standards of care 2019 updated ho · affordable care act increased access to care for individuals...

Diabetes Ed Services© All rights reserved 1998 ‐ 2019 www.DiabetesEd.net

DM Fundamentals – Class 5 Goals & Standards of Care 2019

Beverly Thomassian, RN, MPH, BC‐ADM, CDEPresident, Diabetes Education Services

Standards of Care – 1:45 minutes Review the 16 Standards of Care with a focus on updated standards

Keeping it Patient Centered

National goals and getting to target

Application to your clinical practice

Diabetes “Playbook”

CDE® Coach App – Download Success

Standards of Care Meds PocketCardsQuestion of the WeekOnline Course Viewing


1. Improving Care and Promoting Health in Populations

Annual cost 2017 ‐ $327 billion

To improve population health, need combo of system level and patient level approaches

7.2% = Mean A1c 2007‐2010

33‐49% of pts do not meet targets for A1c, BP or lipids

14% meet targets for A1c, BP, lipids and non smoking status

Keeping in Patient Centered and Utilize Chronic Care Model

Start with the person: Incorporate pt preferences, literacy, life experiences

Provide team‐based care, community involvement, decision support tools.

Align care with Chronic Care Model to ensure proactive practice and informed, activated patient.

Avoid therapeutic inertia

Tailor Treatment for Social Context Consider individualized care and provide resources to support people with: Food insecurity Housing instability Financial barriers Cognitive dysfunction Mental illness (2‐3 x’s higher rates of diabetes

in schizophrenia, bipolar) HIV (meds can cause pancreatic dysfunction)

Health inequities related to: Ethnicity, culture, sex, socioeconomic status

Refer to community resources Provide pt w/ support from lay health coaches, navigators, community health workers


Diabetes in America 2019 30.3 million or > 9.4%

24% don’t know they have it

34 % of US adults have pre diabetes (84 mil)

Strategies for System Improvement Affordable Care Act increased access to care for individuals with diabetes from 84% to 90%

Use evidence based guidelines

Expanded team roles – more intensive disease management

Tracking med taking behavior at a systems level

Redesigning the organization of care process

Empowering participants

Reduce costs

Address psycho‐social issues

Engaging community resources

Telemedicine Ideal for: Rural populations, those with physical limitations that decrease access to care

Telecommunications to facilitate remote delivery of health related services and clinical information. Web‐based portals, text messaging and those that incorporate med adjustments, appear most effective


Address Social Determinants In a recent NHIS study of people with chronic disease: Two thirds of those who didn’t take their meds, never shared this with their provider

50% of adults with diabetes reported financial stress

20% reported food insecurity

Older adults are at highest risk

Food insecurity ‐ unreliable availability of food and resorting to socially unacceptable practices to obtain food (14%)

Homelessness

Language Barriers

Community Support

2. Classification and Diagnosis of Diabetes‐

Natural History of Diabetes

No diabetes

FBG <100

Random <140

A1c <5.7%

PrediabetesFBG 100-125

Random 140 - 199A1c ~ 5.7- 6.4%

50% working pancreas

Diabetes

FBG 126 +

Random 200 +

A1c 6.5% or +

20% working pancreas

Development of type 2 diabetes happens over years or decades

Yes! NO

Diagnostic Criteria

All test should be repeated in the absence of unequivocal hyperglycemia

If test abnormal, repeat same test to confirm diagnosis

If one test normal, the other abnormal, repeat the abnormal test to determine status

For type 1 diagnosis, plasma glucose preferred.


A1c Accuracy A1c test should be certified by the NGSP

Discordance between A1c and BG should raise possibility of A1c inaccuracy

If pt has conditions associated with high RBC turnover, use plasma BG to diagnose diabetes: Sickle cell disease

Pregnancy (2nd and 3rd trimester)

Hemodialysis

Blood loss or transfusion

Erythropoietin therapy

A1c Accuracy – Race/Ethnicity A1c accuracy can vary with race/ethnicity, even with similar BG levels

African Americans can carry hemoglobin variants which lowers accuracy of A1c by 0.3 – 0.8%

Be alert for marked differences between BG an A1c and potential conditions associated with increased red blood cell turnover

Screening for Type 2 Community Screening ‐ Use Validated Diabetes Risk Test (ADA) to identify those at risk and promote behavior change action for individuals and their communities.

25% of all people with diabetes are undiagnosed 50% of all Asian and Hispanic Americans are undiagnosed Most people with prediabetes are undiagnosed.

The duration of glycemic burden is a strong predictor of adverse outcomes.

Dentists have an excellent opportunity to find patients with undetected diabetes, since up to 30% of patients over the age of 30 seen in general dental practices have dysglycemia.


