10/8/13. the diabetes epidemic: strategies for saving sight. financial disclo$ure. unlabeled-investigative use disclosure

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1 10/8/13 ASORN 2013 Annual Meeting New Orleans, LA the diabetes epidemic: strategies for saving sight Kate Goldblum, CNP financial disclo$ure I have no financial interests relevant to my presentation. unlabeled-investigative use disclosure I will not discuss unlabeled no investigational use and/or investigational uses of any commercial products. ed FDA approv 1

diabetes estimates almost 26 million people have diabetes 18.8 million diagnosed 7.0 million undiagnosed 8.

2 diabetes mellitus health & socioeconomic burdens complications macrovascular & microvascular prevention, control, & treatment role of self-management international diabetes foundation 2010 U.S. diabetes estimates almost 26 million people have diabetes 18.8 million diagnosed 7.0 million undiagnosed 8.3% of population 26.9% 65 years old 11.8% men 10.8% women 10.2% non-hispanic whites 18.7% non-hispanic blacks 1.9 million 20 years old newly diagnosed 215,000 < 20 years old newly diagnosed 2

estimates of diagnosed diabetes in adults 20 years (2008) Percent 0 6.5 6.6 8.0 8.1 9.4 9.5 11.1 11.2 www.cdc.

9% 18.0-21.9% 22.0-25.9% 26.0% 1994 Diabetes 2000 2008 No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% 9.

3 estimates of diagnosed diabetes in adults 20 years (2008) Percent obesity epidemic percentage of US adults: obesity & diabetes 1994 Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % 26.0% 1994 Diabetes No Data <4.5% % % % 9.0% Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available online at: Accessed 10/3/

obesity in diabetes prevalence of obesity & overweight among adults 85.2% overweight or obese 54.

2010 population = 79 million 20 years old most people with prediabetes undiagnosed *based on FBG or

4 obesity in diabetes prevalence of obesity & overweight among adults 85.2% overweight or obese 54.8% obese women aged years vs 65 years had significantly higher prevalence of obesity (64.7% vs 47.4%) during prediabetes* in the US 35% 20 years old 50% 65 years old applied to 2010 population = 79 million 20 years old most people with prediabetes undiagnosed *based on FBG or HgA1c morbidity and mortality leading cause of: kidney failure non-traumatic lower limb amputations new cases of blindness among adults major cause of heart disease and stroke seventh leading cause of death in U.S. 4

5 diabetes treatment 16% - no medication 58% - oral medication only 12% - insulin only 14% - oral medication & insulin $ $ $ $ $ $ $ $ $ $ $ $ $ $ economic costs (2007) $174 billion total costs $116 billion excess medical costs $27 billion direct treatment costs $58 billion related chronic complications $31 billion excess medical costs $58 billion reduced national productivity cost breakdown by payee 50% hospital inpatient 12% medications & supplies 11% medications to treat complications 11% office visits $ $ $ $ $ $ $ economic costs average annual expenditures of a person with diabetes $11,744 total $6,649 attributed to diabetes ~2.3 times higher medical expenditures in those with diagnosed diabetes ~1 in 5 health care dollars spent on care for those people ~1 in 10 health care dollars attributed to diabetes $58.2 billion indirect costs 15 million absent work days 120 million reduced productivity days 6 million reduced productivity days for those not in labor force 107 million days permanent disability 284,000 deaths 5

direct and indirect costs disease burden in 2050 prevalence projected to from 1 in

15/1000 3 key factors in increased disease burden aging of the population

with diabetes standards of medical care classification & diagnosis testing in

of type 2 DM diabetes care prevention & management of complications assessment of

strategies for improving diabetes care American Diabetes Association (2013).

