the abcs of mdi - military families learning network...• neutral cv risk con’s • hypo risk •...
TRANSCRIPT
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FD Title Slide
1
learn.extension.org/events/3369
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military
Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
The ABCs of MDI: Gaining a working knowledge of
Multiple Daily Injection insulin therapy
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FD Title Slide
3This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military
Family Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.
The ABCs of MDI: Gaining a working knowledge of
Multiple Daily Injection insulin therapy
learn.extension.org/events/3369
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Kimberly Bisanz, MFCS, RDN, LD, CDE
•At age 14, decided to become a dietitian (thank
you 4-H!) as long as she didn’t have to work with
diabetes
•At age 20, still wanted to be a dietitian, as long as
she could specialize in diabetes
•At age 27, earned the CDE designation
•Research Interest: Flexible intensive insulin
therapy in people with Type 2 Diabetes
Today’s Presenter
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Objectives
After this presentation, you should be able to:
• Identify at least 2 types of basal insulin and 2 types
of bolus insulin used for MDI therapy
• Explain 3 approaches to carbohydrate quantification
• Describe snacking guidelines for persons using MDI
therapy
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Disclosures
• No financial relationships outside of my
current employer, Mayo Clinic
6
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What is your experience
with diabetes?
7Photo by Daniel Frese from Pexels
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By the numbers…
8
Bisanz K, Parker A, Byrne C, Parker S, Thomas J, Mancino J, Hand RK. Identification of generalist RDN knowledge gaps in diabetes MNT
compared to diabetes credentialed RDNs: results of a survey to inform educational opportunities. Journal of the Academy of Nutrition and
Dietetics. E published: http://jandonline.org/article/S2212-2672(18)30072-8/fulltext
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Diabetes Self-Management Education & Support
Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care 2015;38:1372–1382
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MDI = 4 or more
injections per day
• Multiple Daily Injections/Multi-Dose
Injections
• Basal-Bolus Insulin Therapy
• Intensive Insulin Therapy
10Pixabay.com
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Insulin OptionsBasal Insulins
Long-acting
• glargine: Lantus (2000),
Basaglar (2015), Toujeo (2015)
• detemir: Levemir (2005)
Ultra Long-acting
• degludec: Tresiba (2015)
Bolus Insulins
Short-acting
• regular (10/1982)
Rapid-acting
• aspart: Novolog (11/2001), Fiasp
(9/2017)
• lispro: Humalog (6/1996)
• glulisine: Apridra (2/2004)
11©2012 Mayo Foundation for Medical Education and Research. All rights reserved. “Used with permission of Mayo Foundation for Medical
Education & Research”
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Which of the following patient scenarios has
the strongest indication for initiating MDI?
A. PWDT2, new diagnosis, A1c 10%
B. PWDT2 on metformin, A1c 10%
C. PWDT2 on basal insulin, SGLT2, GLP-1, A1c 10%
D. PWDT1, new diagnosis, A1c 10%
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SGLT2i Metformin
DPP-4iSulfonylureas
Pumps GLP-1
NPHBasal Insulin
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Non-diabetic State
14
©2012 Mayo Foundation for Medical
Education and Research. All rights reserved.
“Used with permission of Mayo Foundation for
Medical Education & Research”
This illustration was made available by written permission of The Regents
of the University of California. All rights reserved.
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Type 1 diabetes mellitus
Gold-standard for full pancreas replacement
– Most people with type 1 diabetes should be
treated with multiple daily injections of
prandial insulin and basal insulin or
continuous subcutaneous insulin infusion. A
15American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.
Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.
Insulin pump (continuous insulin infusion – CII)
•Only uses rapid acting insulin
•Always attached so no injections
•Allows for fine tuning of basal rates
•Drawbacks: technology, troubleshooting, DKA, attached, cost
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Type 2 Diabetes Mellitus
When control cannot be achieved with other agents
For patients with type 2 diabetes who are not achieving glycemic goals, drug intensification, including consideration of insulin therapy, should not be delayed. B
• Diabetes Progression– Long-standing T2DM can result in insulin deficiency
• Co-morbidities – Contra-indication of non-insulin oral medications & injectables
16
American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.
Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.
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Which of the following patient scenarios has
the strongest indication for initiating MDI?
A. PWDT2, new diagnosis, A1c 10%
B. PWDT2 on metformin, A1c 10%
C. PWDT2 on basal insulin, SGLT2, GLP-1, A1c 10%
D. PWDT1, new diagnosis, A1c 10%
17
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Pro’s
• “Flexibility”
• Efficacy
• Neutral CV risk
Con’s
• Hypo Risk
• Weight Gain
• Cost
• Injection
• Complexity
MDI Considerations
18American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.
Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.
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T2DM Diagnosis
• 57 year old male financial manager.
• Motivated to improve eating and increase physical activity along with starting metformin.
5 years
• First follow-up with PCP. Presents with fatigue & ED. A1c 9.1%
• SGLT2 initiated and 3 months later GLP-1 added.
• 3 months later A1c 6.9%.
3 years
• Continues on triple-therapy, A1c slowly deteriorating (7.3%)
• CKD stage 3 diagnosed.
6 months
• NSTEMI with stent placement and AKI from contrast. CKD stage 4.
• Metformin, SGLT2, and GLP-1 discontinued.
• Basal insulin started.
3 months
• A1c 8.1%
• Rapid-acting insulin added to meals – 1st to dinner then sequentially to breakfast and lunch as BG targets not met.
19
Pexels
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Intermission
20
Pixabay
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What are your priority topics when
educating PWD (pick 2)?
21
Limiting sugar/carbohydrate
Macronutrient distribution
Label reading
Meal timing
Meal planning
Weight management
Heart health
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Medical Nutrition Therapy –
Diabetes Goals• Encourage healthful eating patterns, to
– achieve glycemic, blood pressure, and lipid goals
– achieve and maintain body weight goals.
– delay or prevent complications of diabetes.
• Individualize MNT based on personal and cultural preferences,
health literacy and numeracy, access to healthful food choices,
willingness and ability to make behavioral changes, as well as
barriers to change.
• To maintain the pleasure of eating by providing positive messages
about food choices while limiting foods only when indicated by
scientific evidence.
• Focus on practical, day-to-day meal planning rather than on
individual macronutrients, micronutrients, or single foods.
22
Evert, A. B., Boucher, J. L., Cypress, M., Dunbar, S. A., Franz, M. J., Mayer-Davis, E. J., Neumiller, J. J., Nwankwo, R., Verdi, C. L., Urbanski,
P., & Yancy, W. S. (2014). Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care, 37(Supplement
1), S120-S143. https://doi.org/10.2337/dc14-S120
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Medical Nutrition Therapy - MDI
23
Healthy Eating
I.D.
Timing
Counting
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Fruit
Vegetables
Breads,
StarchesMeats/
Protein
Milk
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Carbohydrate Identification
25
Protein
Carbohydrates
Sugar
Fruits
Milks
Sweets
Starch
Breads
Starchy Veggie
Grains
Fat
Photo by Miguel Á. Padriñán, Pexels
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Carbohydrate Intake - Timing
• Carbohydrate with bolus insulin
– Non-carb snacking
– Non-carb beverages
• Separate “meals” by at least 4 hours to
avoid insulin stacking
26©2012 Mayo Foundation for Medical Education and Research. All rights reserved. “Used with permission of Mayo Foundation for Medical
Education & Research”
4 hours
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Carbohydrate Intake - Quantity
• Counting in choices (=15g)
• Counting in grams
• Estimation/Consistency with Plate Method
• Estimation of small/medium/large
27©2012 Mayo Foundation for Medical Education and Research. All rights reserved. “Used with permission of Mayo Foundation for Medical
Education & Research”
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Carbohydrate Intake - Goals
DM: Individualize Macronutrient Composition
The registered dietitian nutritionist (RDN), in collaboration with the adult with diabetes,
should individualize the macronutrient composition of the healthful eating plan within the
appropriate energy intake. Limited research regarding differing amounts of carbohydrate
(39% to 57% of energy) and fat (27% to 40% of energy), reported no significant effects
on A1C or insulin levels in adults with diabetes, independent of weight loss. Limited
research reports mixed results regarding the effects of the amount of protein (ranging
from 0.8g to 2.0g per kg per day) on fasting glucose levels and A1C.
