diabetes update

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<ol><li> 1. 1 Diabetes Update 2013 Dr. Erin Koepf, PharmD, BCACP Assistant Professor, Ambulatory Care University of New England College of Pharmacy Maine Pharmacists Association, September 7, 2013 </li><li> 2. 2 Objectives: Based on the American Diabetes Association Standards of Medical Care in Diabetes 2013: Identify the classification, risk factors, diagnosis, and screening criteria for diabetes Explain pharmacologic and non-pharmacologic treatments options for patients with diabetes or pre-diabetes Describe measures that can be taken to prevent diabetes progression and complications including immunization recommendations </li><li> 3. 3 Objectives: Identify the class, mechanism of action, dosing, and administration of new and common diabetes medications Discuss with patients and other health care practitioners diabetes treatment options, monitoring, and the goals for therapy Compare and contrast medication therapies available for the treatment of diabetes and select appropriate options for a given patient Develop a comprehensive care plan for a given patient with diabetes which included pharmacologic and non-pharmacologic measures, monitoring, and preventative measures </li><li> 4. 4 What is Diabetes? Warm-up Spend 60 seconds thinking about and writing down a description of Diabetes Spend the next 2 minutes sharing your description with someone next to you Write down some of the concepts you come up with </li><li> 5. 5 What is Diabetes? Warm-up Endocrine condition that increases risks of Cardiovascular events v. Cardiovascular disease with abnormal processing and distribution of glucose Others? </li><li> 6. 6 Review: Diabetes Pathogenesis Insulin deficiency Quantitative: decreased in production by the -cells of the pancreas Qualitative: insulin resistance especially muscle, liver, adipose, myocardial Improvements in insulin function Weight loss to decrease insulin resistance Can in turn improve -cell function </li><li> 7. 7 Review: Diabetes Pathogenesis Excess secretion of glucagon by -cells of pancreas Glucose overproduction by liver; underutilized by body Gluconeogenesis (making glucose from glycerol and amino acids) Renal tubular transport of glucose to the urine due to hyperglycemia Incretin system deviations (relationship to DM still not fully clear) Glucagon-like peptide 1 (GLP-1) Glucose dependent insulinotropic peptide (GIP) </li><li> 8. 8 Who has Diabetes? Incidence of diabetes is rising (about 25 million adults in the US) Incidence is higher in certain populations Many risk factors/associated conditions are also rising in prevalence About 2/3 of patients with diabetes in the US also have hypertension (HTN) How does Maine compare to the US when it comes to incidence of Diabetes? </li><li> 9. 9 Incidence of Diabetes in the US Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012. Centers For Disease Control and Prevention. Diabetes Data and Trends. .http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.a spx?mode=DBT </li><li> 10. 10 Diabetes in the US Incidence increases with age Incidence ranges from 7.1% - 16.1% between different racial/ethnic groups Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012. </li><li> 11. 11 New Cases of Diabetes Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012. </li><li> 12. 12 Rates of Diabetes in Maine have been similar to that of the US Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention and Control Program, Maine Center for Disease Control and Prevention; 2012. </li><li> 13. 13 Diabetes Incidence in Maine Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention and Control Program, Maine Center for Disease Control and Prevention; 2012. </li><li> 14. 14 Prevalence Varies throughout Maine from 7% to 10.7% Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention and Control Program, Maine Center for Disease Control and Prevention; 2012. </li><li> 15. 15 Diabetes Disease Burden 2009 in Maine, diabetes related deaths had incidence of 65.8 per 100,000 Decreased from 81.5 per 100,000 US 2008 incidence was 72.2 per 100,000 Significantly increased risk of cardiovascular diseases Including stroke and myocardial infarction (MI) Leading cause of Non-traumatic lower extremity amputations, blindness, and kidney failure Medical expenditures are on average 2.3 times higher in patients with diabetes than those without (~ $ 174 billion in direct + indirect costs in 2007) Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention and Control Program, Maine Center for Disease Control and Prevention; 2012. Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012. </li><li> 16. 16 Microvascular Complications: Nephropathy Retinopathy Neuropathy Foot ulcers/lesions Numbness, pain Sexual dysfunction Gastroparesis http://www.mayomedicallaboratories.com/images/articles/communique/2009/09 fig1.jpg </li><li> 17. 17 Macrovascular Complications Cardiovascular Diseases (CVD) Coronary Artery Disease (CAD) Myocardial Infarction (MI) Stroke or transient ischemic attack (TIA) Peripheral Artery Disease (PAD) http://womenshealth.gov/heart-health-stroke/images/heart- attack-signs.gif </li><li> 18. 18 Additional Concerns Depression and other mental disorders Dental disease Increased risk of infection Can affect fertility Severe hyper- or hypo- glycemic events http://diabeticradio.com/wp- content/uploads/2010/06/hypoglycemia.jpg </li><li> 19. 19 Diabetes Preventative Care Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012. </li><li> 20. 20 Preventative Care in Maine Diabetes Surveillance Report, Maine 2012. Augusta, ME: Diabetes Prevention and Control Program, Maine Center for Disease Control and Prevention; 2012. </li><li> 21. 21 How do we classify and diagnose diabetes? Types Diagnosis Screening Case http://a.abcnews.com//images/Health/diabetes_Screening3 _mn.jpg </li><li> 22. 22 Diabetes Classification Type 1 Diabetes Type 2 Diabetes Gestational Diabetes (GDM) Other types related to other causes Exocrine diseases (i.e. cystic fibrosis) Genetic defects affecting insulin action or production Drug/chemically induced (i.e. HIV/AIDs treatments) American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 23. 23 Diagnosis of Diabetes: Measurements that may be used Fasting Plasma Glucose (FPG) Blood glucose measured after 8 hours fasting Oral Glucose Tolerance test (OGTT) Blood glucose measured 2 hours after 75 gram glucose load (use of anhydrous glucose solution) Glycosylated hemoglobin or Hemoglobin A1c (A1C) Test without regard to meals, provides 3 month mean glucose Random plasma glucose (PG) For use in patients with symptoms of hyperglycemia/hyperglycemic crisis American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 24. 24 Diagnosis of Diabetes: Symptoms/Presentation Assessment for signs and symptoms of hyperglycemia Excess thirst, urination, and/or hunger Blurry vision or vision changes In severe hyperglycemia (BG &gt; 240 mg/dL) Ketones may be present in urine Ketoacidosis can occur when the body breaks down fat and other molecules for energy Can not use glucose for energy without insulin </li><li> 25. 25 Diagnosis of Diabetes: Values for Diabetes/Pre-Diabetes Measurement Criteria for Diabetes Criteria for Pre- Diabetes FPG 126 mg/dL 100 - 125 mg/dL OGTT 200 mg/dL 140 - 199 mg/dL A1C 6.5% 5.7 - 6.4% Random PG 200 mg/dL N/A American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 26. 26 Pre-Diabetes Diagnosis Plasma glucose and/or A1C level between normal range and diabetes Risk for developing DM and CVD Estimates for developing diabetes over 5 years range from 9 - 50 % Evaluate and treat other risk factors: Obesity/overweight, dyslipidemia, and hypertension American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 27. 27 Who to Test/Screen for Diabetes? For which patients should you be recommending testing/screening for Diabetes? When/How often should they be screened? Evaluate individual patient risk Assess previous screening results What risk factors can you name? </li><li> 28. 28 Risk Factors* Obesity/overweight (BMI 25 kg/m2 ) History of CVD Physical inactivity Prior diagnosis of pre-diabetes First degree relative with DM HDL cholesterol &lt; 35 mg/dL High risk ethnicity/race: African American Latino Native American Asian Amerian Pacific Islander Triglycerides &gt; 250 mg/dL Hypertension: BP 140/90 mmHg or on treatment Conditions associated with insulin resistance: Severe obesity (BMI 40 kg/m2 ) Acanthosis Nigrans Women with history of GDM or delivering a baby weighing &gt; 9 lbs Women with Polycystic Ovarian Syndrome (PCOS) </li><li> 29. 29 Who to Screen for Diabetes? All adults ( 18 years old) with BMI 25 kg/m2 and 1 or more additional risk factors* In adults without additional risk factors Screening should start at age 45 If results of screening are normal; repeat in 3 years Repeat yearly in those with Pre-diabetes values For diagnosis screening test must be repeated Is better to use same test (i.e. A1C, FPG, etc) for repeat American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 30. 