Diabetes: Beyond the D50. Leslie Huntington, BS, Paramedic Mobile Training Unit Oregon OHA-EMS and Trauma Systems

Transcription

1 Diabetes: Beyond the D50 Leslie Huntington, BS, Paramedic Mobile Training Unit Oregon OHA-EMS and Trauma Systems

2 The EMS View of Diabetes Management BG low? Give some form of sugar. Hero! BG somewhere in the middle? Nothing to see, people. Move on to something else. BG high? Provide supportive care. Turf to the hospital.

3 Chronic Diabetes Management: It s Just That SO COMPLICATED! Simple Pitfalls: internal stressors; knowledge of disease; coping mechanisms Meds Pitfall: medication dosing isn t an exact science Pitfall: complex carbs and fat will delay glucose absorption Diet The Patient Exercise Pitfalls: exercise can raise BG levels during the activity; BG-lowering effects can linger up to 24 hours

4 For This Class, It s All About the Complications The complicated side of chronic management Realities of care and EMS impacts Complicated treatment regimens Learning curves and problem-solving Complicated names! Introducing LADA and MODY The Type 2 twist Complicated research: expanding treatments

5 Practical Realities of Chronic The numbers game Management The myth of management Norms for the patient may vary Success and failure judged by numbers The good versus bad diabetic Expectations from family, physicians, friends, the patient Patients often succumb to failure or denial Patients may not be overly enthusiastic to share their numbers with you or anyone else

6 Practical Realities of Management Diabetes is a very emotional disease Frustration Learning things the hard way Adjusting plans when diabetes gets in the way The blood glucose roller coaster Management based on feelings Depression, denial, resigned to failure Fear of future complications Family dynamics Rebellion, arguments, fights over control, etc. Spousal management

7 Realities of Management Diabetes is a costly disease Triage of basic needs Rent v. test strips Insulin: $100 per bottle for some types Advanced treatment therapies Insulin pump cost: $5000 Pump/sensor supplies: $500 or more per month Management may vary with hard economic times

8 The EMS Help Line Sensitivity to the patient s spectrum of care Minimize the roller-coaster phenomenon Putting situational BGs in perspective Patient education and advocacy Basic education regarding the disease Referrals and resources Problem-solving Medication timing Prevention of future episodes of hypo- or hyperglycemia

9 Diabetes Care: Medications Meds Patient Diet Exercise

10 Current Medication Therapies Type 1 diabetes Insulin Meds Basal insulin Bolus insulin Type 2 diabetes Patient Oral and insulin therapies Diet Exercise Several types of oral medications Direct stimulation of the pancreas Work at the liver Sensitize cells to the work of insulin Slow gastric emptying

11 Medications for Type 2 Patients Drug Name Drug Action Hypoglycemia Risk Metformin; Glucophage Glyburide, glipizide; Glucotrol, Amaryl, Micronase, Diabeta Inhibit glucose production by the liver Increase insulin secretion at the pancreas After exercise 4-6 hours At night Fasting Repaglinide, nateglinide; Prandin, Starlix Pioglitazone, rosiglitazone; Actos, Avandia Acarbose, miglitol; Precose, Glycet Increase insulin secretion at the pancreas Increase glucose uptake by the skeletal muscle Slow or inhibit carbohydrate absorption in the small intestine 1-3 hours None None

12 Notes on Type 2 Medication Therapy The risk for hypoglycemia increases with combination therapy of oral meds Insulin therapy is utilized more commonly now than in years past Perspective: prevention v. an intervention for the bad diabetic Medication interactions Septra, oral meds and hypoglycemia Beta blockers mask signs of hypoglycemia

13 Insulin: Bolus and Basal Drugs Aspart = NovoLog Lispro = Humalog Glulisine = SoloStar Detemir = Levemir Glargine = Lantus

