Download GNRS4DiabetesMellitus

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DIABETES MELLITUS
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OBJECTIVES
Know and understand:
• Consequences of diabetes in older adults
• Pre-diabetes and diabetes and how to establish
these diagnoses
• Managing hypertension, dyslipidemia, and
microvascular complications in patients with diabetes
• The importance of individualized diabetes
management for different types of patients
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TO P I C S C O V E R E D
• Epidemiology of Diabetes in Older Adults
• Consequences of Diabetes in Older Adults
• Classification of Diabetes
• Pathophysiology of Diabetes in Older Adults
• Diagnosis
• Managing Diabetes and Its Complications
• Education and Self-Management Support
EPIDEMIOLOGY OF DIABETES
IN OLDER ADULTS
• 27% of people ≥65 yr have diagnosed or
undiagnosed diabetes
• One of the most common chronic diseases in that
age group
• Age-adjusted prevalence higher among black and
Hispanic Americans than white Americans
In the US, >40% of all people with
diabetes are ≥65
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CONSEQUENCES OF DIABETES
I N O L D E R A D U LT S ( 1 o f 2 )
• 10-year reduction in life expectancy
• 2 higher mortality rate
• 2 higher risk of atherosclerosis, neuropathies,
loss of vision, and renal insufficiency
• 2 higher rates of MI, stroke, kidney failure
• 40% higher risk of blindness
• 2–3 higher risk of mobility disability
• 1.5 higher risk of disability in ADLs
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CONSEQUENCES OF DIABETES
I N O L D E R A D U LT S ( 2 o f 2 )
Older adults with diabetes are at higher risk than those
without diabetes for geriatric syndromes, including:
• Incontinence
• Falls
• Frailty
• Cognitive impairment
• Depressive symptoms
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C L A S S I F I C AT I O N O F D I A B E T E S
• Type 1—results from absolute deficiency in
insulin secretion due to autoimmune destruction
of pancreatic β cells
• Type 2—usually due to tissue resistance to
insulin action and relative insulin deficiency
• Third category—injuries to the pancreas,
endocrinopathies characterized by excesses of
hormone that antagonize insulin action, drug- or
chemical-induced diabetes, and infections that
destroy β cells
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PAT H O P H Y S I O L O G Y O F D I A B E T E S
I N O L D E R A D U LT S ( 1 o f 2 )
• About 90% of older adults with diabetes have type 2
 Diagnosis usually follows years of “pre-diabetes” (glucose
intolerance, insulin resistance, metabolic syndrome)
 Pre-diabetes itself raises the risk of atherosclerosis
• Prevalence of both type 2 diabetes and glucose
intolerance increases with age
 Genetics
 Certain medications
 Lifestyle
 Intercurrent illnesses
 Influence of aging
 Other physiologic stresses
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PAT H O P H Y S I O L O G Y O F D I A B E T E S
I N O L D E R A D U LT S ( 2 o f 2 )
• Pathophysiology similar in younger and older adults
 Prolonged hyperglycemia  protein glycosylation;
accumulation of abnormal proteins  tissue damage
 Hyperglycemia  accumulation of metabolic
products of the aldose-reductase system  impaired
cellular energy metabolism; cell injury and death
• Physiologic changes due to diabetes and its
complications may interact with changes due to
aging to further decrease physiologic reserve
4 WAY S TO E S TA B L I S H T H E
DIAGNOSIS OF DIABETES
• HbA1c ≥6.5% using an assay standardized to the NGSP
• Symptoms of polyuria, polydipsia, and unexplained
weight loss plus casual plasma glucose ≥200 mg/dL
• Plasma glucose after an 8-hour fast ≥126 mg/dL
• Plasma glucose ≥200 mg/dL measured 2 hours after
ingestion of 75 g glucose in 300 mL water, administered
after an overnight fast
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INTERPRETING
B O R D E R L I N E R E S U LT S
Pre-diabetes
• Fasting blood glucose = 110–25 mg/dL
• 2 hour plasma glucose of 140–199 mg/dL after a
