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
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
