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Caring for Patients with Chronic Illness Introduction to Diabetes Mellitus

Caring for Patients with Chronic Illness Introduction to Diabetes Mellitus. Debra L. Simmons, MD Assistant Professor of Medicine Director, Arkansas Diabetes Program Director, Training Program Endocrinology, Diabetes and Metabolism University of Arkansas for Medical Sciences and

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Caring for Patients with Chronic Illness Introduction to Diabetes Mellitus

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  1. Caring for Patients with Chronic IllnessIntroduction to Diabetes Mellitus Debra L. Simmons, MD Assistant Professor of Medicine Director, Arkansas Diabetes Program Director, Training Program Endocrinology, Diabetes and Metabolism University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System

  2. Acute patient seeks doctors advice for a problem frequently a “complaint” headache chest pain cough Chronic regularly scheduled appointment usually no “complaint” fu effectiveness of treatment monitor for complications of treatment or disease General Attributes of Medical Visits

  3. Acute History and physical focuses on determining the cause of the complaint More likely to be physician directed for treatment Chronic History and physical focuses on issues related to the chronic disease Usually requires the patient actively deciding goals of therapy and treatment General Attributes of Medical Visits cont.

  4. Introduction to Diabetes Mellitus • Epidemiology • Diagnosis and classification • Goals of diabetes management

  5. Epidemiology of Diabetes • 15.7 million Americans have diabetes • 10.3 million diagnosed • 5.4 million not diagnosed • 90% have type 2 diabetes • 8.2% of people aged 45 to 64 in Arkansas have diabetes NDEP

  6. Percentage of US Population by Age and Race With Diagnosed Diabetes %  Age group (yr) *% based on medical history interview insubjects asked about previous Dx by physician. Harris MI et al. Diabetes Care. 1998;21:518-524.

  7. Seriousness of Diabetes • Diabetes increases risk of • death • cardiovascular disease • stroke • Diabetes is the leading cause of • adult blindness • end stage renal disease • nontraumatic amputations

  8. 6 4 2 0 45-64 65-74 >74 Mortality in People With Diabetes:US Population Risk vs nondiabetic Relativerisk Age (yr) Men Women Ford ES et al. Am J Epidemiol. 1991;133:1220-1230.

  9. 50 40 30 20 10 0 Mortality in People With Diabetes:Causes of Death %of deaths Ischemicheartdisease Otherheartdisease Diabetes Cancer Stroke Infection Other Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; chap 11.

  10. New Blindness in US Adults: Contribution From Diabetes 30 20 %of new casesof blindness 10 0 45 65 75 85 Age (yr) Due to diabetes Due to diabetic retinopathy Klein R et al. In: Diabetes in America. 2nd ed. 1995; chap 14.

  11. Prevalence of ESRD by Primary Diagnosis, 1996* Glomerulo-nephritis17.7% 24.5%Hypertension Cystic kidneydisease 4.7% Other20.6% 32.5%Diabetes *Prevalence as of December 31, 1998 derivedfrom Medicare billing records. NIDDK. USRDS1998 Annual Report.

  12. Diabetes and Lower Extremity Amputations:Prevalence of All Lower Extremity Amputations % of population Reiber GE et al. In: Diabetes in America. 2nd ed. 1995; chap 18.

  13. Chronic Complications of Diabetes • Macrovascular • coronary artery disease • cerebral vascular disease • peripheral vascular disease • Microvascular • retinopathy • nephropathy • neuropathy

  14. Introduction to Diabetes Mellitus • Epidemiology • Diagnosis and classification • Goals of diabetes management

  15. ADA 1997 Diagnostic Criteria for Diabetes Mellitus 1. Fasting plasma glucose >126 mg/dl* or 2. Symptoms plus random plasma glucose >200 mg/dl* or 3. Oral glucose tolerance test 2-hr plasma glucose >200 mg/dl* * Must confirm on another day unless DKA or HHNC; not for pregnancy ADA Diabetes Care 2000

  16. ADA 1997 Diagnostic Criteria for Diabetes Mellitus 1. Fasting plasma glucose >126 mg/dl • 8 hour fast • preferred test for diagnosis • NOT capillary blood glucose

