Diabetes Update Pennsylvania Association of Developmental Disabilities Nurses

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Diabetes Update Pennsylvania Association of
Developmental Disabilities Nurses

• Gutman Diabetes Institute
• Einstein Medical Center, Philadelphia
• Patricia C. Adams, RN, CDE

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Objectives

• Distinguish the different types of diabetes
• Discuss appropriate administration of insulin
• Discuss prevention and treatment of hypoglycemia
• Review of ADA recommendations for anti-psychotic
  drugs and obesity

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Diabetes Update

• Diabetes - Epidemic Proportions
• Glucose Toxicity
• 25.8 million Americans (8.3 of population)
• 18.8 million have been diagnosed
• 7.0 million are unaware they have the disease
• Lipid Toxicity
• http//www.cdc.gov/diabetes/pubsaccessed 3/8/2011

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Diabetes

• Areas Requiring Control
• Glycemic Control
• A1C lt 7 (ADA Standards)
• lt 6.5 (AACE Standards)
• Blood Pressure Control
• Goal is 130/80
• ACE vs ARB Diuretics
• Lipid Management
• Statins

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Cardiovascular Risk

• Lipids
• Total Cholesterol lt 200
• HDL gt 45 (Men) gt 55 (Women)
• LDL lt 100 lt70 (Hx of cardiac disease)
• Triglycerides (Tg) lt 150
• Aspirin (81 325) mg daily gt21 yrs)

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RecommendationsDyslipidemia/Lipid Management

• Treatment recommendations and goals
• Statin therapy should be added to lifestyle
  therapy, regardless of baseline lipid levels, for
  diabetic patients
• with overt CVD (A) / LDL lt 70
• without CVD who are gt40 years of age and have one
  or more other CVD risk factors (A) / LDL lt 100

ADA. VI. Prevention, Management of Complications.
Diabetes Care 201134(suppl 1)S29.
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Diabetes Update

• Type 1
• Approximately 5
• Type 2
• Approximately 95
• Gestational
• 7 14 of all pregnancies
• 5 10 have type 2 following delivery
• 20 50 chance of developing diabetes in the
  next 5 10 years

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What is a normal blood glucose level?

• A1C gt 6.5
• FPGgt 126 mg/dl
• OGTT gt 200 mg/dl (75g glucose load)
• RPG gt 200 mg/dl with symptoms of hyperglycemia

Diabetes Care, Clinical Practice Recommendations,
2011
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Criteria for Testing for Diabetes in Asymptomatic
Adult Individuals

• Testing should be considered in all adults who
  are overweight (BMI 25 kg/m2) and have
  additional risk factors

Physical inactivity First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who delivered a baby weighing gt9 lb or were diagnosed with GDM Hypertension (140/90 mmHg or on therapy for hypertension)

• HDL cholesterol levellt35 mg/dl (0.90 mmol/l)
  and/or a triglyceride level gt250 mg/dl (2.82
  mmol/l)
• Women with polycystic ovarian syndrome (PCOS)
• A1C 5.7, IGT, or IFG on previous testing
• Other clinical conditions associated with insulin
  resistance (e.g., severe obesity, acanthosis
  nigricans)
• History of CVD

At-risk BMI may be lower in some ethnic groups.
ADA. Testing in Asymptomatic Patients. Diabetes
Care 201134(suppl 1)S14. Table 4.
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Diabetes in Severe Mental Illness

• 2 3 fold increased mortality rate associated
  with physical illness
• Most common cause of death CVD
• More likely to be overweight, smoke, inactive
• More likely to have family hx diabetes,
• Limited access to primary care, cardiovascular
  risk screening

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ADA Consensus

• Baseline monitoring at initiation of
  antipsychotic medications
• Personal/family hx diabetes, obesity,
  dislipidemia, hypertension, CVD
• Calculate BMI
• Waist circumference
• BP, Fasting blood glucose, Fasting Lipid profile
• Interval monitoring
• 4, 8, 12 weeks after initiation of therapy
• Weight gain gt 5 consider change in therapy

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ADA Consensus

• Consideration of metabolic risks when starting
  SGAs
• Patient, family, and care giver education
• Baseline screening
• Regular monitoring
• Refer to specialized services, when needed

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Blood Glucose Regulation
Pancreas
Muscle
Insulin Secretion
Release of GIP GLP - 1
Intestine Glucose Absorption
BLOOD GLUCOSE
Peripheral Glucose Uptake
Brain Nervous System
Fat
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• Type 1 Diabetes

• Type 2 Diabetes

• Initially little insulin production
• Evolves into no insulin production
• Exogenous insulin required daily
• Auto-immune response
• Genetic component
• 5 - 10 prevalence

• Slow, Insidious
• 6.5 years to manifest as elevated FBG
• Elevated postprandial blood glucose levels
• Damage vessel endothelium
• Insulin Resistance
• Beta Cell Deterioration