3. Prevent or Delay Type 2 Diabetes

Prediabetes defined as: A1c 5.7 – 6.4% or fasting BG 100 ‐125mg/dl

Action: Screen yearly for diabetes

Initiate prevention efforts ‐ Refer to intensive behavioral lifestyle intervention program (DPP)

Based on preference, utilize technology interventions

Most helpful eating patterns include Mediterranean Eating plan and low calorie, low fat eating program

Focus on quality foods including whole grains, legumes, nuts, fruits, veggies and minimal processed foods.

Decrease intake of red meats and sugary beverages

3. Prevent or Delay Type 2 Diabetes Diabetes Prevention Trial, those with prediabetes

Lost 7% of body weight Healthy eating, high fiber, low fat, avoid sugar sweetened beverages, reduce total caloric intake

Exercised 150 minutes a week, reduced risk 58%

Consider Metformin Therapy for Women with history of GDM

Patients with BMI of 35 or greater

Under the age of 60

Follow‐up and group education

Annual monitoring and tx of CVD risk factors


CDC Recognized Prevention Programs Medicare approved funding Diabetes Prevention Programs

4. Comprehensive Medical Evaluation, Assessment of Comorbidities

Patient centered communication, strength based language, active listening, literacy, quality of life

It is necessary to take into account all aspects of a patient’s life circumstance

Diabetes Care should be managed by interdisciplinary team: Providers, nurses, dietitians, exercise specialists,

pharmacists, dentists, podiatrists, mental health professionals and other specialists.

It is important to integrate medical eval, patient engagement and lifestyle changes.

American Diabetes Association


Let’s use language that (is) Imparts hope

Neutral, nonjudgmental

Based on fact, actions or biology

Free from stigma

Respectful, inclusive

Fosters collaboration between person and provider

Avoids shame and blame

Language of Diabetes Education

Old Way New Way

Control diabetes

Test BG

Patient

Normal BG

Non‐adherent, compliant

Refuse

Manage

Check

Participant

BG in target range

Focus on what they are accomplishing

Decided, chose

Guiding Language Principles

Strength Based Person‐first

Emphasize what people know, what they can do.

Focus on strengths that empower people

Words that indicate awareness

Sense of dignity

Positive attitude toward person with disability


Comprehensive Medical Evaluation & Assessment of Comorbidities

Medical Evaluation Initial Visit

1. Classify diabetes

2. Detect diabetes complications

3. Review previous treatment and risk factor control

4. Begin pt engagement in formation of a care management plan

5. Develop a plan for continuing care

Medical Evaluation Goal Prioritize components based on time and resources.

Assess: Diabetes self‐management, nutrition, psychosocial health, risk of acute and chronic complications

Immunizations Sleep habits Cancer screening Smoking cessation Ophthalmological, dental and podiatric referrals

Cardiovascular disease

Vaccinations‐ Immunizations Influenza vaccine every year starting at age 6 months

Hepatitis B Vaccine Administer 2‐3 dose series to unvaccinated adults with diabetes age 19 – 59 years.

Consider administering 2‐3 dose series to unvaccinated adults with diabetes ages 60 years plus .

Double risk of Hep B due to lancing devices/ glucose meter exposure


Pneumonia Vaccinations for Diabetes Pneumococcal conjugate vaccine 13 (PCV 13 or Prevnar 13) to all patients before age 2

Adults 2‐ 64 years of age, if not previously vaccinated, should receive

PCV13* Pneumococcal polysaccharide vaccine (PPSV23) Pneumovax 23

Adults ≥ 65 years of age, regardless of vaccination history, additional PPSV23 vaccination is necessary.

https://www.cdc.gov/pneumococcal/vaccination.html

*ADA Standards 2019 do not mention PCV 13 for adults, but CDC guidelines recommend for those at high risk

Initial Eval – Looking for Autoimmunity

Type 1 ‐ Autoimmune Conditions Hashimoto Thyroiditis

Graves disease

Addison disease

Celiac disease

Vitiligo

Autoimmune hepatitis, gastritis

Myasthenia gravis

Pernicious anemia

Dermatomyositis

Initial Eval – Looking for Comorbidities Other conditions that may appear Cancer Cognitive impairment Hyper/Hypoglycemia Psychosocial/Emotional Disorders Obstructive sleep apnea Fatty liver disease Pancreatitis Low Testosterone in Men Hearing Impairment Fractures Periodontal disease Cardiovascular disease


