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

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

4. 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

5. statistics

6. 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, Lancet Diabetes & Endocrinology

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

8. 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

9. 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

10. 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 mg/dL at all times of the day.
Current medications:
Basaglar 45 units at hs
Humalog 15 units TIDac
Lisinopril 20mg daily
Simvastatin 10mg daily

11. 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

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

13. ADA 2018 Standards of Medical Care
New recommendations

14. 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

15. 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

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

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

19. management

20. 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

21. 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

22. 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

23. ADA standards of care, 2018, diabetes.org

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

26. ADA standards of care, 2018, diabetes.org

27. 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

28. 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

29.
Thank you!!

30. Questions???