Diabetes Webinar:

Best Care for Sick DaysKatie Wilson, PharmD, BCACP

and

Vicky Taylor, RN, BSN, CDE

Testing Blood Glucose (blood sugar)

• Primary tool to determine at any point in time if your blood glucose levels are within your target range.

• Blood glucose meter

• Continuous glucose monitor (CGM)

• Log glucose readings to share with your provider

• Fasting blood glucose

• Pre-prandial (before meals)

• Post-prandial (after meals)

• Hemaglobin A1C

Blood Sugar and A1C Targets

• Individualized

TIME Goal

Fasting 80-130 mg/dL

Pre-prandial (Pre Meal)

80-130 mg/dL

Post-prandial (After meal)

<180 mg/dL

A1C <7%

Oral Diabetic Medications

• Metformin (Glucophage)

• Sulfonylureas - glyburide (DiaBeta, Glynase), glipizide (Glucotrol) and glimepiride (Amaryl)

• Meglitinides - repaglinide (Prandin) and nateglinide (Starlix)

• Thiazolidinediones (TZD) - rosiglitazone (Avandia) and pioglitazone (Actos)

Oral Diabetic Medications

Medication How to take Adverse Effects

Metformin Taken 1 or 2 times daily with food. GI, diarrhea

Glyburide , Glipizide and Glimepiride Taken 1 or 2 times daily with meal(s) Hypoglycemia, weight gain

Prandin, Starlix Taken 3 times daily within 30 min of meal

Hypoglycemia, weight gain

Actos Taken once daily with or without food Edema/fluid retention

Newer Oral Diabetic Medications

• DPP-4 inhibitors - sitagliptin (Januvia), saxagliptin (Onglyza) and linagliptin (Tradjenta)

• SGLT2 - canagliflozin (Invokana), dapagliflozin (Farxiga) and empagliflozin (Jardiance)

Newer Oral Diabetic Medications

Medication How to take Adverse Effects

Januvia, Onglyza and Tradjenta

Taken once daily with or without food

Runny/stuffy nose, headache

Invokana, Farxiga, Jardiance

Taken once daily with or without meals

Increased urination, UTIs

Insulin

• Rapid acting (Humalog, Novolog)

• Short acting (Regular Insulin)

• Intermediate acting (Humulin N, Insulin NPH)

• Long acting (Lantus, Levemir)

• Ultra-long acting (Tresiba, Toujeo)

Other injectable diabetic medications

GLP-1 Agonists

• Dulaglutide (Trulicity)

• Exenatide (Byetta)

• Exenatide Ext Rel (Bydureon)

• Liraglutide (Victoza)

• Semaglutide (Ozempic)

Other injectable diabetic medications

Medication How to take Adverse Effects

Trulicity, Byetta, Bydureon, Victoza, Ozempic

Inject 1-2 times daily, or weekly

GI related (nausea, vomiting, diarrhea), weight loss

Poll Question

What’s your biggest fear/concern around insulin?

a. Needles

b. The thought of getting daily injection(s)

c. Side effects (weight gain, hypoglycemia)

Why Take Your Medicine?

https://pdb101.rcsb.org/global-health/diabetes-mellitus/monitoring/complications

The Struggle is Real

•75% of patientsstruggle to take medicines as prescribed1

1. Improving prescription medicine adherence is key to better healthcare: taking medicines as prescribed can lower costs and improve health outcomes. PhRMA website. http://phrma.org/sites/default/files/pdf/PhRMA_Improving%20Medication%20Adherence_Issue%20Brief.pdf. Accessed January 6, 2017.

Barriers

• Starting a New Medication

Starting 31%

• Taking a Medication the way it will work the best for you

Taking 40%

• Stopping a MedicationStopping

33%1. Improving prescription medicine adherence is key to better healthcare: taking medicines as prescribed can lower costs and improve health outcomes. PhRMA website. http://phrma.org/sites/default/files/pdf/PhRMA_Improving%20Medication%20Adherence_Issue%20Brief.pdf. Accessed January 6, 2017. 2. Fischer MA, Stedman MR, Lii J, Vogeli C, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010;25(4):284-290.

What can you do?

• Tricks for reducing costStarting

• Make sure you understand instructions

• Use Tools and TipsTaking

• Tell your health care provider before you stopStopping

Tips on Taking Your Medications

• Know your Medications

• Ask questions, best time to take, with or without food, what if I miss a dose

• Routine

• Consistent time, associate with another daily activity (meal, brushing teeth, bedtime)

• Reminders

• Pill box, phone alarm, make medications visible

• Simplify

• Combinations pills, take medications at the same time if able, ask provider to help simplify regimen

Medications Wrap-up

• Importance of checking glucose to optimize medications and dose

• Individualized medication regimens based on many factors

• Understand importance of taking medications and overcoming barriers

SAINT LUKE’S HEALTH SYSTEM 20

Which of the following are true?

1. If I am sick and unable to eat, I do not need to test my blood sugar.

2. If I am sick and unable to eat, I do not need to take my insulin.

3. If I am sick and unable to eat, I need to test blood sugar only if I feel high or low.

4. Being sick or having and infection will likely cause my blood sugar to go up.

How are you doing?

SAINT LUKE’S HEALTH SYSTEM 21

Impact of illness

Do you have what you need available

Blood sugar high and lows

What is your plan

Self- management on sick days

When should I call the doctor

When do I seek emergency care

Guidelines for sick days

• Minor illness

• Cold

• Flu

• Off of your “regular routine”

• Upset stomach

• Dental

• Minor same day procedure

SAINT LUKE’S HEALTH SYSTEM 22

Sick day supplies

• Thermometer

• Sick day guidelines

• Gelatin packets (one regular and one sugar free)

• Tylenol/ibuprofen

• Cough drops (regular/sugar free)

• Regular and sugar free soft drinks

SAINT LUKE’S HEALTH SYSTEM 23

Sick Day Management

• HYDRATION is important!

