CDCES Exam 2021 - Diabetes Medications & Other Important Info

Overcoming barriers

-confront the key mis-belief -offer pt's evidence-based hope message -frequent contact -paired glucose testing -ask pt "tell me 1 thing that is driving you crazy about your diabetes?" -discuss medication beliefs -diabetes vacation (give up taking care of themselves - give them a small goal they can accomplish to get back on track and restore morale) SMART goals (specific, measurable, attainable, realistic, timely)

"typical" basal insulin needs and fluctiations during a 24 hour period

-growth years: extended peak, evening and overnight -adolescent needs >> childhood needs -post-growth years: dawn phenomenon -senior needs << young adult needs Age 3-10 -12 am - 9 am = remains steady ~.65 unit/hr -9 am - 1 pm = decreases from .65 unit/hr to .45 unit/hr -1 pm - 12 am = increases from .45 unit/hr to .6 unit/hr Age 11-20 -12 am - 9 am = 1 unit/hr -9 am - 1 pm = decreases from 1 unit/hr to .75 unit/hr -1 pm - 12 am = rises from .75 unit/hr to .95 unit/hr Age 21-60 -12 am - 7 am = rises from .7 unit/hr to .8 unit/hr -7 am - 1 pm = decreases from .8 unit/hr to .55 unit per hr -1 pm - 12 am = rises from .55 unit/hr to .6 unit/hr Age > 60 -12 am - 7 am = rises from .4 unit/hr to .6 unit/hr - 7 am -4 pm = decreases from .6 unit/hr to .33 unit/hr -4pm - 12 am = steady and increases from .33 unit/hr to .36 unit per hr source: Diabetes Res & Clinic Prac, 69 (2005) 14-21

Ask people why they don't want to take insulin

-people have legitimate reasons for not wanting to start on insulin -give them space to share their story -help them sort out fact from myth 1) Barrier: Insulin will make me gain weight. Response: Yes, you may gain a few pounds, but that is a sign your body is healing. 2) Barrier: People who need insulin are really sick. Response: It only means your pancreas can't make enough, so you can help it by injecting insulin. 3) Barrier: Injecting insulin will hurt. Response: Most people are surprised that they barely feel the injections.

Step 4 and 5

Need to figure out what is the best oral medication, injectable and insulin combination?

Insulin

Needle phobias common Try pens, Auto Injectors, involve family Needles 31 gauge short or mini needles Use smallest barrel possible (ie 30 unit syringe) Use 1⁄2 unit increment pens / syringes Sites - Young children: legs, arm, buttocks School age can also use abdomen Consider insulin pumps

Alogliptin

Nesina Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Increases insulin release and decreases glucagon release when blood glucose levels are elevated

ADA treatment algorythm

Consider independently of baseline A1C or individualized A1C target -HF or CKD predominates: SGLT2i -Established ASCVD or indicator of high ASCVD risk: GLP1 RA or SGLT2i

Icosapent ethyl (vascepa)

FDA indications Adjunct to maximally tolerated statin therapy to reduce risk of MI, stroke, coronary revascularization and unstable angina in adult patients with TG >150 and established CVD or T2DM + CVD risk factors Adjunct to diet to reduce TG levels in adults with TG>500 Dose: 2 grams PO twice daily with food

Preventing Hypoglycemia

Nocturnal Lows If bedtime glucose <110, eat snack and decrease meds If increased daytime activity, may need extra hs snack Eval pre-dinner insulin/meds Other Monitor kidney function / wt loss Monitor BG trends Too much meds? Skipped /delayed meals? Plan ahead Alcohol precautions

Classifying HTN

Normal = <120/<80 Elevated = 120-129/<80 HTN stage 1 = 130-139 OR 80-89 HTN stage 2 = >140 OR >90

Resistant Hypertension

Not meeting BP targets on 3 classes of antihypertensive meds (including a diuretic) at optimal doses Consider mineralcorticoid receptor antagonist -Spironolactone (Adlactone®) 25-100mg daily -Eplerenone (Inspira®) 50-100mg daily Monitor serum creatinine, potassium

Empowerment Defined

"Helping people discover and develop their inherent capacity to be responsible for their own lives and gain mastery over their diabetes". Posits: Choices made by individuals (not HCPs) have greatest impact. Individuals are in control of their self- management The consequences of self-management decisions affect the individual most. It is their right and responsibility to be the primary decision makers.

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. Mask sure meter /strips are reliable

Transtheoretical Theory

"Readiness" Level determines the approach!" Individuals pass through similar stages as they prepare for change (eating better, decreasing drinking) Simplified version of the Stages of Change: Not ready -no intentions. Unsure: Ambivalent Ready: Committed, just needs to know HOW!

Disconnecting from Pump

**BG rises about 1 mg/dl a minute when disconnected Avoid extended disconnection since can lead to ketones and hyperglycemia Strategies -Short term disconnection < 1 hour, Bolus to replace missed basal insulin -Long term >1 hour and bolus missed basal insulin hourly -Protective caps usually not necessary ***With pump therapy, there is no background insulin on board, it's all rapid acting insulin

Dried Beans, Peas, and Lentils 15g Carb Servings

-Baked beans (1⁄3 cup) -Beans—black, garbanzo, kidney, navy, lima, pinto, white (cooked 1⁄2 cup) -Hummus (1⁄3 cup -Lentils, cooked (1⁄2 cup) -Peas—black-eyed, split, cooked (1⁄2 cup) -Refried beans (1⁄2 cup)

Starchy Vegetables 15 g Carb Servings

-Breadfruit (1⁄4 cup small cubes) -Corn/peas (1⁄2 cup) -Corn on the cob, large (1⁄2 cob) -Mixed vegetables with corn, peas, or pasta (1 cup) -Potato, baked (1 small or 1⁄4 large, 3 oz) -Potatoes, mashed (1⁄2 cup) -Pumpkin, cooked (1 cup small cubes) -Squash, acorn, butternut (1 cup) -Sweet potato (1⁄2 cup) -Yam (1⁄2 cup)

