Diabetes Change Agent A National Pilot Program

1
Diabetes Change AgentA National Pilot Program
2
PreTest

• Name the three ways diabetes can be diagnosed?
• What is the LDL goal for diabetics?
• What is the optional LDL goal?
• What is the A1C goal?
• What is the BP goal?
• What is the BP goal in patients with nephropathy?

3
Pre-Diabetes Definition
If FBG gt100 there is a 10-15 risk of DM within 7
years
or
Fasting
GTT
4
Metabolic Syndrome

• Elevated insulin level, fasting glucose or
  postprandial glucose and any 2 of the following
• Triglyceride 150 or HDL 35
• Blood pressure 140/90 or on medication for HTN
• Waist to hip ration gt 0.9, a BMI 30 or waist
  circumference gt 37 inches
• WHO Guidelines

• Any three of the following
• Waist circumference
• gt40 inches men
• gt35 inches women
• Triglycerides 150
• HDL 40 (men) or
• 50 (women)
• Fasting glucose
• 100
• -- Hypertension
• ATP III Guidelines

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Treatment of Metabolic Syndrome

• TLC Therapeutic Lifestyle Changes
• Smoking cessation
• Increasing physical activity
• Weight reduction
• Healthy meal planning
• Pharmacotherapy
• Management of blood pressure
• Management of lipids
• Management of blood glucose
• Aspirin for CVD prevention

6
Pharmacotherapy Metabolic Syndrome

• Always use TLC first and continue along with
  pharmacotherapy!
• Treat Lipids
• If patient has ? TG and ? HDL, treat TG
• If patient has ? LDL TG and ? HDL, treat LDL
  first then treat TG
• Treat LDL with statins
• Treat TG HDL with fibrates and niacin

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Pharmacotherapy Metabolic Syndrome

• Treat hypertension to goal (lt 130/80)
• Low dose diuretic initially
• 66 will require 2 meds to control
• ACE inhibitor, ARBs, Calcium channel blockers
• Only 54 are treated for HTN
• Of those treated, only 28 are at goal

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Pharmacotherapy Metabolic Syndrome

• Treat clotting disorder
• Daily low dose aspirin (81-325 mg) for men over
  age 45 and postmenopausal women
• Treat blood glucose
• Insulin sensitizers
• Metformin and TZDs pioglitazone (Actos) and
  rosiglitazone (Avandia)

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According to the American Diabetes Association

• 20.8 million children and adults in the U.S. have
  diabetes
• 14.6 million have been diagnosed with diabetes
• 6.2 million are unaware that they have the disease

• Diabetes represents 11 of the U.S. healthcare
  expenditure
• 1 out of every 10 health care dollars spent in
  the U.S. is spent on diabetes and its
  complications

10
Diabetes Classifications

• Pre-Diabetes
• Blood glucose levels are higher than normal but
  not high enough to be diagnosed with diabetes
• Risk factor for future diabetes and
  cardiovascular disease
• Type 1 Diabetes
• Type 2 Diabetes
• Gestational Diabetes
• Pregnant women who have never had diabetes but
  who have high blood glucose levels during
  pregnancy

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Screening

• Individuals 45 years of age, particularly if
  BMI 25 kg/m2
• Individuals lt45 years of age and overweight with
  other risk factors for diabetes
• Are habitually physically inactive
• Have a first-degree relative with diabetes
• Are members of a high-risk ethnic population
  (African American, Latino, Native American, Asian
  American , Pacific Islander)
• Have delivered a baby weighing gt9 lbs or have
  been diagnosed with gestational DM
• Are hypertensive (140/90 mmHg)
• Have an HDL cholesterol level lt35 mg/dl and/or a
  triglyceride level gt250mg/dl
• Have polycystic ovary syndrome
• On previous testing had impaired glucose
  tolerance or impaired fasting glucose
• Have other clinical conditions associated with
  insulin resistance
• Have a history of vascular disease

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Diagnosis

• Three ways to diagnosis
• Fasting plasma glucose (FPG)
• Oral glucose tolerance test (OGTT)
• Symptoms of diabetes and a casual plasma glucose
  200 mg/dl
• Each diagnostic criteria must be confirmed on a
  subsequent day unless unequivocal symptoms of
  hyperglycemia are present.