75 g oral glucose tolerance test (OGTT)
• HbA1c = 5.7%–6.5%
Isolated postchallenge hyperglycemia
• Fasting blood glucose not elevated
• Many pts would have type 2 DM by OGTT criteria
• Appears to increase risk of atherosclerosis,
although not as much as type 2 diabetes does
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C L I N I C A L E VA L U AT I O N
O F O L D E R A D U LT S W I T H D I A B E T E S
• Evaluate risk factors for atherosclerotic disease and
presence of comorbid diseases
• Take thorough medication history
• Assess functional status
• Screen for geriatric syndromes: polypharmacy,
depression, cognitive impairment, UI, injurious falls,
chronic pain
• Assess need for education and self-management
support, and whether to involve a caregiver
GOALS OF DIABETES
MANAGEMENT
• Control hyperglycemia and its symptoms
• Evaluate and treat associated risks for atherosclerotic
and microvascular disease
• Evaluate and treat diabetes complications
• Support diabetes self-management and education
• Maintain or improve general health status
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GENERAL PRINCIPLES
OF DIABETES MANAGEMENT
• Healthy, functional older adults: management should
be directed toward reducing risks associated with
diabetes and treating comorbid conditions
• For some older patients, intensive management is
not likely to provide benefit and may even be harmful
• Patients with intermediate health status should
participate in management decisions based on their
preferences and available evidence
• Diabetes management goals and clinical targets
should be individualized
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PREVENTING AND MANAGING
CARDIOVASCULAR RISK FACTORS
Counsel the patient regarding:
• Maintaining appropriate weight
• Increasing physical activity
• Discontinuing smoking
• Limiting fat and carbohydrate intake
Consider drug therapy to:
• Treat hypertension
• Prevent MI (ie, aspirin)
• Treat dyslipidemia
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MANAGING HYPERTENSION IN OLDER
A D U LT S W I T H D I A B E T E S
• Target BP = 140/80 for most patients
• Lower BP gradually to avoid complications
• Most antihypertensive drug classes have comparable
effectiveness
• ACE inhibitors and angiotensin II receptor blockers
have cardiovascular and renal benefits for people
with diabetes
MANAGING DYSLIPIDEMIA IN
O L D E R A D U LT S W I T H D I A B E T E S
• Dyslipidemia should be corrected if reasonable
considering the patient’s overall health
• Target LDL level < 100 mg/dL
• If LDL ≥ 130 mg/dL, pharmacologic therapy needed
in addition to lifestyle modification
• Measure ALT within 12 weeks of initiation or dose
increase of a statin or niacin
• Measure liver enzymes annually after initiation or
dose increase of a fibrate
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PREVENTING AND MANAGING
M I C R O VA S C U L A R C O M P L I C AT I O N S
• Dilated eye examination by eye care specialist
 At diagnosis
 Repeat annually if exam detects retinopathy, other medical
eye disease, or eye symptoms, or if hyperglycemia or BP is
poorly controlled
 Otherwise, repeat every other year
• Foot examination at least annually
• Test for microalbuminuria at diagnosis and at least
annually thereafter
• Pneumococcal vaccination
M A N A G I N G H Y P E R G LY C E M I A I N
O L D E R A D U LT S W I T H D I A B E T E S
• No evidence that intensive hyperglycemia management
(HbA1c ≤ 6.5%) prevents cardiovascular disease in
older adults with established diabetes
• A1c targets are still actively debated
 Levels can vary from 7.0%–8.5% for different
patients, depending on health status, preferences,
and individualized management plan
• Older adults are at higher risk for hypoglycemia, so
choose medications with less risk when possible
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ORAL NON-INSULIN AGENTS:
BIGUANIDES
Drug
Dosage
Formulations
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Comments (Metabolism)
Decrease hepatic glucose
production; lower HbA1c by
1%–2%, do not cause