Assess Hypoglycemia Risk Insulin or secretagogues

Impaired kidney or liver function

Longer duration of diabetes

Frailty and older age

Cognitive impairment

Hypoglycemia unawareness

Physical or intellectual disability

Polypharmacy

Bone Fracture Risk People with type 1 have in increased relative risk (6.3) of hip fracture Associated with osteoporosis

People with type 2 have in increased relative risk (1.7) of hip fracture Despite higher bone mineral density

Assess fracture history and consider bone mineral density screening

In pts at risk for fractures, use TZDs and SGLT‐2 Inhibitors with caution

American Diabetes Association Diabetes Care 2019;42:S38-S39

©2019 by American Diabetes Association


Follow‐up Visit to include Review of initial visit components including: Med history

Med taking behavior

Physical exam

Lab eval

Assess risk for complications

Self‐management behaviors

Need for referrals

Health maintenance screening

5. LifeStyle Management Education – Setting Up Successful Diabetes Ed Program – Online University Level 2

Nutrition

Physical Activity Nutrition and Exercise Course –Level 1

Smoking Cessation

Psychosocial Care


Diabetes Self‐Management Education and Support (DSMES)

All people with prediabetes and diabetes should participate in DSMES to facilitate the knowledge, skills and ability necessary to self‐manage their diabetes.

DSMES provides support to implement and sustain skills and behaviors needed for ongoing self‐management.

Diabetes Self Management Ed Benefits

Improves knowledge

Lowers A1c

Lose weight

Improved quality of life

Reduced all cause mortality

Reduced health care costs

Diabetes Self Management Ed Benefits

Increased primary care and preventive services

Less frequent us of acute care and inpt admissions

More likely to follow best practice recommendations (esp those with Medicare) Only 5‐7% of Medicare pts receive DSME)


Critical Points to Provide Self‐Management Education

At diagnosis

Annually to assess education, nutrition and emotional needs

When new complicating factors arise that influence self‐management

Transitions in care

Physical Activity Children with diabetes – 60 mins / day

Adults – 150 min/wk moderate intensity over 3 days a week.

Don’t miss > 2 consecutive days w/out exercise

Get up every 30 mins ‐ Reduce sedentary time

T1 and T2 – resistance training 2 ‐3 xs a week

Flexibility and balance training 2‐3 xs a week (Yoga and Tai Chi)

Best Shake For People with Diabetes

From Debbie Nagata’s slide collection


Medical Nutrition Therapy Individualize MNT for all people with Type 1 and Type 2 Diabetes

For those on flexible insulin program, provide education on carb counting, fat and protein gm estimations

For those on fixed insulin program, focus on consistent carb intake considering timing and amount to improve BG control and reduce risk of hypo

Reduce refined Carbs, Added Sugars ‐ ADA

To control wt, reduce risk of CVD and fatty liver disease

ADA strongly discourages consumption of: Sugar sweetened beverages

Processed “low‐fat” or “non‐fat” foods with high amounts of refined grains & added sugar

Sugary and processed foods can displace healthier, more nutrient dense food choices

Non‐Nutritive Sweeteners Use can reduce overall calorie intake if substituting for sugary beverages

But overall, people are encouraged to decrease both sweetened and non‐sweetened beverages.

Emphasize water intake.


Healthy Eating Patterns

Mediterranean Diet

DASH Diet

Plant based eating

Diabetes Plate Method

Weight Watchers or other groups

DASH Diet – Dietary Approaches to Stop Hypertension

The DASH diet emphasizes vegetables, fruits and low‐fat dairy foods — and moderate amounts of whole grains, fish, poultry and nuts.

Pt recommendations Eat lots of whole grains, fruits, vegetables and low‐fat dairy products.

Also includes some fish, poultry and legumes, and encourages a small amount of nuts and seeds a few times a week.

Red meat, sweets and fats in small amounts. Focus on low saturated fat, cholesterol and total fat.

Mediterranean Diet Pyramid


Low Carb Diets for Diabetes Role remains unclear

Wide range of definitions

While some benefits observed, improvements tend to be short lived, and effects are not maintained

Some studies have shown benefit from ketogenic diet (<50 gms carb day), this approach may only be appropriate for short term. No long term research on benefit/harm.

Low carb diet not appropriate for pregnant or lactating women, children, those with renal disease or disordered eating or those taking SGLT2 Inhibitor

Protein and Kidney Disease Maintain dietary protein at 0.8g/kg/day Reducing below this not recommended – does not improve BG, CVD or slow kidney disease progression

Do not use protein foods to treat hypoglycemia (can enhance carb related insulin release)

Tobacco and E‐ Cigarettes Tobacco use higher among people with chronic illness and adolescents with diabetes

E‐Cigs Not supported as an alternative to smoking or to facilitate smoking cessation.