13
Complications

• Heart Disease and Stroke
• Heart disease death rates are 2 to 4 times higher
  than adults without DM
• The risk for stroke is 2 to 4 times higher than
  adults without DM
• High Blood Pressure
• 73 of adults with DM have a blood pressure
  greater than or equal to 130/80 mmHg or use
  prescription medications for hypertension
• Blindness
• Diabetic retinopathy is the leading cause of new
  cases of blindness in adults
• Kidney Disease
• Diabetes is the leading cause of kidney failure
• Nervous System Disease
• 60 to 70 of patients have mild to severe forms
  of nervous system damage.
• 30 of patients age 40 years or older have
  impaired sensation in the feet.

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Complications

• Amputations
• More than 60 of non-traumatic lower-limb
  amputations are due to DM.
• The rate of amputation is 10 times higher in
  patients with DM.
• Dental Disease
• Periodontal (gum) disease is more common in DM
  patients.
• Complications of Pregnancy
• Poorly controlled DM before conception and during
  1st trimester can cause major birth defects in 5
  to 10 of pregnancies and 15 to 20 of
  spontaneous abortions.
• Poorly controlled DM during the 2nd and 3rd
  trimester can result in large babies.
• Sexual Dysfunction
• Men with DM are 2 times are likely to experience
  erectile dysfunction.
• Life-threatening Events
• Diabetic ketoacidosis (DKA)
• Infection
• DM patients are more susceptible to infection and
  have worse prognoses.

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Complications and Preventative Care

• Self-Management Training (education)
• Blood Pressure Control
• Lipid Management
• Anti-Platelet Agents
• Retinopathy
• Nephropathy
• Foot care
• Smoking Cessation
• Immunizations

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Annual foot exam

• Condition of the skin, hair and toenails
• Musculoskeletal Deformities
• Pedal Pulses
• Sensory Exam
• Footwear assessment

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Sensory Exam

• Test five sites per foot.
• The total duration of the approach, skin contact,
  and departure of the filament at each site should
  be approximately 1 to 2 seconds.

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Footwear Assessment

• Examine the inside of the shoes
• Look at the type of footwear
• Look at the fit of the footwear
• Is the footwear appropriate?
• Would the patient benefit from corrective
  footwear?
• From inserts?

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Diabetic Retinopathy

• 20 million diabetics in US
• 50 undiagnosed
• Only 50 of known diabetics receive appropriate
  eye care
• Therefore, DR is leading cause of blindness in
  working-age population in US
• Prevalence of DR increases with duration of
  diabetes (100 Type 1, 60 Type 2 after 20 years)

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Pathophysiologyof DR

• Increased blood sugar shunts excess into aldose
  reductase pathway leading to sorbitol gt loss of
  capillary intramural pericyte function causing
  weakness and outpouching of capillary walls
• Microaneurysmsgt increased leakagegt rupturegt
  hypoxiagt infarction of nerve fiber layer
  (cotton-wool spots)gt
• Compensation for hypoxia leads to
  vasoproliferation, neovascular changesgt extension
  into vitreous gt vitreal hemmorrhage, fibrosis
  with traction

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Classification of DR

• Mild non-proliferative (aka Background)-
  microaneurysms
• Moderate non-proliferative-small vessel occlusion
• Severe non-proliferative-increased vessel
  occlusion
• Proliferative-abnormal vessel development and
  extension

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Diabetic Drug Classes

1. Insulin
2. Sulfonylureas
3. Meglitinides
4. Biguanides
5. Alpha-glucosidase Inhibitors
6. Thiazolidinediones
7. Dipeptidyl Peptidase IV Inhibitor
8. Combinations
9. Amylinomimetic
10. Incretin Mimetic

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Indications for Insulin

• Not contraindicated at anytime
• Consider as initial therapy
• HgbA1C gt 10
• Fasting glucose gt 250mg/dl
• Random glucose gt 300
• Recommended as initial therapy
• Polyuria, polydipsia, weight loss, ketones

