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

• 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