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Chronic Disease Management: Diabetes Mellitus

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Title: Chronic Disease Management: Diabetes Mellitus


1
Chronic Disease Management Diabetes Mellitus
  • Rachel Waite, Pharm.D. Candidate

2
By the end of this talk you should be able to
  • Explain the difference between type 1 and type 2
    diabetes mellitus
  • List risk factors for DMT2
  • Explain the difference between prediabetes,
    diabetes, metabolic syndrome
  • Describe microvasuclar and macrovasular
    complications of diabetes.

3
  • Counsel a patient on hypoglycemia treatment
  • Counsel a patient on non-drug diabetes management
    tools.
  • Counsel a patient on treatment goals of diabetes.
  • List the components of a SOAP note
  • Practice writing a SOAP note from an example case

4
Impact of DM
  • 25.8 million Americans have diabetes (8.3 of
    population)
  • The number of Americans treated for diabetes
    doubled from 1996 to 2007.
  • 1 in 3 Americans born in 2000 will have diabetes
    in their lifetime
  • Annual costs -- 132 billion
  • Leading cause of blindness, ESRD, amputations,
    MI, strokes

5
  • 84 of people with diabetes are on oral
    medication or insulin
  • Source 20072009 National Health Interview Survey

6
Diabetes Mellitus Type 1
  • Results from inability of islet cells to produce
    insulin
  • Also known as insulin-dependent or juvenile-onset
    diabetes
  • Cause is unknown, but likely to have genetic,
    autoimmune component

7
Diabetes Mellitus Type 2
  • Results from decreased insulin sensitivity and
    decreased pancreatic beta-cell function

8
Gestational Diabetes
  • Diabetes that first presents during pregnancy
  • Occurs in 2-10 of pregnancies
  • 30-60 chance of developing T2DM

9
95 of DM patients are Type 2
10
Source SEARCH for Diabetes in Youth Study
NHWnon-Hispanic whites NHBnon-Hispanic blacks
HHispanics/Latinos APIAsian/Pacific Islander
Americans AIAmerican Indians
11
DMT1 v. DMT2
Characteristic Type 1 Type 2
Age of onset Childhood / adolescence gt age 40
Rate of onset Abrupt Gradual
Family hx Increased prevalence with Fm Hx Type 1 Increased prevalence with Fm Hx Type 2
Islet cell Abs Yes No
Body weight Thin, undernourished Overweight, obese
Insulin Marked decrease Insulin Rx mandatory Insulin not necessary initially
Symptoms Weight loss, ?thrist, ?urination, ?hunger May be asymptomatic
12
Risk Factors T2DM
  • Obesity (BMI gt27)
  • Hypertension
  • Hx Gestational DM
  • Family Hx DM
  • Dyslipidemia
  • Hx vascular disease
  • Previous impaired fasting glucose test, impaired
    glucose tolerance
  • Polycystic ovaries
  • Inactive lifestyle
  • Certain ethnicities (African Americans,
    Hispanics, Native Americans, Pacific Islanders).

13
Metabolic Syndrome
  • A group of risk factors that occur together that
    increase risk for diabetes, coronary artery
    disease, and stroke.
  • Not the same as pre-diabetes

14
Metabolic Syndrome
  • Elevated waist circumference
  • Men Equal to or greater than 40 inches
    (102 cm)
  • Women Equal to or greater than 35 inches
    (88 cm)
  • Elevated triglycerides
  • Equal to or greater than 150 mg/dL
  • Reduced HDL (good) cholesterol
  • Men Less than 40 mg/dL
  • Women Less than 50 mg/dL
  • Elevated blood pressure
  • Equal to or greater than 130/85 mm Hg
  • Elevated fasting glucose
  • Equal to or greater than 100 mg/dL

15
Screening
  • Fasting Plasma Glucose (mg/dL) (FPG)
  • Check a fasting glucose level
  • Oral Glucose Tolerance Test (mg/dL) (OGTT)
  • Check blood glucose 2 hours after a 75g oral
    glucose load
  • Hemoglobin A1c
  • Shows percentage of glycated hemoglobin.
  • Reflects glucose control over 6-12 week period.

16
(No Transcript)
17
HbA1c and Average Plasma Glucose Correlation
  • HbA1c Plasma Glucose
  • 6 120
  • 7 150
  • 8 180
  • 9 210
  • Etc.

18
Signs and Symptoms
19
The Polys
  • Polyuria / polydipsia Glucose spilled into
    urine, leads to osmotic diuresis (polyuria). This
    leads to dehydration, and increased thirst
    (polydipsia).
  • Polyphagia without insulin function, glucose
    cannot be transported into cells. Cells are
    hungry and hunger sensation is triggered.
  • Polys can go unnoticed for years.

