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Guidelines for Diabetes Management September 20, 2012 Margaret Pochay RD CDE How Food is Digested 1. Food enters stomach 4. Pancreas releases insulin 5. Insulin unlocks receptors 6. Glucose enters cell 3. Glucose enters bloodstream 2. Food is converted into glucose Diabetes Body lacks insulin or is unable to use insulin effectively Pancreas Muscle and Fat Cells Cannot Produce Enough Insulin Cannot Use Insulin Effectively Insulin Resistance Related Conditions Type 2 Diabetes Cardiovascular Disease Insulin Resistance High Blood Fats Impaired Glucose Tolerance Obesity High Blood Pressure Complications of Diabetes End-Stage Kidney Disease: 17x Stroke: 2-6x Retinopathy: 25x Foot/Leg Amputations: 5x Heart Disease: 2-4x Results from Diabetes Studies Good Diabetes Management results in • REDUCED microvascular disease – eye disease – kidney disease – neuropathy • REDUCED macrovascular disease – heart disease – stroke United Kingdom Prospective Diabetes Study (UKPDS) Change in HbA1C Microvascular Complications 0 0 -1 -5 -2 - 0.9% - 25% -10 -3 -15 -4 -20 -5 -25 1% Decrease in HbA1c = 25% Decrease in Microvascular Risk! Guidelines for Diabetes Management • http://care.diabetesjournals.org/content/35/ Supplement_1/S11.full.pdf+html Diagnostic criteria, standards of care, treatment goals, nutrition guidelines, diabetes self management guidelines, preventing complications Key Numbers in Diabetes Control • Daily Blood Glucose • A1C (2-3 month glucose levels) • Lipids (Blood Fats) • Blood Pressure (Hypertension) • Urine Protein (Microalbuminuria) Targets for Glucose Control Type 1 and Type 2 Diabetes Fasting/Pre-meal glucose 70-130 mg/dL Post-meal glucose <180 mg/dL 2 hr. after start of meal Bedtime glucose 100-140 mg/dL A1C <7.0% Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2003 Checking your blood sugar • Why: – Checking your blood sugar yourself is often the best way to be sure your diabetes is under control. It tells you: • If your insulin or other diabetes medicine is working • How physical activity and the foods you eat affect your blood sugar • Based on your care plan, you may want to test when: – You wake up – Before meals or large snacks – 1 or 2 hours after meals or large snacks – Before and 15 minutes after physical activity HbA1c and Self-Monitoring Results HbA1c 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 60 90 120 150 Blood Glucose (mg/dl) 180 210 240 270 300 330 Targets for Lipids, Blood Pressure and Microalbumin LDL cholesterol (mg/dL) Lipids (Blood Fats) 100 HDL cholesterol (mg/dL) Total cholesterol (mg/dL) Triglycerides (mg/dL) >60 <200 <150 Blood Pressure <130/80 mmHg <30 mg/24 h or <20 µg/min on a timed specimen or Microalbumin <30 mg/g creatinine on a random sample Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2001. Medications Insulin Supplements body’s own insulin Sulfonylureas Meglitinides Pancreas -- stimulates insulin production Metformin DPP4 inhibitor Thiazolidinediones Alpha-glucosidase inhibitors Liver -- decreases glucose release Fat/Muscle -- increases insulin sensitivity Reduces breakdown of GLP1 Fat/Muscle -- increases insulin sensitivity Intestine -- slows carbohydrate metabolism Exenatide (Byetta, Bydureon) and Victoza •GLP-1 agonist or incretin mimetic •Synthetic version of salivary protein found in the Gila monster Indications for Insulin in T2DM •Newly diagnosed symptomatic type 2 pts with severe hyperglycemia •Poor glucose control despite max doses of OA •Intercurrent illness (MI, infection, surgery) •Pregnancy •Renal/Hepatic Disease •Allergies to OA What are the different types of insulin? • Rapid-acting: – Controls blood sugar surges at mealtime • Long-acting: – Controls blood sugar between meals and during sleep • Premixed: – Combines rapid-acting and intermediate-acting insulin – Controls blood sugar at mealtime and all day and night Comparison of Human Insulins and Analogs Insulin Preparations Peak (hr) Duration of Action (hr) 5–15 min 1–2 4–5 Regular Human 30–60 min 2–4 6–10 Human NPH ® 2–3 hr 6–10 10–20 Glargine/Detemir 1-2 hr flat ~24 Mixes 5-15 min Lispro/Aspart/Glulisine Onset of Action 1-2 & 6-10 10-20 Time course of action of any insulin can vary in different people, or at different times in the same person; thus, time periods indicated here should be considered general guidelines only Dosing Insulin • Individual needs to be considered • Type 2 Diabetes: Basal Insulin start 10units change by 3 units every 3 days fasting blood glucose <70 or >130 • Meal time insulin calculate insulin to carb ratio rapid acting divide 500 by total daily insulin dose. Titrate depending on post meal blood glucose Dosing Insulin type 1 diabetes • .5 unit of insulin per kg body weight • 50% insulin basal insulin (goal FBS 70-130 • 1 unit of fast acting insulin per 15gm carbohydrate to be eaten (goal post prandial <180) • Correction also calculated (ex: 1 unit for every 50 points glucose above or below goal) Barriers to Insulin Use: Patient Issues Barriers Fear of injections Fear of hypoglycemia Fear of weight gain Solutions Syringes, pens, and needles vastly improved Low rate of severe hypoglycemia in DM2 Glucose control is more important than mild-tomoderate weight gain • How: Injecting insulin – Insulin pen – Syringe filled from a bottle of insulin – Insulin pump • Where: – Abdomen – Thighs – Backs of the upper arms Pen Delivery of Insulin •Encourages multipledose insulin therapy •Adds convenience •Enhances flexibility in schedule •Reduces insulin waste •May improve accuracy of correct dosage delivery Patient Education Issues •Insulin Administration –Abdomen preferred injection site –Rapid acting insulins within 15 min before meals; regular insulin 30 min before meals •When to self-monitor blood glucose –3-4 times per day (pre-meals) –Intermittent 1–2 hours postmeal to adjust analog •How to recognize and treat hypoglycemia and hyperglycemia Summary • Pathophysiology important part of educationg patients with diabetes • Good control involves proper use of lifestyle tools and medications • Regular and frequent monitoring of all aspects of diabetes is essential to good control • Diabetes is a self managed disease