9/28/2012. Sponsored By: NDSU College of Pharmacy, Nursing and Allied Sciences

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1 Sponsored By: NDSU College of Pharmacy, Nursing and Allied Sciences By PresenterMedia.com Faculty: Wendy Brown Pharm.D, PA-C, AE-C Associate Professor Pharmacy Practice About the Patient Clinical Coordinator About the Patient and MTM Express are owned and operated by the North Dakota Pharmacy Service Corporation in which Dr. Brown is a contract employee. Special recognition to Dr. Eric L. Johnson, M.D. Associate Professor, Department of Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences and Assistant Medical Director Altru Diabetes Center in Grand Forks, North Dakota for his input as an expert content reviewer 1

2 1) Evaluate the pathophysiology and clinical manifestation of diabetes in order to justify blood glucose monitoring and pharmacotherapy. 2) Optimize patients eating and activity for blood glucose and weight control. 3) Describe risk reduction strategies to prevent complications associated with diabetes. 4) Explain healthy coping strategies for patients with chronic disease. A week ago I was diagnosed with Diabetes. The increase in urination was a nuisance until it started waking me up at night. So I went to the clinic and they check my blood sugar and found it to be 234mg/dL. In addition, an A1C was ordered which came back at 9.5%. I've started taking Metformin twice a day. I checked a blood sugar this morning before breakfast which was 150. I will be meeting with the diabetes educator next week. I have always struggled with maintaining a health weight. I had been told that I was pre-diabetic but with my active job in seasonal construction work I did not think I would develop diabetes. I have a history of diabetes in my family. Can diabetes be reversed? And, Metformin seems to make me nauseous is that typical? AADE7 Self-Care Behaviors PatientHandouts.html 2

3 Hyperglycemia Normal Glucose Pre-Diabetes Impaired Fast or impaired glucose tolerance Diabetes No insulin required Insulin for control Insulin for Survival Type 1 Type 2 Diagnosis Random > 200 in symptomatic patient (polyuria, polydipsia, polyphagia) Glucose FPG mg/dL > 126mg/dL 2h-PG mg/dL > 200mg/dL A1C 5.7% - 6.4% > 6.5% Monitoring Fasting mg/dL* < 110mg/dL Ŧ Glucose Random <180mg/dL* < 140mg/dL Ŧ Glucose A1c < 7.0%* < 6.5% Ŧ FPG=Fasting Plasma Glucose, + 2h-PG=2-hour plasma glucose during oral glucose tolerance test, *American Diabetes Association, Ŧ American Association of Clinical Endocrinologists A week ago I was diagnosed with Diabetes. The increase in urination was a nuisance until it started waking me up at night. So I went to the clinic and they check my blood sugar and found it to be 234mg/dL. In addition, an A1C was ordered which came back at 9.5%. I've started taking Metformin twice a day. I checked a blood sugar this morning before breakfast which was 150. I will be meeting with the diabetes educator next week. I have always struggled with maintaining a health weight. I had been told that I was pre-diabetic but with my active job in seasonal construction work I did not think I would develop diabetes. I have a history of diabetes in my family. Can diabetes be reversed? And, Metformin seems to make me nauseous is that typical? Skills Slide Show: Blood Sugar Testing Glucose Meters Methods for Insulin Delivery and Glucose Monitoring in Diabetes: A Summary of Comparative Effectiveness Review JMCP August

4 Interpretation of results Hypo or Hyperglycemic trends Medication(s) dose adjustment or justify additional therapy Comparison to clinic A1C A1C (%) Estimated Average Glucose (eag) (mg/dl) eag=[28.7 x A1C] Problem solving: Month Date: Breakfast breakfast Lunch lunch Dinner dinner Bedtime Awake at night Notes Cheese burger and fries for lunch Walked dinner District meeting for work all day 5 Patient A1C is recheck and found to be 9% Medication Decrease in FPG Decease in H1C Insulin Limited by hypoglycemia % Metformin mg/dl 1 2% Sulfonylureas mg/dl 1 2% GLP-1 Agonists Targets Postprandial Glc 1 1.5% DPP4 Inhibitors Targets Postprandial Glc % Thiazoidinediones mg/dl 1-2% 4

5 Used with permission from Eric Johnson. UND School of Medicine. Diabetes Care 2012 Used with permission from Eric Johnson. UND School of Medicine. Diabetes Care Diabetologia

