Cardiac Rehabilitation New Brunswick: Tutorial Series. Diabetes Mellitus Overview, pharmacotherapy and exercise considerations

Transcription

1 Cardiac Rehabilitation New Brunswick: Tutorial Series Diabetes Mellitus Overview, pharmacotherapy and exercise considerations

2 Overview Prevalence of diabetes Definition and Diagnosis Risk factors and complications Treatment and pharmacotherapy Diabetes and Exercise Benefits Precautions and considerations Exercise prescription

3 Diabetes epidemic 7.3% of Canadian population, expected to rise to 10% by % 32% of patients with a myocardial infarction have both diabetes and coronary artery disease 2 1. Canadian Diabetes Association, 2010 Economic Report 2. Miketic et al., Journal of Cardiovascular Nursing, 2011: 26(3)

4 Definition: Diabetes Mellitus Complex metabolic disorder Characterized by: High levels of plasma glucose (hyperglycemia) due to defective insulin secretion, defective insulin action or both Hyperglycemia over time leads to serious damage to many of the body's systems, such as macrovascular disease, microvascular degeneration, neuropathies and other complications

5 Canadian Diabetes Association Diagnostic Criteria Diabetes Pre diabetes Source: Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S8 11 website: guidelines.diabetes.ca

6 American Values (ADA) Pre diabetes Diabetes ADA, Diabetes Care, 2012, (35) S1: S64 71

7 Conversion mmol to mg/dl: multiply by (x) 18 mg/dl to mmol/l: divide by 18 or multiply by (x) 0.055

8 Classification Type 1 Type 2 Gestational Other genetic defects, diseases of the exocrine pancreas, endocrinopathies, drug or chemical induced, etc. See CDA 2013 Guidelines Appendix 1: Appendix1

9 Diabetes Mellitus: Type 1 About 5 10% of all diabetes Autoimmune disease characterized by β cell destruction Usually leads to absolute insulin deficiency Unknown etiology, maybe virus, toxins, genetics Increase loss of water through sugar in urine Severe thirst, weight loss, increase appetite Subject to ketoacidosis metabolic acidosis

10 Diabetes Mellitus: Type % of all diabetes Characterized by peripheral insulin resistance and defective insulin secretion that can progress to insulin resistance Decrease in sensitivity of peripheral receptors in smooth muscle and liver Reduction in glucose disposal rate Plasma insulin can be increased, may lead to β cell exhaustion

11 Type 1 vs. Type 2 Characteristics Type 1 Type 2 Age of onset Generally <20 > 30 (usually) Type of onset abrupt slow progression Environment Virus, toxins, autoimmune stimulation Family History probable frequent Obesity, poor nutrition, physical inactivity Endogenous insulin Minimal or absent Insulin resistance, secretion adequate but delayed or reduced Symptoms Thirst, polyuria, weight Mild or frequently none loss, appe te Insulin Tx Required for all Required for ~30%

12 Type 2 Risk factors Lifestyle disease! Risk factors are: obesity (central adiposity) sedentary high blood pressure, high cholesterol smoking age non white race genetics gestational diabetes (or baby > 9 lbs)

13 Complications cardiovascular disease ( atherosclerosis, endothelial dysfunction, inflammation) retinopathy (blindness) nephropathy autonomic neurophathy peripheral neuropathy non traumatic amputations erectile dysfunction mental health disorders (dementia)

14 Treatment targets Glycosylated Hemoglobin A1C= Hb A1C =A1C Average blood glucose control over the last 2 3 months, non fasting Treatment goal: A1C below 7% For patients: Morning plasma glucose (FPG) (4 7 mmol/l)

15 Blood Pressure Targets 2010 Canadian Hypertension Guidelines No Diabetes <140/90 mmhg With diabetes or persons with chronic kidney disease <130/80 mmhg

16 Treatments Type 2 Weight loss Oral hypoglycemic agents (see Pharmacotherapy section) Possibly insulin Type 1 Subcutaneous injections of insulin (see Pharmacotherapy section) Dietary regulation Exercise daily

17 Pharmacotherapy Oral Hypoglycemic Agents (OHA) Antihyperglycemic agents Used only in type 2 diabetes, with diet and exercise CDA 2013 Clinical Practice Guidelines Pharmacotherapy in Type 1 diabetes (pages s56 s60), Pharmacologic Management of Type 2 Diabetes (pages s61 s68)

