Download UPDATE ON DIABETES MANAGEMENT

UPDATE ON DIABETES
MANAGEMENT
Naushira Pandya M.D., CMD
Associate Professor and Chair
Nova Southeastern University College of Osteopathic
Medicine
Ft. Lauderdale, Florida
Objectives





Address the epidemiology and disease burden
of diabetes in long-term care
Review existing geriatric guidelines on the care
of elders with diabetes
Explore existing practices by long-term care
providers
Evaluate the management and risks of
hypoglycemia
Facility management of diabetes and the role of
the Medical Director
Duration of Diabetes, Life-Years Lost, and QualityAdjusted Life-Years Lost Among Females
Age at Diagnosis,
years
Duration
Life-Years Lost
QALYs Lost
Total
10
55.5
19.0
32.8
20
46.7
17.9
29.6
30
38.4
16.5
26.1
40
30.8
14.3
22.0
50
23.5
12.1
18.0
60
17.0
9.5
13.8
70
11.8
6.5
9.4
80
7.1
4.1
5.9
Narayan K. et al., JAMA 2003; 290:1884-1890.
INCREASED MORTALITY IN ELDERS WITH
DIABETES
Standardized mortality ratio in 131,535 US elders with diabetes
Versus general US population aged >65y
Bertoni, Krop at al. Diabetes Care;25(3):2002
Prevalence of Diabetes in Nursing Homes
40
32
30.6
% 30
20
10
0
13.4
14
9.9
7.2
Mooradian Grobin Funnell Benbow Sinclair SLU
1988
1989
1995
1997 1997 2000
The Scope of the Problem in LTC



Diabetes is associated with increased fall
prevalence in LTC Maurer MS et al. J Gerontol 60(9);2005
Diabetes associated with higher mortality in
women (RR 2.42) Keily DK. JAMDA 1(1); 2000
Blacks and Hispanics have lower rates of
antidiabetic medication use Ethnicity and Disease
15(2);2005


Higher rates of cardiovascular disease and
depression
Greater degree of functional impairment and
dependancy
Burden of Diabetes in LTC

Analyses of nursing home residents with
diabetes at admission.
Travis, Shirley S. Buchanan, Robert J. Wang, Suojin. Kim, MyungSuk.
Journal of the American Medical Directors Association. 5(5):320-7, 2004 Sep-Oct.




All admission assessments in the MDS recorded throughout the
United States during 2002 to identify 144,969 residents with
diabetes, or 26.4% of all admissions.
Only approximately one fourth of residents with diabetes were
projected to have stays in the facility of 90 days or less when
admitted.
Heart and circulatory comorbidities were common among
residents with diabetes at admission, as was depression.
More than half of residents with diabetes were in pain at
admission. .
Burden of Diabetes in LTC….




A majority of residents with diabetes were either totally
dependent or required extensive assistance in the selfperformance of many ADLs
More than one third were at least moderately impaired in
cognitive performance.
CONCLUSIONS: Residents with diabetes could be one
of the most "heavy care" groups in nursing facilities, as
demonstrated by their levels of functional disability and
prevalence of serious comorbid conditions.
The care provided to residents with diabetes should
address depression, pain, and low rates of advance care
planning.
Geriatric syndromes more prevalent in
persons with diabetes






Polypharmacy
Depression
Cognitive impairment
Urinary incontinence
Injurious falls
Pain
ADDITIONAL COMPLICATIONS OF
DIABETES IN FRAIL ELDERLY







Increased susceptibility to infections
Delayed wound healing
Worsening cardiac ischemia/ silent ischemia
Recurrent CHF
Oral dryness, infections, burning, caries,
periodontal disease
Urinary retention, UTI’s
Weight loss
Diabetes and cognitive decline?





Several case controlled and population-based studies have
shown a clear relationship between diabetes, cognitive
decline, and dementia (Framingham, AWARE,Rotterdam,
Honolulu Heart Study, CV Health study)
Diabetes and HTN positively associated with cognitive
decline over 6 yr in 47-70 yr olds independent of smoking,
carotid intimal wall thickness, lipid levels
Interventions aimed at diabetes and HTN below age 60 may
lessen the burden of cognitive impairment in later life
Mechanism (other than overt CVA) is probably
demyelination, microinfarction in the white matter, and
cortical atrophy
LTC study (Tariot JAGS Apr 1999); diabetics more likely to
have a diagnosis of vascular dementia than non-diabetics
Depression and Diabetes
Geriatric Depression Score
Diabetes and Outcomes
Rosenthal & Morley, Diabetes Care, 1998.
Mortality
Hospitalization
No
Yes
P
7.4
6.7
15.8
9.2
<0.001
<0.001
Diabetes Mellitus is Associated with Increased
Likelihood of Developing Pressure Ulcers
Brandeis et al. Adv in Wound Care 8:18-25, 1995.
Spector. J Invest Dermat 102:425-55, 1994.
Brandeis et al. J Am Geriatr Soc 42:388=93, 1994.
Early decrease in skin blood
flow
in response to locally applied
pressure in diabetic subjects.
Diabetes 51(4). April 2002
REASONS FOR MAINTENANCE OF
EUGLYCEMIA IN DIABETICS




