Transcript Case Presentations

GO! Diabetes
Train the Trainer Program
This project was funded by an
educational grant from Sanofi
Faculty Disclosures
The faculty have no relevant
financial relationships
The content of this presentation will promote quality or improvements in healthcare and
will not promote a specific proprietary business interest or a commercial interest.
Content for this activity, including any presentation of therapeutic options, will be wellbalanced, evidence-based and unbiased according to GAFP policy.
GO! Diabetes Goals
• Educate on the current ADA Standards of
Medical Care in Diabetes
• Identify opportunities in your practice to
improve diabetes care
• Demonstrate tools to implement system
changes
• Implement interdisciplinary teams to
facilitate patient centered care
Why Are We Here?
Diagnosed and undiagnosed diabetes in the
United States, all ages, 2010
• Total: 25.8 million people, or 8.3% of the
U.S. population, have diabetes.
• Diagnosed: 18.8 million people
• Undiagnosed: 7.0 million people
• Future of the epidemic
– 48.3 million with DM by 2050
www.cdc.gov/diabetes/pubs/estimates
Prevalence of Diabetes
Group
• 20 years or older
–♂
–♀
• 65 years or older
US Population
with diabetes
25.6 million
13.0 million
12.6 million
10.9 million
Center for Disease Control National Diabetes Fact Sheet Jan 2011
Age-Adjusted Percentage of Civilian, Noninstitutionalized
Population with Diagnosed Diabetes, by Race and Sex,
United States, 1980–2010
Centers for Disease Control and Prevention, National Center for Health Statistics, Division of
Health Interview Statistics, data from the National Health Interview Survey.
The Cost of Diabetes
$116 billion = direct medical costs
$58 billion = indirect costs (disability, work loss,
premature mortality)
Total cost of diabetes in the United States
$174 billion
Center for Disease Control National Diabetes Fact Sheet Jan 2011
Projected Increase in Cost for
Diabetes Care in the US
Projecting the Future Diabetes Population Size and Related Costs for the U.S.
Diabetes Care 32:2225–2229, 2009
How Do We Change?
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•
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Team based practices
Patient Centered Medical Home (PCMH)
Empower Change Agents
Revamp our approach to diabetes
Identify economic drivers
Use of clinical practice guidelines
How Will GO! Diabetes Help?
• Train the Trainer sessions
• clinical update on diabetes
• practice improvement tools
• skills to become an agent of change
• AAFP METRIC to collect and analyze patient
data
• Webinars, GOing Forward and project
coordinators
What is a Team?
“A group of people with complementary
skills, committed to a common
purpose for which they hold
themselves mutually accountable.”
Katzenbach, JR and Smith, DK. The Discipline of Teams. Harvard Business
Review-The High Performance Organization. July-August 2005, pgs. 1-9.
Team Attributes
Shared leadership roles
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–
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Individual and mutual accountability
Specific team purpose that the team itself delivers
Collective work products
Encourages open ended discussion and active
problem solving meetings
– Measures performance
– Discusses, decides and does real work together
Katzenbach, JR and Smith, DK. The Discipline of Teams. Harvard Business
Review-The High Performance Organization. July-August 2005, pgs. 1-9.
Change Agent Role
Commit to practice improvement
– Champion the change process
– Manage barriers to change
– Facilitate the team to determine goals for the
new initiative
– Ensure good communication
– Collaborate with others who share a similar
passion
thethrivingsmallbusiness.com.
Team Based Practice
Transform the traditional practice into a functioning team
based practice
– Involve all team members
• Reminders on chart/EHR about purpose of visit for
schedulers
• MAs check FPG, foot sensation, review meds
• Appropriate labs ordered, reviewed and available
for providers
– Use PAs and NPs for care of diabetes
– Use Registered Dietitians for medical nutrition therapy
Patient Centered Medical Home
(PCMH)
• Comprehensive primary care for children, youth and
adults
• Personal physician
• Physician directed medical practice
• Whole person orientation
• Integrated/coordinated care
• Hallmarks of quality and safety
• Enhanced access
• Payment
Patient Centered Primary Care Collaborative
2011-12 GO! Project Success
Practice improvement activities resulted in better patient
outcomes with:
Baseline
– LDL <70
– A1C <7.0
– Foot exam
– Dilated retinal exam
Based on 2011-12 GO! Diabetes METRIC data
22%
42%
64%
39%
Follow up
-
24%
46%
75%
51%
Share
Resources
Why Learn Practice
Improvement Tools?
Fundamental Questions for
Improvement
• What are we trying to accomplish?
• How will we know that a change is an
improvement?
• What changes can we make that will result
in an improvement?
Purpose
Learn some tools that will enhance
effectiveness in supporting practice
improvement
Practice Improvement Tool #1
Nominal Group process
Nominal Group Process
1. Present the question, spend a few minutes
reflecting and come up with individual ideas
2. Write each idea on a sticky note and place on the
flip chart
3. Group discusses the ideas, clarifying and
combining similar ideas
4. Each member ranks the ideas by voting with dots
5. Discuss results and determine top idea
6. Vote again only if needed to identify the most
popular idea
Nominal Group Process
Exercise
What would ideal care for your
patients with diabetes look
like?
Nominal Group Process
Exercise
Final vote
– Feasibility
– Cost effectiveness
– Organizational priority
–Timeframe – 6 months
Rosita- the Adolescent Years
Meet Rosita…
• Rosita is a 14 year old Hispanic female
who presents for routine well child care
• Family hx is significant for T2DM in
grandmother
• Birth history significant for SGA, breast-fed
infant with normal development otherwise
• Immunizations are up to date
Physical Exam
•
•
•
•
Height 62” Weight 165 lbs
BMI 30.2 kg/m2 (> 95th % for age/sex)
BP 105/62 (< 50%ile for height/age)
PE: Overweight, adolescent female with
normal eye, CV, neuro, monofilament, skin
exam
Testing for T2DM
in Asymptomatic Children
Overweight
BMI >85th percentile for age/sex, wt/ht >85th %ile, wt >120% of ideal for height
Plus any 2 of the following risk factors:
•
+FH for T2DM in first- or second-degree relative
•
High Risk ethnicity- Native / African or Asian American, Latino, Pacific Islander
•
Signs of insulin resistance or associated conditions, acanthosis nigricans,
hypertension, dyslipidemia, PCOS, or SGA birthweight
•
Maternal history of diabetes or GDM during the child’s gestation
Age of initiation: 10 years or younger if onset puberty
Frequency: every 3 years
Standards of Medical Care in Diabetes-2013. Diabetes Care, 36,
Supplement 1. S15
Labs
•
•
•
•
•
•
FPG 88
A1C 5.2
TG 81
Total Cholesterol 185
LDL 122
HDL 39
Diagnosis of Diabetes
•
•
•
•
A1C ≥ 6.5%
FPG ≥ 126
2-hour OGTT (75gm glucose load) ≥ 200
Random plasma glucose ≥ 200 in a patient
with symptoms and signs of
hyperglycemia
Standards of Medical Care in Diabetes-2013. Diabetes Care, 36,
Supplement 1, S13.
