Glucose Variability & Pattern Management: Way Beyond Logbooks Irl B. Hirsch, M.D. University of Washington, Seattle, WA
|
|
- Lucy Owen
- 5 years ago
- Views:
Transcription
1 Glucose Variability & Pattern Management: Way Beyond Logbooks Irl B. Hirsch, M.D. University of Washington, Seattle, WA 1
2 Normal Renal Glucose Handling 180 g of glucose is filtered each day Virtually all glucose reabsorbed in the proximal tubules & reenters the circulation SGLT2 reabsorbs 90% of the glucose SGLT1 reabsorbs 10% of the glucose Virtually no glucose excreted in urine Wright EM. Am J Physiol Renal Physiol. 2001;280:F10-F18. 2
3 Renal Handling of Glucose in a Non-Diabetic Individual S1 segment of proximal tubule Reabsorption Glucose ~90% ~10% SGLT2 S G L T 1 Collecting duct Distal S2 / S3 segment of NO GLUCOSE proximal tubule Wright EM. Am J Physiol Renal Physiol. 2001;280:F10-F18. Thorens B. Am J Physiol. 1996;270:G541-G553. 3
4 SGLT2 Mediates Glucose Reabsorption in the Kidney Na+ and Glucose at 1:1 stoichiometry Na+ Lumen SGLT2 Glucose S1 Proximal Tubule GLUT2 Blood Glucose Glucose Na + K+ Na+ ATPase Adapted from Dr. Robert Henry, New Classes of Pharmacologic Agents for the Treatment of Hyperglycemia on the Horizon: Sodium Glucose Cotransporter (SGLT) - Type 2 Inhibitors, Feb
5 History of 1,5 Anhydroglucitol (1,5 AG) ,5AG was discovered in plant of Polygala Senega Presence in human body was reported Decrease of plasma 1,5AG concentration with uremia and diabetes mellitus was reported Blood 1,5AG was determined in Japan present- research into relationship between 1,5 AG and diabetes control became active. 5
6 Physiology of 1,5-AG Oral Supply 1,5AG (5-10mg/day) Normoglycemia Oral Supply 1,5AG (5-10mg/day) Hyperglycemia Blood stream Tissues Internal Organs Glucose Blocks Reabsorption Blood Stream (1,5-AG Level Lower) Tissues Internal Organs Kidney Urinary excretion (5-10mg/day) Kidney Urinary excretion (INCREASED) 6
7 Frequency (%) Histogram of serum 1,5AG concentrations Healthy (n=539) 24.6±7.2 µg/ml Diabetes (n=808) 7.3±7.1 µg/ml Serum 1,5AG (µg/ml) 7
8 What We Know About 1,5 AG 1,5 AG is a strong marker for glucose variability and is now available via commercial labs 1,5 AG is not a strong marker for glycemia (MBG or GV) for people p with A1C levels > 8% (ADAG) For measures of glycemic variability, for those with A1C levels < 8%, 1,5 AG correlates better with standard deviation than other measures of GV 8
9 What We DON T Know About 1,5 AG How it correlates and predicts diabetes vascular complications How it correlates to different risks and rates of hypoglycemia-likely likely different for T1 vs. T2DM 9
10 When to USE 1,5 AG When A1C is < 8% To better understand the QUALITY of the A1C Initial goal: >
11 Further Thoughts 1,5 AG may be useful but with different interpretations for Pregnancy Maternal/fetal outcomes? MODY Diagnosis? 11
12 Final Thought About the Kidney The kidney was, is, and will be an important part for the diagnosis and treatment of diabetes 12
13 HbA1c (A1C) Our primary and most fundamental research and clinical endpoint in diabetes for the past 3 decades 13
14 Average Glucose vs. A1C A1C AG mg/dl (95% CI) 5% 97 (76-120) 6% 126 ( ) 7% 154 ( ) 8% 183 ( ) 9% 212 ( ) 10% 249 ( ) 282) 11% 269 ( ) 12% 298 ( ) A1c is an average, more weighted over the past 30 days, with large CIs Diabetes Care 31: ,
15 Even More Importantly HbA1c and duration of diabetes (glycemic exposure) explain only ~11% of the variation in retinopathy risk for the entire DCCT study population (table 9, reference 1) so that other factors may presumably explain the remaining 89% of the variation in risk among subjects independent of A1C. HUH? Diabetes 57: ,
16 What Is Fructosamine? Glycated proteins that provide an approximate 21 day history of glycemia Relationship between glycemia and fructosamine not a straight line No correlations between fructosamine and MBG via CGM and more importantly, complications When would it be used? 16
17 So When Would You Use Fructosamine? In those conditions A1C won t work! Most anemias, polycythemia vera Hemoglobinopathies Drugs: epo, dapsone Splenomegly (many etiologies) Reticulocytosis of any etiology Prosthetic heart valves Recent blood transfusion 17
18 Glycemic Control Biomarkers HbA1C 1,5AG Fructosamine Blood glucose Weeks before measurement 18
19 My History With This Started downloading meters in 1995 due to my frustration with logbooks and an available computer/software program Was provided with mean, standard deviation, and testing frequency Eventually provided time-specific statistics What did I see? 19
20 What I Quickly Realized Few patients will keep detailed logbooks for extended periods of time With downloading, one can observe means, patterns, and variability not possible with logbooks 20
21 There are Common Pathways in Diabetes Complications Glucose Peripheral & Autonomic Neuropathy AGE Formation PKC Hexosamine Pathway Cellular l Dysfunction Oxidative Stress ROS ROS Cell Damage Vascular Damage Nephropathy Retinopathy Different complications (eye, kidney, nerve, blood vessels) arise from limited number of triggers perturbing a limited number of metabolic pathway(s) 21
22 But Variability Also Predicts Severe Hypoglycemia! Variability: SD of 7-point glucose profiles Intensive P=0.004 Conventional Diabetologia 50:2553,
