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Understanding Compression Therapy use in Diabetic Patients: How Healthcare Professionals can Improve Patient Outcomes

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  • Would you say that diabetes has a face? Can you identify a person with diabetes based upon their appearance or the types of clothes they wear? On average how many of patients purchase diabetes related products from your pharmacy? These could be test strips, meters, lancets, insulin, oral medications, bandages for wounds…and the list could go on? Now keep this number in your head for a moment…
  • While statistics are good and can help us to identify a trend, for the purpose of tonight's discussion, we will only highlight a couple that are key to our topic. The CDCs 2011 Fact Sheet, included in your packet, reports that 25.8 million children and adults in the United States—8.3% of the population—have diabetes with 1.9 million new cases of diabetes diagnosed in people aged 20 and older in 2010. Ok, you may ask, well how many Americans are in the US? As a point of reference, the US Census Bureau reported that in 2010 there were 308 million people. Depending on the source, diabetes is listed as the 5 th -7 th leading cause of death in the US. Most current information listed on the CDC website based upon 2009 data, reports it as the 7 th leading cause of death after heart disease, cancer, chronic lower respiratory disease, stroke, accidents, and Alzheimer's disease. Diabetes is also listed as a major cause of heart disease and stroke? The National Health and Nutrition Examination Survey, reports diabetes as the 6 th leading cause of death. What does diabetes cost us? The CDC reports the estimated direct cost in 2007 at $174 billion. More relevant to us as pharmacist is.
  • Diabetic patient patronize us more than the leading disease states attributing to death. Here we see that they spend more money and fill more prescriptions. This data is one reason that so many pharmacies now offer diabetes classes and other management services. Because of the rapid expansion of available therapeutic agents to treat diabetes, the pharmacist's role in caring for diabetic patients has expanded. The pharmacist can educate the patients about the proper use of medication, screening for drug interactions, explain monitoring devices, and make recommendations for ancillary products and services. The pharmacist, although not the health care professional to diagnose diabetes, is important in helping the patient maintain control of their disease. The pharmacist can monitor the patient's blood glucose levels and keep a track of it. During their contact, the patients can ask the pharmacist any questions they did not ask the physicians and can get further information regarding diabetes. By show of hand does your pharmacy offer such services? What is included in your service offerings? Do you counsel patients about prevention who are pre-diabetic? How about newly diagnosed patient, patients returning at regular intervals, or non-compliant patients? What consultation points do you cover with a patient who is pre-diabetic, newly diagnosed, or refilling medications?
  • I’m sure you have heard in school, at other dinner programs, and some other point of practice, that as pharmacist we are in the ideal position to intervene and optimize patients outcomes…WHY? Because we see patients more frequently that other healthcare professionals, we are more readily accessible, and should be in the position to spend more time consulting with patients than the physician who can spend no more than 15-minutes with the patient! To this point, we are often recognized for quasi-triaging a patient and recommending next steps, i.e., see your doctor, recommending an OTC product, or advising them on their disease state. With diabetic patients, many first become aware that they have diabetes when they develop one of its life threatening complications. So…Everyone who mentioned that there pharmacy offers a diabetes management service, clinic, or takes additional care and time to consult with your diabetic patients please raise your hand again. Now, in your consultations with patients do you mention, and as we cover the body as it relates to complications, lower your hand once we come to an area that you do not cover in your consultations. Problems of the foot are the most frequent reasons for hospitalisation amongst patients who have diabetes. Many hospital visits due to diabetes-related foot problems are preventable through simple foot care routines . Doctors estimate that almost half of all amputations are caused by neuropathy and circulatory problems that could be prevented. Amongst people who have diabetes, amputations are reported to be 15 times more common than amongst other people. 50% of all amputations occur in people who have diabetes.