Prevention of hyperglycemic comas
Prevention of long term complications
Prevention of fluid and electrolyte imbalance
Prevention of glucose toxicity
1.Accelerated aging
2.Trace mineral deficiency
3.Infection
4.Dehydration
5.Incontinence/nocturia
6.Pain
Summary of Revisions to Standards of
Medical Care for Diabetes (ADA) Diabetes Care 29:S3 2006

Assessment of glycemic control
 Use of point-of-care testing for HbA1c (A1C) allows for timely decisions
on therapy changes, when needed (E)

Glycemic goals
 The A1C goal for patients in general is <7% (B)
 The A1C goal for the individual patient is an A1C as close to normal
(<6%) as possible without significant hypoglycemia (E)

Nephropathy
 To reduce the risk of nephropathy, protein intake should be limited to the
Recommended Dietary Allowance (RDA) (0.8 g/kg) in those with any
degree of chronic kidney disease (CKD) (B)
 Serum creatinine should be measured at least annually for the
estimation of glomerular filtration rate (GFR) in all adults with diabetes
regardless of the degree of urine albumin excretion. The serum
creatinine alone should not be used as a measure of kidney function but
rather used to estimate GFR and stage the level of CKD (E)
Guidelines for Improving the Care of the
Older Person with Diabetes Mellitus
California Healthcare Foundation/American Geriatrics Society Panel
on Improving
Care for Elders with Diabetes



For older persons, target HB A1C(A1C) should be
individualized.
A reasonable goal for A1C in relatively healthy adults with
good functional status is 7% or lower.
For frail older adults, persons with life expectancy of less
than 5 years, and others in whom the risks of intensive
glycemic control appear to outweigh the benefits, a less
stringent target such as 8% is appropriate. (IIIB)
Wisconsin Essential Diabetes Mellitus
Care Guidelines
Revised 2004
Glucose Tolerance Categories
FPG
Plasma glucose
(mg/dL)
2-h PPG (OGTT)
240
Diabetes
Mellitus
220
200
180
Diabetes
Mellitus
160
140
126
120
IGT
IFG
100
Normal
80
Normal
60
American Diabetes Association. Diabetes Care. 2004;27(suppl 1):S5-S10
8
IFG and IGT
Intermediate Between Normal and
Diabetes
Impaired Fasting Glucose (IFG)
 FPG 100 but 126 mg/dL
 Predicts increased risk
of diabetes and microand macrovascular
complications
Impaired Glucose Tolerance (IGT)
 2-h PG on OGTT
140 but 200 mg/dL
 Predicts increased risk of
diabetes and cardiovascular
disease
9
DIABETES AND DIET



There is no longer a “diabetic diet”
Consistent carbohydrate content, portion size, increased fiber,
and nutritional adequacy are important
Avoid dietary restrictions (especially fat)
- reduces quality of life
- may lead to undernutrition in patients with
depression, dependancy, chewing difficulty, and
functional disability

“No concentrated sweets” diet is inappropriate
- does not significantly improve glycemic control.
Tariq, J Am Diet Assoc 2001, 101(12)

Adjust oral agents and/ or insulin to balance food consumption
The Role of Special Supplements- GLUCERNA
Glucose concentration at 120 min after
interventions.
N=14 (single blind cross over trial of Ensure
High Calcium and Glucerna in young adults)
Diab Obes Metab;May 2006
Insulin sensitivity after interventions.
Older adults preferred the flavor of Glucerna
SR vs. Resource Support in another study.
N=456 Nutricion Hospitalaria; Sept 2004
Neutral on glucose and triglyceries in 63
tube-fed hospitalized pts
J Parent Gut Nutrition;Jan-Feb 2005
Oral Antihyperglycemic Agents
for Type 2 Diabetes
Class
Agents
Secretagogue
Sulfonylureas
Repaglinide, nateglinide
Biguanide
Metformin
α-Glucosidase inhibitor
Acarbose, miglitol
Glitazone (TZD)
Pioglitazone, rosiglitazone
DPPIV inhibitors
Sitagliptan
Antihyperglycemic Agents
Major Sites of Action
-Glucosidase inhibitors
–
Glitazones
Plasma glucose
Carbohydrate absorption
GI tract
Metformin
Secretagogues
+Glucose uptake
+
–
+
Muscle/Fat
Glucose production
Liver
–
Insulin secretion
Pancreas
–
Injected
insulin
+
Oral Antihyperglycemic Monotherapy
Maximum Therapeutic Effect on A1C
Nateglinide
Acarbose
Repaglinid
Rosiglitazon
e
Pioglitazone
Glimepirid
e
e
Glipizide GITS
Metformin
0
-0.5
-1.0
-1.5
Reduction in A1C (%)
Diabetes Care. 2000;23:202-207; Precose (acarbose) package insert; Drugs. 1995;50:263-288;
J Clin Endocrinol Metab. 2001;86:280-288; Diabetes Care. 2000;23:1605-1611; Diabetes Care. 1996;
19:849-856; Diabetes Care. 1997;20:597-606; Am J Med. 1997;102:491-497
-2.0
Mechanism of Action of Sitagliptin
Ingestion
of food
GI tract
X
Inactive
GLP-1

