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Diabetes Update -- 2012

Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE University of Chicago Kovler Diabetes Center

Standards of Medical Care in Diabetes – 2012

• www.diabetes.org – Professionals – Clinical Practice

Recommendations

• Annual update that consists of official American Diabetes Assoc statement regarding diabetes care based on current research – Download available free of charge

Additions/Revisions to Standards of Care -- 2012

•  Section added on driving and diabetes •  Section and table added on common co-

morbidities of diabetes •  Table added listing properties of noninsulin

therapies for hyperglycemia in T2DM •  Therapy for T2DM revised to include more

specific recommendations for starting and advancing meds

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Diagnosis of Diabetes

• FPG > or = 126 mg/dL (>8 hr without food) • OGTT – 2 hr pp >or = 200 mg/dL • 2010 update: A1C > or = 6.5% OR • Classic symptoms of hyperglycemia +

random BG > or = 200 mg/dL

Diagnosis of pre-diabetes

• FPG 100-125 mg/dL • 2 hr plasma glucose 140-199 mg/dL • A1C: 5.7-6.4%

Testing for Diabetes – Asymptomatic patients •  Adult of any age with BMI > or = 25 kg/m2 •  1 or more risk factors for DM

–  Physical inactivity –  1st degree relative with DM –  High risk ethnicity (AA, Latino, Nat Am, Asian Am, Pac Islander –  HTN (>140/90) –  HDL <35 mg/dL or trig >250 mg/dL –  A1C > or = 5.7% –  Hx of CVD –  Women with h/o:

•  PCOS •  GDM during pg or delivered baby >9 #

•  Without risk factors: start at age 45; if results normal, repeat q 3 years

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Testing for T2DM in Kids

•  BMI >85th percentile for age/sex • Wt/Ht >85th percentile • Wt >120% of ideal for ht •  If has 2 risk factors:

–  Family hx –  Ethnicity –  Signs of insulin resistance – PCOS, acanthosis

nigricans, HTN –  Maternal h/o DM or GDM

•  Initiate testing at 10 years of age or onset of puberty –  Check q 3 years

Testing for T1DM

• Not recommended since onset is acute • Post preliminary dx, to confirm T1DM:

–  IAA –  ICA – GAD

A1C recommendations

ADbA: <7% AACE: <6.5% IDF: <6.5% ** ADbA recommendations are based on

targets that are desirable for MOST patients with DM

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A1C vs eAG A1C % eAG (mg/dl) 6.0% 126 6.5% 140 7.0% 154 7.5% 169 8.0% 183 8.5% 197 9.0% 212 9.5% 226 10.0% 240

BG goals • ADbA

– 70-130 mg/dL pre-meals – <180 peak pp (1-2 hr post meal)

• AACE – 80-110 mg/dL – <140 2 hr pp

•  IDF – 80-110 mg/dL – <140 2 hr pp

Medical Nutrition Therapy -- General Recommendations

• Receive individualized MNT as needed • Mix of carb, pro, fat may be adjusted to

meet goals • RDA for carbs: 130 g/day • Medicare coverage:

–  Initial – 3 hrs MNT – Each subsequent year – 2 hrs MNT

• www.cms.gov

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Physical Activity

• 150 minutes/week of moderate-intensity aerobic PA

•  If no contraindications, resistance training twice weekly

Psychosocial assessment •  It is “reasonable” to include assessment

–  Screening –  Follow-up

•  At diagnosis •  During regular DM visits •  Upon discovery of complications •  During hospitalizations • Websites for basic assessments:

–  http://www.diabetesinitiative.org/build/hc_resources.html

Immunizations

• Flu vaccine annually for >6 mths age • Pneumonia vaccine >2 years

– One-time re-vaccination >64 years

• Hepatitis B – CDC updating standards

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Prevention/Management of DM Complications --- CVD

• BP • Measured at every routine DM visit • Goal of <130/80

• Lipids • Annually • LDL <100 mg/dL, if CVD risk factors <70 mg/dL • HDL >50 mg/dL • Triglycerides <150 mg/dL • Lifestyle modification: reduction of sat fat, trans fat,

cholesterol intake, increase in n-3 fatty acids, viscous fiber, plant stanols/sterols, weight loss, increased PA

