Chronic Disease Management: Diabetes Mellitus

1. Chronic Disease Management: Diabetes Mellitus Rachel Waite, Pharm.D. Candidate

2. By the end of this talk you should be able to… • Explain the difference between type 1 and type 2 diabetes mellitus • List risk factors for DMT2 • Explain the difference between prediabetes, diabetes, metabolic syndrome • Describe microvasuclar and macrovasular complications of diabetes.

3. Counsel a patient on hypoglycemia treatment • Counsel a patient on non-drug diabetes management tools. • Counsel a patient on treatment goals of diabetes. • List the components of a SOAP note • Practice writing a SOAP note from an example case

4. Impact of DM • 25.8 million Americans have diabetes (8.3% of population) • The number of Americans treated for diabetes doubled from 1996 to 2007. • 1 in 3 Americans born in 2000 will have diabetes in their lifetime • Annual costs -- $132 billion • Leading cause of blindness, ESRD, amputations, MI, strokes

5. 84% of people with diabetes are on oral medication or insulin Source: 2007–2009 National Health Interview Survey

6. Diabetes Mellitus Type 1 • Results from inability of islet cells to produce insulin • Also known as insulin-dependent or juvenile-onset diabetes • Cause is unknown, but likely to have genetic, autoimmune component

7. Diabetes Mellitus Type 2 • Results from decreased insulin sensitivity and decreased pancreatic beta-cell function

8. Gestational Diabetes • Diabetes that first presents during pregnancy • Occurs in 2-10% of pregnancies • 30-60% chance of developing T2DM

9. 95% of DM patients are Type 2

10. Source: SEARCH for Diabetes in Youth Study NHW=non-Hispanic whites; NHB=non-Hispanic blacks; H=Hispanics/Latinos; API=Asian/Pacific Islander Americans; AI=American Indians

11. DMT1 v. DMT2

12. Risk Factors: T2DM Obesity (BMI >27) Hypertension HxGestational DM Family HxDM Dyslipidemia Hxvascular disease Previous impaired fasting glucose test, impaired glucose tolerance Polycystic ovaries Inactive lifestyle Certain ethnicities (African Americans, Hispanics, Native Americans, Pacific Islanders).

13. Metabolic Syndrome A group of risk factors that occur together that increase risk for diabetes, coronary artery disease, and stroke. Not the same as pre-diabetes

14. Metabolic Syndrome • Elevated waist circumference: Men — Equal to or greater than 40 inches (102 cm) Women — Equal to or greater than 35 inches (88 cm) • Elevated triglycerides: Equal to or greater than 150 mg/dL • Reduced HDL (“good”) cholesterol: Men — Less than 40 mg/dL Women — Less than 50 mg/dL • Elevated blood pressure: Equal to or greater than 130/85 mm Hg • Elevated fasting glucose: Equal to or greater than 100 mg/dL

15. Screening • Fasting Plasma Glucose (mg/dL) (FPG) • Check a fasting glucose level • Oral Glucose Tolerance Test (mg/dL) (OGTT) • Check blood glucose 2 hours after a 75g oral glucose load • Hemoglobin A1c • Shows percentage of glycated hemoglobin. • Reflects glucose control over 6-12 week period.

17. HbA1c and Average Plasma Glucose Correlation HbA1c Plasma Glucose 6 120 7 150 8 180 9 210 Etc.

18. Signs and Symptoms

19. “The Polys” • Polyuria / polydipsia: Glucose spilled into urine, leads to osmotic diuresis (polyuria). This leads to dehydration, and increased thirst (polydipsia). • Polyphagia: without insulin function, glucose cannot be transported into cells. Cells are “hungry” and hunger sensation is triggered. • Polys can go unnoticed for years.