6 direct and indirect costs disease burden in 2050 prevalence projected to from 1 in 10 to 1 in 3 5 adults (diagnosed & undiagnosed) incidence will from 8/1000 to 15/ key factors in increased disease burden aging of the population increasing size of higher-risk minority populations declining mortality among those with diabetes standards of medical care classification & diagnosis testing in asymptomatic patients detection & diagnosis of gestational DM prevention or delay of type 2 DM diabetes care prevention & management of complications assessment of common comorbid conditions diabetes care in specific populations & settings strategies for improving diabetes care American Diabetes Association (2013). Diabetes Care: Clinical Practice Recommendations. Journal of Clinical and Applied Research and Education, 36 (Supplement 1). 6

diagnostic criteria pre-diabetes FPG of 100 to 125 mg/dl (IFG) OR 2 hour plasma glucose of 140-199 mg/dl (IGT) OR HgA1c 5.7% to 6.4% diabetes HgA1c 6.

7 diagnostic criteria pre-diabetes FPG of 100 to 125 mg/dl (IFG) OR 2 hour plasma glucose of mg/dl (IGT) OR HgA1c 5.7% to 6.4% diabetes HgA1c 6.5% OR FPG 126 mg/dl OR 2 hour plasma glucose 200 mg/dl during an oral glucose tolerance test OR random plasma glucose 200 mg/dl in a patient with classic symptoms of hyperglycemia testing recommendations in asymptomatic patients consider in overweight or obese adults with one or more additional risk factors if no risk factors begin testing at age 45 if normal, repeat at least every 3 years use HgA1c, FPG or 2 hour OGTT diabetes mellitus type 1 autoimmune disorder pancreatic β cell destruction insufficient or absent insulin production requires exogenous insulin old terminology: juvenile onset, IDDM type 2 begins as insulin resistance progressive insulin secretory defect over time requires exogenous insulin old terminology: adult onset, NIDDM 7

prevention or delay of type 2 in patients with prediabetes targeted weight loss of 7% of

important for success insurance programs should cover such programs based on

risk factors for cardiovascular disease diabetes care complete evaluation history physical

age) dietician self-management education dentist mental health professional, prn diabetes

8 prevention or delay of type 2 in patients with prediabetes targeted weight loss of 7% of body weight at least 150 minutes/week moderate physical activity follow up counseling important for success insurance programs should cover such programs based on costeffectiveness consider metformin monitor for DM annually screen for & treat modifiable risk factors for cardiovascular disease diabetes care complete evaluation history physical exam laboratory evaluation referrals ophthalmology family planning (for of child-bearing age) dietician self-management education dentist mental health professional, prn diabetes care team patient physicians nurse practitioners physician s assistants nurses dietitians pharmacists mental health professionals 8

glycemic control self-monitoring of blood glucose (SMBG) HgA1c recommended monitoring on multiple dose insulin or pump therapy before meals & snacks (at least) after eating (occasionally) at bedtime

9 glycemic control self-monitoring of blood glucose (SMBG) HgA1c recommended monitoring on multiple dose insulin or pump therapy before meals & snacks (at least) after eating (occasionally) at bedtime before exercise suspicion of low glucose after treating low glucose until normoglycemic before critical tasks (e.g., driving) continuous glucose monitoring intensive insulin regimens in adults 25 and older with type 1 those with hypoglycemia unawareness or frequent hypoglycemia A1c monitoring at least twice yearly in stable patients meeting treatment goals quarterly in patients changing therapy or not meeting glycemic goals 9

10 glycemic goals A1c to 7% or below reduces microvascular complications associated with long-term reduction in macrovascular disease if implemented soon after dx A1c to < 6.5% in select patients (short duration of DM, long life expectancy, no significant CVD) if patients don t get significant hypoglycemia glycemic goals A1c to < 8% may be appropriate hx of severe hypoglycemia limited life expectancy advanced microvascular or macrovascular complications extensive comorbid conditions longstanding DM and difficult goal attainment despite self-management education appropriate glucose monitoring effective doses of multiple glucose lowering agents including insulin glycemic recommendations* A1c >7% preprandial CPG between 70 to 130 mg/dl peak postprandial CPG <180 mg/dl goals should be individualized *nonpregnant adults 10