23 What s a better way to assess glycemic variability? Meter (and sensor) Downloads! 23
24 Which Patient Has More Variable Fasting Glucose Data? Joe: HbA1c = 6.5%; on CSII with insulin aspart Mean = 123 mg% Mary: HbA1c = 6.5%; on HS glargine and prandial lispro Mean = 123 mg% SD = 51 SD = 77 24
25 Statistics 1 SD is a simple measurement of variability SD = square root of the variance SD is based on a group of measurements that is NORMALLY distributed (measurements which are concentrated in the middle but are symmetrical on both sides) 1 problem: glucose is not normally distributed! 25
26 Normal vs. Non-Normal Curves A B In patients with or without diabetes, which one of these curves is consistent with glucose distribution over time? Which curve is normally distributed? 26
27 Standard Deviation Our clinically ca available a ab measurement e e of glycemic variability Many other statistical analysis are available but correlation will be with CGM and outcomes, not SMBG Can determine both overall and time specific SD Need sufficient data points Minimum 5 but prefer 10 27
28 Calculation To Determine SD Target SD X 2 < MEAN Ideally SD X 3 < mean, but extremely difficult with type 1 patients 28
29 Significance of a High SD Insulin deficiency (especially good with fasting blood glucose) Poor matching of calories (especially carbohydrates) with insulin Giving mealtime insulin late (or missing shots completely) Erratic snacking Poor matching of basal insulin, need for CSII? CGM? 29
30 Other Significance of a High SD Increased Oxidative Stress and Inflammation 30
31 Caveats of the SD Need sufficient SMBG data Low or high averages makes the 2XSD<mean rule irrelevant 31
32 Caveats of the SD: Low Mean Mean = 81; SD =
33 Caveats of SD: High Mean Mean = 217; SD =
34 Enough testing Tricks To Reduce GV It is easy to over-react to too much SMBG data One option to reduce variability 34
35 Other Tricks To Reduce GV Enough testing Don t over-treat the lows! Reduce carbs (duh!) Pramlintide (Symlin) Lag times 35
36 BG Level (mg/d dl) Timing of Rapid-Acting Analog Insulin Injection Alters PPG in Type 1 Diabetes Mellitus Insulin Lispro 72 Injection-Meal Interval (minutes) 30 m 15 m 0 m +15 m BG Level (mg/d dl) Insulin Glulisine Injection-Meal Interval (minutes) 20 m 0 m +20 m kcal/kg breakfast 36 Standardized breakfast Minutes Minutes Rassam AG, et al. Diabetes Care. 1999;22: Cobry E, et al. Diabetes Technol Ther. 2010;12:
37 How To Read a BG Download 59 year-old woman with 41 years T1DM NPDR, HTN, past history microalbuminria, CAD with stent placement 5 years ago A1c on clinic i date: 6.3% 37
38 Read aggregate mean/sd 38
39 Read aggregate mean/sd Read frequency of testing 39
40 Read aggregate mean/sd Read frequency of testing Review time-specific means/sds 40
41 Example 2: 38 y/o woman with LADA 2 years ago, presented with polyuria, polydipsia, A1C = 9.5% Started on insulin day of diagnosis GAD positive Family history significant in that 6 year-old daughter with T1DM Now receiving ing 0.32 units/kg/day Risk for severe hypoglycemia? LOW 41
42 When I see a REALLY High SD The typical type 1 patient comes to me on a first visit with an SD of > 100 (no matter the mean) THIS IS BAD For that typical patient, it simply means: Missing insulin, no lag times, poor food choices For the occasional patient it means GASTROPARESIS SD extremely helpful to help determine if doing a reasonable job in matching food to insulin but overall they are lower in type 2 patients 42
43 Meter Downloads Review aggregate g and time-specific means/sds Assess basal insulin replacement BG change between HS and AM with pump or MDI Basal Test -especially with CSII Assess prandial insulin replacement Best done with frequent pc SMBG Assess correction dose What happens to BG after correction? 43
44 How I Interpret Meter/CSII/CGM Downloads No right or wrong way-we just use the technology provided to us Ideal situation: meter download skimmed, then pump/sensor download reviewed in more detail Downloads in evolution, but they are not equal in ability to assist in patient care 44
45 Where I Start After Reviewing the Meter Download in a Patient Using a Pump/Sensor Insulin action time Basal doses: match chart note? Carb ratios, ISF and targets used for BW CGM Alerts and snooze times 45
46 25 year-old woman, depression, anxiety disorder, past history of eating disorder, planning pregnancy in 1 year CSII X 5 years, CGM X 3 months Rapid A1C today = 7.0% WHERE TO START? BUT, excellent overview of pertinent statistics! 46
47 47
48 Where I Spend My Time 48
49 Hypo and Rx Dr. Hirsch-my glucose was 344! This piece of #!%$# doesn't work! Followed BC advice: NO INSULIN Followd BC advice 49
50 What s the Diagnosis? 51 year-old woman diagnosed with GDM during last pregnancy 18 years ago; insulin d/c ed after pregnancy, mother diagnosed with T2DM in her 70s before death from MI 6 months after pregnancy was admitted to hospital in mild DKA, A1C = 11% Since then has had difficulty in managing glucose levels, most A1C levels 8-9% Started CSII in 2004 with no improvement in A1C levels BMI = 26, + acanthosis; tries to get to gym 3-5X/week, states rarely eats more than 80 grams carb PER DAY! 50
