Transcript Caring for Children with Diabetes in Windsor

Diabetes Review
Judy Bornais RN, BScN, MSc, CDE
Prevalence
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More than 2 million Canadians have
diabetes1
By 2010 that number is expected to rise to
3 million 1
31% rise in prevalence in Ontario since
1995 2
Estimated that 1 in 5 individual over 45
years of age have diabetes and 1 in 3 over
the age of 75 3
Studies suggest that up to 30% of people
with diabetes are undiagnosed6
Did You Know?
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About half of all people diagnosed with
diabetes have already had the disease for
as long as 7 years1
20 - 30% of those individuals diagnosed
already have developed complications 3
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Cardiovascular
disease is 2-4 times
more prevalent in
patients with diabetes
than in those without1
Cardiovascular
disease accounts for
at least 60% of the
deaths in patients
with diabetes2
Causes of Death in Diabetes
Other
20%
CVA
15%
Cancer
8%
Sepsis
11%
CV
46%
Cancer
Sepsis
CV
CVA
Other
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When a patient develops vascular
complications like MI or stroke, the
outcome is worse in the individual with
diabetes3
The Burden of Cardiovascular Disease
in Diabetes
35
30
25
20
15
10
5
0
Paris
Prospective
Control
Diabetes
Whitehall
Study
Mortality Rate (deaths per 1,000
patient years)
Mortality rate in patients with diabetes more than
doubled versus those without diabetes
Paris
Prospective
Helsinki Study
Does the outcome depend on
the Type of Diabetes?
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Two large studies, UKDPS and DCCT,
indicate that both Type 1 and Type 2 can
result in macro and microvascular
complications such as:
Coronary heart disease
 Stroke
 Peripheral vascular disease
 Nephropathy
 retinopathy
 Neuropathy
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Clinical Impact of Diabetes
The leading cause of
new cases of end stage
renal disease (ESRD)
A leading cause of
cardiovascular
events in adults
Diabetes
The leading cause
of new cases of
blindness in
working age
adults
The leading
cause of nontraumatic lower
extremity
amputations
Life Expectancy
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Diabetes reduces survival by almost 12 years4
100
80
60
Diabetes
No Diabetes
40
20
0
Males
Females
Diabetes is a Major
Health Care Issue
How does this impact you?
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Patients with diabetes, had higher rates of
hospitalization than the general population
with an excess risk of about 30%
In Essex County, in 1999 there were
18, 982 cases of people who visited a
health care provider for their diabetes7
There is hope!
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Complications of diabetes can be delayed
and in some cases avoided with tight:
glycemic control
 lifestyle modification
 vascular protection
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Health care professionals role…and the battle
begins
Not so long ago in a galaxy
remarkably like ours , the evil
Diabetes Empire ruled over a
terror-stricken population.
Striking without warning
Diabetes would leave suffering ,
mutilation and death in its’
wake. Diabetes had thus ruled
unopposed for generations.
A mere 80 years ago Rebel
Fighters , Banting and Best
devised a weapon to battle the
Empire. The weapon was called
“Insulin”. While powerful , insulin
was difficult to deliver and tricky
to use . Diabetes learned to
exploit these weaknesses over
the years. The war raged on.
To win the battle we
must…Understand Diabetes
Management
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Diabetes management involves balancing
food, medication, and activity to achieve
blood glucose levels that are near the
normal range
Hormones, stress, illness, food - raises
blood sugars
Insulin, medications (type 2), exercise* –
lowers blood sugars
Types of Diabetes?
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You have a patient who takes Novolin
20/80 twice a day. What type of diabetes
does your patient have?
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Individual can have either type 1 or type 2.
Taking insulin does not classify the individual
as having type 1diabetes.
What happens in Diabetes
Type 1 Diabetes
 The pancreas no
longer produces
insulin. The person is
totally dependant on
exogenous insulin
Type 2 Diabetes
 The pancreas is not
making enough
insulin and/or
 the body is resistant
(no longer sensitive to
insulin)
Treatment for Diabetes
Type 1 Diabetes
 Insulin
Type 2 Diabetes
 diet and exercise
 oral hypoglycemics
 oral hypoglycemics
and insulin
 insulin
The Phantom Menace : Diabetes’
New Ally - Hypoglycemia
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Hypoglycemia a new threat in Glucose
Wars.
No easy way to predict or treat (no
glucose tabs or glucagon).
Low blood sugar perceived as greater
threat than hyperglycemia by caregivers.
Targets Blood Sugar Ranges4
Fasting /
preprandial
glucose (mmol/L)
Targets for
most patients
with diabetes
Normal range
2-hour
postprandial
glucose
(mmol/L)
Targets Blood Sugar Ranges4
Fasting /
preprandial
glucose
(mmol/L)
2-hour
postprandial
glucose (mmol/L)
Target for most
patients
4.0 – 7.0
5.0 – 10.0
Normal range
4.0 - 6.0
5.0 – 8.0
Hypoglycemia
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Blood sugars less than 4.0 mmol/L