Basal Insulin Needs

-Dawn phenomena -Higher needs from 3am to 7am for adults -Kids from 12am to 7am -Basal rate can be adjusted to match sleep and work schedule Traveling - change clock in pump to match new time

Benefits of Exercise and Diabetes

-Increase muscle glucose uptake 5-fold -Glucose uptake remains elevated for 24 - 48 hours (depending on exercise duration) -Increases insulin sensitivity in muscle, fat, liver. -Reduce CV Risk factors (BP, cholesterol, A1c) -Maintain wt loss -Contribute to well-being -Muscle strength -Better physical mobility Exercises decreases: -sleep apnea -diabetic kidney disease -depression -sexual dysfunction -urinary incontinence -knee pain -need for medications -healthcare costs Encourage a short walk after meals Each minute of exercise lowers BG by 1 point No change in body weight but 48% loss in viseral fat Exercise is the best medicine. Structured exercise of 8 weeks duration, has been shown to lower A1c by and average of 0.66% in people with type 2, even without a significant change in BMI.

Men w/ DM, 2x risk of low testosterone levels

-Symptoms include low sex drive, ED, depression, lack of energy and vitality -Low T easily diagnosed and managed, only 10% of men currently treated Initial Screening: -Total testosterone: if < 300 ng/dl = hypogonadal -am testing preferred, repeat to confirm Treatment: determine cause, testosterone replacement therapy

Beta blockers

-Use in recurrent MI, heart failure -Side effects: depression, sexual dysfunction, exercise intolerance, sedation, dizziness -Monitor BP, lipids, heart rate, glucose -When stopping, taper dose gradually -Can elevate glucose and mask adrenergic symptoms of hypoglycemia (ex. tachycardia) Sweating will still occur (cholinergic mediated)

Insulin starting range calculation

0.3 units/kg =thin, elderly, impaired kidney function 0.5 units/kg 1 unit/kg = heavy, infection, steroids

CKD stages

1 = Kidney damage with normal GFR > 90 2 = GFR 60-89 3 = GFR 30-59 4 = GFR 15-29 5 = GFR < 15 (End Stage Renal Disease)

Heart Disease | Leading Cause of Disease in US Women

1 in every 5 female deaths. 299,578 deaths in 2017 Leading cause of death for African American & white women. Women more commonly describe nausea, tiredness and jaw pain, although some women may have the same symptoms as men.

Lixisenatide (Adlyxin) & Insulin Glargine (Lantus) = Soliquia 100/33 (iGlarLixi) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Combination 2) MOA = Combination of Long-acting Insulin & GLP-1 Receptor Agonist (GLP-1 RA) ***Long-acting Insulin - controls blood sugars between meals / snacks and while asleep ***GLP-1 Receptor Agonist (GLP-1 RA) -increases glucose dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon 3) Indication = Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes 4) Administration = Once daily within an hour of the first meal Soliqua 100/33 Solostar Pen = 100 units-Glargine/33 microgram-Lixisenatide = per ml Recommended starting dose: • 15 units if not meeting glucose target on 30 units basal insulin or GLP-1 RA • 30 units if not meeting glucose target on 30-60 units basal insulin or GLP-1 RA -Titrate dose up or down by 2-4 units every week to reach target. -Supplied in package of five single-use 3mL pens. 5) Side-Effects = nausea, vomiting, diarrhea, headache, decreased appetite, weight loss, injection site reactions (brusing, pain, irritation, itching, rash), hypoglycemia when combined with insulin or insulin secretagogue, increased heart rate, weight gain, constipation, indigestion, upset stomach, ab pain, GERD, bloating, gas , hypoglycemia 6) Contraindications = Risk of thyroid C-cell tumors, avoid use of (Bydureon, Ozempic, Trulicity, Victoza) in people with personal or family history of medullary thyroid carcinoma, ↑ risk of pancreatitis and acute gallbladder disease, Not recommended in people with severe GI disease (e.g. gastroparesis), PostMarketing reports of acute renal failure and worsening of chronic renal failure, Contraindicated with hypoglycemia 7) Clinical Pearls = Available as multidose pen Once opened, expires in 28 days

Aspart Protamine and aspart (Novolog 70/30)

1) Class = Premixed Combinations 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM2 4) Administration = 5-15 minutes before breakfast and dinner 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = Expiration upon opening is 28 days. 8) Onset is 15-30 minutes 9) Peak Effect is 1-4 hours 10) Duration of Action is 18-24 hours

Dulaglutide (Trulicity) Exenatide Immediate Release (Byetta) Exenatide Extended Release (Bydureon; Bydureon BCise) Liraglutide (Victoza) Lixisenatide (Adlyxin) Semaglutide (Ozempic) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Non-insulin injectables 2) MOA = GLP-1 Receptor Agonist (GLP-1 RA), -glutides, -natides -increases glucose dependent insulin secretion -slows gastric emptying and digestion -promotes satiety -suppresses glucagon -decreases appetite 3) Indication = Adjunct to diet and exercise to improve glycemic control in adults with DM2, Sometimes for DM1, experiencing high post-meal blood sugars and frequent hunger 4) Administration = Varies from Weekly, to before meal to daily 5) Side-Effects = nausea, vomiting, diarrhea, headache, decreased appetite, weight loss, injection site reactions (brusing, pain, irritation, itching, rash), hypoglycemia when combined with insulin or insulin secretagogue, increased heart rate, Subcutaneous nodules may occur with Bydureon 6) Contraindications = Risk of thyroid C-cell tumors, avoid use of [(Exenatude (Bydureon), Semaglutide (Ozempic), Dulaglutide (Trulicity), Liraglutide (Victoza)] in people with personal or family history of medullary thyroid carcinoma, ↑ risk of pancreatitis and acute gallbladder disease, Not recommended in people with severe GI disease (e.g. gastroparesis), PostMarketing reports of acute renal failure and worsening of chronic renal failure 7) Clinical Pearls = NAUSEA SUBSIDES OVER TIME Weight Loss of 1.6 to 6 kg (no other diabetes medication matches their ability to facilitate weight loss) Liraglutide is also available as a 3.0mg dose approved for weightloss as Saxenda. Liraglutide (Victoza), Dulaglutide (Trulicity), Semaglutide (Ozempic): ↓ risk of CV events (CV death, non-fatal MI, non-fatal stroke) in DM2 pt's with CVD Keep refrigerated until first use. Renally Excreted. Available as multidose pen: Byetta, Victoza, Ozemptic, Adlyxin Ozempic comes with pen needles; the other multidose pens require separate prescription for pen needles Available as 1-time disposable pen: Bydureon, Trulicity

