Nursing In-Service:

Diabetes Care in the Elderly in Residential Care focus on anti-hyperglycemic medications

Evergreen House, Lion’s Gate Hospital September 9 & 11, 2013

Joan Ng, B. Sc. Pharm, Pharmacy Resident

1

Outline of Presentation 1. Pathophysiology

2. Diagnosis

3. Signs & Symptoms

4. Considerations in Elderly

5. Goals of Therapy & Treatment Targets

6. Treatment: non-drug measures & drug therapy

7. Insulin sliding scale vs. correctional insulin

8. Case Study: BT

9. Management of hypoglycemia

2

Pathophysiology of Diabetes

• Diabetes Mellitus

– Metabolic disorder characterized by hyperglycemia, due to defective insulin secretion, impaired insulin sensitivity, or both

– T1DM (Insulin dependent)

– T2DM (Non-insulin dependent)

– Gestational Diabetes

– Chronic hyperglycemia complications

3 Reference: 1,2

Diagnosis

4 Reference: 1

Signs & Symptoms

• Fatigue

• Polyuria, polydipsia, weight loss

• Complications: retinopathy, neuropathy, nephropathy, foot ulcers, erectile dysfunction

• Diabetic ketoacidosis

• Elderly:

– Less glucosuria, polyuria, polydipsia

– More confusion, incontinence

5 Reference: 2, 3, 4

Considerations in Elderly

• Most LTC patients are “frail elderly”

– Multiple chronic illnesses with associated vulnerabilities (e.g. dementia, falls, polypharmacy)

• Increased hypoglycemia risk with treatment

– Diminished hypoglycemia counterregulation

– More neuroglycopenic symptoms

– Associated with poorer outcomes (CV events)

– Leads to impaired cognition and function

• Drug pharmacokinetics are changed

6 Reference:

Goals of Therapy & Treatment Targets

• Control symptoms

• Glycemic control

• Prevent/minimize complications

• Reduce all CV risk factors

• LTC Elderly: – HbA1c: 8-8.5%

– Random BG: 7-14 mmol/L

7 Reference: 1, 2, 6

Treatment: non-drug measures

• Exercise:

–Can improve insulin sensitivity

– Encourage in those able to mobilize

• Diet:

–Caution against limiting caloric intake in LTC

• Patients often already have insufficient caloric intake due to confusion, dysphagia, anorexia

8 Reference: 1

Treatment: Metformin

• Biguanide; hepatic glucose production, insulin sensitivity

• 250-500mg qd 1g po bid (max 2550mg/day)

• Elderly: should not be titrated to max dose

• Pros: no hypoglycemia alone, good evidence

• Cons: causes anorexia and weight loss, risk of lactic acidosis (renal/hepatic dysfunction), risk of B12 and folate deficiency long-term

9 Reference: 2, 4, 5, 7, 10

Treatment: Sulfonylureas (Gliclazide, Glyburide)

• Increases beta-cell insulin release, increases peripheral glucose utilization

• Gliclazide: 40mg po bid 80mg po bid (regular release), 30mg MR qd 120mg MR qd

• Pros: very effective, gliclazide less hypoglycemia than glyburide

• Cons: hypoglycemia, needs consistent food intake, needs functioning beta-cells, weight gain

10 Reference: 2, 4, 10

Treatment: Other Drugs Formulary:

• Acarbose (brand: Glucobay, Prandase)

• Thiazolidinendiones (pioglitazone)

Non-formulary:

• Meglitinides (repaglinide, nateglinide)

• DPP-4 Inhibitors (sitagliptin, saxagliptin)

• Incretin Mimetics (exenatide, liraglutide)

11

Treatment: Insulin - types • Rapid acting: insulin lispro, aspart, glulisine

• Short acting: insulin regular

• Intermediate acting: NPH

• Long-acting: insulin detemir, glargine

12 Reference: 2, 4, 8, 10

TYPE OF INSULIN TIME OF ONSET DURATION OF ACTION

Basal insulin

Glargine (Lantus) 1 to 2 hours 24 hours

Detemir (Levemir) 1 to 2 hours 18 to 24 hours

Isophane (NPH) 1 to 2 hours 10 to 20 hours

Nutritional and correctional insulin

Lispro (Humalog), aspart (Novolog), glulisine (Apidra) 5 to 15 minutes 3 to 6 hours

Regular human insulin 1 to 02 hours 6 to 10 hours

Treatment: Insulin - regimens • Basal qhs insulin + oral hypoglycemics

• Conventional regimens: qd – tid insulin

• Intensive: basal + regular/rapid tid ac

• Intensive continuous SC infusion

• Acute: insulin sliding scale, correctional insulin

• Pros: long-term safety and outcome evidence

• Cons: hypoglycemia, weight gain, blood glucose monitoring imperative

13 Reference: 2, 4, 8, 10

Insulin sliding scale vs. correctional: What is different?