51 What s The Diagnosis? More History No retinopathy, intermittent albuminuria + CAD, s/p stent placement in 2003 (at the age of 45 years) Dyslipidemia with high TGs (300s), low HDL-C (30s), LDL-C ~100 mg/dl when not on therapy Does not tolerate statins due to cramping Developed hypothyroidism in 2004 with strongly positive thyroid peroxidase Ab s now on T4 Rx Has required hearing aid for 15 years WHAT S THE DIAGNOSIS? 51
52 What s The Diagnosis? LAB GAD Ab- negative CK, creatinine, electrolytes, TSH all WNL (on T4 Rx) C-peptide: 1.0 ng/ml with concomitant glucose 210 mg/dl WHAT S THE DIAGNOSIS? 52
53 How To Begin Meter Downloading Pick one family of meters (or at the most two) so that you have the minimal number of software programs; the software you pick could be the meters preferred with the majority of insurance companies I would suggest using a dedicated computer (laptops are fine to move between rooms) For larger practices or once you appreciate the value of downloading for insulin-requiring patients, there are several programs that allow downloading of most meters on the market (we use CliniPro from Numedics.com) Get comfortable with meters before tackling CSII/CGM! 53
54 Summary A1C, 1,5 AG, and fructosamine all have different advantages and challenges; only A1C to date is correlated with diabetes- related complications Glucose variability is clearly related to an increase risk of hypoglycemia for those requiring insulin and may be involved in the vascular complications of diabetes 54
55 Summary Blood glucose meter, CSII, and CGM downloading is a powerful tool which assists all of us identify blood glucose trends Blood glucose meter downloading is underutilized by both physicians and patients The concern that it is too time-consuming is not valid since patients can do this at home. 55
5/18/2010. History of 1,5 Anhydroglucitol (1,5 AG) Glucose Variability & Pattern Management: Way Beyond Logbooks. Normal Renal Glucose Handling
Variability & Pattern Management: Way Beyond Logbooks Irl B. Hirsch, M.D. University of Washington, Seattle, WA Normal Renal Handling 180 g of glucose is filtered each day Virtually all glucose reabsorbed
More informationApplications of Technologies to Your Patient. Irl B. Hirsch, MD Professor of Medicine University of Washington School of Medicine Seattle, Washington
Applications of Technologies to Your Patient Irl B. Hirsch, MD Professor of Medicine University of Washington School of Medicine Seattle, Washington Disclosures Consultant: Abbott Diabetes Care, Roche
More informationUsing Insulin in the Primary Care Setting: Interactive Cases
Using Insulin in the Primary Care Setting: Interactive Cases Irl B. Hirsch, MD University of Washington School of Medicine Dualities (Nov, 2011) Research Grants: sanofi-aventis, Novo Nordisk, Halozyme,
More informationDiabetes Technology for the Endocrinologist, Irl B. Hirsch, MD University of Washington
Diabetes Technology for the Endocrinologist, 2017 Irl B. Hirsch, MD University of Washington Dualities Research: Helmsley Charitable Trust, JDRF, ADA, NIDDK, CDC Consulting: Abbott, Roche, Intarcia, Adocia,
More informationUsing and Interpreting Diabetes Data. Irl B. Hirsch, MD University of Washington
Using and Interpreting Diabetes Data Irl B. Hirsch, MD University of Washington Dualities Research: Helmsely Charitable Trust, ADA, JDRF, NIDDK Consulting: Abbott Diabetes Care, Roche, Intarcia, Valeritas,
More informationPump and Sensor Data Interpretation. Irl B. Hirsch, MD University of Washington School of Medicine
Pump and Sensor Data Interpretation Irl B. Hirsch, MD University of Washington School of Medicine Dualities Research: Medtronic Diabetes Consulting: Abbott Diabetes Care, BD, Bigfoot, Roche Raise Your
More informationDiabetes Technology Continuous Subcutaneous Insulin Infusion Therapy And Continuous Glucose Monitoring In Adults: An Endocrine Society Clinical
Diabetes Technology Continuous Subcutaneous Insulin Infusion Therapy And Continuous Glucose Monitoring In Adults: An Endocrine Society Clinical Practice Guideline Task Force Members Anne Peters, MD (Chair)
More informationHarvesting Healthy Hemogobins: Optimal Management of A1c and Beyond. Carol H. Wysham, M.D Rockwood Clinic Spokane, WA
Harvesting Healthy Hemogobins: Optimal Management of A1c and Beyond Carol H. Wysham, M.D Rockwood Clinic Spokane, WA Diabetes: 21 Million and Climbing Estimated 15 million diagnosed + 6.2 million undiagnosed
More informationAdvances in Diabetes Care Technologies
1979 Advances in Diabetes Care Technologies 2015 Introduction Insulin pump use: ~ 20% - 30% of patients with T1DM < 1% of insulin-treated patients with T2DM 2007 FDA estimates ~375,000 insulin pumps for
More informationAdvances in Diabetes Care Technologies
1979 Advances in Diabetes Care Technologies 2015 Introduction Roughly 20% - 30% of patients with T1DM and fewer than 1% of insulin-treated patients with T2DM use an insulin pump In 2007, the US FDA estimated
More informationApplication of the Diabetes Algorithm to a Patient
Application of the Diabetes Algorithm to a Patient Apply knowledge gained from this activity to improve disease management and outcomes for patients with T2DM and obesity Note: The cases in this deck represent
More informationAdvances in Diabetes Care Technologies
Advances in Diabetes Care Technologies 1979 2015 Introduction Roughly 20% to 30% of patients with T1DM and fewer than 1% of insulin-treated patients with T2DM use an insulin pump In 2007, the U.S. FDA