Categories of Prediabetes/
Increased Risk for T2DM
Fasting plasma glucose
100-125 mg/dL
2 hour OGTT
140-199 mg/dL
A1C
5.7-6.4%
2013 ADA Guidelines
International Diabetes Federation (IDF) Definition
of Metabolic Syndrome
(at risk Children and Adolescents )
Age
Obesity TG
HDL BP
FPG or
group
(WC)
known
(yrs)
T2DM
6 to <10 >90th
Further eval prn +FH
%ile
10 to
<16
16+
>90th
%ile
>150 <40
SBP>130
or
DBP>85
Use adult criteria
Diabetes Voice December 2007 Vol 52. Issue 4
>100mg/dl
Goals for Rosita?
•
•
•
•
Achieve healthy body weight
Promote healthy lifestyle
Reduce risk factors
Identify and overcome challenges
– Skips breakfast and school lunch then
calorically compensates throughout the
afternoon and evening.
– >6 hrs screen time per day
– Drinks high caloric beverages
Recommendations
• Family approach to wt management
Parents’ vs Rosita’s responsibilities
• Limit screen time to < 2hrs/day
• Identify exercise/activities Rosita enjoys
Ideally:1 hr/d of moderate to vigorous activity, with
vigorous physical activity 3 d/wk
• Find out why Rosita doesn’t eat breakfast or lunch and
help her develop a workable plan
No time in the morning?
Doesn’t like school lunch?
Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and
identifying at-risk children. Up to Date. Dec 2012, AAP, Health Initiatives, policy on Media
and Children.
The Division of Feeding Responsibilities
PARENT
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•
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•
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Establish predictable eating schedules
Determine when kitchen is open/closed
Plan the same menu for all family members
Involve the child in meal planning/prep/label reading
Model positive eating behaviors
– Enthusiastic about new foods
– Focused eating
– Slow-paced
• Make exercise part of daily life
• Provide non-food rewards
Adapted from: Satter, Ellyn , How to Get Your Child to Eat…But Not Too Much,
www.sccgov.org/sites/.../Division_of_Responsibility_in_Feeding.pdf
The Division of Feeding Responsibilities
CHILD
• How much he/she eats at planned meals and
snacks
• How their body eventually turns out
Adapted from: Satter, Ellyn , How to Get Your Child to Eat…But Not Too Much,
www.sccgov.org/sites/.../Division_of_Responsibility_in_Feeding.pdf
Rosita the Reproductive Years
Rosita
• Rosita is now 28 years old and a new mother.
She presents for her 6 week postpartum visit
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 FPG 90, 1 hr 179, 2 hr 158)
Screening & Diagnosis in Pregnancy
Overt Diabetes (screen high risk patients at first prenatal visit)
FPG>126, or
A1C>6.5, or
2 Hour glucose > 200 using 75 gm GTT
Random glucose >200, with symptoms of hyperglycemia
Gestational Diabetes (screen all patients without overt DM)
75 gm 2hr GTT at 24-28 weeks gestation with 1 abnormal:
FPG > 92
1hr >180
2hr >153 mg/dL
Adapted from Standards of Medical Care in Diabetes-2013. Diabetes
Care, 36, Supplement 1, S15.
Glycemic Goals in Pregnancy
GDM:
preprandial: < 95mg/dL and either
1h postmeal: < 140mg/dL or
2h postmeal: < 120mg/dL
Overt Diabetes (Women with preexisting type 1 or type 2 DM):
premeal, bedtime, and overnight glucose 60–99
peak postprandial glucose 100–129
A1C <6.0%
Standards of Medical Care in Diabetes-2013. Diabetes Care, 36,
Supplement 1. S21
Rosita’s History
• Her last trimester A1C was 5.5
• GDM was adequately controlled with MNT
as evidenced by consistent FPG <95 with
2 hr postprandial <120
• She states no time for exercise with new
baby, and has resumed a “normal diet”
Criteria for Testing for Diabetes in
Asymptomatic Adults
Overweight (BMI >25 kg/m2)
Plus one or more additional risk factors:
•
•
•
•
•
•
•
•
•
•
physical inactivity
first-degree relative with diabetes
high-risk race/ethnicity
women who delivered a baby >9 lb or hx GDM
hypertension
HDL <35 mg/dL and/or a triglyceride >250mg/dL
Hx PCOS
A1C >5.7%, IGT, or IFG on previous testing
other clinical conditions associated with insulin resistance
known CVD
Standards of Medical Care in Diabetes-2013. Diabetes Care, 36,
Supplement 1, S14
Physical Exam
• 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 (96cm)
• PE: Obese, lactating female with normal eye,
CV, neuro, monofilament, skin and GYN exam
Labs
• FPG 101, with 2 hour (75 gm) glucose challenge
180.
• A1C (and Lipids) not checked
Does Rosita have Diabetes?
•
•
•
•
A1C ≥ 6.5%
FPG ≥ 126
2-hour OGTT (75gm glucose load) ≥ 200
Random plasma glucose ≥ 200 in a patient
with symptoms and signs of
hyperglycemia
Standards of Medical Care in Diabetes-2013. Diabetes Care, 36,
Supplement 1, S13.
Does Rosita have Prediabetes/
IFG/ IGT?
Fasting plasma glucose
100-125 mg/dL
2 hour OGTT
140-199 mg/dL
A1C
5.7-6.4%
2013 ADA Guidelines
Suppose Rosita (as described) is
6+months postpartum with the
following additional labs…
• TG 190
• Total Cholesterol 200
• LDL 156
• HDL 35
• A1C 5.7
As before: FPG 101, 2 hour (75 gm) glucose
challenge 180
Is Rosita at Metabolic Risk?
PARAMETERS
NCEP / ATP 3 2005
REQUIRED
IDF 2005
AACE 2003
Waist >= 94 (men) or
80cm (women)
HR for insulin resistance OR BMI
>25 OR Waist >= 102 (men) or
88cm (women)
# ABNORMALS
>=3 OF:
+2 OF:
+2 OF:
GLUCOSE
(mg/dL)
FPG >=100
FPG >=100
FPG >=110,
2hr >=140
HDL (mg/dL)
<40 (men)
<50 (women)
<40 (men)
<50 (women)
<40 (men)
<50 (women)
TG (mg/dL)
>=150
>=150
>=150
OBESITY (cm)
Waist >= 102 (men) or
88cm (women)
HTN (mmHg)
>=130/85
>=130/85
>=130/85
Adapted from: Meigs, James. Metabolic syndrome and the risk for type 2
diabetes. Expert Rev Endocrine Metab. 2006; 1:57. Table 1
Metabolic Syndrome Management
• 7% weight loss yields a 58% reduction
in the incidence of diabetes at the end
of four years
Knowler WC, Barrett-Connor E. Fowler SE, et al; Diabetes Prevention Program Research
Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N
Engl J Med 2002;346:393-403
Metabolic Syndrome
Patient Education
• Medical Nutrition Therapy
– (MNT) refers to the nutrition assessment and
counseling provided by a registered dietitian to treat
an illness, injury, or health condition in order to benefit
the patient's health. 1
• Exercise
• Weight management
• Psychosocial and family implications
1J
Am Diet Assoc 94:838–839, 1994
Medical Nutrition Therapy
(MNT) for Rosita
Teachable moments
• Women with a recent GDM diagnosis present
an ideal group for diabetes prevention
– More motivated
– Desire for healthy baby/ to be a healthy mother
• Women are the gatekeepers for family
nutrition & fitness
– Health behavior changes can affect entire family
– Key time for health education and counseling
What is Rosita Eating?