  • Foot problems are a big risk in diabetics . Diabetics must constantly monitor their feet or face severe consequences, including amputation. Several key factors usually predispose ulceration and ultimately amputation. These include peripheral neuropathy, vascular disease, infection and deformity of the feet . Vascular disease is a common term that most people commonly associate only with PAD (peripheral arterial disease); however, it is any disease that affects the blood vessels of the circulatory system. This can range from diseases of the arteries, veins, lymph vessels, to blood disorders affecting normal circulation. With a diabetic foot , a wound as small as a blister from wearing a shoe that’s too tight can cause a lot of damage. Diabetes decreases blood flow, so injuries are slow to heal. When wounds are not healing, it’s at risk for infection. In diabetic patients infections spread quickly. Diabetic patients should inspect their feet every day . Look for puncture wounds, bruises, pressure areas, redness, warmth, blisters, ulcers, scratches, cuts and nail problems. Diabetic foot complications are more common amongst the elderly, and amputation rates do increase with age.
  • Vascular disease is a common term that most people commonly associate only with PAD (peripheral arterial disease); however, it is any disease that affects the blood vessels of the circulatory system. This can range from diseases of the arteries, veins, lymph vessels, to blood disorders affecting normal circulation.
  • Meticulous foot care and the choice of suitable foot wear can prevent serious damage which is likely to occur in diabetics.
  • Eighteen subjects (9 males, 9 females) average age of 61 years with diabetes, lower extremity edema, and a mean ABI of 1.10 completed the study. Subjects were fitted and dispensed 4-7 pair of stockings and instructed to wear them during all walking hours. Edema quantified through manual circumference measurements midfoot ankle calf Cutaneous edema measurements in the calf quantified via MoistureMeter handheld device that measures the difference in relative humidity between the ambient air and the measured skin
  • Eighteen subjects (9 males, 9 females) average age of 61 years with diabetes, lower extremity edema, and a mean ABI of 1.10 completed the study. Subjects were fitted and dispensed 4-7 pair of stockings and instructed to wear them during all walking hours.
  • Eighteen subjects (9 males, 9 females) average age of 61 years with diabetes, lower extremity edema, and a mean ABI of 1.10 completed the study. Subjects were fitted and dispensed 4-7 pair of stockings and instructed to wear them during all walking hours.
  • Eighteen subjects (9 males, 9 females) average age of 61 years with diabetes, lower extremity edema, and a mean ABI of 1.10 completed the study. Subjects were fitted and dispensed 4-7 pair of stockings and instructed to wear them during all walking hours.
  • Although mild weekly fluctuations are noted, there was an overall decrease in cutaneous edema in Week 0 to Week 4
  • 98.2% of patients responded that they would recommend use of the diabetic compression sock, 94.6% responded that overall comfort in the sock was moderately or very comfortable, 92.9% responded that care for the sock was moderately or very easy. 64.3% of the patients rated ease of removal of the product at an 8 or above out of 10, and 50.0% rated ease of application at an 8 or above out of 10.
  • It is important that graduated compression socks and stockings are measured and fit for each patient by a person who has been properly trained (also referred to as a compression specialist). When graduated compression stockings are not properly fit, it can cause: Reduced blood flow and tissue oxygenation Pressure ulcers Arterial occlusion Thrombosis Gangrene
  • ( “As you can see from this chart, the systemic veins handle most of the blood in the body. The blood volume carried in the veins is enormous— approx. 40% of all the blood in our bodies is in the legs!” Let’s do a quick review… (ASK THESE QUESTIONS:) Which vessels have more muscle—veins or arteries? ( Answer ): arteries Which vessels would then be more prone to dilate or stretch out under pressure? ( Answer ): veins Where is most of the blood found in the body, in the arteries or in the veins? ( Answer ): in the veins” Final point: The vessels that are most prone to damage carry the majority of the blood within our bodies.
  • There is another aspect of vein anatomy that makes veins very different from arteries, the presence of valves in the veins. Venous valves are tissue paper thin structures (cusps) that resemble upside down parachutes and are found every 2 to 7 cm. depending on the size of the vein. These valves provide a one-way flow of venous blood back to the heart and lungs. Valves are uni-directional; they allow blood to flow in only one direction, bicuspid, work against gravity and prevent reverse flow or pooling. “ The calf muscle is not the only source of venous return. Other ‘pumps’ help push the blood toward the heart. Ankle and foot pumps contract to force blood upwards. Venous valves are absent in the sole of the foot, so blood is squeezed out of the veins by body weight when standing or walking. This can also be achieved with compression treatment.”