Encourage all patients not to use cigarettes, other tobacco products, e‐cigs

Provide smoking cessation counseling and support

Discuss use of e-cigarettes, vaping and juuling. These devices can contain flavored nicotine-laced vapor (and often contain other unhealthy stuff).


Consider Referral to Mental Health Provider for Eval and Treatment Diabetes distress even after tailored education

Screens positive for depression, anxiety, FoH*

Disordered eating or disrupted eating patterns

Not taking insulin/meds to lose weight

Serious mental illness is suspected

Youth with repeated hospitalizations, distress

Cognitive impairment or impairment of DSME

Before bariatric/metabolic surgery

*Fear of hypoglycemia

6. Glycemic TargetsIndividualize Targets – ADA

Pre‐Prandial BG 80‐ 130rather than 70–130 mg/dL, to better reflect new data comparing actual average glucose

levels with A1C targets.

1‐2 hr post prandial < than 180*for nonpregnant adults


6. Glycemic Targets Adult non pregnant A1c goals A1c < 7% ‐ a reasonable goal for adults.

A1c < 6.5% ‐ may be appropriate for those without significant risk of hypoglycemia or other adverse effects of treatment.

A1c < 8% ‐ may be appropriate for patients with history of hypoglycemia, limited life expectancy, or those with longstanding diabetes and vascular complications.

6. Pediatric Glycemic Targets A1c goal <7.5 % for all ages; however individualization is still encouraged.

A lower goal, <7% if can be achieved w/out excessive hypoglycemia

Blood glucose goals Before meals: 90‐130

Bedtime/overnight: 90‐ 150


Hypoglycemia (Glucose) Alert Values BG <70mg/dl – Level 1 Follow 15/15 rule and contact provider to make needed changes

BG < 54mg/dl – Level 2 Indicates serious hypo. Contact provider for med change. Glucagon Emergency Kit

Severe Hypoglycemia – Level 3 Requires external assistance – no threshold

Hypoglycemia Considerations Assess pts at each visit about hypoglycemic episodes

Review appropriate treatment

For individuals with significant hypo (<54), get Glucagon ER Kit. Inform and instruct school personnel, family,

coworkers of hypo signs and appropriate action

Review medication for needed adjustment

Ind’s with hypoglycemic unawareness should be instructed to increase BG thresholds

Assess cognitive function and safety

Getting to Goal – Half way there


7. Diabetes Technology Diabetes technology is the term used to describe the hardware, devices and software that people with diabetes use to help self‐manage their diabetes and improve quality of life.

Advances in technology will continue to revolutionize and improve the way diabetes care is delivered.

Diabetes Technology – Topics

This rapid change in the technology landscape can make it difficult and confusing for diabetes educators and providers to keep up to date.

Insulin delivery methods Insulin syringes, pens, disposable patch, pumps

Insulin pump therapy can be used for all ages

Pump complications can include; Dislodgement or occlusion, lipohypertrophy, lipoatrophy and pump site infection

People rarely stop pump therapy due to overall satisfaction

Monitoring – Meters and CGM

Insulin pump Geography Variations Due to health disparities, adoption of insulin pump therapy varies across geographic and socioeconomic landscapes.

Disadvantaged groups have less access to insulin pumps and associated technologies.

These disparities need to be addressed along with insulin affordability.


Continuous Glucose Monitoring (CGM)

Lowers A1c ~0.26% (compared to SMBG)

CGM should be considered in children to adults

Useful tool in those frequent hypoglycemia or hypoglycemia unawareness (alarm features)

Measures percent of time in, above and below range

Given variable adherence to CGM, assess ind readiness

CGM uses interstitial glucose – correlates with plasma glucoseReport glucose in - Real time or- Or intermittent scanning

“flash” (isCGM) like FreeStyle Libre

Automated Insulin Delivery Automated insulin delivery systems may be considered in children 7 years or older and adults to improve BG

Consists of 3 components Insulin pump

Continuous glucose monitor

Algorithm that determines insulin delivery

These systems, insulin delivery can be suspended, increased or decreased.

Currently, a hybrid closed loop (HCL) is approved which calculates basal rate, but requires users to bolus for meals and snacks

Future – truly automated closed loop system

Is Routine Glucose Monitoring Always Necessary for type 2s on orals?

“In people with type 2 diabetes not using insulin, routine SMBG may be of limited use”.

In a one year trial of once‐daily SMBG plus enhanced feedback, there was no significant improvement in A1c

SMBG alone, does not lower BG.

The BG results must be integrated into the clinical plan


Blood Glucose Meter Accuracy It is assumed that personal glucose meters are

accurate if they are FDA cleared, but often that is not the case.