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Types of Insulin Generic and brand names Onset Peak Duration
Rapid-actingAbsorbed more quickly than short-acting insulin, but effects wear off sooner Insulin aspart (NovoLog) Insulin glulisine (Apidra) Insulin lispro (Humalog) 10 to 30 minutes 30 minutes to 3 hours 3 to 5 hours
Short-acting Insulin regular (Humulin R, Novolin R, others) 30 to 60 minutes 2 to 5 hours Up to 8 hours
Intermediate-acting Insulin NPH human (Humulin N, Novolin N) 1 to 2 hours 4 to 12 hours 16 to 24 hours
Long-acting Insulin glargine (Lantus) Insulin detemir (Levemir) 1 to 5 hours No clear peak Up to 24 hours
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Insulin ActionEffect Of Various Formulations
140
120
100
Short (Regular)
Insulin Level (?U/ml)
80
Intermediate (NPH)
60
40
Detimir
20
0
0
2
4
6
8
10
12
14
16
Hours
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Once Daily Insulin OptionsBasals vs. NPH vs.
Premixed
INSULIN TYPE ADVANTAGES DISADVANTAGES
Glargine Peakless, less hypoglycemia, less wt gain simple Cost cant mix no meal time coverage
Detemir Less wt gain, less hypoglycemia simple Cost, shorter duration than glargine cant mix, basal only
Pre Mixed 70/30 or 75/25 Covers meal time and basal easy transition to bid More hypoglycemia than basals
NPH Less expensive More hypoglycemia than basals
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Common Concerns When Transitioning To Insulin

• Adverse impact on lifestyle inconvenient loss
  of personal freedom and independence
• Belief that insulin means diabetes is worse or
  more serious disease
• Insulin as a personal failure
• Insulin causes complications
• Treated differently by family members

Funnel M. Self-management support for insulin
therapy in type 2 diabetes. The Diabetes
Educator 200430274
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Insulin InitiationAnswers to Provider Concerns

• Normalize the fasting glucose
• Fasting FSBS 70-130
• Once Daily Options
• Start 10 units or 0.2 u/kg
• Basal Insulin (glargine or detemir)
• NPH (bedtime)
• Premixed before dinner
• Increase 2-3 units every 3 days prn to reach
  target of 70-130 fasting
• Decrease 3 units for fasting lt 70

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Sulfonylureas

• First Generation
• Acetohexamide (Dymelor)
• Chlorpropamide (Diabinese)
• Tolazamide (Tolinase)
• Tollbutamide (Orinase)
• Second Generation
• Glipizide (Glucotrol, Glucotrol XL)
• Glyburide (Diabeta, Micronase)
• Micronized Glyburide (Glynase)
• Glimepiride (Amaryl)

• Place in Therapy Reasonable first line in type 2
  DM
• Mechanism of Action Stimulate pancreas to make
  more insulin
• Adverse Effects Hypoglycemia, upset stomach,
  skin rash or itching, weight gain

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Meglitinides

• Repaglinide (Prandin)
• Netaglinide (Starlix)
• Mechanism of Action Stimulate the pancreas to
  make more insulin
• Administration Take 30 minutes before meals,
  skip dose if meal is skipped
• Adverse Effects hypoglycemia, weight gain

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Biguanides

• Metformin (Glucophage, Glucophage XR,
  Fortamet)
• Mechanism of Action decrease the amount of
  glucose made by the liver
• Administration with a meal
• Advantage weight loss and improvement in
  cholesterol
• Adverse Effects nausea, diarrhea, abdominal pain
  metallic taste in mouth
• Slow titration and take with food help resolve
  effects

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Biguanides

• Lactic Acidosis serious adverse effect
• Symptoms weakness, malaise, heavy labored
  breathing
• High risk renal dysfunction, liver dysfunction,
  cardiorespiratory dysfunction, or alcohol intake
• Contraindications
• renal impairment (GFR lt60 ml/min, SCr gt1.4 for
  females or 1.5 for males)
• hepatic disease
• congestive heart failure requiring pharmacologic
  treatment
• history of lactic acidosis
• Precaution
• Hold 48 hours before and after iodinated
  parenteral contrast dye procedure

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Alpha-Glucosidase Inhibitors

• Miglitol (Glyset)
• Acarbose (Precose)
• Mechanism of Action Slow the absorption of the
  starches consumed
• Administration 3 times a day with the first bite
  of a meal
• Adverse Effects gas, bloating, diarrhea,
  abdominal pain
• Minimize with slow titration effects lessen over
  time
• If hypoglycemia occurs, administer oral glucose
• Sucrose will not be absorbed by these medications