Pancreas
Release of
active incretins
GLP-1 and GIP
JANUVIA
(DPP-4
inhibitor)
Glucose
dependent
 Insulin
(GLP-1and
GIP)
DPP-4
enzyme
Beta cells
 Blood glucose
in fasting and
postprandial
states
Alpha cells
Glucosedependent
 Glucagon
(GLP-1)
Inactive
GIP
 Glucose
uptake by
peripheral
tissue
 Hepatic
glucose
production
Incretin hormones GLP-1 and GIP are released by the
intestine throughout the day, and their levels  in
response to a meal.
Concentrations of the active intact hormones are increased by JANUVIA™ (sitagliptin
phosphate), thereby increasing and prolonging the actions of these hormones.
Clinical Pharmacology of
Sitagliptan(JANUVIA™)
 Pharmacodynamics

Leads to inhibition of DPP-4 activity for a 24-hour period in
patients with type 2 diabetes, resulting in:

2- to 3-fold  in circulating levels of active GLP-1 and GIP
 glucagon concentrations

 responsiveness of insulin release to glucose




 plasma levels of insulin and C-peptide
 fasting glucose and  glucose excursion after an oral glucose
load or a meal
In healthy subjects, sitagliptan did not lower blood glucose or
cause hypoglycemia
Indications and Usage of Sitagliptan
Monotherapy
 Adjunct to diet and exercise to improve glycemic control in
patients with type 2 diabetes mellitus
 Combination therapy
 To improve glycemic control in combination with metformin
or a PPAR agonist (e.g., thiazolidinediones) when the
single agent alone with diet and exercise does not provide
adequate glycemic control
 Important limitations of use
 Sitalgliptan should not be used in patients with type 1
diabetes or for the treatment of diabetic ketoacidosis

PPAR=peroxisome proliferator-activated receptor gamma.
S
e
c
t
i
o
n
Dosage and Administration
2
The recommended dose of JANUVIA is 100 mg once daily
as monotherapy or as combination therapy with
metformin or a
PPAR agonist.
Patients With Renal Insufficiency*,†
50 mg once daily
25 mg once daily
Moderate
Severe and ESRD‡
CrCl 30 to <50 mL/min
(~Serum Cr levels [mg/dL]
Men: >1.7–≤3.0; Women: >1.5–≤2.5)
CrCl <30 mL/min
(~Serum Cr levels [mg/dL]
Men: >3.0; Women: >2.5)
Assessment of renal function is recommended prior to initiation
of JANUVIA and periodically thereafter.
*JANUVIA can be taken with or without food.
†Patients with mild renal insufficiency—100 mg once daily.
‡ESRD = end-stage renal disease requiring hemodialysis or peritoneal dialysis.
Summary of
Oral Antihyperglycemic Agents





Five major classes of oral agents acting at different sites
are available
Fasting and preprandial glucose are reduced by sulfonylureas, repaglinide,
metformin, and glitazones (TZDs), with lesser effects on postprandial
increments
Postprandial glucose increments are reduced best by
-glucosidase inhibitors and nateglinide
A1C reductions are similar using sulfonylureas, metformin,
and glitazones
Secondary failure to monotherapy routinely occurs
Algorithm on treatment of T2DM based on degree
of hyperglycemia
Algorithm
based on
pathology for
T2DM
patients with
mild or
moderate
hyperglycemia
after diet and
exercise
Pathophysilogically based
treatment
algorithm for
T2DM patients
with severe
hyperglycemia
American Heart
Association and
American
Diabetes Assoc
algorithm for
TZD use and
Heart failure
Efficacy of Oral Antihyperglycemics
Declines With Time




A1C rises at ~0.2% to 0.3% yearly on stable therapy
This rate is the same as for diet alone, sulfonylureas,
and metformin
-Cell function declines at the same rate with all
these treatments
Combination treatments are routinely needed
UKPDS Group. Diabetes. 1995;44:1249-1258; Turner RC et al. JAMA. 1999;281:2005-2012
Improved glycemic control over conventional therapy was attained
with either insulin initiation or early addition of insulin to
sulfonylureas if glycemic targets were not met
WHEN TO USE INSULIN IMMEDIATELY






