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GO! Diabetes Case Studies

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GO! Diabetes Case Studies

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  1. <?xml version="1.0"?><AllQuestions><Question><slideID>ec55511e44df43b6a0e10e79add70895</slideID><slideType>Q&amp;A_QSlide</slideType><questionText>&#xB;What percent of weight loss will have a significant reduction in the incidence of diabetes at the end of four years?&#xB;</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><slideType>Q&amp;A_QSlide</slideType><questionText>&#xB;Which of the following is NOT an indication for screening for diabetes?&#xB;</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>dffc430ffb534fb1953a13bd24d92893</slideID><slideType>Q&amp;A_QSlide</slideType><questionText>&#xB;Patients with Diabetes and Subsequent Limb Amputation Have a 5-year Mortality Rate of Nearly 80%.&#xB;</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>45d239a6aa084977967e702d42d3d325</slideID><slideType>Q&amp;A_QSlide</slideType><questionText>Which of the following is NOT a contraindication of continuing metformin?</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><slideType>Q&amp;A_QSlide</slideType><questionText>Which of the Following Medications Reach Maximum Therapeutic Effect at ½ the Maximal Dose?</questionText><teamScoringFlag>True</teamScoringFlag><correctValue>0</correctValue><incorrectValue>0</incorrectValue></Question><Question><slideID>5d944a45484049a1877834acf7d84ad4</slideID><slideType>Q&amp;A_QSlide</slideType><questionText>Which of the following should be tapered and discontinued with replacement insulin? 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<?xml version="1.0"?><TeamNames><Team1></Team1><NewTeam1></NewTeam1><Team2></Team2><NewTeam2></NewTeam2><Team3></Team3><NewTeam3></NewTeam3><Team4></Team4><NewTeam4></NewTeam4><Team5></Team5><NewTeam5></NewTeam5><Team6></Team6><NewTeam6></NewTeam6><Team7></Team7><NewTeam7></NewTeam7><Team8></Team8><NewTeam8></NewTeam8><Team9></Team9><NewTeam9></NewTeam9><Team10></Team10><NewTeam10></NewTeam10></TeamNames> <?xml version="1.0"?><SlideMaster><tagSlideID>44872650615c4c51b7b44bf6c8eba803</tagSlideID><slideID></slideID></SlideMaster> <?xml version="1.0"?><AllAnswers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>0</answerID><answerText>Dyslipidemia </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>1</answerID><answerText>Hypertension</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>2</answerID><answerText>High risk ethnicity </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>3</answerID><answerText>Age 40</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>24a1d7dc3da64b5ca266b92e19cdabd3</slideID><answerID>4</answerID><answerText>All of the above are appropriate indicators</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa084977967e702d42d3d325</slideID><answerID>0</answerID><answerText>Congestive Heart Failure</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa084977967e702d42d3d325</slideID><answerID>1</answerID><answerText>Renal Insufficiency</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa084977967e702d42d3d325</slideID><answerID>2</answerID><answerText>Hepatic insufficiency </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa084977967e702d42d3d325</slideID><answerID>3</answerID><answerText>IV contrast administration </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>45d239a6aa084977967e702d42d3d325</slideID><answerID>4</answerID><answerText>All of the Above</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a45484049a1877834acf7d84ad4</slideID><answerID>0</answerID><answerText>Metformin</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a45484049a1877834acf7d84ad4</slideID><answerID>1</answerID><answerText>Glyburide</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a45484049a1877834acf7d84ad4</slideID><answerID>2</answerID><answerText>Sitagliptin</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>5d944a45484049a1877834acf7d84ad4</slideID><answerID>3</answerID><answerText>Acarbose</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>dffc430ffb534fb1953a13bd24d92893</slideID><answerID>0</answerID><answerText>True</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>dffc430ffb534fb1953a13bd24d92893</slideID><answerID>1</answerID><answerText>False</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>ec55511e44df43b6a0e10e79add70895</slideID><answerID>0</answerID><answerText>5-10%</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>ec55511e44df43b6a0e10e79add70895</slideID><answerID>1</answerID><answerText>15-20%</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>ec55511e44df43b6a0e10e79add70895</slideID><answerID>2</answerID><answerText>At least 25%</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>0</answerID><answerText>½ cup of juice</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>1</answerID><answerText>2 Tbsp raisins</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>2</answerID><answerText>7 saltine crackers</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f390b1dabe944032bcc6815fdde3a4f2</slideID><answerID>3</answerID><answerText>1 oz soft granola bar with raisins</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>0</answerID><answerText>Metformin</answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>1</answerID><answerText>Acarbose </answerText><isCorrect>None</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>2</answerID><answerText>Sulfonylurea </answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers><Answers><slideID>f515b6ea68f3407b9b08bfab696703ff</slideID><answerID>3</answerID><answerText>All of the Above</answerText><isCorrect>Yes</isCorrect><pointValue>0</pointValue></Answers></AllAnswers> GO! DiabetesCase Studies

