a-1d diabetes an update on american diabetes association guidelines

7/30/2019 A-1D Diabetes an Update on American Diabetes Association Guidelines

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Diabetes: Updates on ADA Guidelines

January 2012


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Objectives

State the standards of diabetic care put forth by the

American Diabetes Association Discuss the co-morbidities of diabetes, the standards

of care that influence their management andstrategies to achieve the goals of care

Discuss ways correctional institutions can improve

compliance with the recommendations for diabetic

care in correctional institutions


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Diabetes Facts

Diabetes affects 25.8 million people in the United

States 18.8 million diagnosed

7 million undiagnosed

Diabetes is the leading cause of kidney failure, non-

traumatic lower limb amputations, and new cases ofblindness among adults in the United States

Diabetes is a major cause of heart disease and stroke

Diabetes is the seventh leading cause of death in theUnited States

Source: CDC Fact Sheet, 2011


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Diabetes Facts

Every 1% drop in A1c blood test results can decrease

the risk of microvascular complications of diabetesby 40%

Blood pressure control reduces the risk ofcardiovascular disease (heart disease or stroke)among people with diabetes by 33% to 50%, and the

risk of microvascular complications by 33%. In general, for every 10 mmHg reduction in systolic

blood pressure, the risk for any complications relatedto diabetes is reduced by 12%.

Reducing diastolic blood pressure from 90 mmHg to80 mmHg in people with diabetes reduces the risk ofmajor cardiovascular events by 50%.



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Diabetes Facts

Improved control of LDL cholesterol can reduce

cardiovascular complications by 20% to 50%. Detecting and treating diabetic eye disease can reduce

development of severe vision loss by an estimated 50%to 60%.

Comprehensive foot care programs risk assessment,

foot care education and preventive therapy, treatment offoot problems and referral to specialists can reduceamputation rates by 45% to 85%.

Detecting and treating early diabetic kidney disease bylowering blood pressure can reduce the decline in kidney

function by 30% to 70%. ACEIs and ARBs are moreeffective than other antihypertensive medications inreducing the decline in kidney function



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Magnitude of Complications

Diabetic

Retinopathy

Leading cause

of blindnessin working age

adults

Diabetic

Nephropathy

Leading cause ofend-stage renal disease

Stroke

Cardiovascular

Disease

2-fold to 4-foldincrease incardiovascularmortalityand stroke

Diabetic

Neuropathy

Leading cause of nontraumatic

lower extremity amputationsNational Diabetes Information Clearinghouse. At:http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm


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Guidelines 2011


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Diabetes Disease Management

Intake Medical Assessment

Complete medical historyand intake physical exam bylicensed health professionalin a timely manner

Insulin-dependent diabeticsshould have capillary bloodglucose (CBG) within 1 to 2hours of arrival

Medications and medical

nutrition therapy (MNT)continued withoutinterruption

Screening for Diabetes

Evaluate for diabetes risk

factors at intake physical and

as appropriate thereafter

BMI 25 with history of

hypertension or hyperlipidemia BMI 25 and additional risk

factors or age > 45 with or

without risk factors

If pregnant, risk assessment

for gestational diabetesmellitus (GDM) at first pre-

natal visit

Re-screen at 24-28 weeks


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Criteria for Testing for Diabetes

Adults who are overweight (BMI 25) and have additional riskfactors: Physical inactivity

First-degree relative with diabetes

High-risk race/ethnicity

Women who delivered a baby weighing > 9 lb or were diagnosed withGDM

Hypertension on therapy for hypertension HDL cholesterol < 35 mg/dl and/or triglyceride > 250 mg/dl

Women with polycystic ovarian syndrome (PCOS)

A1c > 5.7% on previous testing

History of cardiovascular disease

Other clinical conditions associated with insulin resistance If results are normal, repeat testing at three-year intervals or

more frequently depending on initial results and risk status


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Criteria for Diagnosis of Diabetes

A1c 6.5% - NEW!

OR

Fasting plasma glucose (FPG) 126 mg/dl (7.0

mmol/l) no caloric intake for at least 8 hours

OR Two-hour plasma glucose 200 mg/dl (11.1 mmol/l)

during an oral glucose tolerance test (OGTT)

OR

A random plasma glucose 200 mg/dl (11.1 mmol/l)


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Goals of Treatment - Glucose

A1c < 7.0%

Pre-prandial CBG 70 130 mg/dl Peak postprandial CBG < 180 mg/dl

Less stringent A1c goals may be appropriate for patients

with History of severe hypoglycemia, limited life expectancy,

advanced microvascular or macrovascular complications,extensive co-morbid conditions

Those with longstanding diabetes in whom general goal isdifficult to attain despite education, glucose monitoring andeffective doses of multiple glucose lowering agents includinginsulin


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Correlation of A1c with Estimated Average Glucose

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

ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9.