Marked hyperglycemia OR
Significant weight loss OR
Severe symptoms OR
> 2+ ketonuria
Diabetic ketoacidosis, hyperosmolar state OR
Severe intercurrent illness, surgery (CABG)
Insulin Preparations
Class
Agents
Human insulins
Regular, NPH
Insulin analogues
Aspart, glulisine, lispro, glargine
Premixed insulins
Human 70/30, 50/50
Humalog mix 75/25
Novolog mix 70/30
Action Profiles of Insulin Analogues
Plasm
a
insuli
n
levels
Aspart, glulisine, lispro 4–6 hours
Regular 6–8 hours
NPH 12–20 hours
Ultralente 18–24 hours
Glargine 24 hours
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hours
Human Insulins and Analogues
Typical Times of Action
Insulin
Preparation
Onset of
Action
Peak
Duration of
Action
1–2 hours
4–6 hours
Human regular
30–60 minutes 2–4 hours
6–8 hours
Human NPH,
lente
2–4 hours
4–10 hours
12–20 hours
Human
ultralente
4–6 hours
8–16 hours
18–24 hours
Glargine,
Detemir
2–4 hours
Flat
~24 hours
Aspart,
~15 minutes
glulisine, lispro
Which basal insulin?
Once daily bedtime NPH or glargine systematically titrated to give
fasting glucose <100mg/dl achieves similar glycemic control
Significant
reductions
in nocturnal
hypoglycemia in
patients treated with
insulin glargine
compared to NPH
insulin
Efficacy and Safety of Insulin Glargine
in Elderly Patients: A1C Levels at Week
Baseline
T2DM
24
24 Weeks
-1.54
12
-1.13
-1.01
65-74
≥ 75
A1C (%)
10
8
6
4
2
0
<65
Age (y)
No statistically significant differences was found between groups at baseline.
P<0.01, <65 vs 65-74 years and <65 adjusted for study arms, body mass index, baseline glycosylated
hemoglobin (A1C), use of sulfonylurea and metformin, and thiazolidinedione discontinuation at week 24.
Abstracts of the 66th Scientific Sessions of the ADA. Diabetes. 2006; 55(suppl 1): A114 Abstract 480-P.
Study: GOAL A1C
Insulin Glargine Versus Premixed Insulin in
Elderly Patients: A1C Reduction
T2DM
Adjusted Mean
Decrease in A1C (%)
0.0
Insulin Glargine
+ OADs
Premixed Insulin
-0.5
-1.0
-1.44
-1.5
-1.90
-2.0
P=0.003
Janka H, Plewe G, and Busch K. J Am Geriatr Soc.2007;55:182-188.
Insulin Glargine Versus Premixed Insulin in
Elderly Patients: Patients Achieving Glycemic
Control
T2DM
P=0.0057
60
Patients (%)
50
55
40
30
30
20
10
0
Insulin Glargine
+ OADs
Premixed Insulin
Janka H, Plewe G, and Busch K. J Am Geriatr Soc.2007;55:182-188.
Insulin Glargine Versus Premixed Insulin in
Elderly Patients: Hypoglycemic Episodes
T2DM
Episodes per Patient-Year
12
P=0.01
11.39
Insulin Glargine
+ OADs
Premixed Insulin
10
8
6
5.59
4
P=0.26
2
0.39
0
All Types
0.71
Nocturnal
Janka H, Plewe G, and Busch K. J Am Geriatr Soc.2007;55:182-188
Initiation of basal insulin

Continue oral agent if tolerated and no specific
contraindications




Keep metformin dose up to 2000mg/d
Reduce pioglitazone to 15-30mg/g and roziglitazone to 24mg/d
Reduce sulfonylurea to 50% of dose (if glyburide,
substitute to different sulfonylurea or meglitinide)
Start insulin 10 units



Glargine at bedtime or same time
NPH at bedtime or twice daily
Detemir at bedtime or twice daily
What dose of insulin?



Basal insulin: start 10 U/d bedtime NPH or Glargine (whatever time
preferred)
Titration: e.g., in Treat-to-Target trial FPG goal was <100 m/dl and doses
titrated weekly
Bolus (prandial) insulin: start rapid acting analog 0.1
U/kg
Advance Basal Insulin plus Prandial
Insulin at Main Meal


Continue basal insulin weekly self-titration
Consider adding prandial insulin at main meal



if FPG consistently lower than 100mg/dl and
HbA1c remains higher than 7%
Cannot increase further basal insulin without
hypoglycemia
Basal insulin dose is more than 100 units
Management of Hyperglycemia
Advancing to Two Injections
Consider when FPG acceptable but A1C >7% on one injection


Insulin options
 To bedtime NPH, add morning NPH
 To suppertime premix, add morning premix
 To glargine, add regular, aspart, or lispro to main meal
Oral agent options
 Usually stop sulfonylureas
 Continue metformin for weight control?
 Continue glitazones for glycemic stability?
Riddle MC. Endocrinol Metab Clin North Am. 1997;26:659-677
Split-Mixed Regimen
Human Insulins
NPH
Regular
U/mL
100
B
NPH
Regular
L
D
80
Normal pattern
60
40
20
0600
0800
1200
1800
Time of day
B=breakfast; L=lunch; D=dinner
2400
0600
Multiple Daily Injections
Human Insulins
NPH
Regular Regular
U/mL
100
B
L
Regular
NPH
D
80
60
Normal pattern
40
20
0600
0800
1200
1800
Time of day
B=breakfast; L=lunch; D=dinner
2400
0600
Basal-Bolus Insulin Treatment
With Insulin Analogues
Lispro, glulisine, or aspart
U/mL
100
B
L
D
80
Glargine
60
40
Normal pattern
20
0600
0800
1200
1800
Time of day
B=breakfast; L=lunch; D=dinner
2400
0600
Typical Daily Insulin Requirements in Adults



