Nursing In-Service:
Diabetes Care in the
Elderly in Residential Care
focus on anti-hyperglycemic medications
Evergreen Hou...
Outline of Presentation
1. Pathophysiology
2. Diagnosis
3. Signs & Symptoms
4. Considerations in Elderly
5. Goals of Thera...
Pathophysiology of Diabetes
• Diabetes Mellitus
– Metabolic disorder characterized by
hyperglycemia, due to defective insu...
Diagnosis
4Reference: 1
Signs & Symptoms
• Fatigue
• Polyuria, polydipsia, weight loss
• Complications: retinopathy, neuropathy,
nephropathy, foot...
Considerations in Elderly
• Most LTC patients are “frail elderly”
– Multiple chronic illnesses with associated
vulnerabili...
Goals of Therapy & Treatment Targets
• Control symptoms
• Glycemic control
• Prevent/minimize
complications
• Reduce all C...
Treatment: non-drug measures
• Exercise:
–Can improve insulin sensitivity
–Encourage in those able to mobilize
• Diet:
–Ca...
Treatment: Metformin
• Biguanide;  hepatic glucose production, 
insulin sensitivity
• 250-500mg qd  1g po bid (max 2550...
Treatment: Sulfonylureas (Gliclazide,
Glyburide)
• Increases beta-cell insulin release, increases
peripheral glucose utili...
Treatment: Other Drugs
Formulary:
• Acarbose (brand: Glucobay, Prandase)
• Thiazolidinendiones (pioglitazone)
Non-formular...
Treatment: Insulin - types
• Rapid acting: insulin lispro, aspart, glulisine
• Short acting: insulin regular
• Intermediat...
Treatment: Insulin - regimens
• Basal qhs insulin + oral hypoglycemics
• Conventional regimens: qd – tid insulin
• Intensi...
Insulin sliding scale vs. correctional:
What is different?
• Sliding Scale Insulin
– Traditionally: regular/short-acting i...
SSI(+basal) vs physiologic insulin
15
Case Study: BT
• 55yo female on EGH 3S
• T2DM diagnosed 2005, previous poor control
• alcoholic cirrhosis, history of IDU,...
Case Study: BT- CBG control
17
Date Time Before
breakfast
Before
Lunch
Before
Supper
Bedtime Sliding Scale Given
9/1 0750 ...
Case Study: BT
Recommendation:
• change to regular tid prandial insulin + basal
insulin at bedtime
• Initially: 0.3-0.6 U/...
Management of Hypoglycemia
• Hypoglycemia:
CBG <4.0 mmol/L
• If patient is on
acarbose, must
give glucose
• retest BG in 1...
Questions?
20
References
1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association
2...
Treatment: Acarbose
• Alpha-glucosidase inhibitor in intestines
– Delays digestion of complex carbs/disaccharides
– Slower...
Treatment: Meglitinides
• Short-acting insulin secretagogues, stimulates
beta-cell insulin release at meals
• Repaglinide:...
Treatment: Thiazolidinediones
• Enhances insulin effects by activating PPAR-
alpha receptor in cells
• Pioglitazone: 15mg ...
Treatment: DPP-IV Inhibitors
• Dipeptidyl peptidase-4 inhibitors; increases
insulin secretion by ↑incretin, ↓glucagon
• Si...
Treatment: GLP-1 Therapies
• Incretin mimetics, increases insulin secretion
• Exenatide (Byetta): 5-10ug sc bid ac
• Lirag...
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Diabetes Care in the Elderly in Residential Care - a focus on hypoglycemic medications (Nursing In-Service)

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Provided to the nursing staff at Evergreen House, North Vancouver on September 9th and September 11th, 2013.

