simplifying diabetes management · 2019. 4. 29. · common se: nausea, weight loss albiglutide...
TRANSCRIPT
4/29/2019
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Diana Emmick, MSN, ACNP-BC, CDE
St. Vincent Medical Group, Endocrinology
▪Describe diabetes treatment plans which are most appropriate in various settings
▪List new devices available and describe impact for diabetes management
TYPE 1
▪ Autoimmune
▪ Absolute insulin deficiency
▪ Increased insulin sensitivity
▪ Typically lean
▪ Must treat with INSULIN
TYPE 2
▪ Insulin Resistance
▪ May/may not be producing insulin
▪ Obese vs lean
▪ Many treatment options
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▪Treat with insulin
▪Testing: ▪ Anti-GAD antibody, islet cell antibody, zinc transporter antibody,
insulin antibody
▪ C-peptide
▪ Refer to endocrinology
INPATIENT
▪ Critically ill
▪ 140 – 180
▪ Non-Critically ill
▪ Pre meal: <140
▪ Post meals: <180
OUTPATIENT
▪ ADA
▪ Pre meal: 80 – 130
▪ 2 hour post meal: <180
▪ AACE
▪ Fasting < 110
▪ 2 hour post meal: <140
-http://inpatient.aace.com/strategies-for-
achieving-glycemic-control-management-of-
hyperglycemia-in-the-critical-care-setting
-http://inpatient.aace.com/management-of-
hyperglycemia-in-the-noncritical-care-
setting
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Metformin
DPP-4 inhibitors
SGLT2
Sulfonylurea
Glinides
TZDs
▪ Canagliflozin (Invokana)▪ 100 & 300 mg po daily
▪ Dapagliflozin (Farxiga)▪ 5 & 10 mg po once daily
▪ Empagliflozin (Jardiance)
▪ 10 & 25 mg po once daily
▪ Ertugliflozin (Steglatro)▪ 5 & 10 mg po once daily
A1C lowering: ~0.7 to 1% reduction
Caution: Renal function, yeast/UTI, hx amputations
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▪Use in type 1 diabetes →off label
▪ Increased DKA risk!▪ Lack of glucose
▪ Lack of insulin
Euglycemia DKA
→Starvation and alcoholic ketoacidosis
▪ Presenting symptoms▪ Nausea, vomiting, malaise, SOB
▪ Metabolic acidosis
▪ Check for serum ketones
▪ Start dextrose sooner than typical DKA
▪Alogliptin (Nesina)▪ 25 mg –renal dosing
▪Linagliptin (Tradjenta)▪ 5 mg – NO renal dosing
▪Saxagliptin (Onglyza)▪ 5 mg –renal dosing
▪Sitagliptin (Januvia)▪ 100 mg –renal dosing
A1C lowering: ~0.6 to 0.9 % reduction
Side effects: nasopharyngitis
Caution in: history of pancreatitis and CHF
▪ Dulaglutide (Trulicity)▪ 0.75 & 1.5 mg sc once weekly
▪ Exenatide (Byetta)▪ 5 & 10 mcg sc BID
▪ Exenatide (Bydureon)
▪ 2mg sc once weekly
▪ Liraglutide (Victoza)▪ 0.6, 1.2, 1.8 mg sc once daily
▪ Semaglutide (Ozempic)▪ 0.25, 0.5 & 1mg sc once weekly
* * *
BASAL + GLP-1
▪ Degludec/liraglutide (Xultophy)▪ 16 to 50 unit sc daily
▪Glargine/lixisenatide (Soliqua)▪ 15 to 60 unit sc daily
A1C lowering: ~1 % reduction (0.47 to 1.56 %)
Caution: pancreatitis, MTC. Common SE: nausea, weight loss
Albiglutide (Tanzeum) ~ discontinued
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CANVAS - Invokana
EMPAREG – Jardiance
LEADER – Victoza
REWIND – Trulicity
SUSTAIN6 - Ozempic
GLP-1
SGLT2
Basal Insulin
U100 insulins▪ Basaglar, Lantus, Levemir, Tresiba
U200 insulin▪ Tresiba U200
▪ Delivers in 2 units increments
U300 insulin▪ Toujeo Solostar – 1 unit increment
▪ Toujeo Max
▪ 2 units increments
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▪Longer duration of action (up to 36 & 42 hours)
▪ Injecting smaller volume
▪Larger dose all in one injection (160 units)
▪Longer shelf life
▪Aspart (Fiasp & Novolog)▪ Fiasp – onset ~2.5 minutes
▪Lispro (Admelog & Humalog)▪Humalog U200 – 2 units increments
▪Glulisine (Apidra)
$25 per Vial
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✓ More than 200 units/day
✓ BID to QID dosing
✓ Acts as basal & prandial
✓ Pen or Vial
*Actual vs measured units
Onset: 0.5 -1 hr
Peak: 2 - 4 hours
Duration: up to 24 hours
▪ Insulin is preferred treatment
▪Stop oral antihyperglycemic agents and injectables
▪Combination of basal & bolus insulin▪ 50 – 50% split
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▪Anticipate hyperglycemia
▪Diabetes status?
