Gutman Diabetes Institute Einstein Medical Center, Philadelphia Patricia C. Adams, RN, CDE Gutman...

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Transcript of Gutman Diabetes Institute Einstein Medical Center, Philadelphia Patricia C. Adams, RN, CDE Gutman...

  • Slide 1
  • Gutman Diabetes Institute Einstein Medical Center, Philadelphia Patricia C. Adams, RN, CDE Gutman Diabetes Institute
  • Slide 2
  • Distinguish the different types of diabetes Discuss appropriate administration of insulin Discuss prevention and treatment of hypoglycemia Review of ADA recommendations for anti- psychotic drugs and obesity Gutman Diabetes Institute
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  • Diabetes - Epidemic Proportions Glucose Toxicity 25.8 million Americans (8.3% of population) 18.8 million have been diagnosed 7.0 million are unaware they have the disease Lipid Toxicity http://www.cdc.gov/diabetes/pubsaccessed 3/8/2011 Gutman Diabetes Institute
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  • Areas Requiring Control Glycemic Control A1C < 7% (ADA Standards) < 6.5% (AACE Standards) Blood Pressure Control Goal is 130/80 ACE vs ARB; Diuretics Lipid Management Statins Gutman Diabetes Institute
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  • Lipids Total Cholesterol < 200 HDL > 45 (Men) > 55 (Women) LDL < 100; 21 yrs) Gutman Diabetes Institute
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  • Treatment recommendations and goals Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients: with overt CVD (A) / LDL < 70 without CVD who are >40 years of age and have one or more other CVD risk factors (A) / LDL < 100 ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
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  • Type 1 Approximately 5% Type 2 Approximately 95% Gestational 7 14% of all pregnancies 5 10% have type 2 following delivery 20 50% chance of developing diabetes in the next 5 10 years Gutman Diabetes Institute
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  • A1C > 6.5% FPG> 126 mg/dl OGTT > 200 mg/dl (75g glucose load) RPG > 200 mg/dl with symptoms of hyperglycemia Diabetes Diabetes > mg/dl > 126 mg/dl < 126 mg/dl > 100 mg/dl < < 100 mg/dl Pre- Diabetes Normal 70 mg/dl Diabetes Care, Clinical Practice Recommendations, 2011
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  • Criteria for Testing for Diabetes in Asymptomatic Adult Individuals Physical inactivity First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who delivered a baby weighing >9 lb or were diagnosed with GDM Hypertension (140/90 mmHg or on therapy for hypertension) HDL cholesterol level 250 mg/dl (2.82 mmol/l) Women with polycystic ovarian syndrome (PCOS) A1C 5.7%, IGT, or IFG on previous testing Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD *At-risk BMI may be lower in some ethnic groups. 1.Testing should be considered in all adults who are overweight (BMI 25 kg/m 2 *) and have additional risk factors: ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.
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  • 2 3 fold increased mortality rate associated with physical illness Most common cause of death CVD More likely to be overweight, smoke, inactive More likely to have family hx diabetes, Limited access to primary care, cardiovascular risk screening Gutman Diabetes Institute
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  • Baseline monitoring at initiation of antipsychotic medications Personal/family hx diabetes, obesity, dislipidemia, hypertension, CVD Calculate BMI Waist circumference BP, Fasting blood glucose, Fasting Lipid profile Interval monitoring 4, 8, & 12 weeks after initiation of therapy Weight gain > 5% consider change in therapy Gutman Diabetes Institute
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  • Consideration of metabolic risks when starting SGAs Patient, family, and care giver education Baseline screening Regular monitoring Refer to specialized services, when needed Gutman Diabetes Institute
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  • Blood Glucose Regulation BLOOD GLUCOSE Intestine:GlucoseAbsorption Muscle Fat PeripheralGlucoseUptake Pancreas InsulinSecretion+ + Brain & Nervous System + Release of GIP & GLP - 1
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  • Type 1 DiabetesType 2 Diabetes Initially little insulin production Evolves into no insulin production Exogenous insulin required daily Auto-immune response Genetic component 5 - 10% prevalence Slow, Insidious 6.5 years to manifest as elevated FBG Elevated postprandial blood glucose levels Damage vessel endothelium Insulin Resistance Beta Cell Deterioration Gutman Diabetes Institute
  • Slide 15
