1. Gail Bradley MD Community Paramedicine Consortium - West
Diabetes Education
Gail Bradley MD
Community Paramedicine Consortium - West

2. Two Types of Diabetes Type I DM = Insulin-Dependent Type II DM
Oral meds are 1st line treatment
Insulin therapy usually added to oral medications if sugars are poorly controlled
Usually continue metformin to help with resistance
No maximal dosing on insulin
Many patients will need insulin therapy at some point in their disease course
Insulin causes weight gain

3. What Does Insulin Do? Eat  Blood sugar rises
Pancreas is signaled by elevation in blood glucose
Beta cells release insulin
Insulin transports glucose into the cell
Cell is happy and able to provide energy to body
Insulin resistance/no insulin
Rising of blood glucose
Cell unable to get glucose in
Cell unable to create energy
Catabolism

4. Remember brain, liver, and kidneys do not use insulin to get glucose in cell
Instead glucose gets in by diffusion
So high glucose levels-means large amount of sugar getting into liver, kidneys, and brain

5. Summary of Type II Diabetes

6. Who has heard of metabolic syndrome
Who has heard of metabolic syndrome? Metabolic Syndrome is usually heart disease-dyslipidemia-Type II Diabetes
Cancers increased d/t oxidized stress of cells (pre-aging)

8. Gestational Diabetes
Risk factors: Obesity or Overweight, Impaired glucose, Family history, Age
Caused by hormone shifts from placenta
High maternal blood sugar=high baby blood sugar
Growth and development issues

9. Physical Assessment
There are a number of other symptoms and illnesses patients with poorly controlled diabetes develop.

10. Approaching Diabetes 150 min/week of moderate activity
Follow-up counseling
Prediabetics: Metformin
Monitor blood pressure
Have cholesterol checked regularly
Exercise-Weight control
Diet
Monitor glucose levels
Remind about routine eye exams
Stop Smoking (if applicable)
Patients with prediabetes should be referred to an effective ongoing support program targeting weight loss of 7% of body weight and increasing physical activity to at least 150 min/week of moderate activity, such as walking.
Follow up counseling appears to be important for success.
Metformin therapy for prevention of type 2 diabetes may be considered in those with impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or an A1C %, especially for those with BMI > 35 kg/m2, aged <60 years, and women with prior gestational diabetes.
Patients with blood pressure >120/80 mmHg should be advised on lifestyle changes to reduce blood pressure:
DASH (Dietary Approaches to Stop Hypertension) diet
Diet high in whole grains, vegetables, fruits, and low-fat dairy
Lean meats and nuts
Diet low in saturated and trans fat, cholesterol
Increased physical activity
Weight loss, if applicable
If blood pressure is >140/90 mmHg, drug therapy should be used in addition to lifestyle modification:
Combination therapy often necessary
Treatment should include ACE or ARB
Thiazide diuretic may be added to reach goals-Monitor renal function and serum potassium
Lifestyle modification for high cholesterol:
Reduce saturated fat, trans fat, and cholesterol intake
Increase of fatty acids
Increase fiber intake
Lose weight (if indicated)
Increase physical activity
Increasing exercise:
Encourage your patients to find ways to fit activity into their daily routine. Examples include taking the stairs, parking further away, taking the stairs instead of elevator, or walking to another bus stop.
Encourage patients to aim for at least 150 minutes/week of moderate aerobic exercise with no more than 2 consecutive days without exercise.  If they are just starting out, encourage them to start with just 10 minutes, three times per day and build from there.
Adults with type 2 diabetes should be encouraged to perform resistance training at least twice a week in the absence of contraindications.
Many patients are motivated by wearing a pedometer and tracking their steps. Encourage them to join a walking group and challenge each other to more and more steps. 

11. Characteristics of Insulin
Onset = length of time before insulin reaches the bloodstream and starts to lower blood glucose
Peak = time at which insulin is at maximum strength (most effect at lowering glucose)
Duration = how long insulin continues to lower blood glucose

12. Insulins are categorized by differences in:
Onset = how quickly they act
Peak = how long it takes to achieve maximum impact
Duration = how long they last before they wear off
Concentration:
Insulins sold in the U.S. have a concentration of 100 units per ml or U100.
In other countries, additional concentrations are available. Note: If a pt purchases insulin abroad, be sure it is U100. (ex. Mexico)
Route of delivery = whether they are injected under the skin or given intravenously

13. 4 Types of Insulin Rapid-acting Regular or short-acting
Intermediate-acting
Long-acting

14. Rapid-acting Insulin Onset = begins within 5-15 minutes
Peak = approximately 1-2 hours
Duration = 2-4 hours
Examples:
Insulin Lispro (Humalog)
Insulin Aspart (Novolog)
The duration of insulin action is affected by the dose – so a few units may last 4 hours or less, while 25 or 30 units may last 5 to 6 hours.
As a general rule, assume that these insulins have duration of action of 4 hours.

15. Regular or Short-acting Insulin
Onset = within 30 minutes of injection
Peak = 2-4 hours after injection
Duration = 6 hours
Examples:
Regular Insulin
Humulin R
Novolin R

16. Intermediate-acting Insulin
Onset = 2-4 hours after injection
Peak = 4-10 hours
Duration = hours
Examples:
NPH
Humulin N
Novolin N
Absorbed more slowly and last longer
These are generally used to control blood sugar overnight

17. Long-acting Insulin Onset = 1-1 ½ hours after injection
Peak = none (plateau effect)
Duration = hours
Example:
Glargine (Lantus)
Detemir (Levemir)

20. This diagram really demonstrates how different insulin medications work. It is important to ask patients if they know how long their insulin lasts.