Diet history questions to provide a picture of
your patient’s food intake pattern:
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

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“What time do you usually wake up?”
“Do you usually eat something then? What? Where?”
“When is the next time that you eat? What? Where?”
“What do you like to drink?”
“Who shops for food/prepares the meals in your
household?”
Interpreting Rosita’s diet history:
What she says… What she means…
7 am (home)
“Bread”
Pan Dulce (Sweet Bread)
Milk 16 oz
30 to 90g CHO
24g
10 am (work)
“Coffee”
Coffee
Muffin
0
30 to 80g
1 pm (work)
“Burrito”
Chicken, rice, bean burrito
Large 24 oz lemon-lime soda
50 to 120g
72g
6 pm (home)
“Pot roast”
Pot roast with potatoes, corn,
and garlic bread
45g 30g
40g
9 pm (home)
“Cereal”
Bowl Cornflakes
Low fat milk
Banana
30 to 60g
12 To 24g
15 to 30g
How Does Rosita’s Plate Measure Up?
U.S. Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC.
“Healthy Plate” Method for Meal Planning
Individualized MNT Plan for Rosita
• Water to replace caloric beverages
• Include protein at breakfast
– Cottage cheese or egg or nut butter or
beans or plain yogurt
– Provides satiety and improved pp BG
• Select ‘Healthy Plate’ Meals
– Fill ½ plate with vegetables
– Lean protein portion = palm of hand
– Starch portion = “fist-sized” portion
Prevention/delay of DM2
INTENSIVE LIFESTYLE MODIFICATION
• Achieve and maintain 7% weight reduction
• >150 min/wk of moderate physical activity
How do we motivate Rosita to do this?
Help her identify and overcome barriers
Standards of Medical Care in Diabetes- 2013. Diabetes Care, 36, Supplement 1,
S16.
What about Medications for
Rosita?
• Metformin reduced the development of
T2DM by 31%
• TZDs reduce IGT conversion to
diabetes by approximately 50–70%.
• Alpha glucosidase inhibitors and orlistat
have also proven effective
• GLP-1 analogs may be efficacious
Standards of Med Care in Diabetes-2012. Diabetes Care, 35, Supplement 1, S16
J Clin Endocrinol Metab 96: 2354–2366, 2011
Which One?
“Metformin therapy for prevention of type 2
diabetes may be considered in patients with
IGT, IFG, or an A1Cof 5.7–6.4%, especially
for those with BMI >35 kg/m2, those aged
<60 years, and those with prior GDM. “
Standards of Medical Care in Diabetes-2013. Diabetes Care, 36, Supplement 1,
S16.
Bottom Line…
Pharmacological intervention with a variety of agents
reduces the rate of conversion of prediabetes to T2DM,
but Therapeutic Lifestyle Change (TLC) remains the
mainstay of rx
For metabolic syndrome with coexistent prediabetes,
Metformin can be considered.
At least annual monitoring for the development of diabetes
in those with prediabetes is suggested.
(DeFronzo, J Clin Endocrinol Metab 96: 2354–2366, 2011)
Practice Improvement Tool #2
Process Mapping
Process Mapping
• What are the steps that you would go through
as a patient for an office visit in primary care?
• Procedure
– Identify who is involved in the process
– Identify the starting and end points
– Draw swim lanes and post the steps in the
process over time moving left to right
– Map the process using sticky notes
– Use 2 words for the process (noun + verb)
Work Flow and Process
Mapping
Patient Contact
Patient
Front Desk
MA
Nurse
Provider
Lab
Pharmacy
Process Mapping
• Where does the task match the skill set of the
person?
• Where does work back up?
• Where does the patient wait?
• Where does the provider wait?
• Is the right information available at the right
time?
• Can the work flow be simplified?
• Swim lane cross requires a “hand-off”
Work Flow and Process
Improvement
•
•
•
•
•
Patient flow
Availability of information and supplies
Waits and delays
Distance traveled
Facility promotes team function and supports
EMR use
• Teamwork and communication
Rosita the Middle Years
Rosita the Middle Years
Rosita is now 50 years old, obese and
complaining of blurred vision for
several days, weight loss, and feeling
tired all the time.
Which of the following is NOT an indication
for screening for diabetes?
Dyslipidemia
Hypertension
High risk ethnicity
Age 40
All of the above are
appropriate
indicators
65%
22%
4% 4% 4%
Dy
slip
ide
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pe
rte
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hr
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eth
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ity
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ove
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1.
2.
3.
4.
5.
American Diabetes Association. (2013). Standards of Medical Care in Diabetes2013. Diabetes Care, 36, Supplement1, S14.
Diagnosis
• FPG ≥ to 126
• A1C ≥ to 6.5%
• 2 hour OGTT using 75gm glucose load ≥
200
• Random plasma glucose ≥ 200 in a patient
with symptoms and signs of
hyperglycemia
American Diabetes Association .(2013). Standards of Medical Care in Diabetes2013. Diabetes Care, 36, Supplement 1, S13.
Diagnosis
• In the absence of unequivocal
hyperglycemia the abnormal test should
be confirmed
• Preferable to confirm with same test
• If two different tests are used and both are
above threshold, diabetes is confirmed
• If two different tests are used and are
discordant, repeat the abnormal test
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S12.
Type 1 Vs Type 2: How To Tell Them Apart
Type 1
Type 2
Treatment
Always insulin; 4+ shots
Pills  Insulin
Age at Onset
10% of adults w/ new dx
50% of children w/ new dx
Weight
~20% obese
~10% thin
Family History
10% w/ a close relative
>50% w/ a close relative
DKA
Can happen
Can happen
Blood Glucose
More variable; big hypo’s
More stable; milder hypo’s
Thyroid Disease
Often
Sometimes
Antibodies
Usually (Anti-GAD)
Not usually
C-peptide
Early: low nl; Late: ~0
Early: high nl; Late: low nl
Atypical Diabetes
• Maturity Onset Diabetes of the Young
(MODY)
– <5% of children
– Treatment varies
– Family members may benefit from screening
– Consider in Dx <6 months, discordant
phenotypes
American Diabetes Association .(2013). Standards of Medical Care in Diabetes2013. Diabetes Care, 36, Supplement 1, S43-44.