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Thiazolidinediones

• Pioglitazone (Actos)
• Rosiglitazone (Avandia)
• Mechanism of Action Help cells become more
  sensitive to insulin
• Adverse Effects hepatotoxicity, cardiovascular,
  edema, weight gain
• Monitor liver enzymes
• Avoid in patients with advanced heart disease or
  congestive heart failure
• Drug Interaction Potential reduction of oral
  contraceptive efficacy
• Disadvantage takes up to 12 weeks to work

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Dipeptidyl Peptidase IV Inhibitor

• Sitagliptin (Januvia)
• Indication Patients with type 2 diabetes
• Mechanism of Action DDP 4 Inhibitor enhance the
  bodys own ability to keep blood glucose levels
  balanced. Increases insulin levels and reduce
  the amount of sugar made in the liver when food
  is consumed

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Dipeptidyl Peptidase IV Inhibitor

• Dosing one 100mg once daily with or without food
• Adverse Effects upper respiratory infections,
  stuffy or runny nose, sore throat, and headache
• Similar to placebo
• The use of JANUVIA in combination with
  medications known to cause hypoglycemia, such as
  sulfonylureas or insulin, has not been adequately
  studied. Research is ongoing.
• Coming soon Vildagliptin (Galvus)

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Combinations

• Glimepiride and Rosiglitazone (Avandaryl)
• Glimepiride and Pioglitazone (Duetact)
• Glyburide and Metformin (Glucovance )
• Glipizide and Metformin (Metaglip)
• Rosiglitazone and Metformin (Avandamet)
• Pioglitazone and Metformin (ACTOplus Met)
• Sitagliptin and Metformin (Janumet)

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Amylinomimetic

• Pramlintide acetate (Symlin)
• Mechanism of Action Synthetic analog of amylin
• Amylin is a hormone co-secreted with insulin
• Prolongs gastric emptying time in the stomach
• Reduces postprandial (after meals) secretion of
  glucagon (sugar made by liver)
• Reduces calorie intake through centrally-mediated
  appetite suppression
• Indications Type 1 or 2 diabetes
• Adjunct treatment in patients using mealtime
  insulin who have failed optimal insulin therapy

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Amylinomimetic

• Dosing Prescription written in mcg and patients
  use units to draw the medication up in a syringe
• If Dose Is Draw Up This Amount In Syringe
• 15 micrograms 2.5 units
• 30 micrograms 5 units
• 45 micrograms 7.5 units
• 60 micrograms 10 units
• 120 micrograms 20 units
• Administration
• inject in abdomen or thigh before a meal
• do not mix in the same syringe with insulin
• reduce the amount insulin by 50 when starting
  therapy
• Storage Unopened vials in refrigerator and
  opened vials in refrigerator or room temperature
  for up to 28 days

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Amylinomimetic

• Adverse Effects nausea, hypoglycemia
• Contraindications
• Known hypersensitivity to symlin or components
• Confirmed diagnose of gastroparesis
• Recurrent severe hypoglycemia in past 6 months
• Hypoglycemia unawareness
• A1C gt9
• Pediatric patients

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Incretin Mimetic

• Exenatide (Byetta)
• Derived from the gila monster salvia
• Mechanism of Action Analog of hormone incretin
  (glucagon-like peptide 1 or GLP 1)
• Increases insulin secretion
• Prolongs gastric emptying time in the stomach
• Decrease appetite
• Suppresses glucagon
• Indications Adjunctive therapy in type 2
  diabetes who have not achieved desired glycemic
  control while taking metformin, a sulfonylurea,
  or both.

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Incretin Mimetic

• Dosing Administer up to 60 minutes before
  morning and evening meals
• Do not have to adjust based on size of meal or
  amount of exercise
• Administration Inject subcutaneously in thigh,
  abdomen, or upper arm
• Use a new needle with each injection

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Incretin Mimetic

• Storage Store pens in the refrigerator and
  discard in 30 days
• Adverse Effects nausea, hypoglycemia
• Drug Interactions Slow down how quickly
  medications enter the bloodstream
• Consider taking medications like antibiotics and
  contraceptive pills 60 minutes before Byetta

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Type 2 Diabetes Risk Factors