  • SIGVARIS diabetic compression sock is ideal for: Pre-diabetic patients Newly diagnosed patients Diabetic patients with edema Expecting mothers diagnosed with gestational diabetes Because of the precaution of graduated compression therapy in diabetic patients, it is recommended to rule out neuropathy and determine the patients arterial sufficiency. Patients with an ABI>0.6 and no claudication could benefit from graduated compression therapy, but if the patient has cladication refer them to their physician for further evaluation. Most importantly for these patients, your recommendations of SIGVARIS diabetic compression graduated sock will help their legs to feel better because their circulation has improved…with improved ciruclation, your patients are more likely to be compliant with the need and your recommendation to exercise!
  • Below 0.4 is the threshold An index of <0.9 indicates PVD. Lower extremity arterial disease is defined by a low ABI, usually ≤0.9 but ranging in the literature from <0.80 to <0.97.
  • You can’t share what you don’t wear!
  • Transcript

    • 1. Understanding Compression Therapy use in Diabetic Patients: How Healthcare Professionals can Improve Patient Outcomes Presented by: Sponsored by an educational grant by:
    • 2. Program DisclosureThe faculty, planners, and manager who are in a position tohave control over content of this activity (including theirspouse and/or life partner) have disclosed the followingfinancial relationships or relationships to products ordevices they or their spouse/life partner have withcommercial interests relative to the content of this CEactivity. ______________________________________, have nothing to disclose relative to this activity. _________________ has been a consultant, advisor, and speaker for SIGVARIS, Inc.
    • 3. Accreditation Information ____________________________________ is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This program is approved for 1.0 contact hours (0.1 CEUs) under the ACPE universal program number ___________________. The program is available for CE credit through ________________.
    • 4. Objectives• Discuss the epidemiology and pathophysiology of lower extremity complications in the diabetic patient• 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
    • 5. The Face of Diabetes…
    • 6. 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
    • 7. 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.
    • 8. 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
    • 9. The old saying “An ounce ofprevention is worth a pound ofcure” was never as true as it iswhen preventing amputations!
    • 10. 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
    • 11. Audience Response What factors can cause of poor circulation in diabetic patients? C.Venous insufficiency D.Arterial insufficiency E.Lack of exercise F.A and C only G.All of the above
    • 12. 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 insufficiency  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
    • 13. 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.
    • 14. Audience Response True or False. Diabetic patients can not wear graduated compression socks. C.True D.False
    • 15. 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 • Fitted for 4-7 pair of diabetic compression socks which were white, padded foot, and flat toe seamLE=lower extremityDiabetic compression socks provided 18-25mmHg
    • 16. Safety and Efficacy of Mild Compression (18-25mmHg) Therapy in Patients with Diabetes and Lower Extremity EdemaWu SC, Crews RT, Najafi B, et al. J Diabetes Sci Technol 2012 Vol 6 Issue 3Mean Foot Circumference 27.98 27.42 27.58 27.41 27.60
    • 17. 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 Mean Ankle Circumference 25.28 24.42 24.32 24.36 24.14Statistically significant
    • 18. 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 Mean Calf Circumference 41.59 40.32 41.12 41.10 41.08Statistically significant
    • 19. 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 3Cutaneous Edema 31.20 30.05 29.50 29.30 28.58
    • 20. Safety and Efficacy of Mild Compression (18-25mmHg) Therapy in Patients with Diabetes and Lower Extremity EdemaWu SC, Crews RT, Najafi B, et al. J Diabetes Sci Technol 2012 Vol 6 Issue 3ABI 1.26 1.18 1.16 1.10 1.05
    • 21. Safety and Efficacy of Mild Compression (18-25mmHg) Therapy in Patients with Diabetes and Lower Extremity EdemaWu SC, Crews RT, Najafi B, et al. J Diabetes Sci Technol 2012 Vol 6 Issue 3Patient Survey 98.2% 94.6% 92.9% 64.3% 50.0%
    • 22. Safety and Efficacy of Mild Compression (18-25mmHg) Therapy in Patients with Diabetes and Lower Extremity EdemaWu SC, Crews RT, Najafi B, et al. J Diabetes Sci Technol 2012 Vol 6 Issue 3 Mild graduated compression socks decreased swelling in diabetic patients with LE edema without compromising vascularity
    • 23. Lower Extremity Edema: A Complication of Poor Circulation • Lower extremity edema is a common clinical finding in diabetic patients ▫ Also attributable to anti-diabetes medications: Actos, Avandia, ACTOplus met, Byetta • 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 etiologiesBrodovicz 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.
