2013 International Diabetes Center

Transcription

1 Day to Day Management of Diabetes Part 1 Review of Diabetes and Therapies Diane Reader RD, CDE Manager, Diabetes Professional Training International Diabetes Center Overview of Diabetes lucose and Insulin 1

2 Insulin Sensitive Cells (adipose and muscle) Nucleus Liver, pancreas and brain do not require insulin for glucose uptake Insulin lucose Insulin Receptor lucose Transporter (LUT 4) Overview of Classifications Type 1 Diabetes Absolute insulin deficiency; auto-immune destruction of the pancreas; must take insulin estational Diabetes Hyperglycemia first recognized during pregnancy; due to insulin resistance caused by placental hormones; risk of type 2 diabetes post-partum about 50% Type 2 Diabetes Insulin resistance and insulin deficiency Natural History of Type 2 Diabetes lucose 200 (mg/dl) Relative function Post Meal lucose Fasting lucose Clinical diagnosis Insulin Resistance Insulin Level Pre-diabetes (IF, IT) Metabolic Syndrome Incretin Action Onset Diabetes Years Adapted from: UKPDS 33: Lancet 1998; 352, ; DeFronzo RA. Diabetes. 37:667, 1988; Saltiel J. Diabetes. 45: , Robertson RP. Diabetes. 43:1085, 1994; Tokuyama Y. Diabetes 44:1447, Polonsky KS. N Engl J Med 1996;334:777. 2

3 Type 2 Diabetes (NIDDM, adult-onset) Problem: Insulin resistance / insulin deficiency Symptoms: often none, fatigue, blurred vision, frequent infections, poor wound healing, dry / itching skin, numbness / tingling hands and feet Ketones: usually negative Lifestyle factors: obesity, inactivity Age: all ages, recent increase in children enetic predisposition: 80-90% identical twins Treatment: Food plan / exercise May need pills and/or insulin Risk Factors for Type 2 Diabetes Prediabetes (A1C %, FP mg/dl) Older than age 45 Family history (1 st degree relative) Overweight (BMI 25 mg/m 2 ) Physical inactivity Hypertension 140/90mmHg in adults Race/ethnicity: Black or African American, Native American, Latino, Asian American, Pacific Islander, Alaska Native HDL 35 mg/dl and /or triglycerides 250 mg/dl History of CVD Smoking History of DM or delivery of baby > 9 pounds Polycystic ovary syndrome Acanthosis nigricans (dark, velvety patches of skin) Diagnosed Diabetes in Adults by Age, Sex and Ethnicity (%) y 44-64y 65y 25.8 million people in US with DM 8.3% of population Men Women CDC Data: Diabetes Fact Sheet White Black Asian Amer. Hispanic Non-h Non-h Indian, N Alaska 3

4 Diagnosis of Diabetes Test Options A1C 6.5 % Laboratory Value for Diagnosis Fasting Plasma lucose Casual Plasma lucose 2-hour OTT (75g glucose) 126 mg/dl 200 mg/dl and symptoms (polyuria, polydipsia, weight loss) 200 mg/dl Must be confirmed on subsequent day unless unequivocal symptoms of hyperglycemia No gold standard but A1C has less variability with stress or illness, and convenience of not requiring fasting ADA Clinical Practice Recommendations 2013 Suppl.1; ADA, EASD, IDF International Expert Committee Report on A1C for Diagnosis of Diabetes.. Diagnosis: Understanding the A1C RBC Hgb Red Blood Cell Hemoglobin lucose Normal A1C High A1C A1C and Blood lucose oal with diabetes A1C no diabetes Obtained every 3-6 months after diagnosis 4

5 Priorities of Care for Adults with Diabetes Diagnosis Self Management Knowledge and Skills lucose Monitoring Living and Coping Food Plan & Nutrition Risk Reduction Physical Activity Problem Solving Medication lucose Lipid Disorders Hypertension Complications Other Essentials of Care International Diabetes Center, Park Nicollet Clinic Diabetes Treatment Options Nutrition Therapy for Diabetes Many confusing messages Count carbohydrates Eat whole grains Don t eat sugar Lose weight Eat low carb or no carb Must eat snacks Cut back on fat Avoid white carbs Eat fish regularly Add cinnamon 5