hypoglycemia
Class effects
Metformin
(Glucophage)
500–2550 mg
divided
T: 500, 850,
1000
Avoid in patients with eGFR
< 30mL/1.73m2, heart
failure, COPD, elevated liver
enzymes; hold before
contrast radiologic studies;
may cause weight loss (K)
Metformin (generic or
(Glucophage XR)
1500–2000 mg/d
T: ER 500
Same as above
ORAL NON-INSULIN AGENTS:
2ND-GENERATION SULFONYLUREAS
Drug
Dosage
Formulations
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Comments (Metabolism)
Glimepiride (generic or
Amaryl)
4–8 mg once,
begin 1–2 mg
T: 1, 2, 4
Numerous drug interactions;
long-acting (L, K)
Glipizide (generic or
Glucotrol)
2.5–40 mg once
or divided
T: 5, 10
Short-acting (L, K)
Glipizide (Glucotrol XL)
5–20 mg once
T: ER 2.5, 5, 10
Long-acting (L, K)
Glyburide (generic or
Diaβeta, Micronase)
1.25–20 mg once
or divided
T: 1.25, 2.5, 5
Long-acting; risk of
hypoglycemia (L, K); not
recommended in older adults
Micronized glyburide
(Glynase)
1.5–12 mg once
T: 1.5, 3, 4.5, 6
Long-acting; risk of
hypoglycemia (L, K); not
recommended in older adults
ORAL NON-INSULIN AGENTS:
ALPHA-GLUCOSIDASE INHIBITORS
Drug
Dosage
Formulations
Class effects
Comments (Metabolism)
Delay glucose absorption;
lower HbA1c by 0.5 %–1.0%,
can cause hypoglycemia &
weight gain
Acarbose (Precose)
50–100 mg q8h,
just before meals;
start with 25 mg/d
T: 25, 50, 100
GI adverse effects common;
avoid if Cr >2 mg/dL,
monitor liver enzymes (gut,
K)
Miglitol (Glyset)
25–100 mg q8h,
with first bite of a
meal; start with 25
mg/d
T: 25, 50, 100
Same as acarbose but no
need to monitor liver
enzymes (L, K)
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ORAL NON-INSULIN AGENTS:
DPP-4 ENZYME INHIBITORS
Drug
Dosage
Formulations
Class effects
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Comments (Metabolism)
Protect and enhance
endogenous incretin
hormones; lowers HbA1c by
0.5%–1%, do not cause
hypoglycemia, weight
neutral
Linagliptin
(Tradjenta)
5 mg
T: 5
Saxagliptin
(Onglyza)
5 mg; 2.5 mg if CrCl
<50 mL/min
T: 2.5, 5
(K)
Sitagliptin (Januvia)
100 mg once daily
alone or combined
with metformin or a
thiazolidinedione; 50
mg/d if CrCl 31–50
mL/min; 25 mg/d if
CrCl <30 mL/min
T: 25, 50, 100
(K)
ORAL NON-INSULIN AGENTS:
MEGLITINIDES
Drug
Dosage
Formulations
Class effects
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Comments (Metabolism)
Increase insulin secretion;
lower HbA1c by 1%–2%, can
cause hypoglycemia and
weight gain
Nateglinide (Starlix)
60–120 mg q8h
T: 60, 120
Give 30 min before meals
Repaglinide (Prandin)
0.5 mg q6–12h if
HbA1c <8% or
previously
untreated;
1–2 mg q6–12h if
HbA1c ≥8% or
previously treated
T: 0.5, 1, 2
Give 30 min before meals;
adjust dose at weekly
intervals; potential for drug
interactions; caution in
hepatic, renal insufficiency
(L)
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ORAL NON-INSULIN AGENTS:
THIAZOLIDINEDIONES (1 of 2)
Drug
Dosage
Formulations
Comments (Metabolism)
Insulin resistance reducers; lower HbA1c
by 0.5%–1.0%; risk of HF; avoid if
NYHA Class III or IV cardiac status; D/C
if cardiac status declines; check liver
enzymes at start, q2mo during 1st yr,
then periodically; avoid if clinical
evidence of liver disease or if serum
ALT levels > 2.5 upper limit of normal;
may increase risk of fractures in women
(L, K)
Class effects
Pioglitazone
(Actos)
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25
15 or 30 mg/d;
maximum 45
mg/d as
monotherapy,
30 mg/d in
combination
therapy
T: 15, 30, 45
ORAL NON-INSULIN AGENTS:
THIAZOLIDINEDIONES (2 of 2)
Drug
Rosiglitazone
(Avandia)
Dosage
4 mg q12–
24h
Formulations
T: 2, 4, 8
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Comments (Metabolism)
Restricted access: Because of
data suggesting higher
cardiovascular risk, people with
type 2 diabetes who are not
currently taking rosiglitazone can
be prescribed the medication
only if glycemic control cannot be
achieved with an alternative
medication. Rosiglitazone will
continue to be available to those
who are currently taking it only if
they appear to be benefiting and
understand the risks.
