ENDO EXAM 1_ DM CLINICAL-2.pdf

Diabetes Management Guidelines ❖ 2024 ADA Standards of Care in Diabetes Types of Diabetes ❖ Type 1 diabetes (T1DM) ❖ Type 2 diabetes (T2DM) ❖ Gestational diabetes (GDM) Pathophysiology: Think of insulin as the KEY needed to unlock the “door” for glucose to enter the cells ❖ T1DM Autoimmune disease t...

Diabetes Management Guidelines ❖ 2024 ADA Standards of Care in Diabetes Types of Diabetes ❖ Type 1 diabetes (T1DM) ❖ Type 2 diabetes (T2DM) ❖ Gestational diabetes (GDM) Pathophysiology: Think of insulin as the KEY needed to unlock the “door” for glucose to enter the cells ❖ T1DM Autoimmune disease that leads to the destruction of pancreatic beta-cells Leads to severe or absolute insulin deficiency ❖ T2DM Defective insulin secretion by pancreatic beta-cells → relative deficiency Leads to insulin resistance Risk Factors T1DM 5-10% of all DM cases Ethnicity → swedish, finnish, sardinians, african, asian Family hx T2DM GDM 90-95% of all DM cases Develops while pregnant 1st degree relative → mother, father, sibling Usually resolves after childbirth Race → american indians/alaska natives/pacific islanders, 30-50% develop T2DM later in life hispanics, african american Obesity/chronic physical inactivity + diet Hx of GDM Hx of vascular disease HTN ↓ HDL High TG Polycystic ovary disease Differences between T1DM & T2DM Characteristic T1DM T2DM Age at onset < 20 years > 20 years Onset Abrupt Gradual; diagnosis usually 5-7 years after onset Body type Lean Obese/hx of obesity Insulin resistance Absent; no insulin being secreted Present; insulin is being secreted but body does not recognize it Autoantibodies Present Absent B-cell function Absolute deficiency Impaired secretion Symptoms - Polyuria: excessive urination - Nocturia: need for pts to get up at night regularly to urinate - Polydipsia: excessive thirst - Fatigue - Polyphagia: feeling of extreme hunger - Weight loss - Polyuria: excessive urination - Nocturia: need for pts to get up at night regularly to urinate - Polydipsia: excessive thirst - Fatigue - Macro/microvascular complications Ketones Present Usually absent Acute Complications Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic state (HHS) Medications that can cause Diabetes ❖ Corticosteroids Mainly with extended use and high doses Prednisone, cortisone, hydrocortisone, prednisolone ❖ 2nd Generation Antipsychotics Clozapine, olanzapine, risperidone, aripiprazole ❖ Thyroid hormones ❖ Thiazides ❖ Phenytoin ❖ Protease inhibitors (HIV) Screening T1DM GDM Screen in first-degree family members with tests that detect autoantibodies Development of and persistence of autoantibodies may serve as an indication for intervention High risk pt: first gestational visit ↓ risk pt: 24-28 weeks If diagnosed with GDM: ○ 4-12 weeks postpartum ○ Screen for DM every 3 years Asymptomatic adults (DM and pre-DM) Children and adolescents (T2DM and pre-DM) Testing should be considered in adults with overweight or obesity (BMI ≥ 25 or ≥ 23 in Asians) who have one or more of the following risk factors: ○ First-degree relative with DM ○ High-risk race and ethnicity (AA, latino, native american, asians, pacific islanders) ○ Hx of CV disease ○ HTN (≥ 130/80 or on therapy for HTN) ○ HDL < 35 and/or TG > 250 ○ Polycystic ovary syndrome ○ Physical inactivity ○ Other clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans) People with prediabetes (A1C ≥ 5.7%) should be tested yearly People who were diagnosed with GDM should be tested for life at least every 3 years For all other people, testing should begin at age 35 If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status People with HIV, exposure to high-risk meds, hx of pancreatitis Screening should be considered in youth who have overweight (≥ 85th percentile) or obesity (≥ 95th percentile) and have one or more additional risk factors based on the strength of their association with DM: ○ Maternal hx of DM or GDM during the child’s gestation ○ Family