6 oals of Nutrition Therapy for Diabetes Promote healthful eating patterns emphasizing variety appropriate portion sizes improve overall health (BP, lipids, glycemic control, weight) To address individual nutrition needs To maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence Provide practical tools for day-to-day meal planning Evert et al. Diab Care 37(1) 2014, p S Food Basics CARBOHYDRATES PROTEIN FAT Bread rains Fruit Milk Starchy Vegies Sweets Meat Poultry Fish Cheese Eggs Soy Burger / Tofu Peanut Butter /Nuts Butter Oils ravy Salad Dressing Peanut Butter /Nuts lucose Amino Acids Fatty Acids Blood lucose Control Both are important! Lower Risk For Disease 1 Carbohydrate Choice = 15 grams 1 small fruit/ or ⅓ - ½ cup or 1 slice bread ½ cup juice starchy food 1-6 tortilla/chapati ⅓ - 12 injera or 1 cup milk/ or ½ cup ice cream artif. sweetened yogurt 1 oz. candy bar (fun size) 1 Tbsp sugar/honey My Food Plan, 2008, International Diabetes Center Choose Your Foods, Exchange Lists for Diabetes, ADA/American Dietetic Association 6

7 Carbohydrate Counting From My Food Plan, 2014, International Diabetes Center Free Foods Non-Carb Foods Foods with very little or no effect on B levels From My Food Plan, 2014 International Diabetes Center 7

8 Breakfast 2 2 slices toast 1 ½ grapefruit 1 ½ cup oatmeal How many carb choices in this dinner? Roll 1 carb Salad Very low carb Salad dressing Fats Strawberries, 1 cup 1 carb Potato, medium 2 carb reen beans Low carb Chicken No carb 4 carb choices = 60 grams rams Aren t for Everyone ½ plate is about 1 cup = 2-3 carbs ¼ plate is about ½ cup ~ 1 carb 8

9 Count the Carbs in Your Dinner The Food Label 1. Locate Serving Size 2. Locate Total Carbohydrate (grams) 15 grams = 1 carbohydrate choice Sugar: Ignore sugar grams Choose Your Foods: Exchange List for Diabetes 2008 Diabetes Care (37) Supp1: S134, My Food Plan IDC Park Nicollet, 2014 Carbohydrate Per Meal Elderly/ Lose Weight Maintain Weight Very Active Women 2-3 choices (30-45g) 3-4 choices (45-60g) 4-5 choices (60-75g) Men 3-4 choices (45-60g) 4-5 choices 60-75g) 4-6 choices (60-90g) Carb Choices and Approximate Calories* 9-12 per day = kcals per day = kcals * assumes approx 6 oz protein, 1-2 fats per meal, 3 or more servings of vegetables and 0-2 snacks/day Type 2 BASICS 4 nd ed 2014:p28, International Diabetes Center 9

10 To Snack or Not To Snack? Snacks can be included Satisfy hunger Control appetite Individual enjoys Add Calories and carbohydrates Prevent hypoglycemia (balance with medications) Often high in fat, calories, sodium Update: Oral Diabetes Medications and Non-Insulin Injectables Diabetes IDC Type 2 Diabetes: lycemic Control Nutrition and Activity Therapy Metformin Advance/initiate drug treatment if not at target Titrate to clinically effective dose Advance/initiate drug treatment if not at target Two-Drug Therapy Advance/initiate drug treatment if not at target Titrate to clinically effective dose Three-Drug Therapy Advance/initiate drug treatment if not at target Titrate to clinically effective dose Insulin Therapy 10

11 Pathophysiology of Type 2 Diabetes Incretin Deficiency Insulin Resistance Relative Insulin Deficiency Prediabetes and Type 2 Diabetes Natural History of Type 2 Diabetes lucose 200 (mg/dl) Relative function Post Meal lucose Fasting lucose Clinical diagnosis Insulin Resistance Insulin Level Pre-diabetes (IF, IT) Metabolic Syndrome Incretin Action Onset Diabetes Years Adapted from: UKPDS 33: Lancet 1998; 352, ; DeFronzo RA. Diabetes. 37:667, 1988; Saltiel J. Diabetes. 45: , Robertson RP. Diabetes. 43:1085, 1994; Tokuyama Y. Diabetes 44:1447, Polonsky KS. N Engl J Med 1996;334:777. Incretins Deficiency A substance produced by cells in the gut that stimulates insulin secretion Intestine Secretion Insulin = Incretin Insulin response to carbohydrate/fat meals (beta cell) Satiety lucagon secretion after meals (pancreas) lucose output (liver) astric emptying Appetite (CNS) Weight (often) 11

