DIABETES REVIEW

SALPN ConferenceApril 2011

Objectives

The Licensed Practical Nurse will:

1. Describe the difference between Type 1 and Type 2 diabetes

2. State two risks of increased blood sugars in hospital

3. Describe four types of oral medication used in Type 2 diabetes

4. Describe how each medication improves glucose management

4. Describe five types of insulin

5. State two insulins that can not be mixed with other insulin

6. Describe symptoms of low blood sugars

7. State treatment options and follow up for a low blood sugar

Objectives

Type 1 Diabetes (IDDM)

Pancreas not producing insulin

Always need exogenous insulin

Usually younger children/adults

Often diagnosed when admitted with ketoacidosis

Types of Diabetes

Type 2 Diabetes (NIDDM)

Pancreas not producing enough insulin or insulin not being used properly (Insulin Resistance)

May be on diet, pills and/or insulin

Usually over 40 years

Overweight/obese

May or may not have symptoms of diabetes when diagnosed

Optimize Glycemic Control

Nutritional Management

Physical Activity

Pharmacological treatment

Balancing Act to Optimize Blood Glucose Balancing Act to Optimize Blood Glucose ControlControl

Illness

Meds Activity

Blood

Glucose

Monitoring

EDUCATION

Food

In Hospital

Factors that increase blood sugars:

Stress

Infection

Pain

Sleep deprivation

IV solutions

Medications

Hospital routines

Food intake

Increased blood sugars contribute to:

Increased risk of mortality

Longer hospital stays

Increased risk of MI and stroke

Increased risk of infection

In Hospital

Target Goal Ranges

Based on individual health status while in hospital

Premeal:

4 - 7 mmol/L (4 - 6 if possible)

5 - 8 mmol/L (if elderly or unstable)

2 hour pc meals:

5 - 10 mmol/L

When toTest

While in the hospital

QID

A1c (Glycosylated Hemoglobin)2008 CPG’s Target 0.07

A1cAverage Blood

Sugar Level (mmol/L)

0.12 19.50.11 17.50.10 15.50.09 13.50.08 11.50.07 9.50.06 7.5

Oral Diabetes

Medications

Oral Diabetes Medications

INSULIN SECRETAGOGUES

Stimulates insulin release

INSULIN SENSITZERS

Improves insulin response

Alpha-Glucosidase Inhibitors

Delays absorption of glucose from gut

DPP-4 Inhibitors

Inhibits glucagon release

Increases insulin secretion

Decreases gastric emptying

Oral Diabetes Medications

Metformin

Glyburide &

Diamicron

Prandase

Avandia &

Actos

Gluconorm

Starlix

Insulin Secretagogues

Glyburide (Diabeta)

Action - up to 24 hours

Need for snacks

Risk of hypoglycemia - especially in the elderly

Metabolized in liver- excreted by kidney

Contraindicated in renal and hepatic insufficiency

Gliclazide (Diamicron)

Action- up to 24 hr

Reduced risk of hypoglycemia- more appropriate for elderly

Can be used with caution in renal and hepatic insufficiency

Repaglinide (Gluconorm)

Action - 3 - 4 hours

Less chance of hypoglycemia

Take the occasional 2 hr pc blood sugar

Take with just prior meals

NO MEAL = NO GLUCONORM

Metabolized by liver - excreted in bile

Can be used with caution in renal and hepatic insufficiency

Insulin Secretagogues

Insulin Sensitizers

Metformin (Glucophage or Glycon)

Stops excess glucose release from liver

Take with meals

Discontinue 48 hours prior to tests using x-ray (IVP) dye

Metabolized in liver and excreted by kidney

Should not be used in hepatic, renal insufficiency or CHF

Rosiglitazone (Avandia)- Currently not recommended

Pioglitazone (Actos)

Monitor liver enzymes routinely

Takes 8 -12 weeks to work

Less risk of hypoglycemia

Edema can be a side effect

Can be used with caution in renal and hepatic insufficiency and CHF

Insulin Sensitizers

Acarbose (Glucobay)

Decreases postprandial blood sugar

Should be taken with the first bite of the meal

Hypoglycemia must be treated with oral dextrose

Use glucose tablets, not juice

Binds with sugar in small intestine by interfering in the absorption of sugar

Contraindicated in inflammatory bowel disease, colonic ulceration or liver cirrhosis