• Family history of diabetes is very important
• The dramatic increase in Type 2 Diabetes can be
  attributed to obesity and lack of physical
  activity
• 80 of persons with Type 2 Diabetes are
  overweight or obese

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Obesity A Risk Factor

• The U.S. Preventive Services Task Force (USPSTF)
  recommends that clinicians screen all adult
  patients for obesity by BMI and offer intensive
  counseling and behavioral interventions to
  promote sustained weight loss for obese adults.
• Waist circumference, measured by the clinician,
  helps to assess further risk of obesity.

http//www.ahrq.gov/clinic/uspstf/uspsobes.htm
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Body Mass Index Chart
Weight (lb)
http//www.obesityonline.org
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BMI-Associated Disease Risk
Classification BMI (kg/m2) Risk
Underweight lt18.5 Increased
Normal 18.5-24.9 Normal
Overweight 25.0-29.9 Increased
Obese I 30.0-34.9 High
II 35.0-39.9 Very High
III gt40 Extremely high

• Additional risks
• Large waist circumference (mengt40 in women gt35
  in)
• 5 kg or more weight gain since age 18-20 y
• Poor aerobic fitness
• Specific races and ethnic groups

Clinical Guidelines on the Identification,
Evaluation, and Treatment of Overweight and
Obesity in AdultsThe Evidence Report. Obes Res
19986(suppl 2).
49
Relationship Between BMI and Risk of Type 2
Diabetes
Chan J et al. Diabetes Care 199417961. Colditz
G et al. Ann Intern Med 1995122481.
93.2
Men Women
54.0
Age-Adjusted Relative Risk
42.1
40.3
27.6
21.3
15.8
8.1
5.0
11.6
4.3
2.9
2.2
6.7
4.4
1.5
1.0
1.0
1.0
Body Mass index (kg/m2)
50
Lifestyle Weight Management

• Modest weight loss has been shown to reduce
  insulin resistance
• Lifestyle modifications should be the primary
  approach to weight loss.
• Physical activity and behavior modification are
  important components of weight loss programs and
  are helpful in maintenance of weight loss.
• Fat intake should be lt7 of total calories
• Monitoring carbohydrates remains a key strategy
  in achieving glycemic control.
• Sugars and nonnutritive sweeteners are safe if
  consumed within the acceptable daily intake
  levels.

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Lifestyle Physical Activity

• Improve blood glucose control, assist with weight
  maintenance, and reduce the risk of
  cardiovascular disease
• Before beginning a program, patients should be
  assessed for conditions that might be associated
  with increased likelihood of cardiovascular
  disease or that might contraindicate certain
  types of exercise or predispose to injury.
• Added Carbohydrate should be ingested if
  pre-exercise glucose levels are lt100mg/dl to
  avoid hypoglycemia.

52
Lifestyle Physical Activity

• Recommended Amount
• At least 150 min/week of moderate-intensity
  (50-70 of maximum heart rate) aerobic physical
  activity
• And/or 90 min/week of vigorous (gt70 of maximum
  heart rate) aerobic exercise
• Distributed over at least 3 days/week
• No more than two 2 consecutive days without
  physical activity
• Examples walking, bicycling, jogging, swimming,
  water aerobics, etc.
• Patients with type 2 DM should be encouraged to
  perform resistance exercise three times a week
• Targeting all major muscle groups
• Progressing to three sets of 8-10 repetitions at
  a weight that cannot be lifted to more than 8-10
  times

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Primary Approach for Achieving Weight Loss

• Cornerstone is lifestyle modification
• Moderate decrease in caloric intake (500-1000
  kcal/day)
• Dietary guidance should be tailored
• Regular moderate intensity physical activity
  starting modest but increasing to 30-45 minutes
  of moderate aerobic activity 3-5 days per week
• Weight loss maintenance achieved by 1 hour
  moderate or 30 minutes vigorous activity daily
• Group treatment is less costly and as effective
  as individual sessions
• Medications are an alternative but are not for
  all
• Surgical treatment is suitable for selected
  persons with morbid obesity

http//www.guideline.gov/summary/summary.aspx?doc_
id9854nbr005278stringdiabetesandobesity
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Behavior Change Tips

• List specific goals regarding change
• Create a plan with realistic steps
• Start with small steps that fit lifestyle
• Monitor progress with food/fitness journals
• Give realistic timeframe to maintain change
• Use tools and group meetings to reinforce healthy
  behaviors