14 Insulin Problems: Hypoglycemia Daily insulin peaks Trends with mid-day, evening or late night lows Mismatch between insulin and food Forgetting to eat after a bolus Struggles with carb counting Other potential causes Fresh bottle of insulin Seasonal changes Exercise effects

15 How High is That BG? High blood glucose happens Spikes in BG are common From meals: insulin-food mismatch From hormonal changes: menses, menopause, internal stress (illness), external stress Trouble on the horizon: Type 1 several hours of sustained hyperglycemia (DKA potential) Type 2 persistent baseline hyperglycemia with a sudden physiological crisis (HHS, HHNK)

16 Insulin Injection Gadgets

17 Insulin Injection Gadgets iport

18 The Insulin Pump and Pod

19 Pump Stuff

20 Hypoglycemia NEVER disconnect the pump Rebound DKA Clinical hyperglycemia No Delivery phenomenon Kinked catheters Oversaturation of the site Pump Problems

21 Glucose Sensors

22 A New Topic: The Complicated Type 1 Type 2 Diabetes Name Game Adults and children! Type 1.5 No joke! Also known as LADA Latent Autoimmune Diabetes in the Adult MODY Maturity Onset of Diabetes in the Young Genetic issue

23 Type 1.5 Autoimmune disease like Type 1 More common than Type 1 Average age for diagnosis: 30 + May be misdiagnosed as Type 2 More rapid progression to insulin-dependence than the Type 2 folks 6 months versus several years Patients are not typically overweight No family history of Type 2 diabetes Medication effectiveness Preservation of beta cells Future cure

24 MODY Same, yet different from Type 1 and Type 2 Onset in adolescence or early adulthood 1-5% incidence Very slow progression Mild signs of hyperglycemia Family history of early-onset diabetes Patients are not typically overweight

25 MODY Genetic inability to secrete enough insulin 10 different mutations! Varying levels of insulin resistance Not an autoimmune disorder like the Type 1s May or may not require insulin Why should we care? To keep you from getting caught off guard with such a weird name Future research/cure

26 And Speaking of Youths...Type 2 in Children Obesity, poor nutrition and genetics are the primary factors for the development of this disease The disease profile is similar to the adult version of Type 2, except: The symptoms of onset are harder to detect in children Signs vary from no symptoms to blurry vision to full-blown HHNK/HHS

27 Scary Facts Regarding Type 2 in Kids Complications develop faster in youths Unknown reason for this Specific complications found in this group: High lipid levels, MI and microalbuminuria The obesity factor doesn t help, either 49% of children with Type 2 had systolic hypertension Likely contributor to the elevated cholesterol levels 18-61% of selected ethnic groups had left ventricular hypertrophy at diagnosis of Type 2

28 Treatment Challenges Medication options and research are limited for kids Metformin is the only approved oral medication Other medications for complications are not fully explored with children, either Patient compliance is difficult How can EMS help these kids? Family lifestyle and support groups Change of habits/acceptance of the disease CDC: average BG is between

29 Research Running out of time? Go to the summary slide

30 Complicated Research Diabetes is becoming more than an insulin problem Other GI and pancreatic hormones may be dysfunctional Speed up gastric emptying and fail to completely shut off glucacon May explain the exaggerated blood glucose spikes after a meal

31 New and Different Diabetes Drugs Incretin substitutes: Type 2 diabetes May expand to Type 1 patients in the future Drug names Injectable: Symlin, Byetta Oral: Januvia

32 Research on the Horizon Diaport another step closer to an artificial pancreas Surgical placement of catheter into the peritoneal cavity; catheter attaches to an insulin pump Work being done to develop an internal glucose sensor Current problem: infection, need to change internal catheter every 3 months

33 Ah, The Summary EMS treatment of diabetes is relatively simple Chronic management is not Keep this perspective in mind when working with your patients Don t make their life more miserable when you leave, both physically and emotionally Take advantage of the situation to be the patient s advocate and educator Help them with their problem-solving Suggest resources