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Diabetes Care in the Elderly in Residential Care - a focus on hypoglycemic medications (Nursing In-Service)

  1. 1. Nursing In-Service: Diabetes Care in the Elderly in Residential Care focus on anti-hyperglycemic medications Evergreen House, Lion’s Gate Hospital September 9 & 11, 2013 Joan Ng, B. Sc. Pharm, Pharmacy Resident 1
  2. 2. Outline of Presentation 1. Pathophysiology 2. Diagnosis 3. Signs & Symptoms 4. Considerations in Elderly 5. Goals of Therapy & Treatment Targets 6. Treatment: non-drug measures & drug therapy 7. Insulin sliding scale vs. correctional insulin 8. Case Study: BT 9. Management of hypoglycemia 2
  3. 3. Pathophysiology of Diabetes • Diabetes Mellitus – Metabolic disorder characterized by hyperglycemia, due to defective insulin secretion, impaired insulin sensitivity, or both – T1DM (Insulin dependent) – T2DM (Non-insulin dependent) – Gestational Diabetes – Chronic hyperglycemia  complications 3Reference: 1,2
  4. 4. Diagnosis 4Reference: 1
  5. 5. Signs & Symptoms • Fatigue • Polyuria, polydipsia, weight loss • Complications: retinopathy, neuropathy, nephropathy, foot ulcers, erectile dysfunction • Diabetic ketoacidosis • Elderly: – Less glucosuria, polyuria, polydipsia – More confusion, incontinence 5Reference: 2, 3, 4
  6. 6. Considerations in Elderly • Most LTC patients are “frail elderly” – Multiple chronic illnesses with associated vulnerabilities (e.g. dementia, falls, polypharmacy) • Increased hypoglycemia risk with treatment – Diminished hypoglycemia counterregulation – More neuroglycopenic symptoms – Associated with poorer outcomes (CV events) – Leads to impaired cognition and function • Drug pharmacokinetics are changed 6Reference:
  7. 7. Goals of Therapy & Treatment Targets • Control symptoms • Glycemic control • Prevent/minimize complications • Reduce all CV risk factors • LTC Elderly: – HbA1c: 8-8.5% – Random BG: 7-14 mmol/L 7Reference: 1, 2, 6
  8. 8. Treatment: non-drug measures • Exercise: –Can improve insulin sensitivity –Encourage in those able to mobilize • Diet: –Caution against limiting caloric intake in LTC • Patients often already have insufficient caloric intake due to confusion, dysphagia, anorexia 8Reference: 1
  9. 9. Treatment: Metformin • Biguanide;  hepatic glucose production,  insulin sensitivity • 250-500mg qd  1g po bid (max 2550mg/day) • Elderly: should not be titrated to max dose • Pros: no hypoglycemia alone, good evidence • Cons: causes anorexia and weight loss, risk of lactic acidosis (renal/hepatic dysfunction), risk of B12 and folate deficiency long-term 9Reference: 2, 4, 5, 7, 10
  10. 10. Treatment: Sulfonylureas (Gliclazide, Glyburide) • Increases beta-cell insulin release, increases peripheral glucose utilization • Gliclazide: 40mg po bid  80mg po bid (regular release), 30mg MR qd  120mg MR qd • Pros: very effective, gliclazide less hypoglycemia than glyburide • Cons: hypoglycemia, needs consistent food intake, needs functioning beta-cells, weight gain 10Reference: 2, 4, 10
  11. 11. Treatment: Other Drugs Formulary: • Acarbose (brand: Glucobay, Prandase) • Thiazolidinendiones (pioglitazone) Non-formulary: • Meglitinides (repaglinide, nateglinide) • DPP-4 Inhibitors (sitagliptin, saxagliptin) • Incretin Mimetics (exenatide, liraglutide) 11
  12. 12. Treatment: Insulin - types • Rapid acting: insulin lispro, aspart, glulisine • Short acting: insulin regular • Intermediate acting: NPH • Long-acting: insulin detemir, glargine 12Reference: 2, 4, 8, 10 TYPE OF INSULIN TIME OF ONSET DURATION OF ACTION Basal insulin Glargine (Lantus) 1 to 2 hours 24 hours Detemir (Levemir) 1 to 2 hours 18 to 24 hours Isophane (NPH) 1 to 2 hours 10 to 20 hours Nutritional and correctional insulin Lispro (Humalog), aspart (Novolog), glulisine (Apidra) 5 to 15 minutes 3 to 6 hours Regular human insulin 1 to 02 hours 6 to 10 hours
  13. 13. Treatment: Insulin - regimens • Basal qhs insulin + oral hypoglycemics • Conventional regimens: qd – tid insulin • Intensive: basal + regular/rapid tid ac • Intensive continuous SC infusion • Acute: insulin sliding scale, correctional insulin • Pros: long-term safety and outcome evidence • Cons: hypoglycemia, weight gain, blood glucose monitoring imperative 13Reference: 2, 4, 8, 10
  14. 14. Insulin sliding scale vs. correctional: What is different? • Sliding Scale Insulin – Traditionally: regular/short-acting insulin to treat hyperglycemia after it has occurred – (now, almost always give basal insulin too) – Reactive, not proactive; possible insulin stacking • Physiological SC insulin protocol – Basal insulin (NPH or glargine) – Prandial/meal-time insulin (regular or short-acting) – Correctional-dose insulin (fine-tuning) 14Reference: 8, 9