  17. ADA 1997 Diagnostic Criteria for Diabetes Mellitus 2. Symptoms plus random plasma glucose >200 mg/dl • polyuria • polydipsia • polyphagia • weight loss • fatigue • poor healing

  18. ADA 1997 Diagnostic Criteria for Diabetes Mellitus 3. Oral glucose tolerance test plasma glucose 2-hr >200 mg/dl • 75 gram glucose load • 2 hour post glucose load plasma glucose • primarily for research

  19. ADA 1997 Etiologic Classification of Diabetes • Type 1 diabetes • Type 2 diabetes • Gestational diabetes • Other specific types ADA Diabetes Care 2000

  20. Type 1 Diabetes • -cell destruction • Usually leading to absolute insulin deficiency • Ketosis prone • Two forms • immune-mediated • idiopathic which is rare and without known cause

  21. Type 1 DiabetesImmune-mediated • Commonly occurs in childhood • May occur any age, even 9th decade • Rate of -cell destruction variable • usually rapid in childhood • may be slow in adults • Markers include • islet cell autoantibodies • autoantibodies to glutamic acid decarboxylase

  22. Type 1 Diabetes:Typical Presentation • Young age • Thin • Classic symptoms • polyuria, polydipsia, polyphagia and weight loss • May have diabetic ketoacidosis • No family history of diabetes

  23. Type 2 Diabetes • Impaired insulin action • insulin resistance • primarily peripheral tissue defect • Impaired insulin secretion • relative insulin deficiency • primarily -cell defect

  24. Causes of Hyperglycemia in Type 2 Diabetes Peripheral Tissues(Muscle) Insulinresistance Glucose Liver Increased glucoseproduction Pancreas Impaired insulinsecretion

  25. Type 2 Diabetes • Most are obese • Spontaneous ketoacidosis rare • Ketoacidosis may occur with stress • Strong genetic predisposition

  26. Type 2 Diabetes:Typical Presentation • Many people are asymptomatic • Routine physical • Preop labs • Not uncommon to present with complication • MI • Peripheral neuropathy • Foot ulcer • Frequently family history diabetes

  27. Gestational Diabetes Mellitus • Any degree of glucose intolerance • First recognition during pregnancy • Reclassify 6 weeks postpartum

  28. Other Specific Types • Diseases of the exocrine pancreas • pancreatitis • Drug- or chemical-induced • glucocorticoids • nicotinic acid • Many others

  29. Introduction to Diabetes Mellitus • Epidemiology • Diagnosis and classification • Goals of diabetes management

  30. Goals of Diabetes Management • Prevention of acute complications • significant hypoglycemia • symptomatic hyperglycemia including DKA • Prevention of microvascular complications • Prevention of macrovascular complications • Attainment of normal quality of life

  31. Diabetes Control and Complication Trial • 1441 type 1 diabetes • Conventional therapy: 1-2 insulin injections per day • Intensive therapy: 3-4 insulin injections per day or insulin pump • Followed average of 6.5 years • Published 1993

  32. 11 10 9 8 7 6 5 0 1 2 3 4 5 6 7 8 9 10 Effect of Intensive Glycemic Control in the DCCT: HbA1c Levels Conventional therapy HbA1c (%) Intensive therapy 6.05 Normal Study year Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986.

  33. DCCT: Results of Intensive Therapy • Retinopathy 76% • Nephropathy 54% • Neuropathy 60% Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986.

  34. 0 1 2 3 4 5 6 7 8 9 DCCT: Absolute Risk of Sustained Retinopathy Progression by HbA1c and Years of Follow-up Mean HbA1c = 11% 24 10% 9% 20 Conventional treatment 16 Rate/100 person-years 12 8% 8 4 7% 0 Time during study (y) DCCT Research Group. Diabetes. 1995;44:968-983.

