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Managing Diabetes

C elia L evesque RN, MSN, CNS-BC, NP-C, BC-ADM, CDE. Managing Diabetes. MD Anderson Cancer Center. Objectives. Discuss the 2013 American Diabetes Association (ADA) Standards of Medical Care in Diabetes Prescribe a safe and effective diabetes medication regimen

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Managing Diabetes

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  1. Celia Levesque RN, MSN, CNS-BC, NP-C, BC-ADM, CDE Managing Diabetes

  2. MD Anderson Cancer Center

  3. Objectives • Discuss the 2013 American Diabetes Association (ADA) Standards of Medical Care in Diabetes • Prescribe a safe and effective diabetes medication regimen • Prescribe a safe and effective medication regimen for the treatment of hypertension in diabetes • Prescribe a safe and effective medication regimen for the treatment hyperlipidemia in diabetes

  4. Number with DM age 20-79

  5. Screening in Asymptomatic Adults • Test at age 45 if no risk fx • Test if BMI > 25 and • Physical inactivity • First-degree relative with DM • High-risk race/ethnicity • Women who delivered a baby weighing > 9 lb or were dx with GDM • HTN • HDL < 35 and/or a triglyceride > 250 • Women with polycystic ovary syndrome • A1C 5.7%, IGT, or IFG on previous testing • Other clinical conditions associated with insulin resistance • Hxof CVD • If screening is normal, repeat test every 3 years American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  6. Screening for T2DM in Asymptomatic Children • Test at age 10 or puberty if it occurs before age 10 • Test if overweight > 85th percentile or > 120% IBW and have 2 additional risk fx: • Family hx T2DM in first- or second-degree relative • Race/ethnicity • Signs of insulin resistance or conditions associated with insulin resistance • Maternal hxof DM or GDM during the child’s gestation American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  7. Screening for GDM • Perform a 75-g OGTT, with FSG and at 1 & 2 h, at 24–28 wksof gestation without DM • The OGTT should be performed in the morning after an overnight fast of at least 8 h • The dx of GDM is made when any of the following plasma glucose values are exceeded: • Fasting: > 92 mg/dL • 1 h: > 180 mg/dL • 2 h: > 153 mg/dL American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66c

  8. Diagnosis of Pre DM • FPG 100 to 125 mg/dL OR • 2-h plasma glucose in the 75-g OGTT 140 mg/dL to 199 mg/dL OR • A1C 5.7–6.4% American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  9. Recommendations for Pre DM • Weight loss of 7% of body weight • Exercise 150 min/week of moderate activity • Follow-up counseling • Metformin may be considered for those with pre DM especially if BMI > 35, age 60+ yearsor prior GDM • Retest every year for DM • Screen for and reduce modifiable risk fx for CVD American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  10. Diagnosis of DM • A1C > 6.5% by lab * OR • FPG > 126 mg/dL (no caloric intake for at 8+ h) * OR • 2-h plasma glucose > 200mg/dL during an OGTT * OR • Pt with classic sx of hyperglycemia and a random plasma BG > 200 • * = repeat test on separate occasion American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  11. HbA1c / Average BG

  12. Converting HbA1c to Average BG Estimated Average Glucose = 28.3 x HbA1c – 43.9 Example: HbA1c = 7% 28.3 x 7 – 43.9 = 154.2 Nathan, D et al. Translating the A1c Assay into estimated average glucose values. Diabetes Care 2008; 31: 1473-8.

  13. Causes of Inaccurate HbA1c • Factors that affect erythrocytes • Blood loss • Blood transfusion • Hemolysis • Hemoglobin variants (ie if HbA1 is not 99%) • In pts with insulin deficiency and wide swings in BG, HbA1c alone is not the best measure – combine SMGB with HbA1c American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  14. Classifications of DM • Type 1 DM • Type 2 DM • Other specific types of DM due to other causes • genetic defects in β-cell function • genetic defects in insulin action • diseases of the exocrine pancreas ie cystic fibrosis • drug- or chemical-induced • Gestational DM American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  15. Initial Evaluation • Classify DM • Assess for complications • Review previous tx plan and risk fx prevention • Order appropriate labs/tests • Formulate a treatment plan • Provide basis for continuing care American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  16. Components of a DM Evaluation • Age and characteristics of onset of DM • Eating patterns • Nutritional status • Weight hx • Growth and development in children and adolescents • Physical activity habits • DM education hx American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  17. Components of a DM Evaluation • Review of previous treatment regimens and response to therapy (A1C records) • Current treatment of DM: • Current medications • Medication adherence • Meal plan • Physical activity patterns • Readiness for behavior change • Barriers • Results of glucose monitoring and patient’s use of data American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  18. Components of a DM Evaluation • DKA frequency, severity, and cause • Hypoglycemic episodes • Hypoglycemia awareness • Any severe hypoglycemia: frequency and cause American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  19. Components of a DM Evaluation • Hx of DM-related complications • Microvascular: • Retinopathy • Nephropathy • Neuropathy • Sensory, including hx of foot lesions • Autonomic, including sexual dysfunction • Gastroparesis • Macrovascular: CHD, cerebrovascular disease, and PAD • Other: psychosocial problems, dental disease American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  20. Physical Exam • Height, weight, BMI • Blood pressure determination, including orthostatic measurements when indicated • Fundoscopic examination • Thyroid palpation • Skin examination • acanthosisnigricans • insulin injection sites American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  21. Physical Exam • Comprehensive foot examination • Inspection • Palpation of dorsalispedis and posterior tibial • Presence/absence of patellar and Achilles reflexes • Determination of proprioception, vibration, and monofilament sensation American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  22. Laboratory Evaluation • A1C, if results not available within past 2–3 months • If not performed/available within past year: • Fasting lipid profile, including total, LDL and HDL cholesterol and triglycerides • Liver function tests • Test for urine albumin excretion with spot urine albumin-to-creatinine ratio • Serum creatinine and calculated GFR • TSH in type 1 DM, dyslipidemia or women over age 50 years American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  23. Referrals • Eye care professional for annual dilated eye exam • Family planning for women of reproductive age • Registered dietitian for MNT • Diabetes Self Management Education (DSME) • Dentist for comprehensive periodontal examination • Mental health professional, if needed American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  24. Blood Glucose Goals • Non-pregnant goal if safe: • Preprandial 70-130 mg/dL • Peak postprandial < 180 mg/dL • Adjust goals based situation American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  25. Consider When Choosing BG Goals • Patient attitude and expected treatment efforts • Highly motivated = more stringent • Less motivated = less stringent • Risk potentially associated with hypoglycemia • Low = more stringent • High = less stringent