  • Type Type 1 Type 2 Age of OnsetUsually 40 OnsetRapidSlowly - years Insulin Availability Little to NoneSome Progressive Insulin ResistanceDevelops w/TimeUsually present TreatmentExogenous insulin always needed Daily injections MNT, Activity, Oral Agents, Insulin ComplicationsDevelop w/TimePresent at Dx
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  • Gutman Diabetes Institute Type 2 diabetes Environment IGT Impaired insulin secretion Insulin resistance Genes IGT
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  • Gutman Diabetes Institute GenesVs.Jeans
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  • Normal Impaired glucose tolerance Type 2 diabetes Fasting plasma glucose Insulin sensitivity Insulin secretion Insulin sensitive Normal insulin secretion Normoglycaemia Hyperglycaemia -cell exhaustion Insulin resistance Late type 2 diabetes complications Adapted from Bailey CJ et al. Int J Clin Pract 2004;58:867876. Groop LC. Diabetes Obes Metab 1999;1 (Suppl. 1):S1S7. Insulin resistance
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  • Gutman Diabetes Institute How Do Oral Diabetes Medicines Work? Increase insulin action Slow glucose absorption Decrease hepatic glucose Increase insulin secretion AcarboseMiglitol Glyburide Glipizide GlimepirideRepaglinideNateglinide Metformin Metformin XR Metformin/Glyburide PioglitazoneRosiglitazone SecretagoguesBiguanides GlucosidaseInhibitorsTZDS DPP IV Inhibitors Decrease breakdown of GLP-1- increase insulin secretion SitagliptonSaxaglipton
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  • Basal Amount needed to prevent excess gluconeogenesis and ketogenesis Prandial Amount needed to cover discrete meals and/or nutritional supplements Tube Feedings, IV dextrose, TPN Gutman Diabetes Institute
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  • Regular NPH 70/30 Gutman Diabetes Institute
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  • Humalog (Lispro) Humalog Mix 75/25 NovoLog (Aspart) NovoLog Mix 70/30 Apidra (Glulisine) Lantus (Glargine) Levemir (Detemir) Gutman Diabetes Institute
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  • Novolog u100 : _____ units with 1 st meal@_____ ______units with 2 nd meal@_____ ______units with 2 nd meal@_____ ______units with 3 rd meal @_____ ______units with 3 rd meal @_____ Lantus u100 : _____ units in the morning @_____ _____ units in the morning @_____ Sleeping 0123456789101112131415161718192021222324 1231 Meal times: Hours of sleep: _____ _____ _____ ______________
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  • Insulin type: Human u100 Premix R & NPH Onset (Begins to work) - 1 hour following injection Peak action (Works the strongest)Dual following injection Effective duration following injection Actual maximum duration 10-16 hrs Premix (cloudy) Short acting insulin 0123456789101112131415161718192021222324 Intermediate acting insulin
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  • TypeStarts PeaksEnds Lispro (Humalog) 5 min.60 min.3 4 hr. Aspart (Novolog) 5 min.60 min.3 5 hr. Glulisine (Apidra) 5 min.60 min.3 4 hr. Regular30 60 min.2 4 hr.6 8 hr. NPH1.5 hours4 12 hr.10 16 hr. Gutman Diabetes Institute
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  • TypeStartsPeaksEnds Glargine (Lantus) 4 6 hr.None24 hr. Levemir (Detemir) < 2 hr.3 14 hr16 24 hr. 70/300.5 1.0 hr.Dual (NPH/R)12 20 hr. Mix 75/2510 min.Dual ( Lispro/Lispro Protamine) 12 20 hr. Mix 70/3010 min.Dual (Aspart/Aspart Protamine) 12 20 hr. Gutman Diabetes Institute
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  • 70/30 30 minutes prior to meal Regular 20 to 30 minutes prior to meal NPH 20 to 30 minutes prior to meal Aspart- 5 10 minutes prior to meal Lispro- 5 10 minutes prior to meal Apidra - 5 10 minutes prior to meal Gutman Diabetes Institute
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  • Glucose Level Time in Hours 012 3 4 Insulin Peak action
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  • Gutman Diabetes Institute Glucose Level Time in Hours 012 3 4 Insulin Peak Action Hyperglycemia Hypoglycemia
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  • Basal insulin You wouldnt hold the pancreas, so dont hold the lantus Gutman Diabetes Institute
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  • Without insulin, in an insulin deficient individual, blood glucose will increase passively by as much as 45 mg/dl per hour even in the absence of food. Gutman Diabetes Institute
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  • A1C
  • 3 Clinical Features Hyperglycemia - >250 mg/dL Ketonuria or ketonemia Acidosis pH
  • Lab Values Glucose > 600 mg/dl No Ketones or Only Small Amounts Plasma Osmolality > 320 mOsm/kg Gutman Diabetes Institute
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  • DKAHHS MildModerateSevere Glucose 250>250.250>600 pH7.25-7.307.00-7.247.30 BiCarb15-1810-1515 Urine Ketones +++small Serum Ketones +++small Anion Gap>10>12