More informationUniversity College Hospital. Blood glucose and HbA 1 c targets
University College Hospital Blood glucose and HbA 1 c targets Children & Young People s Diabetes Service The diabetes team at UCLH aims to help every child and young person with Type 1 Diabetes to safely
More informationADVANCE Endpoints. Primary outcome. Secondary outcomes
ADVANCE Trial-NEJM 11,140 type 2 patients with h/o microvascular or macrovascular disease or 1 vascular disease risk factor Control A1c to 6.5% vs standard tx Intensive arm received gliclazide XL 30 to
More informationINSULIN THERAY دکتر رحیم وکیلی استاد غدد ومتابولیسم کودکان دانشگاه علوم پزشکی مشهد
INSULIN THERAY DIABETES1 IN TYPE دکتر رحیم وکیلی استاد غدد ومتابولیسم کودکان دانشگاه علوم پزشکی مشهد Goals of management Manage symptoms Prevent acute and late complications Improve quality of life Avoid
More informationWayne Gravois, MD August 6, 2017
Wayne Gravois, MD August 6, 2017 Americans with Diabetes (Millions) 40 30 Source: National Diabetes Statistics Report, 2011, 2017 Millions 20 10 0 1980 2009 2015 2007 - $174 Billion 2015 - $245 Billion
More informationIncorporating CGM Into Clinical Decision Making. Etie Moghissi, MD, FACE Clinical Associate Professor, David Geffen School of Medicine UCLA
Incorporating CGM Into Clinical Decision Making Etie Moghissi, MD, FACE Clinical Associate Professor, David Geffen School of Medicine UCLA 1 Limitations of Current Glucose Monitoring Methods A1c Standard
More informationTechnology in Diabetes Management Irl B. Hirsch, MD University of Washington
Technology in Diabetes Management 2016 Irl B. Hirsch, MD University of Washington Dualities Research: Helmsley Charitable Trust, JDRF, ADA, NIDDK, CDC Consulting: Abbott, Roche, Intarcia Raise Your Hand
More informationTreatment guideline for adult patients with type 1 diabetes?
Treatment guideline for adult patients with type 1 diabetes? Jae Hyeon Kim Division of Endocrinology and Metabolism, Samsung Medical Center, Sungkyunkwan University School of Medicine ICDM 2014 Treatment
More informationExercise and Type 1 Diabetes
Exercise and Type 1 Diabetes QuickTime and a decompressor are needed to see this picture. 1 Characteristics of Type 1 & Type 2 Diabetes Mellitus ACE Mtng 2011 Rate of New Cases of Type 1 & Type 2 Diabetes
More informationJanice Lazear, DNP, FNP-C, CDE DIAGNOSIS AND CLASSIFICATION OF DIABETES
Janice Lazear, DNP, FNP-C, CDE DIAGNOSIS AND CLASSIFICATION OF DIABETES Objectives u At conclusion of the lecture the participant will be able to: 1. Differentiate between the classifications of diabetes
More informationRISK FACTORS OR COMPLICATIONS AND RECOMMENDED TREATMENT GOALS AND FREQUENCY OF EVALUATION FOR ADULTS WITH DIABETES
RISK FACTORS OR COMPLICATIONS AND RECOMMENDED TREATMENT GOALS AND FREQUENCY OF EVALUATION FOR ADULTS WITH DIABETES Risk Factors or Complications Glycemic Control Fasting & Capillary Plasma Glucose Anti-platelet
More informationDiabetes II Insulin pumps; Continuous glucose monitoring system (CGMS) Ernest Asamoah, MD FACE FACP FRCP (Lond)
Diabetes II Insulin pumps; Continuous glucose monitoring system (CGMS) Ernest Asamoah, MD FACE FACP FRCP (Lond) 9501366-011 20110401 Objectives Understand the need for insulin pumps and CGMS in managing
More informationFigure 2.1: Glucose meter
CHAPTER TWO: MONITORING TECHNOLOGIES 2.1 Introduction Glucose monitoring is a method of self-testing glucose (blood sugar) levels for the management of diabetes. Traditionally, it involves pricking the
More informationCGM Use in Pregnancy & Unique Populations ELIZABETH O. BUSCHUR, MD THE OHIO STATE UNIVERSITY WEXNER MEDICAL CENTER
CGM Use in Pregnancy & Unique Populations ELIZABETH O. BUSCHUR, MD THE OHIO STATE UNIVERSITY WEXNER MEDICAL CENTER Case 1: CGM use during pregnancy 29 yo G1P0000 at 10 5/7 weeks gestation presents to set
More informationBasics of Continuous Subcutaneous Insulin Infusion Therapy. Lubna Mirza, MD Norman Endocrinology Associates 2018
Basics of Continuous Subcutaneous Insulin Infusion Therapy Lubna Mirza, MD Norman Endocrinology Associates 2018 Preamble Roughly 20% - 30% of patients with T1DM and fewer than 1% of insulin-treated patients
More informationLOW SUGAR: CAUSES, COMPLICATIONS AND MANAGEMENT OF HYPOGLYCEMIA
LOW SUGAR: CAUSES, COMPLICATIONS AND MANAGEMENT OF HYPOGLYCEMIA Anne Leake, PhD, APRN-Rx, BC-ADM ECHO Diabetes Learning Group 3/28/2018 Objectives 1. Identify common preventable causes of hypoglycemia
More informationType 1 Diabetes Mellitus in the Adult. Katie Davis & Liz DeJulius KNH 411: Medical Nutrition Therapy I
Type 1 Diabetes Mellitus in the Adult Katie Davis & Liz DeJulius KNH 411: Medical Nutrition Therapy I Diabetes Mellitus: Type I Genetic factor Sudden onset Majority children and adolescents with an increasing
More informationDiabetes in Pregnancy
Diabetes in Pregnancy Ebony Boyce Carter, MD, MPH Division of Maternal Fetal Medicine Washington University School of Medicine Disclosures I have no financial disclosures to report. Objectives Review the
More information1. What s the point of a network the case for research? 2. How to use CSII effectively
1. What s the point of a network the case for research? 2. How to use CSII effectively John Pickup King s College London Faculty of Medicine Guy s Hospital, London What should an insulin pump network do?