12 Insulin Deficiency: Impaired β-cell Function In Response to lucose Insulin Response Without Diabetes Type 2 Diabetes Adapted from Diabetes 1989; 38:673abetes Care. 1992;15: Time (hours) 18 Commonly Used Diabetes Pills 5 Main Ways They Help Prevent liver from making too much glucose (sugar) Help pancreas make more insulin Make cells more sensitive to insulin Help pancreas cells work better Help kidneys remove glucose Diabetes Insulin Resistance Biguanide lucophage metformin Reduces fasting Action glucose levels Decreases hepatic glucose production Insulin sensitizer Other Clinical Indications: Limits weight gain, good choice if obese May reduce cardiovascular risk (T, LDL, PAI-1) Concerns: Possible I Side effects, lessened with slow dose titration Avoid if renal or hepatic disease check Cr/ALT), CHF Avoid with excessive or binged alcohol use Extended release: lumetza metformin XR Once daily at dinner Less I side effects 12

13 Relative Insulin Deficiency Sulfonylurea Diabeta Micronase glyburide Amaryl glimepiride Action Stimulates pancreas to secret more insulin Other Clinical Indications: Extensive experience Works quickly Lowest cost Concerns: Hypoglycemia lucotrol glipizide Reduces fasting glucose levels Hypoglycemia Risk Long-Acting Short-Acting Once dosed once per day Short half-life, take with meals Less hypoglycemia May forget to take Insulin Resistance Thiazolidinedione (TZD) Actos Pioglitazone Avandia not recommended Action Increases insulin sensitivity Other Clinical Indications: Consider if very insulin resistant Consider if other therapies not tolerated/contraindicated or significant insulin resistance as 2 nd or 3 rd line therapy May improve lipids (HDL, T) Concerns: Initiation/maintenance not preferred due to associated risk of weight gain edema CHF bladder cancer macular edema bone fractures (post-menopausal women) May cause or exacerbate CHF Black Box Warning Consider discontinuing or dose when insulin initiated due to risk of peripheral edema Incretin Deficiency Dipeptidyl Petidase-4 Inhibitor (DPP-4) Januvia TM Sitagliptin Onglyza TM Saxagliptin Tradjenta TM Linagliptin Nesina TM Alogliptin Reduces glucose Action level after meals Prevents breakdown of natural incretins Improves β-cell function Lower post-meal glucagon Other Clinical Indications: Well tolerated Weight neutral Take with or without food Low risk of hypoglycemia Concerns: Expense; may not be on formulary Reduce dose for moderate-severely impaired renal function (except Tradjenta) 13

14 Increase lucose Excretion SLT-2 Inhibitors Invokana TM Jardiance Action Canagliflozin Empagliflozin Increases glucose excretion from kidneys Other Clinical Indications: Take once per day before first meal Small weight loss Concerns: Check renal function before initiation and periodically enital yeast infections, increased urination, UTI Hypotension (elderly), LDL, cr, K+ Reduces glucose level after meals Incretins: Non-Insulin Injectables LP-1 Byetta Exenatide Victoza Liraglutide Tanzeum Action Reduces glucose level after meals Slows gastric emptying, appetite Enhances insulin release, lucagon after meals Other Clinical Indications: Simple QD (Victoza) or BID dosing (Byetta) Up to 1 hour prior to meals (Byetta) No hypoglycemia unless other hypolgycemic meds used Modest weight common Concerns: Nausea; may over time Pancreatitis (rare) Contraindicated if efr less than 30 ml/min (Byetta) Black Box Warning: Thyroid C-Cell Tumors (Victoza) Not recommended with gastric bypass Sulfonylurea dose by 50% when initiating Incretins: Non-Insulin Injectables Extended Release Bydureon TM Tanzeum TM Exenatide Extended Release Albiglutide Other Clinical Indications: Weekly injection Any time of day Concerns: Black Box Warning: Thyroid C-Cell Tumors 23 guage needle (Bydureon ) Not recommended with gastric bypass Contraindicated if efr less than 30 ml/min or End Stage Renal Not recommended with gastric bypass Sulfonylurea dose by 50% when initiating 14

