diabetes update -- 2012...2/10/12 1 diabetes update -- 2012 amy hess-fischl, ms, rd, ldn, bc-adm,...
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Diabetes Update -- 2012
Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE University of Chicago Kovler Diabetes Center
Standards of Medical Care in Diabetes – 2012
• www.diabetes.org – Professionals – Clinical Practice
Recommendations
• Annual update that consists of official American Diabetes Assoc statement regarding diabetes care based on current research – Download available free of charge
Additions/Revisions to Standards of Care -- 2012
• Section added on driving and diabetes • Section and table added on common co-
morbidities of diabetes • Table added listing properties of noninsulin
therapies for hyperglycemia in T2DM • Therapy for T2DM revised to include more
specific recommendations for starting and advancing meds
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Diagnosis of Diabetes
• FPG > or = 126 mg/dL (>8 hr without food) • OGTT – 2 hr pp >or = 200 mg/dL • 2010 update: A1C > or = 6.5% OR • Classic symptoms of hyperglycemia +
random BG > or = 200 mg/dL
Diagnosis of pre-diabetes
• FPG 100-125 mg/dL • 2 hr plasma glucose 140-199 mg/dL • A1C: 5.7-6.4%
Testing for Diabetes – Asymptomatic patients • Adult of any age with BMI > or = 25 kg/m2 • 1 or more risk factors for DM
– Physical inactivity – 1st degree relative with DM – High risk ethnicity (AA, Latino, Nat Am, Asian Am, Pac Islander – HTN (>140/90) – HDL <35 mg/dL or trig >250 mg/dL – A1C > or = 5.7% – Hx of CVD – Women with h/o:
• PCOS • GDM during pg or delivered baby >9 #
• Without risk factors: start at age 45; if results normal, repeat q 3 years
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Testing for T2DM in Kids
• BMI >85th percentile for age/sex • Wt/Ht >85th percentile • Wt >120% of ideal for ht • If has 2 risk factors:
– Family hx – Ethnicity – Signs of insulin resistance – PCOS, acanthosis
nigricans, HTN – Maternal h/o DM or GDM
• Initiate testing at 10 years of age or onset of puberty – Check q 3 years
Testing for T1DM
• Not recommended since onset is acute • Post preliminary dx, to confirm T1DM:
– IAA – ICA – GAD
A1C recommendations
ADbA: <7% AACE: <6.5% IDF: <6.5% ** ADbA recommendations are based on
targets that are desirable for MOST patients with DM
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A1C vs eAG A1C % eAG (mg/dl) 6.0% 126 6.5% 140 7.0% 154 7.5% 169 8.0% 183 8.5% 197 9.0% 212 9.5% 226 10.0% 240
BG goals • ADbA
– 70-130 mg/dL pre-meals – <180 peak pp (1-2 hr post meal)
• AACE – 80-110 mg/dL – <140 2 hr pp
• IDF – 80-110 mg/dL – <140 2 hr pp
Medical Nutrition Therapy -- General Recommendations
• Receive individualized MNT as needed • Mix of carb, pro, fat may be adjusted to
meet goals • RDA for carbs: 130 g/day • Medicare coverage:
– Initial – 3 hrs MNT – Each subsequent year – 2 hrs MNT
• www.cms.gov
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Physical Activity
• 150 minutes/week of moderate-intensity aerobic PA
• If no contraindications, resistance training twice weekly
Psychosocial assessment • It is “reasonable” to include assessment
– Screening – Follow-up
• At diagnosis • During regular DM visits • Upon discovery of complications • During hospitalizations • Websites for basic assessments:
– http://www.diabetesinitiative.org/build/hc_resources.html
Immunizations
• Flu vaccine annually for >6 mths age • Pneumonia vaccine >2 years
– One-time re-vaccination >64 years
• Hepatitis B – CDC updating standards
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Prevention/Management of DM Complications --- CVD
• BP • Measured at every routine DM visit • Goal of <130/80
