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Diabetes Update Pennsylvania Association of Developmental Disabilities Nurses

Diabetes Update Pennsylvania Association of Developmental Disabilities Nurses. Gutman Diabetes Institute Einstein Medical Center, Philadelphia Patricia C. Adams, RN, CDE. Objectives. Distinguish the different types of diabetes Discuss appropriate administration of insulin

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Diabetes Update Pennsylvania Association of Developmental Disabilities Nurses

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  1. Diabetes Update Pennsylvania Association of Developmental Disabilities Nurses Gutman Diabetes Institute Einstein Medical Center, Philadelphia Patricia C. Adams, RN, CDE Gutman Diabetes Institute

  2. Objectives • 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 Gutman Diabetes Institute

  3. Diabetes Update • 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 Gutman Diabetes Institute

  4. Diabetes • Areas 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 Gutman Diabetes Institute

  5. Cardiovascular Risk • Lipids • Total Cholesterol < 200 • HDL > 45 (Men) > 55 (Women) • LDL < 100; <70 (Hx of cardiac disease) • Triglycerides (Tg) < 150 Aspirin (81 – 325) mg daily >21 yrs) Gutman Diabetes Institute

  6. Recommendations:Dyslipidemia/Lipid Management 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.

  7. Diabetes Update • 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 Gutman Diabetes Institute

  8. Diabetes Diabetes > 126 mg/dl < 126 mg/dl Pre-Diabetes > 100 mg/dl < 100 mg/dl Normal 70 mg/dl What is a normal blood glucose level? • A1C > 6.5% • FPG> 126 mg/dl • OGTT > 200 mg/dl (75g glucose load) • RPG > 200 mg/dl with symptoms of hyperglycemia Diabetes Care, Clinical Practice Recommendations, 2011

  9. Criteria for Testing for Diabetes in Asymptomatic Adult Individuals Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors: • 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. ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.

  10. Diabetes in Severe Mental Illness • 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 Gutman Diabetes Institute

  11. ADA Consensus • 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 Gutman Diabetes Institute

  12. ADA Consensus • Consideration of metabolic risks when starting SGAs • Patient, family, and care giver education • Baseline screening • Regular monitoring • Refer to specialized services, when needed Gutman Diabetes Institute

  13. Blood Glucose Regulation + + + Pancreas Muscle Insulin Secretion Release of GIP & GLP - 1 Intestine: Glucose Absorption BLOOD GLUCOSE Peripheral Glucose Uptake Brain & Nervous System Fat Gutman Diabetes Institute

  14. 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 Type 1 Diabetes Type 2 Diabetes Gutman Diabetes Institute

  15. Type 1 & 2 Comparison Gutman Diabetes Institute

  16. IGT IGT Type 2 diabetes Type 2 Diabetes: A Dual-Defect Disease Genes Genes Impaired insulin secretion Insulin resistance ±Environment Gutman Diabetes Institute

  17. Genes Vs. Jeans Gutman Diabetes Institute

  18. Insulin resistance The Progressive Nature of Type 2 Diabetes Impaired glucose tolerance Type 2 diabetes Late type 2 diabetes complications Normal Insulin sensitive Hyperglycaemia Normal insulin secretion Insulin resistance Normoglycaemia β-cell exhaustion Fasting plasma glucoseInsulin sensitivityInsulin secretion Adapted from Bailey CJ et al. Int J Clin Pract 2004;58:867–876. Groop LC. Diabetes Obes Metab 1999;1 (Suppl. 1):S1–S7.

  19. How Do Oral Diabetes Medicines Work? Glucosidase Inhibitors TZD’S DPP IV Inhibitors Secretagogues Biguanides Increase insulin action Increase insulin secretion Decrease hepatic glucose Decrease breakdown of GLP-1- increase insulin secretion Slow glucose absorption Glyburide Glipizide Glimepiride Repaglinide Nateglinide Pioglitazone Rosiglitazone Metformin Metformin XR Metformin/Glyburide Acarbose Miglitol Sitaglipton Saxaglipton Gutman Diabetes Institute

  20. Terminology: Physiologic Insulin Use AKA “Think like a Pancreas” • Basal • Amount needed to prevent excess gluconeogenesis and ketogenesis • Prandial • Amount needed to cover discrete meals and/or nutritional supplements • Tube Feedings, IV dextrose, TPN Gutman Diabetes Institute

