Optimizing Diabetic Care in Residential Care Lori C. Dupree, PharmD, BCPS Consultant Pharmacist Neil Medical Group Mooresville, North Carolina

Learning Objectives Differentiate between the different types of diabetes. Identify the treatments used for managing diabetes. List common complications associated with diabetes and describe their management. State appropriate monitoring parameters for residents with diabetes.

Scope Affects 25.8 million people in the United States 8.3% of the US population 18.8 million diagnosed 7 million undiagnosed Leading cause of kidney failure, amputation not related to an accident/trauma, newly diagnosed adult blindness Major cause of stroke and heart disease Seventh leading cause of death

County-Level Estimates of Diagnosed Diabetes (%), Adults ≥20 years, 2010 The prevalence of diagnosed diabetes by county was estimated using data from the Center for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) and data from the US Census Bureau’s Population Estimates Program The BRFSS is an ongoing, monthly, state-based telephone survey of the adult population The survey provides state-specific information on behavioral risk factors and preventive health practices. Respondents were considered to have diabetes if they responded "yes" to the question, "Has a doctor ever told you that you have diabetes?” Estimates were restricted to adults 20 years of age or older to be consistent with population estimates from the U.S. Census Bureau The county-level estimates for the 3,141 counties or county equivalents (eg, parish, borough) in the 50 US states and the District of Columbia were based on indirect model-dependent estimates, which employs a statistical model that “borrows strength” in making an estimate for one county from BRFSS data collected in other counties Bayesian multilevel modeling techniques were used to obtain these estimates, and separate models were developed for each of the four census regions: West, Midwest, Northeast and South Percent http://www.cdc.gov/diabetes/atlas/countydata/atlas.html (accessed March 31, 2014) Reference Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available at: http://apps.nccd.cdc.gov/DDTSTRS/default.aspx.

Diabetes in South Carolina http://www.cdc.gov/diabetes/atlas/countydata/atlas.html (accessed March 31, 2014)

Racial/Ethnic Differences in Diabetes Data for years 2007-2009 Race/Ethnicity % Non-Hispanic whites 7.1 Asian Americans 8.4 Hispanics/Latinos Cuban Americans Central and South Americans Mexican Americans Puerto Ricans 11.8 7.6 13.3 13.8 Non-Hispanic blacks 12.6 http://diabetes.niddk.nih.gov/dm/pubs/statistics (accessed March 31, 2014)

What Goes Wrong? After eating, most food is converted to glucose(sugar) Glucose is the most common source of energy for the human body In people without diabetes, insulin is released by the pancreas at the right time and in the right amount Insulin helps glucose enter cells so it may be used for energy Blood glucose stays in a healthy range In people with diabetes, glucose builds up The pancreas does not make insulin well The body cannot use the insulin well The liver makes too much glucose

Types of Diabetes Type 1 Type 2 Gestational diabetes (GDM) Other Problem with pancreatic cells that make insulin Type 2 Problem using insulin in the body properly Insulin “resistance” Gestational diabetes (GDM) Diagnosed in pregnancy Other Medication or chemical exposure Genetic defects of the pancreas Concurrent diseases

Testing for Type 1 Diabetes Patients with type 1 diabetes should have the opportunity to have their relatives screened for type 1 diabetes risk in the setting of a clinical research study

Testing for Type 2 Diabetes Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors: Physical inactivity First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who delivered a baby weighing >9 lb or were diagnosed with GDM High blood pressure Low HDL cholesterol level and/or a high triglyceride level Women with polycystic ovarian syndrome (PCOS) Hemoglobin A1C (Hgb A1C) ≥5.7% or other test indicating impaired glucose Other conditions associated with insulin resistance (e.g., severe obesity) History of heart disease HTN- (≥140/90 mmHg or on therapy for hypertension) Hyperlipidemia- HDL cholesterol level <35 mg/dL and/or a triglyceride level >250 mg/dL

Testing for Type 2 Diabetes In the absence of risk factors, testing for diabetes should begin at age 45 If results are normal, testing should be repeated at least at 3-year intervals Consider testing more frequently depending on initial results (e.g., those with prediabetes should be tested yearly), and risk factors Testing to detect type 2 diabetes and prediabetes should be considered in children and adolescents who are overweight, and who have two or more additional risk factors for diabetes

Diagnosis of Diabetes Hgb A1C ≥6.5% Fasting blood glucose (FBG) ≥126 mg/dL Fasting is defined as no caloric intake for at least 8 h 2-h blood glucose ≥200 mg/dL during an oral glucose tolerance test (OGTT) 75 grams of glucose dissolved in water Random blood glucose ≥200 mg/dL Usually used in people who are experiencing the symptoms of high blood glucose (hyperglycemia)

Diagnosis of Prediabetes Fasting blood glucose of 100–125 mg/dL 2-h blood glucose in the 75-g OGTT of 140–199 mg/dL Hgb A1C of 5.7–6.4%

