DIABETES MELLITUS ISSUES IN THE LONG TERM CARE SETTING AND ALLIED VENUES.

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DIABETES MELLITUS ISSUES IN THE LONG TERM CARE SETTING AND ALLIED VENUES

Transcript of DIABETES MELLITUS ISSUES IN THE LONG TERM CARE SETTING AND ALLIED VENUES.

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DIABETES MELLITUS

ISSUES IN THE

LONG TERM CARE SETTING AND ALLIED VENUES

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DIABETES MELLITUS

Focus: diabetes in the Medicare population

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DIABETES MELLITUS

Definition: a metabolic disorder in which

there is deficiency of insulin production or

resistance of organs to the effect of insulin

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DIABETES MELLITUS

• Diabetes is a disorder of metabolism--the way our bodies use digested food for growth and energy.

• Most of the food we eat is broken down into glucose, the form of sugar in the blood.

• Glucose is the main source of fuel for the body.

• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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DIABETES MELLITUS

• After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy.

• For glucose to get into cells, insulin must be present.

• Insulin is a hormone produced by the pancreas, a large gland behind the stomach.

• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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DIABETES MELLITUS

• NORMAL: When non-diabetic people eat, the pancreas automatically produces the right amount of insulin to move glucose from blood into our cells.

• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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DIABETES MELLITUS

• DIABETES: In people with diabetes, when they eat, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced (or both) => glucose builds up in the blood, overflows into the urine, and passes out of the body in urine => body loses its main source of fuel even though blood contains large amounts of glucose.

• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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DIABETES MELLITUS (DM)

• TYPES OF DIABETES– Type I– Type II– MODY (Maturity Onset Diabetes of

Youth– Gestational

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DM TYPE I

Auto-immune disease

Constitutes 5-10% of DM diagnosed in the USA

Mostly appears in children and young adults

Develops as a result of auto-immune destruction of beta-cells in the pancreas

Presents with polyuria, thirst, weight loss, marked fatigue

Can be complicated by coma with ketoacidosis» <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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DM TYPE II• Most common form of diabetes• Involves about 90-95% of people with DM• Associated with:

– older age – obesity– family history of DM– prior history of gestational diabetes– physical inactivity– ethnicity

» <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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DM TYPE II

• Patient with type II DM usually makes enough insulin but the body cannot use it effectively => insulin resistance

• Gradually insulin production decreases over the following years

• Symptoms are similar to type I but develop more gradually

» <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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DM TYPE II• Symptoms of type II DM include:

– Fatigue– Nausea– Frequent urination/polyuria– Thirst – Unusual weight loss– Blurred vision– Frequent infections – Slow healing of wounds or sores– Sometimes no specific symptoms

• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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GESTATIONAL DIABETES• Develops only during pregnancy• More common in:

– African Americans

– American Indians

– Hispanic Americans

– women with a family history of diabetes

• Women with a history of gestational diabetes have a 20-50% chance of getting type II DM within 5-10 years <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>

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Diabetes Mellitus: Diagnosis

• Fasting plasma glucose = preferred test: Positive test is glycemia of 126mg/dL or higher after fasting at least 8 hours

• Random plasma glucose of 200mg/dL or higher along with symptoms of diabetes

• Oral glucose tolerance test (OGTT) plasma glucose of 200mg/dL or higher done 2 hours after ingestion of 75 grams of glucose in water

• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>• MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

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Diabetes Mellitus

• Hemoglobin A1c measurement is not recommended currently for diagnosis of diabetes.

• HbA1c is used as a marker to monitor glycemia control in patients over time

• MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

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Pre-Diabetes• Pre-diabetes refers to a state between “normal”

and “diabetes” = fasting plasma glucose 100-125mg/dL (higher than normal but not high enough for diagnosis of diabetes)

Affects about 41 million people in USA

(previously referred to as either impaired fasting glucose or impaired glucose tolerance)

• http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#types

• MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

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Type II Diabetes

Diagnostic testing - when to do it:

People 45 years old => if normal then every 3 years

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

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Type II Diabetes: diagnostic testing

Younger than 45 yo or more often than every 3 years if:overweight

first degree relative with diabetes

member of high risk ethnic group (Afro-American, Hispanic American, Native American, Asian American, Pacific Islander)

delivered a baby 9 lbs.

gestational diabetes

hypertensive (BP 140/90mmHg)

High Density Lipoprotein cholesterol 35mg/dl or less

TriGlyceride level 250mg/dl or more

pre-diabetes

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

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DM type II: ManagementBasics:

healthy eating

physical activity

blood glucose testing

Pharmaceuticals:

oral medication(s)

insulin(s)

both oral medicines and insulin

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DM: insulin variations

Daily insulin requirements are influenced by:

diet

exercise

stress

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Diabetes Management: Stress

Stress influences response to insulin

Stress => increased cortisol

increased catecholamines

increased growth hormone

=> these hormones all lead to increased insulin resistance (thus, hyperglycemia)

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Control of Diabetes

Control of Diabetes includes:

glycemia control (FBS < 126mg/dL; HbA1c <7%)

weight management

blood pressure control (BP < 130/80mmHg)

lipid management

reduction in the hypercoagulable state (aspirin or clopidogrel)

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DM type II: Management

Most people with newly discovered type II DM are overweight

Basics are diet and exercise:

nutrition

life style modification

increased physical activity

Goal = Hemoglobin A1c < 7%

If this goal in not reached and maintained => pharmacotherapy (medications)

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Insulins

Type hours to onset time to peak time effective

Fast acting:

Lispro <0.25 (15min) 0.5-1.5 3-4 (max 4-6)

Aspart 0.17-0.33 0.67-0.83 1-3 (max 3-5)