Atypical Diabetes
Type 1.5 or Latent Autoimmune Diabetes in Adults
(LADA) = a form of Type 1 DM
•
•
•
•
10% of Adults-UKPDS
Onset > age 30
Circulating autoantibodies (usually to GAD)
Progression to insulin requirement by 6 years
Fourlanos, S., Stein, M., Stankovich, J., Harrison, L.C., Colman, P.G., Perry, C., (2006). A
Clinical Screening Tool Identifies Autoimmune Diabetes in Adults. Diabetes Care, 29 (5).
970-975.
Latent Autoimmune Diabetes in Adults
(LADA)- When to Consider
•
•
•
•
•
•
•
Age of diagnosis <50
Acute symptoms at diagnosis
BMI <25
Personal history of autoimmune disease
Family history of autoimmune disease
90% sensitivity, 71% specificity
If less than or equal to one predictor are positive
then 99% negative predictive value
Fourlanos, S., Stein, M., Stankovich, J., Harrison, L.C., Colman, P.G., Perry, C., (2006). A
Clinical Screening Tool Identifies Autoimmune Diabetes in Adults. Diabetes Care, 29 (5).
970-975.
Targets for Blood Glucose
ADA Goals
AACE Goals
A1C
< 7.0% (individualize)
≤ 6.5% (individualize)
Preprandial glucose
70-130 mg/dL
< 110 mg/dL
Postprandial glucose < 180 mg/dL
< 140 mg/dL
ADA. Diabetes Care 2012;35:S11–S63
AACE, Endocrine Practice; Vol 17 (Suppl 2) March/April 2011
Blood Pressure in Diabetes
• Measured at every visit
• Goal of < 140/80 -THIS IS A CHANGE
• Lifestyle changes to include exercise, DASHtype diet, weight loss
• Pharmacologic regimen should include ACE
inhibitor or ARB (monitor, serum creatinine/GFR
and potassium)
• At least one medication should be given at
bedtime
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S29
Lipids
• Measure annually
• Statin therapy regardless of LDL value for
patients with diabetes and
– Overt cardiovascular disease (CVD)
– Without overt CVD and age >40 and one or
more other risk factors for CVD
– Goal is <70 mg/dL in those with overt CVD
– Goal to reduce LDL by 30-40% is an
alternative if number not attainable on max
tolerable therapy
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S31.
Lipids
• In lower risk patients (less than 40 yrs old
or without overt CVD) goal LDL is
<100mg/dL
• Treat with statins if lifestyle alone does not
achieve LDL <100mg/dL OR in patients
with multiple risk factors
• Triglycerides <150mg/dL, HDL > 40mg/dL
for men and 50mg/dL for women desirable
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S31.
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 ( 10 year CVD risk greater than
10%)
• Consider in any age with multiple CV risk factors
• Not recommended ages < 21 (Reye’s syndrome)
• Clopidogrel 75 mg/day- intolerance to ASA
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S33.
Nephropathy Screening
• Annually
• Serum Creatinine-use to calculate GFR
• Measure albumin to creatinine ratio in a
spot collection
• When to begin
– Type 1 diabetic patients for >5years
– Type 2 diabetic patients at diagnosis
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S34.
Definitions of Abnormalities
In Albumin Excretion
Category
Spot urine collection albumin/
creatinine (microgram/mg
creatinine)
Normal
<30
Microalbuminuria
30-299
Macroalbuminuria
(clinical)
≥300
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S35
Treatment of Albuminuria
• ACE or ARB is recommended
• Reduce protein to 0.8-1.0 g/kg of body
weight per day in mild CKD
• Reduce protein to 0.8g/kg in more severe
CKD
• Control glucose and blood pressure to
reduce the progression of nephropathy
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S35
Kidney disease can exist
before microalbuminuria
http:/www.nkdep.nih.gov
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S36.
Stages Chronic Kidney Disease
Stage
Description
GFR
1
Kidney damage with normal or inc. GFR
>=90
2
Kidney damage with mild decrease in
GFR
60-89
3
Moderate decrease in GFR
30-59
4
Severe decrease in GFR
15-29
5
Kidney failure
<15 or dialysis
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S36.
Management of CKD in Diabetes
GFR
RECOMMENDATIONS
All Patients
Annual creatinine, screen for nephropathy, potassium
45-60
Referral to nephrology if possibility for nondiabetic kidney disease exists
(duration of type 1 diabetes <10 years, heavy proteinuria, abnormal
findings on renal ultrasound, resistant hypertension, rapid fall in GFR, or
active urinary sediment)
Consider need for dose adjustment of medications
Monitor eGFR every 6 months
Monitor electrolytes, bicarbonate, hemoglobin, calcium,
phosphorus, PTH yearly
Assure vitamin D sufficiency
Consider bone density testing
Referral for dietary counseling
30-45
Monitor eGFR every 3 months
Monitor laboratory values above and weight every 3–6 months
Consider need for dose adjustment of medications
<30
Referral to nephrology
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S37. Table 13.
Early Treatment Makes a Difference
Brenner, et al., 2001
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
Screening for Retinopathy
• Adults and children with type 1 DM within 5
years of diagnosis
• Patients with type 2 DM at time of diagnosis
• Comprehensive exam by ophthalmologist or
optometrist initially
• Retinal photography may be used in intervals
recommended by eye care provider
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S36.
Screening for Retinopathy
• Women with diabetes who are newly
pregnant or planning pregnancy should
have:
– Comprehensive ophthalmologic exam in 1st
trimester
– Counseling on development or progression of
retinopathy
– Close follow up during pregnancy and for one
year postpartum
American Diabetes Association .(2013). Standards of Medical Care in Diabetes-2013.
Diabetes Care, 36, Supplement 1, S36.
Reasons to Look at Feet
• Up to 70% of diabetics eventually develop
a neuropathy
• Up to 15%* develop foot ulcers
• Greater than 50% of foot ulcers become
infected
*The Semmes Weinstein Monofilament Exam as a screening tool for Diabetic
peripheral neuropathy Journal of Vascular Surgery; Sept 2009; 675-682.
Foot Ulcers
Deformity
Neuropathy
Trauma
are the most common factors that
interact leading to ulcers
http://care.diabetesjournals.org/content/31/8/1679.full.pdf+html (accessed
on 01/28/2013).
Risk Factors for Foot Ulcers
–
–
–
–
–
–
–
–
–
Previous amputation
Past foot ulcer history
Peripheral neuropathy
Foot deformity
Peripheral vascular disease
Visual impairment
Diabetic nephropathy (especially patients on dialysis)
Poor glycemic control
Cigarette smoking
http://care.diabetesjournals.org/content/31/8/1679/T1.expansion.html (accessed on
01/28/2013)
Foot Surveillance
• Examine the feet at every visit
• Annual comprehensive evaluation
–
–
–
–
–
–
Testing for loss of protective sensation (LOPS)
Pulses
Skin condition (ulcers, hair, nails)
Anatomic deformities
Shoe evaluation
Consider ABI age >50 and <50 if other risk
factors for PAD
American Diabetes Association .(2013). Standards of Medical Care in
Diabetes-2013. Diabetes Care, 36, Supplement 1, S38.
