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Optimizing Diabetic Care in Residential Care

Optimizing Diabetic Care in Residential Care. Lori C. Dupree, PharmD, BCPS Consultant Pharmacist Neil Medical Group Mooresville, North Carolina. Learning Objectives. Differentiate between the different types of diabetes. Identify the treatments used for managing diabetes .

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Optimizing Diabetic Care in Residential Care

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  1. Optimizing Diabetic Care in Residential Care Lori C. Dupree, PharmD, BCPS Consultant Pharmacist Neil Medical Group Mooresville, North Carolina

  2. 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.

  3. Scope • Affects 25.8 million people in the United States • 8.3% of the US population • 18.8 million diagnosed • 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

  4. County-Level Estimates of Diagnosed Diabetes (%), Adults ≥20 years, 2010 Percent http://www.cdc.gov/diabetes/atlas/countydata/atlas.html (accessed March 31, 2014)

  5. Diabetes in South Carolina http://www.cdc.gov/diabetes/atlas/countydata/atlas.html (accessed March 31, 2014)

  6. Racial/Ethnic Differences in Diabetes • Data for years 2007-2009 http://diabetes.niddk.nih.gov/dm/pubs/statistics (accessed March 31, 2014)

  7. What Goes Wrong? • After eating, most food is convertedto glucose(sugar) • 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 amount • Insulin helps glucose enter cells so it may be used for energy • Blood glucosestays in a healthy range • In people with diabetes, glucose builds up • The pancreas does not make insulin well • The body cannot use the insulin well • The liver makes too much glucose

  8. Types of Diabetes • Type 1 • Problem with pancreatic cells that make insulin • Type 2 • Problem using insulin in the body properly • Insulin “resistance” • Gestational diabetes (GDM) • Diagnosed in pregnancy • Other • Medication or chemical exposure • Genetic defects of the pancreas • Concurrent diseases

  9. 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

  10. Testing for Type 2 Diabetes • 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: • 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

  11. 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 intervals • 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

  12. Diagnosis of Diabetes • Hgb A1C ≥6.5% • Fasting blood glucose (FBG) ≥126 mg/dL • 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) • 75 grams of glucose dissolved in water • Random blood glucose ≥200 mg/dL • Usually used in people who are experiencing the symptoms of high blood glucose (hyperglycemia)

  13. Diagnosis of Prediabetes • Fasting blood glucose of 100–125 mg/dL • 2-h blood glucose in the 75-g OGTT of140–199 mg/dL • Hgb A1C of 5.7–6.4%

  14. 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 diabetes • 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

  15. Treatment of Diabetes • Medical nutrition therapy • Self-monitoring education • Monitoring of blood glucose levels • Signs and symptoms of low and high blood glucose levels • Comprehensive physical examination • Laboratory evaluation • Should include Hgb A1C • Appropriate specialist referrals

  16. Treatment of Type 1 Diabetes • Most patients require treatment with insulin • Insulin is dosed in 3-4 injections per day • Short-acting insulin is usually given before (or with) meals, and a longer acting insulin once a day to provide baseline insulin action • 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 sugar • Understanding how to adjust pre-meal insulin doses is important

  17. Treatment of Type 2 Diabetes • Sulfonylureas • Glipizide (Glucotrol®), glyburide (DiaBeta®), glimepiride (Amaryl®) • Biguanides • Metformin (Glucophage®) • Thiazolidinediones • Pioglitazone (Actos®), rosiglitazone (Avandia®) • Alpha-glucosidase inhibitors • Miglitol (Glyset®), acarbose (Precose®) • DPP-4 inhibitors • Sitagliptin (Januvia®), saxagliptin (Onglyza®) • GLP-1 receptor agonists • Exenatide (Byetta®), liraglutide (Victoza®)

  18. Treatment of Type 2 Diabetes • Meglitinides • Nateglinide (Starlix®), repaglinide (Prandin®) • SGLT2 inhibitors • Dapagliflozin (Farxiga®), canagliflozin (Invokana®) • Insulin • Rapid-acting • Insulin aspart (Novolog®), insulin lispro (Humalog®) • Short-acting • Regular (Novolin R®, Humulin R®) • Intermediate-acting • NPH (Novolin N®, Humulin N®) • Long-acting • Insulin detemir (Levemir®), insulin glargine (Lantus®)

  19. Storage of Insulin • Unopened insulin should be stored in the refrigerator • Store at 36-46o F • Stable until the expiration date on the package • Consult the manufacturer’s information for specific information after opening insulin • Expiration of opened insulin vials, pens and cartridges varies by manufacturer • Do not freeze insulin • Do not expose insulin to extreme heat

  20. Blood Glucose and Hgb A1C Comparison

  21. 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 reasonable • Younger patients with no issues related tolow blood glucose levels • For other patients, a Hgb A1C less than 8% is acceptable • History of severe problems with low blood glucose levels • Patients with a limited life expectancy

  22. 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

  23. Treatment of Hyperglycemia and Hypoglycemia • Hyperglycemia • Insulin • Hypoglycemia • Concentrated oral glucose solutions, tablets • Glucagon injection

  24. Monitoring Diabetic Residents • Foot checks • Skin checks • Blood pressure checks • Fingerstick blood glucose monitoring • Laboratory monitoring • HgbA1C • Cholesterol • Kidney function (serum creatinine/BUN) • Potassium levels • Urine albumin levels

  25. Complications of Diabetes • Heart complications • Stroke • Circulatory complications • Kidney complications • Eye complications • Nerve complications • Skin complications

  26. Preventing Complications of Diabetes • Adequate control of blood glucose • Aspirin • Blood pressure control • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) • ACEI- lisinopril (Prinivil®), ARB- losartan (Cozaar®) • Statins • Atorvastatin (Lipitor®), simvastatin (Zocor®) • Vaccinations • Influenza, pneumococcal, hepatitis B • Smoking cessation

  27. 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

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