Carbohydrate Delaying

DPP-4 Inhibitors

Sitagliptin (Januvia) and Saxagliptin (Onglyza)

A new class of diabetes medications for type 2 diabetes

Inhibits glucagon release

Increases insulin secretion

Decreases gastric emptying

Promotes earlier satiety

Sitagliptin (Januvia) and Saxagliptin (Onglyza)

Tablet OD

Used with TZD or metformin

Decreases A1c

Does not promote weight gain

Low incidence of hypoglycemia

DPP-4 Inhibitors

Insulin

Blood Glucose and Insulin Patterns in a Person Without Diabetes

Blo

od

Glu

co

se

Le

ve

l

Bolus Insulin

Basal Insulin

Insu

lin

Le

ve

l

B L S HS

24 0206 08 10 12 14 16 18 20 22

Types of Insulin

Peak Duration

HumalogNovorapidApidra

Humulin RNovolin Toronto

Humulin N * 1 - 3 5 - 8

Novolin NPH ** Significant variability in action with individuals

Combination of R (Toronto) and N (NPH)Humulin 30/70Novolin 10/90, 20/80, 30/70, 40/60, 50/50Humalog Mix 25 ( combo of Humalog and NPL)

Lantus (Glargine) 4 - 6 Flat Action Profile 24Levemir (Determir) 2 Predictable Flat Action Profile 24

* Must NOT be mixed with any other insulin

** Do NOT use if cloudy

Insulin Appearance

Long-Acting * **

0.5 - 1 2 - 4 5 - 8

Clear 0.16 - 0.25 1 - 1.5 4 - 5

Cloudy

Rapid-Acting (Meal Time)

Short-Acting

Intermediate-Acting

Premixed

Clear

18 - 24Cloudy

Onset (Hours)Characteristics (Hours)

0.25 - 0.5 2 - 12 24

Clear

Rapid Acting Insulin

2416 18 20 228 10 12 140 2 4 6

Short Acting Insulin

2416 18 20 228 10 12 140 2 4 6

Intermediate Acting Insulin

2416 18 20 228 10 12 140 2 4 6

Long Acting Insulin

0 2 4 6 8 10 12 14 16 18 20 22 24

Short Acting Insulin - q6h

DawnPhenomenon

B L S HS

06 08 10 1222 24 02 0414 16 18 2006 08 10 12

Short Acting Insulin with Meals and at HS

DawnPhenomenon

B L S HS

06 08 10 1222 24 02 0414 16 18 2006 08 10 12

Meal Time Short Acting Insulin with HS Intermediate Acting Insulin

B L S HS DawnPhenomenon

14 16 1806 08 10 12 20 22 24 02 1204 06 08 10

Regular- and Intermediate-Acting Insulin

Rapid- and Intermediate-Acting Insulin

Bolus and Basal Insulin

or

Principles for Using Bolusand Basal Insulin

Client is taught how to count the grams of CHO in the meal

and calculate the number of units of rapid acting insulin

needed

Client is taught how to treat pre-meal hyperglycemia with a

correction dose of rapid acting insulin

Add the CHO dose with the correction dose results in the

pre-meal dose (Bolus dose)

The longer acting insulin given OD or BID provides the

background insulin (Basal dose)

By giving the intermediate insulin at bedtime, it is more

effective at reducing the fasting blood glucose and

decreases nocturnal hypoglycemia

Principles for Using Bolusand Basal Insulin

Insulin Pens

Luxura Pen Novolin Pen 4

Insulin Pen

To insure accuracy

Cloudy insulin must be mixed

Must do an air shot each injection

Check to see that the cartridge is not cracked

Cost:

Pump $6,500

Maintenance $350.00 +/month

Insulin Pumps

MEDEC has three nurses that are certified pump trainers

A lot of learning and discipline required to get optimal control with pump

Pumps are not for everyone!

