Diabetes Update: 2018 Standards of Care Veronica J. Brady, PhD, FNP-BC, BC-ADM, CDE NAPNA—March 3, 2018

Objectives Review latest diabetes statistics Discuss latest recommendations for diabetes management Case study

Terminology No longer using the term “diabetic.” Diabetes does not define people. People with diabetes are individuals with diabetes, not “diabetics.” “Diabetic” will continue to be used related to complications, e.g., “diabetic retinopathy.” The Association made one point of clarification this year which we hope clinicians, advocates, journalists, and the general public will adopt: In alignment with our longstanding informal policy Association-wide, the Standards of Care will no longer use the term “diabetic” to refer to patients with diabetes. This decision is in alignment with the American Diabetes Association’s position that diabetes does not define people. Those with diabetes are individuals with diabetes, not “diabetics.” ADA will continue to use the term “diabetic” as an adjective for complications related to diabetes (e.g., diabetic retinopathy). [SLIDE] ADA, Diabetes Care,2016; 4

statistics

Lifetime risk of DM & Years Lost After age 20 years life time risk 40.2% for men and 39.6% for women (highest Hispanic men/women; non Hispanic black women highest >50%) Years lost when diagnosed at age 40 is 5.8years Gregg, et, al, 2014. Lancet Diabetes & Endocrinology

As many as 1 in 3 US adults could have diabetes by 2050 CDC.gov/diabetes

Diabetes – United States 30.3 million in US ( 9.4% of population)— 1/3 unaware that they have diabetes Seniors (65+) 25.2% (12 million dx & undx) 84 million adults with pre-diabetes 7th leading cause of death in the US 252,806 death certificates list diabetes as underlying contributing cause in 2015 Medical expenditures for persons with DM 2.3x higher than those without DM 54million in 2007 with pre-diabetes (in addition to 20.8 million DM) 1/3 unaware is included in the 20.8 million Death rate increasing for DM while for heart dz, stroke etc all decreasing. cdc.gov/diabetes 2018

Diabetes— Nevada 12.4% (281,355)of adult population have diabetes 75,000 don’t know they have diabetes Every year 10,000 Nevadans are diagnosed with diabetes 38.5% (787,000) have pre-diabetes Direct care cost of diabetes in Nevada was an estimated $1.9billion in 2012 Diabetes.org accessed 2/2018

Case S.B. is a 40 year old female with a 10 year h/o T2DM. She has not attended DSME since diagnosis. Since her last visit she has experienced multiple episodes of hypoglycemia with BG ranging 42-70mg/dL. She currently test 3x/ day with BG ranging 42-347mg/dL at all times of the day. Current medications: Basaglar 45 units at hs Humalog 15 units TIDac Lisinopril 20mg daily Simvastatin 10mg daily

Case (cont) PMH-HTN, T2DM, Anemia (heavy periods), hyperlipidemia FH-mother and sister with DM, father deceased heart attack age 54 Labs- A1c 9.7%, cholesterol-240, LDL-120, HDL- 42, GFR-111, micro/alb-45 PE- BP 160/90, 86, BMI 30.4 weight- 90kg

What do the latest standards suggest for management of S.B.?

ADA 2018 Standards of Medical Care New recommendations

Screening Testing for diabetes/pre-diabetes is recommended for children < 18 who are overweight/obese with one or more risk factors Maternal diabetes/GDM Signs of insulin resistance 1st or 2nd degree relative with DM Race/ethnicity ADA standards of care, 2018, diabetes.org

Use of A1c Consider alternate method of testing in persons whose A1c does not match with SMBG readings Consider age, ethnicity, pregnancy, sickle cell disease, etc. when interpreting A1c ADA standards of care, 2018, diabetes.org

Comprehensive Exam ADA standards of care, 2018, diabetes.org

Comprehensive Exam (cont) ADA standards of care, 2018, diabetes.org

management

Diabetes Self-Management Education DSME should be offered to patients at time of diagnosis, annually, when complications arise and when there are transitions in care. Education can be offered in group setting, individually or using technology ADA standards of care, 2018, diabetes.org

Use of Technology CGM helps to improve glycemic control in patients with T1DM starting at 18 years of age. Newest CGM--FreeStyle Libre ADA standards of care, 2018, diabetes.org

Cardiovascular Disease & DM In patients with DM and atherosclerotic cardiovascular disease, diabetes management should begin with metformin and lifestyle changes and then include an agent that reduces major cardiovascular events (empagliflozin & liraglutide) ADA standards of care, 2018, diabetes.org

ADA standards of care, 2018, diabetes.org

Blood pressure Current target ≤140/90 All patients with HTN should monitor BP at home ADA standards of care, 2018, diabetes.org

ADA standards of care, 2018, diabetes.org

Special Populations Pregnant women Older adults Recommend low dose ASA at end of 1st trimester Older adults Decrease risk of hypoglycemia Avoid overtreatment Simplify regimens Personalize targets ADA standards of care, 2018, diabetes.org

Management of S.B. in 2018 Due to her anemia A1c not the best measurement of BG control. She needs to be referred for DSME She would likely benefit from use of CGM to guard against hypoglycemic events Due to HTN, hyperlipidemia, and family history, as well as being obese she would likely benefit from use of liraglutide (if no contraindications) May require additional BP medication Prescribing a home BP monitor is recommended

vbrady@med.unr.edu Thank you!!

Questions???