The 2016 current rules called for +/‐ 20% accuracy for most blood sugar ranges.

The FDA is currently reviewing and updating the guidelines for glucose meter accuracy.

Advocacy groups appealed to the FDA to demand better accuracy since treatment decisions are based on these readings and can dramatically impact outcomes.

A research study by The Diabetes Technology Society Blood Glucose System Surveillance Program, found that in a recent analysis, only 6 of the top 18 glucose meters met the accuracy standards.

The Diabetes Technology Society Blood Glucose System Surveillance Program

8. Obesity Management for Treatment of Type 2 Diabetes

Provides cost information for pharmacologic treatment of obesity

At each pt encounter, calculate BMI and document in medical record

DPP like weight loss programs that offer at weekly and monthly support most effective


Very low calorie diets ‐ <800 cals/day Small studies have demonstrated with type 2 and obesity, extreme dietary restriction Can lead to diabetes remission

A1c <6.5% and FPG <126

Without medications

These improvements are more likely early in the natural history of type 2

Must be provided by trained practitioners in medical care settings with close monitoring

Weight regain more likely than with lifestyle

Section 9‐ Pharmacologic Approaches to Glycemic Treatment

New Algorithm for Oral Meds and Insulin Therapy

More attention to considering CVD and CKD when choosing diabetes medication

Updated chart on cost and attributes of different meds

Medication Taking Behaviors Adequate medication taking is defined as 80%

If pt taking meds 80% of time and treatment goals not met, intensification should be considered.

Barriers to taking meds include: Forgetting to fill Rx, fear, depression, health beliefs, medication complexity, cost, system factors, etc

Work on targeted approach for specific barrier


ADA Step Wise Approach to Hyperglycemia 2019 Step 1 – Metformin + Lifestyle

Step 2 ‐ If A1c target not achieved after 3 months, Metformin + another med

If CVD, CHF, or CKD, consider adding a second agent risk reduction (based on drug effects and patient factors).

SGLT‐2 Inhibitors – empagliflozin (Jardiance) and canagliflozin (Invokana)

GLP‐1 Receptor Agonist – liraglutide (Victoza), semaglutide(Ozempic)

Step 3 ‐ If A1c target still not achieved after 3 months, combine metformin plus one to two other (2‐3 drugs)

Step 4 ‐ If A1c target not achieved after 3 months, add injectable therapy (basal insulin or GLP‐1 RA) to drug combination.

ADA Step Wise Approach to Hyperglycemia 2019

For all steps, consider including medications with evidence of CVD and CKD risk reduction, based on drug specific effects and patient factors.

Other Factors Minimize Hypoglycemia

Minimize wt gain or promote wt loss

Consider Cost


Med sand Insulin PocketCards Download for free

View on CDE Coach App

Annual subscription

Pharmacologic Approaches to Glycemic Management – Diabetes Ed Online University

Join our Meds for Type 2 (Part 1) in Level 1 Series

Join our Meds Management for Type 2 (Part 2) in Level 2 Series

Join Insulin Pattern Management (Part 1) in Level 1 Series

Insulin Pattern Mgmt Gone Crazy (Part 2) in Level 2 Series

10. Cardiovascular Disease and Risk Management

For first time, this section is endorsed by American College of Cardiology.

Cardiovascular disease is the leading cause of mortality and morbidity in diabetes

Large benefits are seen when multiple risk factors are addressed globally


ASCVD – Definition and Consequence

Coronary heart disease

Cerebrovascular disease or

Peripheral arterial disease of atherosclerotic origin

Heart failure rates are double in diabetes

Largest contributor to direct and indirect costs ‐ $37.3 billion a year

Controlling cardiovascular risk improves outcomes

Assess ASCVD and Heart Failure Risk Yearly

Obesity/overweight

Hypertension

Dyslipidemia

Smoking

Family history of premature coronary disease

Chronic kidney disease

Presence of albuminuria

Hypoglycemia Risk

Therapeutic Treatment Plan and Goal Setting Lifestyle, meds, monitoring, referral to DSME

ASCVD (Atherosclerotic Cardiovascular Disease) Assessment

ASCVD Risk Calculator http://tools.acc.org/ASCVD‐Risk‐Estimator‐Plus

Evaluate 10 year risk of CV events (age 40‐59)


BP and Diabetes Targets Calculate ASCVD Risk using calculator:

If CVD Risk <15%

BP target <140/90

If 10 year CVD Risk > 15%

BP target <130/80

BP target based on individual assessment and shared decision making that addresses CV Risk and potential adverse effects of BP meds.

BP GoalBP Goal based on risk Measure B/P at every

routine clinical visit.

