Novo Nordisk Lilly sanofi aventis

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1 Novo Nordisk Lilly sanofi aventis

2 Announcements TURN OFF CELL PHONES Cell phone police are watching If you need to make a call, leave the room Restrooms Breakroom Low blood sugar Copy of presentation, info@beachdoctor.com

3 Brochures Dr. Lucas office Primary Care Offices Pharmacy From a friend or relative From the radio show Other?

4 SCHEDULE 8:30-10:00 DIABETES :00-10:30 BREAK 10:30-11:30 WHAT CAN I EAT? 11:30-12:00 THE REST OF THE STORY

5 What is Diabetes?

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14 WHO IS AT RISK FOR DIABETES? Family history of diabetes (especially Type II) Gestational diabetes Being overweight, especially around the waist Taking medication which increases blood sugar (such as cortisone)

15 WHO IS AT RISK FOR DIABETES? Having had pancreatitis Certain people with hypoglycemia Having elevated triglycerides Having Polycystic Ovary Syndrome Having Acanthosis nigricans, skin tags

16 NATURAL HISTORY OF TYPE 2 DIABETES Insulin resistance High insulin levels, Normal blood sugars Development of fat around waist Sugar cravings, hypoglycemic symptoms

17 NATURAL HISTORY OF TYPE 2 DIABETES Delayed insulin release Elevations in blood sugars after a meal with starches or sugars Insulin release is delayed until after blood sugar is high As blood sugars are coming down, insulin level is too high causing subsequent hypoglycemia Caused by a deficiency in GLP-1

18 NATURAL HISTORY OF TYPE 2 DIABETES Impaired glucose tolerance Pancreas is not able to produce enough insulin to maintain a normal blood sugar Fasting blood sugar is After meals, blood sugar is Hemoglobin A1C is %

19 NATURAL HISTORY OF TYPE 2 DIABETES Type 2 Diabetes Blood sugars are over 125 fasting or over 200 at other times Hemoglobin A1C is 6.5 or higher Pancreas is still making insulin Still have insulin resistance and GLP-1 deficiency.

20 NATURAL HISTORY OF TYPE 2 DIABETES Type 2 Diabetes needing insulin Pancreas is wearing out and cannot produce enough insulin to keep blood sugar down even with oral medications Still have insulin resistance and GLP-1 deficiency.

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22 Why treat diabetes? To feel better To prevent symptoms of a high blood sugar: increased urination, increased thirst, blurred vision, fatigue, tingling in hands and feet To prevent long-term damage to your body in the eyes, kidneys, heart, neurological system.

23 Complications of Diabetes Stroke: 2-6x Retinopathy: 25x End-Stage Kidney Disease: 17x Foot/Leg Amputations: 5x Heart Disease: 2-4x

24 WHY DOES DIABETES AFFECT THE FEET? Circulation Delayed healing Neuropathy Numbness Lack of awareness of injury Infection prone Poor control leads to an increase in infections Bacterial Fungal

25 HOW YOU CAN PREVENT FOOT PROBLEMS Check your feet daily and look for cracks, blisters, sores, cuts, bruises, changes in color, temperature and signs of infection Don't forget the bottom of your feet Wash your feet every day Use lukewarm water and a mild soap Dry them completely, especially between the toes Lotion to help dry skin. Do not put it in-between toes Do not soak feet Clip toenails straight across and file gently

26 HOW YOU CAN PREVENT FOOT PROBLEMS Do not use sharp objects or chemicals on feet Wear comfortable shoes that fit properly Check inside shoes before putting them on Always wear socks or stockings with shoes Break in new shoes slowly and carefully Do not smoke

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40 How do you treat diabetes?

41 Key numbers in diabetes control Daily blood sugar A1C Cholesterol and triglycerides Blood pressure Urine protein

42 Targets for Glucose Control Type 1 and Type 2 Diabetes Fasting/Pre-meal glucose Post-meal glucose 2 hr. after start of meal Bedtime glucose A1C mg/dl mg/dl mg/dl 6.5% Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2002;25:S33-S49, and American College of Endocrinology: Consensus statement on guidelines for glycemic control. Endocrine Pract 2002;8 (Suppl. 1):5 11.

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45 A1C and Self-Monitoring Results A1C 4% 60 5% 90 6% 120 7% 150 Blood Glucose (mg/dl) 8% 180 9% % % % % 330

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47 Treatment of Type 1 Diabetes Type I Diabetes (insulin deficient) Mimic pancreatic secretion of insulin by long and short acting insulin Coordinating insulin doses to match food intake and activity

48 TREATMENT OF TYPE II DIABETES DIET: Total body weight reduction Upper body weight reduction Decrease in waist: hip ratio EXERCISE Improves insulin sensitivity Decreases blood sugar at the time of exercise and up to 24 hours later

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50 GOALS IN TYPE 2 DIABETES Weight control by diet and exercise Controlled carbohydrate diet Control insulin resistance Reduce post meal elevated blood sugars Reduce fasting blood sugar Addition of insulin if oral medication cannot control blood sugar

51 Targets for Lipids, Blood Pressure and Microalbumin LDL cholesterol (mg/dl) HDL cholesterol (mg/dl) Triglycerides (mg/dl) Lipids (Blood Fats) <70 >55 women >45 men <150 Blood Pressure <130/80 mmhg Microalbumin <30 mg/g creatinine on a random sample Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2002;25:S33-S49.

