Diabetes Review

1. Diabetes Review Judy Bornais RN, BScN, MSc, CDE

2. Prevalence • More than 2 million Canadians have diabetes1 • By 2010 that number is expected to rise to 3 million 1 • 31% rise in prevalence in Ontario since 1995 2 • Estimated that 1 in 5 individual over 45 years of age have diabetes and 1 in 3 over the age of 75 3 • Studies suggest that up to 30% of people with diabetes are undiagnosed6

3. Did You Know? • About half of all people diagnosed with diabetes have already had the disease for as long as 7 years1 • 20 - 30% of those individuals diagnosed already have developed complications 3

4. Cardiovascular disease is 2-4 times more prevalent in patients with diabetes than in those without1 • Cardiovascular disease accounts for at least 60% of the deaths in patients with diabetes2

5. When a patient develops vascular complications like MI or stroke, the outcome is worse in the individual with diabetes3

6. The Burden of Cardiovascular Disease in Diabetes Paris Prospective Study Helsinki Study Mortality rate in patients with diabetes more than doubled versus those without diabetes Balkau B, et al. Lancet 1997

7. Does the outcome depend on the Type of Diabetes? • Two large studies, UKDPS and DCCT, indicate that both Type 1 and Type 2 can result in macro and microvascular complications such as: • Coronary heart disease • Stroke • Peripheral vascular disease • Nephropathy • retinopathy • Neuropathy

8. Diabetes Clinical Impact of Diabetes The leading cause of new cases of end stage renal disease (ESRD) A leading cause of cardiovascular events in adults The leading cause of new cases of blindness in working age adults The leading cause of non-traumatic lower extremity amputations

9. Life Expectancy • Diabetes reduces survival by almost 12 years4

10. Diabetes is a Major Health Care Issue

11. How does this impact you? • Patients with diabetes, had higher rates of hospitalization than the general population with an excess risk of about 30% • In Essex County, in 1999 there were 18, 982 cases of people who visited a health care provider for their diabetes7

12. There is hope! • Complications of diabetes can be delayed and in some cases avoided with tight: • glycemic control • lifestyle modification • vascular protection • Health care professionals role…and the battle begins

13. Not so long ago in a galaxy remarkably like ours , the evil Diabetes Empire ruled over a terror-stricken population. Striking without warning Diabetes would leave suffering , mutilation and death in its’ wake. Diabetes had thus ruled unopposed for generations.

14. A mere 80 years ago Rebel Fighters , Banting and Best devised a weapon to battle the Empire. The weapon was called “Insulin”. While powerful , insulin was difficult to deliver and tricky to use . Diabetes learned to exploit these weaknesses over the years. The war raged on.

15. To win the battle we must…Understand Diabetes Management • Diabetes management involves balancing food, medication, and activity to achieve blood glucose levels that are near the normal range • Hormones, stress, illness, food - raises blood sugars • Insulin, medications (type 2), exercise* – lowers blood sugars

16. Types of Diabetes? • You have a patient who takes Novolin 20/80 twice a day. What type of diabetes does your patient have? • Individual can have either type 1 or type 2. Taking insulin does not classify the individual as having type 1diabetes.

17. Type 1 Diabetes The pancreas no longer produces insulin. The person is totally dependant on exogenous insulin Type 2 Diabetes The pancreas is not making enough insulin and/or the body is resistant (no longer sensitive to insulin) What happens in Diabetes

18. Type 1 Diabetes Insulin Type 2 Diabetes diet and exercise oral hypoglycemics oral hypoglycemics and insulin insulin Treatment for Diabetes

19. The Phantom Menace : Diabetes’ New Ally - Hypoglycemia • Hypoglycemia a new threat in Glucose Wars. • No easy way to predict or treat (no glucose tabs or glucagon). • Low blood sugar perceived as greater threat than hyperglycemia by caregivers.

20. Targets Blood Sugar Ranges4

21. Targets Blood Sugar Ranges4

22. Hypoglycemia • Blood sugars less than 4.0 mmol/L • What are the Signs & Symptoms of a low blood sugar?

23. Signs and Symptoms of Hypoglycemia • sweating • shaking • weakness • hunger • nausea • irritability • confusion

24. Neurogenic (autonomic) Sweating (47 – 84%) Trembling (32-78%) Palpitations (8-62%) Hunger (39-49%) Anxiety (10-44%) Nausea (5-20%) Tingling (10-39%) Neuroglycopenic Difficulty concentration (31-75%) Weakness (28-71%) Vision change (24-60%) Confusion (13-53%) Tiredness (38-46%) Difficulty speaking (7-41%) Dizziness (11-41%) Headache (24-36%) Symptoms of Hypoglycemia5

