 mg/dl.  "Casual" means any time of day w/o regard to time since last meal.  The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.

 

n2. FPG > 126 mg/kl.  Fasting is defined as no caloric intake for at least 8 hrs.*

 

  3. 2-hr post load glucose > 200 mg/dl during an OGTT†.  The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

n

      Abnormal should be confirmed by repeat testing on a different day. 

      *The FPG is preferred because it’s easy, convenient, generally acceptable to people, and costs less than the others.

      †OGTT is not recommended for routine clinical use.

n

nShould the A1c be Used to Diagnose Diabetes?

nClassifications of DM

nClassifications of DM (cont.)
20

nDM1

nAbsolute insulin deficiency

nß-cell destruction

nDM2

nInsulin resistance

nExcess gluconeogenesis (liver)

nRelative insulin deficiency

nClassifications of DM (cont.)

nGDM – any degree of glucose intolerance w/ onset or first recognition during pregnancy.  (50% develop DM after pregnancy.)

n“Pre-diabetes” – IGT & IFG

nMetabolic stage between normal glucose homeostasis & diabetes

nIGT = Abnormal OGTT (At 2-h post load, BG > 140 mg/dl but < 200 mg/dl)

nIFG = FBG is > 110 mg/dl but < 126 mg/dl

nDefinitions:
Normal, Pre-diabetes, and Diabetes

nRFs for Developing DMT2

n

nAge (> 45)

nOverweight (BMI > 25)

nHabitual physical inactivity

n+ FH of DM-2 (parents or siblings)

nPMH of GDM or PCOS

ndelivery of > 9# baby

n

nRFs for Developing DMT2(cont.)

nRace

nNative American (prevalence is 12.2%, though some tribes have a 50% prevalence)

nHispanic American (2.0 times more likely)

nAfrican-American (1.7 times more likely to develop DM than general population)

n

n

n RFs for Developing DMT2(cont.)
25

nPresence of HTN w/ dyslipidemia

nTC > 200 mg/dL,

nLDL > 130 mg/dL,

nHDL < 40 mg/dl &/or

nTG > 250 mg/dl),

nPresence of IGT or IFG

nSuspect Diabetes When…

nCC is "fatigue" (DMT2)

nCC is weight loss, polys, and fatigue (DMT1)

nReport of polys

nReport of nocturia

nHx of frequent/recurrent infections (vaginal, UTI, bronchitis, etc.)

nC/O transient or chronic "blurred vision"

nC/O numbness or tingling in the feet

nEthnicity is Native American or Hispanic (DMT2)

n> 45 yrs of age (…or not.  Age is becoming less and less reliable as a predictor.)

nObese/overweight (DMT2)

n+ FH

nElevated BG

nGlucosuria

nHyperglycemia

nKetonuria (-- generally only in DMT1)

nPresence of acanthosis nigricans (DMT2)

nAcanthosis Nigricans

na hypertrophic hyperpigmentation of the skin most commonly seen on the posterior neck and in skin creases. This condition is associated with insulin resistance, hyperinsulinemia, and an increased risk of developing DMT2.

nHirsutism, associated with the polycystic ovary syndrome, and other conditions is frequently associated with insulin resistance in children and adolescents and may be a forerunner of the future development of DMT2.

n

*Onset of adrenal androgen production

n

nAcanthosis Nigricans

nCharacterized by hyperpigmented, velvety, hyperkeratotic plaques that are most often localized to the --

nneck,

naxillae,

ninframammary areas,

ngroin,

ninner thighs, and

nanogenital region.

nAcanthosis Nigricans

nAcanthosis Nigricans
30

nAcanthosis Nigricans

nScreening Recommendations 

nScreen those with BMI > 25 every three years starting at age 45.

n

nStart screening earlier or screen more frequently in those who are overweight or if other RFs are present.

nScreening Recommendations (cont.)

nScreen overweight youth who have > 2 RFs every two yrs. starting at age 10.

nScreen other high-risk individuals who have a FH of DMT2, belong to racial groups where DMT2 is prevalent, or have signs of insulin resistance:  acanthosis nigricans.

n

nLong-Term Complications of DM*

nCAD:  Adults w/ DM die from CAD at rates 2-4 times greater than adults w/o DM.

n

nStroke:  Risk for stroke is 2-4 times higher among people with diabetes than in the general population.

n

nBlindness:  DM is the leading cause of new cases of  blindness among those aged 20-74 in the US.