If B/P elevated, confirm B/P using multiple readings, including measurements on a separate day, to diagnose HTN

All with diabetes and HTN should monitor BP at home.

Some pts may benefit from B/P 130/80 (younger and achieved with undue txburden)

Pregnancy targets for those w/ hypertension120‐160 / 80‐105

Hypertension Guidelines Screening – Check BP at each visit.

If either • systolic 140 or >

diastolic 90 or > repeat on separate day.

Hypertension = Repeat systolic or diastolic above or equal to these levels

When taking B/P

• Pt sit still for 5 min’s

• Feet on floor,

• Arm supported at heart level

• Right size cuff


HTN Lifestyle Treatment Strategies

If BP > 120/80, start with lifestyle

Lose weight through less calories

Sodium intake <2,300mg/day

Eat more fruits & veggies (8‐10 a day)

Limit alcohol 1‐2 drinks a day

Increase activity level

Recommendations for the treatment of confirmed hypertension in people with diabetes.

*An ACE inhibitor (ACEi) or ARB is suggested to treat hypertension for patients with UACR 30–299 mg/g creatinine and strongly recommended for patients with UACR ≥300 mg/g creatinine.

**Thiazide-like diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred. ***Dihydropyridine calcium channel blocker.

BP Treatment in addition to Lifestyle

First Line B/P Drugs

If B/P ≥ 160 /100 start 2 drug combo Any of the 4 classes of BP meds can be used to tx hypertension (without albuminuria).

This includes ACE Inhibitors, ARBs, thiazide‐like diuretics or calcium channel blockers. (Avoid ACE and ARB at same time)

Multiple Drug Therapy often required

For best effect, administer at least one at bedtime


Do Statins lower mortality? Meta‐analysis of data from 18,000 patients with diabetes from 14 randomized statin trials (mean follow‐up 4.3 years)

Demonstrate a 9% proportional reduction in all cause mortality and a 13% reduction in vascular mortality for each mmol/L reduction in LDL cholesterol.

Each 1.0 mmol/L point reduction (40mg/dl)

reduces relative risk of death and CVD by 9‐13%.

Statin Recommendations

Statin Therapy High intensity statins (lowers LDL 50%): Lipitor (atorvastatin) 40‐80mg

Crestor (rosuvastatin) 20‐40mg

Moderate intensity (lowers LDL 30‐50%) atorvastatin (Lipitor) 10‐20mg

rosuvastatin (Crestor) 5‐10mg

simvastatin (Zocor) 20‐40mg

pravastatin (Pravachol) 40 – 80mg

lovastatin (Mevacor) 40 mg

fluvastatin (Lescol) XL 80mg

pitavastatin (Livalo) 2‐4mg


Monitoring Lipids Recommendations

Obtain a lipid profile at initiation of statins or other lipid‐lowering therapy

4–12 weeks after dose change and

annually to monitor response

In adults not taking statins obtain a lipid profile at:

time of diabetes diagnosis

initial medical evaluation

every 5 years thereafter if < of 40 years, or more frequently if indicated.

Coronary Vessel Disease In pts with known CVD, use: Aspirin

Statin

B/P Med In pts with prior MI, Beta Blockers should be continued at least 2 years after the event

Don’t use Actos or Avandia in pts with CHF

Diabetes Meds that significantly decrease CV events: SGLT2 Inhibitors – empagliflozin and canagliflozin

GLP‐1 RAs – liraglutide and semaglutide

A 78 yr old man, smokes ppd A1c was 8.1% (down from 10.4%)

B/P 136/76 AM BG 100, 2 hr pp 190

Chol – TG 54, HDL 46, LDL 98

Meds: Insulin – 16 units Lantus at HS

Benazepril 20 mg

Metropolol 50mg

Warfarin 5mg

Actos 15 mg

What class of meds? Any special instructions?Any med missing?Statin plus can add SGLT2 or GLP-1 to get BG to goal


ABCs of Diabetes

A1c less than 7% (avg 3 month BG) Pre‐meal BG 80‐130 Post meal BG <180

Blood Pressure < 140/90Cholesterol Eval if statin therapy indicated

Mr. Jones ‐ What are Your Recommendations for Self‐Care?

Patient Profile62 yr old with newly dx type 2.

History of previous MI.Meds: Lasix, synthroid

Labs: A1c 9.3%

HDL 37 mg/dl

LDL 156 mg/dl

Triglyceride 260mg/dl

Proteinuria ‐ neg

B/P 142/92

Self‐Care Skills

Walks dog around block 3 x’s a week

Bowls every Friday

Widowed, so usually eats out

11. Microvascular Complications Foot Care

Comprehensive foot eval each year to identify risk & promote prevention.

