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Dr. Escher
 

Dr. Escher

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    Dr. Escher Dr. Escher Presentation Transcript

    • DIABETES MELLITUS ISSUES IN THE LONG TERM CARE SETTING AND ALLIED VENUES
    • DIABETES MELLITUS
      • Focus: diabetes in the Medicare population
    • DIABETES MELLITUS
      • Definition: a metabolic disorder in which
      • there is deficiency of insulin production or
      • resistance of organs to the effect of insulin
    • DIABETES MELLITUS
      • Diabetes is a disorder of metabolism--the way our bodies use digested food for growth and energy.
      • Most of the food we eat is broken down into glucose, the form of sugar in the blood.
      • Glucose is the main source of fuel for the body.
      • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • DIABETES MELLITUS
      • After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy.
      • For glucose to get into cells, insulin must be present.
      • Insulin is a hormone produced by the pancreas, a large gland behind the stomach.
      • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • DIABETES MELLITUS
      • NORMAL: When non-diabetic people eat, the pancreas automatically produces the right amount of insulin to move glucose from blood into our cells.
      • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • DIABETES MELLITUS
      • DIABETES: In people with diabetes, when they eat, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced (or both) => glucose builds up in the blood, overflows into the urine, and passes out of the body in urine => body loses its main source of fuel even though blood contains large amounts of glucose.
      • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • DIABETES MELLITUS (DM)
      • TYPES OF DIABETES
            • Type I
            • Type II
            • MODY (Maturity Onset Diabetes of Youth
            • Gestational
    • DM TYPE I
      • Auto-immune disease
      • Constitutes 5-10% of DM diagnosed in the USA
      • Mostly appears in children and young adults
      • Develops as a result of auto-immune destruction of beta-cells in the pancreas
      • Presents with polyuria, thirst, weight loss, marked fatigue
      • Can be complicated by coma with ketoacidosis
              • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • DM TYPE II
      • Most common form of diabetes
      • Involves about 90-95% of people with DM
      • Associated with:
        • older age
        • obesity
        • family history of DM
        • prior history of gestational diabetes
        • physical inactivity
        • ethnicity
              • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • DM TYPE II
      • Patient with type II DM usually makes enough insulin but the body cannot use it effectively => insulin resistance
      • Gradually insulin production decreases over the following years
      • Symptoms are similar to type I but develop more gradually
              • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • DM TYPE II
      • Symptoms of type II DM include:
        • Fatigue
        • Nausea
        • Frequent urination/polyuria
        • Thirst
        • Unusual weight loss
        • Blurred vision
        • Frequent infections
        • Slow healing of wounds or sores
        • Sometimes no specific symptoms
          • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • GESTATIONAL DIABETES
      • Develops only during pregnancy
      • More common in:
        • African Americans
        • American Indians
        • Hispanic Americans
        • women with a family history of diabetes
      • Women with a history of gestational diabetes have a 20-50% chance of getting type II DM within 5-10 years <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • Diabetes Mellitus: Diagnosis
      • Fasting plasma glucose = preferred test : Positive test is glycemia of 126mg/dL or higher after fasting at least 8 hours
      • Random plasma glucose of 200mg/dL or higher along with symptoms of diabetes
      • Oral glucose tolerance test (OGTT) plasma glucose of 200mg/dL or higher done 2 hours after ingestion of 75 grams of glucose in water
      • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
      • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
    • Diabetes Mellitus
      • Hemoglobin A1c measurement is not recommended currently for diagnosis of diabetes.
      • HbA1c is used as a marker to monitor glycemia control in patients over time
      • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
    • Pre-Diabetes
      • Pre-diabetes refers to a state between “normal” and “diabetes” = fasting plasma glucose 100-125mg/dL (higher than normal but not high enough for diagnosis of diabetes) Affects about 41 million people in USA (previously referred to as either impaired fasting glucose or impaired glucose tolerance)
      • http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#types
      • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
    • Type II Diabetes
      • Diagnostic testing - when to do it:
      • People  45 years old => if normal then every 3 years
      • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
    • Type II Diabetes: diagnostic testing
      • Younger than 45 yo or more often than every 3 years if:
      • overweight
      • first degree relative with diabetes
      • member of high risk ethnic group (Afro-American, Hispanic American, Native American, Asian American, Pacific Islander)
      • delivered a baby  9 lbs.