• Lipids • Annually • LDL <100 mg/dL, if CVD risk factors <70 mg/dL • HDL >50 mg/dL • Triglycerides <150 mg/dL • Lifestyle modification: reduction of sat fat, trans fat,
cholesterol intake, increase in n-3 fatty acids, viscous fiber, plant stanols/sterols, weight loss, increased PA
Prevention/Management DM Complications – Renal
• Annual random/spot urine albumin test in T1DM dx >5 years and all T2DM – Normal: <30 mcg/mg – Microalbuminuria: 30-299 mcg/mg – Macro/Clinical albuminuria: > or = 300 mcg/mg
• Adults: creatinine screening annually – GFR – Stage 1: > or = 90 mL/min GFR – Stage 2: 60-89 – Stage 3: 30-59 – Stage 4: 15-29 – Stage 5: Kidney failure -- <15 or dialysis
Prevention/Management of DM Complications -- Retinopathy
• Adults/children > age 10 with T1DM – Dilated eye exam by eye doctor within 5 years after
dx
• T2DM – Dilated eye exam shortly after dx
• Annual exams after initiaL – Q 2-3 years if one or more normal exams
• Pregnant women with pre-existing DM – Exam within first trimester – Close f/u throughout pregnancy and 1 yr post delivery
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Prevention/Management of DM Complications -- Neuropathy
• Screening for distal symmetric polyneuropathy – T2DM: at diagnosis – T1DM: 5 years post dx
• Foot screening (10 g monofilament) • Pedal pulses • Tuning fork
• Screening for autonomic neuropathy – Resting tachycardia – Exercise intolerance – Orthostatic hypotension – Constipation – Gastroparesis – Erectile dysfunction
Foot Care
• Comprehensive exam completed annually – Pulses – Vibration – Sensation
• General foot exam at each visit • http://www.chronicconditions.org/clearinghouse/doc/
foot_exam_form.pdf
• http://www.hrsa.gov/hansensdisease/leap/
Special Populations – Children/Adolescents -- Type 1 DM
• Glycemic control goals vary depending upon the endo – ADA recommendations: – Age 0-6 100-180 mg/dL A1C <8.5% – Age 6-12 90-180 mg/dL A1C <8% – Age 13-19 90-130 mg/dL A1C <7.5% – If they have hypo awareness, many ped
endos use adult goals
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Children/Adolescents – Type 1 Screening for Chronic Complications • Nephropathy
– Annual spot urine for alb-to-creat ratio
• HTN – www.nhlbi.nih.gov/health/prf/heart/hbp/hbp_ped.pdf
– If >90th percentile for age, sex, ht • HTN must be confirmed on 3 separate days • Initial tx meal planning/PA • If no improvement in 3-6 mths, pharm tx (ACE)
Children/Adolescents – T1DM Screening -- Dyslipidemia
• If family hx • Fasting lipids if child >2 years soon after dx
• If no family hx • Fasting lipids at puberty (~10 years of age)
• If lipids abnormal • Annual monitoring
• If LDL are <100 mg/dL • Repeat q 5 years
• Initial tx • Optimize BG control and MNT (Step 2 AHA diet – low sat fat) • After age 10, adding a statin if LDL >160 md/dL (no risk factors)
or if >130 mg/dL (one or more risk factors) – goal of therapy is <100 mg/dL
Children and Adolescents – T1DM Screening
• Retinopathy – First screening >10 years of age with DM 3-5 years
• Celiac disease – Occurs in 1-16% of people with T1DM (vs 0.3-1% in
general population) – At diagnosis: tissue transglutaminase, anti-endomysial
antibodies, IgA • Re-test if growth failure, failure to gain wt, wt loss, diarrhea,
flatulence, abd pain, unexplained hypoglycemia
– If positive antibodies, endoscopy and biopsy • If biopsy-confirmed celiac, gluten free diet
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Children and Adolescents – T1DM Screening
• Hypothyroidism – Occurs in 17-30% of patients with T1DM – ¼ of children with T1DM have antibodies – After dx
• Thyroid peroxidase and thyroglobulin antibodies, TSH