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Type 1 2 Comparison
Type 1 Type 2
Age of Onset Usually lt30 Usually gt40
Onset Rapid Slowly - years
Insulin Availability Little to None Some Progressive
Insulin Resistance Develops w/Time Usually present
Treatment Exogenous insulin always needed Daily injections MNT, Activity, Oral Agents, Insulin
Complications Develop w/Time Present at Dx
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Type 2 Diabetes A Dual-Defect Disease
Genes
Genes
Impaired insulin secretion
Insulin resistance
Environment
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Genes Vs. Jeans
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The Progressive Nature of Type 2 Diabetes
Normal
Impaired glucose tolerance
Type 2 diabetes
Late type 2 diabetes complications
Insulin sensitive
Hyperglycaemia
Normal insulin secretion
Insulin resistance
Normoglycaemia
ß-cell exhaustion
Fasting plasma glucoseInsulin sensitivityInsulin
secretion
Adapted from Bailey CJ et al. Int J Clin Pract
200458867876. Groop LC. Diabetes Obes Metab
19991 (Suppl. 1)S1S7.
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How Do Oral Diabetes Medicines Work?
Glucosidase Inhibitors
TZDS
DPP IV Inhibitors
Secretagogues
Biguanides
Increase insulin action
Increase insulin secretion
Decrease hepatic glucose
Decrease breakdown of GLP-1- increase insulin
secretion
Slow glucose absorption
Glyburide Glipizide Glimepiride Repaglinide Nategl
inide
Pioglitazone Rosiglitazone
Metformin Metformin XR Metformin/Glyburide
Acarbose Miglitol
Sitaglipton Saxaglipton
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Terminology Physiologic Insulin Use AKA Think
like a Pancreas

• Basal
• Amount needed to prevent excess gluconeogenesis
  and ketogenesis
• Prandial
• Amount needed to cover discrete meals and/or
  nutritional supplements
• Tube Feedings, IV dextrose, TPN

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Human Insulins

• Regular
• NPH
• 70/30

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Insulin Analogs

• Humalog (Lispro)
• Humalog Mix 75/25
• NovoLog (Aspart)
• NovoLog Mix 70/30
• Apidra (Glulisine)
• Lantus (Glargine)
• Levemir (Detemir)

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Basal / Bolus Insulin Therapy
Novolog u100 _____ units with 1st meal _at______
______units with
2nd meal _at______
______units with 3rd meal _at______
Lantus u100
_____ units in the morning _at______

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
1 2 3 1
Sleeping
Meal times
Hours
of sleep _____ _____
_____ ______________
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Premix (cloudy)
Short acting insulin
Intermediate acting insulin
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

Insulin type Human u100 Premix R NPH Onset
(Begins to work) ½ - 1 hour following
injection Peak action (Works the strongest) Dual
following injection Effective duration
following injection Actual maximum duration
10-16 hrs
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Insulin Action Times
Type Starts Peaks Ends
Lispro (Humalog) 5 min. 60 min. 3 4 hr.
Aspart (Novolog) 5 min. 60 min. 3 5 hr.
Glulisine (Apidra) 5 min. 60 min. 3 4 hr.
Regular 30 60 min. 2 4 hr. 6 8 hr.
NPH 1.5 hours 4 12 hr. 10 16 hr.
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Insulin Action Times
Type Starts Peaks Ends
Glargine (Lantus) 4 6 hr. None 24 hr.
Levemir (Detemir) lt 2 hr. 3 14 hr 16 24 hr.
70/30 0.5 1.0 hr. Dual (NPH/R) 12 20 hr.
Mix 75/25 10 min. Dual (Lispro/Lispro Protamine) 12 20 hr.
Mix 70/30 10 min. Dual (Aspart/Aspart Protamine) 12 20 hr.
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Insulin and Timing of Meals

• 70/30 30 minutes prior to meal
• Regular 20 to 30 minutes prior to meal
• NPH 20 to 30 minutes prior to meal
• Aspart- 5 10 minutes prior to meal
• Lispro- 5 10 minutes prior to meal
• Apidra - 5 10 minutes prior to meal

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Proper Matching
Glucose Level
Insulin Peak action
3
0
1
2
4
Time in Hours
30
Improper Matching
Hypoglycemia
Hyperglycemia
Glucose Level
Insulin Peak Action
3
0
1
2
4
Time in Hours
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Clinical Pearl

• Basal insulin
• You wouldnt hold the pancreas, so dont hold the
  lantus

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Clinical Pearl

• Without insulin, in an insulin deficient
  individual, blood glucose will increase passively
  by as much as 45 mg/dl per hour even in the
  absence of food.