Total daily dosage affected by body size, adiposity, physical
activity, and remaining endogenous insulin
Daily dosage usually 0.3 to 0.8 U/kg in adults*
Daily dosage usually 50% basal / 50% bolus insulin
Example
Patient
Dosage
50 kg (110 lb) active
12–24 U/day
70 kg (154 lb) somewhat active
30–40 U/day
100 kg (220 lb) obese inactive
80–120 U/day
*Children and adolescents may need 1.0–1.5 U/kg
Leahy JL. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New
York, NY: Marcel Dekker Inc; 2002:87-112
CLINICAL SITUATION
SUGGESTED INSULIN
REGIMEN
Adding insulin to an oral
agent(s)
Intermediate
Risk of nocturnal
hypoglycemia
Long-acting
acting NPH
Long-acting or basal q hs
(glargine or detemir)
Pre-supper insulin mixture
(75/25 lispro, 70/30)
or basal q hs
(glargine or detemir)
CLINICAL SITUATION
SUGGESTED INSULIN
REGIMEN
Well controlled
Bid
Poor control
Bid
split mixed (NPH and
regular)
Bid insulin mixture (70/30 or
75/25 lispro)
spilt mixed (NPH and
regular)
Rapid-acting lispro ac + NPH 1-2
times a day
Short-acting regular ac + NPH 12 times a day
Rapid-acting lispro ac + longacting or basal q hs (glargine)
CLINICAL SITUATION
SUGGESTED INSULIN
REGIMEN
Tube feedingContinuous
Intermediate
Tube feedingNocturnal
Intermediate
acting NPH
q 12 h
Long acting or basal q hs
(glargine)
Addition of short acting
regular q 6 h
acting NPH
q PM or HS
Supper time insulin mixture
70/30 or 75/25
New Therapies in Clinical Development



Fat absorption blocker─orlistat (Xenical®)
 Oral intestinal lipase inhibitor
 Approved for obesity, proposed for diabetes
Amylin analogue─pramlintide (Symlin™)
 Slows gastric emptying, suppresses glucagon, increases
satiety
 Requires injection
GLP-1 analogues/agonists─exendin-4, Betatropin™
 Potentiate insulin secretion, suppress glucagon
 May promote -cell neogenesis
 Require injection
GLP-1=glucagon-like peptide
The Incretin Effect: Beta cell response to oral
Vs IV glucose
GLP-1 secreted upon
the ingestion of food
Multihormonal Regulation of Glucose
APPEARANCE AND DISAPPEARANCE
Brain
Food
Intake
—
•Insulin helps
regulate glucose
Gastric
Emptying
—
Liver
disappearance
Stomach
Postprandial
Glucagon
Rate of
glucose
appearance
•Amylin helps
Plasma Glucose
Amylin
Insulin
Rate of
glucose
disappearance
Glucose
Disposal
regulate glucose
Gut
appearance
Pancreas
Tissues
GLP-1
Model derived from animal studies
Adapted from Edelman S, et al. Diabetes Technol Ther 2002; 4:175-189
SYMLIN (pramlintide)Clinical Effects
TYPE 2 DIABETES COMBINED PIVOTALS
Placebo + Insulin
120 g SYMLIN BID + Insulin
 Insulin Use (%)
 A1C (%)
Week 4 Week 13 Week 26
 Weight (kg)
Week 4 Week 13 Week 26
1
8
0
Week 4 Week 13 Week 26
6
-0.2
4
-0.4
0
2
**
0
-1
-0.6
**
-0.8
**
-2
*
-4
Placebo + insulin (n=284), Baseline A1C = 9.3%
SYMLIN + insulin (n=292), Baseline A1C = 9.1%
*P <0.01, **P <0.0001; ITT population; Mean (SE) change from baseline
SYMLIN Prescribing Information, 2005. Data on file, Amylin Pharmaceuticals, Inc.
Hollander P, et al. Diabetes Care 2003; 26:784-790
Ratner RE, et al. Diabetes Technol Ther 2002; 4:51-61
**
**
**
-2
**
Comparison of Amylin (Symlin) and Exenatide (Byetta)
Practical Diabetology D. Kruger; March 2006
INHALED INSULIN
Approved Jan 27,2006
“Exubera”
Intended for use as a bolus
Insulin
Basal SC insulin still needed
Not for patients with pulmonary
disease
QUESTION



How prevalent is the use of Sliding Scale Insulin in
LTC?
What do you consider are appropriate indications for
the use of Sliding Scale Insulin?
What does “sliding scale” mean to you?
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Is it really “correctional” or “supplemental” instead of
using a traditional term – “sliding scale”?
Do you use lab values vs. bedside fingersticks
to make dose adjustments?
How do you use bolus/prandial insulin?