More informationCASE STUDY #3 - NUT 116AL Diabetes Mellitus DUE Monday 12/9/13 (by 1:00pm in Meyer 3241)
Last Name Reagan First Name Jason Section 2_ CASE STUDY #3 - NUT 116AL Diabetes Mellitus DUE Monday 12/9/13 (by 1:00pm in Meyer 3241) Patricia C. is a 30 yo Asian American woman with T1DM. She was diagnosed
More informationComprehensive Diabetes Treatment
Comprehensive Diabetes Treatment Joshua L. Cohen, M.D., F.A.C.P. Professor of Medicine Interim Director, Division of Endocrinology & Metabolism The George Washington University School of Medicine Diabetes
More informationType 1 Diabetes-Pathophysiology, Diagnosis, and Long-Term Complications. Alejandro J de la Torre Pediatric Endocrinology 10/17/2014
Type 1 Diabetes-Pathophysiology, Diagnosis, and Long-Term Complications Alejandro J de la Torre Pediatric Endocrinology 10/17/2014 Objectives Understand the pathophysiology of Type 1 diabetes. Be familiar
More informationPumps & Sensors made easy. OPADA ALZOHAILI MD FACE Endocrinology Assistant Professor Wayne State University
Pumps & Sensors made easy OPADA ALZOHAILI MD FACE Endocrinology Assistant Professor Wayne State University DeFronzo RA. Diabetes. 2009;58:773-795. Ominous Octet Relationship of b-cell Dysfunction and Development
More information7/8/2016. Sol Jacobs MD, FACE Division of Endocrinology Emory University School of Medicine
Sol Jacobs MD, FACE Division of Endocrinology Emory University School of Medicine Participation in investigator initiated clinical research supported by: Merck Boehringer Ingelheim Novo Nordisk Astra Zeneca
More informationMaking Sense of Glucose Monitoring. My Journey with Glucose Monitoring Over the Last 37 Years 8/7/2017
HSW1 Disclosure to Participants Making Sense of Glucose Monitoring Alison B. Evert, MS, RD, CDE UW Neighborhood Clinics UW Medicine Seattle, WA Conflict of Interest (COI) and Financial Relationship Disclosures:
More informationUpdate on Continuous Glucose Monitoring (CGM) Technology in Diabetes. Elena Toschi, MD November 12, 2016
Update on Continuous Glucose Monitoring (CGM) Technology in Diabetes Elena Toschi, MD November 12, 2016 Presenter Disclosure Information Elena Toschi, MD No financial disclosure Objectives: Use of CGM
More informationCASE STUDY Diabetes Mellitus FH: PMH: Social Hx PE: Labs: Rx: CAM: Dx: Plan:
CASE STUDY Diabetes Mellitus Patricia C. is a 30 yo Asian American woman with T1DM. She was diagnosed at age 13. Her insulin regimen is 50 units of insulin (Glargine) every evening and 3 units of Lispro
More informationAbbreviations DPP-IV dipeptidyl peptidase IV DREAM Diabetes REduction Assessment with ramipril and rosiglitazone
Index Abbreviations DPP-IV dipeptidyl peptidase IV DREAM Diabetes REduction Assessment with ramipril and rosiglitazone Medication GAD glutamic acid decarboxylase GLP-1 glucagon-like peptide 1 NPH neutral
More informationObjectives. Objectives. Alejandro J. de la Torre, MD Cook Children s Hospital May 30, 2015
Alejandro J. de la Torre, MD Cook Children s Hospital May 30, 2015 Presentation downloaded from http://ce.unthsc.edu Objectives Understand that the obesity epidemic is also affecting children and adolescents
More informationHypoglycemia a barrier to normoglycemia Are long acting analogues and pumps the answer to the barrier??
Hypoglycemia a barrier to normoglycemia Are long acting analogues and pumps the answer to the barrier?? Moshe Phillip Institute of Endocrinology and Diabetes National Center of Childhood Diabetes Schneider
More informationType 1 Diabetes & Continuous Glucose Monitoring. Dr Sheila Cook Director of Diabetes & Endocrinology Toowoomba Hospital
Type 1 Diabetes & Continuous Glucose Monitoring Dr Sheila Cook Director of Diabetes & Endocrinology Toowoomba Hospital Let s consider the traditional diabetes clinic The Diabetes Clinic Whenever I check
More informationDISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.
DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this
More informationDiabetes Management with Continuous Glucose Monitoring & Multiple Daily Injections. Aaron Michels MD
Diabetes Management with Continuous Glucose Monitoring & Multiple Daily Injections Aaron Michels MD Outline SMBG & CGM by age group JDRF CGM Trial Sensor Augmented Insulin Pump Therapy for A1c Reduction
More informationType 2 Diabetes Mellitus Insulin Therapy 2012
Type 2 Diabetes Mellitus Therapy 2012 Michael T. McDermott MD Director, Endocrinology and Diabetes Practice University of Colorado Hospital Michael.mcdermott@ucdenver.edu Preparations Onset Peak Duration
More informationCGM and Closing The Loop
CGM and Closing The Loop Dualities Research: Helmsely Charitable Trust, ADA, JDRF, NIDDK Consulting: Abbott Diabetes Care, Roche, Intarcia, Valeritas, Adocia, Big Foot Like With Pumps, We ve Come A Long
More informationSGLT2 Inhibition in the Management of T2DM: Potential Impact on CVD Risk
Managing Diabetes & CVD: Expling New Evidence & Opptunities ESC Congress, London, UK 30 August, 2015 SGLT2 Inhibition in the Management of T2DM: Potential Impact on CVD Risk Silvio E. Inzucchi MD Yale
More informationErtugliflozin (Steglatro ) 5 mg daily. May increase to 15 mg daily. Take in the morning +/- food. < 60: Do not initiate; discontinue therapy
Sodium-glucose Cotransporter-2 (SGLT2) s Inhibit SGLT in proximal renal tubules, reducing reabsorption of filtered glucose from tubular lumen Lowers renal threshold for glucose à increase urinary excretion
More informationDiabetes: Definition Pathophysiology Treatment Goals. By Scott Magee, MD, FACE
Diabetes: Definition Pathophysiology Treatment Goals By Scott Magee, MD, FACE Disclosures No disclosures to report Definition of Diabetes Mellitus Diabetes Mellitus comprises a group of disorders characterized
More informationVipul Lakhani, MD Oregon Medical Group Endocrinology
Vipul Lakhani, MD Oregon Medical Group Endocrinology Disclosures None Objectives Be able to diagnose diabetes and assess control Be able to identify appropriate classes of medications for diabetes treatment
More informationInvokana (canagliflozin) NEW INDICATION REVIEW
Invokana (canagliflozin) NEW INDICATION REVIEW Introduction Brand name: Invokana Generic name: Canagliflozin Pharmacological class: Sodium-glucose cotransporter 2 (SGLT2) inhibitor Strength and Formulation:
More informationInjecting Insulin into Out Patient Practice
Injecting Insulin into Out Patient Practice Kathleen Colleran, MD Associate Professor UNMHSC 4/22/10 Overview Natural history of Type 2 diabetes Reasons clinicians are reluctant to start insulin therapy
More informationNon-insulin treatment in Type 1 DM Sang Yong Kim
Non-insulin treatment in Type 1 DM Sang Yong Kim Chosun University Hospital Conflict of interest disclosure None Committee of Scientific Affairs Committee of Scientific Affairs Insulin therapy is the mainstay
More informationMaking the Most of Continuous Glucose Monitoring
Making the Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner & Clinical Director Integrated Diabetes Services LLC Wynnewood, PA AADE 2014 Diabetes Educator of the Year gary@integrateddiabetes.com
More informationComplete this CE activity online at ProCE.com/InsulinPart2
Complete this CE activity online at ProCE.com/InsulinPart2 Case 1: A 67 year old male with T2DM History and Presentation John is a 67 year old retiree who has been visiting your pharmacy/clinic for over
More informationClinical Value and Evidence of Continuous Glucose Monitoring
Clinical Value and Evidence of Continuous Glucose Monitoring 9402313-012 Objective To review the clinical value and the recent clinical evidence for Professional and Personal CGM Key Points CGM reveals
More informationMedical Nutrition Therapy for Diabetes Mellitus. Raziyeh Shenavar MSc. of Nutrition
Medical Nutrition Therapy for Diabetes Mellitus Raziyeh Shenavar MSc. of Nutrition Diabetes Mellitus A group of diseases characterized by high blood glucose concentrations resulting from defects in insulin
More informationINSULIN INITIATION AND INTENSIFICATION WITH A FOCUS ON HYPOGLYCEMIA REDUCTION
INSULIN INITIATION AND INTENSIFICATION WITH A FOCUS ON HYPOGLYCEMIA REDUCTION Jaiwant Rangi, MD, FACE Nov 10 th 2018 DISCLOSURES Speaker Novo Nordisk Sanofi-Aventis Boheringer Ingleheim Merck Abbvie Abbott
More informationCurrent Clinical Practice Guideline for Diabetes Management
Current Clinical Practice Guideline for Diabetes Management Chaicharn Deerochanawong M.D. Professor of Medicine, i Rangsit Medical University it Diabetes and Endocrinology Unit Department of Medicine Rajavithi
More informationThe ABCs of MDI: Gaining a working knowledge of Multiple Daily Injection insulin therapy. Today s Presenter
FD Title Slide The ABCs of MDI: Gaining a working knowledge of Multiple Daily Injection insulin therapy learn.extension.org/events/3369 3 This material is based upon work supported by the National Institute
More informationAkio Ohta, Kaori Arai, Ami Nishine, Yoshiyuki Sada, Hiroyuki Kato, Hisashi Fukuda, Shiko Asai, Yoshio Nagai, Takuyuki Katabami and Yasushi Tanaka
Endocrine Journal 2013, 60 (2), 173-177 Or i g i n a l Comparison of daily glucose excursion by continuous glucose monitoring between type 2 diabetic patients receiving preprandial insulin aspart or postprandial
More informationClinical Practice Guidelines for Diabetes Management
Clinical Practice Guidelines for Diabetes Management Diabetes is a disease in which blood glucose levels are above normal. Over the years, high blood glucose damages nerves and blood vessels, which can
More informationDisclosures. Diabetes and Cardiovascular Risk Management. Learning Objectives. Atherosclerotic Cardiovascular Disease
Disclosures Diabetes and Cardiovascular Risk Management Tony Hampton, MD, MBA Medical Director Advocate Aurora Operating System Advocate Aurora Healthcare Downers Grove, IL No conflicts or disclosures
More informationObesity, Insulin Resistance, Metabolic Syndrome, and the Natural History of Type 2 Diabetes