Prevention/Management DM Complications – Renal

•  Annual random/spot urine albumin test in T1DM dx >5 years and all T2DM –  Normal: <30 mcg/mg –  Microalbuminuria: 30-299 mcg/mg –  Macro/Clinical albuminuria: > or = 300 mcg/mg

•  Adults: creatinine screening annually – GFR –  Stage 1: > or = 90 mL/min GFR –  Stage 2: 60-89 –  Stage 3: 30-59 –  Stage 4: 15-29 –  Stage 5: Kidney failure -- <15 or dialysis

Prevention/Management of DM Complications -- Retinopathy

•  Adults/children > age 10 with T1DM –  Dilated eye exam by eye doctor within 5 years after

dx

•  T2DM –  Dilated eye exam shortly after dx

•  Annual exams after initiaL –  Q 2-3 years if one or more normal exams

•  Pregnant women with pre-existing DM –  Exam within first trimester –  Close f/u throughout pregnancy and 1 yr post delivery

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Prevention/Management of DM Complications -- Neuropathy

•  Screening for distal symmetric polyneuropathy –  T2DM: at diagnosis –  T1DM: 5 years post dx

•  Foot screening (10 g monofilament) •  Pedal pulses •  Tuning fork

•  Screening for autonomic neuropathy –  Resting tachycardia –  Exercise intolerance –  Orthostatic hypotension –  Constipation –  Gastroparesis –  Erectile dysfunction

Foot Care

• Comprehensive exam completed annually – Pulses – Vibration – Sensation

• General foot exam at each visit •  http://www.chronicconditions.org/clearinghouse/doc/

foot_exam_form.pdf

• http://www.hrsa.gov/hansensdisease/leap/

Special Populations – Children/Adolescents -- Type 1 DM

• Glycemic control goals vary depending upon the endo – ADA recommendations: – Age 0-6 100-180 mg/dL A1C <8.5% – Age 6-12 90-180 mg/dL A1C <8% – Age 13-19 90-130 mg/dL A1C <7.5% –  If they have hypo awareness, many ped

endos use adult goals

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Children/Adolescents – Type 1 Screening for Chronic Complications • Nephropathy

– Annual spot urine for alb-to-creat ratio

• HTN –  www.nhlbi.nih.gov/health/prf/heart/hbp/hbp_ped.pdf

–  If >90th percentile for age, sex, ht • HTN must be confirmed on 3 separate days • Initial tx meal planning/PA • If no improvement in 3-6 mths, pharm tx (ACE)

Children/Adolescents – T1DM Screening -- Dyslipidemia

•  If family hx •  Fasting lipids if child >2 years soon after dx

•  If no family hx •  Fasting lipids at puberty (~10 years of age)

•  If lipids abnormal •  Annual monitoring

•  If LDL are <100 mg/dL •  Repeat q 5 years

•  Initial tx • Optimize BG control and MNT (Step 2 AHA diet – low sat fat) •  After age 10, adding a statin if LDL >160 md/dL (no risk factors)

or if >130 mg/dL (one or more risk factors) – goal of therapy is <100 mg/dL

Children and Adolescents – T1DM Screening

•  Retinopathy –  First screening >10 years of age with DM 3-5 years

•  Celiac disease –  Occurs in 1-16% of people with T1DM (vs 0.3-1% in

general population) –  At diagnosis: tissue transglutaminase, anti-endomysial

antibodies, IgA •  Re-test if growth failure, failure to gain wt, wt loss, diarrhea,

flatulence, abd pain, unexplained hypoglycemia

–  If positive antibodies, endoscopy and biopsy •  If biopsy-confirmed celiac, gluten free diet

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Children and Adolescents – T1DM Screening

• Hypothyroidism – Occurs in 17-30% of patients with T1DM – ¼ of children with T1DM have antibodies – After dx