How can we convert sliding scale use to basal bolus?
Sliding Scale Insulin (SSI)
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Frequently used; often indefinitely and rarely modified!
Associated with a large number of medication errors and adverse
events including hypoglycemia and hyperglycemia
Is reactive instead of proactive
Uses hyperglycemia as a threshold (may begin >200 mg/dL)
Does not provide basal insulin
Glycemic control is not assessed; physician contacted if glucose
is <60 or >400 mg/dL
Relieves the medical team of task of closely monitoring diabetes
One size does not fit all; patient’s previous regimen is not taken
in account:patient-specific scale is needed
No controlled trial demonstrates the benefit of SSI
WHAT ABOUT HYPOGLYCEMIA?

Accounts for 9% of post-acute adverse drug
reactions in nursing facilities
Hypoglycemia Definitions (Per Protocol)
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Symptomatic
 Patient has symptoms related to hypoglycemia, confirmed
by
PG 72 mg/dL (4.0 mmol/L)
Severe
 Patient has symptoms related to hypoglycemia and requires
assistance; associated with PG <56 mg/dL (<3.1 mmol/L)
Nocturnal
 Patient has PG 72 mg/dL (4.0 mmol/L); hypoglycemia
occurs after bedtime insulin injection and before morning
administration of oral hypoglycemic agent(s)
PG=plasma glucose.
Riddle M, Rosenstock J, and Gerich, J. Diabetes Care. 2003;26(11):3080-3086.
RISK FACTORS FOR SEVERE
HYPOGLYCEMIA
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Age
Unawareness of hypoglycemia or previous severe hypoglycemia
High doses of insulin or sulfonylureas
Recent hospitalization or intercurrent illness
Polypharmacy (>5 prescribed meds)
“Tight control” of diabetes
Poor nutrition or fasting
Chronic liver, renal or cardiovascular disease
Vigorous sustained exercise
Endocrine deficiency (thyroid, adrenal, or pituitary)
Alcohol use
Loss of normal counter-regulation
Chelliah. Drugs Aging 2004:21
Risk factors for
Insulin-induced
Hypoglycemia in
Elderly patients
With diabetes
Chelliah.
2004:21
Drugs Aging
SYMPTOMS OF HYPOGLYCEMIA IN THE FRAIL
ELDERLY
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Confusion, disorientation
Poor concentration and coordination
Drowsiness
Weakness
Altered behavior, aggression
Falls
Myocardial infarction
Seizures
Stroke
Coma, death
Counter-regulatory hormones
Glycemic thresholds for subjective symptomatic awareness of
hypoglycemia and for the onset of cognitive dysfunction in young and
elderly nondiabetic males. Matyka et al. (13). Diabetes and Old Age
Treatment of Hypoglycemia
Blood
Treatment
Glucose
(mg/dL)
50–70
Oral carbohydrates (12–15
g)
Further Management
<50
Hospitalize patient until stabilized if:
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Oral carbohydrates if mental
status permits, or
Intramuscular injection of
glucagon, or
Intravenous (IV) glucose
Observe for improvement
•
•
•
•
Unresponsive to treatment
Persistent neuroglycopenia
Blood glucose remains
<50 mg/dL
Patient will be alone for the next
12 hours
Cefalu WT et al, eds. CADRE Handbook of Diabetes Management. New York, NY:
Medical Information Press; 2004
ATYPICAL ANTIPSYCHOTICS AND
DIABETES RISK
Atypical antipsychotics and diabetes

4.4% annual incidence of diabetes in a
large VA population (56,800) receiving
antipsychotics

The FDA requires that all patients receiving
antipsychotics undergo metabolic monitoring
Clozapine and olanzapine appear to have the
highest incidence of weight gain and diabetes