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Components of Management

Blood sugar control

Patient education Nutrition counseling

Medication

Physical activity

Foot care

Retinopathy

Nephropathy

Cardiac

Lipid Management

Smoking cessation

Vaccines

Transfer and discharge


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Blood Sugar Control

Goal is A1c < 7.0%

Chronic care clinic for management

Every 3 6 months if A1c consistently < 7.0%

Every 2 3 months if A1c is 7.0% - 9.0%

Every month if A1c > 9.0% until better control is achieved Achieving good control requires:

Patient education and motivation

Effective combination of medications

Appropriate diet and compliance

Daily blood glucose monitoring


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Patient Education

Nutrition including commissary choices

Medication

Empowerment for self-management

Choice

Control Consequences

Peer groups


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Nutritional Counseling

Individuals who have diabetes or pre-diabetes should

receive individualized medical nutrition therapy Include counseling regarding the better choices

from items available in the commissary

Use commissary purchase list as an additional

opportunity for education and counseling Encourage weight loss if BMI 25

Education regarding portion control

Think about implementing a heart healthy diet forALL inmates benefits everyone and reduces needfor special medical diets


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Medication

Formularies should provide access to usual and

customary oral medications and insulins to treatdiabetes and related conditions

Patients should have access to medications at dosing

frequencies that are consistent with their treatment

plan and direction

Correctional institutions and police lock-ups should

implement policies and procedures to diminish the

risk of hypo- and hyperglycemia during off-site travel


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Physical Activity

Exercise 150 minutes/week of moderate intensity

aerobic activity Almost everyone can walk

If there isnt sufficient place to walk on the grounds,consider setting aside gym time for walking around

the court or running laps Exercise does not mean everyone has to work out in

the weight room

In absence of contraindications, people with type 2diabetes should be encouraged to perform resistancetraining three times per week


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Foot care

Instruct the patient with diabetes to examine his/her

feet daily and report to medical at the first sign ofbreakdown

Examine the patients feet at every encounter

Annual comprehensive foot exam to includeinspection, assessment of pulses, testing for loss of

protective sensation (monofilament, pinprick, etc.)

Multidisciplinary approach at the first sign of foot

ulcer and for those with high-risk feet


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Monofilament Testing

Upper panel

To perform the 10-gmonofilament test, place thedevice perpendicular to theskin, with pressure applieduntil the monofilamentbuckles

Hold in place for 1 secondand then release

Lower panel

The monofilament testshould be performed at thehighlighted sites while thepatients eyes are closed

Boulton AJM, et al. Diabetes Care.2008;31:1679-1685


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Retinopathy

Initial dilated retinal and comprehensive eye exam by

an ophthalmologist or optometrist shortly afterdiagnosis

Subsequent examinations annually

High quality fundus photographs can detect most

clinically significant diabetic retinopathy.Interpretation should be performed by a trained eyecare provider. This is not a substitute for acomprehensive eye exam.

Eye exam in the first trimester with close follow upthroughout pregnancy and for one year postpartum


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Nephropathy

Annual test to assess urine albumin excretion in type 1

diabetic patients with diabetes duration of 5 years Annual test to assess urine albumin excretion in all type 2

diabetic patients starting at diagnosis

Serum Creatinine at least annually in all adults with

diabetes regardless of the degree of urine albuminexcretion

GFR at least annually to stage level of chronic kidneydisease

If micro- or macroalbuminuria, treat with ACE or ARB(contraindicated in pregnancy)

Reduction of protein intake if patient has CKD


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Stages of Chronic Kidney Disease

Stage Description

GFR (ml/min per

1.73 m

2

bodysurface area)

1 Kidney damage* with normal or

increased GFR

90

2 Kidney damage* with mildly decreased

GFR

6089

3 Moderately decreased GFR 3059

4 Severely decreased GFR 1529

5 Kidney failure


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Cardiovascular Disease

BP at every encounter goal is < 130/80

If not at goal: Lifestyle therapy for maximum of 3 months if systolic 130

139 or diastolic 80 89

Weight loss if overweight

Dietary Approaches to Stop Hypertension (DASH) diet

Increased physical activity

Moderation of alcohol intake

If systolic 140 or diastolic 90 at diagnosis or follow up,begin pharmacologic therapy in addition to lifestyle

therapyACE or ARB and diuretic (thiazide if GFR 30 andloop if GFR < 30)

Monitor kidney function and serum potassium levels


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Antiplatelet Agents

Consider aspirin therapy (75 to 162 mg/day) as a primaryprevention strategy in those with type 1 and type 2 diabetesat increased cardiovascular risk (10-yr risk > 10%)

Includes men > 50 years or women > 60 years with at least oneadditional major risk factor (family history of CVD, HTN, smoking,dyslipidemia, albuminuria)

ASA not recommended for those at low cardiovascular risk

Use aspirin as a secondaryprevention strategy in patientswith diabetes and history of CVD

For patients with CVD and documented ASA allergy,clopidogrel (75 mg/day) should be used

Combination therapy with ASA and clopidogrel is reasonablefor up to one year after an acute coronary syndrome