  2. Rosita

  3. Case #1 • Rosita is an 18 year old Hispanic female who is a new mother. She presents for postpartum care 6 weeks after the birth of a 9 lb. 2 oz. boy • She was diagnosed with GDM based on her 2 hour glucose challenge at 26 weeks gestation (results FBS 90, 1 hour 179, 2 hour 158)

  4. Rosita’s History • Her original screening HbA1c was 5.4 • GDM was adequately controlled with MNT as evidenced by consistent FBS <95 with 2 hour PP <120 with home glucose monitoring • She is breastfeeding, desires contraceptives and otherwise has no additional concerns

  5. Vital Signs • Ht. 5 feet 4 inches (162.56 cm), Wt 190 lbs. (86.18 kg.), BMI 32.6 kg/m2, afebrile and BP 114/61 • Waist circumference: 38 inches • PE: Obese, lactating female with normal eye, CV, neuro, monofilament, skin and GYN exam

  6. Labs • TG 185 • Total Cholesterol 208 • LDL 122 • HDL 48 • FBG 88, 2 hour (75 gm) glucose challenge WNL

  7. Screening & Diagnosis in Pregnancy Overt Diabetes FPG>=126, or A1C>=6.5, or Random glucose>=200, confirmed by FPG or A1C Gestational Diabetes FPG >= 92 mg/dL, but < 126 at any gestational age, or 75 gm 2hr GTT at 24-28 wk gestation with 1 abnormal: FBS>= 92, but <126, or 1hr >=180, or 2hr >=153

  8. Metabolic Syndrome

  9. Risk Factors for Diabetes in Pregnancy • Obesity • Family history (Type 2 DM) • Specific ethnic groups • Female • Conditions associated with insulin resistance • Other risk factors in pregnancy

  10. Metabolic SyndromePatient Education • Medical Nutrition Therapy (MNT) • carbs, fats, proteins and calories • Exercise • Weight management • Psychosocial and family implications

  11. Medical Nutrition Therapy (MNT) for Rosita USDA Government

  12. Metabolic Syndrome Management 5-10% weight loss yields a 58% reduction in the incidence of diabetes at the end of four years What community resources have benefited your patients?

  13. What about Medications for Rosita? • Metformin reduced the development of T2DM by 31% • Recommended by the American Diabetes Association in patients with pre-diabetes Diabetes Care, Volume 34, Supplement 1, January 2011

  14. Bottom Line… Pharmacological intervention with a variety of agents reduces the rate of conversion of IGT/ IFG to T2DM, but Therapeutic Lifestyle Change (TLC) remains the mainstay of rx. For metabolic syndrome without coexistent prediabetes, routine pharmacoprevention for DM is not recommended at this time. (DeFronzo, J Clin Endocrinol Metab 96: 2354–2366, 2011)

  15. Monitoring your Metabolic Patients • Laboratory • Hgb A1C, FPG or GTT • Lipids • BP • Weight • PE • Dermatology and neuro manifestations

  16. Rosita

  17. Case #2 Rosita, a 50 year-old obese female patient presents with blurred vision for several days, weight loss, and feeling tired all the time.

  18. Who and When to Screen? • Family history • Dyslipidemia • HTN • GDM or baby >9lb • Women with PCOS • High risk ethnicity • Vascular disease • Prior glucose elevation • Hx or exam findings • Physical inactivity • Starting at age 45, a fasting blood glucose every three years • Obesity (specifically abdominal) has one of the highest associations with insulin resistance • Earlier/more frequent screening if BMI >25, AND a (2010) Standards of Medical Care in Diabetes-2010. Diabetes Care, 33, Supplement 1, S14.