ATYPICAL ANTIPSYCHOTICS AND
METABOLIC ABNORMALITIES
Suggested Monitoring Protocols for patients on atypical
Antipsychotics- America Diabetes Association Consensus
Statement 2004
FEET CAN LAST A LIFETIME
Quickly identify the patient with current
foot problems or a foot at risk
Make an initial diagnosis of a foot
problem.
Develop a treatment plan.
Identify needs for referral to foot care
specialists.
Schedule follow-up examinations.
Document the level of foot
deformity and/or disability.
Determine the need for therapeutic
footwear.
*Compare future examinations
with this baseline information.
Low Risk Patient - All of the
following:
Intact protective sensation
Pedal pulses present
No severe deformity
No prior foot ulcer
No amputation
High Risk Patient - One or more of
the following:
Loss of protective sensation
Absent pedal pulses
Severe foot deformity
History of foot ulcer
Prior amputation
Follow Up with High Risk Patients.
Place "high risk feet" stickers on medical record.
Examine feet at every visit.
Prescribe special inserts and shoes as needed.
Refer to specialists for a risk factor you cannot rectify.
Provide education about self-care.
Ensure that the elderly and blind have help for daily foot care.
Assess metabolic control.
Toe Deformities
(Hammer/Claw
Toes)
Bunions
(Hallux Valgus)
Plantar View of
Charcot Joint
Oral health complications of diabetes
severe periodontitis
subsequent tooth loss
gingivitis
dental abscesses
diabetes increases the risk of xerostomia and
soft tissue lesions of the tongue and oral mucosa
(candidiasis)
Explanation
Prolonged hyperglycemia and accumulation of advanced glycation
end products in gingival tissue are thought to be primarily
responsible for oral and other complications of diabetes
Consequently, tooth loss and chronic infection worsen
glycemic control
Monitoring Glucose levels
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Glucose Monitoring is an essential part of diabetes management
No clear guideline of frequency of CBG
Patient needs may be complex (e.g., post acute care)
High demand on nursing time
Physician notification and physician review are still a problem
Should be tailored to the timing and peak action of type of insulin
used
Q ac, q 2 hr. PPBG, q hs, and q 3am blood sugars are
advantageous until therapy has been stabilized and goals are
met
Protocols that define goals and allow nursing staff to adjust
frequency may be advantageous
Assessment of Glycemic control
Medical Care in Diabetes)
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(ADA Standards of
Diabetes Care 29:S3 2006
The frequency and timing of SMBG should be dictated by the
particular needs and goals of the patients.
Daily SMBG is especially important for patients treated with
insulin to monitor for and prevent asymptomatic hypoglycemia
and hyperglycemia.
The optimal frequency and timing of SMBG for patients with type
2 diabetes on oral agent therapy is not known but should be
sufficient to facilitate reaching glucose goals.
Patients with type 2 diabetes on insulin typically need to perform
SMBG more frequently than those not using insulin.
When adding to or modifying therapy, type 2 diabetic patients
should test more often than usual.
The role of SMBG in stable diet-treated patients with type 2
diabetes is not known.
Self-monitoring blood glucose
ICSI Type 2 diabetes guideline Nov 2005
Set frequency and timing of glucose monitoring. Examples include:
Frequency and Timing
Therapy
Nonpharmacologic
or oral agent
Twice daily, rotate times, at least 2 to 3 days per week.
Postprandial may be helpful.
Simple insulin
regimens (1 or 2
shots daily)
Twice daily, rotate times, at least 3 to 4 days per week.
Postprandial may be helpful.
Complex insulin
regimens (3 or
more shots daily)
Four or more times every day. Postprandial may be
helpful.
MONITORING BLOOD GLUCOSE LEVELS
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Insufficient evidence for glucose control goals in LTC
Monthly testing of FBG alone is ineffective
PPG provides a larger contribution to HbA1c than FBG
Monitor FBG for patients on sulfonylureas, metformin, TZDs
- at least 2x /week
- more often if poor control or change in
drug or dosage
Consider 2h PPG for patients on alpha-glucosidase inhibitors,
or shorter-acting insulin secretagogues
HbA1c – on admission if needed and q 6 months
_ q 3 months if poor control, anemic,
change of treatment
AMDA Diabetes CPG 2002
Relative Contribution of FPG and PPG to Overall
Hyperglycemia Depending on A1C Quintiles
Contribution, %
Postprandial glucose
Fasting glucose
100
80
60
40
20
0
n=58
<7.3
n=58
7.3–8.4
Monnier L et al. Diabetes Care. 2003;26:881–885.
n=58
8.5–9.2
A1C
n=58
9.3–10.2
n=58
>10.2
Development of a Protocol for Capillary Blood Glucose
Testing in Nursing Home and Rehabilitation Settings –
Mader et al; JAGS July 2006
VA N home and
Rehab
N=101
69% received orders
For CBG protocol
Of these, 78% were
advanced or could
have been to less
frequent testing
WHEN TO CALL THE PHYSICIAN
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Immediately or ASAP if:
-CBG <60 mg/dl or <75mg/dl with hypoglycemic symptoms
- CBG >400 mg/dl (unless this is an improvement)
- CBG >200 mg/dl with worsening of symptoms
- poor intake of food and fluids for >2 days with
fever lethargy, hypotension, confusion, abdominal
pain, respiratory distress
Non-urgently (e.g. fax, 24hr response time) if:
- consistent pattern of poorly controlled or
worsening BG levels
Utilize standing orders and protocols to enable first line
caregivers to treat hypoglycemia and obtain prompt physician
referral
INDICATOR
SUGGESTED MONITORING
A1c
Q 6mth if well controlled
Q 3 mth if poorly controlled
Blood pressure
Monthly
More frequently if poor control or dose change
Orthostatic VS if symptomatic
Foot examination
Daily by patient who is able
Weekly by caregivers
Urine MA/creat
Annually if <30µg/mg
Q 6mth if >300µg/mg
24h urine protein/Cr Cl
If significant decline in renal function
If nephrotic syndrome suspected
Lipid profile
Annually
6 wk after initiating or changing medication
Weight
Monthly or more frequently if >5% gain or loss
Pain control
Daily if treated for pain, or at each care plan
Cognition
Annually or as required
Depression
Annually or as required
AMDA CPG 2002
What do physicians actually do?