– If normal, re-check q 1-2 years, esp if abnormal growth, symptoms of thyroid dysfunction
Children/Adolescents – Type 2
• Incidence increasing – Distinction between T1DM and T2DM
becoming more difficult due to increased prevalence of overweight in children
– BP, lipids, microalbuminuria assessment, and dilated eye exam all be completed at time of dx
DM Care in the Hospital
• BG goals – Critically ill
• Insulin tx initiated if BGs >180 mg/dL • Once initiated: 140-180 mg/dL is goal range for
majority of patients, but 110-140 mg/dL if no significant hypoglycemia
– Non-critically ill • No RCT data to corroborate effective goals • Pre-meal <140 mg/dL • Random <180 mg/dL
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MNT in the hospital
• ADA does not endorse any one meal plan or specified percentages of macronutrients
• “ADA diet” should no longer be used • Consistent carb meal plans preferred • MNT should be completed by a RD
Diabetes and Driving
• Some states impose no special requirements • IL – requires a medical report form to be completed
before each license renewal – For new drivers, completed before permit as well – http://www.cyberdriveillinois.com/publications/pdf_publications/
dsd_dc163.pdf – By law, you are required to file a a Medical Report Form
completed by your physician, if: – you have any medical or mental condition which could result in a
loss of consciousness or any loss of ability to safely drive a vehicle, or
– you take any medications that may impair your ability to drive.
Diabetes and Driving
• ADA position statement recommends against blanket statement restrictions based on dx of DM
• ADA DC office working on removing/reducing many restrictions – FAA
• Meeting planned
– Truck drivers
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Review/Discussion
• The role of the nutrition professional regarding the Clinical Practice Recommendations
• What information should be disseminated to the person with DM?
Current Medications for Type 2 DM Biguanides Action site: liver Reduces the glucose output by the liver Metformin, Glucophage, Glumetza
GLP-1 receptors: Incretin mimetics (injected) Byetta, Victoza DPP-4 inhibitors: Incretin enhancers Januvia, Galvus, Onglyza, Tradjenta
Alpha-glucosidase inhibitors Action site: intestines Slows carb digestion Glyset, Precose
Thiazolidinediones Action Site: muscle cells Increases insulin sensitivity Actos, Avandia
Sulfonylureas and glinides Action site: pancreas Increase insulin production Glipizide, glyburide, Prandin, Starlix
Oral meds and hypoglycemia
• Sulfonylureas and glinides have highest incidence of hypoglycemia – When working with patients, remind them not
to skip meals and make sure to incorporate carbs to reduce the risk of hypo
– Create a plan for sick days, physical activity
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Diabetes medications awaiting FDA approval/newly approved • SGLT2 inhibitors
– Dapagliflozin
• DPP-4 – Alogliptin
• GLP-1 – Albiglutide – Dilaglutide – Lixisenatide
• Afrezza (inhaled insulin) • Degludec (24 hour insulin) • Bydureon (FDA approved 1/27/2012)
– Once-weekly version of Byetta
• Jentadueto (linagliptin/metformin) 1/31/2012
Insulin
Insulin Comparison Chart:
TYPE ONSET PEAK DURATION ASSESS EFFECT AT
Apidra 10-15 min 30-90 min 3-4 hr 2-4 hr
Humalog 15-20 min 30-90 min 3-4 hr 2-4 hr
NovoLog 15-20 min 40-50 min 3-4 hr 2-4 hr
Regular 30-60 min 80-120 min 4-6 hr 3-7 hr
NPH 2-4 hr 6-10 hr 14-16 hr 6-12 hr
Lantus 1-4 hr Peakless 18-26 hr 6-10 hr
Levemir 1-4 hr Minimal 16-22 hr 6-10 hr
Pre-mixed- regular 30-60 min 2-12 hr 16-18 hr 4 hr & 6-12 hr
Pre-Mixed –rapid 15-20 min 1-6 hr 18-24 hr 2 hr and 6-12
hr