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Drugs Approved by FDA for Treating Obesity
Generic Name Trade Names DEA Schedule Approved Use Year Approved
Orlistat Xenical, Alli None Long-term 1999
Sibutramine Meridia IV Long-term 1997
Diethylpropion Tenulate IV Short-term 1973
Phentermine Adipex, lonamin IV Short-term 1973
Phendimetrazine Bontril, Prelu-2 III Short-term 1961
Benzphetamine Didrex III Short-term 1960
Rimonabant 2007 Not FDA
http//www.guideline.gov/summary/summary.aspx?doc_
id9854nbr005278stringdiabetesandobesity
http//www.obesityonline.org
56
Additive Effects of Behavior and Diet Therapy
with Pharmacotherapy for Obesity
Wadden et al. Arch Intern Med 2001161218.
Medication alone
Medication and behaviormodification

Weight Change ()

Medication, behaviormodification and meal
replacements
0
2
4
8
12
10
6
Time (months)
Plt0.05 vs medication alone.
57
Diabetes Control

• Diabetes control starts by knowing patients A1c
  levels.
• Good diabetes control will avoids or delay
  complications.
• A1c test every 3 months.
• A1c lt 7 is the goal

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Diabetes Self-management
What a person with diabetes should do by
her/himself to maintain control

• Meal plan (always eating healthy)
• Exercise moderately (walking 30 minutes a day)

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Diabetes Self-management

• monitor glucose levels frequently
• take medications properly
• take care of eyes, feet, teeth and skin

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Why self-monitoring glucose?
a person with diabetes should use the glucose
meter to control their blood glucose to prevent
hyperglycemia and hypoglycemia
Fasting values 90 - 130 mg/dl
1-2 hours after eating Less than 180 mg/dl
Be careful with hypoglycemia Less than 90 mg/dl
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Remember the values of good control
A1c test lt 7
Blood Pressure lt 130/80
LDL cholesterol lt 100
If a person with diabetes keeps these values
between medical check ups, means a good diabetes
control
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Long-term Care Comprehensive Care

• Medical history
• Laboratory results
• Physical exam
• Referrals
• Annual dilated eye exam
• Family planning for women of reproductive age
• Registered dietitian
• Diabetes education
• Mental health, if needed

American Diabetes Association (2008). Standards
of medical care in diabetes. Diabetes Care, 31,
S12-S54.
64
Comprehensive Care

• Teams may include
• Physicians, physicians assistants, nurse
  practitioners, nurses, dietitians, pharmacists,
  educators, mental health professionals
• It is essential in this collaborative and
  integrated team approach that individuals with
  diabetes assume an active role in their care.

American Diabetes Association (2008). Standards
of medical care in diabetes. Diabetes Care, 31,
S12-S54.
65
Diabetes Self-management Plans

• Plans should be
• Individualized and coordinated with the patient
  and family, the physician, and other members of
  the healthcare team
• Reasonable in terms of goals and treatment
• Understood and agreed on by the patient and the
  care provider

American Diabetes Association (2008). Standards
of medical care in diabetes. Diabetes Care, 31,
S12-S54
66
METRIC

• Metric stands for Measuring, Evaluating, and
  Translating Research Into Care.
• It is an innovative online practice improvement
  program where you will input records of 10
  diabetic patients prior to today and again within
  90 days.
• www.aafp.org/metric

67
Diabetes Portal

• Sponsored by the American College of Physicians
• Extensive tools for patient management
• Patient self-management and negotiation
• Calculators
• Personal Health Decision tool
• Coding tool
• http//diabetes.acponline.org/index.html

68
Other online resourcescheck them out!

• http//www.diabetes.org/home.jsp
• One of the first places patients look for
  information
• http//docnews.diabetesjournals.org/?WTLPromoHP
• http//www.bddiabetes.com/us/main.aspx?cat1id25
  8
• Insulin injection animation
• http//www.healthhopmusic.com/music.htmdiabetesba
  ck
• Education set to hip hop music

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Other online resources

• http//ndep.nih.gov
• http//www2.niddk.nih.gov/
• http//www.mdtext.com/diabetes/diabetes17/diabetes
  17.htm
• http//www.ahrq.gov/clinic/epcindex.htmendocrine

70

• Thank you!