What are the Signs & Symptoms of a low
blood sugar?
Signs and Symptoms of
Hypoglycemia
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sweating
shaking
weakness
hunger
nausea
irritability
confusion
Symptoms of Hypoglycemia5
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Neurogenic
(autonomic)
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Sweating (47 – 84%)
Trembling (32-78%)
Palpitations (8-62%)
Hunger (39-49%)
Anxiety (10-44%)
Nausea (5-20%)
Tingling (10-39%)
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Neuroglycopenic
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Difficulty concentration
(31-75%)
Weakness (28-71%)
Vision change (2460%)
Confusion (13-53%)
Tiredness (38-46%)
Difficulty speaking (741%)
Dizziness (11-41%)
Headache (24-36%)
SEVERITY OF HYPOGLYCEMIA4
MILD
Autonomic symptoms are present
Individual is able to self-treat
MODERATE
Autonomic and neuroglycopenic symptoms are
present
Individual is able to self-treat
SEVERE
Individual requires assistance of another
person
Unconsciousness may occur
How do you treat a low blood
sugar?
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A) Chocolate bar?
B) A hard candy?
C) Juice?
D) Glucose tabs?
How do you treat a low blood
sugar?
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A)
B) A hard candy (2-3)
C) Juice (3/4 cup)
D) Glucose tabs (3 glucose tabs)
Treatment for Hypoglycemia
Obtain a capillary glucose sample
If result is <4.0 mmol/L and
Patient is conscious
and symptomatic or asymptomatic
*Retest blood sugar
If blood sugar remains below <4.0mmol/L treat
Patient is unconscious (unable to swallow)
Known diabetic give dextrose 50% 25 ml direct IV or
glucagon (medical directive)
Treat with 15 grams of carbohydrates
i.e. 3 glucose tabs or 3/4 cup of juice
and
2 digestive cookies or 4-6 soda crackers
Glucagon treatment (unconscious pt with no IV)
If Pt/child under 20 Kg give 0.5mg s/c
If patient is over 20 kg give
1mg s/c
Check blood sugar again in 15 minutes
Treat again if blood glucose remains less
than 4 mmol/L
Check blood glucose after 5 minutes
Call MD
When do Hypo’s occur?
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Episodes of hypoglycemia most commonly occur
before meals or when the insulin effect is
peaking.
Patient is on Humalog/Novorapid at breakfast
eats less than normal when would you expect
the hypoglycemia?
Patient takes NPH at bedtime when are they
most likely to have a low?
Medications can blunt response to
hypoglycemia6
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Salicylates (Aspirin – in large doses; >4g/day)
Sulfonomide antibiotics (Probenecid;
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Tricyclic antidepressants (Amitriptyline –
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Phenylbutazone (for rheumatoid arthritis,
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Benemid, Benuryl, Probalan)
Elavil; Anafranil, Sinequan, Triadapin, Impril,
Novopramine, Nortriptyline – Aventyl; Triptil)
osteoarthritis or gouty arthritis)
Warfarin (Coumadin)
Fibrates
.
Medications can blunt response to
hypoglycemia
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Pentamidine (Nebupent, Pentacarinat)
Acetaminophen (Tylenol)
ACE Inhibitors (Captopril, Lisinopril, Enalapril,
Ramipril)
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Beta Blockers (Acebutolol, Carvedilol, Labetalol,
Metoprolol)
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Celexa (antidepressant)
.
Hyperglycemia
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Elevated blood sugars outside of the
normal/target ranges i.e. a blood sugar
over 10.0 mmol/L (2 hours post-prandial)
What are the Signs & Symptoms of
hyperglycemia?
Signs and Symptoms of
Hyperglycemia
Extreme thirst
Frequent urination
Blurred vision
Fatigue
Weight loss
Treatment for Hyperglycemia…the
forces strike back
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Obtain near normal blood sugar levels
through:
Insulin,
 Medications
 Exercise
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The Phantom Menace : Fatalists –
the Other Ally of Diabetes
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A large faction of caregivers and
individuals with diabetes believed that all
complications were genetically
programmed – would occur no matter what
the blood glucose levels were !
Treated to relieve symptoms only.
Waited for complications to show up. Fate
and luck !
Review of Complications of
Diabetes
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Neuropathy
Retinopathy
Nephropathy
Macro vascular complications
Foot Problems (ulcers & amputations)
Dental & Skin Problems
A New Hope : The DCCT
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1993 New England J. of Medicine
Glucose hypothesis proven to be true
Never too late to improve control
Any improvement in control is beneficial
A powerful way to employ insulin
(medications) in the battle with Diabetes
Summary DCCT
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69% reduction in Neuropathy
Trend toward reduction in risk of heart
disease
Improved Insulin and Delivery
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1985 modernization of insulin by genetic
engineering to produce
Human insulin Humulin
Novolin
1995 Introduction of insulin analogues
Lispro – Humalog
Aspart - Novorapide
2005 Introduction of new long acting insulin
Glarzine – Lantus
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2006 Another long acting insulin