18 Pharmacotherapy Class: Biguanides (Insulin Sensitizer) Generic Brand Advantages Disadvantages A1C Metformin Glucophage, 1 2% Glumetza Weight neutral low risk of hypoglycemia GI side effects (nausea, bloating, diarrhea, decreased appetite) Mechanism of Action: hepa cglucose produc on and intes nal glucose absorp on, glucose uptake and insulin sensitivity, lowers basal and post prandial blood glucose levels Comments: first line agent in type 2 good as initial therapy especially if overweight best to gradually increase dose to GI side effects Contraindicated if CrCl/eGFR <30 ml/min or hepatic failure Caution with renal insufficiency (egfr<30ml/min) lactic acidosis may be precipitated by renal impairment, excessive alcohol intake, hepatic disease, acute CHF

19 Pharmacotherapy Class: Sulfonylureas and Meglitinides (Insulin Secretagogues) Generic Brand Advantages Disadvantages A1C Glyburide* Diabeta rapid effect weight gain, risk of hypoglycemia, 1 2% Gliclazide Diamicron dizziness, headache, nausea, weakness Glimepiride Amaryl Repaglinide Gluconorm expensive Mechanism of Action: Stimulates functional β cells in pancreas to release insulin, glucose output from liver Comments: take with food hypoglycemia and weight gain are especially common with glyburide* caution with patients at high risk of hypoglycemia (e.g. the elderly, renal/hepatic failure)

20 Pharmacotherapy Class: Alpha glucosidase inhibitors Generic Brand Advantages Disadvantages A1C Acarbose Glucobay Prandase Weight neutral low risk of hypoglycemia GI side effects (diarrhea, gas, cramps, liver dysfunction) % Mechanism of Action: Delays digestion of CHO and gastrointestinal absorbtion of glucose. Inhibits pancreatic amylase and membrane bound intestinal α glucoside hydrolase. Comments: Take with food (first bite of meal) Takes up to 8 weeks for maximum efffect Not recommended as initial therapy in people with marked hyperglycemia (A1C >9.0%)

21 Pharmacotherapy Class: Tiazolidinidediones (TZD) or Glitazones (Insulin sensitizers) Generic Brand Advantages Disadvantages A1C Pioglitazone Rosiglitazone Actos Avandia improved lipid profile, low risk of hypoglycemia, potential decrease in MI (pio) Slow onset, fluid retention, weight gain, bone fractures, expensive, potential increase in MI (rosi) 0.5 2% Mechanism of Action: insulin resistance, improves target cell response to insulin, hepa c glucose production Comments: may induce ovulation only covered by blue cross through special authorization must be intolerant to metformin take at same time everyday some blood pressure lowering

22 Pharmacotherapy Class: Glucacon Like Peptide 1 (GLP 1) (Incretins) Generic Brand Advantages Disadvantages A1C Liraglutide Exenatide Victoza Byetta weight loss, low risk of hypoglycemia injection, expensive, long term safety not established, GI side effects % Mechanism of Action: Glucagon Like Peptide 1 (GLP 1) receptor agonists act to insulin release in the presence of glucose, glucagon secre on and delay gastric emptying Comments: may be beneficial for weight loss may delay gastric emptying and impact absorption of oral meds (caution with antibiotics and contraceptives) caution with patients at high risk of hypoglycemia (e.g. the elderly, renal/hepatic failure)

23 Pharmacotherapy Class: Dipeptidylpeptidase 4 (DPP 4) Inhibitors (Incretin) Generic Brand Advantages Disadvantages A1C Sitagliptin Saxagliptin Januvia Onglyza weight neutral, low risk of hypoglycemia expensive, longterm safety not established % Mechanism of Action: DPP 4is an enzyme that breaks down the incretin hormones GIP and GLP 1 to help increase the release of insulin and decrease glucagon levels in the circulation Comments: Better post prandial glucose control

24 Pharmacotherapy Insulin Rapid Acting Humalog (lispro) Short Acting Humulin R Novolin Intermediate Acting Humulin N Long Acting Lantus Levemir

25 Acute response to exercise Acute exercise results in glucose use and sensitivity to insulin Improves uptake of glucose for type 2 Aids in glucose homeostasis Can lower blood glucose for up to 72 hours post exercise

26 Benefits of chronic exercise Improved insulin sensitivity Increased muscle capillary density, use glucose more efficiently Changes in insulin signaling (translocation of GLUT 4) Improved blood glucose control = decrease in A1C

27 Benefits of chronic exercise (cont.) Decreased CV risk Improved blood lipids Improved blood pressure in those with hypertension Increase in caloric expenditure (improve BMI) Control body weight ( visceral fat) Increased fitness Improved psychological well being (decrease in depression)