  21. Human Insulins • Regular • NPH • 70/30 Gutman Diabetes Institute

  22. Insulin Analogs • Humalog (Lispro) • Humalog Mix 75/25 • NovoLog (Aspart) • NovoLog Mix 70/30 • Apidra (Glulisine) • Lantus (Glargine) • Levemir (Detemir) Gutman Diabetes Institute

  23. Gutman Diabetes Institute

  24. Basal / Bolus Insulin Therapy Novolog u100: _____ units with 1st meal @_____ ______units with 2nd meal @_____ ______units with 3rd meal @_____ Lantus u100 : _____ units in the morning @_____ Sleeping Meal times: Hours of sleep: _____ _____ _____ ______________

  25. Premix(cloudy) Short acting insulin Intermediate acting insulin Insulin type:Human u100 Premix R & NPH Onset (Begins to work) ½ - 1 hour following injection Peak action (Works the strongest) Dual following injection Effective duration following injection Actual maximum duration 10-16 hrs

  26. Insulin Action Times Gutman Diabetes Institute

  27. Insulin Action Times Gutman Diabetes Institute

  28. Insulin and Timing of Meals • 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 Gutman Diabetes Institute

  29. Proper Matching Glucose Level Insulin Peak action 3 0 1 2 4 Time in Hours Gutman Diabetes Institute

  30. Improper Matching Hypoglycemia Hyperglycemia Glucose Level Insulin Peak Action 3 0 1 2 4 Time in Hours Gutman Diabetes Institute

  31. Clinical Pearl Basal insulin You wouldn’t hold the pancreas, so don’t hold the lantus Gutman Diabetes Institute

  32. Clinical Pearl • 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. Gutman Diabetes Institute

  33. Location, Location, Location Gutman Diabetes Institute

  34. Glycemic Recommendations for Non-Pregnant Adults with Diabetes (1) *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.

  35. Control Hyperglycemia • 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 Gutman Diabetes Institute

  36. Treating Hypoglycemia • 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 Problems Nursing solutions Gutman Diabetes Institute

  37. Hypoglycemia • “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 Gutman Diabetes Institute

  38. Hypoglycemia Gutman Diabetes Institute

  39. Medical Nutrition Therapy • 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 Gutman Diabetes Institute

  40. Medical Nutrition Therapy • Consume Fewer Animal Fats • Emphasize Low Fat Dairy Products • Emphasize Monounsaturated Fats • Emphasis upon Fiber • Decrease Use of Sweets • Decrease Use of Alcohol Gutman Diabetes Institute

  41. The Plate Method 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 vegetables. It can be used to eat healthfully, lose weight, and/or manage your diabetes. Fill a quarter of your plate with starch or bread Fill half your plate up with non starchy vegetables Fill a quarter of your plate with protein (choose lean cuts) Source: National Diabetes Education Program To learn more about how meal planning can help prevent or manage your diabetes, contact the Gutman Diabetes Institute, 215-456-6839 or gutmandiabetesinstitute@einstein.edu

  42. Juice is a Carbohydrate Too! Even Light Juice Cocktail Contains ˜ 8 gm CHO No Sugar Free Juices

  43. Sugar Free Foods • 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, xylitol, mannitol

  44. Physical Activity • 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 Gutman Diabetes Institute

  45. Diabetic Ketoacidosis Precipitating Factors • Infection • Insulin Omission • Inadequate Amount of Insulin • Newly Diagnosed Diabetes Gutman Diabetes Institute

  46. Diabetic Ketoacidosis • 3 Clinical Features • Hyperglycemia - >250 mg/dL • Ketonuria or ketonemia • Acidosis • pH <7.3 • and/or serum bicarb <15 mEq/L Gutman Diabetes Institute

  47. Diabetic Ketoacidosis • Absence or reduced effect of insulin • Excess of counter regulatory hormones • Glucagon • Cortisol • Growth hormone • Catecholemines Gutman Diabetes Institute

  48. Diabetic Ketoacidosis Clinical Presentation • Presence of Acidosis • Abdominal Pain • Nausea • Vomiting • Anorexia Gutman Diabetes Institute

  49. Diabetic Ketoacidosis Clinical Presentation • Hyperglycemia 3 – 4 Days • Metabolic Alterations < 24 Hours • Respiratory Symptoms • Kussmaul Respirations Gutman Diabetes Institute

  50. Hyperosmolar Hyperglycemic State Lab Values • Glucose > 600 mg/dl • No Ketones or Only Small Amounts • Plasma Osmolality > 320 mOsm/kg Gutman Diabetes Institute

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