Sensation Exam
• Monofilament PLUS one of the following:
– Vibratory with 128 Hz tuning fork
– Pinprick
– Ankle reflexes
– Vibratory threshold with a biothesiometer
American Diabetes Association .(2013). Standards of Medical Care in Diabetes2013. Diabetes Care, 36, Supplement 1, S38.
Foot Exam Sites
http:/ /care.diabetesjournals.org/content/31/8/1679.long
(accessed 02/24/13)
Risk Classification Based on
Comprehensive Foot Exam
Risk
Category
Definition
Treatment
Follow up
0
No LOPS, No
PAD, No
Deformity
Patient Education
Advice on protective footwear
Yearly by PCP and/or
specialist
1
LOPS ±
Deformity
Patient Education
Consider prescriptive Footwear
Consider surgery if deformity cannot be
accommodate
Every 3-6 months by
PCP and/or Specialist
2
PAD ±LOPS
Patient Education
Consider prescriptive footwear
Consider vascular surgery
Every 2-3 months by
specialist
3
History of
ulcer or
amputation
Patient Educations
Consider prescriptive footwear
Consider vascular surgery if PAD
Every 1-2 months by
specialist
http://care.diabetesjournals.org/content/31/8/1679/T4.expansion.html (accessed
02/24/13)
Co-Morbidities Assessment
• Screen for depression and diabetesrelated distress, anxiety, eating disorders,
and cognitive impairment when self
management is poor.
• Bariatric surgery may be considered for
adults with BMI >35 and Type 2 DM
American Diabetes Association. (2013). Executive Summary- Standards of Medical Care in
Diabetes-2013. Diabetes Care, 36, Supplement 1 , S6.
Co-Morbidities Assessment
•
•
•
•
•
•
•
•
•
Hearing impairment
Obstructive sleep apnea
Fatty liver disease
Low testosterone in men
Periodontal disease
Certain cancers
Fractures
Cognitive impairment
Depression
American Diabetes Association .(2013). Standards of Medical Care in Diabetes2013. Diabetes Care, 36, Supplement 1, S39.
Health Maintenance
• Vaccinations
– Influenza
– Pneumovax
– Hepatitis B - all adults age 19-59
• Smoking cessation
– Counseling
– Pharmacotherapy
American Diabetes Association. (2013). Executive Summary- Standards of
Medical Care in Diabetes-2013. Diabetes Care, 36, Supplement 1 , S6-7.
Referrals to consider
•
•
•
•
•
•
Certified Diabetes Educator
Registered Dietitian
Eye care provider
Nephrology when appropriate
Podiatry when appropriate
Behavioral Medicine
Rosita
Remember Rosita is a team member
Medical Nutrition Therapy for DM2
Consistent carbohydrate intake
Modify fat and
calorie content
Monitor blood glucose
to adjust therapy
Optimize BG control
Improve blood lipids
Control blood pressure
Moderate weight loss
Spacing of meals
Increase physical activity
Key Nutrition Teaching Points
Familiarity with macronutrients
 Identify and limit carbohydrate foods.
• Starches, fruits, root vegetables, milk, sweets
• Caloric beverages
• Portion sizes and carbohydrate grams
 Include protein-rich foods with meals.
• Lean choices
• Portable protein snacks
 Reduce intake of saturated and trans fats.
• Omega 6: Omega 3 ratios
Rosita’s Blood Glucose Record
Fasting
151 mg/dl
2hr pp
220
Fasting
147 mg/dl
165
2hr pp
178
2 hr pp
189
183
191
Diet and Blood Glucose Record
151
2 c cereal
1½ c nf milk
Banana
147
2 slices whole 165
wheat toast
Low sugar
jam
220
Turkey
baloney
sandwich
Grapes
Iced tea
178
2 cups spaghetti
189
Turkey meat sauce
Salad, dressing
Tuna salad
Apple
5 crackers
Iced tea
183
Chinese take-out:
Orange chicken
1 cup rice
Diet soda
191
Looking at Carbohydrate Grams
6 a.m.
151 mg/dL
2 c cereal
1 ½ c nf milk
Banana
60 g
18 g
30 g
108g
Turkey baloney
sandwich
Grapes
Iced tea
147 mg/dL
2 slices
whole wheat
toast
Low sugar
jam
30
Tuna salad
Apple
5 crackers
Iced tea
10
40g
30
30
52
112g
0
15
15
52
82g
2 cups spaghetti w/
Turkey meat sauce 90
Salad, dressing
10
100g
Chinese take-out:
Orange chicken
1 cup rice
Diet soda
40
45
0
85g
Carb Counting
• Most meal-related glucose excursions are related to
carbohydrate content of the meal
– Carbohydrate begins to raise blood glucose within
15 minutes of eating
– 90 to 100% of dietary CHO enters the blood
stream as glucose within an hour
• Teach patients to keep a carbohydrate budget for
meals and snacks
– 45 to 60 grams per meal
– 15 to 30 grams per snack
15 Gram Carbohydrate Portions
STARCHES
FRUITS
MILK
1/3 cup pasta
½ cup oatmeal
1/3 cup rice
½ cup corn
1 apple
1 c milk
1 cup berries ½ c yogurt
1 cup melon
¼ cup dried fruit
1 oz slice bread
½ English muffin
1 corn tortilla
4-6 crackers
15 grapes
½ large banana
Medical Nutrition Therapy for CKD
(Stages 3 to 5)
Calories
30-35 kcals/kg IBW
Protein
0.6-0.8 gm/kg IBW
Sodium
1000-4000mg
Fluids
Evaluate need to restrict
Potassium
Evaluate need to restrict
Calcium
<2000mg
Phosphorus
800-1000 mg
Vitamins
Individualized
Medical Nutrition Therapy for CKD
Carbohydrate
4 kcals/g
Protein
4 kcals/g
Fat
9 kcals/g
1 cup milk
12
8
0 –10
1 oz meat
0
7
1 – 12
1 oz bread
15
3
0
1 cup veg
1 fruit
5
15
2
0
0
0
1 teaspoon
fat/ oil
0
0
5
Food
Diabetes Education Resources
www.diabeteseducator.org
www.diabetes.org
www.cdc.gov/diabetes
www.eatright.org
www.joslin.org/info/diabetes-and-nutrition
Rosita’s A1C-Six months later
7.5
How The Body Handles Glucose
(Fed State)
LIVER
PANCREAS
GLUCAGON
GLUCAGON
AMYLIN
INSULIN
BRAIN
Blood
Glucose
Glucose
60-90 mg/dL
90-140
mg/dL
I
N
S
U
L
I
N
FAT
GI TRACT
MUSCLE
Pathophysiology of Type 2 Diabetes
PANCREAS
LIVER
Metformin
TZDs
BRAIN
GLUCAGON
GLUCAGON
GLUCAGON
AMYLIN
INSULIN
INSULIN
A1C < 7%
Premeal
~ 100mg/dL
Hyperglycemia
PPG < 200 mg/dL
II
N
N
S
S
U
LU
L
II
N
N
Insulin
Sulfonylureas
Glinides
Incretin tx
FAT
Pramlintide
GI TRACT
Dietary Composition
Portion Control
-Glucosidase Inhibitors MUSCLE
Weight Loss
Exercise
TZDs
(Metformin)
ADA-EASD Position Statement: Management of
Hyperglycemia in T2DM
Anti-hyperglycemic Therapy
Therapeutic options: Oral agents & non-insulin