    • 24. Defining Graduated Compression Therapy • 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.
    • 25. The Significance of Veins The venous system contains 100 Most of Percent Distribution 90 the most of the blood as it moves 80 blood through the circulatory system. 70 60 50 40% in the legs!!! 40 30 The rest of the blood 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
    • 26. Sources of Venous Return• Calf muscle• External foot pump• Arterial pressure• Abdominal/intrathoracic pressure
    • 27. Arterial Insufficiency vs. Venous InsufficiencyArterial Insufficiency/PAD Venous Insufficiency/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
    • 28. 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!
    • 29. Audience Response What features should a diabetic compression sock include? C.At least 18-25mmHg D.Is graduated in pressure above the calf E.Flat-toe seam F.Cushioned sole G.Only C and E H.All of the above
    • 30. 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.
    • 31. Key Benefits:• Designed for oversized legs•Made with Nano Bamboo Charcoal Fiber which is a naturaldeodorizer that absorbs odor causing agents and reducesmicrobial growth• Helps regulate skin temperature•Releases Infrared Rays that may promote blood circulation.• Padded heel and forefoot for extra comfort.• Ventilated airflow mesh on top of forefoot and instep.Compression Level: 10-15mmHg up to 20-30mmHgStyle(s): Ankle, Crew, Merry Jane, Over the CalfColor(s): Black, Navy, Sand, White (Not all styles in allcolors) Sizing based on shoe size, availability varies byproduct
    • 32. Silver SoleKey Benefits:• Unisex. Sized by shoe size.• Silver knitted for antimicrobial benefits• Pillowed sole adds cushion to reduce blisteringand callous buildup• Mid-foot compression to prevent sockbunchingCompression Level: 12-16mmHgSize(s): S, M, L, XLStyle(s): Anklet, Low Cut, Crew Length, Knee-HighColor(s): Black, White, Pink
    • 33. 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 Sizing ankle & calf measurements Price: $30-40
    • 34. Diabetic-friendly Compression Sock 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
    • 35. Key Benefits:•Non-irritating, smooth toe seam•Extra padding in the foot, heel and toe•Moisture-wicking acrylic multi-fiber yarns•Antibacterial, antifungal finishCompression Level: 8-15mmHgStyle(s): Knee Length, Crew Length, Mini-Crew LengthColor(s): White, Black, Navy, Brown/ Mini-Crew white only
    • 36. “Your labs show you have diabetes. I know your legs hurt but you need to exercise to improve your circulation, and start these medications!”What compression consultation would you offer this diabetic patient presenting to your pharmacy?
    • 37. Compression Consultation Points for the Diabetic Patient• Avoid diabetic compression socks in diabetic patients with: ▫ Severe arterial insufficiency ▫ Intermittent claudication ▫ Ischemia ▫ Weeping wounds ▫ Uncontrolled CHF• Seek physician consultation and approval to wear diabetic compression socks if diabetic patients present with neuropathy• Remove socks if they cause persistent pain to the LE that does not improve with activity
    • 38. 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
    • 39. SIGVARIS Graduated Compression Socks … “It’s Medicine you Wear” Questions & Discussion
    • 40. Thank You for Attending!Presenter Information

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