20
Complications
  • Microvasuclar damage to eyes, kidneys, nerves
    (retinopathy, nephropathy, neuropathy)
  • Macrovascular 2X risk for heart attack and
    stroke, peripheral vascular disease

21
Hypoglycemia
  • Definition plasma glucose lt70
  • A complication of treatment!
  • Normal plasma glucose 70-150
  • 40 is the minimum for brain function
  • lt40 Risk for diabetic coma, seizures

22
Symptoms of Hypoglycemia
  • Heat palpitations
  • Confusion
  • Tremor
  • Sweating
  • Anxiety
  • Hunger
  • Visual disturbances
  • Seizure
  • Loss of Consciousness

23
Hypoglycemia Treatment
  • Glucose
  • 15 grams of simple carbohydrates
  • 8oz. fruit juice
  • Half can regular soda
  • 3 glucose tabs
  • 1 tablespoon honey
  • Glucagon injection
  • Stimulates glycogen breakdown

24
Patient Education
Diabetes Survival Skills
  • Food, exercise, meds
  • Treatment plan
  • Goals / targets
  • Self-monitored blood glucose
  • Hypoglycemia
  • Emergency numbers
  • If insulin injection technique, syringe
    disposal, storage, etc.
  • Foot care
  • Ophthalmic exams

25
Target Goals
  •  Glycemic Control

A1c 7
Fasting (preprandial) Plasma Glucose 70-130 mg/dL
Postprandial or HS Plasma Glucose lt180 mg/dL
26
Target Goals
  • Blood pressure
  • lt130/80
  •  
  • Lipids
  • LDL lt 100mg/dL (if CAD lt70)

27
  • What if your patient doesnt make goals?
  • It is okay. Any decline decline in risk

28
Non-Drug Management Tools
  • Diet
  • Exercise
  • Smoking cessation
  • Alcohol in moderation
  • Education
  • Monitoring

29
Questions
  • ?

30
A Case
  • Mr. Smith came to the pharmacy this morning to
    pick up his refill prescription for lisinopril
    10mg once daily, metformin 1000mg twice daily,
    and lispro insulin. This is the second time he
    has filled his insulin prescription. He did not
    receive diabetes education. He said that he often
    gets dizzy about 20 minutes after taking his
    lispro, especially when he hasnt eaten recently.
    He uses the insulin at 8am, noon, and 6pm, but
    his prescription says that he should take 15units
    15min. before meals. He does not eat regular
    meals. His injection technique is good and I
    observed his technique in the pharmacy. He takes
    a baby aspirin every day. He was diagnosed with
    type 2 diabetes and hypertension 1 year ago at a
    routine physical. His last visit with his PMD was
    2 months ago and at that time he had a blood
    glucose of 245, an A1c of 9.5, BP of 145/92 and
    a serum creatinine of 1.8. At this visit he got
    a prescription for insulin. He describes his
    hypoglycemia reaction as getting dizzy, shaky,
    and he sometimes feels lightheaded, like he might
    pass out. He pulled out his blood glucose meter
    and the last 5 readings were 65, 138, 142, 95,
    112. He checks his blood glucose before giving
    his insulin. I think that he should only use the
    insulin after meals, and I told him that if he
    has symptoms of hypoglycemia he should have a
    small sugar snack like 8 oz. of juice or 3
    glucose tabs. Mr. Smith works as a construction
    worker and eats a lot of fast food on the run. He
    does not smoke or drink and he plays in a church
    softball league on the weekends. He is 57 years
    old and he weighs 220lbs and he is 5foot9. I
    think Mr. Smith should go to a diabetes education
    class and I called his physician to get a
    prescription for glucagon, just in case. I also
    sold him a roll of glucose tabs. His dad had T2DM
    and also came to this pharmacy. I told Mr. Smith
    to eat less fast food.

31
Written Communication
  • Useful tool to pass along information when
    transitioning patient care from one person to
    another
  • Shift changes
  • From one healthcare field to another
  • Guidance for future encounters

32
SOAP Format
  • Subjective
  • Objective
  • Assessment
  • Plan

33
Subjective
  • Information the pt tells you about him/herself
  • Includes
  • ID Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Past Medical History (PMH)
  • Drug History (DH)
  • Family History (FH)
  • Social History (SH

34
Objective
  • Observable/factual information obtained from or
    verified by a healthcare provider
  • Vital signs (BP, HR, RR, temp, wt, ht)
  • Physical Exam
  • Labs (blood tests, urine tests, microbiology,
    etc)
  • Diagnostic tests (x-rays, CT/MRI, EKG, EEG)
  • Medications (from profile or chart)

35
Active Learning
  • 1. Find a partner
  • 2. With your partner, circle all of the
    subjective information in the case.
  • 3. With your partner, underline all of the
    objective information in the case.
  • Use your handout to decide what information is
    subjective, and what is objective.