6 Candidates for More Stringent (<6.5%) No Significant CVD Shorter Duration of disease and longer life expectancy Candidates for Less Stringent (<7.5-8+) Focus on drug safety More likely to be compromised from Hypoglycemia At risk for adverse events from polypharmacy Advanced complications or comorbid conditions Higher CVD burden Reduced GFR Reduced life expectancy Other Considerations: Obesity Intensive lifestyle program Medication management Bariatric Surgery Lean Patient Latent Autoimmune Diabetes Co-morbidities: Coronary Disease, Heart Failure, Renal Disease, Liver Dysfunction Risk and Benefits of Medication American Association of Clinical Endocrinologist Diabetes Algorithm for Glycemic Control: American Diabetes Association Standards of Medical Care in Diabets

7 A week ago I was diagnosed with Diabetes. The increase in urination was a nuisance until it started waking me up at night. So I went to the clinic and they check my blood sugar and found it to be 234mg/dL. In addition, an A1C was ordered which came back at 9.5%. I've started taking Metformin twice a day. I checked a blood sugar this morning before breakfast which was 150. I will be meeting with the diabetes educator next week. I have always struggled with maintaining a health weight. I had been told that I was pre-diabetic but with my active job in seasonal construction work I did not think I would develop diabetes. I have a history of diabetes in my family. Can diabetes be reversed? And, Metformin seems to make me nauseous is that typical? Three Months Later: A1C=9% Month Date: Breakfast breakfast Lunch lunch Dinner dinner Bedtime Awake at night Notes Cheese burger and fries for lunch Walked dinner Safety meeting for work all day 5 Used with permission from Eric Johnson. UND School of Medicine. Diabetes Care Diabetologia 2012 Month Date: Breakfast breakfast Lunch lunch Dinner dinner Bedtime Awake at night Notes Cheese burger and fries for lunch Walked dinner Safety meeting for work all day 5 Starting Insulin in Type 2 patient: 7

8 Foods with 15 grams carbohydrates: 4 oz (1/2 cup) of juice or regular soda 2 tablespoons of raisins 4 or 5 saltine crackers 4 teaspoons of sugar 1 tablespoon of honey or corn syrup Portion Distortion: Carbohydrate Counting A general guideline for patients is g/meal and g/snack Food List: American Dietetic Association: Choose Your Foods: Exchange Lists for Diabetes 8

9 Recall that our patient s Fasting glucose was 150mg/dL. Then he had the following for breakfast: 2 Cups of Multigrain Cheerios=? 8-fl-oz 2% milk=? 1 Blueberry Muffin=? How many total carbohydrates were consumed? 2 Cups of Multigrain Cheerios= 48g 8-fl-oz 2% milk= 12g 1 Blueberry Muffin= 35g Total: 95g For more information on advanced carbohydrate counting and insulin incorporation: insulin_adjustment_workbook_complete.pdf Any activity that a person with diabetes participates in can help lower blood sugar and pressure as well as increase quality of life. Goals: Cardiovascular: 5 days/week for 30 minutes Resistance: 3 days/week 9

10 SMART Goal Setting Specific Measurable Attainable Relevant Time Bound Goal needs work Goal is Much better Adapted from Paul J Meyers Attitude is Everything Cardiovascular Disease Nephropathy Neuropathy Retinopathy Oral Health Tobacco cessation Alcohol consumption Cardiovascular Adult Blood Pressure Goal: / Cholesterol especially LDL goal: (with CV disease: ) Maintaining ideal weight that is patient specific. 10

11 Cardiovascular Consider aspirin therapy ( mg/day) as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk (10-year risk >10%) Most men >50 years or women >60 years of age Have at least one additional major risk factor: Family history of CVD, Hypertension, Smoking, Dyslipidemia, or Albuminuria Diabetes Care January 2012 vol. 35 no. Supplement 1 S11-S63 Microvascular complication ACE/ARB Use LEAP Exam Annual Dilated Eye Exam Habits Oral Health: Brush teeth at least twice a day and floss once a day. Check-ups q 6month or more frequent if dental disease is present Screen for substance abuse Tobacco Cessation: State Quit Lines Standard Drinks per Day Men-two glasses per day Women- one glass per day 11

12 Immunizations: Annual Influenza Pneumococcal vaccination Hepatitis B Once before age 65 then a one-time revaccination is recommended for individuals >64 years of age previously immunized when they were <65 years of age if the vaccine was administered more than 5 years Adults with diabetes under the age of 60, and optional for those 60 years and older Identifying patient frustration Chronic Disease and support structure Sickness and managing sick days Management of disease at work/school/travel Sexual Health Skin Health Screen for Depression PRIME-MD PHQ (2 Question Screen) PHQ-9%20two%20question.pdf Living with Diabetes Program Core Concepts Course-American Association of Diabetes Educators educational_conferences.html 12

13 Questions: 13