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1、Diabetes Confusion:How to Develop a Preliminary Treatment Plan,Presented by Deborah Gruver MSN,FNP-BCWork:Aspirus Keweenaw HospitalLocation:Laurium,MI 49913Phone:906-337-6587Email:dgruveraspiruskeweenaw.org,What is Diabetes,It is a disease where blood sugar levels in the blood are too high.,Definiti
2、on of Diabetes,Definition A chronic disease with abnormalities in:Metabolism of carbohydrate,protein,fat and insulin(resulting in hyperglycemia).Structure and function of blood vessels and nerves(resulting in complications).,Regulation of Blood Glucose Concentration,Beta cells secrete insulinAlpha c
3、ells produce hormone glucagonDelta cells inhibit release of both insulin and glucagonInsulin and glucagon regulate blood sugar concentrationsWhen working properly the following occurs:,Regulation of High Blood Glucose,We all just ate our beta cells should be responding to the rising blood sugar leve
4、ls by now.Insulin signals other tissues muscle and adipose to take in glucose If the glucose is not used for energy it is stored in adipose tissue.Result lowered blood sugars,Regulation of Low Blood Sugars,Now if you had missed supper before this presentations:If blood sugars are low alpha cells in
5、the pancreas are stimulated to release glucagon from the pancreas which stimulates the liver to release glucose for energy.Homeostasis is maintained.,Regulation of Blood Glucose,Definition of Pre-diabetes,Also known as impaired glucose tolerance,impaired fasting glucose tolerance,This is an in betwe
6、en stage that can last up to 10 to 12 years where your pancreas is producing large amounts of insulin trying to overcome insulin resistance eventually wearing down.Life style changes important here.,Types of Diabetes:Type 1,Previously called“IDDM”,“Type I”,Juvenile onset”5 10%of those with diabetesG
7、enetic predisposition:autoimmune response that destroys the insulin producing cells in the pancreasUsually 35 of years or youngerSymptoms come on quicklyRequires daily insulin balanced with food intake and activity,Types of Diabetes:Type 2,Previously called“NIDDM”,“Type II”,“Adult onset”90-95%of peo
8、ple with diabetesStrong genetic link with environmental/lifestyle impactUsually 45 years or older and overweight(although seeing in youth)Symptoms are usually mild or non-existentPancreas still makes insulin;insulin resistance is common.Treated with meal plan,activity and possibly pills/insulinScree
9、n every 3 years(more frequently if overweight),How is Diabetes Diagnosed?,Causes of Hyperglycemia,Loss of 1st phase insulin release Peripheral tissue insulin resistanceHepatic glucose overproductionRelative lack of insulinIncreased gastric emptying timeIncreased glucagon production after mealsOver t
10、ime the inner linings of the blood vessels are affected thus affecting many organs.,Blood Glucose Goals,Treatment Options,Self-Monitoring Blood GlucoseKetone Testing Type 1UsuallyContinuous Glucose MonitorsPersonalized Activity PlanSelf-management education Personal Medical Nutrition TherapyPharmaco
11、logic ManagementStress Management,Self-Monitoring Blood Glucose,Why do we monitor blood glucose?Assists in achieving and maintaining glycemic goals.Provide immediate blood glucose results to detect,avoid and/or correct:Hyperglycemia.HypoglycemiaHypoglycemia unawarenessThere are no bad numbers just n
12、umbers giving us treatment clues,Why we monitor blood glucose levels,Helps manage intercurrent illness.Allows for Pattern Management.Evaluates pre-meal and post-meal BG patterns.Coordinates amount and timing of food,activity and meds to reach target BGs.Identifies safe levels to operate equipment.(e
13、.g.driving),One Way Diabetes is Monitored,month weighted average50%:BG control for past 30 days25%:for the past 30-60 days25%:for the past 60-90 daysReflects a percentage,which relates to a blood glucose number,A1C(%)Mean Plasma Glucose mg/dl6 1357 1708 2059 24010 27511 31012 34513 380,Comparison of
14、 A1C and eAG,Soon you may be seeing eAG which stands for Estimated Average Glucose replacing the HbA1C.This number will closely correlate with the patients blood glucose monitor instead of a percentage.,Case Study 1,Currently on oral medications adding more oral medications,Case Study 1AG 75 Y/O fem
15、ale on oral medications but still having high blood sugars(BS).Patient does not want to start insulin therapy.Patient is on Actos 30 mg with supper,Metformin 750mg in AM and 500 mg at HS.BS levels at breakfast are all in range,PP breakfast 188,201,and 193,Pre-lunch 120s,PP lunch 150s,Dinner fasting
16、140s,PP dinner 250,184,217,3 am 107,118,114.We tried Diabeta in the past with major hypoglycemic effects.Hemoglobin A1C is 7.8%.Weight=132.2 pds,Case Study 1,Solution added Januvia 100mg orally dailyDPP 4 Inhibitor Slows inactivation/breakdown of incretin hormones increasing insulin response to gluc
