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Compression consultations for the diabetic patient new orleans dinner programPresentation Transcript
Compression Consultations for the Diabetic Patient Kimberly Simmons, PharmD, MBA US Pharmacy Relations Manager SIGVARIS, Inc. Adjunct Associate Professor of Pharmacy Practice Mercer University College of Pharmacy and Health Sciences University of Georgia College of Pharmacy
Program Sponsored by SIGVARIS Global leader in graduated compression garments for prevention and management of venous insufficiency/diseaseThis is commercial program; no CE credits will be offered!
The SIGVARIS Difference… Covered spandex Double Covered Yarns • Increased durability 2nd covering (S-twist) • Omission of ‘shininess’ • Provides for anatomically correct fit 1st covering (Z-twist) • Enhances patient level of comfort in donning and doffing • Improved patient compliance 8
The SIGVARIS Difference… SIGVARIS offers flexible ready-to-wear sizing options to fit 98.2% of the population while ensuring maximum comfort and increasing compliance
The SIGVARIS Difference… …we work for you & with you to so you can generate alternative revenue! Pharmacist managed Provide complimentary pharmacy relations customized & generic department for marketing materials business support Quarterly business Healthy leg days reviews Physician detailing Training & education Online dealer locator programs Distributed dealer list
o you currently carry and/or consultpatients on graduated compressionsocks or stockings for your patients?
Objectives• Discuss the epidemiology of lower extremity complications in the diabetic patient• Discuss graduated compression therapy and it’s uses• Explain the etiology of lower extremity edema in the diabetic patient• Describe lower extremity edema management with graduated compression therapy• Discuss compression consultation points for diabetic patients
Diabetic Patient use of Pharmacy ServicesGeorgetown University. Center on an Aging Society. Sept. 2002 (5). 1-6. Available at:http://hpi.georgetown.edu/agingsociety/pdfs/rxdrugs.pdf. Accessed 05/03/12.
25.8 $174 BILLION1 American Diabetes Association. Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011). Available at:http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Accessed 05/03/12
1 American Diabetes Association. Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011).Available at: http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Accessed 05/03/12
The old saying “An ounce ofprevention is worth a pound ofcure” was never as true as it iswhen preventing amputations!
Factors Leading toLower Extremity Amputations• Peripheral neuropathy• Infection ▫ Antibodies respond slower to infections secondary to the poor circulation• Deformity of the feet ▫ Diabetes can affect the joints making them stiffer• Vascular disease ▫ Poor circulation can affect the body’s ability to heal when damage occurs
Vascular Disease: Arterial & Venous Disease Arterial Disease (PAD) Venous Disease (PVD) Narrowing of the arteries, commonly Inadequate return of venous the pelvis & legs blood from the legs to the heart Clinical Symptoms: Clinical Symptoms: cramping, pain, tired/heavy, achy cramping in tired legs or hip muscles that worsens the legs; pain worsens when during walking/activity and subsides standing and improves with leg with rest elevation and activityPAD=peripheral arterial disease; PVD=peripheral venous disease
Epidemiology of Vascular Disease 60% of American suffer from vascular disease and its sequelae More people lose time from work and are affected by venous disease than from arterial disease 50% of Americans are affected by vein disease Diabetic patients have a 2-5 times greater risk for developing PAD vs. non-diabetic patients Approx. 1 in 3 diabetic patients >50 years has concomitant PADPAD= Peripheral arterial diseaseNational Heart Lung and Blood Institute (NHLBI). Available at: http://www.nhlbi.nih.gov/ Accessed 01/27/11.Society of Interventional Radiology (SIR) Website. 2003. Available at:http://www.scvir.org/patients/varicose-veins/. Accessed 05/28/2009/Vascular Disease Foundation Newsletter. Spring 2005; Volume 5, N2
100 Most of 90 the The venous system containsPercent Distribution 80 blood most of the blood as it moves 70 through the circulatory system. 60 50 40 30 20 10 0 Veins Lungs Heart Arteries Capillaries 60-70% 10-12% 8-11% 10-12% 4-5%Hole’s Human Anatomy and Physiology, 7th Edition, 1996