  19. Diagnosis • FPG ≥ to 126 • HbA1C ≥ to 6.5% • 2-hour OGTT using 75gm glucose load • Random plasma glucose ≥ 200 in a patient with symptoms and signs of hyperglycemia (2010) Executive Summary: Standards of Medical Care in Diabetes-2010. Diabetes Care, 33, Supplement 1, S4.

  20. Type 1 Vs Type 2: How To Tell Them Apart

  21. Atypical Diabetes • Type 1.5 or Latent Autoimmune Diabetes in Adults (LADA) • “Double Diabetes”

  22. Co-Morbidities Assessment • Screen for depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment when self management is poor1. • Bariatric surgery may be considered for adults with BMI >35 and Type 2 DM1 1Diabetes Care, volume 34, Supplement 1 January 2011 pg S5-S6

  23. Co-Morbidities Assessment • Skin exam • Acanthosis nigricans • MRSA • Fungal infections • Wound care • Skin tags • Dental exam • Gingivitis • Infection

  24. Eye Care • Diabetic retinopathy (DR) is the leading preventable cause of blindness • Prevalence of DR increases with duration of diabetes (100% Type 1, 60% Type 2 after 20 years) • Of all recommendations, eye screening is the least likely to get done

  25. Reasons to Look at Feet • Up to 70% of diabetics eventually develop a neuropathy • Up to 15%* develop foot ulcers • More than half of the foot ulcers become infected at some point *The Semmes Weinstein Monofilament Exam as a screening tool for Diabetic peripheral neuropathy Journal of Vascular Surgery; Sept 2009; 675-682.

  26. The real morbidity… • 10-20% of infected ulcers lead to amputation • More than 50% of nontraumatic lower limb amputations are due to diabetic foot ulcers • One amputation increases the likelihood of another

  27. Foot Surveillance • Examine the feet at every visit • Annual comprehensive evaluation • Sensation • Pulses • Skin condition (ulcers, hair, nails) • Anatomic deformities • Shoe evaluation • Consider ABI age >50 and <50 if other risk factors for PAD (2010) Standards of Medical Care in Diabetes-2010. Diabetes Care, 33, Supplement 1, S39.

  28. Sensation Exam • Monofilament PLUS one of the following: • Vibratory • Pinprick • Ankle reflexes Diabetes Care, Volume 34, Supplement 1, January 2011, Page S8

  29. Foot Exam Sites • Fewer sites than 10 years ago…

  30. Lab Surveillance • A1c • Lipids • Microalbumin

  31. Anti-platelet Therapy ADA Guidelines • Recommendations for Aspirin • ASA 75-162 mg/day for 2o prevention • ASA 75-162 mg/day for 1o prevention • Age > 50 in men and > 60 in women with at least one risk factor • Consider in any age with multiple CV risk factors • Not recommended ages < 21 (Reye’s syndrome) • Clopidogrel 75 mg/day • Very high risk diabetics; intolerance to ASA

  32. Lipids American Diabetes Association LDL <100 mg/dL (<70 mg/dL in patients at “highest risk”) HDL >40 mg/dL (>50 mg/dL in females) TG <150 mg/dL National Cholesterol Education Program LDL <100 mg/dL (<70 mg/dL in patients at “highest risk”) Non-HDL <130 mg/dL

  33. ADA Guidelines Dyslipidemia • Fasting lipid profile annually • Simvastatin 80 mg/day warning • Without overt CVD • LDL<100 • At age 40 start on statin regardless of LDL to reduce LDL 30-40% • With overt CVD • Start statin to reduce LDL 30-40% • LDL<70 is an option • Normalizing triglycerides and raising HDL with fibrates reduces CV events http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm257884.htm

  34. ADA Guidelines Dyslipidemia • High LDL, High triglycerides, Low HDL • Consider statin + fibric acid • Remember the increased risk of rhabdomyolysis • Consider statin + niacin • Remember niacin can increase glucose levels • moderate doses = mild changes in glycemia

