What are the Current or Changing Standards of Care for Diabetic Clients?

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The updated standards of care for diabetic patients. Topcs include a discussion of diagnostic testing, insulin and oral therapies as well as life style strategies.

The updated standards of care for diabetic patients. Topcs include a discussion of diagnostic testing, insulin and oral therapies as well as life style strategies.

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  • 1. Tony Ramsey, RN, MSN, FNP-C What are the Current or Changing Standards of Care for Diabetic Clients?
  • 2. Figure 44.1 Glucagon- and insulin-secreting cells in the islets of Langerhans. Source: Pearson Education/PH College
  • 3. Figure 44.2 Insulin, glucagon, and blood glucose.
  • 4. Type I Diabetes Mellitus
    • Caused by absolute lack of insulin secretion
      • Due to autoimmune destruction of pancreatic islet cells
    • If untreated, results in serious, chronic conditions
      • Cardiovascular damage
      • Nervous system damage
  • 5. Type I Diabetes Mellitus
    • Treatment
      • Dietary restrictions
      • Exercise
      • Insulin therapy
  • 6. Type II Diabetes Mellitus
    • Causes
      • Lack of sensitivity of insulin receptors at target cells (insulin resistance)
      • Deficiency in insulin secretion
    • If untreated, results in same chronic conditions as type 1 DM
  • 7. Prevalence
    • 23.6 million Americans have diabetes — 7.8 percent of the U.S. population. Of these, 5.7 million do not know they have the disease.
    • Each year, about 1.6 million people ages 20 or older are diagnosed with diabetes.
    • The number of people diagnosed with diabetes has risen from 1.5 million in 1958 to 17.9 million in 2007, an increase of epidemic proportions.
    • It is estimated that 57 million adults aged 20 and older have pre-diabetes. Pre-diabetes is a condition where blood glucose levels are higher than normal but not high enough to be called diabetes. Studies have shown that by losing weight and increasing physical activity people can prevent or delay pre-diabetes from progressing to diabetes.  
  • 8. Prevalence by Type
    • Type 1 (previously called insulin-dependent or juvenile-onset) diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes.
    • Type 2 (previously called non-insulin-dependent or adult-onset) diabetes accounts for 90 to 95 percent of all diagnosed cases of diabetes. Type 2 diabetes is increasingly being diagnosed in children and adolescents
  • 9. Cost
    • Total health care and related costs for the treatment of diabetes run about $174 billion annually.
    • Of this total, direct medical costs (e.g., hospitalizations, medical care, treatment supplies) account for about $116 billion.
    • The other $58 billion covers indirect costs such as disability payments, time lost from work, and premature death.
  • 10. Risk Factors
    • Overweight adult
    • Family history
    • History of gestational diabetes
    • Hypertension
    • Abnormal lipid levels
    • IGT or IFG
    • Signs of insulin resistance
    • History of vascular disease
    • Inactive lifestyle
    • In the absence of the above risk factors, people age 45 and older are considered at risk and should be tested.
  • 11. Diabetes Identification
    • Consider testing if:
      • Age 45 or older
      • An overweight adult with another risk factor
        • Pre-diabetes IFG Fasting plasma glucose (FPG) 100–125 mg/dl after an overnight fast IGT 2-hr post 75g glucose challenge 140–199 mg/dl
        • Diabetes   Random plasma glucose >200 mg/dl with symptoms (polyuria, polydypsia, and unexplained weight loss) and/or FPG>126 mg/dl* and/or 2-hr plasma glucose>200 mg/dl* post 75g glucose challenge * Repeat to confirm on a subsequent day unless symptoms are present.
  • 12. Pre-Diabetes Care
    • Weight Loss of 5-10% of total body weight
    • 150 minutes/week of exercise
    • Nutrition therapy
    • Physical activity
    • Behavior therapy
    • Weight loss
    • Follow-up and referral
  • 13. Addition of Metformin
    • The use of metformin may be considered in addition to lifestyle changes to prevent or delay the onset of diabetes in individuals with IFG and IGT and one or more of the following:
