Daniel Lorber, MD, FACP, CDE

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Science of Diabetes and Diabetes Management as it
Relates to Legal Issues and the Need for
Accommodations

• Daniel Lorber, MD, FACP, CDE
• Linda Siminerio, RN, PhD
• John Griffin, JD

www.diabetes.org
1-800-DIABETES
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Session Outline

• CAUSE/CLASSIFICATIONS
• COMPLICATIONS
• CARE
• CHALLENGES

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The prevalence of diabetes - current estimates -
world

• Number of people with diabetes
• 177 million (154 million projected)
• Top 10 countries (number of people with
  diabetes)
• India, China, USA, Indonesia, Russia, Japan, UAE,
  Pakistan, Brazil, Italy

Source WHO Global Burden of Disease
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U.S. Diabetes Facts

• 20 increase in past 20 years
• 70 increase in diabetes in 30-39 yr. age range
• from 1990-1998
• 1 in 3 children born in 2003 will get diabetes
• 125,000 in U.S. under the age of 19
• Type 2 in children is increasing
• 14 million lost work days
• Annual costs -- 132 billion

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What is Diabetes?

• Ancient Greek Diabetes Mellitus
• Diabetes Copious Urine
• Mellitus Sweet
• Lay Definition
• Abnormally High Blood Sugar
• American Diabetes Association
• Fasting Blood Glucose above 126 mg/dl
• Fasting Blood Glucose above 7 mM

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CLASSIFICATIONS/CAUSE
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What is the Cause of High Glucose in Diabetes?

• Type 1 Failure of the pancreas to make Insulin
  cause autoimmune
• Type 2 Resistance of the body to Insulin cause
  unknown
• Both of these are areas of active research in the
  U.S. and internationally

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What Kinds of Diabetes are There?

• Type 1 (Juvenile, Insulin-Deficient)
• 10
• Under 40 y.o.
• Hereditary
• Type 2 (Adult Onset, Insulin-Resistant)
• 90
• Strongly Hereditary
• Associated with Overweight
• Secondary Diabetes
• E.g., medications like cortisone pancreatitis

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What is the Cause of High Glucose in Diabetes?
How is Glucose Regulated?
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Meet the Cast
Brain
Blood
Fat
Glucose 100 mg/dl
Muscle
Liver
Pancreas
Intestine
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Effects of Eating
Brain
Food
Blood
Fat
Glucose 100 mg/dl
Muscle
Liver
Pancreas
Intestine
12
Effects of Eating
Brain
Food
Blood
Fat
Glucose
Muscle
Liver
Pancreas
Intestine
13
Effects of Eating
Brain
Food
Blood
Fat
Glucose
Muscle
Liver
Pancreas (makes Insulin)
Intestine
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Effects of Eating
Brain
Food
Blood
Fat
Glucose 100 mg/dl
Glucose
140 mg/dl
Muscle
Liver
Pancreas (makes Insulin)
Intestine
15
Brain
Food
Blood
Fat
Glucose 100 mg/dl
Glucose
500 mg/dl
Muscle
Liver
Pancreas No Islets, No Insulin
Intestine
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BALANCING ACT

• Insulin and food must stay in balance
• The insulin you inject will work whether you eat
  or not
• Timing and amounts of food are important
• If you do not eat enough, your blood sugar
  (glucose) could go LOW
• If you eat too much, your blood sugar could go
  too HIGH
• Physical activity will effect your blood sugar
  level

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HbA1c and Glucose

• 5 - - - - 90
• 6 - - - - 120
• 7 - - - - 150
• 8 - - - - 180
• 9 - - - - 210
• 10 - - - 240
• 11 - - - 270
• 12 - - - 300

GOAL
Take Action
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CARE
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(No Transcript)
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How Do You Treat Diabetes?

• Type 1
• Glucose Monitoring (fingersticks)
• Insulin Injections or infusion pump therapy
  (replacement doses)
• Meal Plans
• Physical Activity

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How Do You Monitor Blood Glucose Control?