injectables Metformin
Meglitinides
Sulfonylureas
a-glucosidase inhibitors
Thiazolidinediones
Bile acid sequestrants
DPP-4 inhibitors
Dopamine-2 agonists
GLP-1 receptor agonists
Amylin mimetics
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Class
Mechanism
Advantages
Disadvantages
%A1C
Change
Biguanide
Metformin
• Hepatic
glucose
production
• No hypoglycemia
• Weight neutral
• ?  CVD events
•Low cost
• Gastrointestinal
• Lactic acidosis
• B-12 deficiency
• Contraindications
1-2
SUs /
Glinides
• Insulin
secretion
•  Microvascular risk
• Low cost
•Extended experience
• Hypoglycemia
• Weight gain
• Low durability
• ?  Ischemic
preconditioning
1-2
TZDs
• Insulin
sensitivity
• No hypoglycemia
• Durability
•  TGs,  HDL-C
• ?  CVD events (pio)
• Weight gain
• Edema / HF
• Bone fractures
• ?  MI (rosi)
• ? Bladder ca (pio)
•High cost
<1
a-GIs
•Slows
carbohydrate
absorption
• No hypoglycemia
• Nonsystemic
•  PP glucose
• ?  CVD events
• Gastrointestinal
• Dosing frequency
• Modest  A1c
•Moderate cost
<1
Adapted from “ Properties of anti-hyperglycemic agents”
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Class
Mechanism
Advantages
Disadvantages
%A1C
Change
DPP-4
inhibitors
• Inhibits DPP-4
• Increases GLP-1,
GIP
• No hypoglycemia
• Well tolerated
•Weight neutral
• Modest  A1c
• ? Pancreatitis
• Urticaria
•High cost
<1
GLP-1
receptor
agonists
• Insulin, 
glucagon
•  gastric emptying
•  appetite
• Weight loss
• No hypoglycemia
• ?  Beta cell mass
• ? CV protection
• GI
• ? Pancreatitis
• Medullary ca
• Injectable
•High cost
<1
Amylin
mimetic
•  glucagon
•  gastric emptying
•  appetite
• Weight loss
•  Post-prandial
glucose
• GI
•Injectable
• Hypo w/ insulin
• dose with meals
•High cost
<1
Bile acid
sequestrant
• Binds bile acids
•  Hepatic glucose
production
• No hypoglycemia
• Nonsystemic
•  LDL-C
• GI
• Modest  A1c
•  TGs
• Dose with meals
Adapted from “ Properties of anti-hyperglycemic agents”
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Class
Mechanism
Advantages
Disadvantages
%A1C
Change
Dopamine- • Modulates
2
hypothalamic
agonists
control of
metabolism
•  Insulin
sensitivity
Insulin
• No hypoglycemia
• Glucose
• Universally effective
disposal
• Unlimited efficacy
•  Hepatic
glucose production
• Nausea
• Dizzy/syncope
• Fatigue
< 0.5
• Hypoglycemia
• Weight gain
• ? Mitogenicity
• Injectable
• Training
requirements
• “Stigma”
1.5 –
3.5
Adapted from “ Properties of anti-hyperglycemic agents”
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
General Rules
Hyperglycemic 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
General Rules
Hyperglycemic Therapy
• Self Management
• Using meters
– Making the invisible… visible
– Testing 2hr postprandial
– Learn how to use a meter!
ADA-EASD Position Statement: Management of
Hyperglycemia in T2DM
Anti-Hyperglycemic Therapy
• Implementation strategies:
- Initial therapy
- Advancing to dual combination therapy
- Advancing to triple combination therapy
- Transitions to & titrations of insulin
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Fig. 2. T2DM Antihyperglycemic Therapy: General Recommendations
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Fig. 2. T2DM Antihyperglycemic Therapy: General Recommendations
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Fig. 2. T2DM Antihyperglycemic Therapy: General Recommendations
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
ADA-EASD Position Statement: Management of Hyperglycemia in T2DM
KEY POINTS
• Glycemic targets & BG-lowering therapies must be individualized.
• Diet, exercise, & education: foundation of T2DM therapy
• Unless contraindicated, metformin = optimal 1st-line drug.
• After metformin, data are limited. Combination therapy with 1-2 other
oral / injectable agents is reasonable; minimize side effects.
• Ultimately, many patients will require insulin therapy alone / in
combination with other agents to maintain BG control.
• All treatment decisions should be made in conjunction with the patient
(focus on preferences, needs & values.)
• Comprehensive CV risk reduction - a major focus of therapy
Diabetes Care 2012;35:1364–1379
Diabetologia 2012;55:1577–1596
Key Points to Consider for Therapy
Maximal benefits of Metformin are observed
at the recommended daily dose of 2000 mg (1 g BID)1
Thiazolidinediones should be started at low doses and
slowly increased to minimize side effects2
Glucose-lowering effects of a sulfonylurea plateau at half
the maximum recommended dose3
1.Garber AJ et al. Am J Med 1997;103:491
2.Nesto RW et al. Diabetes Care 2004;27:256
3.Stenman S et al. Ann Intern Med 1993;118:169
Lunchtime
Those Pesky Details…
Project Schedule and Funds
Today:
1. Complete and return the evaluations,
W-9 and Change Agent LOA. If you
receive honoraria from GO! we will send
you a 1099 form reporting miscellaneous
income
Those Pesky Details…
Project Schedule and Funds
2. Give a GO! presentation to your
colleagues no later than April 16, 2013,
fax the sign in sheet with emails. There
is a $3,000 honorarium for the
presenters or the residency program.
3. Recruit colleagues for the Diabetes
METRIC module, receive up to $1,000
per residency.
Those Pesky Details…
4. Physicians-in-training will be reimbursed
for travel to the Research Workshop
(Kansas City) and GO! Diabetes Summit
(San Diego).
5. Lead poster authors will receive a $800
honorarium for presenting at the GO!
Summit.
Now back to our regular
programming…
To improve, you must make changes
But…
Not all changes lead to improvement
Practice Improvement
Tools # 3 and 4
An Aim Statement is SMART
• Answers and clarifies “What are we trying
to accomplish?”
• Creates a shared language to
communicate the project to others.