70/30 insulin preparation

1) gently roll the pen between hands 10 times to mix 2) move the pen up and down (invert) 10 times. Mixing by rolling and inverting the Pen is important to make sure you get the right dose. 3) Prime pens - give 2 unit "air shot" to make sure pen and needle is functional 4) after injecting insulin, count to 5 before pulling needle out 5) use new needle with each injection

Onboarding a New Patient

1. Pre-pump group class 2. Individual CDCES visit(s) for advanced carb counting as needed 3. Pump start (2-3 hour individual CDCES visit) • Pt sends BGs regularly for rate adjustments 4. Advanced pumping follow-up visit with CDCES in 2-4 weeks 5. MD/NP follow-up in 4-6 weeks Based on Cleveland Clinic insulin pump program

7 Steps to Solve Type 1 Glucose Mysteries

1. Toolkit in working order 2. Gather 3 days of 7 point data 3. Check basal insulin (look for drifts) 4. Insulin to carb ratio need adjustment 5. Insulin timing 6. Insulin correction ratio need adjustment 7. Exercise plan Bonus - Self-care including sleep, positive self talk, healthy eating, and meaningful connections

7 Steps to Solve Type 2 Glucose Mysteries

1. Toolkit in working order 2. Gather 3 days of data (A1c) 3. Meal plan 4. Oral and or injectable medications right ones at optimal dose? 5. Insulin basal insulin - fasting glucose on target? Bolus insulin - before next meal glucose on target Correction insulin needed? 6. Insulin timing 7. Exercise plan Bonus - Self-care including sleep, positive self talk, healthy eating, and meaningful connections

Carb to Insulin Ratio > 450-500 / Total Daily Dose

500 Rule - Humalog and Novolog • Divide 500 by total daily insulin dose. • Equals Gms of carb covered by one unit • Example: 40 total units /day. The equation is: 500 / 40 (total dose) = 12.5 • 1 unit insulin covers 13 grams carb 450 Rule for Regular Insulin • Divide 450 by total daily insulin dose. • Equals Gms of carb covered by one unit • Example: Takes 40 units daily. The equation is: 450 divided by 40 (total dose) = 11.25 • 1 unit covers 11 grams of carb

Case Study:

70 yr old, avid walker BMI 24, Weighs 60kg, GFR 58 A1c - 10.1%, BG 300s for past weeks 30 units Lantus Pen (60kg x .5 = 30units max dose) Oral Meds: Metformin 2000 mg daily What medication changes? Keep metformin Add on changes? Add GLP-1 RA or basal insulin/GLP combo (iGlarlixi or IDegLira) Add 1 bolus injection at largest meal Switch to 70/30 30 x 0.8 = 24 units total (16 units am and 8 units pm) Consider adding SGLT2 to preserve kidney function

Case Study

70 yr old, weighs 100kg History of CABG, tobacco A1c - 11.3%, BG 400-500 for past weeks Insulin - 100+ units Lantus at hs (solostar) Oral Meds: Metformin, canagliflozin (Invokana) Pt can't afford Lantus insulin pen or canagliflozin (Invokana) - what other option? Cheapest insulin: Regular & NPH Basal insulin max dose = 100kg * 0.5 units/kg = 50 units max insulin daily dose What can we do next to improve his blood sugars? 1) Consider GLP-1 RA 2) add 4 units bolus insulin to largest meal (or 10% of basal) 3) Switch him to 70/30 insulin -total previous dose 100 units (with poor BG level so conversion is 100%) -2/3 in am = 65 units (43 NPH, 22 regular) -1/3 predinner - 35 units pm (23 NPH / 12 regular) what will imform you how you proceed? Insurance coverage His willingness to stick to a complex regimen His ability to self-monitor His social support and connection to his medical team

Create a Toolkit

A safe place to put injectables alcohol wipes insulin vials syringes insulin pens insulin pump supplies meter strips log book carb snacks

NPH and Regular 70/30

Novolin 70/30 Premixed Insulin Combinations Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Abc's of diabetes

A1C and aspirin A1C less than 7% for most (avg 2-3 month BG) Pre-meal BG 80-130 Post meal BG <180 Aspirin: previous CVD event or ages 50- 70 with CVD risk factors Blood Pressure < 140/90 or 130/80 based on risk assessment Cholesterol -Eval if statin therapy indicated

decision tree for medications for new-onset DM in youth with overweight or obesity with clinical suspicion of DM2 Initiate lifestyle management and diabetes education

A1c <8.5% - no acidosis or ketosis -Metformin - titrate up to 2,000mg per day as tolerated A1c >8.5% - no acidosis or without ketosis -Metformin - titrate up to 2,000mg per day as tolerated -Basal insulin start at 0.5 units/kg/day and titrate every 2-3 days based on SMBG Acidosis and/or DKA and/or HHNK -manage DKA or HHNK -IV insulin until acidosis resolves then subcutaneous as for DM1 until antibodies are known Test for pancreatic autoantibodies if negative -continue or start metformin -if on insulin titrate guided by SMBG values - A1c goals not met = continue metformin, consider adding liraglutide -titrate/initiate insulin therapy - if using basal insulin only and glycemic target not met with escalating doses then add prandial insulin If positive -continue or initiate MDI insulin or pump therapy as for DM1 -discontinue metformin