hx of T2DM in first or second-degree relative ○ Race and ethnicity (AA, latino, native american, asians, pacific islanders) ○ Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, HTN, dyslip, polycystic ovary syndrome, or underweight at birth) After the onset of puberty or after 10 YO (whichever happens earlier), if tests are normal, repeat at a minimum of 3-year intervals (or more frequent if BMI is increasing or risk factor profile is deteriorating) Hemoglobin (HGB) A1C ❖ Measures how much glucose is being carried by RBC ❖ HGB is what transports oxygen ❖ Too much glucose in blood stream can bind to HGB’s binding site and prevent oxygen from binding ❖ Less oxygen = Macrovascular complications Microvascular complications Patients take longer to recover from wounds/diseases d/t lack of oxygen HGB A1C Reading ❖ Glucose binds irreversibly to the RBC ❖ HgbA1c provides an average blood sugar levels over the past 3 months ❖ Higher A1c = uncontrolled BG levels ❖ Tested every 3 months in uncontrolled pts 3 months is the average lifespan of a RBC ❖ Tested every 6 months in controlled pts Diagnosis Fasting BG PPBG-Random/2 hr 75 g OTT A1c Pre-DM 100-125 mg/dL 140-199 mg/dL 5.7-6.4 % DM (T1 & T2) ≥ 126 mg/dL ≥ 200 mg/dL (or random tests w/ symptoms) ≥ 6.5% GDM (1-step) ≥ 95 mg/dL 1hr: ≥ 180 mg/dL 2hr: ≥ 153 mg/dL N/A *OGTT: oral glucose tolerance test (75 g glucose) Confirming Diagnosis ❖ Clear diagnosis: Confirming Diagnosis Example: - Pt comes in with no sxs, we perform a fasting BG test and the result is 200 mg/dL - We have 2 options: We perform A1C now We perform fasting BG test in one week Hyperglycemic crisis (DKA or HHS) OR Sxs of hyperglycemia + RBG ≥ 200 mg/dL ❖ No clear diagnosis (no sxs): 2 abnormal test results are needed ○ Can repeat the same test at another time or use a different test ASAP If both tests are abnormal → diagnosis is confirmed If only one test is abnormal → repeat abnormal test carefully Hypoglycemia Definitions ❖ BG < 70 mg/dL but every pt has a different threshold ❖ Hypoglycemia is more dangerous than hyperglycemia → do not ↓ BG levels drastically bc it can be harmful ❖ Hypoglycemic unawareness: pt does not have sxs Symptoms Hyperglycemia The 3 “P”s: ○ Polyphagia: excessive hunger → glucose is not going into the cell so the body thinks we need more food ○ Polydipsia: excessive thirst → the rise in BG causes the body to try and dilute it ○ Polyuria: excessive urination → d/t amount of water intake Fatigue → the body does not have the energy to function: glucose is in the blood but not in the cell Tingling/numbness in fingers/toes → early sxs of neuropathy d/t lack of oxygen Acanthosis nigricans → discoloration: sign of insulin resistance in some pts Management Hypoglycemia Dizziness Sweatiness Shakiness/tremors Nausea Anxiety Heart palpitations Night sweats Blurry vision Severe symptoms include: seizures, unconsciousness, muscle weakness Hyperglycemia Ensure medication is being taken Incorporate less carbs/sweets in diet Visit provider to address inadequate glycemic control Hypoglycemia Rule of 15 ○ Take 15-20 g of glucose: half a cup of orange juice (or any juice) or soda ○ Wait 15 min and check BG ○ If ﹥70 mg/dL: eat a small snack/meal ○ If ﹤70 mg/dL: repeat glucose until 70 mg/dL is achieved, then have a small snack/meal ○ If no results: CALL 911! Goals of DM and GDM ❖ Primary goals Safely reduce FBG, BG, A1C Reduce microvascular and macrovascular complications → neuropathy, retinopathy, nephropathy Reduce symptoms Reduce mortality Improve quality of life ❖ Secondary goals Minimize weight gain Minimize hypoglycemia Minimize hospitalization ADA Goals of DM and GDM ❖ Goals may be more or less precise depending on if the pt experiences hyper- or hypoglycemia Non-Pregnant Adults Pregnant Adults A1c < 7.0% A1c < 6% FBG 80-130 mg/dL FBG < 95 mg/dL PPBG/Random BG < 180 mg/dL 1h PPBG < 140 mg/dL 2h PPBG < 120 mg/dL Non-Pharmacological Therapy ❖ High frequency counseling with focus on nutritional