20. Complications Microvasuclar: damage to eyes, kidneys, nerves (retinopathy, nephropathy, neuropathy) Macrovascular: 2X risk for heart attack and stroke, peripheral vascular disease

21. Hypoglycemia Definition: plasma glucose <70 A complication of treatment! Normal plasma glucose 70-150 40 is the minimum for brain function <40 = Risk for diabetic coma, seizures

22. Symptoms of Hypoglycemia • Heat palpitations • Confusion • Tremor • Sweating • Anxiety • Hunger • Visual disturbances • Seizure • Loss of Consciousness

23. Hypoglycemia Treatment • Glucose • 15 grams of simple carbohydrates • 8oz. fruit juice • Half can regular soda • 3 glucose tabs • 1 tablespoon honey • Glucagon injection • Stimulates glycogen breakdown

24. Patient Education Food, exercise, meds Treatment plan Goals / targets Self-monitored blood glucose Hypoglycemia Emergency numbers If insulin: injection technique, syringe disposal, storage, etc. Foot care Ophthalmic exams Diabetes Survival Skills:

25. Target Goals  Glycemic Control:

26. Target Goals Blood pressure: <130/80 Lipids: LDL < 100mg/dL (if CAD <70)

27. What if your patient doesn’t make goals? It is okay. Any decline = decline in risk

28. Non-Drug Management Tools Diet Exercise Smoking cessation Alcohol in moderation Education Monitoring

29. Questions ?

30. A Case Mr. Smith came to the pharmacy this morning to pick up his refill prescription for lisinopril 10mg once daily, metformin 1000mg twice daily, and lispro insulin. This is the second time he has filled his insulin prescription. He did not receive diabetes education. He said that he often gets dizzy about 20 minutes after taking his lispro, especially when he hasn’t eaten recently. He uses the insulin at 8am, noon, and 6pm, but his prescription says that he should take 15units 15min. before meals. He does not eat regular meals. His injection technique is good and I observed his technique in the pharmacy. He takes a baby aspirin every day. He was diagnosed with type 2 diabetes and hypertension 1 year ago at a routine physical. His last visit with his PMD was 2 months ago and at that time he had a blood glucose of 245, an A1c of 9.5%, BP of 145/92 and a serum creatinine of 1.8. At this visit he got a prescription for insulin. He describes his hypoglycemia reaction as getting dizzy, shaky, and he sometimes feels lightheaded, like he might pass out. He pulled out his blood glucose meter and the last 5 readings were 65, 138, 142, 95, 112. He checks his blood glucose before giving his insulin. I think that he should only use the insulin after meals, and I told him that if he has symptoms of hypoglycemia he should have a small sugar snack like 8 oz. of juice or 3 glucose tabs. Mr. Smith works as a construction worker and eats a lot of fast food on the run. He does not smoke or drink and he plays in a church softball league on the weekends. He is 57 years old and he weighs 220lbs and he is 5foot9. I think Mr. Smith should go to a diabetes education class and I called his physician to get a prescription for glucagon, just in case. I also sold him a roll of glucose tabs. His dad had T2DM and also came to this pharmacy. I told Mr. Smith to eat less fast food.

31. Written Communication • Useful tool to pass along information when transitioning patient care from one person to another: • Shift changes • From one healthcare field to another • Guidance for future encounters

32. SOAP Format Subjective Objective Assessment Plan

33. Subjective Information the pt tells you about him/herself Includes: • ID & Chief Complaint (CC) • History of Present Illness (HPI) • Past Medical History (PMH) • Drug History (DH) • Family History (FH) • Social History (SH

34. Objective Observable/factual information obtained from or verified by a healthcare provider • Vital signs (BP, HR, RR, temp, wt, ht) • Physical Exam • Labs (blood tests, urine tests, microbiology, etc) • Diagnostic tests (x-rays, CT/MRI, EKG, EEG) • Medications (from profile or chart)

35. Active Learning 1. Find a partner 2. With your partner, circle all of the subjective information in the case. 3. With your partner, underline all of the objective information in the case. Use your handout to decide what information is subjective, and what is objective.