Back to AL

AL is now taking insulin glargine 16 units daily and he is taking insulin aspart 4 units at meals. He asks to switch to insulin glargine U300 because he feels insulin glargine wears off too early. Current A1C = 7.2%. What is the best recommendation? Insulin glargine U300 16 units daily

ACE inhibitors / ARB adverse effects

Adverse effects -Dry cough with ACEI -Caused by inhibition of bradykinin breakdown -Hyperkalemia - Angioedema (< 1%) •Occurs 2-4x more frequently in African Americans -Bump in SCr •Up to 30% is acceptable -Orthostatic hypotension (initial dose) - Skin rash (captopril) Contraindications -Pregnancy - Bilateral renal artery stenosis

Neuropathy Risk Factors

Age Hypertension Hyperglycemia Elevated LDL Smoking Overweight Excess alcohol Nutrition (eat lots of omega-3 fatty acids to prevent DN) Lack of exercise

Note about Concentrated Insulins

All concentrated insulin pens and the U-500 syringe automatically deliver correct dose (in less volume). No conversion, calculation or adjustments required. For example, if order reads 30 units, dial the concentrated pen to 30 units or draw up 30 units on the U-500 syringe. Important - never withdraw concentrated insulin from a pen using a syringe.

Bile Acid Sequestrants

Also called bile acid-binding agents, cause the intestine to get rid of more cholesterol. Cholestyramine (Questran®, Questran® Light, Prevalite®, Locholest®, Locholest® Light) Colestipol (Colestid®) Colesevelam Hcl (WelChol®)

Snack Foods 15 g Carb Servings

Animal crackers (8 crackers) Gingersnaps (3 cookies) Graham crackers (3 squares) Popped popcorn (3 cups) Pretzels (3⁄4 oz) Rice cakes (2 cakes) Snack chips (15-20 chips) Vanilla wafers (5 wafers)

Glulisine

Apidra Rapid Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Children with Celiac Disease - DM Type 1

Asymptomatic children with positive antibodies Consider referral to gastroenterologist for evaluation with possible endoscopy and biopsy for confirmation of celiac disease Children with biopsy-confirmed celiac disease Place on a gluten-free diet Consult with a dietitian experienced in managing both diabetes and celiac disease

Saxagliptin

Onglyza Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Increases insulin release and decreases glucagon release when blood glucose levels are elevated

Treatment options for overweight and obesity in type 2 diabetes

BMI 25-26.9 (23-24.9 in Asians) -diet, physical activity, and behavioral therapy BMI 27-29.9 (25-27.4 in Asians) -diet, physical activity, and behavioral therapy -pharmacotherapy BMI >30 (>27.5 in Asians) -diet, physical activity, and behavioral therapy -pharmacotherapy -metabolic surgery Consider using diabetes medications that contribute to weight loss, including GLP-1 RAs and SGLT-2 inhibitors.

Adjusting Bolus and Correction Doses Carbohydrate-to-Insulin Ratio

Based on four questions before meals: 1. How much carbohydrate am I going to eat? 2. What is my insulin dose for this amount of carbohydrate? 3. Should I lower the dose because I plan to be very active or have recently been active? (1 unit = 30 minutes of exercise = drops blood sugar by 30-50) 4. Should I lower dose because my blood sugar is low? (decrease 1 unit if low)

Written Plan for Pump Use

Blood glucose checks or CGM Checks Record keeping of BG, Carbs, insulin, activity and other issues Site-change guidelines Restart injections if needed When to check ketones and action to take Hypoglycemia and Hyperglycemia treatment guidelines

Common Pump Features

Bolus calculator Temporary basal or temp target Insulin-on-board/active insulin feature Multiple basal patterns Small dose increments Integration with CGM Designed to work with U100 insulin 4-year warranty/contract

Visual Inspection/Palpation

Breaks in the skin Erythema Trauma Pallor on elevation Dependent rubor Changes in the size of shape of the foot Nail deformities Extensive callus Tinea pedis (skin or nails) Pitting edema

Semaglutide

Ozempic Noninsulin Injectables Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon

PCSK9 inhibitors

PCSK9 inhibitors are powerful LDL-lowering drugs. They bind to and inactivate a protein on cells found in the liver to lower LDL (bad) cholesterol. alirocumab evolocumab

HTN stages

Classification > Systolic > Diastolic Normal = less than 120 AND less than 80 Elevated = 120-129 AND less than 80 HTN Stage 1 = 130-139 OR 80-89 HTN Stage 2 = >140+ OR >90+ Hypertensive Crisis = >180+ AND/OR >120+ *Consult with doctor immediately

Sick Day Patient Guidelines

Continue to take diabetes medication, may need to adjust dose down or up* Test glucose at least every 4 hrs Drink plenty of water and sugary liquids Rest Contact physician Plan ahead Check urine ketones, if BG >240 & ill *If at risk of dehydration, hold metformin to prevent lactic acidosis Reasons to call MD: Vomiting more than once Diarrhea > than 5x's or for > 24 hrs Difficulty breathing Blood glucose > than 300 mg/dl on 2 consecutive readings Temperature > 101 F. Positive ketones in urine. Call doctor if not better in 24 hours

Patient with insulin pump admitted to hospital

Patient with insulin pump admitted to hospital Critically ill = transition to IV insulin infusion Undergoing surgical procedure -if longer than 2 hours = transition to IV insulin infusion -if short procedure (<2 hours) = continue insulin pump Noncritically ill -able to operate insulin pump = continue insulin pump -not able to operate insulin pump = transition to basal-bolus regimen Changes to pump therapy with imaging studies X-ray/CT = pump should be covered by lead apron MRI = pump and metal infusion set should be removed Ultrasound = no need to remove pump, but transducer should not be pointed directly at the pump Cardiac catheterization = pump should be covered by lead apron colonoscopy/EGD = pump can remain in palce laser surgery = pump can remain in place Diabetes Care 2018;41:1579-1589

