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

Gutman Diabetes InstituteGutman Diabetes InstituteEinstein Medical Center, Einstein Medical Center,

PhiladelphiaPhiladelphiaPatricia C. Adams, RN, CDEPatricia C. Adams, RN, CDE

Gutman Diabetes Institute Gutman Diabetes Institute

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


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


‣Areas Requiring ControlAreas 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


Lipids◦Total Cholesterol < 200◦HDL > 45 (Men) > 55 (Women)◦LDL < 100; <70 (Hx of cardiac disease)

◦Triglycerides (Tg) < 150Aspirin (81 – 325) mg daily >21 yrs)


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.

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


A1C > 6.5% FPG> 126 mg/dl OGTT > 200 mg/dl

(75g glucose load) RPG > 200 mg/dl

with symptoms of hyperglycemia

DiabetesDiabetes

Diabetes

> > 126 mg/dlmg/dl

< 126 mg/dl

> 100 mg/dl

< < 100 mg/dl

Pre

-P

re-

Dia

bet

esD

iab

etes

Nor

mal

Nor

mal

70 mg/dl

Diabetes Care, Clinical Practice Recommendations, 2011Diabetes Care, Clinical Practice Recommendations, 2011

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<35 mg/dl (0.90 mmol/l) and/or a triglyceride 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.

1.1. Testing should be considered in all adults who are overweight (BMI Testing should be considered in all adults who are overweight (BMI ≥25 kg/m≥25 kg/m22*) and have additional risk factors: *) and have additional risk factors:

ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.

• 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


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


Consideration of metabolic risks when starting SGAs

Patient, family, and care giver education Baseline screening Regular monitoring Refer to specialized services, when needed



BLOOD GLUCOSEBLOOD GLUCOSEIntestine:Intestine:Glucose Glucose AbsorptionAbsorption

MuscleMuscle

FatFat

PeripheralPeripheralGlucoseGlucoseUptakeUptake

PancreasInsulinInsulin

SecretionSecretion

++

++

Brain &Brain &Nervous SystemNervous System

++Release of Release of

GIP & GIP & GLP - 1GLP - 1

Type 1 Diabetes Type 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



TypeType 1 Type 2Type 2

Age of Onset Usually <30 Usually >40

Onset Rapid Slowly - years

Insulin Availability

Little to None Some

•Progressive

Insulin Resistance Develops w/Time Usually present

Treatment Exogenous insulin always needed

•Daily injections

MNT, Activity, Oral Agents, Insulin

Complications Develop w/Time Present at Dx


Type 2 diabetes

± Environment

IGT

Impaired insulin secretion

Insulin resistance

GenesGenes

IGT


GenesGenesVs. Vs.

JeansJeans

Normal Impaired glucose

tolerance

Type 2 diabetes

Fasting plasma glucoseInsulin sensitivityInsulin secretion

Insulin Insulin sensitivesensitive

Normal insulin Normal insulin secretionsecretion

NormoglycaemiaNormoglycaemia

HyperglycaemiaHyperglycaemia

ββ-cell -cell exhaustionexhaustion

Insulin Insulin resistanceresistance

Late type 2 diabetes

complications

Adapted from Bailey CJ Adapted from Bailey CJ et al. Int J Clin Practet al. Int J Clin Pract 2004;58:867–876. 2004;58:867–876. Groop LC. Groop LC. Diabetes Obes Metab Diabetes Obes Metab 1999;1 (Suppl. 1):S1–S7. 1999;1 (Suppl. 1):S1–S7.

Insulin resistanceInsulin resistance


How Do Oral Diabetes Medicines Work?