Audience Response What etiologic factors directly contribute to the development and progression of venous disease? C.Incompetent valves D.High blood pressure E.Improper venous return F.A and B G.All of the above
Physiology of the Normal Venous Circulation:Competent Valves Valve Open Valve Closed Pumps blood against Inhibits gravitational reflux of gravity towards heart pumped blood
Physiology of the Normal Venous Circulation:Incompetent Valves Vein Wall Injury ↑ ↑ Venous Hypertension ↑ ↑ Damaged Valves
Examples of Vein Disease Complications Telangiectasia Varicose Veins Lipodermatosclerosis (spider veins) Deep Vein Thrombosis Superficial Phlebitis
Examples of Vein DiseaseComplications Venous Ulcers Chronic Venous Leg Edema Insufficiency Venous Hypertension
Lower Extremity Edema: A Complication of Poor Circulation• Lower extremity edema is a common clinical finding in diabetic patients ▫ Graduated compression therapy is the standard treatment for edema ▫ Graduated compression therapy is a precaution in diabetic patients because of concomitant arterial disease• Lack of reliable measures to objectively quantify edema makes it difficult to assess it’s prevalence in diabetic patients• Edema in diabetics is difficult to isolate and may have multiple etiologies ▫ Edema may be attributable to anti-diabeties meds such as: Actos, Avandia, ACTOplus met, ByettaBrodovicz KG, et al. Clin Med Res. 2009;7(1-2):21-31.Fries R. MMW Fortschr Med. 2004;146(16):39-41.Powell AA, et al. Am Fam Physician. 1997;55(5):1721-6.
Safety and Efficacy of Mild Compression (18-25mmHg) Therapy in Patients with Diabetes and Lower Extremity Edema Wu SC, Crews RT, Najafi B, et al. J Diabetes Sci Technol 2012 Vol 6 Issue 3 • 4-week pilot study • N=18 ▫ Diabetes ▫ Lower extremity edema of the leg, foot, and ankle ▫ Ankle-brachial index (ABI) >0.6 • Assess whether diabetic compression socks* can reduce LE edema in diabetic patients without compromising vascularity • Mild graduated compression socks (18-25mmHg) decreased swelling in diabetic patients with LE edema without compromising vascularityLE=lower extremity
Defining Anti-embolisms (TEDs) “TEDS are for BEDS” Anti-embolisms Therapeutic Compression Ranges: 18-8mmHg, 20-10mmHg Utilized in the hospital or nursing home setting For bed-ridden patients Anti-embolisms Indicated for prevention of thromboembolisms in recumbent patientsClass A (8-15mmHg) compression reflects the standard in some countries but there is insufficient clinicalevidence to support it’s use in practice. (European Prestandard, 2001)TEDS=Thromboembolic Deterrent Stockings
Defining Graduated Compression Therapy “Stockings are for Walking” • Compression therapy is the application of controlled graduated external pressure to the 20 - 40% limb to reduce venous pressure within the limb. 50 - 80% 100% • Strongest at the ankle and decreasing in the proximal direction • To be effective, must fit over the calf • Require measurement, fitting, and patient counseling by a certified and trained compression specialistPictures obtained from http://www.newlook.com.sg/tedantiembolismstockings.asp. Accessed 09/02/10.
Audience Response How do you know what level of compression pressure is appropriate for the patient? C.Physician prescription D.Patient request E.Assessment of venous complications F.A and B only G.All of the above
Graduated Compression Indications Shoe Size Precisely Measured 15-20mmHg 18-25mmHg 20-30mmHg 30-40mmHg 40+mmHg• Tired, achy legs • Lower extremity • Heavy, fatigued, • Moderate • Severe• Occupational or edema in diabetic aching legs varicosities w/ varicosities evening edema patients without • Mild edema in mild-moderate • Severe edema• Leg discomfortsimple change of socks!!! ± A contraindications lower extremities edema • CEAP C4, C5, from prolonged and ABI >0.6 • Mild varicosities pregnancy C6 standing/sitting w/ minimal • Post-procedure • Recurrent• Preventing edema of larger veins venous pregnancy • Mild varicosities • CEAP C3, C4, ulceration varicosities & pregnancy C5, C6 • Severe post &swelling edema • Recurrent or traumatic,• Predisposed risk • Post-procedure active venous fracture edema• Reduce travel of small veins ulceration • Severe PTS swelling • DVT prevention • DVT prevention• Prevention of or management or management traveler’s • DVT or PTS thrombosis treatmentThere is insufficient clinical evidence to support the clinical efficacy of compression pressures <15mmHg tosupport ambulatory patients. (European Prestandard, 2001)
Why are graduated compressiongarments sized and measured toprecisely fit patients?