Aim Statement
S – specific
M – measurable
A – attainable
R – relevant /realistic
T − timely
Defining the Measures
A good aim statement helps define the
measures.
– Measurement should not slow things down
– Seek usefulness, not perfection
– Use sampling
– Use accessible measures (don’t wait for IT)
Aim Exercise
• Choose an area in your theme you want to
improve
• Write an aim statement for the next few
months of the project
• How will you measure it?
Developing an Aim Statement
“We would like to improve the care of our
diabetic patients.”
“To improve the care of our diabetic patients
we would like for them to leave the
practice with an updated list of their
medications.”
“By the end of 2013, 75% of our diabetic
patients seen at the office will leave with
an updated list of their medications.”
Rosita in Transition
Rosita in Transition
• Rosita is now 60 years old and has been living with Type
2 DM since the age of 50.
• Treatment regimen includes: DASH diet, 150 min/week
exercise, and oral medications with intermittent
adherence (lisinopril, metformin, and sitagliptin).
• Over the past two years, Rosita has been working more
and exercising less.
• Her last visit to her PCP was 18 months ago.
• How do you know that Rosita doesn’t already have
cardiovascular disease???
Risk Factors for CV Disease
•
•
•
•
Hypertension
Current cigarette smoking
Male age >45, female age >55
HDL <40 males, HDL <50 females
– HDL >60 negative risk factor
• Family history of CV disease-MI or sudden death
– male 1° relative <55
– female 1°relative < 65
http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf
Coronary Heart Disease Risk
Equivalents
• Symptomatic Carotid Artery Disease
• Abdominal Aortic Aneurysm
• Peripheral Vascular Disease
http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf
Screening for CV Disease
• Asymptomatic patients - screening not
recommended as it does not improve
outcomes as long as risk factors are
treated
• Cardiac testing
– Typical or atypical cardiac symptoms
– Abnormal resting ECG (ST-T abnormalities,
ischemia, or infarction)
Diabetes Care, volume 36, Supplement 1 January 2013 pg S34
Rosita’s A1C…..
9.1
Rosita in Transition
• Rosita’s husband brings her to the office because she is
confused, has been losing weight, complains of blurry
vision, and is hungry and thirsty all the time.
• Vital Signs: Temp 103, HR 110, BP 166/92, 02 85% RA
• Physical Exam: Tachycardic, tachypneic, rales RLL
• Labs: Urine ketones, moderate glucose and protein
What is your assessment and plan?
Rosita Inpatient Transition
• Labs
– Glucose 480 mg/dL
– Creatinine 1.6, BUN 35, K 3.7
– TC 242, LDL 137, HDL 42, TG 180
• Medication Reconciliation
– Discontinue metformin, sitagliptin
– Continue lisinopril
Rosita Inpatient Transition
Medication Orders
– Statin
– ASA
– Antibiotics
Medication Options
– Diuretic?
– Beta blocker?
– Insulin?
Rosita Insulin Transition
• Basal/bolus therapy
–
–
–
–
–
–
–
–
175 pounds ~ 80 kg
80 * 0.5 units/kg
40 units
40/2
20 units basal
20 units bolus
20/3 meals
~ 6 units/meal
• Home BG monitoring
– qac + qhs
• Basal/bolus orders
– 20 units glargine sc qhs
– 6 units aspart sc qac
Rosita Insulin Transition
• TDDI calculated
• Scheduled insulin +
additional doses
required
• 40 units basal/bolus +
10 units
• TDDI = 50 units
TDDI=Total Daily Dose Insulin
CF=Correction Factor
•
•
•
•
•
CF calculated
1,500/TDDI
1,500/50 units
CF = 30
Blood glucose target
before meals = 130
1500 for patients using regular insulin
1800 for patients using analog insulin
Determine the Correction Factor
CF is the number of mg/dL one unit of insulin lowers glucose
• Select a sensitivity constant
– 1800 for patients using analog insulin
– 1500 for patients using regular insulin
• Divide by Total Daily Dose Insulin (TDDI)
-sample calculation for severely insulin resistant patientPatient currently administers 50 units insulin per day
TDDI = 50
Correction Factor = 1500/50 = 30
One unit of insulin will lower BG by 30 mg/dL
Davidson PC, et.al. An empirical basis for modifying the“1500
rule”[abstract] Diabetes. 2002;51(Suppl. 2):A128
Determine the Additional Insulin Dose
(Current BG-Target BG) ÷ C.F. = Additional Insulin Dose
• Before Breakfast – Glucose Goal 130
• Glucose 220 220-130 = 90/30 = 3 units to correct BG
• Scheduled insulin 6 units + 3 corrective = 9 units
• Before Lunch
• Glucose 280 280-130 = 150/30 = 5 units to correct BG
• Scheduled insulin 6 units + 5 corrective = 11 units
• Before Dinner
• Glucose 190 190-130 = 60/30 = 2 units to correct BG
• Scheduled insulin 6 units + 2 corrective = 8 units
(Current glucose – target glucose) ÷ Correction Factor = Additional Insulin Dose
Management of Diabetes in the
Hospitalized Patient
• Critically ill: Insulin treatment for persistent BG
>180 to maintain a range of 140-180 mg/dl
• Non-critically ill: No clear evidence. Pre-meal
goal of <140mg/dl and random BG of <180
mg/dl if treated with insulin
• More stringent goals in patients with previous
tight control and less stringent goals in patients
with multiple co-morbidities
Diabetes Care, volume 36, Supplement 1 January 2013 pg S47.
Preparing for Home
Team-based care
–
–
–
–
–
–
–
–
Patient & Family
Nurse Assistant
Bedside Nurse
Pharmacist
Certified Diabetes Educator
Case Manager & Social Worker
Resident, Physician Assistant & Attending
Primary Care Provider
Preparing for Home
•
•
•
•
•
•
Eating habits
Movement regimen
Social support
Immunizations
Medication reconciliation & adherence
Follow up with primary care provider
Beta Cell Function Declines
UKPDS Data
• Beta cell function
declines with time
• 5-10% failure per
year
• Eventually Insulin
needed
Challenges with Achieving
Target A1C Values
• Therapeutic inertia
• Complexity of care
• Lack of effective lifestyle intervention
• Role of postprandial glucose in failure
• Late diagnosis and initiation of therapy
• Adverse events associated with antihyperglycemic therapies
Insulin Therapy
• ACE and AACE recommend insulin when:
initial A1C is >9, DM is uncontrolled >7
despite optimal oral meds
• FPG > 250mg/dl
• Random glucose >300mg/dl
• Not contraindicated at any time
• Polyuria, polydipsia, weight loss, ketones
Petznick, Allison. Insulin Management of Type 2 DM. American Family
Physician. July 2011 Volume 84 (2); 183-189.
What are some common
patient concerns when
transitioning to insulin?
Patient Barriers to Insulin Therapy
• Fear of needles or pain from injections
• Fear of addiction to insulin
• Fear of hypoglycemia
• Weight gain
• High cost of care
Brunton et al. Update on Insulin Management in Type 2 Diabetes. The Journal
of Family Practice Supplement May 2012;61:5.