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Lipid Management

Fasting lipid profile at least annually

Goal is LDL-C < 100 mg/dl

Goal for those with CVD is < 70 mg/dl

If goal is not met on maximum drug therapy, reduction of30% - 40% from baseline is an alternative goal

Lifestyle therapy for all diabetic patients Statin therapy should be added to lifestyle therapy,

regardless of lipid levels, for diabetic patients:

With overt CVD

Without CVD who are over the age of 40 and have one or moreother CVD risk factor

Statin therapy is contraindicated in pregnancy


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Smoking Cessation

Advise all patients not to smoke

Include smoking cessation counseling and otherforms of treatment as a routine component of

diabetes care


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Immunizations

Provide an influenza vaccine annually to all diabetic

patients 6 months of age Administer pneumococcal polysaccharide vaccine to

all diabetic patients 2 years

One-time revaccination recommended for those > 64

years previously immunized at < 65 years ifadministered 5 years ago

Other indications for repeat vaccination:

Nephrotic syndrome

Chronic renal disease

Immunocompromised states


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Transfer and Discharge

For all inter-institutional transfers, complete a

medical transfer summary to be transferred with thepatient

Diabetes supplies and medication should accompany

the patient during transfer

Begin discharge planning with adequate lead time to

ensure continuity of care and facilitate entry into

community diabetes care


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Diabetic Emergencies


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Diabetes Emergencies

People experiencing diabetes emergencies may:

Appear intoxicated

Appear under the influence of drugs

Appear uncooperative

When in doubt, ask the person or his/her

companions if the person has diabetes and check for

medical identification bracelet, necklace, or card


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Warning Signs that Require Action

Hypoglycemia

Sweating

Shakiness

Anxiety

Confusion

Difficulty speaking Uncooperative behavior

Paleness

Irritability

Dizziness

Inability to swallow

Seizure

Loss of consciousness

Hyperglycemia

Flushed skin

Labored breathing

Confusion

Cramps Very weak

Sweet breath

Nausea

Loss of consciousness


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Emergency Treatment

Hypoglycemia

Give can sugared (non-

diet) soda unless the

person cannot swallow

Obtain immediate

assistance from a qualifiedhealth care professional

Continue to give sugar

source every 15 minutes

until blood sugar > 70

If unconscious, give

Glucagon or D50 IV

Hyperglycemia

Give access to water

Give access to bathroom

Give access to medication

Obtain immediateassistance from a qualified

health care professional

Give regular NOT LONG-

ACTINGinsulin


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How to Ensure Safety of Patients with Diabetes

Identification Promptly identify patients with diabetes and ensure that this information

accompanies the patient to all facilities while he/she is in custody Location

Patients with diabetes should only be held where there is immediate access tohealth care professionals who are able to manage their care and respond todiabetes emergencies

Access to diabetes medication and food Patients with diabetes must continue their medication without interruption and

must alwayshave access to food. In addition, it is important to coordinate mealsand medication to maintain blood glucose levels in a safe range

Sugar If a patient with diabetes requests a source of sugar, immediatelyprovide that

person with a sugared soft drink, juice, or another fast-acting source of sugar,followed by bread or crackers

Emergencies If a patient with diabetes requests medical care or exhibits symptoms of diabetic

illness, immediatelyobtain assistance from a qualified health care professional.Know the fastest way to obtain medical help in the case of an emergency thatcannot be handled by on-site personnel

d i


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Summary and Key Points

People with diabetes should receive care that meets nationalstandards. Being incarcerated does not change these standards.

Patients must have access to medication and nutrition needed tomanage their diabetes.

In patients who do not meet treatment targets, medical andbehavioral plans should be adjusted by health care professionals incollaboration with the custody staff.

It is critical for correctional institutions to identify particularly high-risk patients in need of more intensive evaluation and therapy,including pregnant women, patients with advanced complications, ahistory of repeated severe hypoglycemia, or recurrent DKA.

A comprehensive, multidisciplinary approach to the care of peoplewith diabetes can be an effective mechanism to improve overall

health and delay or prevent the acute and chronic complications ofthis disease.

R f


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References

Diabetes Management in Correctional Institutions. Agency forHealthcare Research and Quality. Available online athttp://guideline.gov

Standards of medical care in diabetes. VI. Prevention andmanagement of diabetes complications. Agency forHealthcare Research and Quality. Available online at

http://guideline.gov American Diabetes Association. Standards of medical care in

diabetes 2011. Diabetes Care 2011;34(suppl 1):S11-12.Available online athttp://care.diabetesjournals.org/content/34/Supplement_1

National Diabetes Fact Sheet, 2011. National Center forChronic Disease Prevention and Health Promotion. Division ofDiabetes Translation. Available online at http://www.cdc.gov

C I f i
http://guideline.gov/http://guideline.gov/http://care.diabetesjournals.org/content/34/Supplement_1http://www.cdc.gov/http://www.cdc.gov/http://care.diabetesjournals.org/content/34/Supplement_1http://guideline.gov/http://guideline.gov/


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Contact Information

Sr. Mary Jane Bookstaver:

[email protected]
mailto:[email protected]:[email protected]

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