30 Screening in Children and Adolescents Test for type 2 diabetes and pre-diabetes in children/adolescents Overweight (BMI &gt; 85th percentile for age and gender or &gt; 120% of ideal weight for height) Plus 2 risk factors: Family history in 1st or 2nd degree relative Race/ethnicity (same as in adults) Signs of insulin resistance or associated conditions Gestational DM in mother while child was in utero American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 31. 31 Screening for Gestational Diabetes Screen at first pre-natal visit for those with risk factors Without risk factors screen at 24-28 weeks Use OGTT for diagnosis (fasting, 1 hour, and 2 hour) FPG 92 mg/dL 1 hour 180 mg/dL 2 hour 153 mg/dL In women with gestational DM, screen for type 2 DM at 6-12 weeks post- delivery then every 3 years American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 32. 32 Who to screen for Diabetes? 1. Which of the following symptom-free patients is due to be screened for diabetes today? A. 50 year old Latina female who delivered a baby weighing 10 lbs when she was 27, but had a negative diabetes screening test 24 months ago B. 25 year old Caucasian female with a BMI of 28 kg/m2 who reports low to no physical activity and is taking medication to treat his hypertension C. 40 year old African American male with a BMI of 24 kg/m2 and family history significant for diabetes in his mother and maternal grandfather D. 42 year old Caucasian male with a BMI of 26 kg/m2 who has no comorbidities and is physically active, but has never been screened </li><li> 33. 33 Meet Mr. L. Labor </li><li> 34. 34 Patient: L. Labor 25 year old Caucasian Male who frequents your community pharmacy and has just been to his doctors office (routine visit) Claims he is generally healthy (admits his diet could be better) BMI = 28 kg/m2 (height: 73 inches; weight: 215 lbs) Has a wife and daughter (~ 1 year old) Previously had a very physically active job, but now spends most of his time sitting at a computer both at work and at home Carpentry and Coaching little league v. Webpage design and Watching games from the stands with snacks </li><li> 35. 35 Patient: L. Labor He mentions his doctor wants him to get lab work done to check for diabetes He does not understand why He feels he is young and healthy How can you explain to him the importance and potential benefit to having the tests done? Can you explain to him what diabetes is and what it means for his health? </li><li> 36. 36 Interpreting test results Which of the following values is one of the criteria for the diagnosis of pre-diabetes? A. Glycosylated Hemoglogbin (A1C) = 6.2 % B. Fasting Plasma Glucose (FPG) = 90 mg/dL C. Plasma Glucose 2 hours after a 75 grams glucose load = 130 mg/dL D. Glycosylated Hemoglogbin (A1C) = 5.7 % </li><li> 37. 37 Diagnosis of Diabetes: Values for Diabetes/Pre-Diabetes Measurement Criteria for Diabetes Criteria for Pre- Diabetes FPG 126 mg/dL 100 - 125 mg/dL OGTT 200 mg/dL 140 - 199 mg/dL A1C 6.5% 5.7 - 6.4% Random PG 200 mg/dL N/A </li><li> 38. 38 Interpreting test results What does it mean if LLs lab test shows: Glycosylated Hemoglogbin (A1C) = 6.0 % And Fasting Plasma Glucose (FPG) = 110 mg/dL What else would you like to know about him or test for? What should we recommend for him going forward? </li><li> 39. 39 Next Steps To prevent/delay the onset of Type 2 Diabetes in patients who have been diagnosed with Pre-diabetes, which of the following are recommended as part of an ongoing support plan: A. Weight loss of 7% of the patients initial body weight B. Moderate physical activity for a minimum of 150 minutes/week C. Initiation of canagliflozin therapy D. A and B are correct E. A, B, and C are all correct </li><li> 40. 40 Treatment for Pre-Diabetes http://www.diabetes-warrior.net/wp-content/uploads/2010/10/pre- diabetes1.jpg </li><li> 41. 41 Lifestyle Modifications for Pre-Diabetes and Diabetes Medical Nutrition Therapy (MNT) Moderation, variety of carbohydrates Increased physical activity Minimum 150 minutes/week moderate level Weight loss/maintenance Initial 7% of body weight and maintenance of weight loss Smoking cessation Encourage and support with counseling and/or pharmacotherapy American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 42. 42 Lifestyle Modifications for Pre-Diabetes and Diabetes Can decrease progression from pre-DM to DM Group and individual delivery methods have both been found to be effective Monitoring for and managing other CVD risk factors: Hypertension (HTN) Hyperlipidemia (HLD) Overweight/obesity (especially excessive abdominal fat) Tobacco use American Diabetes Association (ADA) Professional Practice Committee. Standards of medical care in diabetes - 2013. Diabetes Care. 2013;36(1): S11-S66. </li><li> 43. 43 L...</li></ol>