Increase insulin Increase insulin actionaction

Slow glucose Slow glucose absorptionabsorption

Decrease hepatic Decrease hepatic glucose glucose

Increase insulin Increase insulin secretionsecretion

AcarboseAcarboseMiglitolMiglitol

Glyburide GlipizideGlyburide GlipizideGlimepirideGlimepirideRepaglinideRepaglinideNateglinideNateglinide

MetforminMetforminMetformin XRMetformin XRMetformin/GlyburideMetformin/Glyburide

SecretagoguesSecretagogues BiguanidesBiguanides GlucosidaseGlucosidaseInhibitorsInhibitors

TZD’STZD’S DPP IV DPP IV InhibitorsInhibitors

Decrease breakdown Decrease breakdown of GLP-1- increase of GLP-1- increase

insulin secretioninsulin secretion

SitagliptonSitagliptonSaxagliptonSaxaglipton

BasalBasalAmount needed to prevent excess

gluconeogenesis and ketogenesis PrandialPrandial

Amount needed to cover discrete meals and/or nutritional supplements Tube Feedings, IV dextrose, TPN


RegularNPH70/30


Humalog (Lispro) Humalog Mix 75/25 NovoLog (Aspart) NovoLog Mix 70/30 Apidra (Glulisine) Lantus (Glargine) Levemir (Detemir)


Novolog u100Novolog u100: _____ units with 1: _____ units with 1stst meal meal @_____ @_____ ______units with 2______units with 2ndnd meal meal @_____@_____ ______units with 3______units with 3rdrd meal meal @_____@_____

Lantus u100 Lantus u100 :: _____ units in the morning _____ units in the morning @_____ @_____

SleepingSleeping

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 2 3 1

Meal times: Hours of sleep:Meal times: Hours of sleep:_____ _____ _____ ___________________ _____ _____ ______________

Insulin type:Insulin type: Human u100 Premix R & NPHHuman u100 Premix R & NPHOnset Onset (Begins to work)(Begins to work) ½ - 1 hour ½ - 1 hour following injectionfollowing injectionPeak actionPeak action (Works the strongest) (Works the strongest) Dual Dual following injectionfollowing injectionEffective durationEffective duration following injectionfollowing injection

Actual maximum durationActual maximum duration 10-16 hrs 10-16 hrs

PremixPremix (cloudy)(cloudy) Short acting insulinShort acting insulin

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Intermediate acting insulinIntermediate acting insulin

TypeType StartsStarts Peaks EndsEnds

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.

Regular 30 – 60 min. 2 – 4 hr. 6 – 8 hr.

NPH 1.5 hours 4 – 12 hr. 10 – 16 hr.


Type Starts Peaks EndsGlargine

(Lantus)

4 – 6 hr. None 24 hr.

Levemir

(Detemir)

< 2 hr. 3 – 14 hr 16 – 24 hr.

70/30 0.5 – 1.0 hr. Dual (NPH/R) 12 – 20 hr.

Mix 75/25 10 min. Dual (Lispro/Lispro

Protamine)

12 – 20 hr.

Mix 70/30 10 min. Dual (Aspart/Aspart

Protamine)

12 – 20 hr.


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



Glu

cose

Lev

elG

luco

se L

evel

Time in HoursTime in Hours

00 11 22 33 44

Insulin Peak actionInsulin Peak action


Glu

cose

Lev

elG

luco

se L

evel

Time in HoursTime in Hours

00 11 22 33 44

Insulin Peak ActionInsulin Peak Action

HyperglycemiaHyperglycemia HypoglycemiaHypoglycemia

Basal insulin

You wouldn’t hold the

pancreas, so don’t hold the

lantus


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.


A1C <7.0%*

Preprandial capillary plasma glucose

70–130 mg/dl* (3.9–7.2 mol/l)

Peak postprandial capillary plasma glucose†

<180 mg/dl* (<10.0 mmol/l)

*Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.

Hyperglycemia needs to be controlled.◦ Any glucose excursion causes endothelial damage

Don’t relax with one good glucose reading Need to look at trends over 24 – 48 hours Need basal and prandial insulin coverage Rare to withhold basal insulin Insulin sliding scales do not work alone!

