diabetes update pennsylvania association of developmental disabilities nurses
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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 - PowerPoint PPT PresentationTRANSCRIPT
Gutman Diabetes InstituteGutman Diabetes InstituteEinstein Medical Center, Einstein Medical Center,
PhiladelphiaPhiladelphiaPatricia C. Adams, RN, CDEPatricia C. Adams, RN, CDE
Gutman Diabetes Institute Gutman Diabetes Institute
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
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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
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‣Areas Requiring ControlAreas 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
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Lipids◦Total Cholesterol < 200◦HDL > 45 (Men) > 55 (Women)◦LDL < 100; <70 (Hx of cardiac disease)
◦Triglycerides (Tg) < 150Aspirin (81 – 325) mg daily >21 yrs)
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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.
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
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A1C > 6.5% FPG> 126 mg/dl OGTT > 200 mg/dl
(75g glucose load) RPG > 200 mg/dl
with symptoms of hyperglycemia
DiabetesDiabetes
Diabetes
> > 126 mg/dlmg/dl
< 126 mg/dl
> 100 mg/dl
< < 100 mg/dl
Pre
-P
re-
Dia
bet
esD
iab
etes
Nor
mal
Nor
mal
70 mg/dl
Diabetes Care, Clinical Practice Recommendations, 2011Diabetes Care, Clinical Practice Recommendations, 2011
Criteria for Testing for Diabetes in Asymptomatic Adult Individuals
•Physical inactivity
•First-degree relative with diabetes
•High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
•Women who delivered a baby weighing >9 lb or were diagnosed with GDM
•Hypertension (≥140/90 mmHg or on therapy for hypertension)
• 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.
1.1. Testing should be considered in all adults who are overweight (BMI Testing should be considered in all adults who are overweight (BMI ≥25 kg/m≥25 kg/m22*) and have additional risk factors: *) and have additional risk factors:
ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.
• 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
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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
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Consideration of metabolic risks when starting SGAs
Patient, family, and care giver education Baseline screening Regular monitoring Refer to specialized services, when needed
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BLOOD GLUCOSEBLOOD GLUCOSEIntestine:Intestine:Glucose Glucose AbsorptionAbsorption
MuscleMuscle
FatFat
PeripheralPeripheralGlucoseGlucoseUptakeUptake
PancreasInsulinInsulin
SecretionSecretion
++
++
Brain &Brain &Nervous SystemNervous System
++Release of Release of
GIP & GIP & GLP - 1GLP - 1
Type 1 Diabetes Type 2 Diabetes
■ 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
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TypeType 1 Type 2Type 2
Age of Onset Usually <30 Usually >40
Onset Rapid Slowly - years
Insulin Availability
Little to None Some
•Progressive
Insulin Resistance Develops w/Time Usually present
Treatment Exogenous insulin always needed
•Daily injections
MNT, Activity, Oral Agents, Insulin
Complications Develop w/Time Present at Dx
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Type 2 diabetes
± Environment
IGT
Impaired insulin secretion
Insulin resistance
GenesGenes
IGT
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GenesGenesVs. Vs.
JeansJeans
Normal Impaired glucose
tolerance
Type 2 diabetes
Fasting plasma glucoseInsulin sensitivityInsulin secretion
Insulin Insulin sensitivesensitive
Normal insulin Normal insulin secretionsecretion
NormoglycaemiaNormoglycaemia
HyperglycaemiaHyperglycaemia
ββ-cell -cell exhaustionexhaustion
Insulin Insulin resistanceresistance
Late type 2 diabetes
complications
Adapted from Bailey CJ Adapted from Bailey CJ et al. Int J Clin Practet al. Int J Clin Pract 2004;58:867–876. 2004;58:867–876. Groop LC. Groop LC. Diabetes Obes Metab Diabetes Obes Metab 1999;1 (Suppl. 1):S1–S7. 1999;1 (Suppl. 1):S1–S7.
Insulin resistanceInsulin resistance
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How Do Oral Diabetes Medicines Work?
Increase insulin Increase insulin actionaction
Slow glucose Slow glucose absorptionabsorption
Decrease hepatic Decrease hepatic glucose glucose
Increase insulin Increase insulin secretionsecretion
AcarboseAcarboseMiglitolMiglitol
Glyburide GlipizideGlyburide GlipizideGlimepirideGlimepirideRepaglinideRepaglinideNateglinideNateglinide
MetforminMetforminMetformin XRMetformin XRMetformin/GlyburideMetformin/Glyburide
SecretagoguesSecretagogues BiguanidesBiguanides GlucosidaseGlucosidaseInhibitorsInhibitors
TZD’STZD’S DPP IV DPP IV InhibitorsInhibitors
Decrease breakdown Decrease breakdown of GLP-1- increase of GLP-1- increase
insulin secretioninsulin secretion
SitagliptonSitagliptonSaxagliptonSaxaglipton
BasalBasalAmount needed to prevent excess
gluconeogenesis and ketogenesis PrandialPrandial
Amount needed to cover discrete meals and/or nutritional supplements Tube Feedings, IV dextrose, TPN
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RegularNPH70/30
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Humalog (Lispro) Humalog Mix 75/25 NovoLog (Aspart) NovoLog Mix 70/30 Apidra (Glulisine) Lantus (Glargine) Levemir (Detemir)
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Novolog u100Novolog u100: _____ units with 1: _____ units with 1stst meal meal @_____ @_____ ______units with 2______units with 2ndnd meal meal @_____@_____ ______units with 3______units with 3rdrd meal meal @_____@_____
Lantus u100 Lantus u100 :: _____ units in the morning _____ units in the morning @_____ @_____
SleepingSleeping
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
1 2 3 1
Meal times: Hours of sleep:Meal times: Hours of sleep:_____ _____ _____ ___________________ _____ _____ ______________
Insulin type:Insulin type: Human u100 Premix R & NPHHuman u100 Premix R & NPHOnset Onset (Begins to work)(Begins to work) ½ - 1 hour ½ - 1 hour following injectionfollowing injectionPeak actionPeak action (Works the strongest) (Works the strongest) Dual Dual following injectionfollowing injectionEffective durationEffective duration following injectionfollowing injection
Actual maximum durationActual maximum duration 10-16 hrs 10-16 hrs
PremixPremix (cloudy)(cloudy) Short acting insulinShort acting insulin
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Intermediate acting insulinIntermediate acting insulin
TypeType StartsStarts Peaks EndsEnds
Lispro
(Humalog)
5 min. 60 min. 3 – 4 hr.