  15. 15. SSI(+basal) vs physiologic insulin 15
  16. 16. Case Study: BT • 55yo female on EGH 3S • T2DM diagnosed 2005, previous poor control • alcoholic cirrhosis, history of IDU, BPD • Current drug therapy: – Insulin glargine (lantus) 18u q am, 15u q dinner – Insulin regular sliding scale at 0800, 1100, 1630 – Metformin 750mg bid 16
  17. 17. Case Study: BT- CBG control 17 Date Time Before breakfast Before Lunch Before Supper Bedtime Sliding Scale Given 9/1 0750 14.9 none 9/1 1155 23.1 10 units insulin regular 9/1 1600 28.1 14 units insulin given 9/1 2145 12.7 N/A 9/2 0730 21.5 10 units insulin regular 9/2 1130 21.6 none? 9/2 1645 17.1 5 units insulin regular • Suboptimal control • Nursing labour intensive: 3-4 times daily CBGs
  18. 18. Case Study: BT Recommendation: • change to regular tid prandial insulin + basal insulin at bedtime • Initially: 0.3-0.6 U/kg body weight total daily dose – ½ basal, ½ regular tid before meals • Measure BG more regularly in beginning, but when patient stabilizes, can decrease monitoring
  19. 19. Management of Hypoglycemia • Hypoglycemia: CBG <4.0 mmol/L • If patient is on acarbose, must give glucose • retest BG in 15 mins, re-treat with another 15 g carbohydrate if BG still <4.0 mmol/L 19Reference: 1
  20. 20. Questions? 20
  21. 21. References 1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212. 2. Chau D, Edelman SV. Clinical Management of Diabetes in the Elderly. Clin Diabetes. 2001 Oct 1;19(4):172–5. 3. e-Therapeutics+ : Therapeutic Choices : Endocrine and Metabolic Disorders: Diabetes Mellitus [Internet]. [cited 2013 Sep 3]. Available from: https://www-e-therapeutics-ca. 4. Treatment of type 2 diabetes mellitus in the elderly patient [Internet]. [cited 2013 Sep 1]. Available from: https://uptodate.vch.ca/ 5. Laubscher T, Regier L, Bareham J. Diabetes in the frail elderly Individualization of glycemic management. Can Fam Physician. 2012 May 1;58(5):543–6. 6. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2012 Dec 20;36(Supplement_1):S67–S74. 7. Lee M, Jensen B, Regier L. Oral Anti-Hyperglycemic Agents - Comparison chart. RxFiles drug comparison charts. 7th ed. Saskatoon, SK: Saskatoon Health Region; 2012. p. 25. Available from: www.RxFiles.ca. Accessed 2013 Sep 3. 8. Nau KC, Lorenzetti RC, Cucuzzella M, Devine T, Kline J. Glycemic control in hospitalized patients not in intensive care: beyond sliding-scale insulin. Am Fam Physician. 2010 May 1;81(9):1130–5. 9. Hirsch IB. SLiding scale insulin—time to stop sliding. JAMA. 2009 Jan 14;301(2):213–4. 10. Acarbose, Metformin, Gliclazide, Repaglinide, Sitagliptin, Exenatide, Liraglutide, Insulin. Lexi-Drugs Online [Internet]. Hudson (OH) : Lexi-Comp, Inc. 1978-2013 [cited 2013 Sep 5]. Available from: http://online.lexi.com. 21
  22. 22. Treatment: Acarbose • Alpha-glucosidase inhibitor in intestines – Delays digestion of complex carbs/disaccharides – Slower rise in postprandial glucose • 25mg qd  50-100mg tid cc • Not recommended if CrCl <25mL/min • Pros: safe, little hypoglycemia • Cons: less effective than other agents, GI side effects (flatulence, diarrhea) 22Reference: 2, 4, 10
  23. 23. Treatment: Meglitinides • Short-acting insulin secretagogues, stimulates beta-cell insulin release at meals • Repaglinide: 0.5mg tid ac  4mg po tid ac • Pros: less hypoglycemia than sulfonylureas, flexible with food intake • Cons: lack outcome data on morbidity/mortality 23Reference: 2, 4, 10
  24. 24. Treatment: Thiazolidinediones • Enhances insulin effects by activating PPAR- alpha receptor in cells • Pioglitazone: 15mg qd  45mg qd • Pros: no hypoglycemia • Cons: limited usefulness in elderly (fluid retention, CHF, MI, fractures) 24Reference: 2, 4
  25. 25. Treatment: DPP-IV Inhibitors • Dipeptidyl peptidase-4 inhibitors; increases insulin secretion by ↑incretin, ↓glucagon • Sitagliptin: 100mg qd; Saxagliptin: 2.5-5mg qd • Pros: no hypoglycemia, weight-neutral • Cons: no long-term safety data, expensive 25Reference: 2,4,7,10
  26. 26. Treatment: GLP-1 Therapies • Incretin mimetics, increases insulin secretion • Exenatide (Byetta): 5-10ug sc bid ac • Liraglutide (Victoza): 0.6-1.2mg sc daily • Pros: no risk of hypoglycemia • Cons: causes weight loss, nausea, diarrhea 26Reference: 4, 7, 10

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