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53 Benefits of Exercise To increase endurance, firm up certain muscle groups, and to increase cardiovascular health To aid in a weight reduction program in three ways: a) To prevent the decrease in metabolic rate which accompanies low calorie dieting b) To help burn off some calories c) As a way to relieve stress and depression without eating to do so To reduce stress and increase resistance to fatigue To improve mood, overall well-being, self-confidence, and self-image To help with blood sugar control. To improve the ratio of good to total cholesterol and in triglycerides To improve blood pressure To improve the ability to fall asleep and sleep well

54 TREATMENT OF TYPE II DIABETES ORAL AGENTS To increase insulin production: Glimepiride, Glipizide, Glyburide To increase insulin production at meals only: Prandin, Starlix To improve pancreatic release of insulin at meals: Byetta, Victoza, Bydureon, Tanzeum, Januvia, Onglyza, Tradjenta, Nesina To improve insulin sensitivity: Metformin, Actos, Avandia To prevent kidney from holding on to sugar: Invokana, Farxiga, Jardiance To delay absorption of carbohydrates: Precose

55 TREATMENT OF TYPE II DIABETES INSULIN Add to oral agent to reduce highest blood sugar Start with basal insulin to reduce fasting blood sugar. Add pre-meal short-acting insulin to cover largest meal of the day. As blood sugar is controlled, taper off insulin, if possible

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57 GLP-1 secreted upon the ingestion of food

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60 INSULIN Long-acting: Lantus, Levemir Intermediate: Novolin N, Humulin N Short: Novolin R, Humulin R Rapid: Novolog, Humalog, Apidra Mixed: Novolog 70/30, Humalog 75/25, Humalog 50/50, Humulin 70/30, Novolin 70/30

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64 Clinical Research in Diabetes

65 CLINICAL RESEARCH IN DIABETES Reasons to participate in diabetes research: Try out new medications prior to approval Concentrate more on your diabetes while in the study Contribute to knowledge about new medications Monitoring supplies, lab work, and medication provided at no charge. Personal attention

66 Stages of Research Ideas Computer modeling Animal Testing: Rats, mice, monkeys Human Testing Phase 1: Safety studies in healthy adults Phase 2: Dose ranging studies in patients Phase 3: Efficacy studies. Comparison with approved medication Phase 4: New indications for an approved medication

67 Benefits for Participants Do you brush and floss your teeth more before a dental visit? Do you dress up for work when the boss is visiting? Participants in Diabetes studies have improved blood sugar control during a study because of constant monitoring and frequent visits to the office. Even if they are not taking the study medication, the diabetes improves from being aware of it. Placebo versus Study Medication. Why do it? It is worth the investment in time to participate to benefit your future health.

68 CURRENT RESEARCH STUDIES For those on metformin alone For those on 1-2 oral medications for diabetes Type 1 or 2 Diabetes with kidney damage (excessive protein in the urine) Type 2 Diabetes with heart disease Type 1 Diabetes

69 If you are interested in participating in a study Fill out the questionnaire at the clinical research table Send us an at beachdoctor.com Call the office and ask to speak to the research staff. Be put on mailing list for future studies as well.

70 Other Medications

71 Medications that Elevate Blood Sugar Prednisone, Medrol, Cortisone shots Major Tranquilizers: Zyprexa, Risperdal, Seroquel Niacin For Prednisone, may need to double usual insulin supplements If on oral agents, may need insulin

72 Medications which affect diabetic complications Non-steroidal anti-inflammatories and COX-2 inhibitors (arthritis medications) Examples: Motrin, Advil, Naprosyn, Aleve, Indocin, Relafen, Celebrex May worsen diabetic nephropathy May raise BP May cause swelling

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74 Insulin Resistance Related Conditions Type 2 Diabetes Cardiovascular Disease High Blood Fats Insulin Resistance High Blood Pressure Impaired Glucose Tolerance Obesity

75 BLOOD PRESSURE MEDICATIONS ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS Captopril, Enalapril. Lisinopril, Benzapril, Accupril Side-effect: cough ANGIOTENSIN RECEPTOR BLOCKERS (ARBS) Losartan, Diovan, Avapro, Atacand, Micardis, Benicar RENIN INHIBITOR: Tekturna Inhibit production of hormones which increase BP Also protect kidney from damage due to diabetes