• Thyroid peroxidase and thyroglobulin antibodies, TSH

–  If normal, re-check q 1-2 years, esp if abnormal growth, symptoms of thyroid dysfunction

Children/Adolescents – Type 2

•  Incidence increasing – Distinction between T1DM and T2DM

becoming more difficult due to increased prevalence of overweight in children

– BP, lipids, microalbuminuria assessment, and dilated eye exam all be completed at time of dx

DM Care in the Hospital

• BG goals – Critically ill

• Insulin tx initiated if BGs >180 mg/dL • Once initiated: 140-180 mg/dL is goal range for

majority of patients, but 110-140 mg/dL if no significant hypoglycemia

– Non-critically ill • No RCT data to corroborate effective goals • Pre-meal <140 mg/dL • Random <180 mg/dL

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MNT in the hospital

• ADA does not endorse any one meal plan or specified percentages of macronutrients

•  “ADA diet” should no longer be used • Consistent carb meal plans preferred • MNT should be completed by a RD

Diabetes and Driving

•  Some states impose no special requirements •  IL – requires a medical report form to be completed

before each license renewal –  For new drivers, completed before permit as well –  http://www.cyberdriveillinois.com/publications/pdf_publications/

dsd_dc163.pdf –  By law, you are required to file a a Medical Report Form

completed by your physician, if: –  you have any medical or mental condition which could result in a

loss of consciousness or any loss of ability to safely drive a vehicle, or

–  you take any medications that may impair your ability to drive.

Diabetes and Driving

• ADA position statement recommends against blanket statement restrictions based on dx of DM

• ADA DC office working on removing/reducing many restrictions – FAA

• Meeting planned

– Truck drivers

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Review/Discussion

• The role of the nutrition professional regarding the Clinical Practice Recommendations

• What information should be disseminated to the person with DM?

Current Medications for Type 2 DM Biguanides Action site: liver Reduces the glucose output by the liver Metformin, Glucophage, Glumetza

GLP-1 receptors: Incretin mimetics (injected) Byetta, Victoza DPP-4 inhibitors: Incretin enhancers Januvia, Galvus, Onglyza, Tradjenta

Alpha-glucosidase inhibitors Action site: intestines Slows carb digestion Glyset, Precose

Thiazolidinediones Action Site: muscle cells Increases insulin sensitivity Actos, Avandia

Sulfonylureas and glinides Action site: pancreas Increase insulin production Glipizide, glyburide, Prandin, Starlix

Oral meds and hypoglycemia

• Sulfonylureas and glinides have highest incidence of hypoglycemia – When working with patients, remind them not

to skip meals and make sure to incorporate carbs to reduce the risk of hypo

– Create a plan for sick days, physical activity

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Diabetes medications awaiting FDA approval/newly approved •  SGLT2 inhibitors

–  Dapagliflozin

•  DPP-4 –  Alogliptin

•  GLP-1 –  Albiglutide –  Dilaglutide –  Lixisenatide

•  Afrezza (inhaled insulin) •  Degludec (24 hour insulin) •  Bydureon (FDA approved 1/27/2012)

–  Once-weekly version of Byetta

•  Jentadueto (linagliptin/metformin) 1/31/2012

Insulin

Insulin Comparison Chart:

TYPE ONSET PEAK DURATION ASSESS EFFECT AT

Apidra 10-15 min 30-90 min 3-4 hr 2-4 hr

Humalog 15-20 min 30-90 min 3-4 hr 2-4 hr

NovoLog 15-20 min 40-50 min 3-4 hr 2-4 hr

Regular 30-60 min 80-120 min 4-6 hr 3-7 hr

NPH 2-4 hr 6-10 hr 14-16 hr 6-12 hr

Lantus 1-4 hr Peakless 18-26 hr 6-10 hr

Levemir 1-4 hr Minimal 16-22 hr 6-10 hr

Pre-mixed- regular 30-60 min 2-12 hr 16-18 hr 4 hr & 6-12 hr

Pre-Mixed –rapid 15-20 min 1-6 hr 18-24 hr 2 hr and 6-12

hr

At diagnosis:

Lifestyle +

Metformin

Lifestyle + Metformin +

Basal insulin

Lifestyle + Metformin +

Sulfonylurea

Lifestyle + Metformin

+ Intensive insulin

Lifestyle + Metformin

+ TZD

No hypoglycemia Edema/CHF Bone loss

Lifestyle + Metformin +

TZD +

Sulfonylurea

Tier 1: Well validated core therapies

Tier 2: Less well validated therapies

STEP 1 STEP 2 STEP 3

Lifestyle + Metformin

+ GLP-1 agonistb

No hypoglycemia Weight loss N/V

Lifestyle + Metformin +

Basal insulin

ADA/EASD Treatment Algorithm for T2DM

Adapted from Nathan DM et al, Diabetes Care, 2009:32(1); 193-203

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Expected Decrease in A1C with Monotherapy -- ADA/EASD Consensus Statement •  Lifestyle 1.0-2.0% •  Metformin 1.0-2.0% •  Insulin 1.5-3.5% •  Sulfonylureas 1.0-2.0% •  TZDs 0.5-1.4% •  GLP-1 agonists 0.5-1.0% •  DPP-4 inhibitors 0.5-0.8% •  Glinides 0.5-1.5% •  Alpha-glucosidase inhibitors 0.5-0.8% •  Pramlintide 0.5-1.0%

Nathan DM et al, Diabetes Care, 2009:32(1); 193-203

Pattern Management

• Assessing –  Insulin/oral medication dosing –  insulin to carb ratios – correction factors

• General rule of thumb for carb ratios – At 2 hours after dosing, if BG is within 30-50

points of goal, ratios are accurate

Medication Review

• Role of the nutrition professional regarding medications and BG – MNT vs meds

• Teaching points for the person with DM – Effect of meds on BG – Site selection for injections – Rotation of sites for optimal absorption – Carb counting and medications

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Insulin Pens

Discontinued 2011

Pen needles

Insulin Pumps -- 2012

Dana Diabecare IISG

Animas Ping

Medtronic Paradigm Revel Deltec Cozmo

**discontinued 2009, out of circulation by end 2012

Nipro Amigo Accu-Chek Spirit

Insulet OmniPod

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Awaiting FDA Approval/Launch

Medingo’s Solo Patch Pump

Tandem t:slim

Awaiting FDA Approval

Asante Solutions’ Pearl Insulin Pump

Cellnovo Mobile Patch Pump

30% smaller OmniPod

New Products

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New products

Technology Review

• Helping the person with DM choose the right pump/meter for them

• Staying updated on the technology • Becoming a pump/CGM trainer

Current Clinical Trials

• Search : diabetes and chicago – 102 trials still actively recruiting subjects

• Medication trials • Islet cell transplant • Sleep apnea • Fitness and sleep

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Clinical trials

• NIDDK List of Type 1 Diabetes Clinical Trials – TrialNet natural History Study – TrialNet Oral Insulin Study – SEARCH for Diabetes in Youth –  Islet Transplantation

Artificial Pancreas Project

•  JDRF-funded project •  Three components:

–  Pump –  Sensor –  Specialized computer

•  Reads the sensor and tells the pump how much insulin to deliver

•  Dec 1 – FDA issued draft guidance for the development of the algorithm

•  Estimated timeline: 2015-2017 for market approval •  1st phase

–  Pump and sensor with low glucose suspend

Artificial Pancreas Project

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Stem cell/Islet Cell

• Edmonton protocol – Transplant islets into patients with T1DM that

is difficult to control – 3 centers in Chicago

• UIC • NW • U of C

• Collaborative Islet Transplant Registry – www.citregistry.org

Clinical Trial Review

• What do the patients need to know? • What does the nutrition professional need

to know? • Working with clinical trials

Additional resources

• Diabetes Health – annual product reference guide – www.diabeteshealth.com/charts

• DiabetesPro SmartBrief – daily emails – www.smartbrief.com/diabetespro

• Diabetes Care & Education practice group – www.dce.org

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Thank you!

amy.fischl@uchospitals.edu 773-702-0123