• Know when to call your diabetes team!

• NEVER stop taking insulin without talking to your healthcare provider

• You may need to change your usual routine when you are ill

• Test blood sugar frequently

S A I N T L U K E ’ S H E A L T H

S Y S T E M 2 4

•Blood sugar every 2-4 hours

• Temperature

• Frequency of fluid intake

•Vomiting/diarrhea

•Urine Ketones

Monitoring and tracking

SAINT LUKE’S HEALTH SYSTEM 25

SAINT LUKE’S HEALTH SYSTEM 26

Sick Day Log

Time Temp Eat/drink Medication Blood glucose

Urine Ketones(test every 4 hr)

Notes:

8 AM 97.8 8 oz hot tea with 2 tsp honey

None 161Feeling nauseated

11:30 183 Feeling worse –really nauseated

1:30 101.2 12 regular 7-UP 6 units Humalog

250 Moderate Tylenol (2-325 mg)

2:45 8 oz Diet 7-UP3 saltine crackers

187

6:00 pm 100.4 Hot tea with honey, 1 pc dry toast

6 units Humalog

143 Trace

Frequentfeedings/hydration

Sick day meal/carb goals, likely need to include snacks

(listed are grams of carbohydrate)

S A I N T L U K E ’ S

H E A L T H S Y S T E M 2 7

BREAKFAST15-30 SNACK 15-30 LUNCH 30-45

SNACK 15-30 SUPPER 30-45 SNACK 15-30

SAINT LUKE’S HEALTH SYSTEM 28

Carb count for sick day foods

Food Portion Carb grams

Soft drink (regular) ½ cup 15 grams

Apple or Orange juice ½ cup 15 grams

Cooked cereal ½ cup 15 grams

Gelatin (regular) ½ cup 20 grams

Popsicle 1 24 grams

Soup (thin creamy) 1 cup 15 grams

Pudding (regular) ½ cup 30 grams

Pudding (sugar free) ½ cup 15 grams

Saltine crackers 6 15 grams

Toast 1 piece 15 grams

Fruit ½ cup 15 grams

Sports drink 1 cup 15 grams

Regular soda pop 5 oz 15 grmas

Honey or syrup 1 Tablespoon =3 teaspoons 15 grams

SAINT LUKE’S HEALTH SYSTEM 29

Meal (carb goal) Food Portion Carb grams Total carb/ feeding

Breakfast (15-30) Hot tea 1 cup 0 grams

Honey 2 tsp 10 grams

Toast 1 pc 15 grams 25

Snack (15-30) Saltine crackers 6 15 grams

SF 7-Up 12 oz can 0 grams 15

Lunch (30-45) Regular jello 1 cup 40 grams 40

Snack (15-30) Popsicle 1 24 grams 24

Supper (30-45) Oatmeal 1 cup 30 grams

Honey 2 tsp 10 grams

Hot tea 1 cup 0 grams 40

Snack (15-30) SF 7 up 6 oz 0 grams

Toast 1 piece 15 grmas 15

Emergency Attention• Serious complication from VERY HIGH

blood sugars• “Diabetic Coma”

• Type 1

• Type 2

• LOW blood sugar

SAINT LUKE’S HEALTH SYSTEM 30

Warning Signs

Heart Attack:• May last short time and go away then come back

• Pain in arm(s), jaw, back, neck or stomach

• Cold sweat, nausea, vomiting

• Decreased awareness of pain (silent heart attack)

Stroke:• Sudden numbness or weakness of face, arm, body

(one side)

• Sudden difficulty with speech/understanding

• Sudden visual changes (one or both eyes)

• Sudden loss of balance, dizziness or trouble walking

• Sudden, severe headache (no cause)

SAINT LUKE’S HEALTH SYSTEM 31

RemindersPrevention is best plan

Plan Ahead for illnessVaccines up to date?

No one size fits all

Blood sugar testing when ill – every 2-4 hours for some

Have your sick day supplies and Sick Day Plan ready

Medications

Emergency plan

SAINT LUKE’S HEALTH SYSTEM 33

Which of the following are true?

1. If I am sick and unable to eat, I do not need to test my blood sugar.

2. If I am sick and unable to eat, I do not need to take my insulin.

3. If I am sick and unable to eat, I need to test blood sugar only if I feel high or low.

4. Being sick or having and infection will likely cause my blood sugar to go up.

Resources:

Saint Luke’s Diabetes Centers

S A I N T L U K E ’ S

H E A L T H S Y S T E M 3 4

Individualized Diabetes Education on site or virtual visit

Call 816-932-2707 to make an appointment (requires provider referral)

Centers available at Saint Luke's Plaza, North, South and East Clinics

Resources:

Saint Luke’s Primary Care

S A I N T L U K E ’ S

H E A L T H S Y S T E M 3 5

Barry Road

816-880-6100

Blue Springs

816-347-4600

Blue Valley

913-323-8830

Cushing

913-651-6565

East

816-347-5600

Independence 816-251-5200

Lee’s Summit

816-347-5100

Mission Farms 913-317-7990

Parkville

816-569-1506

Platte City

816-858-7050

Plaza

816-932-3100

Shoal Creek

816-437-8161

Smithville 816-532-3999

Southridge913-317-3200

Resources:

Saint Luke’s Community Resource Hubhttps://saintlukesresources.org/