changes, physical activity and behavioral therapy ❖ Nutrition modifications should be individualized based on pt’s background/traditions ❖ When developing a plan of care, consider socioeconomic factors that may impact nutrition patterns ❖ Nutritional supplements have NOT been shown to be effective for weight loss and are not recommended Non-Pharm: Diet ❖ Weight loss of 5% to improve glucose control ❖ Replace refined carbohydrates with complex carbohydrates ❖ Carbohydrate counting ❖ ↓ fat Non-Pharm: Aerobic Exercise ❖ 150 min/week for 3-5 days ❖ Improves insulin sensitivity ❖ Improves glycemic control ❖ Reduces CV risk ❖ Contributes to weight ❖ Improves well-being loss/maintenance T1DM Management Insulin ❖ Delivery Subcutaneous (under the skin) Inhaled IV ❖ ADRs Weight gain → insulin hormone naturally causes weight gain Hypoglycemia → highest rate Lipohypertrophy → injection site rx: rotate sites ❖ Differences in insulins Duration of action Peak times Time of administration Type Drug Rapid “Bolus” - Administer 10-15 mins before meals - *FOCUS* Short “Bolus” Intermediate “Basal” Long and Ultra Long “Basal” - Can administer any time of day (night preferred) - *FOCUS* Onset Peak Duration Insulin Lispro (Humalog, Admelog, Lyumjev) Insulin Aspart (Novolog, Fiasp) Insulin Glulisine (Apidra) 15 min 30-90 min 3-4 hrs Inhaled regular (Afrezza) 5-10 min 0.75-1 hr 3 hrs Regular insulin Novolin R Humulin R 0.5-1 hr 2-3 hrs 4-6 hrs NPH insulin Novolin N Humulin 1-4 hrs 4-10 hrs 10-16 hrs Insulin Glargine (Lantus, Basaglar, Toujeo, Semglee) Insulin Detemir (Levemir) 1-4 hrs None 20-24 hrs Insulin Degludec (Tresiba) Up to 42 hrs ❖ Mixed Insulin If a correction in dosing is needed, both types need to be corrected Pts will experience hypoglycemia at different times of the day NOT A FAN Brand Generic Novolog 70/30 70% Aspart protamine* 30% Aspart** Humalog 50/50 50% Lispro protamine 50% Lispro Humalog 75/25 75% Lispro protamine 25% Lispro Humulin 70/30 Novolin 70/30 70% NPH 30% regular * Long-acting ** Short-acting ❖ Storage and expiration Refrigerate until first use, then can leave at room temperature ○ Do not inject while it is cold → have them roll it with their hands to warm it up if it’s taken out of the fridge ○ Do not leave in the fridge 24/7 because the constant temperature change will destabilize the insulin Avoid heat Avoid shaking ❖ How to dose insulin in T1DM Regimen consists of basal + bolus ○ Calculate total daily dose (TDD) → the amount/units of insulin (basal AND bolus) needed daily Start with 0.5 u/kg/day for TDD Split TDD in half: 50% as basal + 50% as bolus Split bolus among all mealsBasal dose remains consistent Bolus dose depends on: ○ Pre-meal BG ○ Anticipated carb intake ○ Anticipated physical activity for the next 3-4 hrs Insulin Dosing Example: Lilly is a 6 Y/O female, 20 kg. Develop an insulin regimen for her. 1. Calculate TDD 0.5 u/kg x 20 kg = 10 u/day 2. Split TDD in half 5 u/day basal insulin 5 u/day bolus insulin 3. Split bolus dose amongst all meals 5 u/day / 3 u/day = 1.7 u/meal ~ 1-2 u/meal Total regimen: - 5 u/day: basal insulin - 2 u before each meal: bolus insulin Mixed insulins do not provide much flexibility ❖ Insulin Adjustments Can ↑ insulin dose every 2-3 days until controlled ↑ insulin dose by 10-20% Before changing insulin dose, determine if something else is causing hyperglycemia If pt is experiencing hypoglycemia, do the opposite Elevated Value Insulin Adjustment Overnight BG or FBG ↑ basal insulin 2h post-breakfast or pre-lunch ↑ breakfast bolus insulin 2h post-lunch or pre-dinner ↑ lunch bolus insulin 2h post-dinner or bedtime ↑ dinner bolus insulin Breakfast, lunch, and dinner values BID basal dosing: ↑ AM basal Once daily basal dosing: Split bedtime basal between HS and AM Insulin Adjustment Example #1: If pt is taking Lantus 10 U daily QAM and avg FGB is 210 mg/dL → ↑ basal insulin by 10-20% 10 x 0.1 = 1 u 10 x 0.2 = 2 u Insulin Adjustment Example #2: Rx Lantus 45 units q HS Novolog 