Diabetes Management: A diagnostic perspective

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1 Diabetes Management: A diagnostic perspective Images:

2 Type 1 diabetes 5-10% of all diabetes More common in children and young adults, but possible at any age Immune system destroys pancreatic beta cells that produce insulin (dx=gad antibodies +, c-peptide -) Insulin replacement is required

3 Type 2 diabetes 90-95% of cases More common in adults, but increasingly seen in younger age groups Tissues not responding to insulin or not taking in glucose like before ( insulin-resistance ) Pancreas compensates by increasing insulin production, but gradually loses ability to produce more The body (usually the liver) makes too much glucose Oral meds often first tx, but insulin replacement may ultimately be needed

4 Diagnosis & Screening

5 Insulin types: Basal Drug Names Onset Peak Duration NPH (Novolin) Glargine (Lantus) Detemir (Levemir) Degludec 2-4 hours 4-8 hours 8-18 hours 4-5 hours None hours 2 hours 6-8 hours hours ~36 hours Image:

6 Insulin types: Prandial Drug Names Onset Peak Duration Regular Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) min 2-3 hours 4-8 hours min 1-2 hours 3-6 hours min 1-2 hours 3-6 hours min 1-2 hours 3-6 hours Image:

7 Medicines for type 2 diabetes Drug Names Primary Site of Action and Drug Class Mechanism of Action Route Possible Adverse Effects Metformin (Glucophage) Liver Biguanide Decreases amount of glucose the liver releases into bloodstream; May help reduce insulin resistance Orally Nausea, vomiting, diarrhea, gas (can minimize effects by slowly increasing dose) Glyburide Glipizide Repaglinide (Prandin) Pancreas Insulin secretagogues Helps the pancreas release more insulin Orally Hypoglycemia Nateglinide (Starlix) Exenatide (Byetta, Bydureon) Liraglutide (Victoza) Pancreas, Liver, Gut Incretin Increases satiety, Promotes pancreas release of adequate insulin; Prevents overproduction of glucose in the liver; Slows movement of food out of the gut; Subcutaneously Nausea, vomiting, hypoglycemia

8 Medicines for type 2 diabetes Drug Names Sitagliptin (Januvia) Saxagliptin (Onglyza) Primary Site of Action and Drug Class Pancreas, Liver DPP-IV inhibitor Mechanism of Action Route Possible Adverse Effects Reduced degradation of GLP-1 (see GLP-1 MOAs) Orally No major side effects, possible cold symptoms Rosiglitazone (Avandia) Pioglitazone (Actos) Muscle Thiazolidine-diones (TZDs) Improves the ability of muscle and other cells to use insulin Orally Weight gain, swelling, lipid increases Acarbose (Precose) Miglitol (Glyset) Gut Alpha glucosidase inhibitors Slows breakdown of carbohydrates from food Orally Diarrhea, gas, nausea (can minimize effects by slowly increasing dose) Canagliflozin (Invokana) Dapagliflozin (Farxiga) Kidney SGLT2 inhibitors Inhibits glucose reabsorption in the kidney, resulting in urinary glucose excretion Orally UTIs, renal impairment

9 Case Alice is a 58yo female with T2DM and heart failure. She comes to the clinic for help managing these conditions. She takes metformin 1000 mg daily, NPH 50units SC am and pm, and Novolog 8-10units before meals. Labs: BUN 1, Scr 1, egfr 57 ml/min) You download her glucometer data and print the results. Image:

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11 Questions about Alice s meter data What is the target range for normal glucose control? What trends do you see? Do you see episodes of hypoglycemia?

12 Case Rick is a 65yo male, and has been coming to the clinic for help managing his type 2 diabetes. He takes Lantus 40 units SC in the evenings, and Humalog 4-6 units at meals. You download his glucometer data and print the results. Image:

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15 Questions about Rick s meter data What trends do you see? Do you see episodes of hypoglycemia? From the table, why is standard deviation relevant?

16 Case Kevin is a 36yo male, an avid mountaineer, who plans to summit Mt. Rainier. He has type 1 diabetes, and wants to talk about what an appropriate glucometer option would be for him. Image:

17 Questions about Kevin s case What things might you consider when selecting a glucometer for a patient? What about Kevin s lifestyle might influence your glucometer recommendation? What meter might be the best option for Kevin, considering his plans?

18 How does a glucometer work? Test strips containing glucose oxidase react with glucose in a blood droplet, and an electrode in the meter reads the flux of the reaction. The number reported corresponds to the signal strength so, the more glucose, the higher the number. Image:

19 Other glucometer technology: Glucose dehydrogenase meters Glucometers containing glucose dehydrogenase work in a similar way, but utilize an oxygenindependent process instead. Image:

20 Altitude and glucometer reliability Several studies have been done over the years to assess this Mixed results Many earlier studies report consistent inaccuracy of meters Dehydrogenase meters typically reported to perform better Some recent studies have not found a difference

21 Some references regarding altitude and glucometer assessment Diabetes Care Dec;19(12): Diabet Med Sep;18(9): Diabetes Technol Ther. 2002;4(5): Diabetes Care May;28(5):1261. J Med Eng Technol Mar-Apr;31(2): PLoS One Nov 12;5(11):e doi: /journal.pone High Alt Med Biol Sep;14(3): doi: /ham Marco Cardosi and Zuifang Liu (2012). Amperometric Glucose Sensors for Whole Blood Measurement Based on Dehydrogenase Enzymes, Dehydrogenases, Prof. Rosa Angela Canuto (Ed.), ISBN: , InTech, DOI: / Available from:

22 Insulin pump case Madeline is a 17yo female, who has just started coming to the clinic for help managing her type 1 diabetes. She wears an insulin pump and sensor, and says she s really starting to get the hang of using these. A= Pump system B= Infusion set C= Sensor D= Transmitter Image:

23 Questions about Madeline s case What type of patients would be good candidates for pump therapy? What device-related concerns would you have to consider with a pump? What other counseling points would be pertinent to cover with Madeline?