DIABETES MANAGEMENT: DIFFERENT TREATMENTS FOR DIFFERENT TIMES

Faith Pollock, APRN, CNS, CDE

Objectives

1. Verbalize types of diabetes and diagnostic criteria.

2. Discuss the management options for diabetes.

3. Discuss the perioperative management of patients with diabetes.

Number of Americans withDiagnosed Diabetes, 1980-2009

www.cdc.gov

New Cases of Diagnosed Diabetes

National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

Source: 2005-2008 National Health and Nutrition Examination Survey estimates projected to the year 2010

Oralmedication

only58%

No medication

16%

Insulin only 12%

Insulin and oral

medication14%

Treatment of Diabetes

National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/

Types of Diabetes

Type 1 diabetes Beta-cell destruction Do NOT make insulin

Type 2 diabetes Progressive deficit of insulin secretion Do make insulin, but resistant and decreases over

time Others

Gestational Chemical or drug induced Disease

Diagnosis of Diabetes

ADA. 2. Classification and Diagnosis. Diabetes Care 2015;38(suppl 1):S9-10; Table 2.1and 2.3

A1c Fasting glucose

2-h post OGTT glucose

Diabetes ≥6.5% ≥126 mg/dL ≥200 mg/dL

Pre-Diabetes

5.7–6.4%

100–125 mg/dL 140–199 mg/dL

Medications for Diabetes

Oral agent 9 categories

5 categories mostly used Non-insulin injectable

2 categories Insulin

5 categories

Oral Medications

Biguanides i hepatic glucose

production metformin

Liver

Sulfonylureas h insulin secretion

glyburide glipizide glimepiride

Pancreas

Oral Medications (2)

TZDs h insulin sensitivity

pioglitazone rosiglitazone

Muscle

DPP-4 Inhibitors h insulin secretion

(with food) i glucagon secretion

sitagliptin saxagliptin linagliptin alogliptin

Pancreas and Liver

Oral Medications (3)

SGLT2 Inhibitors Blocks glucose

reabsorption by the kidney h glucosuria canagliflozin deapagliflozin empagliflozin

Kidney

Non-insulin Injectables

GLP-1 Receptor Agonists h insulin secretion (with food) i glucagon secretion Slows gastric emptying h satiety

exenatide exenatide extended release liraglutide albiglutide dulaglutide

Non-insulin Injectables (2)

Amylin Mimetics i glucagon secretion Slows gastric emptying h satiety

pramlintide

Insulins

Basal Controls glucose when NOT eating

Insulins (2)

Short and Rapid-acting To bolus for meals or to correct high

glucose

Insulins (3)

Mixed (basal and short or rapid-acting)

0600 0600

Time of day

20

40

60

80

100 B L D

Insulins Compared to Normal Insulin Profile

B=breakfast; L=lunch; D=dinner

0600 0800 18001200 2400 0600

Insulin

Insulin

glargine / determir

aspart / lispro / glulisine

Regular

NPH

Components of Insulin Pumps

Infusion Set

Reservoir(for insulin)

Picture from diabetes.niddk.nih.gov

Very thin cannulain subcutaneous

tissue

How Does a Pump Work?

Reservoir is filled with rapid acting insulin Infusion set—

administers insulin SQ 24 hours/day often placed in the abdomen, thigh or hip/buttock area patient can disconnect pump from the infusion set and

reconnect later (exception: disposable pumps) Pump programmed to administer—

Basal – continuous rate/hour to maintain glucose control when NOT eating

Prandial – bolus per patient for nutrition intake Correction – bolus per patient for high glucose

Patient should NOT be disconnected from the pump for more than 1 to 2 hours

19

Meal Planning with Diabetes

Carbohydrate Foods

Starch

(bread, rice, potatoes

pasta, cereal)

Fruit and

fruit juices

Milk and yogurt

Sweets

Digested

Glucose from

Carbohydrate foods

Bloodstream

2004 Adapted from International Diabetes Center, Minneapolis

Preoperative Assessment

A detailed history of diabetes therapy is essential to guide the practitioner in preoperative instructions medication therapy characteristics of the surgery

when the patient must stop eating prior to the procedure

timing of the procedure duration of the procedure

Clinic Assessment

Type of diabetes type 1 patients CANNOT be without insulin

Does patient reliably glucose monitor A1c

How well has the patient been controlling glucose?