17、ose levels and decrease glucagon concentration.Decreased PPsCheck Kidney Function in 30 days Contraindications creatinine clearance 30-49 50 mg daily,1.7 to 1.5 to 2.5 in womenConsider if hemoglobin A1C is less than 8Repeat hemoglobin A1C 6.9%after 2 months,Case Study 2,On oral medication starting i
18、nsulin,Case Study 2,YY 61 Y/O newly diagnosed diabetic with hemoglobin A1C 12.8%.Started on Metformin four weeks ago with some improvement in her sugar levels.Her blood sugar levels were running 500s now 300s fasting and post prandial all meals.Patient had limited insurance coverage.She also wanted
19、limited injections.Weight=247 pounds,Case Study 2,Started Novolog 75/25(.2 mg/kg/day).Consider weight gainContinued Metformin weight neutral.Preserve Beta Cells,less shots,well-tolerated,weight neutral,and improved serum lipid levels.Decrease hepatic glucose production while increasing peripheral gl
20、ucose uptake and decreasing intestinal absorption of glucose.Adverse effects of Metformin renal disease or dysfunction serum creatinine 1.4 in women and 1.5 in men.CHF caution,held with radiologic studies before and 48 hours after,lactic acidosisInsulin will decrease fasting and post prandial blood
21、sugar levels without effecting the liver or kidney.,Case Study 2,Adverse effects hypoglycemia,didnt cover lunch PPs,two insulins combined when one is adjusted they both are.Patient continued to have high PPs after lunch but didnt want to add on another insulin shot.We added Glyburide at lunch with i
22、mprovement in lunch PPs.Glyburide stimulate and augment pancreatic insulin release,decrease hepatic glucose production,increase the number of insulin receptor sites,and cause some improvement in post receptor defects in insulin action thereby decreasing insulin resistance.Contraindication:type 1 dia
23、betic,allergy including sulfa based,hepatic or renal disease,severe hypoglycemia.Creatinine clearance 50 avoid.Rechecked hemoglobin A1C at three months 8%.Takes about 3 to 6 months to get to target when sugars are high.Go slow to avoid hypoglycemic effects even if blood sugars are high.,Case Study 3
24、,On oral medications with abnormal kidney function added Basel insulin.,Case Study 3,MM 74 Y/O lady on Metformin and Glyburide for many years.Hemoglobin A1C 9.1%.Kidney function Creatinine 1.7.Creatinine Clearance 42%.Guidelines for Metformin creatinine 1.4 females and 1.5 males.Weight 170.1 pounds.
25、Blood sugars levels were average 240 before meals and after.(Good patient for basel insulin),Case Study 3,Stopped oral medications and started insulin.Trial of Levemir first.Patient was scared of insulin and didnt want us to adjust the dose up to fast.Used samples in our office.Levemir is presumed t
26、o be more weight neutral than Lantus.Hemoglobin A1C went up to 9.1%in three months.Fasting and PPs continued to be in the 200s all meals.,Case Study 3,Added Novolog for all three meals.Patient was not a snacker in between meals if she had been I would have considered Regular insulin.Novolog is fast
27、acting peaks quickly and only lasts about 4 hours.Regular lasts 4 to 6 hours.Adjusted weekly until currently hemoglobin A1C 7.6%.Repeat kidney function testAdjusting insulin varies between patients.It depends on the patient how aggressive you want to be,diet,exercise,cost,psychosocial stressors,and
28、hypoglycemic episodes.There are a few formulas available to adjust insulin.,Insulin Sensitivity Method,Insulin sensitivity 2 methods(1800 or the 1500 rule)Take the total dose of insulin(prandial plus basal insulin)divide into 1800(rapid-acting)or 1500(short-acting).The result is the sensitivity fact
29、or which equals the mg/dl value that one unit of insulin will be expected to decrease or increase the plasma glucose level.Example 40 units divided into 1800=45 General rule 1 unit will increase or decrease by 50 mg/dl.*Current Trends in Diabetes Management Healthways,Correctional Insulin Dose,The m
30、edian target plasma glucose level is subtracted from the current plasma glucose level.This value is then divided by the sensitivity factor(SF)and the result is the dose of insulin to add or subtract from the prandial insulin does to be given.Care of stacking doses is needed when treating for hypergl
31、ycemia.Example:180 120(target)=60 divided by 45=1.3 units to be given to the prandial dose.*Current Trends in Diabetes Management Healthways,Lantus/Levemir,The initial dose of Lantus and Levemir is 0.2IU/kg at baseline.Lantus adjustments are about every 3 days.There is no real peak.Levemir is usuall
32、y about 8 to 12 hours peak.It usually requires more Levemir for the same effect.,Case Study 4,On oral medication uncontrolled added Lantus insulin and Regular insulin.,Case Study 4,JK 80 Y/O male patient from the VA.Sent to the clinic to start Lantus and Regular insulin vials.Starting Hemoglobin A1C