22. Pre-Mixed Insulins SA = Short Acting IA = Intermediate Acting
First number is intermediate acting, second is fast acting.
Usually dosed twice daily prior to am and pm meal
Humulin/Novolin products use regular as the fast-acting.
Dosing occurs 30 minutes before the meal.
Humalog/Novolog use a rapid-acting.
Dosing occurs 5-15 minutes before meal.

23. Pre-Mixed Insulin Examples: Onset: SA: 30 minutes, IA: 2 hours
Humulin 70/30
Novolin 70/30
Onset: SA: 30 minutes, IA: 2 hours
Peak: SA: 2-4 hours, IA: 4-12 hours
Duration: SA: 5-8 hours, IA: hours
70% of the dose is NPH, 30% of the dose is regular

24. Pre-Mixed Insulin Examples: Onset: SA: 5-15 minutes, IA: 2 hours
Novolog 70/30
Humalog 70/30
Onset: SA: 5-15 minutes, IA: 2 hours
Peak: SA: minutes, IA: 4-12 hours
Duration: SA: 2-4 hours, IA: hours
70% of the dose is intermediate acting, 30% of the dose is rapid acting

25. 6 Types of Non-Insulin Diabetes Meds
Metformin: Pills that reduce sugar production from the liver
Thiazolidinediones (glitazones): Pills that enhance sugar removal from the blood stream
Insulin releasing pills (secretagogues): Pills that increase insulin release from the pancreas
Starch blockers: Pills that slow starch (sugar) absorption from the gut
Incretin based therapies: Pills and injections that reduce sugar production in the liver and slow the absorption of food
Amylin analogs: Injections that reduce sugar production in the liver and slow the absorption of food

26. Metformin 1st line drug used to treat diabetes
Works at the liver to reduce excessive glucose release
Requires functioning liver and kidneys
“euglycemic” = restores blood sugar to normal levels
Will NOT cause hypoglycemia (unless combined with other drug)

27. Sulfonylureas Insulin-releasing pills (secretagogues)
Lowers blood sugar by stimulating pancreas to release insulin
Requires a functioning pancreas to work
#1 side effect = hypoglycemia
Examples:
Glyburide
Glipizide
Glimepiride

28. Glinides Newer insulin-releasing medication
Shorter acting compared to Sulfonylureas
Still have side effect of hypoglycemia
Some are combined with other DM meds
Examples:
Repaglinide (Prandin)
Nateglinide (Starlix)

29. Bottom line
Hypoglycemia due to sulfonylureas are at risk for recurrent hypoglycemia
Diabetes meds ending with “IDE” rIDE the ambulance to the hospital

30. Insulin Sensitizers
Lower blood sugar by increasing the muscle, fat, and liver’s sensitivity to insulin
“euglycemics” = return blood sugar to normal
Examples:
Rosiglitazone = Avandia
Pioglitizone = Actos

31. Starch Blockers
Inhibits digestive enzyme which slows carbohydrate absorption  gives body more time to process carbohydrates after a meal
“euglycemic” = normalizes blood sugar
Will not cause hypoglycemia
Example:
Acarbose

32. Incretin-based Medications
Decrease post-meal glucagon levels and help reduce post-meal blood sugar levels
Also increase insulin release from the pancreas
“euglycemics” = normalize blood sugar
Typically used in combination with other diabetes medications
Both pill and injection forms

33. Incretin-based Medications
DPP-4 Inhibitors (oral medications)
Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Linagliptin (Trajenta)
GLP-1 Analogs (injected medications)
Exenatide (Byetta)
Liraglutide (Victoza)

34. Other new meds SGLT 2 Inhibitors:
Increase glucose excretion in the urine
Example:
Canaglifozin (Invokana)

35. Amylin Analog Medications
Injected medication that woks by:
lowering glucagon during meals
Slows food emptying from the stomach
Curbs appetite
Example:
Pramlintide (Symlin)

36. When interviewing patients with recurrent hypoglycemia it is critical to know:
What medications are they are taking
When they take their medications
If they monitor their blood sugars
Do they have food in their home?
Are they abusing alcohol?
If they are having other medical issues which may be affecting their blood sugar control
Infection
Renal failure

37. Meds that Cause Hypoglycemia
Known to cause:
Insulin
Sulfonylureas (Glipizide, Glyburide)
Meglitinides (Nateglinide, Repaglinide)
Possibly when used with above:
DPP-4 inhibitors (Alogliptin, Linagliptin, Sitagliptin, Saxagliptin)
GLP-1 Agonists (Exenatide, Liraglutide, Albiglutide)
May be precipitated with taking medications and skipping meals

38. Patient Knowledge
This is the first really important screening question.
Type of diabetes lists the different types and helps gauge patient knowledge.

39. Diabetes medications?
This question is aimed at determining what meds the patient is on, oral vs insulin, vs both.
If they are on insulin, it is important to know if they are on a long-acting insulin.

40. Long-acting Insulin Pop-up

41. Comorbid conditions
Many patients with poorly controlled diabetes develop secondary illnesses

42. More comorbid conditions

43. Diabetes monitoring
Do they check their blood sugar, what is their normal high and low? What does their doctor feel their normal high and low should be?

44. Secondary assessment
Newly diagnosed includes options for length of disease.
Change in meds has option of diet-controlled to oral meds or oral meds to insulin.
Have they had a recent major event, do they need routine maintenance evaluations to rule out neuropathy/ulcers, diabetic retinopathy?

46. Diabetes Scenario Ask the patient about their medications
Inquire about the blood sugar monitoring
Go through the screening questions
Use treatment protocol