Graduated compression therapy is “Medicine you Wear”
“Your labs show you have diabetes. I know your legs hurt but you need to exercise to improve your circulation, and start Actoplus met!”What compression consultation would you offer this diabetic patient presenting to your pharmacy?
Selecting the ‘Right’ Diabetic Compression Sock • Promotes circulation • Fiber blend of cotton, acrylic, nylon, and elastic ▫ Regular 100% wool or cotton socks are too tight on the foot, reduce circulation, and are not cool and do not keep the foot dry • Cushioned ▫ Regular socks do not provide comfort and protection • Flat seams ▫ Coarse seams on regular socks rub the foot and . cause blisters and calluses to emergeFeldman CB, et al. Diabetes Spectrum.14(2), 59-613Herring KM, et al. J Amer Pod Med Assn. 80, 63-70.
Diabetic Compression SockTarget Patient Population • Pre-diabetic • Newly diagnosed • Edema • Gestational diabetes • No neuropathy • ABI >0.6 without claudication Diabetic patients a more likely to exercise when their legs feel good!
Diabetic Compression Sock Key Benefits: •Clinically proven to reduce swelling and improve circulation •American Podiatric Medical Association (APMA) Seal of Approval •Non-binding calf band •Flat toe seam •Extra padding on foot •DriRelease fiber blend for moisture wicking, odor control, and softness •Latex free •True graduated compression Compression Level: 18-25mmHg Style(s): Over the Calf Color(s): White Retail Price: $30-40
Diabetic-friendly Compression SockCushioned Cotton Key Benefits: •Diabetic-friendly •Non-binding calf band •Flat toe seam •Extra padding on foot •DriRelease fiber blend for moisture wicking, odor control, and softness •Latex free •True graduated compression Compression Level: 15-20mmHg & 20-30mmHg 15-20mmHg Style(s): Over the Calf Color(s): White & Black Shoe size, ankle & calf measurements20-30mmHg Retail Price: $30-60
Compression Consultation Points for the Diabetic Patient• Avoid diabetic compression socks upon development of: ▫ Severe arterial insufficiency ▫ Intermittent claudication ▫ Ischemia ▫ Weeping wounds ▫ Uncontrolled CHF• Seek physician consultation and approval to wear diabetic compression socks if neuropathy presents• Remove socks if they cause persistent pain to lower extremities and pain does not improve with activity
Compression Consultation Pointsfor the Diabetic Patient • Put on diabetic compression socks daily upon waking & remove at bedtime • Launder socks every night in a mild washing detergent • Diabetic compression socks will decrease LE edema & improve circulation to help legs & feet feel better • Moisturize feet daily before & after sock application with a foot cream to minimize dry, cracked skin
Compression Consultation Pointsfor the Diabetic Patient • When donning and doffing stockings, it’s best to wear gloves. • To don, do not bunch the garment like ordinary socks. • Use the ‘pull-on’ or ‘sock-puppet’ method to don graduated compression garments. • To doff the garment, pull off like a banana.
Foot Care Consultation Points • Wash feet daily with luke warm water • Dry feet and between toes well • Keep skin supple with moisturizing lotion • Use soft socks or stockings, which must neither be too big or small • Avoid walking bare-foot • Examine shoes daily for abnormalities/defects • A brisk walk daily stimulates circulation and makes patient feel betterPalaian S, et al. The Internet Journal of Pharmacology. 2005 Volume 4 Number 1. Available at:http://www.ispub.com/journal/the-internet-journal-of-pharmacology/volume-4-number-1/role-of-pharmacist-in-counseling-diabetes-pat. Accessed 05/04/12.
SIGVARIS Graduated Compression Socks … “It’s Medicine you Wear” Questions & Discussion
Thank You for Attending! Kimberly Simmons, PharmD, MBA US Pharmacy Relations Manager SIGVARIS Inc. email@example.com 770-632-2571 (office) 770-632-2973 (fax)