• Frequent Blood Sugar Measurements
• Fingersticks, multiple times each day
• Hemoglobin A1c (HbA1c)
• Quarterly

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MONITORING

• Blood Glucose Meters
• Small, lightweight and user friendly
• Many varieties available
• One size does not fit all
• No danger to others

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MONITORING

• How often?
• Some suggestions
• Before each meal and at bedtime
• Fasting and two hours after you eat
• Before and after each meal
• Once daily before breakfast
• Fasting and once more during different times of
  the day
• More often if you are ill, exercising, having a
  low blood sugar, driving.

Always individualized for each person with
diabetes!
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BACK
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MONITORING

• How to test?
• Wash hands with warm soap and water
• Dangle fingers
• Prick side of finger
• Milk your finger to get a good drop of blood
• Do not use the same finger over and over for
  testing

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URINE TESTING

• Done to detect ketones
• Ketones are BAD!!
• Ketones happen mostly in Type 1 diabetes
• Type 1 test in the presence of persistent
  hyperglycemia
• Should test if consistently high or anytime
  during illness
• Moderate or large ketones should be reported to
  physician immediately

Urine testing is NOT used to detect glucose
levels or as a measure of diabetes control
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RAPID-ACTING INSULINS

• HUMALOG AND NOVOLOG
• Work very quickly
• Starts working in 15 minutes
• Peak 1-1 1/2 hours
• Clear

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SHORT-ACTING INSULIN

• REGULAR
• Works quickly
• Starts to work in 1/2 hour
• Peaks in 2-4 hours
• Should be taken 15-30 minutes before a meal
• Clear

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INTERMEDIATE-ACTING INSULINS

• NPH and LENTE
• Work more slowly
• Most often taken with oral medicine
• Starts to work 1-2 hours after it is given
• Peaks in 6-12 hours
• Cloudy
• Can be mixed with Humalog, Novolog and Regular

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LONG-ACTING INSULIN

• ULTRALENTE and LANTUS
• Lasts for 24 hours with little or no peak
• Usually taken at bed
• Ultralente is cloudy
• Lantus(Glargine) is clear
• Lantus CANNOT be mixed with any other insulin

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Insulin Delivery Systems

• Insulin Pump
• Other technology

• Injectors
• Injection Aids
• Pen delivery

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Other Delivery Systems Being Explored

• Closed-loop insulin pumps
• Lectin-and polymer-bound systems
• New routes inhalation, oral, and transdermal
• Microencapsulation of islet cells
• Biohybrid artificial pancreas
• Pump cannula at portal vein (Disetronic)

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How Do You Treat Diabetes?

• Type 2
• Careful Diet Weight Reduction Glucose
  Monitoring
• Reduce glucose absorption from gut
  (alpha-glucosidase inhibitors)
• Increase Sensitivity of Liver, Muscle to Insulin
  (Thiazoladinediones, Metformin)
• Stimulate Insulin Secretion (Sulfonylureas,
  Repaglinide)
• Insulin large doses
• Physical Activity

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INSULIN

• INSULIN
• Needed to lower blood sugar levels.
• Diet alone or diet and oral medicine did not
  control your blood sugar levels (type 2)
• Does NOT mean your diabetes is worse
• What your body needs to keep blood sugar in
  control

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Kinds of Oral Medicines

• Sulfonylureas
• Biguanides
• Alpha-glucosidase Inhibitors
• Insulin-sensitizing agents
• Meglitinides

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Brain
Food
Blood
Fat
Glucose 100 mg/dl
Glucose
500 mg/dl
Muscle
Liver
Pancreas Liver, Fat, Muscle Resist Insulin
Intestine
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Oral Medicines

• Medicines can be used alone, with each other or
  with insulin.
• Sulfonylureas and meglitinide.
• Help the pancreas make more insulin.
• Biguanides and insulin sensitizers
• Help the insulin to work better

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Oral Medicines

• Sulfonylureas
• Lower pre-meal blood sugar levels
• Carbohydrate Inhibitors and Meglitinides
• Lower after meal blood sugar levels

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SULFONYLUREAS

• Help pancreas make more insulin
• Several different types
• Do not exchange one for another
• Side effects
• Low blood sugar
• Weight gain
• Upset stomach

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BIGUANIDES

• GLUGOPHAGE
• Help keep the liver from putting out too much
  sugar
• Help insulin to work better
• Lower cholesterol
• Do not cause weight gain
• Side effects diarrhea, nausea and loss of
  appetite
• Do NOT take is liver, kidney problems or heart
  failure