Prevention Strategies in Prediabetes Refer patients with impaired glucose tolerance test, impaired fasting blood glucose, or Hgb A1C 5.7–6.4% to ongoing support program Target weight loss of 7% of body weight Increase physical activity to at least 150 min/week of moderate activity Follow-up counseling is important for success Programs may be covered by third-party payers Consider metformin (Glucophage®) for prevention of type 2 diabetes BMI >35 kg/m2, age <60 years, and women with prior GDM Monitor for development of diabetes every year Screen for and treat modifiable risk factors for heart disease and stroke

Treatment of Diabetes Medical nutrition therapy Self-monitoring education Monitoring of blood glucose levels Signs and symptoms of low and high blood glucose levels Comprehensive physical examination Laboratory evaluation Should include Hgb A1C Appropriate specialist referrals

Treatment of Type 1 Diabetes Most patients require treatment with insulin Insulin is dosed in 3-4 injections per day Short-acting insulin is usually given before (or with) meals, and a longer acting insulin once a day to provide baseline insulin action Insulin pumps may be used to provide a continuous supply of insulin Oral medications do not work for treating type 1 diabetes Carbohydrate intake and activity level affect blood sugar Understanding how to adjust pre-meal insulin doses is important

Treatment of Type 2 Diabetes Sulfonylureas Glipizide (Glucotrol®), glyburide (DiaBeta®), glimepiride (Amaryl®) Biguanides Metformin (Glucophage®) Thiazolidinediones Pioglitazone (Actos®), rosiglitazone (Avandia®) Alpha-glucosidase inhibitors Miglitol (Glyset®), acarbose (Precose®) DPP-4 inhibitors Sitagliptin (Januvia®), saxagliptin (Onglyza®) GLP-1 receptor agonists Exenatide (Byetta®), liraglutide (Victoza®)

Treatment of Type 2 Diabetes Meglitinides Nateglinide (Starlix®), repaglinide (Prandin®) SGLT2 inhibitors Dapagliflozin (Farxiga®), canagliflozin (Invokana®) Insulin Rapid-acting Insulin aspart (Novolog®), insulin lispro (Humalog®) Short-acting Regular (Novolin R®, Humulin R®) Intermediate-acting NPH (Novolin N®, Humulin N®) Long-acting Insulin detemir (Levemir®), insulin glargine (Lantus®)

Storage of Insulin Unopened insulin should be stored in the refrigerator Store at 36-46o F Stable until the expiration date on the package Consult the manufacturer’s information for specific information after opening insulin Expiration of opened insulin vials, pens and cartridges varies by manufacturer Do not freeze insulin Do not expose insulin to extreme heat

Blood Glucose and Hgb A1C Comparison Mean plasma glucose A1C (%) mg/dL mmol/L 6 126 7.0 7 154 8.6 8 183 10.2 9 212 11.8 10 240 13.4 11 269 14.9 12 298 16.5

Blood Glucose Goals Maintaining the Hgb A1C around or less than 7% has been shown to lower the risk of eye, kidney and nerve complications If this goal is obtained shortly after diagnosis, the risk of stroke, heart attack, and poor circulation is lowered In some patients, a Hgb A1C less than 6.5% may be reasonable Younger patients with no issues related to low blood glucose levels For other patients, a Hgb A1C less than 8% is acceptable History of severe problems with low blood glucose levels Patients with a limited life expectancy

Monitoring Medication Therapy Hyperglycemia (High Blood Glucose) Hypoglycemia (Low Blood Glucose) Increased thirst Increased urination Blurry vision Feeling tired Slow healing of cuts or wounds More frequent infections Weight loss Nausea and vomiting Shakiness Confusion Sweating/clamminess Rapid heart beat Irritability or anger Headaches Weakness Feeling tired Seizures Loss of consciousness

Treatment of Hyperglycemia and Hypoglycemia Insulin Hypoglycemia Concentrated oral glucose solutions, tablets Glucagon injection

Monitoring Diabetic Residents Foot checks Skin checks Blood pressure checks Fingerstick blood glucose monitoring Laboratory monitoring Hgb A1C Cholesterol Kidney function (serum creatinine/BUN) Potassium levels Urine albumin levels

Complications of Diabetes Heart complications Stroke Circulatory complications Kidney complications Eye complications Nerve complications Skin complications

Preventing Complications of Diabetes Adequate control of blood glucose Aspirin Blood pressure control Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) ACEI- lisinopril (Prinivil®), ARB- losartan (Cozaar®) Statins Atorvastatin (Lipitor®), simvastatin (Zocor®) Vaccinations Influenza, pneumococcal, hepatitis B Smoking cessation

Conclusion Diabetes is a complex disease that can affect many parts of the body The goal is to prevent complications The development of diabetes may be delayed with effective lifestyle changes and, in some cases, medication therapy Numerous opportunities exist to help those affected with diabetes to manage their disease, as well as prevent complications