▪Bolus vs Continuous feeds
Treatment:
➢Correction insulin only
➢Basal + Correction
➢Basal + Rapid/Regular insulin + Correction
Watch out for Abrupt discontinuation
Intravenous ~ Oral ~ Intra-articular
▪Anticipate hyperglycemia
▪Steroids are counter regulatory hormone▪ Impair insulin action
→Increase insulin resistance
▪Appears to diminish insulin secretion
▪ Insulin = preferred treatment▪ Basal & Bolus insulin
▪ Increased prandial insulin needs
▪ Insulin infusion
▪Severe and persistent hyperglycemia
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Pre-procedure
▪Hold metformin 24 hours before and 48 hours after
▪Sulfonylurea/insulins – cut down▪Consume around same amount of carbs
▪Not all ‘sugar free’ items
▪Basal insulin ~ ½ usual dose night before
▪Bolus insulin▪Continue carb count during prep
▪ Sliding scale coverage
Intra-operative
▪ Insulin infusion if long procedure- open heart
Post surgery/procedure
▪ If taking diet, resume usual doses
▪NPO: basal insulin and correction doses
~Glycemic control is very important for healing process
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Newly diagnosed:
▪Metformin▪Must document why not taking it
▪ Intolerance
▪Contraindication
▪GFR <30
▪ Alcohol abuse
▪ Lactic acidosis
Metformin
DPP-4 inhibitors
SGLT2
Sulfonylurea
Glinides
TZDs
▪Oral agents
▪Injectables
▪Insulin ▪Basal + Oral/injectable
▪Basal and bolus
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▪Any uncontrolled patient
▪Already on multiple oral/injectable agents
▪Multiple intolerances
▪Pregnancy
▪Unsure of diabetes type
▪Must use INSULIN
▪Divided doses ▪50% basal
▪50% bolus
▪Diabetes education
▪Carbohydrate counting
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PROS
▪Variable insulin needs
▪Ease to bolus
CONS
▪DKA risk
▪Always connected
Small electronic device that delivers insulin based on pre-
programmed settings
▪ Pump terms:
Basal rates – individualized hour by hour
Bolus rates: Carbohydrate ratio
Correction/sensitivity factor
➢ ‘Sensors’
➢ Interstitial glucose
➢ Separate site
➢ Calibrations
➢ Integrated into
pump
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Freestyle
Libre
Medtronic
DexCom
How can Continuous Glucose Monitoring
impact diabetes management?
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Targets
▪Hypoglycemia < 3 %
▪Time in Range > 70 %
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▪Professionally inserted
▪90 day wear (up to 6 months)
▪Removable transmitter▪ Sensor not wasted
▪On body vibe
▪FDA approved for MRI
▪3 months accuracy 8.5 % MARD (40 -400 mg/dl)
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▪Glucose trends
▪Alert at/before glucose excursion
▪ Increase time in range
▪ Increased awareness
▪Do NOT rely only on A1C▪ Fingerstick/sensor readings very important
▪ ESRD, blood transfusion, etc
▪A1C lowering from >14 to 9% is relatively easy▪ Tougher zone A1C 8.5 to 6.5 %
▪Hypoglycemia risk increases with stricter diabetes control
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▪GLP-1 and DPP4
▪Sulfonylurea dosing▪ 50% of maximum dose or LESS
▪No basal sliding scale
Thank you