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ALPHA-GLUCOSIDASE INHIBITORS

• PRECOSE AND GLYCET
• Work in digestive tract
• Block enzymes that break down carbohydrates to
  sugar
• Prevent blood sugar from going up after meal
• Side Effects Bloating, gas, diarrhea
• Side effects usually go away after a few months

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INSULIN SENSITIZERS

• ACTOS AND AVANDIA
• Help your body to use insulin better
• May take 2-12 weeks to work
• Give medicine a fair trial
• Monitor liver functions

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MEGLITINIDES

• PRANDIN AND STARLIX
• Help pancreas make more insulin
• Work in response to blood sugar levels
• Take before each meal and snack

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Oral Medicine

• Most pills should be taken at mealtime
• Glucotrol (Glipizide) works best if taken 1/2
  hour before a meal
• Prandin should be taken 15 minutes before a meal
• Precose and Glycet should only be taken with the
  first bite of food

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Benefits of Oral Medicine

• Lower blood sugar will mean you will feel better
• Remember not a cure for diabetes
• The Person with Diabetes must
• Take medicine every day, eat at planned times,
  eat meals per appropriate diet.
• Stay in touch with his/her health team
• Test blood sugar level to see if the medicine is
  working

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COMPLICATIONS

• Acute
• Chronic

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Hypoglycemia
Hyperglycemia

• Gradual Onset
• Drowsiness
• Extreme Thirst
• Very Frequent Urination
• Flushed Skin
• Vomiting
• Fruity or Wine-Like Breath Odor
• Heavy Breathing
• Eventual Stupor or Unconsciousness

• Sudden Onset
• Staggering, Poor Coordination
• Anger, Bad Temper
• Pale Color
• Confusion, Disorientation
• Sudden Hunger
• Sweating
• Eventual Stupor or Unconsciousness

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Why Do We Care? Chronic Complications(Years,
Decades)

• Diabetic Nephropathy
• Kidney Failure, Dialysis, Kidney Transplant
• Diabetic Retinopathy Blindness
• Diabetic Neuropathy
• Numbness, Impotence, GI Probs, and more
• Accelerated Cardiovascular Disease
• Stroke, Heart Attack, Impotence, Peripheral
  Vascular Disease (Amputations)

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Are These Chronic Complications Preventable?

• Absolutely!
• Tight Glucose Control Prevents or Delays
  Complications.

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Proven Studiesbenefits of intensified control

• UKPDS (type 2)
• ? HbA1c 0.9
• Intensive therapy reduced overall microvascular
  complications by 25 and decreased risk of
• retinopathy 21
• microalbuminuria 33
• Reduction in microvascular complications seen
  regardless of primary treatment modality for
  intensive therapy
• insulin, sulfonylureas, or metformin

• DCCT (type 1)
• ?HbA1c 1.9
• Complications in the DCCT Trial showed profound
  reduction
• Retinopathy 76
• Nephropathy 56
• Neuropathy 60

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HbA1c and Glucose

• 5 - - - - 90
• 6 - - - - 120
• 7 - - - - 150
• 8 - - - - 180
• 9 - - - - 210
• 10 - - - 240
• 11 - - - 270
• 12 - - - 300

GOAL
Take Action
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Decision SupportADA Standards of Medical Care

• A1C
• Blood pressure
• Lipids
• LDL
• Triglycerides
• HDL 40mg/dl
• Dilated eye exams
• Foot exam (Monofilament)
• Microalbumin

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CHALLENGES
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CHALLENGES at SCHOOL

• Meet both the students health and educational
  needs one at the expense of the other
• Blood glucose testing assistance as
  appropriate, right to carry equipment
• Eating meals, snacks, treat low blood sugar
• Medication assistance as needed per individual
  child, right to carry,
• Field trips
• Extra-curricular activities
• Treatment of severe low blood sugar
• Testing accommodations

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at WORK

• Right to a job for which the person with diabetes
  is qualified
• Individual assessments not blanket bans
• Reasonable accommodation for testing, eating
  other care needs
• Access to supplies and equipment
• Modified work schedule