11 insulin therapy in type 1 DM multidose insulin (3-4 injections/day of basal and prandial insulin continuous infusion is good alternative patients need to know how to match prandial insulin dose to CHO intake, preprandial CPG, & anticipated activity most should use insulin analogs to reduce risk of hypoglycemia therapy in type 2 DM metformin preferred as initial pharmacological agent consider insulin therapy (with or without other agents at the outset if newly diagnosed and markedly symptomatic or with very elevated blood glucose or HgA1c levels add second oral agent if not within goal in 3 to 6 months on noninsulin monotherapy patient-centered approach & recognition that insulin therapy eventually indicated for many recommended eye exams type 1 initial exam 3-5 years after diagnosis subsequent follow up yearly type 2 initial exam at time of diagnosis subsequent follow up yearly pregnancy prior to conception early in 1 st trimester every 3-12 months if mild/moderate NPDR every 1-3 months if severe NPDR 11

scope of diabetic retinopathy one of leading causes of new blindness in U.S. adults 20 to 74 years of age estimated projections for adults 40 years of age by 2050 DR: 5.

12 scope of diabetic retinopathy one of leading causes of new blindness in U.S. adults 20 to 74 years of age estimated projections for adults 40 years of age by 2050 DR: million vision-threatening DR: million estimated projections for adults 65 years of age by 2050 DR: million vision-threatening DR: million epidemiology of DR type 1 5 years 25% 10 years 60% 15 years 80% type 2 < 5 years 40% of those taking insulin 24% of those not taking insulin 5 to 19 years 84% of those taking insulin 53% of those not taking insulin disease duration: major risk factor diabetic retinopathy non-proliferative earlier stage of DR (NPDR) Microaneurysms dot-blot or flame-shaped retinal hemorrhages cotton-wool spots severe NPDR 4 quadrants of microaneurysms (>20 in each quadrant) 2 quadrants of venous beading or 1 quadrant of IRMA 15% chance of progressing to proliferative DR within 1 year proliferative later stage of DR (PDR) abnormal blood vessels on optic disc, retina, iris, angle structures vitreous/pre-retinal hemorrhage associated with severe vision loss 12

CDME clinically significant macular edema retinal thickening at or within 500 microns of macula hard exudates at or within 500 microns of macula if associated with thickening of the adjacent retina

13 CDME clinically significant macular edema retinal thickening at or within 500 microns of macula hard exudates at or within 500 microns of macula if associated with thickening of the adjacent retina zone(s) of retinal thickening one disc area in size, any part of which is within 1 disc diameter of the macula may be present in NPDR or PDR if present, requires increased vigilance/treatment proliferative DR type 1 50% in patients with 20 years disease duration* 18% in patients with > 15 years disease duration** type 2 2% in patients with < 5 years disease duration*** 25% in patients with 25 years disease duration*** *Wisconsin Epidemiologic Study of Diabetic Retinopathy: II (1984) **Prevalence of Diabetic Retinopathy in Adult Latinos: The Los Angeles Latino Eye Study (2004) and Diabetes and Diabetic Retinopathy in a Mexican American Population: Proyecto VER (2001) ***Wisconsin Epidemiologic Study of Diabetic Retinopathy: III (1984) landmark research DCCT diabetes control & complications trial EDIC epidemiology of diabetes interventions & complications DRS diabetic retinopathy study ETDRS early treatment diabetic retinopathy study DRVS diabetic retinopathy vitrectomy study UKPDS united kingdom prospective diabetes study 13

The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.