*Emphasize that risk of complications increases with A1c; that

complications are more likely to occur in those with A1c above target

(> 7.0%)

nLong-Term Complications of DM
(cont.)
35

nESRD:  DM is the leading cause of ESRD

nNeuropathies:  60-70% of those with DM have mild to severe nervous system damage.

nOrthostatic hypotension

nGastroparesis

nBladder dysfunction

nED

nHypoglycemia unawareness

nAmputations:  > 60% of non-traumatic amputations of the lower-limb in the US occur among those with DM

nComplications of pregnancy:  Poorly controlled DM is associated with major birth defects in 5-10% of pregnancies, & with spontaneous abortions in 15-20% of pregnancies.

nHTN:  Approx. 73% of adults with DM have HTN

n

nBenefits of DM Education
Results of the Diabetes Prevention Program Study of 2002

nParticipants were at risk for developing DMT2.

nThose who made lifestyle changes reduced their risk of developing DMT2 by 58%.

nCornerstones of Control of Diabetes

nHealthy food choices 

nRegular exercise

nBlood glucose monitoring

nSometimes, medication

nDiabetes Control Always Includes These:

nDiabetes Control Sometimes Includes These:

nKeys to Success?
40

nEducation about --

nDiabetes

nWays to obtain and maintain BG control

nWhat to expect of your health care provider

nTests and examinations that are critical to your health

nHaving a good relationship between patient and health care provider

n

nThe Role of the Health Care Provider with the Patient with DM

nDiabetes care is 99.9% self-care

nEducation is critical to success

nSupport is critical to wanting to learn

nApply --

n"Change theory" – Allow pt. to grieve losses

n"Systems theory" – include the family

n"Educational theories" – start where learner is

nTheories of self-efficacy

nPrinciples of empowerment, etc.

nThe Role of Research in Diabetes Care

Mid-1980s:  Primary research question:

What difference does blood glucose

control make in terms of the risk of

long-term, vascular-related complications?

nThe "DCCT" -- 1993

nDiabetes

nControl and

nComplications

nTrial

nGood News for Type 1 Diabetes

nUKPDS – 1998
45

nUnited

nKingdom

nProspective

nDiabetes

nStudy

nGood News for Type 2 Diabetes

nDCCT's & UKPDS's Conclusions

nBG control is important!

nReducing HBG A1C is CRITICAL!

n¯ nephropathy (ESRD)

n¯ retinopathy (PDR)

n¯ neuropathy

n¯ CV/cerebrovascular diseases

n¯ PVD

n­ quality & quantity of life

n

n

nA1c Blood Test

n

nADA’s Clinical Practice Recommendations for Glycemic Control
50

     Index           Goal (mg/dL) 

 

  Peak ac BG             90-130 

  Peak pc BG      < 180

  HS BG (mg/dl)            100-140 

  A1c                    <7 span="">

       *AACE’s goal is 6.5%         

nMinimum Standards of Care
 for People with DMT2

nComplete H&P – 1st, only

nWeight – q visit

nBP – q visit

nDilated funduscopic retinal exam – “shortly after initial diagnosis” & then q yr

nFoot exam – q visit

nDental inspection – q visit

nHgb A1C – q 6 mos

nLipid profile -- q year

nMicroalbuminuria – q year

nDiabetes education – q visit

n

n

nResults of Research/Clinical Trials: 
Improvement in Diabetes Care

nResults of Research/Clinical Trials: 
Improvement in Diabetes Care (cont.)

nContinuous glucose monitoring systems:

nMiniMed’s “CGMS”

nCygnus’ “Glucowatch”

nOngoing development of OHAs

nNew injectables

nNew class:  "Incretin Mimetics" – exanatide (Byetta®)

nSynthetic amylin (hormone) – pramlintide (Symlin®)

nNewer insulins:

nHumalog/Novolog – “Rapid”-est

nLantus – “The Pumper’s Holiday”

n

nByetta – Synthetic Version of a Hormone in the Saliva of the Gila Monster

nInjectable Exenatide
(Byetta®)
55

nInjectable Symlin
(pramlintide acetate)

WARNING

nSYMLIN is used with insulin and has been associated with an increased risk of insulin-induced severe hypoglycemia, particularly in patients with type 1 diabetes. When severe hypoglycemia associated with SYMLIN use occurs, it is seen within 3 hours following a SYMLIN injection.