Obesity, Insulin Resistance, Metabolic Syndrome, and the Natural History of Type 2 Diabetes Genetics, environment, and lifestyle (obesity, inactivity, poor diet) Impaired fasting glucose Decreased β-cell
More informationDiabetes Mellitus in Older Adults. Presenter Disclosure Information
Diabetes Mellitus in Older Adults Medha Munshi, M.D. Joslin Diabetes Center Beth Israel Deaconess Medical Center Harvard Medical School Presenter Disclosure Information Medha Munshi Research grant from
More informationObjectives. Kidney Complications With Diabetes. Case 10/21/2015
Objectives Kidney Complications With Diabetes Brian Boerner, MD Diabetes, Endocrinology, and Metabolism University of Nebraska Medical Center Review screening for, and management of, albuminuria Review
More informationDiabetes Mellitus Case Study
COLORADO STATE UNIVERSITY Diabetes Mellitus Case Study Medical Nutrition Therapy By: Emily Lancaster 9/28/2012 [Type the abstract of the document here. The abstract is typically a short summary of the
More informationTips and Tricks for Starting and Adjusting Insulin. MC MacSween The Moncton Hospital
Tips and Tricks for Starting and Adjusting Insulin MC MacSween The Moncton Hospital Progression of type 2 diabetes Beta cell apoptosis Natural History of Type 2 Diabetes The Burden of Treatment Failure
More informationCollin College. BIOL Anatomy & Physiology. Urinary System. Summary of Glomerular Filtrate
Collin College BIOL. 2402 Anatomy & Physiology Urinary System 1 Summary of Glomerular Filtrate Glomerular filtration produces fluid similar to plasma without proteins GFR ~ 125 ml per min If nothing else
More informationUsing the Bolus Wizard Calculator
9501179-011 Using the Bolus Wizard Calculator Objective Describe the features and benefits of the Bolus Wizard Calculator Key Points The Bolus Wizard: Estimates high blood glucose corrections using the
More informationAntihyperglycemic Agents in Diabetes. Jamie Messenger, PharmD, CPP Department of Family Medicine East Carolina University August 18, 2014
Antihyperglycemic Agents in Diabetes Jamie Messenger, PharmD, CPP Department of Family Medicine East Carolina University August 18, 2014 Objectives Review 2014 ADA Standards of Medical Care in DM as they
More informationGlycemic Variability:
Glycemic Variability: Do the Differences Make a Difference? Kim L Kelly, PharmD, BCPS, FCCP Define Variability VERY LOW GLYCEMIC VARIABILITY LOW GLYCEMIC VARIABILITY HIGH GLYCEMIC VARIABILITY So what s
More informationStroke Hyperglycemia Insulin Network Effort (SHINE) Trial Treatment Protocols. Askiel Bruno, MD, MS Protocol PI
Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial Treatment Protocols Askiel Bruno, MD, MS Protocol PI SHINE Synopsis Acute ischemic stroke
More informationDiabetes Technology in Irl B. Hirsch, MD University of Washington School of Medicine Seattle, WA
Diabetes Technology in 2018 Irl B. Hirsch, MD University of Washington School of Medicine Seattle, WA Dualities Research: Medtronic Diabetes Consulting: Abbott Diabetes Care, BD, Bigfoot, Roche Let s First
More informationThe York Diabetes Care Model
This Session The York Diabetes Care Model The annual review what s it for and how to do it How to make the diagnosis of diabetes and who to test Categorisation of diabetes at diagnosis Basics of Insulin
More informationssociation of Children s Diabetes Clinicians Clinicians Continuous Glucose Monitoring (CGM) Training for Healthcare Professionals and Patients
ssociation of Children s Diabetes Continuous Glucose Monitoring (CGM) Training for Healthcare Professionals and Patients 1 ssociation of Children s Diabetes Contents Chapter Page no. STEP 1...3 Getting
More information1. Continuous Glucose Monitoring
1. Continuous Glucose Monitoring 1. Physiology of interstitial fluid glucose 2. Comparison of CGM and self-monitored blood glucose (SMBG) data 3. Insulin dosing indication in BGM vs. CGM & the FDA 4. Protection
More informationMANAGEMENT OF TYPE 1 DIABETES MELLITUS
MANAGEMENT OF TYPE 1 DIABETES MELLITUS INVESTIGATIONS AND TREATMENT MANSI NAIK VII SEMESTER INVESTIGATIONS FASTING BLOOD SUGAR PLASMA GLUCOSE HEMOGLOBIN A 1c SYMPTOMS OF TYPE 1 DIABETES MELLITUS Polyuria
More informationType 1 Diabetes Update Robin Goland, MD
Naomi Berrie Diabetes Center Type 1 Diabetes Update 2008 Robin Goland, MD Type 1 diabetes is: A manageable condition A chronic condition Often challenging Entirely compatible with a happy and healthy childhood
More informationBackground: Brief review of epidemiology, diagnosis, classification and pathophysiology of diabetes mellistus.
Insulin Therapy in Diabetes Mellitus Part 1 Lekshmi T. Nair, MD, MHS Assistant Professor Department of Internal Medicine Division of Endocrinology, Diabetes and Metabolism The Ohio State University Wexner
More informationPREVENTION OF NOCTURNAL HYPOGLYCEMIA USING PREDICTIVE LOW GLUCOSE SUSPEND (PLGS)
PREVENTION OF NOCTURNAL HYPOGLYCEMIA USING PREDICTIVE LOW GLUCOSE SUSPEND (PLGS) Pathways for Future Treatment and Management of Diabetes H. Peter Chase, MD Carousel of Hope Symposium Beverly Hilton, Beverly
More informationWhat is a CGM? (Continuous Glucose Monitor) The Bionic Pancreas Is Coming
The Bionic Pancreas Is Coming Montana Diabetes Professional Conference October 23, 2014 H. Peter Chase, MD Professor of Pediatrics University of Colorado Barbara Davis Center Stanford: Bruce Buckingham,
More informationPhysiology of Normoglycemia
Case 1 45 year-old male patient seen at the clinic (Medicine). Workplace stress (financial analyst); occasionally goes jogging. Two-year duration of T2DM. No previous cardiovascular events. Coexisting
More informationInpatient Management of Diabetes Mellitus. Jessica Garza, Pharm.D. PGY-1 Pharmacotherapy Resident TTUHSC School of Pharmacy
Inpatient Management of Diabetes Mellitus Jessica Garza, Pharm.D. PGY-1 Pharmacotherapy Resident TTUHSC School of Pharmacy 2 Disclosure Jessica Garza does not have any actual or potential conflicts of
More informationThis certificate-level program is non-sponsored.