Should elective surgery be postponed? Comorbidity risk Wound healing Risk of infection

97

126

154

183

212

240

269

298

326

10

6

7

8

9

5

11

12

13

Estimated Average Blood Glucose (mg/dL) over 3 to 4

months

A1C (Perce

nt)

Normal 4 to 6%

A1c

Clinic Assessment (2)

Hypoglycemia Symptomatic of hypoglycemia? At what glucose level is patient

symptomatic? When does hypoglycemia usually occur?

Hypoglycemia is defined by the

American Diabetes Association as a blood glucose less than 70 mg/dL.

Some patients have symptoms at higher glucose levels.

Clinic Assessment

Oral diabetes medication Insulin Hypoglycemic injectables Inhalable insulin

Obtain dose and specific timing

Pre-Surgery Medication Guidelines

Oral Diabetes Medications

Guidelines

See List Below Hold dose(s) the day of procedure.

• metformin• glyburide, glipizide, glimepiride• sitagliptin, saxagliptin, linagliptin, alogliptin,

vildagliptin• canagliflozin, dapagliflozin, empagliflozin• pioglitazone, rosiglitazone• acarbose, miglitol• repaglinide, nateglinide• combinations of these drugs

Pre-Surgery Medication Guidelines (2)

Insulin GuidelinesRapid-acting or short-acting(Regular, lispro, aspart, glulisine)

Hold scheduled mealtime dose the day of procedure.If using sliding (correction) scale insulin, dose according to scale to correct elevated glucoses.

Long-acting (glargine, detemir)

If taking ONLY glargine or detemir:Take 75% of usual dose evening before procedure.Take 75% of usual morning dose day of procedure.If taking glargine or determir with meal time insulin:Take usual dose evening before procedure.Take 75% of usual morning dose day of procedure.

Intermediate (NPH)

Take usual dose evening before procedure.Take 50% of usual morning dose day of procedure.

Pre-Surgery Medication Guidelines (3)

Insulin GuidelinesMixed Insulin:(70/30, 75/25, 50/50)

Take usual dose evening before procedure.Hold dose day of procedure. Recommend contacting the patient’s provider for further orders.

Insulin Concentrated:R-U-500

Take 50% usual dose evening before procedure.Hold dose day of procedure. Recommend contacting the patient’s provider for further orders.

Insulin Pumps Continue BASAL rate only. Decrease BASAL rate by 25% the day of procedure. Instruct patient to bring extra pump supplies to the procedure.

Inhalable Insulin:Afreeza ®

Hold scheduled mealtime dose day of procedure.

Pre-Surgery Medication Guidelines (4)

Hypoglycemic Injectables

Guidelines

albiglutidedulaglutideexenatide, exenatide XRliraglutidepramlintide

Hold dose(s) day of procedure.

Pre-Surgery Glucose Management OUTPATIENTS

Monitor glucose morning of procedure and every 4 hours until procedure

Correct HYPERglycemia per usual routine if using sliding (correction) scale insulin

For symptoms of HYPOglycemia or blood glucose <100 mg/dL, drink 4 oz of CLEAR fruit juice. Then monitor glucose every 15 minutes. Repeat treatment until glucose >100 mg/dL.

Hospital or procedure areas will manage glucose upon arrival.

Pre-Surgery Glucose Management (2)

INPATIENTS Monitor glucose prior to procedure Correct HYPERglycemia per sliding

(correction) scale insulin or per physician order

Follow HYPOglycemia protocol if needed Preoperative nursing will manage glucose

per Anesthesia orders after arrival to surgical area

Hyperglycemia Pre-Surgery

Causes Inappropriate discontinuation of diabetes

medication History of poor glucose control Stress hyperglycemia

When to post-pone surgery Acute complications of hyperglycemia

Dehydration Ketoacidosis Hyperosmolar nonketotic state

Hypoglycemia Pre-Surgery

Hypoglycemia is defined by the

American Diabetes Association as a blood glucose less than 70 mg/dL.

Some patients have symptoms at higher glucose levels.

Follow hypoglycemia protocol D50 IV Dextrose containing IV fluids

Intra and Post-Operative Management

Glucose goal Patient outcomes Insulin therapy

Insulin pumps

Intraoperative Glucose Goal

Patients with well controlled glucose 100-180 mg/dL 120-180 mg/dL for coronary bypass surgery

Patient with poorly controlled glucose Preop glucose baseline

Symptomatic of hypoglycemia at normal glucose

Increased oxidative stress with glucose reduction

Postoperative Outcomes

Retrospective study in 55,408 noncardiac surgeries Higher rates of postoperative infection were

associated with a mean 24 hour postoperative serum glucose concentrations of 150 mg/dL or higher

King, J.T., et. al. (2011). Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Annals of Surgery. 253(1), 158-165.