***Levermir (expected to be available in Jan./06)
Challenge of Insulin
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To mimic the pancreas
2 patterns:
a basal secretion of insulin
 intermittent bolus of insulin in
response to food
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Goals of Insulin Therapy
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To control blood glucose levels
Prevent the development and progression of
long-term complications from hyperglycemia
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Minimize effects of hypoglycemia
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Mimic endogenous insulin
Insulins are divided into 5 main
types:
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Rapid-acting
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Short-acting
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Intermediate-acting
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Long-acting
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Premixed
Rapid-Acting Insulin (new analogues)
Insulin Lispro (Humalog)
Insulin Aspart (Novorapid)
Insulin lispro (Humalog)
Insulin aspart (Novorapid)
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May be taken before or after meals
appearance: clear
onset: 10 -15 min
peak: 45 min - 3 hrs
duration: 3 - 5 hrs
Take WITH meals
Short-acting or Regular (R)
Insulin
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Novolin ge Toronto (R) or Humulin R
appearance: clear
onset: 1/2 hr - 1 hr
peak: 2 - 5 hrs
duration: 6 - 8 hrs
Take 30 minutes before meals
Intermediate-acting or
NPH/Lente
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Novolin NPH or Humulin N
Novolin Lente or Humulin L
appearance: cloudy
onset: 1 - 3 hrs
peak: 4 - 12 hrs
duration: 18 - 24 hrs
Long-acting: Two types
Ultra Lente
 Novolin Ultra Lente or
Humulin U
 appearance: cloudy
 onset: 4 - 6 hrs
 peak: 8 - 20 hrs
 duration: 24 >
Long-acting: Two types
Glargine (Lantus) NEW!
***Levemir***
 appearance: clear
 onset: 3-4 hrs
 peak: no peak
 duration: 24 hrs
 acts like basal insulin
 Can not be mixed with
any other insulin
Example profiles: interstitial
glucose fluctuations from the mean
360
20
270
180
90
(mmol/l)
25
(mg/dl)
Glucose
450
15
10
5
0
360
20
180
90
(mmol/l)
25
(mg/dl)
0
Glucose
450
270
Patient 1 – NPH insulin
06:00
08:00
10:00
12:00
14:00
16:00
18:00
20:00
22:00
00:00
02:00
04:00
06:00
22:00
00:00
02:00
04:00
06:00
Patient 2 – Insulin detemir
15
10
5
0
06:00
08:00
10:00
12:00
14:00
16:00
18:00
Russell-Jones D et al. Clinical Therapeutics 2004;26:724-36
Time
20:00
CGMS profiles
Hypoglycaemia:
Relative Risk (Insulin detemir vs. NPH)
10
HbA1c
6
1
Baseline
*
18%
NPH insulin
39%
*
16%
*
50%
Relative risk
8
1.2
Insulin detemir
0.8
0.6
4
0.4
2
0.2
0
0
All
Major
Minor
*Between-group difference, p< 0.05
Kolendorf et al. Diabetes 2004;53(Suppl. 2):A130.
All nocturnal
Action Times of Insulin
Premixed: 10/90, 20/80, 30/70, 40/60,
Example:
 20/80
 Short-acting or
Regular insulin
 Works on the meal
you take it with
50/50
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20/80
Intermediate or NPH
insulin
Acts as the
background insulin
throughout the day
or night
When is the ideal time to give a
patient their premixed 30/70
insulin?
a) 30 minutes before their meal
b) With their meal
c) After their meal
Premixed:Humalog Mix 25
***Novomix 30***
Example:
 25/75
 Fast acting insulin
 Works on the meal
you take it with
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25/75
Intermediate or NPH
insulin
Acts as the
background insulin
throughout the day or
night
When is the ideal time to give a
patient their premixed Humalog
Mix 25 insulin?
a) 30 minutes before their meal
b) With their meal
c) After their meal
Giving Insulin
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Vial and syringe
Which insulin do you draw up first if you
are mixing insulins?
Clear then cloudy to avoid contaminating
the clear insulin
Insulin Pens
Site Selection: Where can I give
my injections?
4 major areas:
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upper outer area of arm
abdomen - avoid 1 inch
area around navel
front and sides of thighs
upper outer surfaces of
the buttocks
Site Selection: Do you rub the
site after injection?
Case study
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You have a 19 year old female who has
Type 1 diabetes who receives Novolin
30/70 before breakfast and supper. She is
late awakening and doesn’t eat her
breakfast and is going to university to
return home for lunch. What do you do?
Types of oral hypoglycemics
Biguanides: Decrease glucose release in the liver and
decrease insulin resistance in muscles:
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Metformin (Glucophage) take with meals
duration of action 8-12 hours
Key: No risk for hypoglycemia when taken alone and at the
recommended dose
Contraindicated in patients with renal or hepatic dysfunction or
cardiac failure
Alcohol not recommended
Types of oral hypoglycemics
Insulin Secretagogues: Sulfonylureas
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increase insulin secretion and potentiate insulin
action on liver and peripheral tissues
Glyburide (Diabeta) lasts 18-24 hours
Gliclazide (Diamicron) last 12 -24 hours
(Diamicron MR) last 24 hours
Glimepiride (Amaryl) lasts 24 hours
KEY: cannot skip meals - risk of hypoglycemia
Types of oral hypoglycemics