For those with loss of protective sensation, foot deformities, or a history of foot ulcers, check feet at each visit.

“When you see your provider, take off your shoes and socks and show your feet!“ Bev’s note.


11. Microvascular Complications Chronic Kidney Disease (CKD) Optimize glucose and B/P Control to protect kidneys

Screen for Albumin‐Creat ratio and GFR Type 2 at dx then yearly

Type 1 with diabetes for 5 years, then yearly

Treat hypertension with ACE or ARB and for elevated albumin‐to‐creatinine ratio of 30‐299mg/g

Consider use of SGLT2 or GLP1 to slow CKD progression

Monitor serum creat and K+ if on ACE, ARB or diuretics

See Level 2 Course, Microvascular Complications

CKD Stages and Corresponding Focus of Kidney‐Related Care

Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S105-S118

Microvascular Complications ‐ Eyes Optimize BG and B/P Control to protect eyes

Screen with initial dilated and comprehensive eye exam by ophthalmologist or optometrist

Type 2 at diagnosis, then every one to 2 years

Type 1 within 5 years of dx, then every 1‐2 years

Programs that use validated retinal photography can be used for screening

Promptly refer pts with macular edema, severe non‐proliferative disease to trained specialist

Treatment for retinopathy includes laser therapy and Antivascular and Endothelial Growth Factor, ranibizumab. AEGF can also be used for Macular Edema


Microvascular Complications Nerve Disease Tight glycemic control

Screen all patients for nerve disease using simple tests, such as a monofilament, pinprick & vibration Type 2 at diagnosis, then annually

Type 1 diabetes 5 years, then annually

Assess and treat to reduce pain and symptoms to improve quality of life. Pregabalin, duloxetine or gabapentin are recommended as initial pharmacologic treatments

12. Older Adults 26% of people over 65 have diabetes (expected to rise)

Asses the medical, functional, mental and social geriatric domains for diabetes.

Provide individualized care Determine targets and therapeutic approaches

Over age 65, high risk for depression

Provide nursing home staff with education

See Level 2 Course, Older Adults and Diabetes

Older Adults (≥65 years) with diabetes Annual screening for early detection of mild cognitive impairment or dementia

High priority population for depression screening and treatment

Avoid hypoglycemia in this high risk group Prevent hypo by adjusting glycemic targets and adjusting pharmacologic interventions


Older Adults and Medications

In older adults at increased risk of hypoglycemia, meds with low risk of hypoglycemia are preferred.

Overtreatment of diabetes is common in older adults and should be avoided.

Deintensification (or simplification) of complex regimens is recommended to reduce the risk of hypoglycemia, if it can be achieved within the individualized A1C target.

Algorithm to simplify insulin regimen for older patients with type 2 diabetes. eGFR, estimated glomerular filtration rate. *Basal insulins: glargine U-100 and U-300, detemir, degludec, and human NPH. **See Table 12.1. ¥Mealtime insulins: short-acting (regular human insulin) or rapid-acting (lispro, aspart, and glulisine).

§Premixed insulins: 70/30, 75/25, and 50/50 products. American Diabetes Association Dia Care 2019;42:S139-S147 ©2019 by American Diabetes Association

Older Adults – Considerations for Treatment Regimen

Page S142 ADA Stds 2019


13. Children and Adolescents Type 1 or Type 2 Diabetes? Many children are overweight with new

hyperglycemia.

6% of children with new type 2 present in DKA.

Type 2 in kids is different than type 2 in adults, including more rapid decline in beta cell function and accelerated development of diabetes complications.

Evaluate autoantibodies and do a careful history to determine the correct diagnosis and provide early and

appropriate treatment.

See Level 2 Course - Kids and Diabetes for full detail

Type 1 Glycemic Control ‐ Peds Type 1 diabetes benefit from intensive

insulin regimens, either via multiple daily injections or pump

Self‐monitor blood glucose levels multiple times daily, including premeal, prebedtime, and as needed for safety

Continuous glucose monitoring should be considered in children and adolescents with type 1 diabetes, whether using injections or pumps, to improve glycemic control.

Automated insulin delivery systems improve glycemic control and reduce hypoglycemia and should be considered in adolescents with type 1 diabetes.