28 Benefits of Exercise: Type 2 vs. Type 1 Type 2 Reduced blood glucose and A1c levels Improved glucose tolerance Improved insulin response to oral glucose Type 1 Improvement in insulin sensitivity may be transient

29 Response to exercise Acute exercise results in increased glucose utilization In turn, increased glucose production to maintain normal levels Compromised in diabetic state (those on insulin or insulin secretagogues) can lead to risk of hypoglycemia

30 Screening Procedures History and Physical exam Diabetes evaluation (screening for neuropathy, retinopathy, poor glycemic control) Cardiovascular Exam May include exercise stress test (see 2010 ACSM Position Stand and 2013 Canadian Diabetes Association guidelines)

31 CDA recommendations People with diabetes with possible CVD or microvascular complications of diabetes who wish to undertake exercise that is substantially more vigorous than brisk walking should have medical evaluation for conditions that might increase exercise associated risk. The evaluation would include history, physical examination (including funduscopic [eye] exam, foot exam, and neuropathy screening), resting ECG and, possibly, exercise ECG stress testing [Grade D, Consensus]. Physical Activity and, Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1 S21

32 Exercise testing Other considerations: Asymptomatic (silent) ischemia more common in people with diabetes Parasympathetic and sympathetic dysfunction Altered autonomic control (neuropathy) HR variability, impaired HR recovery, blunted BP response, postural hypotension Monitor blood glucose pre and post May consider submax for prescription

33 Considerations for exercise: Hypoglycemia Be aware of signs and symptoms profuse sweating (diaphoresis) tachycardia hunger blurred or double vision confusion tremors headache memory loss seizure or coma

34 Precautions for Avoiding Hypoglycemic Events The risk of hypoglycemia is greater in those on insulin or insulin secretagogues (sulfonylureas and meglitinides) In these individuals, monitor blood glucose before exercise: If blood glucose is < 100mg/dL (5.5 mmol/l) eat 15 30g CHO snack If controlled by diet or other oral medication, the risk of hypoglycemia is minimal and most individuals will not need to monitor blood glucose levels or supplement CHO for exercise lasting < 1 hour.

35 Precautions for Avoiding Hypoglycemic Events For those on insulin: Adjust insulin dosages associated with exercise Avoid exercise during periods of peak insulin activity Insulin should not be injected into an exercising muscle Exercise late in the evening may increase the risk of nocturnal hypoglycemia

36 Considerations for exercise: Hyperglycemia Be aware of signs and symptoms dizziness dehydration nausea polyuria blurred vision lethargy sweet smelling breath vomiting Hyperventilation monitor for signs especially if exercising in heat

37 Hyperglycemia guidelines Type 1: if > 16.7mmol/L (300mg/dL) and patient does not feel well and/or keytones = postpone exercise Type 2: if > 16.7 mmol/l, do not need to postpone exercise provided they are feeling well, monitor for signs and symptoms Ensure adequate hydration Use caution; may want to warm up 10 min and ensure blood glucose is not increasing

38 Contraindications to exercise ACSM Guidelines Box 3.5 Uncontrolled proliferative retinopathy

39 Exercise programming: Aerobic Training F: 3 7 days per week I: 50 80% if VO 2 R or HRR, RPE 12 to 16, talk test T: min/day Bouts of at least 10 min CDA guidelines: Total 150 minutes/week moderate or 90 min vigorous 5 10 min warm up and cool down Type: Aerobic: large muscle groups

40 FITT Intensity Other Considerations For substantially vigorous exercise Symptom limited exercise stress test recommended due to increased risk of complications THR always 10bpm below: 1mm horizontal or downsloping ST segment depression Anginal symptoms or other CV insufficiency SBP 240mmHg, plateau SBP or SBP DBP 110mmHg

41 FITT Intensity Other Considerations THR always 10bpm below: frequency ventricular dysrhythmias Other significant ECG disturbances Radionuclide evidence LV dysfunction Mod/sev wall motion abnormal with exercise Other signs/symptoms of intolerance

42 Exercise programming: Resistance Training F: 2 3 days per week I: 2 3 sets, of 8 12 reps at 60% 80% 1 RM T: 8 10 multi joint exercises of major muscle groups Type: Tailor to need of client Evidence for resistance bands is unclear Avoid Valsalva Exhale on exertion

43 Canadian Diabetes Association: 2013 Clinical Practice Guidelines Exercise Prescription

44 Exercise counseling: Discuss proper glucose control, signs and symptoms, eating appropriately Medications Hydration Footwear Caution with extreme temperatures Medical ID bracelet May want to exercise with a partner