Patient with insulin pump admitted to hospital

Patient with insulin pump admitted to hospital Critically ill = transition to IV insulin infusion Undergoing surgical procedure -if longer than 2 hours = transition to IV insulin infusion -if short procedure (<2 hours) = continue insulin pump Noncritically ill -able to operate insulin pump = continue insulin pump -not able to operate insulin pump = transition to basal-bolus regimen Changes to pump therapy with imaging studies X-ray/CT = pump should be covered by lead apron MRI = pump and metal infusion set should be removed Ultrasound = no need to remove pump, but transducer should not be pointed directly at the pump Cardiac catheterization = pump should be covered by lead apron colonoscopy/EGD = pump can remain in palce laster surgery = pump can remain in palce Diabetes Care 2018;41:1579-1589

Correction Bolus Scale

Correction Bolus Rapid/Fast Acting Insulin (1 unit for every 50 mg/dl greater than 150) less than 70 = subtract 1 unit 70-150 = 0 units 151-200 = 1 unit 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units 351-400 = 5 units

Correction Bolus

Correction Bolus = this is a separate amount of insulin to cover CURRENT levels of blood sugars at meals SEPARATE from meal carbs blood sugars in mg/dl = insulin dose 70 or less = Treat for Hypo, Hold Dose 71-150 = 0 units 151-200 = 1 unit 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units 351-500 = 5 units

DiaBulimia

People with diabetes give themselves less insulin than needed to lose weight Tends to start in adolescence, more likely to occur in women than men. Signs: unexplainable spikes, A1c, weight loss, lack of marks from fingerpricks, lack of prescription refills for diabetes meds, records that don't match A1c. Treatment - Mental health specialist and team

Already on insulin at home? Dosing

Person with Type 2 treated with insulin prior to hospital admission Review total daily insulin dose at home: Reduce dose by 20% to 25% to prevent hypoglycemia, particularly in those with poor or uncertain caloric intake.

IV insulin DKA treatment

DKA start IV at 0.05 - 0.1 units/kg/hr Example, pt weighs 100 kg 100 kg x 0.05 - 0.1 = 5-10 units insulin per hour Blood sugar checks hourly to adjust as needed (see algorithm)

Comparison of DM1, DM2, LADA

DM1, DM2, LADA excess weight: x, xxx, x insulin dependence: xxx, 30%, 6 months insulin resistance: 0, xxx, x respond to oral agents: 0, xxx, x ketosis: xxx, 0, xx antibodies present: xxx, 0, xx typical age of onset: teens, adult, adult

Hormone Response -Type 2

Decreased secretion of endogenous insulin Increased insulin sensitivity Increased glucose disposal

Glucagon Emergency Kit 1) description 2) supplied 3) dosage range for adults / pediatrics 4) Age / Route / Storage

Description: Injection requires mixing glucagon powder Supplied: 1 mg/ 1 ml vial + syringe DOSE RANGE: Adult: 1 mg Peds/Age Wt Dosing: 0.03 mg/kg or <6 years or <25 kg = 0.5 mg >6 years or >25 kg = 1 mg Age / Route / Storage: All ages approved. SubQ or IM administration Expires in 2 years at room temperature

Peripheral Arterial Disease Intermittent Claudication

Physical Exam - Skin Pale or blue, purple Dependent rubor, blanching when elevated Cool to touch, loss of hair, nonhealing wounds, gangrenous Diminished pulses Treatment = Protect feet Avoid constriction, increase walking, stop smoking, get ABI, medications and/or surgery Intermittent claudication: a typical symptom of PAD defined as walking induced pain in one or both legs that does not go away with continued walking and is relieved only by rest.

Dosing Strategies u-500

Dosing - take total daily needs and split into 2-3 doses -2 doses: 60% am / 40% pm or -3 doses: 40/30/30 or 40/40/20 No basal insulin needed, because U-500 has bolus and basal action "intermediate insulin" Needs careful monitoring/ education Example - patient on 240 units of insulin a day 140 units am / 100 units pm (2 doses) 100 / 70 / 70 or 100 / 100/ 40

Retinopathy Risk Factors

Duration of diabetes, age at diagnosis, race other genetic factors Glycemic control, hypertension, smoking, hyperlipidemia, proteinuria and renal disease

Hyperglycemia and Fetal Risk

During 2nd & 3rd trimester, insulin resistance increases risk of hyperglycemia Maternal insulin does not cross the placenta unless it is bound to IgG antibody, which carries it through the placenta or insulin is forced through the placenta by high perfusion. Diabetic fetopathy is thought to be the result of fetal hyperinsulinemia. Fetus exposed to maternal glucose but not maternal insulin. Fetus makes insulin. Insulin stimulates fetal growth, increase in adipose tissue

Hypoglycemia Risk Increases With

During exercise Immediately after exercise Post exercise late onset hypo More often in type 1 More often at night Moderate to high intensity exercise > 30 min 4 to 15 hours following an exercise session

HHS Clinical Signs - Days or Weeks

Polydipsia Polyuria Weakness Weight loss Hypothermia Hypotension Tachycardia Altered Sensorium

Signs of Diabetes

Polyuria Polydipsia Polyphagia Weight loss Fatigue Skin and other infections Blurry vision Dehydration Fuel Depletion Loss of body tissue poor energy utilization hyperglycemia increases incidence of infection osmotic changes (losing a lot of fluids through glucose-concentrated urine)

Facilitating Behavior Change and Well- Being to Improve Health Outcomes

Education - Setting Up Successful Diabetes Ed Program - Online University Level 2 Nutrition Physical Activity Smoking Cessation Psychosocial Care -high levels of diabetes distress significantly impact medication-taking behaviors and are linked to high A1c, lower self-efficacy, and poorer dietary and exercise behaviors -address distress -mindful self-compassion is important -counseling and DSME can help

BG Running High?