Insulin Secretagogues: Non sulfonylureas
(Meglitidines) increase insulin secretion
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Repaglinide (GlucoNorm): lasts approx 3 hours
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Nateglinide (Starlix): lasts approx.1.5-3 hours
KEY: Less risk of hypoglycemia in the context of
missed meals
Types of oral hypoglycemics
Alpha glucosidase inhibitors: slow
absorption of carbohydrates
 Acarbose (Prandase) lasts to cover the meal
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Decrease CHO digestion / prolongs uptake of CHO
Key: Treat hypoglycemia ONLY with dextrose
tablets, milk or honey
Types of oral hypoglycemics
Thiazolidinediones decrease insulin
resistance
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Pioglitazone (Actose) lasts 16-24 hours
Rosiglitazone (Avandia) lasts 15-20 hours
 Insulin sensitizers
 Increase peripheral utilization of insulin (at the
tissue level)
 Modify lipoproteins (increase HDLs)
Contraindicated in renal, hepatic and CHF patients
Challenge of Diabetes
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Imagine as an adult having to check your
blood sugar on average 5-6 times a day –
more often during periods of illness or
stress
Imagine having to carry your
glucometer/insulin/meds with you at all
times
Imagine Having to give yourself insulin at
a restaurant before eating
Issues of Cost
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Blood Glucose strips average $1/strip
Lancets $10
Box Insulin Pen needles $25-$35
Cost of insulin
– cartridge $40-$69
_ vials $27-$39
Total: $300/month
The Empire Strikes Back
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Insurers : ODB , Green Shield , and others
- Barriers to treatment
LU for Humalog
Section 8 for NovoRapide (Pen 3 Jr.)
Decreased coverage for insulin
pumps/pump supplies
Restricted coverage for Glucagon ($96
per single injection kit)
Attack of the Clones
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Improved delivery systems
Pen injectors
Ultrafine needles
Jet injectors
Improved glucose surveillance systems
Improved glucose meters
Computer downloading of results
Ultrafine lancets
Dorsal arm testing
Diagnosis - grieving
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May newly diagnosed patients and/or their
families experience cycle through:
Denial
Anger
Bargaining
acceptance
Sick Day Management
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Minor illnesses – cold, flu, gastroenteritis –
impair glucose control
Stress on the body
Cause an increase in blood sugar levels
for 2 reasons:
- an increase in hormones that cause
the liver to pump out glucose into the
blood
- hormones also increase the
resistance of cells to insulin
Sick Day Management
MONITORING
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Patients should be testing their blood sugar
before meals and/or every 4 hours around
the clock, until no longer sick or as directed
by their physician or Nurse practitioner
Urine should be tested for ketones (Type 1)–
presence means a serious situation.
Sick Day Management
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MEDICATION
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Patients should continue to take their insulin,
even if they are vomiting
If the patient uses Humalog or Novorapid
and they are nauseated, consider giving the
injection AFTER they eat – determine
carbohydrates and insulin dose.
Patients may require additional doses of
short or rapid acting insulin - notify the
physician if your patient requires insulin and
has been vomiting.
Sick Day Management Cont’d…
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LIQUIDS
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If a patient is losing fluids due to diarrhea,
fever, or vomiting , or they are drinking less
than usual or urinating more than usual, they
are at risk for dehydration.
They should drink 8 oz of liquid every hour
(avoid caffeine)
Case Study #2
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You have a patient with the stomach flu
who has a temperature of 38.3 C and
unable to eat.
A) What should you do?
B) Do you still give her insulin?
Diabetic Ketoacidosis (DKA)
Can be caused by:
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Too little insulin and increased food intake
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Physical or emotional stress
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Undiagnosed diabetes
.
DKA: Signs & Symptoms
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Abdominal pain
Nausea and vomiting
Dehydration
Blurred Vision
Fruity smelling ‘ketone
breath’
Excessive Thirst
Frequent urination –ketones
present
Dry mouth
Restlessness, confusion
Flushed feeling
Rapid breathing or heart
beat
Sleepiness, difficulty staying
Ketones: What Are They?
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Normally, our bodies turns the food you
eat into sugar (glucose)
Sugar is the bodies main source of energy
Without insulin, body cells cannot use
sugar present in the blood
The body receives a message to use
energy from fat
The body uses the fat for energy by
changing it into sugar
.
Ketones: What Are They?
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When fat is broken down, KETONES are
made
KETONES are acid chemicals which are
harmful to the body
The body tries to filter them from the
bloodstream into the urine
.
DKA: What happens?
Not enough insulin