      • gestational diabetes
      • hypertensive (BP  140/90mmHg)
      • High Density Lipoprotein cholesterol 35mg/dl or less
      • TriGlyceride level 250mg/dl or more
      • pre-diabetes
      • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
    • DM type II: Management
      • Basics:
      • healthy eating
      • physical activity
      • blood glucose testing
      • Pharmaceuticals:
      • oral medication(s)
      • insulin(s)
      • both oral medicines and insulin
    • DM: insulin variations
      • Daily insulin requirements are influenced by:
      • diet
      • exercise
      • stress
    • Diabetes Management: Stress
      • Stress influences response to insulin
      • Stress => increased cortisol
      • increased catecholamines
      • increased growth hormone
      • => these hormones all lead to increased insulin resistance (thus, hyperglycemia)
    • Control of Diabetes
      • Control of Diabetes includes:
      • glycemia control (FBS < 126mg/dL; HbA1c <7%)
      • weight management
      • blood pressure control (BP < 130/80mmHg)
      • lipid management
      • reduction in the hypercoagulable state (aspirin or clopidogrel)
    • DM type II: Management
      • Most people with newly discovered type II DM are overweight
      • Basics are diet and exercise:
      • nutrition
      • life style modification
      • increased physical activity
      • Goal = Hemoglobin A1c < 7%
      • If this goal in not reached and maintained => pharmacotherapy (medications)
    • Insulins
      • Type hours to onset time to peak time effective
      • Fast acting:
      • Lispro <0.25 (15min) 0.5-1.5 3-4 (max 4-6)
      • Aspart 0.17-0.33 0.67-0.83 1-3 (max 3-5)
      • Long acting
      • Glargine 2 none 24
      • Ultralente 6-10 10-16 18-20 (max 20-24)
      • Short acting
      • regular 0.5-1.0 2-3 3-6 (max 6-8)
      • Intermediate acting
      • NPH 2-4 6-10 10-16 (max 14-18)
      • Lente 3-4 6-12 12-18 (max 16-20)
      • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
    • Insulin
      • Insulin dependency regimens - examples:
      • 1. insulin glargine q24h and pre-meal insulin
      • 2. NPH and regular before breakfast and supper
      • 3. Rapid or short acting insulin before meals & intermediate acting insulin (NPH or Lente) at bedtime
      • 4. Insulin Glargine at bedtime and rapid or short acting insulin before meals
      • Insulin regimens depend on individual patient requirements
    • Medications for DM type II
      • Sulfonylureas & Meglitinides : promote glucose-stimulated release of insulin from pancreas (they need enough remaining beta-cell function in the pancreas to work) (insulin secretogogues)
      • Metformin : mostly blocks gluconeogenesis in the liver; also interferes with glycogenolysis and improves insulin sensitivity of muscle
      • Thiazolidinediones : bind to nuclear receptors in tissues & activate or suppress expression of specific genes (insulin sensitizers) - risk of fluid retention & weight gain; 4-12 week latency to work; monitor liver enzymes q2mo
      • Acarbose : alpha-glucosidase inhibitor; interferes with intestinal absorption of carbohydrates; causes flatulence & bloating (discontinuation)
      • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
    • Medications for DM type II
      • Sulfonylureas: insulin secretogogues
      • glyburide
      • glipizide
      • glimeperide
      • chlorpropamide
      • Meglitinides: insulin secretogogues
      • repaglinide
      • nateglinide
      • Biguanide: decreases hepatic gluconeogenesis
      • metformin
      • Thiazolidinediones : insulin sensitizers
      • pioglitazone
      • rosiglitazone
      • Alpha-glucosidase inhibitor : decreases GI absorption of carbohydrate
      • acarbose ;
    • Insulin in Type II DM
      • Usually indicated if HbA1c > 7% despite life style modification and 2 oral medications
      • May be postponed in borderline cases where HbA1c is < 8.5% pending addition of a 3rd oral agent; otherwise =>