At diagnosis:
Lifestyle +
Metformin
Lifestyle + Metformin +
Basal insulin
Lifestyle + Metformin +
Sulfonylurea
Lifestyle + Metformin
+ Intensive insulin
Lifestyle + Metformin
+ TZD
No hypoglycemia Edema/CHF Bone loss
Lifestyle + Metformin +
TZD +
Sulfonylurea
Tier 1: Well validated core therapies
Tier 2: Less well validated therapies
STEP 1 STEP 2 STEP 3
Lifestyle + Metformin
+ GLP-1 agonistb
No hypoglycemia Weight loss N/V
Lifestyle + Metformin +
Basal insulin
ADA/EASD Treatment Algorithm for T2DM
Adapted from Nathan DM et al, Diabetes Care, 2009:32(1); 193-203
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Expected Decrease in A1C with Monotherapy -- ADA/EASD Consensus Statement • Lifestyle 1.0-2.0% • Metformin 1.0-2.0% • Insulin 1.5-3.5% • Sulfonylureas 1.0-2.0% • TZDs 0.5-1.4% • GLP-1 agonists 0.5-1.0% • DPP-4 inhibitors 0.5-0.8% • Glinides 0.5-1.5% • Alpha-glucosidase inhibitors 0.5-0.8% • Pramlintide 0.5-1.0%
Nathan DM et al, Diabetes Care, 2009:32(1); 193-203
Pattern Management
• Assessing – Insulin/oral medication dosing – insulin to carb ratios – correction factors
• General rule of thumb for carb ratios – At 2 hours after dosing, if BG is within 30-50
points of goal, ratios are accurate
Medication Review
• Role of the nutrition professional regarding medications and BG – MNT vs meds
• Teaching points for the person with DM – Effect of meds on BG – Site selection for injections – Rotation of sites for optimal absorption – Carb counting and medications
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Insulin Pens
Discontinued 2011
Pen needles
Insulin Pumps -- 2012
Dana Diabecare IISG
Animas Ping
Medtronic Paradigm Revel Deltec Cozmo
**discontinued 2009, out of circulation by end 2012
Nipro Amigo Accu-Chek Spirit
Insulet OmniPod
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Awaiting FDA Approval/Launch
Medingo’s Solo Patch Pump
Tandem t:slim
Awaiting FDA Approval
Asante Solutions’ Pearl Insulin Pump
Cellnovo Mobile Patch Pump
30% smaller OmniPod
New Products
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New products
Technology Review
• Helping the person with DM choose the right pump/meter for them
• Staying updated on the technology • Becoming a pump/CGM trainer
Current Clinical Trials
• Search : diabetes and chicago – 102 trials still actively recruiting subjects
• Medication trials • Islet cell transplant • Sleep apnea • Fitness and sleep
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Clinical trials
• NIDDK List of Type 1 Diabetes Clinical Trials – TrialNet natural History Study – TrialNet Oral Insulin Study – SEARCH for Diabetes in Youth – Islet Transplantation
Artificial Pancreas Project
• JDRF-funded project • Three components:
– Pump – Sensor – Specialized computer
• Reads the sensor and tells the pump how much insulin to deliver
• Dec 1 – FDA issued draft guidance for the development of the algorithm
• Estimated timeline: 2015-2017 for market approval • 1st phase
– Pump and sensor with low glucose suspend
Artificial Pancreas Project
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Stem cell/Islet Cell
• Edmonton protocol – Transplant islets into patients with T1DM that
is difficult to control – 3 centers in Chicago
• UIC • NW • U of C
• Collaborative Islet Transplant Registry – www.citregistry.org
Clinical Trial Review
• What do the patients need to know? • What does the nutrition professional need
to know? • Working with clinical trials
Additional resources
• Diabetes Health – annual product reference guide – www.diabeteshealth.com/charts
• DiabetesPro SmartBrief – daily emails – www.smartbrief.com/diabetespro
• Diabetes Care & Education practice group – www.dce.org