CVD Management If hypertension confirmed on 3 separate days Initiate lifestyle changes

If BP not at target in 3‐6 months, consider starting an ACE Inhibitor or ARB

BP goal: consistently <90 percentile for age, sex, ht

Check fasting lipids at 10 years of age If above target, provide lifestyle counseling

If LDL > 160, in spite of lifestyle, add statin (after age 10)

LDL goal < 100

Provide preconception counseling in both situations


Risk based Screening Criteria PreDiabetes & T2 Kids & Adolescents

Overweight plus any ONEfactor: Maternal history of diabetes or GDM

Family history type 2 in 1st or 2nd

degree relative

Race/ethnicity

Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, HTN, dyslipidemia, PCOS, small for gestational age)

Type 2 in Youth ‐ Lifestyle Provide youth and families with developmentally and

culturally appropriate comprehensive lifestyle programs to achieve 7–10% decrease in excess weight.

Lifestyle intervention should be based on a chronic care model and offered in the context of diabetes care over long term.

Encourage at least 60 min of moderate to vigorous physical activity per day (and strength training on at least 3 days/week) and to decrease sedentary behavior.

Focus on healthy eating patterns that emphasize consumption of nutrient‐dense, high‐quality foods and decreased consumption of calorie‐dense, nutrient‐poor foods, particularly sugar‐added beverages.

Type 2 Medication Strategy ‐ Kids Initiate pharmacologic therapy, in addition to lifestyle therapy, at diagnosis of type 2 diabetes.

If A1C <8.5% and asymptomatic, start metformin, if renal function is normal.

If A1C above target on metformin, start basal insulin therapy. If on basal insulin and metformin and meeting BG targets taper

basal insulin over 2–6 weeks by decreasing the insulin dose by 10–30% every few days.

If marked hyperglycemia (blood glucose ≥250 , A1C ≥8.5%) without ketoacidosis but are symptomatic with polyuria, polydipsia, nocturia, and/or weight loss Treat initially with basal insulin and metformin and titrate to to achieve A1C goal.


14. Management of Diabetes In Pregnancy

GDM prevalence increased by ∼10–100% during the past 20 yrs Affects about 7% of women

Native Americans, Asians, Hispanics, African‐American women at highest risk

Within 5 years, 50% chance of developing DM in next 5 years.

Start preconception counseling at puberty.

Get A1c <6.5 before pregnancy

Get to healthy weight

A1c and BG Goals for Type 1 & 2 and GDM During Pregnancy

A1c < 6‐6.5% (closer to 6 in 2nd/3rd tri)

Fasting <95 mg/dL and either

One‐hour postprandial <140 mg/dL or

Two‐hour postprandial <120 mg/dL

BG self‐monitoring recommendations: Fasting and postprandial

Some women w/ preexisting DM may need to also check preprandially


Gestational Diabetes Test for undiagnosed diabetes at first prenatal visit in those with risk factors

Test for GDM at 24‐28 weeks

Test GDM women for post partum diabetes at 4‐12 weeks, using OGTT

Women with GDM need lifelong screening for prediabetes/diabetes at least every 3 yrs

Women with hx of GDM, found to have prediabetes need intensive lifestyle interventions or metformin to prevent diabetes.

Management of Gestational DM

Lifestyle change is an essential component and may suffice for many women

If additional therapy is needed, insulin is preferred for GDM Does not cross placenta Can overcome insulin resistance assoc w/ type 2

Sulfonylureas pass through placenta / associated with neonatal hypo

Metformin – lower risk of hypo and maternal wt gain, but may increase prematurity rate. Passes through placenta. Stop when pregnancy confirmed.

Refer women with GDM to specialized center

Management of Diabetes in Pregnancy

Insulin is preferred for type 1 and 2 Does not cross placenta

Can overcome insulin resistance assoc w/ type 2

Sulfonylureas pass through placenta / associated with neonatal hypo

Metformin – lower risk of hypo and maternal wt gain, but may increase prematurity rate. Passes through placenta. Stop when pregnancy confirmed.

Refer to specialized center


Preeclampsia and Aspirin Diabetes and pregnancy = higher risk of preeclampsia

Based on results U.S. Preventive Task Force

Pregnant Women with Type 1 or Type 2 should be prescribed Aspirin (81mg/day) after 12 weeks of gestation to lower risk of preeclampsia

15. Diabetes Care in the Hospital

A1c on all patient with DM/hyperglycemia

Insulin dosing should be based on standard protocols that allow for predefined adjustments based on BG fluctuations (no sliding scale)

Consider consulting with glucose mgmt. team

Have hypoglycemia protocol. Ongoing quality improvement to keep BG > 70.

Inpatient glucose goals:

Start insulin if BG >180

Goal BG 140‐ 180 (some pts may benefit from 110‐140)

Create structured discharge plan based on individual

16. Diabetes Advocacy People living with diabetes should not face discrimination

We need to all be a part of advocating for the best care and the rights of people living with diabetes.

Insulin should be affordable for all


Thank You Please email us with anyquestions.

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www.diabetesed.net

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