    • Age <60 years
    • BMI >35 kg/m2
    • Family history of diabetes in first-degree relatives
    • Elevated triglycerides
    • Reduced HDL cholesterol
    • Hypertension
    • A1C >6.0 percent
    • Metformin is not FDA approved for treatment of pre-diabetes
  • 14. Diabetes Care
    • Components of comprehensive care
      • Medical history
      • Physical Exam
      • Labs
      • Meds
      • Diabetes self-management
      • Referrals
  • 15. Medical History
    • Education history
    • Current medication regimen
    • DKA or Hypoglycemic episodes?
    • Complication history
      • Microvascular
      • Macrovascular
  • 16. Physical Exam
    • Height, weight and vitals
    • Skin
    • Thyroid
    • Fundoscopic eye
    • Feet
  • 17. Labs
    • Review Self monitoring values
    • A1C
      • < 7% optimal
    • Lipids
    • LFT’s
    • Serum Creatnine
    • Urine
    • TSH
    • 1,5-anhydroglucitol (1,5-AG)?
  • 18.  
  • 19. Stepwise Approach to Selecting Treatments for Type 2 Diabetes Diagnosis of type 2 diabetes1 Counsel patients regarding lifestyle modification (weight loss, exercise) (expected decrease in A1c 1-2%) [well-validated*] and Initiate metformin [ Glucophage, others] 500 mg once or twice daily, titrate to 850 mg to 1000 mg twice daily (expected decrease in A1c 1-2%) [well-validated*] A1c 7% or greater three months later Add sulfonylurea, not glyburide or chlorpropamide (expected decrease in A1c 1– 2%) [well validated*] or Add basal insulin (bedtime intermediate-acting insulin or bedtime or morning long-acting insulin) (expected decrease in A1c 1.5%) [well-validated*] or Add pioglitazone [ Actos], NOT rosiglitazone [Avandia] (expected decrease in A1c 0.5-1.4%) [less well-validated] or Add exenatide [ Byetta] (expected decrease in A1c 0.5-1%) [Insufficient clinical use to be confident regarding safety, less-well-validated] A1c 7% or greater three months later In those receiving metformin and basal insulin or sulfonylurea, change to metformin plus intensive or basal insulin, respectively [well-validated*] or In those receiving metformin plus pioglitazone, add sulfonylurea or change to metformin plus basal insulin [less well-validated] or In those receiving metformin plus exenatide, change to metformin plus pioglitazone and sulfonylurea or metformin plus basal insulin [less well-validated] A1c 7% or greater three months later In patients not yet receiving metformin plus insulin, change to metformin plus basal insulin [well- validated*]
  • 20. Self-Care
    • Diet
    • Activity
    • Taking Meds
    • Reducing Risks
    • Coping
  • 21. Referrals
    • Eyes
    • Dietician
    • Diabetes Education
    • Dentist
    • Mental Health
    • Feet
  • 22. Other Management Priorities
    • Kidneys
    • Eyes
    • Depression
    • Neuropathy
    • Retinopathy
  • 23. Situations Unique to Free Clinics
    • Money
    • Compliance
    • Appalachians
      • http://www.diabetesfamily.net/
  • 24. References
    • American College of Physicians (2007). Diabetes Care Guide . Philadelphia, PA: Author.
    • American Diabetes Association (2009). Executive summary: Standards of medical care in diabetes-2009. Diabetes Care, 32 (Suppl. 1), S6-S12.
    • Arnold, K. C. (2009, November). Treating type 2 diabetes: A specialist's approach. Advance for Nurse Practitioners, 17 (11), 20-24.
    • California Department of Public Health (2009, August). Basic guidelines for diabetes care. Retrieved November 14, 2009, from www.caldiabetes.org
    • Christensen, B. L., & Williams, M. (2009, October). Assessing postprandial glucose using 1,5-anhydroglucitol: An integrative literature review. Journal of the American Academy of Nurse Practitioners, 21 (10), 542-548.
    • Hinnen, D., Kruger, D. F., & Pratley, R. E. (2008, November). Treating to success in type 2 diabetes: What to do when oral therapies fail. Journal of the American Academy of Nurse Practitioners, 20 (Suppl. 1), 5-21.
    • U.S. Department of Health and Human Services (2008). National Diabetes Education Program. Retrieved November 14, 2009, from www.ndep.nih.gov/
  • 25. Discussion?