15 Commonly Used Diabetes Pills 5 Main Ways They Help Prevent liver from making too much glucose (sugar) Help pancreas make more insulin Make cells more sensitive to insulin Help pancreas cells work better Help kidneys remove glucose Metformin lucophage Metformin ER lyburide lipizide lucotrol lipizide XL Repaglinide Prandin Pioglitazone Actos Rosiglitazone Avandia Sitagliptin Januvia Saxagliptin Onglyza Linaglipitin Tradjenta Canagliflozin Invokana Diabetes Nateglinide Starlix Alogliptin Nesina IDC Type 2 Diabetes: lycemic Control Nutrition and Activity Therapy Metformin Advance/initiate drug treatment if not at target Titrate to clinically effective dose Advance/initiate drug treatment if not at target Two-Drug Therapy Advance/initiate drug treatment if not at target Titrate to clinically effective dose Three-Drug Therapy Advance/initiate drug treatment if not at target Titrate to clinically effective dose Insulin Therapy The Ins and Outs of Insulin Therapy 15

16 Normal Insulin Secretion Mealtime (bolus) insulin needs ~ 50% Background (Basal) Insulin Needs ~ 50% Time Kruszynska et al. Diabetologia 30: 16-21, 1987 Polonsky et a. J. Clin. Invest. 81: , 1988 Background Insulin Human Insulin Starts Working Works Hardest Stops Working Effectively Intermediate 2-4 hrs 4-8 hrs hrs Relative Insulin Effect Long 2 hrs Steady most of day Intermediate: NPH Up to 24 hrs Long- largine Detemir Acting (LA): (Lantus) (Levemir) Time (Hours) Bergenstal International Textbook of Diabetes Mellitus Vol 1. 3rd Ed 2004: Mealtime Insulin Human Begins Works Stops Working Insulin to Work Hardest Effectively Rapid 5-15 min 1-2 hrs 3-4 hrs Short min 2-3 hrs 4-8 hrs Relative Insulin Effect Rapid-acting (RA): Lispro Aspart lulisine (Humalog) (Novolog) (Apidra) Short-acting: Regular Novolin R, Humulin R, Reli-On R Time (Hours) Hirsch, NEJM, 352:2, 2005 Bergenstal International Textbook of Diabetes Mellitus Vol 1. 3rd Ed 2004:

17 Premixed Insulin Background with Mealtime Insulin Premixed Human Insulin Starts Working Works Hardest Stops Working Effectively With Rapid-acting 5-15 minutes 1-2 hrs and 4-8 hrs hrs Relative Insulin Effect With Regular minutes 2-3 hrs and 4-8 hrs hrs Premixed with Rapid-acting Premixed with Regular Time (Hours) Bergenstal International Textbook of Diabetes Mellitus Vol 1. 3rd Ed 2004: Common Insulin Regimens 1 injection per day Background only Continue non-insulin meds 2 injections per day Background plus 1 mealtime Premixed 4+ injections per day Background plus all mealtimes Factors to Consider when Selecting an Insulin Regimen Insulin Regimen Background Only Premixed Background + Mealtime (3 meals) lycemic Factors Targets fasting glucose Targets pre and post meal Targets pre and post meal Most physiologic Patient Factors Overwhelmed Resistant to starting insulin One shot per day Has or is willing to have consistent meal times Opposed to more than 2 injections Needs flexible schedule Desires tight control 17

18 Carbohydrate Strategy Varies With Treatment Meal Plan Only Oral Agents / LP-1 Agonist Background Insulin and Oral Agents or LP 1 Avoid excessive carb at any one meal Consistent carb intake Spread carb out over the day (portion control) Premixed insulin Background and Mealtime Insulin Match insulin to carb Consistent carb or insulin to carb ratio Diabetes Diab Care 37(1): S124, 2014 IDC Clinical Consensus 18