• Sliding Scale Insulin

– Traditionally: regular/short-acting insulin to treat hyperglycemia after it has occurred

– (now, almost always give basal insulin too)

– Reactive, not proactive; possible insulin stacking

• Physiological SC insulin protocol

– Basal insulin (NPH or glargine)

– Prandial/meal-time insulin (regular or short-acting)

– Correctional-dose insulin (fine-tuning)

14 Reference: 8, 9

SSI(+basal) vs physiologic insulin

15

Case Study: BT

• 55yo female on EGH 3S

• T2DM diagnosed 2005, previous poor control

• alcoholic cirrhosis, history of IDU, BPD

• Current drug therapy:

– Insulin glargine (lantus) 18u q am, 15u q dinner

– Insulin regular sliding scale at 0800, 1100, 1630

– Metformin 750mg bid

16

Case Study: BT- CBG control

17

Date Time Before breakfast

Before Lunch

Before Supper

Bedtime

Sliding Scale Given

9/1 0750 14.9 none

9/1 1155 23.1 10 units insulin regular

9/1 1600 28.1 14 units insulin given

9/1 2145 12.7 N/A

9/2 0730 21.5 10 units insulin regular

9/2 1130 21.6 none?

9/2 1645 17.1 5 units insulin regular

• Suboptimal control

• Nursing labour intensive: 3-4 times daily CBGs

Case Study: BT

Recommendation:

• change to regular tid prandial insulin + basal insulin at bedtime

• Initially: 0.3-0.6 U/kg body weight total daily dose – ½ basal, ½ regular tid before meals

• Measure BG more regularly in beginning, but when patient stabilizes, can decrease monitoring

Management of Hypoglycemia

• Hypoglycemia: CBG <4.0 mmol/L

• If patient is on acarbose, must give glucose

• retest BG in 15 mins, re-treat with another 15 g carbohydrate if BG still <4.0 mmol/L

19 Reference: 1

Questions?

20

References 1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association

2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.

2. Chau D, Edelman SV. Clinical Management of Diabetes in the Elderly. Clin Diabetes. 2001 Oct 1;19(4):172–5.

3. e-Therapeutics+ : Therapeutic Choices : Endocrine and Metabolic Disorders: Diabetes Mellitus [Internet]. [cited 2013 Sep 3]. Available from: https://www-e-therapeutics-ca.

4. Treatment of type 2 diabetes mellitus in the elderly patient [Internet]. [cited 2013 Sep 1]. Available from: https://uptodate.vch.ca/

5. Laubscher T, Regier L, Bareham J. Diabetes in the frail elderly Individualization of glycemic management. Can Fam Physician. 2012 May 1;58(5):543–6.

6. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2012 Dec 20;36(Supplement_1):S67–S74.

7. Lee M, Jensen B, Regier L. Oral Anti-Hyperglycemic Agents - Comparison chart. RxFiles drug comparison charts. 7th ed. Saskatoon, SK: Saskatoon Health Region; 2012. p. 25. Available from: www.RxFiles.ca. Accessed 2013 Sep 3.

8. Nau KC, Lorenzetti RC, Cucuzzella M, Devine T, Kline J. Glycemic control in hospitalized patients not in intensive care: beyond sliding-scale insulin. Am Fam Physician. 2010 May 1;81(9):1130–5.

9. Hirsch IB. SLiding scale insulin—time to stop sliding. JAMA. 2009 Jan 14;301(2):213–4.

10. Acarbose, Metformin, Gliclazide, Repaglinide, Sitagliptin, Exenatide, Liraglutide, Insulin. Lexi-Drugs Online [Internet]. Hudson (OH) : Lexi-Comp, Inc. 1978-2013 [cited 2013 Sep 5]. Available from: http://online.lexi.com.

21

Treatment: Acarbose

• Alpha-glucosidase inhibitor in intestines

– Delays digestion of complex carbs/disaccharides

– Slower rise in postprandial glucose

• 25mg qd 50-100mg tid cc

• Not recommended if CrCl <25mL/min

• Pros: safe, little hypoglycemia

• Cons: less effective than other agents, GI side effects (flatulence, diarrhea)

22 Reference: 2, 4, 10

Treatment: Meglitinides

• Short-acting insulin secretagogues, stimulates beta-cell insulin release at meals

• Repaglinide: 0.5mg tid ac 4mg po tid ac

• Pros: less hypoglycemia than sulfonylureas, flexible with food intake

• Cons: lack outcome data on morbidity/mortality

23 Reference: 2, 4, 10

Treatment: Thiazolidinediones

• Enhances insulin effects by activating PPAR-alpha receptor in cells

• Pioglitazone: 15mg qd 45mg qd

• Pros: no hypoglycemia

• Cons: limited usefulness in elderly (fluid retention, CHF, MI, fractures)

24 Reference: 2, 4

Treatment: DPP-IV Inhibitors

• Dipeptidyl peptidase-4 inhibitors; increases insulin secretion by ↑incretin, ↓glucagon

• Sitagliptin: 100mg qd; Saxagliptin: 2.5-5mg qd

• Pros: no hypoglycemia, weight-neutral

• Cons: no long-term safety data, expensive

25 Reference: 2,4,7,10

Treatment: GLP-1 Therapies • Incretin mimetics, increases insulin secretion

• Exenatide (Byetta): 5-10ug sc bid ac

• Liraglutide (Victoza): 0.6-1.2mg sc daily

• Pros: no risk of hypoglycemia

• Cons: causes weight loss, nausea, diarrhea

26 Reference: 4, 7, 10