Possible Causes Glucose Toxic Infection Started on steroids Physical stress Insulin dose too low

Repaglinide

Prandin Meglitinides Stimulates the pancreas to release insulin from pancreatic beta cells

Dapagliflozin

Farxiga Sodium-Glucose CoTransporter-2 (SGLT-2) Inhibits sodium-glucose cotransporter 2 (SGLT2) in the proximal convoluted tubules of the kidney, reducing glucose reabsorption, and increasing urinary glucose excretion

Dairy 12-15 g Carb Servings

Fat-free or low-fat milk, soy or cow's (1 cup) Fat-free plain yogurt (2⁄3 cup) Fat-free, artificially sweetened flavored yogurt (2⁄3 cup)

Fibrates

Fibrates are especially good for lowering triglyceride (blood fat) levels and have a mild LDL-lowering action. Gemfibrozil (Lopid®) Fenofibrate (Antara®, Lofibra®, Tricor®, and Triglide™) Clofibrate (Atromid-S)

cholesterol absorption inhibitors

Prevents cholesterol from being absorbed in the intestine. It's the most commonly used non-statin agent. Ezetimibe

Postnatal Health: Maternal Behavior

For children: Breastfeeding decreases risk type 1 and type 2 and excess weight For mom Breastfeeding decreases diabetes risk by 50%. Plus breastfeeding decreases blood pressure, risk of breast cancer and helps with weight management

SubQ DKA Treatment

For mild and moderate DKA, some hospitals are experimenting with SubQ DKA treatment to reduce staff exposure. SubQ DKA Protocol Example-Umpierrez et al 2017 Give IV fluids, (check lytes first eval K+) Give 0.2 to 0.3 units/kg bolus* initially Then 0.1 to 0.2 units/kg bolus every 2 hours *Rapid acting bolus insulins; lispro or aspart Example: Pt weighs 100 kg 100kg x 0.2 - 0.3 20 to 30 units bolus insulin initial dose Then: 100 kg x 0.1 - 0.2 = 10 to 20 units bolus every 1-2 hours until blood glucose < 250. When BG < 250, reduce insulin dose by half and continue until ketone negative

Glipizide

Glucotrol Sulfonylureas Increases insulin secretion from pancreatic beta cells

Children Type 2 Clinical Presentation

Glycosuria without ketonuria But 33% have ketonuria ~6% present in DKA To make dx, assess antibodies prn May need insulin during acute phase Mild thirst, increased urination, little or no wt loss At onset, may have retinopathy, microalbuminuria, hypertension, hyperlipidemia

Spaghetti Graph

Graph with lines showing differing blood sugars

Advanced Insulin Pump Features

Prolonged bolus for Gastroparesis, amylin, GLP-1 Receptor Agonists Advanced Basal Features Temporary basal rates Secondary, tertiary programs Custom alerts examples A1c of 13% - Alarm at 70 A1c of 8% - Alarm 70 - 300 A1c of 7 % - Alarm 70-250 Data downloads

Medications associated with hyperglycemia

Protease Inhibitors - For HIV treatment Fluoroquinolone - Antibiotics such as gatifloxacin and levofloxacin Corticosteroids (increased insulin resistance - pancreatic stress test) Thiazide Diuretics Calcineurin inhibitors - (anti-rejection meds cyclosporine, sirolimus, tacrolimus) Beta-blockers (Atenolol, Metoprolol, Propanolol)

Transition from Insulin Drip to Injections

Protocol helpful Give sub q insulin 2-4 hours before stopping drip Can determine insulin needs based on body weight and Insulin drip daily infusion times 60-80% for basal dose example: Weight based example: pt weighs 100kg 100 * 0.5 = 50 units 50/2 = 25 basal plus 8 units bolus each meal OR insulin drip example: insulin drip 5 units * 24 hours = 100 units * 0.6 = 60 units basal plus correction

Pumpers Responsibility in Hospital

Provide own pump (and sensor) supplies Change pump reservoirs and infusion sets Provide staff with SMBG and insulin doses Notify staff of adjustments to standard doses Respond to alarms

JR BG log

Pt on Metformin, Glargine 50 Type 2, 90kg - A1c 9.6% Breakfast, Lunch, Dinner, HS Week 1: 130s (5 unit Regular), 190, 160, 180 (50 unit glargine) Week 2: 120s (6 unit regular), 170, 160, 170 (50 unit glargine) Week 3: 100s (7 units regular), 150, 160, 170s (50 unit glargine) week 4: 80s (8 unit regular), 130s, 160s, 160s (40 unit glargine)

Keeping connected - Pump Users need to contact clinical staff if:

Pump Users need to contact clinical staff if: Severe or repeated hypo Ketosis Signs of infection Call pump company if technical difficulties See pumper in 1-2 weeks, download device, troubleshooting At 3-4 weeks review more advanced features

What are the high and moderate intensity statins?

High intensity statins (lowers LDL 50%): -atorvastatin (Lipitor) 40‐80mg -rosuvastatin (Crestor) 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) 1‐4mg

insulin efficacy

How is the effectiveness of bolus insulin determined? -2 hour post meal (if you can get it) Target < 180 -Before next meal blood glucose Target 80-130 How is the effectiveness of basal insulin determined? -Fasting blood glucose -Target 80-130

What about insulin on board (IOB)?

