Diabetes Basics - The who, what, why, and how of diabetes care

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Eleanore Harrell
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1 Diabetes Basics - The who, what, why, and how of diabetes care Garrett Huxall Pharm.D, CGP,FASCP Consultant Pharmacist PharmCare/Deer Creek Consulting

2 Objectives Understand what diabetes is and the complications that can arise in diabetic residents. Understand why it is important to take an active role in both treating and controlling diabetes. Explain ways to improve current diabetes care as well as implement new processes in your facility regarding diabetes management.

3 The Numbers! Diabetes 5 th leading cause of death in US Higher rates of morbidity and complications in 4 nursing home residents >65 years had diabetes Typically diabetic residents: Take more medications Have ~50% risk of having pressure ulcers Have decreased healing times

4 The Numbers! Direct medical and indirect expenditures attributable to diabetes in 2002 were estimated at $132 billion. $23.2 billion for diabetes care $24.6 billion for chronic complications attributable to diabetes People with diabetes had medical expenditures that were 2.4 times higher than people without diabetes. American Diabetes Association 2002: Economic Costs of Diabetes in the U.S. in 2002

5 The Numbers! Study from 2007: Diabetic residents' care generally failed to meet several of the American Diabetes Association's standards of care. Those standards were developed for diabetic adults living on their own, and not in nursing homes However, since there are no specific diabetes guidelines for nursing homes, the ADA standards are all we have.

6 The Numbers! 98% of residents are having their blood glucose levels regularly monitored Only 38% of them are meeting their short-term glucose goals 67% of nursing home residents with diabetes are meeting their long-term goal If homes are good about monitoring blood sugar regularly, then why are so many resident s not meeting short term goals?

7 The Numbers! Barriers may exist when dealing with diabetic residents Lack of training and/or education to staff May be due to high turnover rates, etc. Lack of available resources Time, equipment, etc. High level of co-morbidities that accompany diabetes Other problems more acute and require immediate attention Lack of national standards within long-term care facilities

8 The Numbers! Common management difficulties Decreased appetite May increase low blood sugar risk Recurrent infections (URI, UTI, etc.) Leads to high blood sugar Urinary incontinence caused by elevated sugar Increased wound development Increased vulnerability to low blood sugar Cognitive impairment

9 Different Types of Diabetes Pre-diabetes Type 1 diabetes Type 2 diabetes Gestational diabetes

10 Different Types of Diabetes Pre-diabetes NOT borderline diabetes no such thing! Normal fasting blood sugar is between 70 and 100 mg/dl Some people have blood sugar higher than 100 mg/dl but lower than 126 mg/dl Becoming very common Can lead to diabetes

11 Pre-Diabetes: Preventing Diabetes Physical Activity Medication, if necessary How to Prevent Diabetes Healthy food choices Maintaining healthy weight

12 Different Types of Diabetes Type 2 Diabetes Previously know as non-insulin dependent diabetes Cells do not use insulin well Insulin resistance Ability of pancreas to make insulin decreases over time 9 in 10 diabetics have type 2 Most common in people over 40

13 Different Types of Diabetes Symptoms of type 2 diabetes Frequent urination Extra thirst or hunger Tiredness Blurred vision Dry, itchy skin Numbness or tingling in hands and feet

14 Diagnosing Diabetes Diabetes is diagnosed by how high the blood sugar is!

15 How is diabetes diagnosed? Three ways to determine whether blood sugar is high enough to be diagnosed as diabetes: Random blood sugar test Fasting blood sugar test Oral glucose tolerance test Usually test is repeated to confirm diagnosis

16 How is diabetes diagnosed? Random blood sugar test 200 mg/dl at any time of day AND classic symptoms of diabetes

17 How is diabetes diagnosed? Fasting glucose test Most common test used Nothing eaten for at least 8 hours then a blood sample is taken If the result is 126 mg/dl or higher, it is diagnostic for diabetes

18 How is diabetes diagnosed? Oral glucose tolerance test (OGTT) Least common test Drink sugary liquid or glucose pills dissolved in water If result at two hours is 200 mg/dl or higher, it is diagnostic for diabetes

Hemoglobin A1c (HgA1c) Red Blood Cell Sugar Low Hb A1c High Hb A1c The higher the glucose level is in the blood, the more glucose will bind to the hemoglobin.

19 Hemoglobin A1c (HgA1c) Red Blood Cell Sugar Low Hb A1c High Hb A1c The higher the glucose level is in the blood, the more glucose will bind to the hemoglobin. Not influenced by daily fluctuations of the blood glucose concentration. Useful indicator of how well blood glucose has been controlled in the past 6 to 8 weeks.

20 HgA1c verses Blood Glucose

21 HgA1c Non-diabetic HgA1c 5 6% Diabetic Goal < 7 Only about 40% of residents meet this goal Lowering A1C to < 7% has been shown to reduce microvascular and neuropathic complications of type 1 and type 2 diabetes. Lowering A1C to < 7% also appears to be associated with long-term reduction in the risk of macrovascular disease.