Postoperative Outcomes (2)

Perioperative hyperglycemia (>180 mg/dL) was associated with adverse outcomes in general surgery patients with and without diabetes (11, 633) Reoperative interventions Infections Death

Patients with hyperglycemia on the day of surgery who received insulin (with or without diabetes) had no significant increase in these adverse outcomes

Kwon, S., et. al. (2012). Importance of perioperative glycemic control in general surgery: A report from the Surgical Care and Outcomes Assessment Program. Ann Surgery, 257(1), 8-14.

Glucose Control with Insulin

Subcutaneous Rapid or short acting

Short acting preferred (aspart, lispro, glulisine) Injection before and/or after surgery Not often during surgery

IV insulin IV push Insulin pump (continuous subcutaneous insulin

infusion-CSII) Insulin infusion

Major surgeries Replace insulin pump

Insulin Pump Therapy or CSII Insulin pumps are a SAFETY concern

perioperatively Several different models available

With tubing, without tubing, wireless, disposable

Continuous glucose sensor Cannot be exposed to MRI, CT scans and X-

rays Basal rate may not be accurate when

patient NPO Patient not alert to self-manage!

There are NO standardized guidelines!

CSII Perioperative Guidelines Abbott NW Hospital task team developed

Clinical specialist, anesthesia, managers, pharmacy, nursing, medical safety officer

CSII may be considered— For surgical procedures 2 hours or less of

actual scheduled OR time If the infusion site is not located in the

operative area If glucose <300 mg/dL If there will be no MRI, CT scan or X-rays

CSII Perioperative Guidelines (2)

Preoperative Metered glucose within 60 minutes of

arrival RN contacts Diabetes CNS or hospitalist for

assessment Decision made if CSII or alternative insulin

plan Close relationship with Anesthesia Diabetes CNS or hospitalist documents

recommendations

CSII Perioperative Guidelines (3)

Intraoperative CSII if meets criteria

Basal rate (may be reduced) CSII disconnected for short procedures with radiology

May give bolus dose of insulin via pump before disconnect Insulin infusion

Procedures >2 hours Major surgery Expect high doses of pain meds post op Initiation rate determined by Diabetes CNS or hospitalist

Metered glucose every 1 hour

CSII Perioperative Guidelines (4)

Postoperative Metered glucose upon arrival to recovery RN contacts Diabetes CNS or hospitalist Decision made if—

Safe to discharge home for ambulatory patients Safe to continue CSII Will continue insulin infusion

Inpatient policies and protocols implemented CSII Insulin infusion

Summary

Know the type of diabetes for which your patient has been diagnosed

Assess glucoses regularly perioperatively Know what medication your patient takes for

glucose management What medication and dose was taken evening prior and

the day of surgery Assess if your patient has experienced

hypoglycemia overnight prior and the day of surgery

If your patient uses a CSII, collaborate with the perioperative team for safe use with surgery

Questions

References

Abdelmalak, B., et al. (2012). Perioperative glycemic management in insulin pump patients undergoing noncardiac surgery. Current Pharmaceutical Design.18, 6204-6214.Boyle, M. E., et.al. (2012). Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period. Journal of Diabetes Science and Technology. 6(1), 184-190.Desai, S. P., et. al. (2012). Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized control trial. The Journal of Thoracic and Cardiovascular Surgery, 143, 318-325.Joshi, G. P., et. al. (2010). Society for ambulatory anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesthesia Analg, 111, 1378-87.King, J.T., et. al. (2011). Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Annals of Surgery. 253(1), 158-165.Kwon, S., et. al. (2012). Importance of perioperative glycemic control in general surgery: A report from the Surgical Care and Outcomes Assessment Program. Ann Surgery, 257(1), 8-14.Micromedex Solutions. (2015). Drug reference library. Retrieved February 6, 2015, from http://www.micromedexsolutions.comSmiley DD, Umpierrez GE. (2006). Perioperative glucose control in the diabetic or non diabetic patient. South Med J. 99:580.UpToDate. (2013). Perioperative management of diabetes mellitus. Retrieved September 20, 2013, from http://www.uptodate.com/contents/perioperative-management-of-diabetes-mellitus.