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Location, Location, Location
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Glycemic Recommendations for Non-Pregnant Adults
with Diabetes (1)
A1C lt7.0
Preprandial capillary plasma glucose 70130 mg/dl (3.97.2 mol/l)
Peak postprandial capillary plasma glucose lt180 mg/dl (lt10.0 mmol/l)
Postprandial glucose measurements should be made
12 h after the beginning of the meal, generally
peak levels in patients with diabetes.
ADA. V. Diabetes Care. Diabetes Care
201134(suppl 1)S21. Table 10.
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Control Hyperglycemia

• Hyperglycemia needs to be controlled.
• Any glucose excursion causes endothelial damage
• Dont relax with one good glucose reading
• Need to look at trends over 24 48 hours
• Need basal and prandial insulin coverage
• Rare to withhold basal insulin
• Insulin sliding scales do not work alone!
• Reactive vs proactive

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Treating Hypoglycemia

• DM medication given too early
• DM medication dosage too high
• Meals delayed or not eaten

• Give DM medication at right time
• Advocate for adjustment of medication
• Offer food when appropriate

• Problems

• Nursing solutions

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Hypoglycemia

• Test dont Guess
• Anything under 70 mg/dl is hypoglycemia
• Treat
• 16 grams of carbohydrate fast acting
• Glucose gel 15 grams
• Glucose Tabs 4
• ½ cup juice or regular soda
• Wait 15 minutes, - retest

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Hypoglycemia
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Medical Nutrition Therapy

• No longer a diabetic diet (ADA)
• Currently Carb Controlled
• Requires Individualization
• Need for Consistent Carbohydrates
• Some sweets OK
• Meals 4.5to 5 Hours Apart
• Divide Protein and Fats

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Medical Nutrition Therapy

• Consume Fewer Animal Fats
• Emphasize Low Fat Dairy Products
• Emphasize Monounsaturated Fats
• Emphasis upon Fiber
• Decrease Use of Sweets
• Decrease Use of Alcohol

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The Plate Method
The Plate Method is an easy to remember
technique for meal planning. This method
recommends a healthy distribution of
carbohydrates, a lower fat intake, and a greater
amount of fruits and vegetables. It can be used
to eat healthfully, lose weight, and/or manage
your diabetes.
Fill a quarter of your plate with starch or bread
Fill half your plate up with non starchy
vegetables
Fill a quarter of your plate with protein (choose
lean cuts)
Source National Diabetes Education Program
To learn more about how meal planning can help
prevent or manage your diabetes, contact the
Gutman Diabetes Institute, 215-456-6839 or
gutmandiabetesinstitute_at_einstein.edu

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Juice is a Carbohydrate Too!
Even Light Juice Cocktail Contains 8 gm CHO
No Sugar Free Juices
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Sugar Free Foods

• Non-nutritive sweeteners are OK
• Sugar contains 4 kcal/gm
• Sugar alcohols contain ? 2-3 kcal/gm
• End in ol
• May contain more carbohydrate than regular item
• Need to read the label
• Can cause diarrhea

Sorbitol, xylitol, mannitol
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Physical Activity

• Role of Physical Activity
• 150 mins / week most days of the week
• Cells More Receptive to Insulin
• Decreases Insulin Resistance
• Lowers Blood Glucose
• Integral Part of Diabetes Management

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Diabetic Ketoacidosis

• Precipitating Factors
• Infection
• Insulin Omission
• Inadequate Amount of Insulin
• Newly Diagnosed Diabetes

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Diabetic Ketoacidosis

• 3 Clinical Features
• Hyperglycemia - gt250 mg/dL
• Ketonuria or ketonemia
• Acidosis
• pH lt7.3
• and/or serum bicarb lt15 mEq/L

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Diabetic Ketoacidosis

• Absence or reduced effect of insulin
• Excess of counter regulatory hormones
• Glucagon
• Cortisol
• Growth hormone
• Catecholemines

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Diabetic Ketoacidosis

• Clinical Presentation
• Presence of Acidosis
• Abdominal Pain
• Nausea
• Vomiting
• Anorexia

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Diabetic Ketoacidosis

• Clinical Presentation
• Hyperglycemia 3 4 Days
• Metabolic Alterations lt 24 Hours
• Respiratory Symptoms
• Kussmaul Respirations

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Hyperosmolar Hyperglycemic State

• Lab Values
• Glucose gt 600 mg/dl
• No Ketones or Only Small Amounts
• Plasma Osmolality gt 320 mOsm/kg

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Diagnostic Criteria DKA vs HHS
DKA HHS
Mild Moderate Severe
Glucose 250 gt250 .250 gt600
pH 7.25-7.30 7.00-7.24 lt7.00 gt7.30
BiCarb 15-18 10-15 lt10 gt15
Urine Ketones small
Serum Ketones small
Anion Gap gt10 gt12 gt12 lt12
Mentation Alert Alert/Drowsy Stupor/Coma