Rating: Fair
Imperative
• Consider co-morbidities
28Academy of Nutrition and Dietetics Evidence Analysis Library Diabetes Type 1 and 2. Accessed 4 May 2018
https://www.andeal.org/topic.cfm?menu=5305&pcat=5488&cat=5470
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Insulin Dose Adjustment/
Pattern Management• American Diabetes Association
• Consider: blood glucose levels, pharmacodynamic profile of each
formulation
• Yale Diabetes Center• Rely SMBG for several days to 1–2 weeks
• Consider: diet, activity level, and stress
• In absence of severe hyper/hypoglycemia, adjust in 10–20% increments
• Mayo Clinic• Based on 3-day patterns
• Basal: adjust by 10% if BG +/- for >40mg/dL HS to pre-breakfast (-20% if
>80mg/dL drop
• Bolus: adjust preceding bolus +/-10% if BG outside of pre-prandial BG goal
range. (-20% if severe hypoglycemia)
29
Yale Diabetes Center. (2011). Diabetes Facts and Guidelines. Silvio E. Inzucchi, M.D. Available at:
https://medicine.yale.edu/intmed/drc/diabetescenter/living/50135_Yale%20National%20F_102165_284_13584_v1.pdf
American Diabetes Association (2018). Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2018.
Diabetes Care, 41(Supplement 1), S73-S85. Accessed April 03, 2018. https://doi.org/10.2337/dc18-S008.
Mayo Clinic Integrated Outpatient Adult Protocol: Multiple Daily Injection (MDI) Insulin Dose Adjustment, MC2222-160. Internal document.
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Real Life Challenges
– Using insulin to carbohydrate ratio (1:15)• Flexibility vs. responsibility
– How to snack• non-carb vs. >3-4 hours
– Alcohol• Risk of hypoglycemia but hyperglycemia possible too
– Exercise• Type of activity and timing with food matters
• Dose adjustment of bolus insulin vs. adjust food intake
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Beyond Vial & Syringe
• NovoPen Echo: • Half units dosing increments
• Memory: records dose, time since last injection
• https://www.novologpro.com/prescribing/insulin-pens/novopen-echo.html
• Insulin Delivery: V-Go• T2DM only
• Daily application
• U-100 rapid-acting insulin only
• Preset basal rate (20, 30, or 40u/24 hours)
• Bolus, 2u/click, up to 36u/day
• https://www.go-vgo.com/hcp
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Image used with permission from Valeritas
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Innovations in BG Monitoring
CGM: Libre• Factory calibration = no daily fingerstick calibrations
• Wear for 10 days
• Measure BG every minute, records readings q 15 min,
stores up to 8 hours of data
• https://www.myfreestyle.com/provider/freestyle-libre-product
32
Image used with permission of Abbott
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Resources
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Questions
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Pixabay
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Evaluation
Continuing Education Credits
MFLN Nutrition & Wellness is offering 1.0 CPEU for
today’s webinar.
Please complete the evaluation at:
https://vte.co1.qualtrics.com/jfe/form/SV_bI3QDkNDE7jYhH7
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Upcoming Event
Enhancing the U.S.
Army Performance
through Key
Nutrition Initiatives
• Tuesday June 19, 2018
• 11:00am - 12:00pm EDT
• learn.extension.org/events/3370
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militaryfamilies.extension.org/webinars
37This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family
Readiness Policy, U.S. Department of Defense under Award Number 2015-48770-24368.