Long acting

Glargine 2 none 24

Ultralente 6-10 10-16 18-20 (max 20-24)

Short acting

regular 0.5-1.0 2-3 3-6 (max 6-8)

Intermediate acting

NPH 2-4 6-10 10-16 (max 14-18)

Lente 3-4 6-12 12-18 (max 16-20)

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

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Insulin

Insulin dependency regimens - examples:

1. insulin glargine q24h and pre-meal insulin

2. NPH and regular before breakfast and supper

3. Rapid or short acting insulin before meals & intermediate acting insulin (NPH or Lente) at bedtime

4. Insulin Glargine at bedtime and rapid or short acting insulin before meals

Insulin regimens depend on individual patient requirements

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Medications for DM type II

Sulfonylureas & Meglitinides: promote glucose-stimulated release of insulin from pancreas (they need enough remaining beta-cell function in the pancreas to work) (insulin secretogogues)

Metformin: mostly blocks gluconeogenesis in the liver; also interferes with glycogenolysis and improves insulin sensitivity of muscle

Thiazolidinediones: bind to nuclear receptors in tissues & activate or suppress expression of specific genes (insulin sensitizers) - risk of fluid retention & weight gain; 4-12 week latency to work; monitor liver enzymes q2mo

Acarbose: alpha-glucosidase inhibitor; interferes with intestinal absorption of carbohydrates; causes flatulence & bloating (discontinuation)

MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.

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Medications for DM type IISulfonylureas: insulin secretogogues

glyburide

glipizide

glimeperide

chlorpropamide

Meglitinides: insulin secretogogues

repaglinide

nateglinide

Biguanide: decreases hepatic gluconeogenesis

metformin

Thiazolidinediones: insulin sensitizers

pioglitazone

rosiglitazone

Alpha-glucosidase inhibitor: decreases GI absorption of carbohydrate

acarbose;

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Insulin in Type II DM

Usually indicated if HbA1c > 7% despite life style modification and 2 oral medications

May be postponed in borderline cases where HbA1c is < 8.5% pending addition of a 3rd oral agent; otherwise =>

Addition of bedtime dose of basal insulin therapy (glargine)

to sulfonylureas +/- metformin (not thiazolidinediones because of risk of CHF

from fluid retention)

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The Metabolic Syndrome

• Hypertension

• Visceral (central) obesity

• Hypertriglyceridemia

• Low HDL cholesterol

• Insulin resistance or glucose intolerance

• Prothrombotic state (high fibrinogen or plasminogen activator inhibitor [-1] in blood)

• Proinflammatory state (high C-reactive protein in blood)

• http://www.americanheart.org/presenter.jhtml?identifier=4756

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Acute Complications of type II DM

Hyperglycemic hyperosmolar state:

common in elderly

triggered by underlying disorder(s)

risk increased in elderly due to decreased thirst reflex

often complicated by delirium

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Acute Complications of type II DM

Hyperglycemic hyperosmolar state:

serum osmolarity > 320 mosm/L

plasma glucose > 600mg/dL

dehydration

no ketoacidosis

underlying disorder(s)

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Hyperosmolar State

Therapy:

rehydration with hypotonic solution

insulin infusion (initially)

watch for signs of fluid overload/CHF

monitor potassium

treat underlying cause (eg UTI, cellulitis)

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Hypoglycemia

Hypoglycemia = plasma glycemia < 50mg/dL with or without symptoms

More common in type I DM and patients with significant renal or liver disease

Another reason for glucose monitoring

Treated with po sugar (e.g. fruit juice or glucose tablets)

or IV dextrose 50% in water or IV glucagon or both

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Complications of DM

Chronic complications of diabetes mellitus include:

Macrovascular

Microvascular

Neuropathic

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Complications of DM

Macrovascular

atherosclerosis/cardiovascular disease

peripheral vascular disease

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Complications of DM

Microvasculardiabetic retinopathy: due to ischemia of retna; provokes neovascularization with vessels more fragile => leaking => scarring & fibrosis

diabetic nephropathy: common cause of ESRD;

prevention via control of blood pressure and glycemia; earliest signs urine albumin 30mg/day or 20g/min; appears to benefit from ACE-I’s and ARB’s too

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Complications of DM

Diabetic Neuropathy

peripheral sensory neuropathy

cardiovascular autonomic neuropathy

gastrointestinal autonomic neuropathy

erectile dysfunction

mononeuropathy

diabetic foot

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Complications of DM

Peripheral sensory neuropathy

variable presentation

dysesthesia

tingling

pain

loss of pain sensation (risk of injury)

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Complications of DM

Cardiovascular Autonomic Neuropathy

orthostatic hypotension

lack of normal variation in heart rate with breathing, tachycardia

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Complications of DM

Gastrointestinal Autonomic Neuropathy

gastroparesis: nausea, bloating, vomiting (tx metoclopramide)

diarrhea: often nocturnal

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Complications of DM

Erectile dysfunction:

autonomic neuropathy

absent nocturnal and morning erections

more common than diagnosed

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Complications of DM

Mononeuropathy

acute local pain

distribution of a nerve

may recede if treated early with improved glucose control (glucotoxicity)

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Complications of DM

Diabetic Foot

sensory deficit (skin, bone, ligament)

fungal infection

wounds

pulses (PVD)

slow healing

ulcers

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Type II DM: Goals

Prevention of pre-diabetes

Prevention of change from pre-diabetes to diabetes

Diagnosis through screening

Early management/therapy

Prevention of complications

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Type II DM: Goals

Screening via fasting glycemia and history

Life-style history and modification

Physical activity

Diet

Treatment of glycemia, lipids, hypercoagulable state, blood pressure

Management of complications

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