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Cardiac RehabilitationNew Brunswick: Tutorial Series
Diabetes MellitusOverview, pharmacotherapyand exercise considerations
Overview Prevalence of diabetes Definition and Diagnosis Risk factors and complications Treatment and pharmacotherapy Diabetes and Exercise Benefits Precautions and considerations Exercise prescription
Diabetes epidemic
7.3% of Canadian population, expected to rise to 10% by 20201
25%‐32% of patients with a myocardial infarction have both diabetes and coronary artery disease2
1. Canadian Diabetes Association, 2010 Economic Report2. Miketic et al., Journal of Cardiovascular Nursing, 2011: 26(3) 210‐17
Definition: Diabetes Mellitus
Complex metabolic disorder Characterized by: High levels of plasma glucose (hyperglycemia) due to
defective insulin secretion, defective insulin action or both
Hyperglycemia over time leads to serious damage to many of the body's systems, such as macrovascular disease, microvascular degeneration, neuropathies and other complications
Canadian Diabetes Association Diagnostic Criteria
Pre‐diabetes
Diabetes
Source: Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl1):S8‐11website: guidelines.diabetes.ca
American Values (ADA)Pre‐diabetes
Diabetes
ADA, Diabetes Care, 2012, (35) S1: S64‐71
Conversion
mmol to mg/dL: multiply by (x) 18 mg/dL to mmol/L: divide by 18 or multiply by (x) 0.055
Classification
Type 1 Type 2 Gestational Other ‐ genetic defects, diseases of the exocrine pancreas, endocrinopathies, drug or chemical induced, etc.
See CDA 2013 Guidelines Appendix 1: http://guidelines.diabetes.ca/Browse/Appendices/Appendix1
Diabetes Mellitus: Type 1 About 5‐10% of all diabetes
Autoimmune disease characterized by β‐cell destruction
Usually leads to absolute insulin deficiency
Unknown etiology, maybe virus, toxins, genetics
Increase loss of water through sugar in urine Severe thirst, weight loss, increase appetite
Subject to ketoacidosis metabolic acidosis
Diabetes Mellitus: Type 2 90‐95% of all diabetes
Characterized by peripheral insulin resistance and defective insulin secretion that can progress to insulin resistance
Decrease in sensitivity of peripheral receptors in smooth muscle and liver
Reduction in glucose disposal rate
Plasma insulin can be increased, may lead to β‐cell exhaustion
Type 1 vs. Type 2
Characteristics Type 1 Type 2
Age of onset Generally <20 > 30 (usually)
Type of onset abrupt slow progression
Environment Virus, toxins, autoimmune stimulation
Obesity, poor nutrition,physical inactivity
Family History probable frequent
Endogenous insulin Minimal or absent Insulin resistance, secretion adequate but delayed or reduced
Symptoms Thirst, polyuria, weight loss, ↑ appe te
Mild or frequently none
Insulin Tx Required for all Required for ~30%
Type 2 Risk factors• Lifestyle disease! • Risk factors are:
•obesity (central adiposity)•sedentary•high blood pressure, high cholesterol•smoking•age •non‐white race •genetics •gestational diabetes (or baby > 9 lbs)
Complications
• cardiovascular disease (↑ atherosclerosis, endothelial dysfunction, inflammation)
• retinopathy (blindness) • nephropathy• autonomic neurophathy• peripheral neuropathy• non‐traumatic amputations• erectile dysfunction• mental health disorders (dementia)
Treatment targets
Glycosylated Hemoglobin A1C= Hb A1C =A1C Average blood glucose control over the last 2‐3
months, non‐fasting
Treatment goal: A1C below 7%
For patients: “Morning” plasma glucose (FPG) (4‐7 mmol/L)
Blood Pressure Targets
2010 Canadian Hypertension Guidelines
No Diabetes
<140/90 mmHg
With diabetes or persons with chronic kidney disease
<130/80 mmHg
Treatments
Type 2 Weight loss Oral hypoglycemic agents (see Pharmacotherapy section) Possibly insulin
Type 1 Subcutaneous injections of insulin (see Pharmacotherapy
section) Dietary regulation Exercise daily
Pharmacotherapy
Oral Hypoglycemic Agents (OHA)
Antihyperglycemic agents Used only in type 2 diabetes, with diet and exercise
CDA 2013 Clinical Practice GuidelinesPharmacotherapy in Type 1 diabetes (pages s56‐s60), Pharmacologic Management of Type 2 Diabetes (pages s61‐s68)
Generic Brand Advantages Disadvantages A1C ↓
Metformin Glucophage, Glumetza
‐Weight neutral‐low risk of hypoglycemia
‐GI side effects(nausea, bloating, diarrhea, decreased appetite)
1‐2%
Mechanism of Action:↓ hepa c glucose produc on and intes nal glucose absorp on, ↑glucose uptake and insulin sensitivity, lowers basal and post‐prandial blood glucose levels
Comments:‐first line agent in type 2‐good as initial therapy especially if overweight‐best to gradually increase dose to ↓ GI side effects‐Contraindicated if CrCl/eGFR <30 mL/min or hepatic failure‐Caution with renal insufficiency (eGFR<30ml/min)‐lactic acidosis may be precipitated by renal impairment, excessive alcohol intake, hepatic disease, acute CHF
PharmacotherapyClass: Biguanides (Insulin Sensitizer)
Generic Brand Advantages Disadvantages A1C ↓
Glyburide*
Gliclazide
Glimepiride
Repaglinide