Sugar not being used for energy
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Break down fat for energy
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Production of ketones
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Ketones (acid chemicals) cause altered pH and acidosis
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Ketonuria (to try and get rid of them)

Dehydration and Loss of Electrolytes
.
DKA Treatment?
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Replacement of fluid losses
Correction of hyperglycemia….
With low dose IV insulin (to prevent
cerebral edema
Replacement of electrolyte losses (Na and
K+)
Detection of cause and prevention of
future episodes – ketone testing
What do all these tests mean?
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Fasting blood
sugar
Creatinine
Albumin to
Creatinine ratio
Blood Pressure
A1C
Lipids
 Cholesterol//HDL
ratio
 HDL cholesterol
 LDL cholesterol
 Triglyceride
Fasting Blood Sugar (FBS)
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Measures the amount of sugar in the
blood after fasting for 8 hrs
Usually done just before breakfast
Target: Current goal is between 4 – 7
mmol/L CDA guidelines (2003)
.
Creatinine
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A blood test to check kidney function
Creatinine clearance - is an estimate of the
kidney’s ability to filter toxins from the blood
Target: 20 - 120 umol/L
Should be checked every year
Patients may remain asymptomatic until as
much as 75% of renal function is lost8
The older and smaller the patient, the lower their
creatinine should be
Albumin to Creatinine Ratio
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A urine test to catch early signs of kidney
damage
Detection of microalbuminuria identifies
individuals at high risk of progressing to
later stages of renal disease9-10, those at
risk for cardiovascular events and death4,
11
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Target: < 2.0 mg/mmol for men4
< 2.8 mg/mmol for women4
Blood Pressure (review)
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The pressure blood puts on the wall of the
blood vessel
Measures systolic pressure (heart
contracts)
diastolic pressure (heart relaxes)
Target: 130/80
Research from HOT and
UKPDS 38 trials
Tips to Lower Blood Pressure –
Health Promotion
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Reach/keep a healthy weight
Be more active
Drink less alcohol/eat less salt
Stop smoking
Take blood pressure medicine (as
prescribed by your doctor or nurse
practitioner)
LIPIDS: Important
1. Cholesterol/HDL Ratio
 The ratio describes how much HDL (good)
cholesterol is part of the total cholesterol
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It is a better measure of risk for heart
disease than Total Cholesterol alone
Target: less than 4.0 for most individuals
with diabetes
How to lower the cholesterol/HDL
ratio and triglycerides – Health
Promotion
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Reach and keep a healthy
weight
Be active!
Choose lower fat foods
Reach and keep good blood
glucose control
Reduce OR stop smoking
See their MD to have levels
rechecked in 3 months
2. HDL Cholesterol (High
Density Lipoprotein)
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“Healthy Cholesterol”
measures “good” cholesterol levels
called “good” because it carries extra
cholesterol out of the blood vessels
a LOW level is a risk factor for heart
disease (elevated plasma apo B4 )
Lowering triglycerides helps improve HDL
levels
3. LDL Cholesterol (Low Density
Lipoprotein)
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“Unhealthy” cholesterol
measures “bad” cholesterol
because it tends to collect in
artery walls, and can speed
hardening of the arteries
Target: < 2.5mmol/L for most
individuals with diabetes
.
Tips to Lower LDL – Health
Promotion