How much "insulin on board" IOB to prevent stacking and hypoglycemia Typical active insulin duration is 3-5 hours for pump which uses rapid acting insulin) -average about 4 hours ***Action time shorter in leaner, young, active individuals in hot climates ***Action time is longer, 6-8 hours, for those with renal disease or using regular insulin Careful monitoring or CGM to eval if bolus rates set correctly Subtract insulin on board from insulin to carb ratio AND correction insulin for premeal blood sugar

Lispro U-200

Humalog Rapid Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Humalog Humalog KwikPen U-200 200 units insulin/mL

Humalog Humalog KwikPen U-200 200 units insulin/mL. Lispro (Humalog) Bolus 3 mL pen holds 600 units. Max dose 60 units. Once opened good for 28 days.

Lispro Protamine and Lispro 50/50

Humalog Mix 50/50 Premixed Insulin Combinations Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Lispro U-100

Humalog, Admelog Rapid Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

NPH and Regular 70/30

Humulin 70/30 Premixed Insulin Combinations Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Humulin Regular U-500

Humulin Regular U-500 Regular Bolus / Basal 500 units insulin/ml KwikPen or Vial Considerations: Indicated for those taking 200+ units daily 3 mL pen holds 1,500 units. Max dose 300 units. Once opened, good for 28 days. ---------------------- 20 mL vial holds 10,000 units. (500 units/ml *20) Max dose 250 units using U-500 syringe. Once opened, good for 40 days.

What Happens with a Bent Cannula?

Hyperglycemia

Hyperglycemia and Exercise

Hyperglycemia can occur before, during, and after physical activity insulin deficiency can lead to worsening hyperglycemia with exercise and ketosis risk. Postpone intense activity if glucose ≥350 mg/dL and moderate to large urine ketones, and/or β-hydroxybutyrate (B-OHB) >1.5 mmol/L. Caution may be needed when B-OHB levels are ≥0.6 mmol/L

Nephropathy

Hyperglycemia causes renal hyperfiltration and glomerular capillary hyperperfusion. Causes functional and structural damage to glomeruli, increasing permeability, proteinuria, mesangial expansion and sclerosis... destroys nephrons Due to insufficient insulin, glycosylation, increased growth hormone, glucagon, and vasoactive hormones. Keep Kidneys Healthy To reduce the risk or slow the progression of nephropathy Optimize glucose control (A) Optimize blood pressure control (A)

Neurocognitive function

Hyperglycemia is associated with cognitive function decline Persistent hypo and hyperglycemia can double risk of cognitive dysfunction and dementia Longer duration of diabetes worsens cognitive function and may lead to vascular dementia and alzheimer's disease -disrupted gut bacteria linked with dementia development Diabetes increases risk of incident depression by 27% Perform annual cognition screen Treatment: Refer to specialist for assessment Achieve optimal BG control Pharmacist to evaluate drug safety and potential drug interactions Keep physically active

Hyperglycemic - what's the big deal?

Hyperglycemia is associated with increased morbidity and mortality in hospital settings. Acute Myocardial Infarction Stroke Cardiac Surgery Infection Longer lengths of stay

Caregiver education about pumps

Hypo detection /treatment Hyperglycemia trouble shooting Basic bolus procedure Cartridge set change process Understand what alarms mean History recall

When to Contact Provider - Hypo/Hyper Guidelines:

Hypoglycemia indicates TOO MUCH Diabetes Medication Have plan in case of low blood glucose ahead of time For People with diabetes - When to contact Health Care Team BG < 70 - Eat and call provider immediately If BG 70 - 100 - Eat and call provider within 24 hours BG > 250 within 24 hr period BG > 300 on 2 consecutive days, unusually high BG If sick, risk of dehydration and/or hyperglycemic crises

Treatment of Severe Hypoglycemia

If can swallow w/out risk of aspiration, try gel, honey, etc. inside cheek If unable to swallow, D50 IV or Glucagon Glucagon injection - teach support person -Dosing: Adults 1mg Children <20kg 0.5mg -Glycemic effect 20 - 30mg, short lived Must intake carb as soon as able Need prescription, check exp. date

Steps to Prevent Hypoglycemia

If fasting BG < 100, decrease basal insulin If renal failure, conservative insulin dosing required Anticipate events that increase hypoglycemia risk NPO for surgery, decreasing steroid dose, improving infection, recovering after cardiac event Strive to admin the least amount of insulin necessary to reach glycemic targets N/V or not consistent eater? Give bolus insulin after meals Only use basal plus correction

Pregnancy and Hypertension

If pregnant with diabetes and chronic hypertension Blood pressure target of 110-135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension and minimizing impaired fetal growth. Stop potentially harmful medications in prep for pregnancy -(stop ACE inhibitors, angiotensin receptor blockers, statins) at conception and avoid in sexually active women of childbearing age who are not using reliable contraception).

Contraindications to Insulin Pumps in the Hospital

Impaired level of consciousness (except during short-term anesthesia) Patient's inability to correctly demonstrate appropriate pump settings Critical illness requiring intensive care Psychiatric illness that interferes with a patient's ability to self-manage diabetes Diabetic ketoacidosis and hyperosmolar hyperglycemic state Refusal or unwillingness to participate in self-care Lack of pump supplies Lack of trained health care providers, diabetes educators, or diabetes specialist Patient at risk for suicide Umpierrez G et al. Diabetes Care 2018 Aug; 41(8): 1579-1589

Example Correction Bolus for Steroids

Rapid/Fast Acting Insulin (1 unit:50 mg/dl>150) 30mg prednisone vs 45 mg prednisone: <70 = -1 unit, -1 unit 70-150 = 0 units, 0 units 151-200 = 1 units, 2 units 201-250 = 2 units, 3 units 251-300 = 3 units, 4 units 301-350 = 4 units, 5 units 351-400 = 5 units, 6 units

Prevent or Delay Type 2 Diabetes (screen yearly for diabetes) What did the Diabetes Prevention Program demonstrate?