Patient Barriers to Insulin Therapy
• Belief of becoming
more ill
• Perceived negative
impact on quality of
life
• Co-morbidities:
– Poor eyesight
– Arthritis
– Forgetfulness
•
•
•
•
Perceived failure
Social stigmatization
Treatment complexity
Lack of understanding
seriousness of
diabetes
• Perception that
quality of previous
treatment was low
Brunton et al. Update on Insulin Management in Type 2 Diabetes. The Journal
of Family Practice Supplement May 2012;61:5.
General Strategies for Initiation
• Patient active role
• Diabetes is selfmanaged
• Minimizes long-term
complications
• Treatment plan will be
modified
• Insulin pen devices
convenient
• Lifestyle management
emphasis
• Willingness to
participate in group
• Individualized written
action plan:
– Dosing
– Self-monitoring
– Hypoglycemia
Brunton et al. Update on Insulin Management in Type 2 Diabetes. The Journal
of Family Practice Supplement May 2012;61:5.
What are your concerns when
transitioning a patient to
insulin?
Insulin Initiation
Provider Concerns
•
•
•
•
•
Which insulin?
How much?
How do I adjust?
How do I teach?
How often do I change dosages?
Insulin Initiation
Answers to Provider Concerns
• Normalize the fasting glucose
– FPG 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 < 70
Once Daily Insulin Options
Basal vs. NPH vs. Premixed
INSULIN TYPE
ADVANTAGES
DISADVANTAGES
Glargine
Peakless, less
hypoglycemia, less wt
gain; simple
Cost; can’t mix; no
meal time coverage,
basal only
Detemir
Less wt gain, less
hypoglycemia; simple
Cost, shorter duration
than glargine; can’t
mix, basal only
Pre Mixed 70/30 or
75/25
Covers meal time and
basal; easy transition
to bid
More hypoglycemia
and weight gain than
basal
NPH
Less expensive
More hypoglycemia
than basal
Analog vs. Human
No difference in A1c lowering but
less hypoglycemia with analog in
Type 1 Diabetes
Diabetes Care, volume 35, Supplement 1 January 2012 pg S21.
Insulin therapy
• Augmentation – basal and/or bolus with partial
beta-cell failure
– Basal regimen fewer adverse side effects vs.
premixed or bolus.
– Dose 0.3 u/kg/day
• Replacement - basal and bolus when beta cell
function is absent
– 50% basal and 50% bolus in divided doses
– Dose 0.6 u/kg/day
1Petznick,
Allison. Insulin Management of Type 2 DM. Am. Fam. Physician. July
2011 Vol. 84 (2); 183-189.
Oral Meds When Starting Insulin
• Metformin
– Continue unless contraindicated
– Reduces CV risk in overweight Type 2 DM pts
• Secretagogues
– Can generally continue with basal insulin
– Stop if using large, multi-dose or premixed insulin
• TZDs
– Proceed with caution
– Exacerbates weight gain and edema
Causes of Hypoglycemia
• Incorrect amount of insulin/oral agents
• Skipped or delayed meal/snack
• Carbohydrate intake less than normal
• Alcohol intake without food
• Exercise without insulin/food adjustment
• Not re-testing 1 to 2 hours after hypoglycemia
treatment if meal or snack is not eaten
Recognizing Hypoglycemia
• Hypoglycemia: Glucose <70 mg/dL
• Symptoms may or may not be present¹ ²
– Neurogenic: hunger, palpitations, sweating, trembling
– Neuroglycopenic: behavior changes, cognitive impairments,
confusion, difficulty concentrating, difficulty speaking, seizures
• On average, 15 g of rapidly absorbed carb can raise BG by 25 to
50mg/dL
• BG begins to fall at 60 minutes and reaches previous tx level at 2
hours.
¹Diabetes Care: Challenges From a Primary Care Perspective October 2012; p 11.
²Cryer et al. Diabetes Care 2003;26:1902
Rule of 15
• Treat with 15 grams of fast-acting carb
15 grams fast-acting carbs:
• 6 oz fruit juice or regular (not diet) soda
• 1 tube of glucose gel or 1 tablespoon honey
• 4 teaspoons of sugar
• Wait 15 minutes and re-test BG
• If BG remains <70 mg/dL– repeat tx
• After achieving normalized BG, eat
meal/snack within the hour.
Treatment of Severe Hypoglycemia
• Definition: Requires assistance to treat
• Inject glucagon with loss of consciousness or seizure
• Administered by another person (may be given
intramuscular or subcutaneous)
• Standard dose
• 1.0 mg for adults; 0.5 mg for
children under 5 yrs
• Prescription required
• Precautions
• May cause nausea /vomiting/headache
• Call 911
Hypoglycemia Prevention
Instruct patients to…
– Follow action plan
– Test blood glucose daily
– Carry carbohydrates
– Wear medical
identification
– Teach others how to
inject glucagon
Which of the following should be tapered
and discontinued with replacement insulin?
Metformin
Glyburide
Sitagliptin
Acarbose
12%
arb
ose
Ac
Sit
agl
ipt
in
Gl y
bu
ri d
e
orm
in
0%
Me
tf
1.
2.
3.
4.
84%
4%
Rosita Safe at Home
• Team-based care
– Patient & Family
– Receptionist
– Medical Assistant
– Office Manager
– Certified Diabetes Educator
– Physician Assistant
– Resident & Attending
Model for Improvement
What are we trying to accomplish?
Aim
How will we know a change is an
improvement?
Measures
What change can we make that will result in
Improvement?
Plan
Act
Do
Study
Ideas
PDSA Pitfalls
•
•
•
•
Plan, Plan, Plan, Panic
The Nike Model “Just do it”
The research model – Plan-do-study-publish
Neglecting to follow up on previous changes
introduced (leaving out the “s”)
• Piloting on a large scale – more than just a test
• “Do” and “Act” are NOT a PDSA cycle
PDSA Cycle Exercise
• Write out the Plan section for 2 PDSA cycles
– Objective
– Questions and predictions
– Plan to carry out the cycle (who, what, where,
when)
– Plan for data collection
• Report out on one Plan
Call to Action
Wrap Up
Change Agent Next Steps
•
•
•
•
•
Recruit participants for METRIC
Present local program
Implement practice improvement activities
Measure change using METRIC
Develop research
Change Agent Resources
Susan Reichman, BSN, Project Director, Green Team
Coordinator
[email protected] or 1-888-388-8215
Kara Sinkule, Blue Team Project Coordinator
[email protected] or 1-888-388-8216
Change Agent Resources
www.godiabetes.org
GOing Forward – e-newsletter
[email protected]
Change Agent Role
•
•
•
•
•
•
Champion of the project
Help give a local presentation
Actively recruit METRIC participation
Nurture collaborative environment
Guide practice change using the PI tools
Encourage research
GO!