Challenges in Glycemic Control in Adult and Geriatric Patients. Denyse Gallagher, APRN-BC, CDE Endocrinology Nurse Practitioner

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1 Challenges in Glycemic Control in Adult and Geriatric Patients Denyse Gallagher, APRN-BC, CDE Endocrinology Nurse Practitioner

2 Provide an overview of diabetes prevalence; discuss challenges and barriers in disease prevention, treatment, and management while caring for adults with type II diabetes Present the use of technology in patient care for type II diabetes in the Endocrinology and outpatient setting Demonstrate patient outcomes when transitioned to basal bolus regimen, insulin pump delivery and continuous glucose monitoring devices Objectives

3 93% 46% % 15% 54% 7.6% 9.0% Non-Hispanic White Asian American 12.8% 15.9% 13.2% 39% Diabetes Statistics Hispanic American Non-Hispanic Indian/Alaska Black Native

4 Screen Treat Manage Key Points of Discussion

5 Screen CHALLENGES Pre-diabetes Diabetes Lifestyle Change

6 86 MILLION The number of adults with PREDIABETES; 1 out of 3 Education Community Initiatives & Outreach Lifestyle & Behavioral Health Management Pre-diabetes Statistics

7 Treat CHALLENGES Medication Regimen Adherence Multi-system Disorder Complications Cost

8 Medication Regimen address insulin resistance, pancreas function, liver activity, appetite, reabsorption of sugar by the kidney s Cost and Insurance coverage issues Complication Management care team collaboration Medication Management

9 Manage CHALLENGES Acute & Chronic Complications HYPOGLYCEMIA

10 Neuropathy, Nephropathy, Retinopathy Goal setting; A1C recommendations considering age and co-morbid conditions Hypoglycemia prevention and management Complication Management

11 Defined as a blood glucose of less than 70 Falls, seizures, frequent hospitalizations and death Patient/Family stress Overtreatment from fear of running low Hypoglycemia unawareness Hypoglycemia

12 Patient: JT an 84 year old male with type 2 DM Diagnosis: February 2014, hospitalized for severe hypo and seizure, BG 29, A1C 9.0 Medication Regimen: Januvia 50 daily, Lantus 47 am, Humalog 2-6 units pre meal Issues: Was correcting at night, over treated hypo, pattern of lows, seizures, elderly spouse distraught, traumatic situation for patient and his family Case Study - Hypoglycemia

13 Post Care: Januvia d/cd, Lantus decreased to 44, Humalog 2-6, frequent testing, visits every 4-6 weeks first few months, phone calls in between for log review, team involvement Present Status: Recently A1C 8.3, same regimen, mild and rare hypo, no hospitalizations Recommendations: included family involvement, frequent testing hypo unaware, frequent visits with care team, taught to titrate insulin activity Case Study JT continued

14 Frequent testing is key to prevention management pre meal 2 hours post before during and after activity Over treating and fear of hypo can be a difficult scenario to manage Consider safest methods, goals less stringent Management & Prevention Hypoglycemia

15 Treat CHALLENGES Technology strategies to lessen challenges

16 V-Go Delivery Device

17 V-Go

18 The pump contains insulin, delivered in a continuous and precise flow through a thin, flexible tube called an infusion set. Basal Rate You can program your insulin pump to continuously deliver tiny and precise amounts of insulin 24 hours a day. Bolus Dose You can deliver additional insulin, called a bolus dose, to cover meals and to correct a high blood-glucose reading. Insulin Pump

19 Insulin Pump Choices

20 Flexibility Better BG control while minimizing the risk of low blood glucose Ability to match insulin to food and exercise Controls the dawn phenomenon Precise delivery of insulin Basal insulin delivery as low as.025 (25/100th) of a unit Bolus insulin delivery.1 (1/10th) of a unit Benefits of an Insulin Pump

21 Patient: 45 year old male, diagnosed with type 2 at 38. Holds 2 jobs, married with 2 children. Referred in 2013 with A1C Co-morbid Conditions: hypertension, high cholesterol, high triglycerides, low testosterone, obesity Medication Regimen: Lantus 10 units at bedtime, Metformin 1000 mg bid, Januvia 100 mg daily, Actos 30 mg daily Issues: High A1C, overweight, poor diet, lack of exercise Post Care: Medtronic insulin pump May 2014, CGM added, Victoza 1.8 mg 2 mos. A1C 4 mos. A1C 6 mos. weight decreased 30 lbs. and TDD insulin decreased by 30% Case Study Insulin Pump

22

23 Dexcom CGM

24 A small transmitter connected to a receiver reads interstitial; fluid at 228 readings per day Less accurate than blood glucose; not a replacement, works through calibration Provides predictive information on rise and fall of glucose - use with pump therapy or with MDI Continuous Glucose Monitor

25

26 Tracking to gain insight into patterns and trends can improve control, stabilize variability and prevent harm. This can be achieved with a log. book or various Apps that are available. Conclusion

27

28

29

30 AACE Comprehensive Diabetes Management Guidelines American Association of Clinical Endocrinologists. American Diabetes Association. Standards of Medical Care in Diabetes-2015, Diabetes Care 2015;38. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, Atlanta, GA: US Department of health and Human Services G4 Platinum References

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