  35. ADA Guidelines - 2011 • Hypertension control individualized • for most 130/80 is ideal • Glycemic control individualized • for most < 7% is ideal • Nephropathy management • Table included for diagnosis and surveillance • Advances CKD management guidelines (modified from NKF) • Chronic health care delivery systems restructuring paramount (NDEP resources)

  36. Health Maintenance • Vaccinations • Influenza • Pneumovax • Smoking cessation • Counseling • Pharmacotherapy

  37. Diabetes Education • Diabetes education • is a collaborative process • develop knowledge and skills needed to change behavior • successfully self-manage the disease and its related conditions • Goals of education • improve health • better quality of life • reduce the need for costly healthcare • Diabetes Educators • Prepared in diabetes knowledge • Use principles of teaching, learning, and counseling • Behavior change for successful self-management

  38. Value of the Diabetes Educator: Summary of Findings • People with diabetes education: • Save money and have better outcomes. • Are more likely to adhere to recommendations for screening/HEDIS measures. • Are younger, more likely to be female, located in more affluent areas, have lower clinical risk, higher adherence to diabetes care recommendations and lower average costs. • Physicians and patients exhibit high variation in their use of diabetes education.

  39. Diabetes Prevention Project (DPP)A randomized clinical trial to prevent Type 2 Diabetes that evaluated the efficacy of 3 treatments Incidence of Diabetes Risk reduction 31% by Metformin 58% with modest lifestyle change sustained for 4 years Lifestyle (n=1079, p<0.001) vs. Metformin (n=1073, p<0.001) vs. Placebo (n=1082) SOURCE: The DPP Research Group, NEJM, 2002;346:393-403

  40. Diabetes Education Resources http://www.diabeteseducator.org /DiabetesEducation/Find.html http://www.diabetes.org/ http://www.cdc.gov/diabetes/

  41. Patient Education Who’s responsible? EVERYONE!

  42. LUNCH TIME

  43. Glycemic Control – Oral Agents

  44. Rosita’s A1C 7.5

  45. PANCREAS GLUCAGON GLUCAGON GLUCAGON AMYLIN INSULIN INSULIN How The Body Handles Glucose (Fed State) LIVER BRAIN Glucose 90-140 mg/dL Blood Glucose 60-90 mg/dL FAT GI TRACT MUSCLE

  46. PANCREAS GLUCAGON GLUCAGON GLUCAGON AMYLIN AMYLIN INSULIN INSULIN INSULIN GI TRACT Pathophysiology of Type 2 Diabetes LIVER Metformin TZDs Insulin Sulfonylureas Glinides Incretin tx BRAIN INSULIN INSULIN A1C < 7% Premeal ~ 100mg/dL PPG < 200 mg/dL Hyperglycemia FAT Weight Loss Exercise TZDs (Metformin) Pramlintide Dietary Composition Portion Control -Glucosidase Inhibitors MUSCLE

  47. General RulesHyperglycemic Therapy • Normalize fasting glucose levels first • Many patients will achieve glycemic targets • When to target postprandial glucose levels? • Pre-prandial values are at goal • A1C levels are not met • Measure 1-2 hours after beginning of the meal • Glucose are generally at their peak

  48. Glycemic Goals of Therapy Verbal Target ~100 <<200 As low as possible w/o unacceptable adverse effects Goal Premeal plasma glucose (mg/dL) 2-h postprandial plasma glucose A1C ADA 90-130 <180* <7%** ACE <110 <140 <6.5% * Evaluation and treatment of postprandial glucose may be useful in the setting of suspected postprandial hyperglycemia, with the use of agents targeting postprandial hyperglycemia and for suspected hypoglycemia ** More stringent glycemic goals (i.e. a normal A1C, <6%) may further reduce complications at the cost of increased risk of hypoglycemia Diabetes Care 2009;32:S6-12

  49. Biguanides: Metformin Mechanism of action • Reduces hepatic glucose production • Depends upon presence of insulin Safety and efficacy • Decreases A1C 1-2% • Adverse effects: diarrhea and nausea; main risk: lactic acidosis • Discontinuation rate 5% • Contraindications: renal, cardiac, hepatic insufficiency; IV contrast • No direct effect on kidney Dosing • Initial dose: 500 mg once a day; dosing: usually BID • Maximum effective dose: 2,000 mg per day • Titration frequency: week(s) to months • Alternate formulations: “XR” and combinations

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