      • Addition of bedtime dose of basal insulin therapy (glargine) to sulfonylureas +/- metformin (not thiazolidinediones because of risk of CHF from fluid retention)
    • The Metabolic Syndrome
      • Hypertension
      • Visceral (central) obesity
      • Hypertriglyceridemia
      • Low HDL cholesterol
      • Insulin resistance or glucose intolerance
      • Prothrombotic state (high fibrinogen or plasminogen activator inhibitor [-1] in blood)
      • Proinflammatory state (high C-reactive protein in blood)
      • http://www.americanheart.org/presenter.jhtml?identifier=4756
    • Acute Complications of type II DM
      • Hyperglycemic hyperosmolar state:
      • common in elderly
      • triggered by underlying disorder(s)
      • risk increased in elderly due to decreased thirst reflex
      • often complicated by delirium
    • Acute Complications of type II DM
      • Hyperglycemic hyperosmolar state:
      • serum osmolarity > 320 mosm/L
      • plasma glucose > 600mg/dL
      • dehydration
      • no ketoacidosis
      • underlying disorder(s)
    • Hyperosmolar State
      • Therapy:
      • rehydration with hypotonic solution
      • insulin infusion (initially)
      • watch for signs of fluid overload/CHF
      • monitor potassium
      • treat underlying cause (eg UTI, cellulitis)
    • Hypoglycemia
      • Hypoglycemia = plasma glycemia < 50mg/dL with or without symptoms
      • More common in type I DM and patients with significant renal or liver disease
      • Another reason for glucose monitoring
      • Treated with po sugar (e.g. fruit juice or glucose tablets)
      • or IV dextrose 50% in water or IV glucagon or both
    • Complications of DM
      • Chronic complications of diabetes mellitus include:
      • Macrovascular
      • Microvascular
      • Neuropathic
    • Complications of DM
      • Macrovascular
      • atherosclerosis/cardiovascular disease
      • peripheral vascular disease
    • Complications of DM
      • Microvascular diabetic retinopathy : due to ischemia of retna; provokes neovascularization with vessels more fragile => leaking => scarring & fibrosis
      • diabetic nephropathy : common cause of ESRD;
      • prevention via control of blood pressure and glycemia; earliest signs urine albumin 30mg/day or 20  g/min; appears to benefit from ACE-I’s and ARB’s too
    • Complications of DM
      • Diabetic Neuropathy
      • peripheral sensory neuropathy
      • cardiovascular autonomic neuropathy
      • gastrointestinal autonomic neuropathy
      • erectile dysfunction
      • mononeuropathy
      • diabetic foot
    • Complications of DM
      • Peripheral sensory neuropathy
      • variable presentation
      • dysesthesia
      • tingling
      • pain
      • loss of pain sensation (risk of injury)
    • Complications of DM
      • Cardiovascular Autonomic Neuropathy
      • orthostatic hypotension
      • lack of normal variation in heart rate with breathing, tachycardia
    • Complications of DM
      • Gastrointestinal Autonomic Neuropathy
      • gastroparesis: nausea, bloating, vomiting (tx metoclopramide)
      • diarrhea: often nocturnal
    • Complications of DM
      • Erectile dysfunction:
      • autonomic neuropathy
      • absent nocturnal and morning erections
      • more common than diagnosed
    • Complications of DM
      • Mononeuropathy
      • acute local pain
      • distribution of a nerve
      • may recede if treated early with improved glucose control (glucotoxicity)
    • Complications of DM
      • Diabetic Foot
      • sensory deficit (skin, bone, ligament)
      • fungal infection
      • wounds
      • pulses (PVD)
      • slow healing
      • ulcers
    • Type II DM: Goals
      • Prevention of pre-diabetes
      • Prevention of change from pre-diabetes to diabetes
      • Diagnosis through screening
      • Early management/therapy
      • Prevention of complications
    • Type II DM: Goals
      • Screening via fasting glycemia and history
      • Life-style history and modification
      • Physical activity
      • Diet
      • Treatment of glycemia, lipids, hypercoagulable state, blood pressure
      • Management of complications
    •