25. SEVERITY OF HYPOGLYCEMIA4 MILD Autonomic symptoms are present Individual is able to self-treat MODERATE Autonomic and neuroglycopenic symptoms are present Individual is able to self-treat SEVERE Individual requires assistance of another person Unconsciousness may occur Plasma glucose is typically < 2.8 mmol/L

26. How do you treat a low blood sugar? • A) Chocolate bar? • B) A hard candy? • C) Juice? • D) Glucose tabs?

27. How do you treat a low blood sugar? • A) • B) A hard candy (2-3) • C) Juice (3/4 cup) • D) Glucose tabs (3 glucose tabs)

28. Treatment for Hypoglycemia

29. When do Hypo’s occur? • Episodes of hypoglycemia most commonly occur before meals or when the insulin effect is peaking. • Patient is on Humalog/Novorapid at breakfast eats less than normal when would you expect the hypoglycemia? • Patient takes NPH at bedtime when are they most likely to have a low?

30. Medications can blunt response to hypoglycemia6 • Salicylates (Aspirin – in large doses; >4g/day) • Sulfonomide antibiotics (Probenecid; Benemid, Benuryl, Probalan) • Tricyclic antidepressants (Amitriptyline – Elavil; Anafranil, Sinequan, Triadapin, Impril, Novopramine, Nortriptyline – Aventyl; Triptil) • Phenylbutazone (for rheumatoid arthritis, osteoarthritis or gouty arthritis) • Warfarin (Coumadin) • Fibrates .

31. Medications can blunt response to hypoglycemia • Pentamidine (Nebupent, Pentacarinat) • Acetaminophen (Tylenol) • ACE Inhibitors (Captopril, Lisinopril, Enalapril, Ramipril) • Beta Blockers (Acebutolol, Carvedilol, Labetalol, Metoprolol) • Celexa (antidepressant) .

32. Hyperglycemia • Elevated blood sugars outside of the normal/target ranges i.e. a blood sugar over 10.0 mmol/L (2 hours post-prandial) • What are the Signs & Symptoms of hyperglycemia?

33. Signs and Symptoms of Hyperglycemia Extreme thirst Fatigue Frequent urination Weight loss Blurred vision

34. Treatment for Hyperglycemia…the forces strike back • Obtain near normal blood sugar levels through: • Insulin, • Medications • Exercise

35. The Phantom Menace : Fatalists – the Other Ally of Diabetes • A large faction of caregivers and individuals with diabetes believed that all complications were genetically programmed – would occur no matter what the blood glucose levels were ! • Treated to relieve symptoms only. • Waited for complications to show up. Fate and luck !

36. Review of Complications of Diabetes • Neuropathy • Retinopathy • Nephropathy • Macro vascular complications • Foot Problems (ulcers & amputations) • Dental & Skin Problems

37. A New Hope : The DCCT • 1993 New England J. of Medicine • Glucose hypothesis proven to be true • Never too late to improve control • Any improvement in control is beneficial • A powerful way to employ insulin (medications) in the battle with Diabetes

41. Summary DCCT • 69% reduction in Neuropathy • Trend toward reduction in risk of heart disease

43. Improved Insulin and Delivery • 1985 modernization of insulin by genetic engineering to produce Human insulin Humulin Novolin • 1995 Introduction of insulin analogues Lispro – Humalog Aspart - Novorapide • 2005 Introduction of new long acting insulin Glarzine – Lantus • 2006 Another long acting insulin ***Levermir (expected to be available in Jan./06)

44. Challenge of Insulin • To mimic the pancreas • 2 patterns: • a basal secretion of insulin • intermittent bolus of insulin in response to food

45. Goals of Insulin Therapy • To control blood glucose levels • Prevent the development and progression of long-term complications from hyperglycemia • Minimize effects of hypoglycemia • Mimic endogenous insulin

46. Insulins are divided into 5 main types: • Rapid-acting • Short-acting • Intermediate-acting • Long-acting • Premixed

47. Rapid-Acting Insulin (new analogues) Insulin Lispro (Humalog) Insulin Aspart (Novorapid)

48. Insulin lispro (Humalog) Insulin aspart (Novorapid) • May be taken before or after meals • appearance: clear • onset: 10 -15 min • peak: 45 min - 3 hrs • duration: 3 - 5 hrs • Take WITH meals

49. Short-acting or Regular (R) Insulin • Novolin ge Toronto (R) or Humulin R • appearance: clear • onset: 1/2 hr - 1 hr • peak: 2 - 5 hrs • duration: 6 - 8 hrs • Take 30 minutes before meals

50. Intermediate-acting or NPH/Lente • Novolin NPH or Humulin N • Novolin Lente or Humulin L • appearance: cloudy • onset: 1 - 3 hrs • peak: 4 - 12 hrs • duration: 18 - 24 hrs