Optimizing Diabetic Care in Residential Care

Lori C. Dupree, PharmD, BCPSConsultant Pharmacist

Neil Medical GroupMooresville, North Carolina

Learning Objectives• Differentiate between the different types of

diabetes. • Identify the treatments used for managing

diabetes.• List common complications associated with

diabetes and describe their management.• State appropriate monitoring parameters for

residents with diabetes.

Scope• Affects 25.8 million people in the United States• 8.3% of the US population

o 18.8 million diagnosedo 7 million undiagnosed

• Leading cause of kidney failure, amputation not related to an accident/trauma, newly diagnosed adult blindness

• Major cause of stroke and heart disease• Seventh leading cause of death

http://www.cdc.gov/diabetes/atlas/countydata/atlas.html (accessed March 31, 2014)

County-Level Estimates of Diagnosed Diabetes (%), Adults ≥20 years, 2010

Percent

Diabetes in South Carolina

http://www.cdc.gov/diabetes/atlas/countydata/atlas.html (accessed March 31, 2014)

Racial/Ethnic Differences in

Diabetes• Data for years 2007-2009

Race/Ethnicity %

Non-Hispanic whites 7.1

Asian Americans 8.4

Hispanics/LatinosCuban AmericansCentral and South

AmericansMexican AmericansPuerto Ricans

11.8 7.6 7.613.313.8

Non-Hispanic blacks 12.6

http://diabetes.niddk.nih.gov/dm/pubs/statistics (accessed March 31, 2014)

What Goes Wrong?• After eating, most food is converted to

glucose(sugar)o Glucose is the most common source of energy for the human body

• In people without diabetes, insulin is released by the pancreas at the right time and in the right amounto Insulin helps glucose enter cells so it may be used for energyo Blood glucose stays in a healthy range

• In people with diabetes, glucose builds upo The pancreas does not make insulin wello The body cannot use the insulin wello The liver makes too much glucose

Types of Diabetes• Type 1

o Problem with pancreatic cells that make insulin• Type 2

o Problem using insulin in the body properlyo Insulin “resistance”

• Gestational diabetes (GDM)o Diagnosed in pregnancy

• Othero Medication or chemical exposureo Genetic defects of the pancreaso Concurrent diseases

Testing for Type 1 Diabetes

• Patients with type 1 diabetes should have the opportunity to have their relatives screened for type 1 diabetes risk in the setting of a clinical research study

Testing for Type 2 Diabetes

• Low HDL cholesterol leveland/or a high triglyceride level

• Women with polycystic ovarian syndrome (PCOS)

• Hemoglobin A1C (Hgb A1C) ≥5.7% or other test indicating impaired glucose

• Other conditions associated with insulin resistance (e.g., severe obesity)

• History of heart disease

• 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

• High blood pressure

Testing should be considered in all adults who are overweight(BMI ≥25 kg/m2*) and have additional risk factors:

Testing for Type 2 Diabetes

• In the absence of risk factors, testing for diabetes should begin at age 45

• If results are normal, testing should be repeated at least at 3-year intervalso Consider testing more frequently depending on initial results (e.g.,

those with prediabetes should be tested yearly), and risk factors• Testing to detect type 2 diabetes and prediabetes

should be considered in children and adolescents who are overweight, and who have two or more additional risk factors for diabetes

Diagnosis of Diabetes• Hgb A1C ≥6.5%• Fasting blood glucose (FBG) ≥126 mg/dL

o Fasting is defined as no caloric intake for at least 8 h• 2-h blood glucose ≥200 mg/dL during an oral

glucose tolerance test (OGTT)o 75 grams of glucose dissolved in water

• Random blood glucose ≥200 mg/dLo Usually used in people who are experiencing the symptoms of high

blood glucose (hyperglycemia)

Diagnosis of Prediabetes

• Fasting blood glucose of 100–125 mg/dL • 2-h blood glucose in the 75-g OGTT of

140–199 mg/dL • Hgb A1C of 5.7–6.4%

Prevention Strategies in Prediabetes

• Refer patients with impaired glucose tolerance test, impaired fasting blood glucose, or Hgb A1C 5.7–6.4% to ongoing support program– Target weight loss of 7% of body weight– Increase physical activity to at least 150 min/week of moderate activity

• Follow-up counseling is important for success • Programs may be covered by third-party payers• Consider metformin (Glucophage®) for prevention of

type 2 diabeteso BMI >35 kg/m2, age <60 years, and women with prior GDM

• Monitor for development of diabetes every year• Screen for and treat modifiable risk factors for heart

disease and stroke

Treatment of Diabetes• Medical nutrition therapy• Self-monitoring education

o Monitoring of blood glucose levelso Signs and symptoms of low and high blood glucose levels

