Guidelines for Diabetes Management September 20, 2012 Margaret Pochay RD CDE.

Guidelines for Diabetes Management

September 20, 2012

Margaret Pochay RD CDE

How Food is Digested

1. Food enters stomach

5. Insulin unlocks receptors

4. Pancreas releases insulin

2. Food is converted into glucose

3. Glucose enters bloodstream

6. Glucose enters cell

Pancreas

Cannot Produce Enough Insulin

Body lacks insulin or is unable to use insulin effectively

Diabetes

Muscle and Fat Cells

Cannot Use Insulin

Effectively

Cardiovascular Disease

Type 2 Diabetes

High Blood Pressure

ObesityHigh Blood Fats

Impaired Glucose Tolerance

Insulin ResistanceRelated Conditions

InsulinResistance

Retinopathy: 25x

Complications of Diabetes

End-Stage Kidney Disease:

17x

Heart Disease: 2-4x

Foot/Leg Amputations:

5x

Stroke: 2-6x

Good Diabetes Management results in

• REDUCED macrovascular disease – heart disease– stroke

Results from Diabetes Studies

• REDUCED microvascular disease– eye disease– kidney disease– neuropathy

Changein HbA1C

Microvascular Complications

0

-1

-2

-3

-4

-5

United Kingdom Prospective Diabetes Study (UKPDS)

0

- 5

-10

-15

-20

-25

- 0.9%

- 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

• Daily Blood Glucose

• A1C (2-3 month glucose levels)

• Lipids (Blood Fats)

• Blood Pressure (Hypertension)

• Urine Protein (Microalbuminuria)

Key Numbers in Diabetes Control

• Daily Blood Glucose

Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2003

Targets for Glucose ControlType 1 and Type 2 Diabetes

Fasting/Pre-meal glucose

Post-meal glucose2 hr. after start of meal

Bedtime glucose

A1C

70-130 mg/dL

<180 mg/dL

100-140 mg/dL

<7.0%

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

8% 180

9% 210

10% 240

11% 270

12% 300

13% 330

4% 60

5% 90

6% 120

HbA1cBlood Glucose(mg/dl)

HbA1c and Self-Monitoring Results

7% 150

Targets for Lipids, Blood Pressure and Microalbumin

Lipids (Blood Fats)

Blood Pressure

Microalbumin

LDL cholesterol

(mg/dL)

100

Triglycerides

(mg/dL)

<150

HDL cholesterol

(mg/dL)

>60

<130/80 mmHg

Total cholesterol

(mg/dL)

<200

<30 mg/24 h or <20 µg/min on a timed specimen or <30 mg/g creatinine on a random sample

Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2001.

Pancreas -- stimulates insulin production

Liver -- decreases glucose release

Fat/Muscle -- increases insulin sensitivity

Fat/Muscle -- increases insulin sensitivity

Reduces breakdown of GLP1

Intestine -- slows carbohydrate metabolism

Medications

Insulin

SulfonylureasMeglitinides

Metformin

DPP4 inhibitorThiazolidinediones

Alpha-glucosidase inhibitors

Supplements body’s own insulin

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 Onset of Duration ofPreparations Action Peak (hr) Action (hr)

Lispro/Aspart/Glulisine 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 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 Solutions

Fear of injections Syringes, pens, and needles vastly improved

Fear of hypoglycemia Low rate of severe hypoglycemia in DM2

Fear of weight gain Glucose control is more important than mild-to- moderate weight gain

Injecting insulin• How:

– Insulin pen– Syringe filled from a bottle of insulin– Insulin pump

• Where:– Abdomen – Thighs– Backs of the upper arms

Pen Delivery of Insulin•Encourages multiple-

dose 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

• 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

Summary

• Pathophysiology important part of educationg patients with diabetes