Diabetes Case Studies Eric L. Johnson, M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine.

Slides:



Advertisements
Similar presentations
Diabetes Case Studies Eric L. Johnson, M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine.
Advertisements

In-Patient Management of Hyperglycemia Rey Vivo, MD Assistant Professor of Medicine Texas Tech University Health Sciences Center.
Katee Lira, PharmD PGY2 Ambulatory Care Pharmacy Resident
Managing T2DM during Ramadan Dr. Asrar Said Hashem Specialist in Internal Medicine (Al-Amiri Hospital) Fellow of KIMS Endocrine, Diabetes and Metabolism.
ABC’s and…..P of Diabetes Eric L. Johnson, M.D. Assistant Professor Department of Family and Community Medicine UNDSMHS Assistant Medical Director Altru.
The New HbA1c HbA1c – DCCT (%) HbA1c – IFFC (mmol/mol)
Diabetes Medications: An Overview Eric L. Johnson, M.D. Assistant Professor Department of Community and Family Medicine University of North Dakota School.
National Diabetes Statistics Report Fun Facts on Diabetes 29.1 million people or 9.3% of the US population have diabetes. Diagnose : 21.0 million people.
Gestational Diabetes: Diagnosis, Treatment Long Term Management, and Followup Eric Lind Johnson, M.D. Assistant Professor Department of Family and Community.
Diabetes in Pregnancy Screening.
Special Diabetes Program for Indians Competitive Grant Program SPECIAL DIABETES PROGRAM FOR INDIANS Competitive Grant Program Clinical Goals for the Healthy.
Gestational Diabetes Mellitus (GDM)
Facts and Fiction about Type 2 Diabetes Michael L. Parchman, MD Department of Family & Community Medicine September 2004.
Managing Diabetes Medications. Topics What medications are available to –Manage diabetes? –Lower blood pressure? –Improve cholesterol? How can you keep.
Prevalance of Chronic Kidney Disease 26 million people have diagnosed chronic kidney 26 million people have diagnosed chronic kidney disease (CKD) ( National.
Barriers to Diabetes Control Mark E. Molitch, MD.
LONG TERM BENEFITS OF ORAL AGENTS
Department of Medicine Grand Rounds Clinical Vignette April 15, 2009 Michael Owen, PGY 2.
Source: Site Name and Year IHS Diabetes Audit Diabetes Health Status Report ______Site Name_________ Health Outcomes and Care Given to Patients with Diabetes.
Criteria for Diagnosis of DM * Testing must be repeated on separate day. FPG is the preferred test ** Symptoms of DM IFG = Impaired fasting glucose IGT.
Diabetes in the 21 st Century 2010 Update. American Diabetes Association 2010 Guidelines – Diagnostic Criteria A1C > or = 6.5% is included as diagnostic.
Kathryn A. Hanavan ANP-BC; BC-ADM Harold Schnitzer Diabetes Health Center September 12,
Diabetes Mellitus Ibrahim Sales, Pharm.D. Assistant Professor of Clinical Pharmacy King Saud University
Section 6: Management in primary care Particular emphasis on nurse practitioner’s role.
Type 2 Diabetes- Treatment Toolbox by: Karen L. Staples, FNP, ACNP Where Do I Start?
Clinical Update in Type 2 Diabetes A Case Discussion Dr. Yancey R. Holmes, MD, FACE Ohio Valley Endocrinology.
Titrating Insulin to Glycemic Target Judy Bowen, MD CIM Rotation September, 2006.
Leveraging Weight Loss in the Treatment of Type 2 Diabetes Part 1 of 4.
CARDIOVASCULAR CARE of the OUTPATIENT Diane M. Enzweiler, MSN, ANP-BC St. Elizabeth Physicians: Heart and Vascular.
Consider this Combo: GLP-1 Receptor Agonists and Basal Insulin Matt Heinsen, PharmD PGY2 Pharmacotherapy Resident Butler University & Community Health.
Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine
Diabetes Survival Camp – Session 2  You can strive and thrive with diabetes Welcome.
Chronic Disease Management- Diabetes. 43 year old male presents with one month history of feeling very thirsty and hungry. Urinating 5 times every night.
ORIGIN Outcome Reduction with an Initial Glargine Intervention (ORIGIN) Trial Overview Large international randomized controlled trial in patients with.
Dyslipidemia.  Dyslipidemia is elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high- density lipoprotein level that contributes.
Basal Bolus: The Strategy for Managing All Diabetes Fall, 2003 Paul Davidson, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia.
Clinical Practice Glycemic Management of Type 2 Diabetes Mellitus Faramarz Ismail-Beigi, M.D., Ph.D. Dr.kalantar N Engl J Med Volume 366(14):
The Role of DPP-IV Inhibitors in the Management of Type 2 Diabetes
Diabetes 101: Are You Ready?. Objectives Identify education as an essential treatment mode of diabetes Describe practical tips in preparing patients awaiting.
A Diabetes Outcome Progression Trial
January 2013 Webinar: “Practical Ways to Help Get Our Diabetes Patients to Goal” Controlling the ABC’s Cases.
Health Promotion and Wellness GNRS 5521: Clinical Role Practicum Case Presentation by Elizabeth Lopez On January 27, 2014 ____________________________________________.
Type 2 diabetes treatment: Old and New Emily Szmuilowicz, MD, MS Assistant Professor of Medicine Division of Endocrinology Northwestern University.
Oral Diabetes Medications Carol Cordy, MD. Goals Understand how type 2 diabetes affects many organs and how this changes over the course of the illness.
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Scott W. Rypkema, M.D.
Journal Club 9/15/11 Sanaz Sakiani, MD 1 st Year Endocrine Fellow Combining Basal Insulin Analogs with Glucagon-Like Peptide-1 Mimetics.
Helping Medical Students Counsel Patients With Uncontrolled Type II Diabetes: An Innovative Approach Alice Fairman Daniels, MD,MS Assistant Professor Cook.
Who is considered elderly? “Young old” years “Old, old” >75 years.
April 22, 2016 Connie Tien Daniel Kim Jeffrey Hughes Michelle Di Fiore
Carina Signori, DO Journal Club August 2010 Macdonald, M. et al. Diabetes Care; Jun 2010; 33,
Therapeutics IV Tutoring May 6, 2016 Lisa Hayes
Special Situations In The Management Of In-Patient Hyperglycemia
Gerti Tashko, M.D. DM Journal Club 12/16/2010. The use of exenatide with insulin is not FDA approved. The study was designed to evaluate if exenatide.
Bariatric Surgery for T2DM The STAMPEDE Trial. A.R. BMI 36.5 T2DM diagnosed age 24 On Metformin, glyburide  insulin Parents with T2DM, father on dialysis.
Objective 2 Discuss recent data, guidelines, and counseling points pertaining to the older adults with diabetes.
2012 ADA Clinical Practice Guidelines Therapies for DM- Type 2
Diabetes, Dyslipidemia, and Continuous Quality Improvement Using the Chronic Care Model in the Treatment of Patients Class of 2011, Family and Community.
Diabetes 101: Myths and Facts
Diabetes Health Status Report
Heart Health & Diabetes
Sodium-glucose co-transporter 2 (SGLT2) inhibitors work by blocking the reabsorption of filtered glucose in the kidneys. This leads to glucosuria and improved.
RCHC’s Cardiovascular Health Initiative
Key Insulin Side Effects*
Diabetes Update: 2018 Standards of Care
Train-the-Trainer Cases
Train-the-Trainer Cases
Train-the-Trainer Cases
Dyslipidemia And Diabetes
Insulin Delivery Systems Atlanta Diabetes Associates
Oral hypoglycemics Jennifer R Marks, MD.
Presentation transcript:

Diabetes Case Studies Eric L. Johnson, M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine And Health Sciences Assistant Medical Director Altru Diabetes Center Grand Forks, ND

Case #1 42 y/o hispanic female with hx of GDM 6 years ago, term 10lb 5 oz male infant Has not been seen for follow-up in 3 years FBS done at annual pap/px is 149 Does this patient have type 2 diabetes? What next?

Case #1 Diagnosis of diabetes generally requires 2 abnormal values Patient is at high risk for developing type 2 diabetes GDM is a pre-diabetes condition Repeat FBS 3 days later…….

Case #1 Repeat FBS 135 Dx: Type 2 diabetes - FBS >126 on 2 separate occasions - Could have done an A1C as well What should be done next for this patient?

Case #1 Lipids: Cholesterol 210 (<200) TG’s 185 (<150) HDL 43 (>50) LDL 106 (<100) BP 132/84 (<130/<80)

Diabetes Diagnosis Category FPG (mg/dL) 2h 75gOGTT A1C Normal <100 <140 <5.7 Prediabetes Diabetes >126** >200 >6.5 Or patients with classic hyperglycemic symptoms with plasma glucose >200 ** On 2 separate occasions Diabetes Care 34:Supplement 1, 2011

Case #1 Patient had tubal ligation after last delivery Start Metformin 500mg BID, advance to mg BID Most newly diagnosed patients should start Metformin (current ADA recommendation)

Case #1 Diabetes Educator and Dietician SMBG Lifestyle (for now) for BP and lipids Make a list of activity, try to start with 10 min/day, work up to 150 min/week

Case #2 54 y/o white male Diagnosed with type 2 diabetes after 2 fasting blood sugars of 154 and 142 and A1C of 6.8 Pre-existing HTN and dyslipidemia

Case #2 Cholesterol 240 (<200) TG’s 205 (<150) HDL 30 (>40) LDL 129 (<100)

Case Study #2 Started Metformin 500 mg BID BP, cholesterol tx with statin and ACEI (need titration), could add fish oil, on ASA Referred to Diabetes Educator and Dietician Recommend developing graduated exercise plan (exercise prescription) Six months after diagnosis A1C = 6.8% (target <7%)

Case Study #2 Three years later, patients A1C has risen to 8.4% (target <7%) Blood pressure and cholesterol effectively treated (ACEI, HCTZ, Simvistatin, Fish Oil) Now what?