Top 10 Reasons for Blood Sugar Variations When In the Hospital

Administering insulin after scheduled time

Holding insulin because of hypoglycemic event

Administering sliding scale insulin dose based on a blood sugar result done 2 hours earlier

Over treating hypoglycemia

Insulin sliding scale not appropriate

Lantus and Levemir being mixed with other insulins

Inactivity while in hospital

Staff unaware inconsistent food intake

Insulin not on the ward

Assigned times for insulin not appropriate

Hypoglycemia

Risk Factors for Hypoglycemia

Incorrect match of diabetes medication (type, amount and timing) to carbohydrate intake

History of severe hypoglycemia or hypoglycemia unawareness

General anesthesia or sedation

Decreased oral intake

Sudden NPO status

Large amounts of alcohol or ASA

Decreasing steroid dose

Emesis

Decreased or discontinuation of IV dextrose

Interruption of tube feeds

Diabetes medication error

Unexpected transport shortly after giving rapid or fast acting insulin

Illnesses that can alter the action of the diabetes medication

Risk Factors for Hypoglycemia

What Promotes Hypoglycemia

Stress resolution

Insufficient IV glucose

Infection resolution

Excessive insulin doses

Loss of appetite

Increased activity

Hypoglycemia Procedure

Only patients treated with insulin and insulin secretagogue oral agents (e.g. glyburide, gliclazide, etc.) experience drug-induced hypoglycemia and require treatment with fast acting carbohydrates.

Treatment of hypoglycemia must be initiated if the patient meets the stated blood glucose values even if they are asymptomatic.

Signs and Symptoms of Hypoglycemia

Trembling/shaky

Hunger

Sweating

Pale or clammy skin

Anxiety

Nausea

Tingling

Palpitations

Weakness/tiredness

Difficulty concentrating

Mental confusion

Dizziness

Vision changes

Difficulty speaking

Loss of coordination

Blood Glucose Level forTreatment of Hypoglycemia

Adults & Children < 4.0 mmol/L

Hypoglycemia treatment levels may be individualized for infants, elderly (> 75 years old) and adults with cardiovascular or renal complications (i.e. < 5 mmol/L)

Case Study- Hypoglycemia -

Case Study

Eva

65 years old

T2 Diabetes

On insulin for 1 year

Recent Hb1c is 0.094

Admitted for cellulitis of left foot

States she has gained a lot of weight

Blood glucose range 2.1 -17.0 mmol/L at home

At 14:30 hrs

States she does not feel well

Weak and shaky

BGM reading 2.3 mmol/L

What are the next 5 steps to take?

Case Study

Note

Call lab to draw stat blood glucose if blood glucose monitoring result is <3 mmol/L

then

proceed immediately to next step

Step 1

Treat the conscious patient with 15 g of fast-acting carbohydrate

Fast-acting carbohydrate choices for Adults and Children (over 25 kg)

15 g of carbohydrate, as glucose/dextrose tablets

3 packets sugar, dissolved in water

200 ml juice

1 packet honey

DO NOT use juice with patients on fluid and/or potassium restrictions.

Wait 10 - 15 minutes

Step 2

Re-check the blood glucose level with meter

Step 3

Repeat steps 1-3 if blood glucose remains below target level or if symptoms persist.

If blood glucose is above target level proceed to Follow up Treatment.

Step 4

Follow-up Treatment Once SafeBlood Glucose Level is Achieved

Do not treat further if meal or snack is less than an hour away.

If next scheduled meal or snack is more than an hour away, give a slower-acting carbohydrate and protein

Slower-Acting Protein Choices:Carbohydrate Choices:

- 2 cookies - 1 packet of peanut butter- 1 slice of bread or toast - 1 packet of cheese- 6 soda crackers

Omit protein choice for patients on restricted protein diets

Document time, blood glucose result and treatment used on Blood Glucose Monitoring Record.

Step 5

Prevention of Night Hypoglycemia

Give a bedtime snack of one slower-acting carbohydrate and protein if the bedtime blood glucose <7 mmol/L and patient is on insulin or sulfonylureas.

Case Study

What changes would you make if blood glucose was3.8 mmol/L?

What changes would you make if this blood glucose was taken at 16:45 hrs?

When do You Hold Insulin?

Never (especially with Type 1) or almost never.

The dose may need to be adjusted.

Call the doctor if you think dose should be changed.

4. Try to have the client drink CHO containing beverages

5. Test blood sugars more frequently.

6. If client is unable to eat or drink - contact doctor.

7. They will need diabetes medication but dose or type of the medication may need to be changed.

What Can be Done if the Client Does Not Want to Eat?

MEDEC

What is MEDEC?

Diabetes Education Centre

Who can refer?

Anyone with the client’s consent

How to contact?

Phone 766-4540

Questions ???