33、 10.7%.Patient snacks all day long.Ate two large meals a day.Lived by himself with assistance from Home Health.Poor eye sight and dexterity.Medication sent with the patient from the VA.Patient refused to give four shots a day but would agree to two shots a day.Weight 254 pounds,Case Study 4,Changed
34、insulin to Novolog 70/30 twice a day.Continued Metformin 1000 mg BIDPatient tolerated better with improved blood sugar levels fasting and PP.Worked on life style modification Patient wouldnt count carbohydrates but would decrease portion sizesHemoglobin A1C 9.3%Current weight 231.3 pounds,Case Study
35、 5,On oral medication start Byetta,Case Study 5,JG 75 Y/O male with normal kidney function tests currently on Glucovance 5/500 mg 1 tab BID.Hemoglobin A1C 7.6%.Weight 238 pounds.No history of:pancreatitis.Desired better blood sugar control and weight loss.Trial of Byetta.Only incretin mimetic curren
36、tly available.A class of drugs focusing on the hormones released from the gastrointestinal tract.The release of these gut hormones is prompted by the ingesting of nutrients and triggers an increase in pancreatic insulin secretion in a glucose-dependent manner.These gut hormones are known as incretin
37、s.There are two of them glucose-dependent insulinotropic peptide(GIP)and glucagon-like peptide-1(GIP-1).Both hormones stimulate the increase in insulin secretion.GIP-1 also inhibits the alpha cells in glucagon release.Slows gastric emptying.,Byetta,Contraindicated:Type 1 diabetesDiabetic ketoacidosi
38、sSevere renal impairment Severe gastrointestinal diseaseMust have functioning B-cells.,Case Study 5,Blood sugar averages improved greatly over three months average 6.9%with a 20 pound weight loss.One year later however hemoglobin A1C increased to 8.2%.Sugar averages running 200s fasting and post pra
39、ndial.Byetta and Glucovance on max doses.Patient following life style modifications.Still uncontrolled diabetes.,Case Study 5,Stopped Byetta and Started Levemir.2mg/kg/day in the morning.Depending on which blood sugar numbers are high sometimes you will get better results starting it in the morning
40、or at bedtime.No real peak except in Type 1 diabetics.Continued GlucovanceBlood sugar averages improved fasting and PPs.Next hemoglobin A1C not due until September but meter average around 170s(7%average).,Case Study 6,On Oral medication and insulin still uncontrolled blood sugars with increased wei
41、ght gain,Case Study 6,CK 61 Y/O lady with hemoglobin A1C of 8.5%originally on oral medications changed to Levemir continued high PPs started on Novolog.Continued to have insulin resistance.Weight increased on insulin therapy.Weight 286.3.Patient frustrated and scared.Consider Humulin R U 500 or Syml
42、in,Case Study 6,Added on Symlin 60 mcg SQ with meals.Increased to 120mcg SQ with meals after one month.Decrease rapid insulin by half.Symlin a synthetic version of the fullness hormone amylin.Amylin is secreted by the pancreatic beta cells and works in concert with insulin to affect post-prandial gl
43、ucose levels.It suppresses post-meal release of glucagon and slows gastric emptying and decrease appetite.Can be used with both Type 1 or 2.Starting doses different.,Case Study 6,Contraindication:Severe hypoglycemiaHypoglycemia unawarenessPoorly compliant HbA1C 9%Age 15CrCl 20 50 no adjustment;CrCl
44、20 not studiedWeight decreased by 14 pounds within 1 month.Blood sugar averages improved greatly.Hemoglobin A1C 7.2%three months later.,Case Study 7,Type 1 Diabetic Newly Diagnosed,Case Study 7,15 Y/O male with increased urinary frequency,weight loss,etc.,Hemoglobin A1C 17%.Started NPH BID and Regul
45、ar insulin TIDTaught carbohydrate counting and life style modificationsBlood sugars poorly controlled with lots of low blood sugar reactions,Case Study 7,Changed NPH to Lantus started at supper had lows in the night changed to AM improved lows.Four meals a day plus snacks continued Regular but incre
46、ased to QID.DKA after 1 year of diagnosis.Patient had been recording blood sugar levels for us but not putting accurate levels.Always ask to see the meter.Encourage nutritionist and if possible refer to endocrinologist all younger patients.,Case Study 7,Consider Insulin Pump Therapy if:Sub-optimal g
47、lycemic controlWide plasma glucose excursionsNocturnal hypoglycemiaFrequent severe hypoglycemiaPregnancyDawn phenomenonIncreases lifestyle flexibility,Other Diseases that are Affected by Diabetes,Heart DiseaseCholesterolBlood PressureRetinopathyPeripheral NeuropathyAutonomic Neuropathy,Guidelines fo
48、r Other Diseases,Blood Pressure 130/80Vision check annuallyDental examination every 6 monthsCholesterol check annually LDL50 for a women and 40 for menUrine Microalbumin annually Foot examination every visitDepression screenStress TestBaby aspirin dailyConsider ACE inhibitorBMI 25,Questions?,References,http:/diabetes.niddk.nih.gov/dm/pubs/insulinresistance/index.htmwww.diabetes.orghttp:/www.diabeteseducator.org/http:/,