INJECTABLE NON-INSULIN AGENTS
FOR TREATING DIABETES
Drug
Dosage
Formulations
Comments (Metabolism)
Exenatide
(Byetta)
5–10 mcg SC
q12h
1.2-, 2.4-mL
Incretin mimetic; lowers HbA1c by
prefilled syringes 0.4%–0.9%; nausea and
hypoglycemia common; less
weight gain than insulin; avoid if
CrCl < 30 mL/min (K)
Liraglutide
(Victoza)
0.6–1.8 mg SQ
once daily
0.6, 1.2, 1.8
(6 mg/mL) in
prefilled,
multidose “pen”
Glucagon like peptide-1 receptor
agonist; lowers HbA1c by 1%;
risks include acute pancreatitis
and possibly medullary thyroid
cancer
Pramlintide
(Symlin)
60 mcg SC
immediately
before meals
0.6 mg/mL in 5mL vial
Amylin analogue; lowers HbA1c by
0.4%–0.7%; nausea common;
reduce pre-meal dose of shortacting insulin by 50% (K)
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RAPID-ACTING
INSULIN PREPARATIONS
Preparation
Onset
Peak
Duration
Insulin glulisine (Apidra)
20 min
0.5–1.5 h
3–4 h
Insulin lispro (Humalog)
15 min
0.5–1.5 h
3–4 h
Insulin aspart (NovoLog)
30 min
1–3 h
3–5 h
Regular insulin
(eg, Humulin, Novolin)a
0.5–1 h
2–3 h
5–8 h
a Also
available (not in the United States) as mixtures of NPH and regular in
50:50 proportions. NPH = neutral protamine Hagedorn (insulin).
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INTERMEDIATE OR LONG-ACTING
INSULIN PREPARATIONS
Preparation
Onset
Peak
Duration
NPH insulin
(eg, Humulin, Novolin)a
1–1.5 h
4–12 h
24 h
Insulin detemir (Levemir)
3–4 h
6–8 h
6–24 h
Insulin glargine (Lantus)
1–2 h
—
24 h
Isophane insulin & regular
insulin injectable (Novolin
70/30)
30 min
2–12 h
24 h
a Also
available (not in the United States) as mixtures of NPH and regular in
50:50 proportions. NPH = neutral protamine Hagedorn (insulin).
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E D U C AT I O N A N D
SELF-MANAGEMENT SUPPORT (1 of 2)
• If the patient is clinically complex, consider
referral to a diabetes educator, disease
management program, or specialist care
• Annual diabetes self-management training is
covered under Medicare Part B
• Involve and educate a caregiver if the patient
is cognitively impaired, significantly disabled
or frail, or has limited proficiency in English
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E D U C AT I O N A N D
SELF-MANAGEMENT SUPPORT (2 of 2)
Educate patients and caregivers about:
• Hypo- and hyperglycemia—precipitating factors,
prevention, symptoms, monitoring, treatment, when
to notify the provider
• Blood glucose self-monitoring, when appropriate
• Diet and physical activity
• Medications—purpose of drug, how to take it,
common side effects, important adverse reactions
• Foot care
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S U M M A RY
• Both diabetes and pre-diabetes are important to identify
and address
• Because of the great heterogeneity in older population,
treatment goals for diabetes must be individualized
• Although the target is debated, attempts to lower BP, as
tolerated, are important for older hypertensive patients
with diabetes
• Diabetes self-management is an important part of
diabetes care, and annual self-management training is
covered by Medicare Part B
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CASE 1 (1 of 4)
• A 75-year-old woman receives a new diagnosis of
type 2 diabetes mellitus. History includes deep-vein
thrombosis 5 years ago, hypertension, depression, and
generalized anxiety disorder.