Case Study #2 Choices include –Adding a basal insulin once daily –Adding any other oral agent –Adding exenatide or liraglutide Any of these are good choices Choice may be made on individual factors Reinforce lifestyle management

Case Study #2 Basal insulin –Advantages: Once-daily, comes in pen, easy, likely good results, durable over time –Disadvantages: potential hypoglycemia (not difficult to manage/avoid), weight gain, likely will need combo with another insulin later (not a difficult transition)

Case Study #2 Additional oral agent –Advantages: Easy –Disadvantages: eventually lose effectiveness, weight gain (sulfonylureas, TZD’s)

Case Study #2 Other injectable (exenatide or liraglutide) –Advantages: Comes in pen, easy, may have weight loss –Disadvantages: eventually lose effectiveness, nausea, vomiting

Case Study #2  Patient chose additional oral agent (sitagliptin)  A1C:  6 months later = 7.4% (target <7%)  3 years later = 8.1% (target <7%)  Basal insulin eventually started once daily  Sitagliptin continued  Metformin continued

Case #3 62 y/o caucasian female dx with DM 2 18 months ago Metformin 1000 mg BID Very active, swims 5 days a week, uses stairmaster

Case #3 PMH: breast cancer, hypothyroidism, sleep apnea, dyslipidemia, HTN, microalbuminuria Physical Exam: s/p mastectomies, BP 136/82, P 72, BMI 36

Case #3 Medications: Valsartan/HCT 160/12.5 mg daily Metformin 1000 mg BID Atorvastatin 40mg daily Folic acid Calcium + D 3 tablets daily Fluticasone Glucosamine/Chondroitin Pantoprazole 40 mg daily Levothyroid150 mcg daily ASA 81 mg daily

Case #3 Lab A1C 6 months ago= 6.7, Now 7.6 CBC, Chem panel unremarkable Lipids, BP treated to target What now?

Case #3 Started on Exenatide (Byetta) 5 mcg SQ BID x 30 days, advance to 10 mcg SQ BID (Liraglutide (Victoza) OK too GLP 1 can be used with Glyburide, Metformin, TZD’s, (insulin data) A1C 6 months after start= 6.8

Case #4 87 y/o white female resident admitted to LTC facility Type 2 Diabetes for 20 years PMH: HTN, dyslipidemia, mild dementia, hypothyroidism, CVA, CHF Stage 3 CKD (GFR 37, Creatinine 1.0)

Case #4 Current meds: Metformin 500 mg BID Glyburide 5 mg BID Lisinopril 10mg daily Furosemide 20 mg daily ASA 81 mg daily Simivistatin 20mg daily

Case #4 Lipids adequately treated BP 142/86 A1C 9.0 What is appropriate for this patient?

Case #4 Metformin, sulfonylurea NOT good choices >80 y/o, or declining renal function Metformin NOT good choice with CHF risk or history

Case Study #4 BP abnormal- high risk of recurrent CVA Lipids- Evidence show benefit of treating to age 85, case by case

Case #4 A1C = 8.0 appropriate for this age group -less risk of hypoglycemia vs. lower A1C (demented poor at reporting symptoms) -better alertness than higher A1C -less urinary incontinence than higher A1C

Case Study #4 BP: Increase Lisinopril to 20mg, monitor creatinine and K+ Lipids: Continue present (patient desired Rx) DM: ?

Case #4 Choices for Treatment of DM in elderly Single injection of basal insulin once daily OR Gliptin (sitagliptin or saxagliptin) Both have low risk of significant hypoglycemia, can be renally dosed, easy to use, few significant drug interactions

Case Study #4 Started on basal insulin (detemir or glargine) 8 units with evening meal (patient likely has little beta cell function) Metformin stopped Glyburide stopped A1C 3 months later 8.2

Elderly Diabetes Patients Sulfonylureas and Metformin generally NOT good choices (renal) TZD’s may be limited by CHF history or risk DPP-IV inhibitors may be good choice -renal dosing,hypoglycemia rare Insulin, particularly basal, may be optimum Johnson EL Brosseau J et al Clinical Diabetes 2008 (26) 4; American Medical Directors Association,2002 American Diabetes Association. Diabetes Care. 2011;34(suppl 1)

Summary Patients have different requirements depending on diabetes status Many choices exist to individualize treatment Reinforce lifestyle, treat blood sugar, lipids, BP

Contact Info/Slide Decks/Media Phone cell Facebook “North Dakota Diabetes” Slide Decks (Diabetes, Tobacco, other) iTunes Podcasts (Diabetes) (Free downloads) or iTunes>> search UND Medcast WebMD Page: (under construction) Diabetes e-columns (archived): Dakota Diabetes Coalition website

Acknowledgements William Zaks, M.D., Ph.D., Assistant Medical Director Altru Diabetes Center Grand Forks, ND Slide and Content Review