◦ Reactive vs proactive


Problems Nursing solutions

DM medication given too early

DM medication dosage too high

Meals delayed or not eaten

Give DM medication at right time

Advocate for adjustment of medication

Offer food when appropriate


“Test don’t Guess” Anything under 70 mg/dl is

hypoglycemia Treat

◦16 grams of carbohydrate – “fast acting” Glucose gel – 15 grams Glucose Tabs –4 ½ cup juice or regular soda

◦ Wait 15 minutes, - retest


050

100150200250300350400450500

1:00AM

3:00AM

5:00AM

7:00AM

11:00AM

3:00PM

5:00PM

9:00PM

11:00PM

PatientCarbs


No longer a diabetic diet (ADA)◦Currently Carb Controlled

Requires Individualization Need for Consistent Carbohydrates

◦Some sweets OK Meals – 4.5to 5 Hours Apart Divide Protein and Fats


Consume Fewer Animal Fats Emphasize Low Fat Dairy Products Emphasize Monounsaturated Fats Emphasis upon Fiber Decrease Use of Sweets Decrease Use of Alcohol


The Plate Method is an easy to remember technique for meal planning. The Plate Method is an easy to remember technique for meal planning. This method recommends a healthy distribution of carbohydrates, a lower fat intake, and a greater amount of fruits and This method recommends a healthy distribution of carbohydrates, a lower fat intake, and a greater amount of fruits and

vegetables. It can be used to eat healthfully, lose weight, and/or manage your diabetes.vegetables. It can be used to eat healthfully, lose weight, and/or manage your diabetes.

Fill half Fill half your your

plate up plate up with non with non starchy starchy

vegetablvegetableses

Fill a quarter Fill a quarter of your plate of your plate with starch with starch or bread or bread

Fill a Fill a quarter quarter of your of your plate plate with with

protein protein (choose (choose

lean lean cuts)cuts)

The Plate MethodThe Plate Method

Source: National Source: National Diabetes Education Diabetes Education

ProgramProgramTo learn more about how meal planning can help prevent or manage your diabetes,To learn more about how meal planning can help prevent or manage your diabetes,

contact the Gutman Diabetes Institute, 215-456-6839 or [email protected] contact the Gutman Diabetes Institute, 215-456-6839 or [email protected]

Even Light Juice Even Light Juice Cocktail Cocktail

Contains Contains ˜ 8 gm ˜ 8 gm CHOCHO

No Sugar Free No Sugar Free JuicesJuices

Non-nutritive sweeteners are OK Sugar contains 4 kcal/gm Sugar alcohols contain 2-3 kcal/gm

◦End in “ol”◦May contain more carbohydrate than

regular item◦Need to read the label◦Can cause diarrhea

Sorbitol,

Sorbitol, xylitol,

xylitol, mannitol

mannitol

Role of Physical Activity◦150 mins / week; most days of the week

Cells More Receptive to Insulin◦Decreases Insulin Resistance◦Lowers Blood Glucose

Integral Part of Diabetes Management


Precipitating Factors Infection Insulin Omission Inadequate Amount of Insulin Newly Diagnosed Diabetes


3 Clinical Features◦ Hyperglycemia - >250 mg/dL◦ Ketonuria or ketonemia◦ Acidosis pH <7.3 and/or serum bicarb <15 mEq/L


Absence or reduced effect of insulin

Excess of counter regulatory hormones◦ Glucagon◦ Cortisol◦ Growth hormone◦ Catecholemines


Clinical Presentation Presence of Acidosis Abdominal Pain

◦ Nausea◦ Vomiting◦ Anorexia


Clinical Presentation Hyperglycemia 3 – 4 Days Metabolic Alterations < 24 Hours Respiratory Symptoms

◦Kussmaul Respirations


Lab Values Glucose > 600 mg/dl No Ketones or Only Small Amounts Plasma Osmolality > 320 mOsm/kg


DKA HHS

Mild Moderate Severe

Glucose 250 >250 .250 >600

pH 7.25-7.30 7.00-7.24 <7.00 >7.30

BiCarb 15-18 10-15 <10 >15

Urine Ketones

+ + + small

Serum Ketones

+ + + small

Anion Gap >10 >12 >12 <12

Mentation Alert Alert/Drowsy Stupor/Coma