Differences in diabetes management of nursing
home patients based on functional and cognitive
status.
SourceJournal of the American Medical Directors Association. 6(6):375-82,
2005 Nov-Dec.
McNabney, Matthew K. Pandya, Naushira. Iwuagwu, Cletus. Patel,
Meenakshi. Katz, Paul. James, Vicki. Calabrese, Barbara. Lawhorne, Larry.
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N=255 (51% Research Foundation, 23% AMDA- non
CMD, 33% AMDA CMD) survey by mail
3 patient profiles
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Profile 1; cognitvely intact, functionally impaired
Profile 2; cognitively impaired, functionally intact
Profile 3; cognitively AND functionally impaired
Frequency of Prescribing Special Diet
60
50
40
30
20
10
Prof 1
Prof 2
Prof 3
A
lw
So ay
s
m
et
im
es
R
ar
ely
N
ev
er
N
o
A
ns
0
P<0.01
Frequency of Monitoring Daily
Fingersticks
A
lw
So ay
s
m
et
im
es
R
ar
ely
N
ev
er
N
o
A
ns
80
70
60
50
40
30
20
10
0
Prof 1
Prof 2
Prof 3
P<0.01
Frequency of Regular Monitoring of
HbA1C
100
80
60
40
20
Prof 1
Prof 2
Prof 3
A
lw
So ay
s
m
et
im
es
R
ar
ely
N
ev
er
N
o
A
ns
0
P<0.01
Frequency of Acceptable HbA1C
N 9+
ot
A
pp
N
o l
A
ns
<9
Prof 1
Prof 2
Prof 3
<8
<7
80
70
60
50
40
30
20
10
0
P<0.01
Frequency of Using Sliding Scale
Insulin
A
lw
So ay
s
m
et
im
es
R
ar
ely
N
ev
er
N
o
A
ns
70
60
50
40
30
20
10
0
Prof 1
Prof 2
Prof 3
P<0.01
Frequency of Ordering Routine
Ophthalmology Exams
A
lw
So ay
s
m
et
im
es
R
ar
ely
N
ev
er
N
o
A
ns
80
70
60
50
40
30
20
10
0
Prof 1
Prof 2
Prof 3
P<0.01
Frequency of Regular Foot Exam
100
80
60
40
20
Prof 1
Prof 2
Prof 3
A
lw
So ay
s
m
et
im
es
R
ar
ely
N
ev
er
N
o
A
ns
0
P<0.01
Preliminary Conclusions:
Diabetes Management

Approach to diabetes management in LTC
appears to depend on the medical/functional
status of the resident.
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Assessment and monitoring
Treatment
Findings were generally consistent across the
3 physician sub-groups evaluated.
Recommendations for
Glycemic Control in Diabetes*
AMDA, ADA, AGS
Dependant on
AGE

Life expectancy
Comorbid
conditions
*Generalized for entire population with diabetes.
† Measurement of capillary blood glucose.
‡ Values calibrated to plasma glucose.
American Diabetes Association.
Diabetes Care. 2001;24(suppl 1):S33-S43.
Management of Diabetes Mellitus in the Elderly
Requires a Team Approach
Educator
Physician
or
Medical
Director
Dietitian
Pharmacist
Podiatrist
Optometrist/
Ophthalmologist
Psychologist
Medical Specialists
Cardiologist
Nephrologist
Neurologist
Vascular Surgeon
COMPONENTS OF A SYSTEMATIC
FACILITY APPROACH TO DIABETES
MANAGEMENT
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Interdisciplinary care model; specified roles for
members
Individualization of therapy with consideration of
- quality of life
- cognitive and functional status
- disease severity
- expressed preferences
- life expectancy
COMPONENTS OF A SYSTEMATIC FACILITY
APPROACH TO DIABETES MANAGEMENT…
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Regular review of glycemic control, medical,
functional, and psychosocial issues
Involvement of patients if feasible
Continuing staff education (inservices and informal
bedside teaching) on care of patients with diabetes
Use of outcome and process indicators to measure
facility performance
TREATMENT GOALS
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INDIVIDUALIZE GOALS FOR EACH PATIENT
Target ranges for glucose control (FBG, PPG, or HbA1c)
Improved nutritional status
Preventing LE infections, ulcers, and limb loss
Educating patient and family
Controlling pain and neuropathic symptoms
Blood pressure management
Maximizing functional status
Hyperlipidemia management (if appropriate)
Discussion of Advance Directives and end-of-life care
Facility Ideas for the Medical Director
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Staff education
 Patient assessment and care
 Hypoglycemia recognition and management
Institute a Diabetes Flow Sheet for the chart
Monitor management of diabetes by all practitioners (regular
sample chart review)
Monitor facility management of diabetes
 A1c levels
 Hypoglycemia
 Use of Sliding Scale Insulin
 Foot examinations
 ER visits or hospitalizations
Assist in implementing a diabetes clinical practice guideline
Thank You