76 BLOOD PRESSURE MEDICATIONS CALCIUM CHANNEL BLOCKERS Amlodipine, Nifedipine, Verapamil, Diltiazem Block calcium influx into blood vessels and heart leading to lower BP These medications do not raise blood sugar DIURETICS HCTZ, Indapamide, Lasix, Bumex, Demadex, spironolactone, Inspra

77 BLOOD PRESSURE MEDICATIONS PERIPHERAL ALPHA BLOCKERS Minipres, Hytrin, Cardura Dilate arteries, lower BP Also improve urine flow in men with prostate problems CENTRAL ALPHA BLOCKERS Clonidine, Catapres, Tenex May cause fatigue and dry mouth BETA BLOCKERS Propranolol, atenolol, Toprol XL, metoprolol, nadolol, Bystolic May impair response to hypoglycemia by lowering symptoms and inhibiting release of glucose by the liver ALPHA AND BETA BLOCKER Carvedilol (Coreg) does not elevate blood sugar and helps in heart failure

78 LIPID LOWERING MEDICATIONS STATINS Zocor, Pravachol, Lipitor, Crestor, Lescol CHOLESTEROL BLOCKERS Zetia, Questran, Colestid, Welchol TRIGLYCERIDE LOWERING MEDICATIONS Gemfibrozil, Tricor, Trilipix, Fenofibrate OTHER Niacin, Niaspan, Lovaza, Fish Oil

79 Why monitor blood sugar?

80 To understand how the following things affect your blood sugar (glucose): Food Activity Medicine Daily life (e.g., illness, stress, drinking alcohol) To help you relate symptoms of high or low blood sugar with the actual results To provide you and your healthcare team with information to analyze and act upon

81 What can cause blood sugar to go up or down?

82 Go up Not taking enough or any medication Eating too much food (carbs) Exercising less than usual Physical or emotional stress, illness Go down Taking too much diabetes medication Not eating enough when taking certain medications More exercise than usual Alcohol

83 Times to check more often: When starting a new diabetes medicine When making another change in your treatment plan (food, exercise) When having more highs or lows During times of illness or stress When you are planning a pregnancy or are pregnant

84 Use your tools (logbook, meter, etc.) Look at 3 days in a row Use a 4-step guide to interpret the numbers: Gather information Look for a pattern Think about possible causes Take action

85 Sample logbook: Bob Breakfast Lunch Dinner Before After Before After Before After Bedtime Bedtime Time Time Time Time Time Time Time Day Date Medication Blood Glucose Blood Glucose Medication Blood Glucose Blood Glucose Medication Blood Glucose Blood Glucose Medication Blood Glucose Tue Comments: Additional Blood Glucose: Wed Comments: Additional Blood Glucose: Thur Comments: Additional Blood Glucose:

86 The impact of food Food has a major impact on blood sugar Check blood sugar before and 1 2 hours after meals Eat about the same size meals each day Have a meal plan that supports carbohydrate guidelines Look for patterns of highs and lows and compare to carbs eaten, medications taken, exercise, etc.

87 Sample logbook: Carol Breakfast Lunch Dinner Bedtime Before After Before After Before After Bedtime Time Time Time Time Time Time Time Day Date Medication Blood Glucose Blood Glucose Medication Blood Glucose Blood Glucose Medication Blood Glucose Blood Glucose Medication Blood Glucose Tue Comments: Additional Blood Glucose: Wed Comments: Additional Blood Glucose: Thur Comments: Additional Blood Glucose:

88 You are in control By reviewing your blood sugar for patterns and using the event markers in your meter, you can find out what s affecting your glucose numbers. Share this information with your diabetes care provider so together you can make better treatment changes that help you manage your diabetes, feel better and enjoy life!

89 Clinical Research in Diabetes

90 CLINICAL RESEARCH IN DIABETES Reasons to participate in diabetes research: Try out new medications prior to approval Concentrate more on your diabetes while in the study Contribute to knowledge about new medications Monitoring supplies, lab work, and medication provided at no charge. Personal attention

91 CURRENT RESEARCH STUDIES For those on metformin alone For those on 1-2 oral medications for diabetes Type 1 or 2 Diabetes with kidney damage (excessive protein in the urine) Type 2 Diabetes with heart disease Type 1 Diabetes

92 Benefits for Participants Participants in Diabetes studies have improved blood sugar control during a study because of constant monitoring and frequent visits to the office. Even if they are not taking the study medication, the diabetes improves from being aware of it. It is worth the investment in time to participate to benefit your future health.

93 If you are interested in participating in a study Fill out the questionnaire at the clinical research table Send us an at beachdoctor.com Call the office and ask for the research staff Be put on mailing list for future studies as well.

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96 Virginia Laura Seth

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