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Guidelines for Diabetes Management

Guidelines for Diabetes Management. September 20, 2012 Margaret Pochay RD CDE. How Food is Digested. 1. Food enters stomach. 4. Pancreas releases insulin. 5. Insulin unlocks receptors. 6. Glucose enters cell. 3. Glucose enters bloodstream. 2. Food is converted into glucose. Pancreas.

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Guidelines for Diabetes Management

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  1. Guidelines for Diabetes Management September 20, 2012 Margaret Pochay RD CDE

  2. How Food is Digested 1. Food enters stomach 4. Pancreas releases insulin 5. Insulin unlocks receptors 6. Glucose enters cell 3. Glucose enters bloodstream 2. Food is converted into glucose

  3. Pancreas Muscle and Fat Cells Cannot Produce Enough Insulin Cannot Use Insulin Effectively Diabetes Body lacks insulin or is unable to use insulin effectively

  4. Type 2 Diabetes Cardiovascular Disease Impaired Glucose Tolerance High Blood Fats Obesity High Blood Pressure Insulin ResistanceRelated Conditions Insulin Resistance

  5. Stroke: 2-6x End-Stage Kidney Disease: 17x Retinopathy: 25x Foot/Leg Amputations: 5x Heart Disease: 2-4x Complications of Diabetes

  6. Results from Diabetes Studies • REDUCED macrovascular disease • heart disease • stroke Good Diabetes Management results in • REDUCED microvascular disease • eye disease • kidney disease • neuropathy

  7. United Kingdom Prospective Diabetes Study (UKPDS) Microvascular Complications Change in HbA1C 0 - 5 -10 -15 -20 -25 0 -1 -2 -3 -4 -5 - 0.9% - 25% 1% Decrease in HbA1c = 25% Decrease in Microvascular Risk!

  8. Guidelines for Diabetes Management • http://care.diabetesjournals.org/content/35/ Supplement_1/S11.full.pdf+html Diagnostic criteria, standards of care, treatment goals, nutrition guidelines, diabetes self management guidelines, preventing complications

  9. Key Numbers in Diabetes Control • Daily Blood Glucose • A1C(2-3 month glucose levels) • Lipids (Blood Fats) • Blood Pressure (Hypertension) • Urine Protein (Microalbuminuria) • Daily Blood Glucose

  10. Fasting/Pre-meal glucose Post-meal glucose 2 hr. after start of meal Bedtime glucose A1C 70-130 mg/dL <180 mg/dL 100-140 mg/dL <7.0% Targets for Glucose ControlType 1 and Type 2 Diabetes Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2003

  11. Checking your blood sugar • Why: • Checking your blood sugar yourself is often the best way to be sure your diabetes is under control. It tells you: • If your insulin or other diabetes medicine is working • How physical activity and the foods you eat affect your blood sugar • Based on your care plan, you may want to test when: • You wake up • Before meals or large snacks • 1 or 2 hours after meals or large snacks • Before and 15 minutes after physical activity

  12. 8% 180 9% 210 10% 240 11% 270 12% 300 13% 330 7% 150 HbA1cand Self-Monitoring Results 4% 60 5% 90 6% 120 HbA1c Blood Glucose (mg/dl)

  13. Targets for Lipids, Blood Pressure and Microalbumin Triglycerides (mg/dL) <150 LDL cholesterol (mg/dL) 100 HDL cholesterol (mg/dL) >60 Total cholesterol (mg/dL) <200 Lipids (Blood Fats) Blood Pressure Microalbumin <130/80 mmHg <30 mg/24 h or <20 µg/min on a timed specimen or <30 mg/g creatinine on a random sample Adapted from: American Diabetes Association. Clinical Practice Recommendations. Diabetes Care. 2001.

  14. Medications Pancreas -- stimulates insulin production Liver -- decreases glucose release Fat/Muscle -- increases insulin sensitivity Fat/Muscle -- increases insulin sensitivity Supplements body’s own insulin Insulin Sulfonylureas Meglitinides Metformin DPP4 inhibitor Thiazolidinediones Alpha-glucosidase inhibitors Reduces breakdown of GLP1 Intestine -- slows carbohydrate metabolism

  15. Exenatide (Byetta, Bydureon) and Victoza • GLP-1 agonist or incretin mimetic • Synthetic version of salivary protein found in the Gila monster

  16. Indications for Insulin in T2DM • Newly diagnosed symptomatic type 2 pts with severe hyperglycemia • Poor glucose control despite max doses of OA • Intercurrent illness (MI, infection, surgery) • Pregnancy • Renal/Hepatic Disease • Allergies to OA

  17. What are the different types of insulin? Rapid-acting: Controls blood sugar surges at mealtime Long-acting: Controls blood sugar between meals and during sleep Premixed: Combines rapid-acting and intermediate-acting insulin Controls blood sugar at mealtime and all day and night

  18. Comparison of Human Insulins and Analogs Insulin Onset of Duration ofPreparations Action Peak (hr) Action (hr) Lispro/Aspart/Glulisine 5–15 min 1–2 4–5 Regular Human 30–60 min 2–4 6–10 Human NPH ® 2–3 hr 6–10 10–20 Glargine/Detemir 1-2 hr flat ~24 Mixes 5-15 min 1-2 & 6-10 10-20 Time course of action of any insulin can vary in different people, or at different times in the same person; thus, time periods indicated here shouldbe considered general guidelines only

  19. Dosing Insulin • Individual needs to be considered • Type 2 Diabetes: Basal Insulin start 10units change by 3 units every 3 days fasting blood glucose <70 or >130 • Meal time insulin calculate insulin to carb ratio rapid acting divide 500 by total daily insulin dose. Titrate depending on post meal blood glucose

  20. Dosing Insulin type 1 diabetes • .5 unit of insulin per kg body weight • 50% insulin basal insulin (goal FBS 70-130 • 1 unit of fast acting insulin per 15gm carbohydrate to be eaten (goal post prandial <180) • Correction also calculated (ex: 1 unit for every 50 points glucose above or below goal)

  21. Barriers to Insulin Use: Patient Issues BarriersSolutions Fear of injections Syringes, pens, and needles vastly improved Fear of hypoglycemia Low rate of severe hypoglycemia in DM2 Fear of weight gain Glucose control is more important than mild-to- moderate weight gain

  22. Injecting insulin How: Insulin pen Syringe filled from a bottle of insulin Insulin pump Where: Abdomen Thighs Backs of the upper arms

  23. Pen Delivery of Insulin • Encourages multiple-dose insulin therapy • Adds convenience • Enhances flexibility in schedule • Reduces insulin waste • May improve accuracy • of correct dosage delivery

  24. Patient Education Issues • Insulin Administration • Abdomen preferred injection site • Rapid acting insulins within 15 min before meals; regular insulin 30 min before meals • When to self-monitor blood glucose • 3-4 times per day (pre-meals) • Intermittent 1–2 hours postmeal to adjust analog • How to recognize and treat hypoglycemia and hyperglycemia

  25. Summary • Good control involves proper use of lifestyle tools and medications • Regular and frequent monitoring of all aspects of diabetes is essential to good control • Diabetes is a self managed disease • Pathophysiology important part of educationg patients with diabetes

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