Decrease intake of
foods high in
cholesterol,
saturated fats and
trans fats
Eat more soluble
fibre (beans, oats,
barley and some
fruits and
vegetables)
4. Triglycerides



Measures another type of fat
that moves in the blood along
with cholesterol
High levels often appear with
other well-known risk factors
for heart disease, such as
obesity and diabetes
Optimal: < 1.5 mmol/L
More Tips to Lower
Triglycerides

Eat fewer sweets

Drink less alcohol

Lower your blood
sugar
LIPID TARGETS BASED ON
RISK OF A VASCULAR EVENT4
Risk
LDL-C
(mmol/L)
High
(most DM)
< 2.5
TC : HDLC
and
< 4.0
 Moderate risk = younger age with short duration of DM, no complications and no
Moderate
< 3.5
and
< 5.0
other CVD risks.
 TG are not indicated as a target because almost all individuals with hypertriglyceridemia can be identified as having an elevated TC:HDL-C.
 Optimal TG is < 1.5 mmol/L. Optimal apo B: < 0.9 g/L for high-risk individuals, and
1.05 g/L for moderate-risk individuals
Glycosylated Hemoglobin OR
Hemoglobin A1C (A1C)

A check of long term control

Average blood sugar over 3 months

Do not need to fast for this test

Goal is less than 7%
WHEN WILL THE BATTLE END?




NOT TILL THE “CURE” IS FOUND
MANY DEDICATED SCIENTISTS AND
PHYSICIANS WORKING DILIGENTLY
THE COMPLETION OF THE HUMAN
GENOME PROJECT BRINGS US ONE
STEP CLOSER TO VICTORY
NOT UNTIL PREVENTION OF TYPE 2
OCCURS
Are you at Risk for Diabetes?











Age  40 years
First-degree relative with diabetes
Member of high-risk population (people of Aboriginal,
Hispanic, South Asian, Asian or African descent)
History of IGT or IFG
Presence of complications associated with diabetes
Vascular disease
History of gestational diabetes or macrosomic infant
Hypertension, dyslipidemia, overweight or abdominal
obesity
Polycystic ovarian syndrome
Acanthosis nigricans
Schizophrenia
BUT !!! , TILL THEN




THE BATTLE MUST STILL BE WAGED
HELP YOUR DIABETES PATIENTS
RECEIVE THE BEST POSSIBLE CARE
TILL THE FINAL VICTORY , WHEN
TYPE 1 DIABETES WILL FADE INTO
HISTORY
TILL TYPE 2 DIABETES IS PREVENTED