15 units TID AC Which average values are uncontrolled? ○ FBG (> 80-130 mg/dL) ○ 2h post-lunch (> 180) Which insulin(s) need(s) to be adjusted? ○ Lantus (basal dose) d/t elevated FBG ○ Novolog (lunch bolus dose) d/t elevated post-lunch New regimen ○ 45 u x 0.1 or 0.2→ 4.5 or 9 → Lantus 50 or 54 units q HS ○ 15 u x 0.1 or 0.2 → 1.5 or 3 → Novolog 16 or 18 units TID AC ❖ U100 Insulin 100 U/mL Dose is always written in units ★ Example: ○ Pt is on: Lantus 30 units BID Humalog 10 units TID AC ○ Drawn up as: Lantus = 30 units on INSULIN syringe Humalog = 10 units on INSULIN syringe ○ NEVER DRAW ON TB SYRINGE Usually: ○ 1 vial = 10 mL ○ 1 pen = 3 mL ❖ Concentration of Insulins U-100 = 100 U/mL U-200 = 200 U/mL U-300 = 300 U/mL U-500 = 500 U/mL ★ Higher concentration → more insulin/mL ❖ Insulin Conversions ★ Humalog U-200 Insulin lispro Rapid acting U-200 only available as pen → 200 U/mL Pt dials the total insulin UNITS If pt was using Humalog U100 20 units TID, they would still dial up to 20 units TID → because it is the same amount of units daily, the only thing that changed was the amount of U/mL Do not draw out with syringe ★ Tresiba Insulin degludec Long acting TDD of glargine or detemir = ONCE DAILY dose of Tresiba If pt was using Lantus 50 u BID, they would dial up Tresiba 100 u QD ★ Toujeo Insulin glargine Long acting When converting from TDD Lantus/Levemir = TDD of Toujeo Lantus/Levemir 50 u BID → Toujeo 50 u BID When converting to Lantus/Levemir = 80% of Toujeo dose Toujeo 50 u BID → Lantus/Levemir 40 u BID ❖ Afrezza Bolus insulin CI: chronic lung disease Not recommended in smokers/those who recently quit smoking Strengths: 4, 8, 12 u cartridges Inhaler device replaced every 15 days Keep refrigerated Unopened cards/strips: 10 days room temperature Opened cards/strips: 3 days room temperature ❖ Carbohydrate Counting Rule of 500 ○ 500/TDD of insulin = g of carbs that 1 u of insulin will “cover” Carbohydrates ○ Starches Peas, corn, beans, potatoes Oats, barley, rice, wheat ○ Sugar Milk, fruit Added sugar ○ Fiber Vegetable, fruit, nuts, whole grain Cannot be digested Carbohydrate Counting Example: Lantus 30 u QD Humalog 10 u TID What is the TDD? 30 u QD + 10 u TID (30) = 60 U/day 500/60 = 8.3 AKA 1 u of insulin will cover 8.3 g of carbs New regimen? Lantus 30 u QD Humalog 1 U/8.3 g carbs in each meal (it replaces the Humalog 10 u TID) ❖ Correction Factor Normally used after pts eats on top of bolus + basal ○ Approximate glucose ↓ering effect of 1 unit of rapid-acting insulin in mg/dL ○ Rule of 1800 (Humalog & Novolog) or Rule of 1500 (regular insulin) Divide 24h insulin dose into 1800 (1500 if on regular insulin) Result = estimated BG ↓ering from 1 unit of insulin ❖ Calculation of needed Pen or Vials Example #1: U200 pen 200 units per mL 3 mL pens How many units per pen? 200 u/mL x 3 mL = 600 u/pen How many pens per month for 80 units daily RX? (80 u)(30 days) = 2400 u/month (2400 u/month)/(600 u/pen) = 4 pens Example #2: U100 vial 100 units per mL 10 mL vials How many units per vial? 100 u/mL x 10 mL = 1000 u/vial How many vials per month for 60 units daily RX? (60 u)(30 days) = 1800 u/month (1800 u/month)/(1000 u/vial) = 2 vials ❖ Mixed Insulin: How much of each type (basal and bolus) are in each dose? ★ Novolog 70/30: 10 units BID 70% basal → 10 x 0.7 = 7 units BID 30% bolus → 10 x 0.3 = 3 units BID ★ Humalog 75/25: 25 units BID 75% basal → 25 x 0.75 = 18.75 units BID 25% basal → 25 x 0.25 = 6.25 units BID ❖ Devices Injectable medications ○ Insulin Vial 1. Wash hands 2. Roll insulin bottle if needed 3. Wipe top of bottle with alcohol swab 4. Pull plunger of syringe back to desired units 5. Push needle into bottle 6. Push plunger down 7. Pull plunger back to desired units, filling with insulin 8. Remove air bubbles Pen 1. Wash hands 2. Remove pen cap 3. Wipe stopper with alcohol swab 4. Take out new pen needle 5. Position needle along pen axis 6. Push needle down onto pen 7. Screw on needle 8. Pull off outer and inner shield 9. Follow directions on priming pen ★ Injection Techniques 1. Clean injection site 2. Pinch 1 inch of skin 3. Put needle in at a 45-degree angle 4. Thicker skin tissue: inject at 90-degree angle 5. Push needle all the way into skin 6. Leave needle in place for 5 seconds Correction Factor Example: Lantus 30 units QD Humalog 10 units TID What is the correction factor? 