Diabeta
Diamicron
Amaryl
Gluconorm
‐rapid effect ‐weight gain, risk of hypoglycemia, dizziness, headache, nausea, weakness
‐expensive
1‐2%
Mechanism of Action:Stimulates functional β cells in pancreas to release insulin, ↓ glucose output from liver
Comments:‐take with food‐hypoglycemia and weight gain are especially common with glyburide*‐caution with patients at high risk of hypoglycemia (e.g. the elderly, renal/hepatic failure)
PharmacotherapyClass: Sulfonylureas and Meglitinides(Insulin Secretagogues)
Generic Brand Advantages Disadvantages A1C ↓
Acarbose Glucobay
Prandase
‐Weight neutral‐low risk of hypoglycemia
‐GI side effects(diarrhea, gas, cramps, liver dysfunction)
0.5‐0.75 %
Mechanism of Action:Delays digestion of CHO and gastrointestinal absorbtion of glucose. Inhibits pancreatic amylase and membrane bound intestinal α‐glucoside hydrolase.
Comments:‐Take with food (first bite of meal)‐Takes up to 8 weeks for maximum efffect‐Not recommended as initial therapy in people with markedhyperglycemia (A1C >9.0%)
PharmacotherapyClass: Alpha‐glucosidase inhibitors
Generic Brand Advantages Disadvantages A1C ↓
Pioglitazone
Rosiglitazone
Actos
Avandia
‐improved lipidprofile, low risk of hypoglycemia, potential decrease in MI (pio)
‐Slow onset, fluidretention, weight gain, bone fractures, expensive, potential increase in MI (rosi)
0.5‐2%
Mechanism of Action:↓ insulin resistance, improves target cell response to insulin, ↓ hepa c glucose production
Comments:‐may induce ovulation‐only covered by blue cross through special authorization –must be intolerant to metformin‐take at same time everyday‐some blood pressure lowering
PharmacotherapyClass: Tiazolidinidediones (TZD)or Glitazones (Insulin sensitizers)
Generic Brand Advantages Disadvantages A1C ↓
Liraglutide
Exenatide
Victoza
Byetta
‐weight loss, low risk of hypoglycemia
‐injection, expensive,long‐term safety not established, GI side effects
0.5‐1.5%
Mechanism of Action:Glucagon Like Peptide 1 (GLP‐1) receptor agonists act to ↑ insulin release in the presence of ↑ glucose, ↓ glucagon secre on and delay gastric emptying
Comments:‐may be beneficial for weight loss‐may delay gastric emptying and impact absorption of oral meds (caution with antibiotics and contraceptives)‐caution with patients at high risk of hypoglycemia(e.g. the elderly, renal/hepatic failure)
PharmacotherapyClass: Glucacon Like Peptide 1 (GLP‐1)(Incretins)
Generic Brand Advantages Disadvantages A1C ↓
Sitagliptin
Saxagliptin
Januvia
Onglyza
‐weight neutral, low risk of hypoglycemia
‐expensive, long‐term safety not established
0.5‐0.75%
Mechanism of Action:DPP‐4 is an enzyme that breaks down the incretin hormones GIP and GLP‐1 to help increase the release of insulin and decrease glucagon levels in the circulation
Comments:‐Better post prandial glucose control
PharmacotherapyClass: Dipeptidylpeptidase 4 (DPP‐4) Inhibitors (Incretin)
PharmacotherapyInsulin Rapid Acting Humalog (lispro)
Short Acting Humulin R Novolin
Intermediate Acting Humulin N
Long Acting Lantus Levemir
Acute response to exercise
Acute exercise results in glucose use and sensitivity to insulin
Improves uptake of glucose for type 2 Aids in glucose homeostasis Can lower blood glucose for up to 72 hours post exercise
Benefits of chronic exercise Improved insulin sensitivity Increased muscle capillary density, use glucose more efficiently
Changes in insulin signaling (translocation of GLUT‐4)
Improved blood glucose control = decrease in A1C
Benefits of chronic exercise (cont.) Decreased CV risk Improved blood lipids Improved blood pressure in those with hypertension
Increase in caloric expenditure (improve BMI) Control body weight (↓ visceral fat)
Increased fitness
Improved psychological well‐being (decrease in depression)
Benefits of Exercise: Type 2 vs. Type 1
Type 2– Reduced blood glucose and A1c levels– Improved glucose tolerance– Improved insulin response to oral glucose
Type 1– Improvement in insulin sensitivity may be transient
Response to exercise
Acute exercise results in increased glucose utilization
In turn, increased glucose production to maintain normal levels
Compromised in diabetic state (those on insulin or insulin secretagogues) can lead to risk of hypoglycemia
Screening Procedures
History and Physical exam Diabetes evaluation (screening for neuropathy, retinopathy, poor glycemic control)
Cardiovascular Exam May include exercise stress test (see 2010 ACSM
Position Stand and 2013 Canadian Diabetes Association guidelines)
CDA recommendations
“People with diabetes with possible CVD or microvascular complications of diabetes who wish to undertake exercise that is substantially more vigorous than brisk walking should have medical evaluation for conditions that might increase exercise‐associated risk. The evaluation would include history, physical examination (including funduscopic [eye] exam, foot exam, and neuropathy screening), resting ECG and, possibly, exercise ECG stress testing [Grade D, Consensus].”