36. S • MS is a 57 y.o. male who presented at the pharmacy today to pick up refill prescriptions, complaining of symptoms of hypoglycemia. • CC: He describes feeling dizzy, shaky, lightheaded when he takes his insulin and does not eat. • DH: Lisinopril 10mg Qday, Metformin 1000mg BID, Insulin Lispro 15 units 15 min. before meals, Aspirin 81mg daily. • PMH: He was recently diagnosed with T2DM and HTN 1 year ago at a routine physical. • FH: Father had T2DM. • SH: He works as a construction worker and frequently eats fast food. He does not smoke or drink. He did not receive diabetes education.

37. O From PMD visit 2 mo. ago: Blood Pressure: 145/92, Serum Cr: 1.8, BG 245, HA1c 9.5%, Wt. 220lb. Ht. 5’9.’’ Calculated BMI is 32.5. The patient demonstrated good insulin injection technique at home. His last 5 self-monitored blood glucose readings were 65, 138, 142, 95, 112. He monitors his blood glucose 3 times daily before administering his insulin.

38. Assessment Yourclinical judgment of the patient’s drug-related problems • Problem list (numbered) • Each item should include • problem, solution, evidence/reason for your solution • Prioritize problems • start with most urgent (usually relates to CC) • end with least urgent

39. Plan Specific solution for each problem outlined in the assessment • Numbered list to match the Assessment • Recommendations for drug dose, frequency, duration • Monitoring • Follow-up

40. Find another partner • For the practice case, pick out the parts of the pharmacist’s assessment and plan with your partner. • Is there any assessment in the note as written? • Discuss what things go in Assessment, and what goes in Plan

41. A 1. Insulin use: Lispro is a rapid-acting insulin and can cause hypoglycemia. It should be given 15 minutes before meals. 2. Hypoglycemia: The patient is experiencing hypoglycemia symptoms approximately 3 times a week when he skips meals. He should be counseled on preventing hypoglycemia, recognizing signs and symptoms of hypoglycemia, and how to treat hypoglycemia. 3. Education: This patient does not eat regular meals. He could benefit from a diabetes education class to learn carbohydrate counting and other diabetes survival skills. Diabetes education has been shown to improve outcomes. 4. Lifestyle changes: Increasing exercise to most days of the week, reducing fast food consumption, and increasing complex carbohydrates and lean protein in the diet are non-pharm strategies this patient can implement to manage his diabetes. Weight loss to a BMI ≤ 25 can increase insulin sensitivity.

42. P 1. Administer insulin 15 minutes before meals. Encourage regular meal. If skipping a meal, do not administer insulin. 2. If SMBG reading is <70 have a small meal or snack of 15g simple carbohydrates. Examples are 8oz. juice or half a can of regular soda. Counsel the patient that dizziness, shaking, anxiety, and lightheadedness are symptoms of hypoglycemia. If the experiencing these symptoms check blood sugar and have a snack if necessary. 15 min. after a snack, recheck blood sugar. Get a prescription for glucagon pen, 1mg IM if unresponsive due to hypoglycemia. Counsel friends and family members to use pen if patient unresponsive. 3. Recommend a diabetes education class at the community hospital next week. 4. Recommend 150 min. aerobic exercise per week and resistance training 3 times per week. Increase consumption of complex carbohydrates and lean protein. Encourage a “Mediterranean diet” and less fast food. Recommend weight loss to a goal of <170lbs (BMI ≤ 25). • Will follow up with patient at next refill in one month.

43. Questions ?

44. References • Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34 Suppl 1:S11-61. • Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. • Triplitt Curtis L, Reasner Charles A, Isley William L, "Chapter 77. Diabetes Mellitus" (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 7e: http://www.accesspharmacy.com.offcampus.lib.washington.edu/content.aspx?aID=3207048. • Odegard, P. Diabetes Mellitus: Type I. Pharm 561. University of Washington School of Pharmacy, Seattle, WA. Feb 22 2010 Lecture. • Ellsworth A. Pharmacotherapy, Diabetes Type 2. Pharm 561. University of Washington School of Pharmacy, Seattle, WA. Feb 24 2010 Lecture. • Mayoclinic.com/health/hypoglycemia