  26. Consider When Choosing BG Goals • Important comorbidities • Absent = more stringent • Severe = less stringent • Established vascular complications • Absent = more stringent • Severe = less stringent

  27. Frequency of BG Testing American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  28. HbA1c • Perform at least 2 x yrin ptsmeeting goal • Perform q 3 m in pts if RX has changed or not meeting goal • Use point of care testing for A1C if able American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  29. HbA1c Goal American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  30. HbA1c Goals for Kids

  31. Impact of Intensive DM TX

  32. Benefit of Each 1% Drop in A1c • Diabetes related deaths: 25% • Microvascular complications: 35% • Decrease in MI: 18% • Decrease in all cause mortality: 7% UKPDS. Lancet 1998; 352: 837-853.

  33. Weight Loss Weight loss is recommended for all overweight or obese individuals who have or are at risk for DM. (A) For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short term (up to 2 years). (A) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  34. Weight Loss For pts on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy) and adjust hypoglycemic therapy as needed. (E) Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss.

  35. Bariatric Surgery • Bariatric surgery may be considered for adults with BMI > 35 kg/m2 and type 2 DM, especially if the DM or associated comorbidities are difficult to control with lifestyle and pharmacological therapy. (B) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  36. Immunizations • Annual influenza to all pts with DM > 6 months • Pneumococcal to all DM pts> 2 years of age. A one-time revaccination is recommended for > 64 years if the previous vaccine was > 5 years • Administer hepatitis B vaccination to unvaccinated adults with DM who are aged 19 through 59 years. (C) • Consider administering hepatitis B vaccination to unvaccinated adults with DM who are aged > 60 years. (C) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  37. Blood Pressure • Measure BP at every visit • If BP elevated, recheck at another visit • If dx with HTN treat to the goal of: • systolic < 140 mmHg • diastolic < 80 mmHg • In pts with BP > 120/80 treat with lifestyle changes American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  38. HTN • Lower systolic targets, such as < 130 mmHg, may be appropriate for certain individuals, such as younger pts, if it can be achieved without undue treatment burden. (C) • If BP > 140/80 mmHg, in addition to TLC, initiate pharmacologic tx American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  39. Dyslipidemia Screening • Screen fasting lipid profile annually in most adults with DM (B) • Screen every 2 years in adults with low-risk lipid values (E) • LDL cholesterol < 100 mg/dL • HDL cholesterol >50 mg/dL • Triglycerides < 150 mg/dL American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  40. ASA Therapy for Primary Prevention • Consider ASA therapy (75–162 mg/day) as a primary prevention strategy in those with T1 or T2 DM at increased CV risk (10-year risk > 10%) • Most men aged > 50 or women aged > 60 who have at least one additional major risk factor • Family hxof CVD • HTN • Smoking • Dyslipidemia • Albuminuria (C) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  41. ASA Therapy for Primary Prevention • ASA should not be recommended for CVD prevention for adults with DM at low CVD risk since the potential adverse effects from bleeding likely offset the potential benefits. (C) • 10-year CVD risk < 5% • Men aged < 50 and women aged < 60 with no major additional CVD risk factors • Use of aspirin in ptsunder the age of 21 years is contraindicated due to the associated risk of Reye syndrome. American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  42. ASA Therapy for Secondary Prevention • Use ASA therapy (75–162 mg/day) as a secondary prevention strategy in those with DM with a hx of CVD. (A) • Use ASA therapy (75–162 mg/day) as a secondary prevention strategy in those with DM with a hx of CVD. (A) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  43. ASA Allergy • For ptswith CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. (B) • Combination therapy with aspirin (75–162mg/day) and clopidogrel (75mg/day) is reasonable for up to a year after an acute coronary syndrome. (B) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  44. Smoking Cessation • Advise all ptsnot to smoke or use tobacco products. (A) • Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. (B) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  45. CHD Screening • In asymptomatic pts, routine screening for CAD is not recommended, as it does not improve outcomes as long as CVD risk factors are treated. (A) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

  46. CHD Treatment • In ptswith known CVD, consider ACE inhibitor therapy (C) and use aspirin and statin therapy (A) (if not contraindicated) to reduce the risk of cardiovascular events. • In ptswith a prior MI, β-blockers should be continued for at least 2 years after the event. (B) American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care 2013; 36:S11-66

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