nIf severe hypoglycemia occurs while operating a motor vehicle, heavy machinery, or while engaging in other high-risk activities, serious injuries may occur. Appropriate patient selection, careful patient instruction, and insulin dose adjustments are critical elements for reducing this risk.

nInhalable Insulin? -- Exubera

Adult dosing in the treatment of diabetes*:

nInitial pre-meal doses: body weight (kg) X 0.05 mg/kg = pre-meal dose (mg); round the dose down to the nearest whole number, such as 5.8 mg rounded down to 5 mg
 

nMaintenance: dosing is individualized per patient needs

n

*Safety and efficacy have not been established for use in the pediatric population

n

nSome Innovative Ways to Take Insulin

nProtocols for Care of Persons With DM

nStep-Wise Treatment of DMT2
60

n

nIs FBG < 250?  Start at Stage I.

n

nIs FBG > 250 but < 400*?  Start at Stage II. (* W/O dehydration, acidosis, or marked ketosis)

nIs FBG >250 with dehydration, acidosis or marked ketosis?  Send to the emergency room for intensive insulin therapy!

Note:  This slide is a revision of the slide posted earlier.  Delete the earlier

posting.

nWhat if BG is VERY high!

…Severe hyperglycemia can develop in either DMT1 or DMT2

Note:  This slide is not in your file.

nHHNK State/Coma = HHS

nHyperglycemic Hyperosmolar Nonketotic (HHNK) is now called "HHS" – Hyperglycemic Hyperosmolar State

nHallmarks are --

nsevere hyperosmolarity (>320 mOsm/L) and

nhyperglycemia (>600 mg/dL)

nPossible causes –

novereating

ninfection – May also result in DKA.

nEither HHNK/HHS or DKA is an emergent condition which requires hospitalization for fluid resuscitation, electrolyte replacement/monitoring, and insulin therapy.

Note:  This slide is not in your file.

nBack to the Main Topic:

nStep-wise treatment of DMT2

n

n

n

n

n

nNote:  This slide is not in your file.

n

n     Stage I

nStage I (continued)
65

nWeight loss ® ¯ insulin resistance (greater sensitivity)

nWeight loss = key to success in Stage I.

n

nIf goals are not reached in 3 months (max), go to Stage II.

n

Note:  This slide includes the correction of a typo.  See bullet #3 above

which WAS "in 2 months (max)" and has been corrected to "in 3 months

(max)".

n

nStage II

nContinue LSM.

n

nAdd one oral agent (mono-therapy).  This is usually metformin (AKA Glucophage®), unless contraindicated.

nOral Medications for Type 2 Diabetes: Biguanides

nStage II (continued)

nBiguanide

nmetformin (Glucophage) is DOC in many cases, esp. if pt. is obese. 

nResearch is suggesting better success if metformin is started w/ another oral agent (combination drugs):  Glucovance (glyburide & metformin), Metaglip (glipizide & metformin)

n

nCombination drugs may actually cost less than two separate prescriptions!

nRegular LFTs required due to risk of lactic acidosis.  Cannot be used in persons w/ liver or renal insufficiency.  Not DOC in elders.

n

n

n

nOral Medications for Type 2 Diabetes: Sulfonylureas

nStage II (continued)
70

nSulfonylureas (2nd-generation)
 

nCaution in those w/ allergy to sulfa.

n

nOral Medications for Type 2 Diabetes: Meglitinides

nStage II (continued)

nNon-sulfonylurea secretagogues –  "Meglitinides":  repaglinide (Prandin), nateglinide (Starlix) –

nstimulate insulin secretion

ntarget post-prandial hyperglycemia

ntaken 30” ac.  Do not forget to eat!! 

nCan cause significant hypoglycemia!

n

n

nOral Medications for Type 2 Diabetes: Insulin Sensitizers

nStage II (continued)
74

nThiazolidinediones ("TZDs")

n“Insulin Sensitizers”= newest agents ($$)

nRegular LFTs required.  Cannot be used in persons w/ liver or renal insufficiency.

nContraindicated or listed under “Precautions” for those w/  CHF.

n

n

nOral Medications for Type 2 Diabetes: Alpha-Glucosidase Inhibitors

nStage II (continued)

nAlpha-glucosidase inhibitors –

ntarget post-prandial hyperglycemia (so they delay digestion of CHO – specifically sucrose). 

n

nGI effects are BAD!  BAD!  BAD! (Can buffer GI effects by starting with lower dose & reducing amount of CHO ingested).