Aspart
(Novolog)
5 min. 60 min. 3 – 5 hr.
Glulisine
(Apidra)
5 min. 60 min. 3 – 4 hr.
Regular 30 – 60 min. 2 – 4 hr. 6 – 8 hr.
NPH 1.5 hours 4 – 12 hr. 10 – 16 hr.
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Type Starts Peaks EndsGlargine
(Lantus)
4 – 6 hr. None 24 hr.
Levemir
(Detemir)
< 2 hr. 3 – 14 hr 16 – 24 hr.
70/30 0.5 – 1.0 hr. Dual (NPH/R) 12 – 20 hr.
Mix 75/25 10 min. Dual (Lispro/Lispro
Protamine)
12 – 20 hr.
Mix 70/30 10 min. Dual (Aspart/Aspart
Protamine)
12 – 20 hr.
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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
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Gutman Diabetes Institute Gutman Diabetes Institute
Glu
cose
Lev
elG
luco
se L
evel
Time in HoursTime in Hours
00 11 22 33 44
Insulin Peak actionInsulin Peak action
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Glu
cose
Lev
elG
luco
se L
evel
Time in HoursTime in Hours
00 11 22 33 44
Insulin Peak ActionInsulin Peak Action
HyperglycemiaHyperglycemia HypoglycemiaHypoglycemia
Basal insulin
You wouldn’t hold the
pancreas, so don’t hold the
lantus
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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.
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A1C <7.0%*
Preprandial capillary plasma glucose
70–130 mg/dl* (3.9–7.2 mol/l)
Peak postprandial capillary plasma glucose†
<180 mg/dl* (<10.0 mmol/l)
*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.
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
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Problems Nursing solutions
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
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“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
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050
100150200250300350400450500
1:00AM
3:00AM
5:00AM
7:00AM
11:00AM
3:00PM
5:00PM
9:00PM
11:00PM
PatientCarbs
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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
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Consume Fewer Animal Fats Emphasize Low Fat Dairy Products Emphasize Monounsaturated Fats Emphasis upon Fiber Decrease Use of Sweets Decrease Use of Alcohol
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The Plate Method is an easy to remember technique for meal planning. 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 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.vegetables. It can be used to eat healthfully, lose weight, and/or manage your diabetes.
Fill half Fill half your your
plate up plate up with non with non starchy starchy
vegetablvegetableses
Fill a quarter Fill a quarter of your plate of your plate with starch with starch or bread or bread
Fill a Fill a quarter quarter of your of your plate plate with with
protein protein (choose (choose
lean lean cuts)cuts)
The Plate MethodThe Plate Method
Source: National Source: National Diabetes Education Diabetes Education
ProgramProgramTo learn more about how meal planning can help prevent or manage your diabetes,To learn more about how meal planning can help prevent or manage your diabetes,
contact the Gutman Diabetes Institute, 215-456-6839 or [email protected] contact the Gutman Diabetes Institute, 215-456-6839 or [email protected]
Even Light Juice Even Light Juice Cocktail Cocktail
Contains Contains ˜ 8 gm ˜ 8 gm CHOCHO
No Sugar Free No Sugar Free JuicesJuices
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,
Sorbitol, xylitol,
xylitol, mannitol
mannitol
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
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Precipitating Factors Infection Insulin Omission Inadequate Amount of Insulin Newly Diagnosed Diabetes
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3 Clinical Features◦ Hyperglycemia - >250 mg/dL◦ Ketonuria or ketonemia◦ Acidosis pH <7.3 and/or serum bicarb <15 mEq/L
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Absence or reduced effect of insulin
Excess of counter regulatory hormones◦ Glucagon◦ Cortisol◦ Growth hormone◦ Catecholemines
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Clinical Presentation Presence of Acidosis Abdominal Pain
◦ Nausea◦ Vomiting◦ Anorexia
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Clinical Presentation Hyperglycemia 3 – 4 Days Metabolic Alterations < 24 Hours Respiratory Symptoms
◦Kussmaul Respirations
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Lab Values Glucose > 600 mg/dl No Ketones or Only Small Amounts Plasma Osmolality > 320 mOsm/kg
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DKA HHS
Mild Moderate Severe
Glucose 250 >250 .250 >600
pH 7.25-7.30 7.00-7.24 <7.00 >7.30
BiCarb 15-18 10-15 <10 >15
Urine Ketones
+ + + small
Serum Ketones
+ + + small
Anion Gap >10 >12 >12 <12
Mentation Alert Alert/Drowsy Stupor/Coma
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