Understanding and Managing Diabetes

Introduction to Patients with Diabetes

• The lecture introduces diabetes, covering type 1 and type 2 differences, risk assessment, screening and diagnosis, insulin storage and types, injection techniques, dosage calculations, blood glucose meter use, hypoglycemia, and monofilament exams.
• It aims to equip learners with the knowledge to understand diabetes, assess risk, apply diagnostic criteria, manage insulin, educate patients, and recognize/treat hypoglycemia.

What is Diabetes?

• Diabetes is a metabolic disorder marked by either insulin resistance, insufficient insulin secretion, or both.
• Type 1 Diabetes involves the autoimmune destruction of insulin-producing beta cells in the pancreas, leading to insulin dependence.
• Type 2 Diabetes is characterized by insulin resistance and a gradual decline in insulin secretion, initially managed with oral medications but potentially requiring insulin over time.
• Beta cell function in type 2 diabetes gradually decreases while insulin resistance increases.

Glucose Control in the Body

• After meals, glucose levels increase, stimulating insulin release from the pancreas.
• The liver releases glucose when the body requires energy, leading to increased glucose levels and insulin release.
• Insulin causes the liver to store glucose as glycogen, removing it from the bloodstream.
• Glucagon is released when blood glucose levels are low, signaling the liver to release glucose into the blood.

Screening for Type 2 Diabetes

• Screening for type 2 diabetes in asymptomatic patients is important with a high-risk score or specific criteria.
• Screening involves lab values such as fasting blood glucose, two-hour postprandial glucose, and A1C.

Criteria for Diagnosis of Type 2 Diabetes

• Diagnosis requires meeting one of the following criteria: A1C ≥ 6.5%, fasting blood sugar > 126 mg/dL, 2-hour postprandial blood sugar > 200 mg/dL, or hyperglycemia symptoms with random glucose > 200 mg/dL.
• Two abnormal lab results are needed from two separate instances to confirm a diagnosis.

General Goals for Patients Diagnosed with Type 2 Diabetes

• A1C goal is less than 7%.
• Preprandial blood sugar target is between 80 and 130 mg/dL.
• Peak postprandial blood sugar should be less than 180 mg/dL.

CGM Goals (Continuous Glucose Monitoring)

• For CGM users, the target Time in Range (TIR) is a blood sugar level between 70 and 180 mg/dL.
• Most patients should aim for greater than 70% TIR.
• Older adults should target a TIR of greater than 50%.

Role of the Community Pharmacist in Diabetes

• Community pharmacists counsel on blood glucose meters, continuous glucose monitors, injectable therapies, diet, and physical activity.
• They offer general education and counseling due to their accessibility and the complexity of diabetes management.

General Insulin Product Review

• Insulin is measured in units, with a common concentration of 100 units per ml.
• Higher concentrations exist, including 200, 300, and 500 units/ml.
• Most insulin pens contain 3 ml (300 units), and come in boxes of 5 pens (1,500 units total).
• Insulin vials usually contain 10 ml (1,000 units).
• The abbreviation "U" should never be used when writing units.

Availability of Different Insulins

• Insulins are available both over the counter (OTC) and by prescription.
• Humulin and Novolin are available OTC.
• Prescription insulins include all other insulin products besides Humulin and Novolin.

Insulin Storage

• Store insulin in the refrigerator before dispensing.
• Unused insulin should be refrigerated and actively used insulin can be stored at room temperature.
• Temperature extremes should be avoided.
• In Florida, insulin should not be left in the car.

Types of Insulins

• Insulins are categorized by onset and duration of action, including rapid-acting, long-acting, and mixed insulins.
• Mixed insulins combine intermediate and rapid- or short-acting insulins, with the larger percentage being the intermediate-acting component.
• Different insulins are used for meals (bolus) or basal insulin (fasting blood sugars).

Insulin Administration

• In a hospital setting, insulin is commonly administered as an IV infusion.
• In an outpatient setting, insulin is administered as a subcutaneous injection via a vial and syringe or an insulin pen, or via an insulin pump.
• Inject insulin subcutaneously into the abdomen (fastest absorption), upper arms (intermediate), or thighs/buttocks (slowest).
• Rotate injection sites to prevent lipohypertrophy, avoiding the area within two inches of the belly button.

Non-Insulin Injectables

• GLP-1 Receptor Agonists include Byetta, Bydureon, Victoza, Tanzeum, Ozempic, and Trulicity.
• Mounjaro is a GIP/GLP-1 Receptor Agonist.
• Counseling patients on the use of these injectables is critical.

Syringes and Needles (for Insulin Vials)

• It is crucial to understand syringe capacity (0.3 ml holds 30 units, 0.5 ml holds 50 units, 1 ml holds 100 units), needle length (6 mm is smallest seen, 4 mm even smaller, up to 12 mm) and needle gauge (29 to 32 gauge, higher number means thinner needle) for accurate insulin administration.

Example Prescription Calculations

• To determine the quantity of insulin to dispense, calculate the total units needed for the prescribed duration (e.g., 30 days) and consider the insulin's concentration and packaging (vial or pen).
• Always round up to the nearest full vial or pen.

Blood Glucose Meters

• Medicare-Medicaid typically covers one fingerstick meter per year and a CGM if the patient uses insulin.
• Meter selection factors include ease of use, sample size, speed, display, features, and audio capabilities.
• Blood glucose meters are either for periodic monitoring (fingerstick) or continuous monitoring (CGM).

Alternate Site Testing for Blood Glucose

• Alternate testing sites include upper arms, thighs, and calves.
• Avoid alternate site testing within two hours of meals, exercise, or insulin administration, or when hypoglycemia is suspected.

Potential Blood Glucose Meter Errors

• Potential errors include timing of the sample, calibration issues, hygiene problems, and low battery.

Hypoglycemia (Low Blood Sugar)

• Hypoglycemia is defined as blood glucose less than 70 mg/dL.
• Mild symptoms include hunger, shaking, dizziness, nervousness, and tachycardia.
• Moderate symptoms include blurry vision, personality changes, irritability, and poor coordination.
• Severe symptoms include seizure and coma.

Management of Hypoglycemia

• Conscious patients should ingest 15 grams of fast-acting carbohydrates, such as glucose tablets, glucose gel, juice, soda, or candy, and recheck blood sugar after 15 minutes.
• Repeat if necessary and eat a small meal or snack to maintain blood sugar levels.
• Unconscious patients should be treated with glucagon.

Safety Considerations

• Insulin is a high-risk medication.
• Pharmacists should take extra precautions, such as double/triple-checking prescriptions, separating lookalike/soundalike insulins, reviewing insulin history, and verifying dose changes.
• Label prescriptions carefully to avoid covering important markings.

Goals of Therapy (Beyond Numbers)

• Prevent acute complications of hypoglycemia and hyperglycemia such as DKA and HHS.
• Prevent chronic complications like retinopathy, neuropathy, nephropathy, cardiovascular disease, and stroke.
• Improve quality of life by educating and supporting patients and minimizing side effects.

Monofilament Foot Exam

• It is performed to identify neuropathy, a common diabetes complication.
• Pharmacists can perform this exam yearly to detect early signs of neuropathy and help prevent foot ulcers and amputations.