36
S
  • MS is a 57 y.o. male who presented at the
    pharmacy today to pick up refill prescriptions,
    complaining of symptoms of hypoglycemia.
  • CC He describes feeling dizzy, shaky,
    lightheaded when he takes his insulin and does
    not eat.
  • DH Lisinopril 10mg Qday, Metformin 1000mg BID,
    Insulin Lispro 15 units 15 min. before meals,
    Aspirin 81mg daily.
  • PMH He was recently diagnosed with T2DM and HTN
    1 year ago at a routine physical.
  • FH Father had T2DM.
  • SH He works as a construction worker and
    frequently eats fast food. He does not smoke or
    drink. He did not receive diabetes education.

37
O
  • From PMD visit 2 mo. ago Blood Pressure
    145/92, Serum Cr 1.8, BG 245, HA1c 9.5, Wt.
    220lb. Ht. 59.
  • Calculated BMI is 32.5.
  • The patient demonstrated good insulin injection
    technique at home.
  • His last 5 self-monitored blood glucose readings
    were 65, 138, 142, 95, 112. He monitors his blood
    glucose 3 times daily before administering his
    insulin.

38
Assessment
  • Your clinical judgment of the patients
    drug-related problems
  • Problem list (numbered)
  • Each item should include
  • problem, solution, evidence/reason for your
    solution
  • Prioritize problems
  • start with most urgent (usually relates to CC)
  • end with least urgent

39
Plan
  • Specific solution for each problem outlined in
    the assessment
  • Numbered list to match the Assessment
  • Recommendations for drug dose, frequency,
    duration
  • Monitoring
  • Follow-up

40
Find another partner
  • For the practice case, pick out the parts of the
    pharmacists assessment and plan with your
    partner.
  • Is there any assessment in the note as written?
  • Discuss what things go in Assessment, and what
    goes in Plan

41
A
  • 1. Insulin use Lispro is a rapid-acting insulin
    and can cause hypoglycemia. It should be given 15
    minutes before meals.
  • 2. Hypoglycemia The patient is experiencing
    hypoglycemia symptoms approximately 3 times a
    week when he skips meals. He should be counseled
    on preventing hypoglycemia, recognizing signs and
    symptoms of hypoglycemia, and how to treat
    hypoglycemia.
  • 3. Education This patient does not eat regular
    meals. He could benefit from a diabetes education
    class to learn carbohydrate counting and other
    diabetes survival skills. Diabetes education has
    been shown to improve outcomes.
  • 4. Lifestyle changes Increasing exercise to most
    days of the week, reducing fast food consumption,
    and increasing complex carbohydrates and lean
    protein in the diet are non-pharm strategies this
    patient can implement to manage his diabetes.
    Weight loss to a BMI 25 can increase insulin
    sensitivity.

42
P
  • 1. Administer insulin 15 minutes before meals.
    Encourage regular meal. If skipping a meal, do
    not administer insulin.
  • 2. If SMBG reading is lt70 have a small meal or
    snack of 15g simple carbohydrates. Examples are
    8oz. juice or half a can of regular soda. Counsel
    the patient that dizziness, shaking, anxiety, and
    lightheadedness are symptoms of hypoglycemia. If
    the experiencing these symptoms check blood sugar
    and have a snack if necessary. 15 min. after a
    snack, recheck blood sugar. Get a prescription
    for glucagon pen, 1mg IM if unresponsive due to
    hypoglycemia. Counsel friends and family members
    to use pen if patient unresponsive.
  • 3. Recommend a diabetes education class at the
    community hospital next week.
  • 4. Recommend 150 min. aerobic exercise per week
    and resistance training 3 times per week.
    Increase consumption of complex carbohydrates and
    lean protein. Encourage a Mediterranean diet
    and less fast food. Recommend weight loss to a
    goal of lt170lbs (BMI 25).
  • Will follow up with patient at next refill in one
    month.

43
Questions
  • ?

44
References
  • Standards of medical care in diabetes--2011.
    Diabetes Care. 2011 Jan34 Suppl 1S11-61.
  • Centers for Disease Control and Prevention.
    National Diabetes Fact Sheet national estimates
    and general information on diabetes and
    prediabetes in the United States, 2011. Atlanta,
    GA U.S. Department of Health and Human Services,
    Centers for Disease Control and Prevention, 2011.
  • Triplitt Curtis L, Reasner Charles A, Isley
    William L, "Chapter 77. Diabetes Mellitus"
    (Chapter). Joseph T. DiPiro, Robert L. Talbert,
    Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L.
    Michael Posey Pharmacotherapy A
    Pathophysiologic Approach, 7e http//www.accessph
    armacy.com.offcampus.lib.washington.edu/content.as
    px?aID3207048.
  • Odegard, P. Diabetes Mellitus Type I. Pharm 561.
    University of Washington School of Pharmacy,
    Seattle, WA. Feb 22 2010 Lecture.
  • Ellsworth A. Pharmacotherapy, Diabetes Type 2.
    Pharm 561. University of Washington School of
    Pharmacy, Seattle, WA. Feb 24 2010 Lecture.
  • Mayoclinic.com/health/hypoglycemia
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