Daniel Lorber, md, facp, cde linda Siminerio, rn, PhD



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  • Daniel Lorber, MD, FACP, CDE

  • Linda Siminerio, RN, PhD

  • John Griffin, JD


Session Outline

  • CAUSE/CLASSIFICATIONS

  • COMPLICATIONS

  • CARE

  • CHALLENGES



The prevalence of diabetes - current estimates - world*

  • Number of people with diabetes:

    • 177 million (154 million projected)
  • Top 10 countries (number of people with diabetes):

    • India, China, USA, Indonesia, Russia, Japan, UAE, Pakistan, Brazil, Italy


U.S. Diabetes Facts

  • 20% increase in past 20 years

  • 70% increase in diabetes in 30-39 yr. age range

    • from 1990-1998
  • 1 in 3 children born in 2003 will get diabetes

  • 125,000 in U.S. under the age of 19

  • Type 2 in children is increasing

  • 14 million lost work days

  • Annual costs -- $132 billion



What is Diabetes?

  • Ancient Greek: “Diabetes Mellitus”

    • Diabetes: Copious Urine
    • Mellitus: Sweet
  • Lay Definition:

    • Abnormally High Blood Sugar
  • American Diabetes Association:

    • Fasting Blood Glucose above 126 mg/dl
    • Fasting Blood Glucose above 7 mM


CLASSIFICATIONS/ CAUSE



What is the Cause of High Glucose in Diabetes?

  • Type 1: Failure of the pancreas to make Insulin: cause = autoimmune

  • Type 2: Resistance of the body to Insulin: cause unknown

  • Both of these are areas of active research in the U.S. and internationally



















BALANCING ACT

  • Insulin and food must stay in balance

    • The insulin you inject will work whether you eat or not
    • Timing and amounts of food are important
    • If you do not eat enough, your blood sugar (glucose) could go LOW
    • If you eat too much, your blood sugar could go too HIGH
    • Physical activity will effect your blood sugar level


HbA1c and Glucose

  • 5% - - - - 90

  • 6% - - - - 120

  • 7% - - - - 150

  • 8% - - - - 180

  • 9% - - - - 210

  • 10% - - - 240

  • 11% - - - 270

  • 12% - - - 300



CARE









MONITORING

  • Blood Glucose Meters

    • Small, lightweight and user friendly
    • Many varieties available
    • One size does not fit all
    • No danger to others


MONITORING

  • How often?

    • Some suggestions:
      • Before each meal and at bedtime
      • Fasting and two hours after you eat
      • Before and after each meal
      • Once daily before breakfast
      • Fasting and once more during different times of the day
      • More often if you are ill, exercising, having a low blood sugar, driving.




MONITORING

  • How to test?

    • Wash hands with warm soap and water
    • Dangle fingers
    • Prick side of finger
    • Milk your finger to get a good drop of blood
    • Do not use the same finger over and over for testing


URINE TESTING

  • Done to detect ketones

    • Ketones are BAD!!
    • Ketones happen mostly in Type 1 diabetes
    • Type 1: test in the presence of persistent hyperglycemia
    • Should test if consistently high or anytime during illness
    • Moderate or large ketones should be reported to physician immediately


RAPID-ACTING INSULINS

  • HUMALOG AND NOVOLOG

    • Work very quickly
    • Starts working in 15 minutes
    • Peak 1-1 1/2 hours
    • Clear


SHORT-ACTING INSULIN

  • REGULAR

    • Works quickly
    • Starts to work in 1/2 hour
    • Peaks in 2-4 hours
    • Should be taken 15-30 minutes before a meal
    • Clear


INTERMEDIATE-ACTING INSULINS

  • NPH and LENTE

    • Work more slowly
    • Most often taken with oral medicine
    • Starts to work 1-2 hours after it is given
    • Peaks in 6-12 hours
    • Cloudy
    • Can be mixed with Humalog, Novolog and Regular


LONG-ACTING INSULIN

  • ULTRALENTE and LANTUS

    • Lasts for 24 hours with little or no peak
    • Usually taken at bed
    • Ultralente is cloudy
    • Lantus(Glargine) is clear
    • Lantus CANNOT be mixed with any other insulin