14 glycemic control exponential relationship between mean HgA1c and risk of DR HgA1c by 10% (e.g. from 9.0% to 8.1%) = risk of retinopathy progression by 39% no glycemic threshold at which risk was eliminated above non-diabetic range of HgA1c (4.0% to 6.05%) Diabetes Control & Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329: glycemic control take home message good control of hyperglycemia works reduction in complications cardiovascular disease kidney disease neuropathy retinopathy management & treatment normal or minimal NPDR & no CSME FU 12 months mild to moderate NPDR no CSME FU 6-12 months with CSME FU 2-4 months IVF usually focal or grid laser usually American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2008 (4 th printing 2012). Available at 14

15 management & treatment severe NPDR & non-high-risk PDS PDR no CSME FU 2-4 months PRP sometimes* IVF rarely focal or grid laser no With CSME FU 2-4 months PRP sometimes* IVF usually Focal or grid laser usually *may be considered if approaching high-risk PDR American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2008 (4 th printing 2012). Available at management & treatment high-risk PDR no CSME FU 2-4 months PRP usually IVF rarely focal or grid laser no with CSME FU 2-4 months PRP usually IVF usually focal or grid laser usually American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2008 (4 th printing 2012). Available at management & treatment inactive or involuted PDR PDR no CSME FU 6-12 months PRP no IVF no focal or grid laser usually with CSME FU 2-4 months PRP no focal or grid laser usually American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2008 (4 th printing 2012). Available at 15

10/8/13 cost effectiveness of treatment study of treating retinopathy in type 1

lost productivity and human suffering computer model ophthalmic care decreased

losses & costs of disability facilities Javitt JC, Aiello LP, Bassi LJ, et al.

Savings associated with improved implementation of current guidelines.

knowledge needs ophthalmic complications other information diet & exercise

implications holistic approach is crucial self-management is key multiple health

16 10/8/13 cost effectiveness of treatment study of treating retinopathy in type 1 DM substantial savings compared to direct costs didn t include indirect costs in lost productivity and human suffering computer model ophthalmic care decreased prevalence of blindness by 52% direct costs of care were less than productivity losses & costs of disability facilities Javitt JC, Aiello LP, Bassi LJ, et al. Detecting and treating retinopathy in patients with type I diabetes mellitus. Savings associated with improved implementation of current guidelines. American Academy of Ophthalmology. Ophthalmology 1991;98: ; discussion knowledge needs ophthalmic complications other information diet & exercise pharmacologic therapies oral agents insulin symptoms of hypoglycemia nursing implications holistic approach is crucial self-management is key multiple health care professionals often involved education is a major component of care ophthalmic-related other health aspects 16

nursing interventions communication with PCP written report following every eye examination direct communication when indicated patient education list of useful resources print and webbased handout

17 nursing interventions communication with PCP written report following every eye examination direct communication when indicated patient education list of useful resources print and webbased handout for every patient with diabetes ABCs HgA1c less than 7% Blood pressure 140/80 or below Cholesterol LDL less than 100 Report of Diabetes Eye Examination on To: Clinic/Office Primary Care Provider Phone Fax Patient Name DOB Visual Acuity OD OS Intraocular Pressure OD OS Retinal Examination Findings No retinopathy or history of retinopathy; recommend re-examination in one year. Needs no laser now, but should return in months because of risk of developing diabetic macular edema (DME) or high risk proliferative diabetic retinopathy (PDR). DME requiring focal laser photocoagulation. High risk PDR or iris neovascularization requiring panretinal photocoagulation. Tractional retinal detachment or vitreous hemorrhage requiring vitrectomy. Other Ocular Conditions Cataracts, not interfering with activities of daily living or functional abilities. Cataracts, interfering with activities of daily living or functional abilities. Glaucoma, controlled. Ocular hypertension. Pseudophakia. Glaucoma, suboptimally controlled. Vitreous floaters. Other Treatment Plan Refer to retinal specialist Follow up in weeks/months Fluorescein angiogram OD OS Panretinal laser photocoagulation OD OS Focal laser photocoagulation OD OS Vitrectomy OD OS Cataract surgery OD OS Other Date Kate Goldblum, CNP for Kenneth Goldblum, MD John Hickox, MD Todd Goldblum, MD Rebecca Leenheer, MD EXAM Family Eye Care/Children s Eye Center of NM 303 Mulberry NE Albuquerque, NM Phone: (505) Fax: (505)

