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

2. 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.

3. 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

4. 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
(accessed March 31, 2014)
Reference
Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available at:

5. Diabetes in South Carolina
(accessed March 31, 2014)

6. Racial/Ethnic Differences in Diabetes
Data for years
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
(accessed March 31, 2014)

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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%

14. 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

15. 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

16. 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

17. 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®)

18. 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®)

19. 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

20. 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

21. 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

22. 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

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

24. 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

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

26. 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

27. 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