• Comprehensive physical examination• Laboratory evaluation

o Should include Hgb A1C• Appropriate specialist referrals

Treatment of Type 1 Diabetes

• Most patients require treatment with insulino Insulin is dosed in 3-4 injections per dayo Short-acting insulin is usually given before (or with) meals, and a

longer acting insulin once a day to provide baseline insulin actiono Insulin pumps may be used to provide a continuous supply of insulin

• Oral medications do not work for treating type 1 diabetes

• Carbohydrate intake and activity level affect blood sugaro Understanding how to adjust pre-meal insulin doses is important

Treatment of Type 2 Diabetes

• Sulfonylureaso Glipizide (Glucotrol®), glyburide (DiaBeta®), glimepiride (Amaryl®)

• Biguanideso Metformin (Glucophage®)

• Thiazolidinedioneso Pioglitazone (Actos®), rosiglitazone (Avandia®)

• Alpha-glucosidase inhibitorso Miglitol (Glyset®), acarbose (Precose®)

• DPP-4 inhibitorso Sitagliptin (Januvia®), saxagliptin (Onglyza®)

• GLP-1 receptor agonistso Exenatide (Byetta®), liraglutide (Victoza®)

Treatment of Type 2 Diabetes

• Meglitinideso Nateglinide (Starlix®), repaglinide (Prandin®)

• SGLT2 inhibitorso Dapagliflozin (Farxiga®), canagliflozin (Invokana®)

• Insulino Rapid-acting

• Insulin aspart (Novolog®), insulin lispro (Humalog®)o Short-acting

• Regular (Novolin R®, Humulin R®)o Intermediate-acting

• NPH (Novolin N®, Humulin N®)o Long-acting

• Insulin detemir (Levemir®), insulin glargine (Lantus®)

Storage of Insulin• Unopened insulin should be stored in the

refrigeratoro Store at 36-46o Fo Stable until the expiration date on the package

• Consult the manufacturer’s information for specific information after opening insulino Expiration of opened insulin vials, pens and cartridges varies by

manufacturer• Do not freeze insulin• Do not expose insulin to extreme heat

Blood Glucose and Hgb A1C Comparison

Mean plasma glucoseA1C (%) mg/dL mmol/L

6 126 7.07 154 8.68 183 10.29 212 11.810 240 13.411 269 14.912 298 16.5

Blood Glucose Goals• Maintaining the Hgb A1C around or less than 7% has

been shown to lower the risk of eye, kidney and nerve complications

• If this goal is obtained shortly after diagnosis, the risk of stroke, heart attack, and poor circulation is lowered

• In some patients, a Hgb A1C less than 6.5% may be reasonableo Younger patients with no issues related to low blood glucose levels

• For other patients, a Hgb A1C less than 8% is acceptableo History of severe problems with low blood glucose levelso Patients with a limited life expectancy

Monitoring Medication Therapy

Hyperglycemia (High Blood Glucose)

Hypoglycemia (Low Blood Glucose)

• Increased thirst• Increased urination• Blurry vision• Feeling tired• Slow healing of cuts or

wounds• More frequent infections• Weight loss• Nausea and vomiting

• Shakiness• Confusion• Sweating/clamminess• Rapid heart beat• Irritability or anger• Headaches• Weakness• Feeling tired• Seizures• Loss of consciousness

Treatment of Hyperglycemia and

Hypoglycemia• Hyperglycemia

o Insulin• Hypoglycemia

o Concentrated oral glucose solutions, tabletso Glucagon injection

Monitoring Diabetic Residents

• Foot checks• Skin checks• Blood pressure checks• Fingerstick blood glucose monitoring• Laboratory monitoring

o Hgb A1Co Cholesterolo Kidney function (serum creatinine/BUN)o Potassium levelso Urine albumin levels

Complications of Diabetes

• Heart complications• Stroke• Circulatory complications• Kidney complications• Eye complications• Nerve complications• Skin complications

Preventing Complications of

Diabetes• Adequate control of blood glucose• Aspirin• Blood pressure control• Angiotensin-converting enzyme (ACE) inhibitors

or angiotensin receptor blockers (ARBs)o ACEI- lisinopril (Prinivil®), ARB- losartan (Cozaar®)

• Statinso Atorvastatin (Lipitor®), simvastatin (Zocor®)

• Vaccinations o Influenza, pneumococcal, hepatitis B

• Smoking cessation

Conclusion• Diabetes is a complex disease that can affect

many parts of the body• The goal is to prevent complications• The development of diabetes may be delayed

with effective lifestyle changes and, in some cases, medication therapy

• Numerous opportunities exist to help those affected with diabetes to manage their disease, as well as prevent complications