22 Diagnosing Diabetes HgA1c HgA1c NOT diagnostic of diabetes yet However strong push to use HgA1c as a diagnostic tool HgA1c can be deceptive If A1c is normal: Could mean having extreme highs balanced with extreme lows

23 Hypoglycemia Low blood sugar

different people Lots of common symptoms: Shaky Sweaty

24 Low Blood Sugar Hypoglycemia Blood sugar less than 70 mg/dl 70 mg/dl is the lower end of normal range Feels different to different people Lots of common symptoms: Shaky Sweaty Anxious Clumsy Dizzy Hungry Angry Weak Confused Sleepy Grouchy Headache

25 Causes of Low Blood Sugar Delaying or skipping meals Eating too little at a meal More activity or exercise than usual Too much diabetes medication Drinking alcohol

26 Treating Low Blood Sugar If resident reports symptoms OR have a reading below 70 mg/dl, do the following: Eat 15 grams of a quick acting carbohydrate ½ can regular soda 1 cup fruit juice 5-6 lifesavers Wait 15 minutes and recheck blood sugar

27 Treating Low Blood Sugar After 15 minutes: If blood sugar is above 70 mg/dl Have a snack Glass of milk and half a sandwich Cheese and crackers If blood sugar is still less than 70 mg/dl Repeat the 15 grams of carbohydrates and recheck blood sugar in 15 minutes If still less than 70 or dropping then call physician or go to the emergency room!

28 Treating Low Blood Sugar Eating and/or drinking for the entire 15 minutes will cause your blood sugar to increase dramatically so be patient!

29 Hyperglycemia High blood sugar

30 High Blood Sugar A normal blood sugar level depends on individual blood sugar targets High blood sugar can cause long-term complications Most common symptoms of high blood sugar Increased thirst Increased urination Increased fatigue/tiredness

31 Causes of High Blood Sugar Eating too much food No exercise or less exercise than usual Being sick or in pain Being upset or under stress Not taking your diabetes medication Taking a medication that raises blood sugar

32 Complications of Diabetes

Complications of Diabetes Short-term complications are typically day-to-day problems that happen without warning: hypoglycemia hyperglycemia Long-term hyperglycemia can

33 Complications of Diabetes Short-term complications are typically day-to-day problems that happen without warning: hypoglycemia hyperglycemia Long-term hyperglycemia can lead to chronic complications including: Blindness Kidney disease Nerve damage Amputation Cardiovascular disease Stroke Heart attack Loss of circulation in arms and legs

34 Complications of Diabetes Other issues that may arise in elderly residents with diabetes: Depression Increased Pain Changes in weight (gain or loss) Oral health problems

35 Complications of Diabetes Avoid complications? By practicing the A, B, C s of diabetes A A1c, Aspirin B Blood Pressure C Cholesterol

36 Complications of Diabetes The closer we get to the therapeutic goals for blood sugar, blood pressure and cholesterol the lower the risk of developing complications There are recommended screening test that can be done to find complications at their earliest stage Most complications are treatable when found early!

37 Recommended Screenings At diagnosis: Baseline EKG may be done Depression screening, if needed Tobacco cessation counseling

38 Recommended Screenings Blood pressure Goal is less than 130/80 While most residents are having blood pressure checked regularly, only about half actually meet this goal.

39 Recommended Screenings At least once a year: Kidney test Check for small protein called microalbumin < 30 mg albumin/24hr = Normal mg/24 hr = Microalbuminuria > 300 mg/ 24 hr = Macroalbuminuria Dilated eye exam or retinal photo Check for retinopathy Ankle Brachial index (ABI) Checks for circulation problems

40 Recommended Screenings Cholesterol test Total cholesterol Goal is less than 200 mg/dl LDL cholesterol Goal is less than 100 mg/dl (70) HDL cholesterol Goal is greater than 40 mg/dl for men and greater than 50 mg/dl for women TG Goal is less than 150 mg/dl Statin therapy is the first line treatment, unless contraindicated, for LDL reduction.

41 Recommended Screenings Skin High blood sugar can effect the skin anywhere on your body Dryness and itching are common Skin infections may also be problematic

42 Recommended Screenings Teeth High blood sugar can lead to tooth and gum problems Germs in the mouth grow like weeds when blood sugar is high Germs produce acid that forms tartar and can lead to decay Infected gums are a stress that can raise blood sugar

43 Recommended Screenings Feet Diabetic nerve damage (neuropathy) can take away your ability to feel pain Most common in the feet but can also occur in the hands Cut toenails straight across Needs to be done by nurse or podiatrist Protect your feel at all times Shoes outside and socks and/or slippers inside

44 Recommended Screenings Eyes Diabetic eye disease (retinopathy) typically has NO symptoms Especially not in the early, most treatable stages These eye tests are not usually done by primary care doctors This is not the same test as a checkup for glasses! Eye is dilated to the retina

45 Recommended Screenings Eyes Contact physician if resident is reporting any of these symptoms: Blurred or double vision Narrowed field of vision Dark spots Pressure or pain in your eyes Unusual difficulty seeing in dim light

46 Treatment of Diabetes

47 Treatment of Diabetes Diabetes can be treated with five tools Oral medicines for type 2 diabetes Insulin for type 1 and type 2 Blood sugar testing Food Exercise

48 Diet Utilize the services of your dietician Typically don t use diabetic diet anymore Sugar free diets don t always have to be used for a diabetic resident Trying to provide a variety of nutritionally balanced foods may help Be aware of supplements, OTC medication, etc. that may cause elevated blood sugar Thickening agents, Ensure, Protein supplements, etc.