  35. United Kingdom Prospective Diabetes Study • 5102 newly diagnosed type 2 diabetes • Conventional policy: diet • Intensive policy: sulfonylurea, metformin (in overweight patients), or insulin • Mean 10-year follow-up • Published 1998, designed 1970s

  36. Patients followed for 10 years All patients assigned to regimen Conventional Conventional Intensive Intensive Cross-sectional and 10-Year Cohort Data:Intensive vs Conventional Policy • FPG • HbA1c • 200 • 9 • 180 • 8 • 160 MedianFPG(mg/dL) Median HbA1c(%) • 140 • 7 • 120 • 6 • 0 • 100 • 0 • 3 • 6 • 9 • 12 • 15 • 0 • 3 • 6 • 9 • 12 • 15 Time from randomization (y) Time from randomization (y) UKPDS Group. Lancet. 1998;352:837-853.

  37. UKPDS Results of Intensive Policy:Sulfonylurea/Insulin • Microvascular complications 25% • Retinopathy progression 21% • Nephropathy 34% UKPDS Group. Lancet. 1998;352:837-853.

  38. ADA Recommendations for Glycemic Control Goal Take Action Preprandial glucose mg/dl <80 80-120 >140 Bedtime glucose mg/dl <100 100-140 >160 HbA1c % <7 >8 ADA Diabetes Care 2000

  39. Prevention of Macrovascular Disease • Control of hypertension • Control of lipids • Cessation of smoking • Aspirin use

  40. Prevention of Macrovascular Disease: Control of Hypertension • UKPDS substudy proved effectiveness of BP control • Intensive control (mean 144/82 vs 154/87) reduced strokes 44%, diabetes related deaths 32% and heart failure 56% • Goal <130/85 mmHg • ACE inhibitor currently preferred due to renal protective effect ADA Diabetes Care 2000

  41. Prevention of Macrovascular Disease:Control of Lipids • Primary goal is LDL cholesterol <100 mg/dl • same as NCEP guidelines for secondary prevention • due to very high risk of CAD in diabetes • Secondary goal is HDL cholesterol >45 mg/dl for men and >55 mg/dl in women ADA Diabetes Care 2000

  42. Prevention of Macrovascular Disease: Cessation of Smoking • Cigarette smoking and diabetes • increases risk of morbidity and mortality of CVD • Counsel to quit smoking ADA Diabetes Care 2000

  43. Prevention of Macrovascular Disease: Aspirin Use • Low dose aspirin • 81-325 mg/day if >21 YO • Secondary prevention • MI, stroke, TIA, PVD, angina, claudication • Primary prevention if high risk • family history CVD, cigarette smoking, hypertension, obese, albuminuria, dyslipidemia ADA Diabetes Care 2000

  44. Attainment of Normal Quality of Life • Patient at center of team of health care providers • Psychosocial issues extremely important

  45. Diabetes Team Primarycare provider Social worker Nutritionist PATIENT Podiatrist Exercise physiologist Diabetes educator Psychologist Endocrinologist

  46. Patient Education: Diabetes Self-Management • Understand diabetes disease process • emphasis on benefit of good control • Learn appropriate diet • individualized diet plans • Learn self-monitoring of blood glucose • use of meter • what to do with the results

  47. Patient Education: Diabetes Self-Management cont. • Learn how to use prescribed medications • how it works • when to take it • side effects • Learn how to balance diet, exercise and medications as well as stress • Learn sick day rules

  48. Psychosocial Issues:Impact of the Disease • May be devastating due to fear of complications • May be overwhelming due to complexity of caring for the disease • must watch what they eat, when they eat, take medications on time, juggle activity with food intake and medications, go to the doctor regularly • can not just think about it occasionally

  49. Psychosocial Issues:Other • Many psychosocial issues may impact the ability of the patient to care for themselves • lack of money, access to healthcare providers • turmoil in family such as caring for a dying parent, spouse with Alzheimer’s disease, child involved with drugs • psychiatric illness such as depression greatly impairs the patient’s ability to care for diabetes

  50. Summary of Goals of Diabetes Management • HbA1c <7% • BP <130/85 • LDL cholesterol <100 mg/dl • Smoking cessation • 1 aspirin/day • Normal quality of life

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