Program Name: Diabetes Education : A Comprehensive Review Module 5 Intensive Insulin Therapy Planning Committee: Michael Boivin, B. Pharm. Johanne Fortier, BSc.Sc, BPh.LPh, CDE Carlene Oleksyn, B.S.P.
More informationUsefulness of Ambulatory Glucose Profile (AGP) in Diabetes Care
C H A P T E R 41 Usefulness of Ambulatory Glucose Profile (AGP) in Diabetes Care K Chaithanya Murthy, B Ramya, E Vidya, RM Anjana, V Mohan ABSTRACT Over the past decades, several newer technologies have
More informationManaging Problematic Hypoglycaemia Pratik Choudary
Managing Problematic Hypoglycaemia Pratik Choudary Control Hypoglycaemia What is normal? Rate per 100 years 100 80 60 40 Is tighter control associated with more severe hypoglycaemia? Intensive Conventional
More informationDr. Yash Pal Munjal MD, FICP, MAMS, FRCP (EDIN), FACP (USA) FIACM, FIAMS, FIMSA
Dr. Yash Pal Munjal MD, FICP, MAMS, FRCP (EDIN), FACP (USA) FIACM, FIAMS, FIMSA Medical Director, Banarsidas Chandiwala Institute of Medical Sciences Chief Consultant, Centre for Diabetes & Lifestyle Diseases,
More informationApplication of the Diabetes Algorithm to Patients
Application of the Diabetes Algorithm to Patients Apply knowledge gained from this activity to improve disease management and outcomes for patients with T2DM and obesity Note: The cases in this deck represent
More informationClinicalTrials.gov Identifier: sanofi-aventis. Sponsor/company:
These results are supplied for informational purposes only. Prescribing decisions should be made based on the approved package insert in the country of prescription Sponsor/company: sanofi-aventis ClinicalTrials.gov
More informationDiabetes and Technology. Saturday, September 9, 2017 Aimee G sell, APRN, ANP-C, CDE
Diabetes and Technology Saturday, September 9, 2017 Aimee G sell, APRN, ANP-C, CDE Disclosure Speaker s Bureau: Janssan Pharmaceuticals Current Technology V-Go by Valeritas Continuous Sensors (personal
More informationTorbay Children s Diabetes Service
Torbay Children s Diabetes Service Preventing Diabetes Complications Retinopathy Stroke Gum Disease Nephropathy Cardiovascular disease Neuropathy Diabetes Complications Thinking and talking about the possibility
More informationThe Diabetes Link to Heart Disease
The Diabetes Link to Heart Disease Anthony Abe DeSantis, MD September 18, 2015 University of WA Division of Metabolism, Endocrinology and Nutrition Oswald Toosweet Case #1 68 yo M with T2DM Diagnosed DM
More informationSTANDARDS OF MEDICAL CARE IN DIABETES 2014
STANDARDS OF MEDICAL CARE IN DIABETES 2014 I. CLASSIFICATION AND DIAGNOSIS Classification of Diabetes Type 1 diabetes β-cell destruction Type 2 diabetes Progressive insulin secretory defect Other specific
More informationDiabetes and Pregnancy
Diabetes and Pregnancy Eric L. Johnson, M.D. Associate Professor Department of Family and Community Medicine University of North Dakota School of Medicine And Health Sciences Assistant Medical Director
More informationSponsor / Company: Sanofi Drug substance(s): insulin glargine (HOE901) According to template: QSD VERSION N 4.0 (07-JUN-2012) Page 1
These results are supplied for informational purposes only. Prescribing decisions should be made based on the approved package insert in the country of prescription. Sponsor / Company: Sanofi Drug substance(s):
More informationWHAT CAN I DO TO REDUCE MY RISK OF DEVELOPING THE COMPLICATIONS OF TYPE 1 DIABETES?
Christian In better control with his pump since 2012 WHAT CAN I DO TO REDUCE MY RISK OF DEVELOPING THE COMPLICATIONS OF TYPE 1 DIABETES? Many people with Type 1 diabetes worry about potential long-term
More informationStandards of Care in Diabetes What's New? Veronica Brady, FNP-BC, PhD, BC-ADM,CDE Karmella Thomas, RD, LD,CDE
Standards of Care in Diabetes 2016-- What's New? Veronica Brady, FNP-BC, PhD, BC-ADM,CDE Karmella Thomas, RD, LD,CDE Terminology No longer using the term diabetic. Diabetes does not define people. People
More informationWhy do we care? 20.8 million people. 70% of people with diabetes will die of cardiovascular disease. What is Diabetes?
What is Diabetes? Diabetes 101 Ginny Burns RN MEd CDE Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action
More informationClinical Practice Guidelines
Clinical Practice Guidelines Diabetes Objective The purpose is to guide the appropriate diagnosis and management of Diabetes. This guideline is designed to assist the clinician by providing a framework
More information