n

nIn persons taking these drugs, do not treat hypoglycemia w/ sucrose (table sugar)!

n

nStage II (continued)

nStage II (continued)

nIf goals aren’t reached by 2-4 wks, move to Stage III.

n

nUp to 40% respond poorly to oral agents, particularly the sulfonylureas -- 1° & 2° failure

nPrimary failure = w/in 3 mos (30%)

nSecondary failure = w/in 2 yrs (10%)

n50% fail by 10 yrs

n

n“Failure” = reappearance of persistent hyperglycemia despite max. dosing of agent.

nStage III
80

nAdd 10 U* of HS insulin

n(Insulin glargine (Lantus) is recommended, but NPH or Lente may also be used – recognize risk of nocturnal hypoglycemia w/ intermediate-acting insulins).

nMay be able to wean off insulin after initial hyperglycemia is controlled.

n

nIncrease dose by 3-5 U every 3-4 days until FBG control is achieved.

n

*Or calculate 0.10-0.25 U/Kg of body weight

n

nTypes of Insulin

nLong-Acting Insulins

nStage III (continued)

nIf BG remains poorly controlled after 3 mos. (i.e. A1C remains > 7.0%), d/c oral agents & move to Stage IV (Intensive Insulin Therapy*).

n

nKey to success w/ each stage is securing adequate, reliable data from the patient = Self-Blood Glucose Monitoring (SBGM) performed & recorded correctly.  Important also to get 3 a.m. BG when pt takes evening or HS insulin.  (Negotiate w/ pt. to obtain HS then 3 a.m. BG periodically).

n

nPt. must understand risks of hypoglycemia – S/S, how to prevent, how to treat.

*NPH insulin before breakfast, before supper, or at HS, or glargine insulin (Lantus® daily (at the same time daily), plus

fast-acting insulin before each meal (based on individually determined insulin sensitivities and carbohydrate-to-insulin

ratios).  Clearly, this person needs to be referred to and followed by a specialist.

Note:  This slide is a revision of the slide posted earlier.  Delete the earlier posting.

n"My Glucometer is a Vital Tool"

nSMBG "snap shot" vs.

nTrend marker

nTexas Diabetes Council
-- An Excellent Resource --

n

nSee algorithms (related to primary care of individuals with diabetes) at the following site.

n

http://www.dshs.state.tx.us/diabetes/hcstand.shtm

nPublic Health Safety Issue:
85

Safe disposal of insulin syringes and

lancets:

http://www.safeneedledisposal.org/

nSummary of ADA Recommendations for Adults with DMT2

nGlycemic control

nA1C  < 7.0%

nPreprandial BG  90-130 mg/dl

nPeak postprandial BG  < 180 mg/dl

nBP  <130 hg="" mm="" span="">

nLipids

nLDL  < 100 mg/dl

nTG  < 150 mg/dl

nHDL  > 40 mg/dl 

nAdopt a Healthy Lifestyle

nSchedule Regular Visits with Diabetes Care Providers

nPeripheral Neuropathy in Diabetes -- Foot Ulcer
Is it Possible for the Patient to Miss This???
89

nInspect Feet Every Day

nAn Annual Foot Exam is a Must!

nDetect Eye Problems in Diabetes Early

nDetect Kidney Problems in Diabetes Early

nTreating Co-Morbidities in People with DM

nRecognize that systemic corticosteroids lead to significant hyperglycemia in those with DM, and can create metabolic acidosis in the individual with DMT1.

nDecadron

nKenalog

nAvoid using them if at all possible

nResearch About New Ways to Administer Insulin
95

nEmisphere® Technologies, Inc. – oral insulin tablets

(Usefulness in lowering BG is being studied)

n

nTexas Department of State Health Services'*
"Texas Diabetes Council"
97

nhttp://www.dshs.state.tx.us/diabetes/

nThe Texas Diabetes Council addresses issues affecting people with diabetes in Texas and advises the Texas Legislature on legislation that is needed to develop and maintain a statewide system of quality education services for all people with diabetes and the health care professionals who care for them.

n

nVision: A Texas free of diabetes and its complications

n

nMission: To effectively reduce the health and economic burdens of diabetes in Texas

n

nNational Diabetes Education Program (NDEP)
 http://www.ndep.nih.gov/
98

na federally funded program sponsored by the U.S. DHHS' NIH and CDCP

nincludes over 200 partners at the federal, state, & local levels, working together to reduce the morbidity & mortality associated with diabetes.

n