1800/60 daily units = 30 1 unit of insulin ↓ers BG by 30 mg/dL 7. Remove needle and discard in sharps container Insulin pumps A device connected to the body and delivers insulin Some contain CGM and deliver insulin as needed Can let patient manually put insulin Can calculate carb correction for the patient and deliver the needed insulin Alerts patient when BG is out of range Are generally water resistant, not waterproof! ❖ When to Administer Insulin Basal insulin → morning or evening Bolus insulin → prior to meals: ○ Rapid: ~ 10 mins ○ Regular: ~ 30 mins ❖ Self-monitoring of BG (SMBG) Monitor BG from finger Alternative sites ○ Palm, forearm, thigh ○ Glucose readings lag 20-30 mins behind fingers ❖ How to Check BG After washing your hands, insert a test strip into your meter Use your lancing device on the side of your fingertip to get a drop of blood Touch and hold the edge of the test strip to the drop of blood and wait for result Your BG level will appear on the meter’s display If you use your fingertip, stick the side of your fingertip to avoid having sore spots on the frequently used part of your finger ❖ Continuous BG Monitoring Monitors interstitial fluid Lags behind capillary SMBG Useful in pts with frequent hypoglycemia, hypoglycemic unawareness, nocturnal hypoglycemia ❖ Monitoring on Insulin Basal insulin or combo non-insulin agents ○ FBG ○ Occasional pre- or post-prandial ○ Suspect hypoglycemia ○ After treating hypoglycemia ○ Testing ~ 1-3 times per day Oral agents: debated Intensive insulin regimen ○ FBG ○ Pre-prandial ○ Bedtime ○ Occasional PPG ○ Prior to exercise ○ Suspect hypoglycemia ○ After treating hypoglycemia ○ Frequent testing 6-10 times a day Non-Insulin Agents Pramlintide Metformin Modest A1c reduction (0.3-0.4%) and modest weight loss Small reduction in weight and lipids, but did not improve A1c GLP-1 RA Modest A1c reduction (~0.4%), weight loss, and reduction in insulin doses SGLT-2 Inhibitors Improvements in A1c, weight loss, improved BP ↑ rate of DKA ** The debate for oral agents continues, but insulin MUST be main form of therapy for T1DM Glucagon ❖ Used when pts are unconscious d/t hypoglycemia ❖ Must train family/caregivers ❖ May take 10-20 mins to start working ❖ Inject in thigh or upper arm (NOT through clothes) ❖ ADRs Vomiting (turn pt on their side) Hyperglycemia T2DM Management Lifestyle Modifications Make realistic lifestyle changes the pt can comply with With adequate lifestyle modifications, a pt’s A1c can ↓ 1-2% Prevention of T2DM ❖ Lifestyle Potential to ↓ rate of DM by 58% Achieve and maintain a minimum of 7% weight loss Maintain 150 mins of physical activity/week ❖ Metformin 850 mg BID Potential to ↓ rate of DM by 31% Considered in those with BMI ≥ 35, < 60 YO, rising A1c despite lifestyle intervention Long-term use associated with vitamin B12 deficiency Tzield (Teplizumab) Delays onset of T1DM Given IV once daily x 14 years Approved in 8 years and older who are developing T1DM Drug Classes Class Biguanides SGLT-2 Inhibitors Generic Metformin Brand *sometimes starting dose is not therapeutically effective = given to desensitize body For once weekly agents: administer missed dose if at least 72h until next dose, and administer next dose on regularly scheduled day; if next dose < 72h away, skip missed dose and administer on next dose day 500-1000 mg PO BID Canagliflozin Invokana eGFR ≥60: 100-300 mg PO QD eGFR 45-59: 100 mg PO QD eGFR 7.3 Anion gap ≤ 12 mEq/L ★ HHS BG < 300 mg/dL Osmolality WNL Alert patient Once resolved can transition to sc insulin Overlap sc 1-2h with IV Appropriate Vaccinations