49 Oral Medications Several different classes of medications to help your reach your blood glucose targets Sulfonylureas Biguanides Meglitinide Thiazolidinedione Alpha-glucosidase inhibitors

50 Oral Medications - Sulfonylureas Help the pancreas make more insulin Typically work for several hours therefore usually given 1-2 times daily Medication should be taken with a meal because low blood sugar is a possible risk Examples include glyburide, glipizide and glimepiride Other side effects: Weight gain and rash

51 Oral Medications Biguanides (Metformin) Works in two different ways Makes cells more sensitive to insulin Stops the liver from releasing stored insulin Side effects from metformin usually include stomach upset, bloating and diarrhea Will usually resolve within 7-14 days Can minimize side effects by starting with low dose and increasing slowly

52 Oral Medications Biguanides (Metformin) People who should not take Metformin Kidney problems Metformin is removed through kidneys Heart Failure Increase risk of lactic acidosis Liver Problems Drink Alcohol

53 Oral Medications - Metglitinides Work similar to sulfonylureas help pancreas make more insulin However, these medications only work for a few hours so they are typically give mulitple times a day Do not contain sulfa component so may be good option for patients with sulfa allergy Again, low blood sugar is a risk with these medications so they should be taken with food Examples: Starlix and Prandin

54 Oral Medications - Thiazolidinediones Allows your body to use insulin better Side effects Weight gain and/or swelling Use in caution in patients with heart failure Potential for liver problems Need to have routine blood tests for your liver Examples: Actos and Avandia

55 Oral Medications Alphaglucosidase inhibitors Slows/prevents the breakdown of carbo-hydrates and complex sugar into simple sugars Simple sugars are the ones that are absorbed in stomach and cause blood sugar rise Must be taken with first bite of meal If you miss your meal then don t take medication Side effects Diarrhea, gas and bloating Can be minimized if we start at low doses and slowly increase Treatment of hypoglycemia Must use glucose tablets! No pop or juice

56 Oral Medications Since each class of medication helps control blood sugar in a different way, it is common too take two or more medications together Combinations: Avandamet Metaglip Glucovance

57 New Oral Medications - Gliptins Januvia New medication class called incretin enhancers Incretin is a hormone that increases the release of insulin in response to meals Oral pill usually taken once a day

58 Injectable Medications Symlin Typically used with insulin to help with elevated blood sugar that happens after meals Usually taken with meals but can cause low blood sugar Most common 3 hours after injection Guidelines Do not take Symlin if any of the following apply: Are not going to eat or only eat a small meal (less than 30 grams of carbohydrate) If you are sick or having a medical procedure If you miss a dose Wait until your next scheduled meal and take it then.

59 Injectable Medications Byetta Helps your body produce the right amount of insulin at the right time Usually taken twice a day 60 minutes before morning and evening meals Usually given in combination with other oral medications Guidelines Make sure and eat within 60 minutes after taking your injection Store Byetta in the refrigerator but do not freeze it Side effects Nausea Weight loss If you miss a dose Take at the next meal and do not double the dose

60 Insulin - types Onset is when the insulin usually starts to work. The start of the curve (left side) shows this. Peak is when the insulin usually has its strongest effect. The highest part of the curve shows this. Duration is how long the insulin usually works. The end of the curve (right side) shows this.

62 Rapid-acting insulin Insulin Work very quickly and only a short time This is the best insulin for mealtime Short-acting insulin Work slower and peak several hours after you take them These are also used to provide your mealtime needs

63 Insulin Intermediate and long-acting insulin Start the slowest and last the longest Premixed insulin Combinations of intermediate-acting and either rapid-acting or short-acting insulin

64 Insulin- Insulin tips Rotate injection sites Use a regular plan of rotating your injection sites Don t shake insulin roll the vial to mix cloudy insulin Store insulin in a cool place You must refrigerate Lantus All insulin should be discarded 30 days after opening

65 How? Develop a facility protocol for diabetic patients Hypo-/hyperglycemia How to recognize and/or treat Provide updated education for staff Comprehensive diabetes care plan Specific dietary plan Detailed list of potential complications to watch for Therapeutic goals Annual review to make sure recommended screening tests are completed Medications

66 How? Follow recommended guidelines for the following areas: Aspirin therapy Smoking cessation Blood Pressure Glycemic Control Depression Cognitive Impairment Injurious falls Education Cholesterol Eye care Foot Care Nephropathy Polypharmacy Pain Urinary Incontinence Life expectancy

67 Questions?

Diabetes Mellitus Type 2

Diabetes Mellitus Type 2 What is it? Diabetes is a common health problem in the U.S. and the world. In diabetes, the body does not use the food it digests well. It is hard for the body to use carbohydrates