Physical Activity and , Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1‐S21
Exercise testing
Other considerations: Asymptomatic (silent) ischemia ‐more common in people with diabetes
Parasympathetic and sympathetic dysfunction Altered autonomic control (neuropathy) ↓HR variability, impaired HR recovery, blunted BP response, postural hypotension
Monitor blood glucose pre and post May consider submax for prescription
Considerations for exercise: Hypoglycemia
Be aware of signs and symptoms profuse sweating (diaphoresis) tachycardia hunger blurred or double vision confusion tremors headache memory loss seizure or coma
Precautions for Avoiding Hypoglycemic Events The risk of hypoglycemia is greater in those on insulin or insulin secretagogues (sulfonylureas and meglitinides)
In these individuals, monitor blood glucose before exercise: If blood glucose is < 100mg/dL (5.5 mmol/L) eat 15‐30g CHO snack
If controlled by diet or other oral medication, the risk of hypoglycemia is minimal and most individuals will not need to monitor blood glucose levels or supplement CHO for exercise lasting < 1 hour.
Precautions for Avoiding Hypoglycemic Events
For those on insulin: Adjust insulin dosages associated with exercise Avoid exercise during periods of peak insulin activity Insulin should not be injected into an exercising muscle
Exercise late in the evening may increase the risk of nocturnal hypoglycemia
Considerations for exercise: Hyperglycemia
Be aware of signs and symptoms dizziness dehydration nausea polyuria blurred vision lethargy sweet smelling breath vomiting Hyperventilation
monitor for signs especially if exercising in heat
Hyperglycemia guidelines
Type 1: if > 16.7mmol/L (300mg/dL) and patient does not feel well and/or keytones = postpone exercise
Type 2: if > 16.7 mmol/L, do not need to postpone exercise provided they are feeling well, monitor for signs and symptoms
Ensure adequate hydration Use caution; may want to warm‐up 10 min and ensure blood glucose is not increasing
Contraindications to exercise
ACSM Guidelines Box 3.5
Uncontrolled proliferative retinopathy
Exercise programming: Aerobic Training
F: 3‐7 days per week I: 50‐80% if VO2R or HRR, RPE 12 to 16, talk test T: 20‐60 min/day Bouts of at least 10 min CDA guidelines: Total 150 minutes/week moderate or
90 min vigorous 5‐10 min warm‐up and cool down
Type: Aerobic: large muscle groups
FITT IntensityOther Considerations
For substantially ‘vigorous’ exercise– Symptom‐limited exercise stress test recommended due to
increased risk of complications
THR always 10bpm below:– 1mm horizontal or downsloping ST segment depression
– Anginal symptoms or other CV insufficiency
– SBP 240mmHg, plateau SBP or SBP– DBP 110mmHg
FITT IntensityOther Considerations
THR always 10bpm below:– frequency ventricular dysrhythmias– Other significant ECG disturbances– Radionuclide evidence LV dysfunction– Mod/sev wall motion abnormal with exercise– Other signs/symptoms of intolerance
Exercise programming: Resistance Training
F: 2‐3 days per week I: 2‐3 sets, of 8‐12 reps at 60%‐80% 1‐RM T: 8‐10 multi‐joint exercises of major muscle groups
Type: Tailor to need of client Evidence for resistance bands is unclear
Avoid Valsalva Exhale on exertion
Canadian Diabetes Association: 2013 Clinical Practice GuidelinesExercise Prescription
Exercise counseling:
Discuss proper glucose control , signs and symptoms, eating appropriately
Medications Hydration Footwear Caution with extreme temperatures Medical ID bracelet May want to exercise with a partner
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