Insulin Delivery Systems

  • Injectors

  • Injection Aids

  • Pen delivery



Other Delivery Systems Being Explored

  • Closed-loop insulin pumps

  • Lectin-and polymer-bound systems

  • New routes: inhalation, oral, and transdermal

  • Microencapsulation of islet cells

  • Biohybrid artificial pancreas

  • Pump cannula at portal vein (Disetronic)





INSULIN

  • INSULIN

    • Needed to lower blood sugar levels.
    • Diet alone or diet and oral medicine did not control your blood sugar levels (type 2)
    • Does NOT mean your diabetes is worse
    • What your body needs to keep blood sugar in control


Kinds of Oral Medicines

  • Sulfonylureas

  • Biguanides

  • Alpha-glucosidase Inhibitors

  • Insulin-sensitizing agents

  • Meglitinides





Oral Medicines

  • Medicines can be used alone, with each other or with insulin.

  • Sulfonylureas and meglitinide.

  • Help the pancreas make more insulin.

  • Biguanides and insulin sensitizers

  • Help the insulin to work better



Oral Medicines

  • Sulfonylureas

  • Lower pre-meal blood sugar levels

  • Carbohydrate Inhibitors and Meglitinides

  • Lower after meal blood sugar levels



SULFONYLUREAS

  • Help pancreas make more insulin

  • Several different types

  • Do not exchange one for another

  • Side effects

    • Low blood sugar
    • Weight gain
    • Upset stomach


BIGUANIDES

  • GLUGOPHAGE

    • Help keep the liver from putting out too much sugar
    • Help insulin to work better
    • Lower cholesterol
    • Do not cause weight gain
    • Side effects: diarrhea, nausea and loss of appetite
    • Do NOT take is liver, kidney problems or heart failure


ALPHA-GLUCOSIDASE INHIBITORS

  • PRECOSE AND GLYCET

    • Work in digestive tract
    • Block enzymes that break down carbohydrates to sugar
    • Prevent blood sugar from going up after meal
    • Side Effects: Bloating, gas, diarrhea
    • Side effects usually go away after a few months


INSULIN SENSITIZERS

  • ACTOS AND AVANDIA

    • Help your body to use insulin better
    • May take 2-12 weeks to work
    • Give medicine a fair trial
    • Monitor liver functions


MEGLITINIDES

  • PRANDIN AND STARLIX

    • Help pancreas make more insulin
    • Work in response to blood sugar levels
    • Take before each meal and snack


Oral Medicine

  • Most pills should be taken at mealtime

  • Glucotrol (Glipizide) works best if taken 1/2 hour before a meal

  • Prandin should be taken 15 minutes before a meal

  • Precose and Glycet should only be taken with the first bite of food



Benefits of Oral Medicine

  • Lower blood sugar will mean you will feel better

  • Remember not a cure for diabetes

  • The Person with Diabetes must

  • Take medicine every day, eat at planned times, eat meals per appropriate diet.

  • Stay in touch with his/her health team

  • Test blood sugar level to see if the medicine is working



COMPLICATIONS

  • Acute

  • Chronic



Hypoglycemia

  • Sudden Onset

  • Staggering, Poor Coordination

  • Anger, Bad Temper

  • Pale Color

  • Confusion, Disorientation

  • Sudden Hunger

  • Sweating

  • Eventual Stupor or Unconsciousness







Proven Studies “benefits of intensified control”

  • DCCT (type 1)

  • HbA1c = 1.9%

  • Complications in the DCCT Trial showed profound reduction

    • Retinopathy 76%
    • Nephropathy 56%
    • Neuropathy 60%


HbA1c and Glucose

  • 5% - - - - 90

  • 6% - - - - 120

  • 7% - - - - 150

  • 8% - - - - 180

  • 9% - - - - 210

  • 10% - - - 240

  • 11% - - - 270

  • 12% - - - 300



Decision Support ADA Standards of Medical Care

  • A1C <7%

  • Blood pressure <130/80 mmHg

  • Lipids

    • LDL <100 mg/dl
    • Triglycerides <150mg/dl
    • HDL >40mg/dl
  • Dilated eye exams

  • Foot exam (Monofilament)

  • Microalbumin



CHALLENGES



CHALLENGES at SCHOOL



at WORK



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