• Medications include hydrochlorothiazide 12.5 mg/day,
lisinopril 10 mg/day, citalopram 40 mg/day, and aspirin
81 mg/day.
• She lives alone in an apartment in a retirement
community. She has a history of poor appetite; she
typically has toast and coffee for breakfast, fruit and half
a sandwich for lunch, and meat and salad for dinner.
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CASE 1 (2 of 4)
• She walks 1 mile daily and assists in the community
garden.
• Height is 152 cm (5 ft) and weight is 39 kg (86 lb).
Blood pressure is 130/80 mmHg and pulse is 82 bpm.
• Laboratory findings:
 Fasting glucose
 Serum creatinine
 BUN
 Hemoglobin A1c
147 mg/dL
(change from 152 mg/dL last month)
1.0 mg/dL
16 mg/dL
9%
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CASE 1 (3 of 4)
Which of the following would be the best initial approach
for the patient’s diabetes mellitus?
A.
B.
C.
D.
No therapy needed at this time
Oral metformin 500 mg q12h
Oral glyburide 10 mg/day
Subcutaneous insulin glargine 7 U/day
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CASE 1 (4 of 4)
Which of the following would be the best initial approach
for the patient’s diabetes mellitus?
A.
B.
C.
D.
No therapy needed at this time
Oral metformin 500 mg q12h
Oral glyburide 10 mg/day
Subcutaneous insulin glargine 7 U/day
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CASE 2 (1 of 4)
• An 80-year-old woman is brought to the office by her
daughter because she has become less active and
frequently skips her daily walks.
• History includes diabetes mellitus, hypertension, and
hyperlipidemia.
• Medications include lisinopril 10 mg/day, metformin
500 mg with dinner, and atorvastatin 10 mg at
bedtime.
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CASE 2 (2 of 4)
• The patient says she is walking less often because
of the weather. She reports no pain with walking,
recent fall, trouble with balance, or change in vision.
• On examination, blood pressure is 145/85 mmHg.
She has lost 1.8 kg (4 lb) since her last visit 6
months ago. Past hemoglobin A1c, lipid panel, and
creatinine tests have been acceptable.
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CASE 2 (3 of 4)
Which of the following is the most appropriate next
step in management?
A. Evaluate for depression and cognitive impairment.
B. Measure hemoglobin A1c and lipid levels.
C. Increase lisinopril to 20 mg/d.
D. Refer for biennial retinal screening.
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CASE 2 (4 of 4)
Which of the following is the most appropriate next
step in management?
A. Evaluate for depression and cognitive impairment.
B. Measure hemoglobin A1c and lipid levels.
C. Increase lisinopril to 20 mg/d.
D. Refer for biennial retinal screening.
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CASE 3 (1 of 3)
• An 84-year-old man who lives in a nursing home is
seen for his monthly evaluation.
• History includes moderate dementia, diabetes mellitus,
and heart failure.
• Medications include metformin 1000 mg twice daily
with meals and glipizide 10 mg q12h.
• He undergoes fingerstick monitoring twice daily; values
have ranged between 100 and the low 200s for several
months. His most recent HbA1c level was 8.3%.
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CASE 3 (2 of 3)
Which of the following is the most appropriate next step
in the management of this patient’s diabetes?
A. Obtain fructosamine level.
B. Increase glipizide to 20 mg q12h.
C. Add sitagliptin.
D. Add NPH insulin at bedtime.
E. Discontinue fingerstick monitoring.
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CASE 3 (3 of 3)
Which of the following is the most appropriate next step
in the management of this patient’s diabetes?
A. Obtain fructosamine level.
B. Increase glipizide to 20 mg q12h.
C. Add sitagliptin.
D. Add NPH insulin at bedtime.
E. Discontinue fingerstick monitoring.
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GNRS4 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS4 Teaching Slides modified from GRS8 Teaching Slides
based on chapter by Caroline Blaum, MD
and questions by Sei J. Lee, MD, MAS
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society