18 Your Eyes and Diabetes Eye Problems. Diabetes can cause blurred vision if your blood sugar level goes up and down. When your blood sugar goes up and down, it makes the lens in your eye swell or shrink. This means your vision may be blurry at one time, and clear at another time. If this happens, you need to get your sugar levels under control before changing the lenses in your glasses. People with diabetes may also get cataracts more often and at a younger age. Worse eye problems can begin when diabetes affects the small blood vessels in the retina at the back of your eye. New blood vessels start to grow but they are not normal and can leak or bleed. This causes blurred vision if the blood vessels leak fluid into the retina near the macula (the part of the retina that gives you central vision) or if they bleed into the vitreous. The vitreous is the clear gel- like liquid that fills the back part of the eye. This leaking and bleeding can cause very poor vision and even blindness. Preventing Eye Problems. There are many research studies showing that people have fewer longterm problems from diabetes when their treatment keeps blood sugar levels normal or near normal. Keeping your blood sugar level normal helps prevent all the long- term problems of diabetes, not just eye problems. High blood pressure (even if it s only a little high) or high LDL cholesterol levels can also make you more likely to have long-term problems with your eyes, heart, blood flow (circulation), and kidneys. A blood test called a hemoglobin A1C (HgA1C) is a measure of your average blood sugar level over the past three months. It should be less than 7% in most cases to help keep you and your eyes healthy. Your blood pressure should be 130/80 or lower. Your LDL cholesterol should be below 100. If you do not know your HgA1C, blood pressure, or LDL cholesterol, talk to your primary care provider. The best way to keep your eyes healthy is by taking good care of yourself - so follow the ABC s of Diabetes. A1C - less than 7% Blood pressure - 130/80 or below Cholesterol - LDL less than 100 Treating Eye Problems. It is important to see your eye doctor (ophthalmologist) at least once a year. Your eye doctor can tell by looking at the retina in the back of your eye if you are beginning to have eye problems from your diabetes. If eye problems do start, early treatment with a laser can help keep the problems from getting worse. Your eye doctor will use a laser to treat the retina. This helps keep new vessels from growing. It also helps stop leaking or bleeding from new vessels that may already be there. If bleeding from new blood vessels is very bad, you may need surgery to remove the vitreous and blood from the back of the eye (a vitrectomy). This surgery will help clear your vision and help prevent blood clots. Blood clots can pull the retina away from the back of the eye (a retinal tear or detachment) and cause very poor vision or even blindness. Your Diabetes Team. Diabetes is a chronic problem. That means it will never go away, but you can control it. We can help you take care of your eyes, and we want to help you and the rest of your Diabetes Team keep your diabetes under good control. Your primary care provider should be your first source of help. You may also need help from a registered nurse, dietician, diabetes educator, foot doctor, or another specialist. They can all help you, but you are the only one who can take charge of your day-to-day care you are the leader of your Diabetes Team. You should keep all your appointments with your primary care provider. He or she can help you control your diabetes, blood pressure, and LDL cholesterol. Keeping your ABC s low will help prevent eye problems and blindness. Ask your primary care provider about your ABC s and write them here to show Dr. Goldblum at your next visit. HgA1c Blood Pressure LDL Cholesterol To learn more about diabetes contact The American Diabetes Association DIABETES 303 Mulberry NE Albuquerque, NM (505) (800) (505) fax useful links American Diabetes Association Blood Sugar Basics (American College of Endocrinology) Center for Disease Control and Prevention Diabetes Fact Sheet factsheet11.htm 18

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Diabetic Retinopathy. Barry Emara MD FRCS(C) Giovanni Caboto Club October 3, 2012

Diabetic Retinopathy. Barry Emara MD FRCS(C) Giovanni Caboto Club October 3, 2012 Diabetic Retinopathy Barry Emara MD FRCS(C) Giovanni Caboto Club October 3, 2012 Outline Statistics Anatomy Categories Assessment Management Risk factors What do you need to do? Objectives Summarize the