Reduced risk by 58% for those with prediabetes moving to diabetes Trial characteristics: Lost 7% BW (1-2 lbs per week) - included food diary, weekly weighing, coaching, high fiber, low fat, avoid SSBs, reduce total kcal intake, 150 minutes exercise per week **Exercise without weight loss reduced risk of moving from prediabetes to diabetes by 44% 16 group lifestyle sessions in 24 weeks Then monthly for next 6 months

Diabetes Kidney Disease (DKD) Treatment

Refer for evaluation for renal replacement treatment if eGFR <30 Promptly refer to a physician experienced in the care of kidney disease for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease.

What is Retinopathy?

Retina - layer of nerve tissue in back of eye responsible for processing images and light Damage to the microvascular layer that nourishes the retina Leads to leakage of blood components through vessel walls and creation of unstable blood vessels hypoxia Disturbance in nerve layer = visual symptoms LOSS OF CENTRAL VISION

Long Term Effects of GDM on Adult

Risk for excess weight Visceral Adiposity Hyperinsulinemia Insulin Resistance Type 2 Cardiovascular Disease Metabolic Syndrome

Adjusting Robs Bolus Insulin With Ratios

Rob plans to eat 70 gms of carbohydrate, BG before breakfast 180. Carb coverage: 70gms / 13 = 5.4 units insulin Correction Scale - 180-130 = 50 over target - 1 unit 5 units bolus insulin to cover carbs in meal 1 units bolus insulin to correct to target Total adjusted dose: 6 units bolus insulin

Semaglutide

Rybelsus Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) Increases glucose-dependent insulin secretion, slows gastric emptying, promotes satiety, suppresses glucagon

Infusion Sets

Infusion sets are usually Teflon -Available in different sizes (ex. 9mm vs 6mm) -Silhouette (angled) may be better for kids/thinner/very active people -Steel infusion sets a good option for people with frequent site occlusions Insert at least 1 inch from CGM site - Auto-injectors vs. manually injecting Site selection/rotation Longer tubing options -Good if connected on leg, arm or wearing pump further from site Caution with kids/babies/pets-pouches available to hide pump When changing out infusion set, check glucose or CGM 1-2 hours after to ensure successful insulin delivery -Don't change right before bed

Mr. K BG Levels WAY above target Transferred to ICU for Insulin Drip

Insulin Drip • 100 units insulin in 100 cc NS Bag 1 cc = 1unit of insulin Start with 0.1 units/kg/hour 100kg BW x 0.1 = 10 units an hour

How do we know someone has DM1 vs DM2?

Insulin-dependent diabetes Type 1 -positive anti-bodies GAD, ICA, IAA and others Younger people develop quickly Older people take longer to develop Body weight and presentation other autoimmune conditions -celiac disease, -vitiligo - skin pigment loss/discoloration -graves disease (hyperthyroidism) -Hashimoto thyroiditis (hypothyroidism) -autoimmune hepatitis -myasthenia gravis (muscle weakness) -pernicious anemia (B12 deficiency due to lack of intrinsic factor in stomach -dermatomyositis distinctive skin rash, muscle weakness, and inflammatory myopathy

Psychosocial Assessment - Screen for:

Integrate psychosocial care using a collaborative, person-centered approach for all people with diabetes to optimize health outcomes and health-related quality of life Assess for: -distress -depression -anxiety -disordered eating -cognitive capacities Use validated tools Screen after initial visit and periodically If over 65, screen for depression & cognitive impairment

Humulin N

Intermediate Acting Neutral Protamine Hagedorn (NPH) Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Step 4 - We NEED A CARB PLAN

Is the carb to insulin ratio correct? -Look at 2 hour post meal glucose, On target?, Above or below target? -Evaluate carb counting accuracy -Are math calculations correct?

Step 6. Insulin Correction Ratio

Is the correction insulin on target? Rob is "winging it" After adding correction, do glucose levels: -Go below target? -Go above target? -If adding to carb coverage, first make sure carb count was correct

JR, 90kg - A1c 10.6% | Metformin, Glyburide- Max dose. Glargine intensified

JR, 90kg - A1c 10.6% | Metformin, Glyburide- Max dose. Glargine intensified Month 1: Breakfast 190s, HS: 298, 10 units Glargine Month 2: Breakfast: 180s, HS: 233, 25 units Glargine Month 3: Breakfast: 160s, HS: 216, 35 units glargine Month 4: Breafkast: 120s lunch: 278 dinner: 184 HS: 209, 50 units glargine

Sitagliptin

Januvia Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Increases insulin release and decreases glucagon release when blood glucose levels are elevated

Empagliflozin

Jardiance Sodium-Glucose CoTransporter-2 (SGLT-2) Inhibits sodium-glucose cotransporter 2 (SGLT2) in the proximal convoluted tubules of the kidney, reducing glucose reabsorption, and increasing urinary glucose excretion

DKA Presentation and Action

Labs -glucose 250+ -NA - low to high -K+ - moves into vascular space -HCT and Hgb increases with dehydration -BUN/Creatinine increases -WBC increases (no infections) -pH low to normal -anion gap 12+ -ABGs - pH <7.3 -Beta-hydroxybutyrate levels (3 mmol/L +) -ketone levels - positive in blood and urine -Bicarb - 18 or less -amylase and lipase -urine and blood cultures (if infection suspected) -ECG if warranted

Personal CGM Options

Libre 2 Guardian Connect or Guardian 3 Libre 14 day G6 Eversense

Lyumjev KwikPen U-200

Lispro (Lyumjev) Bolus 3 mL pen holds 600 units. Max dose 60 units. Once opened good for 28 days.

ADA or AADE Recognized Program DSME & Medical Nutrition Therapy - What Medicare Covers

MNT -3 hours initial benefit in first calendar year -2 hours follow-up annually DSME -1 hour individual assess -9 hours group (once in a lifetime) -2 hours follow up annually (starts on month 13 after first DSME bill) Meeting with a RD can result in 1-2% drop in A1c

Postpartum with PreExisting DM

Meal plan adjustment for goals/needs Breastfeeding and BG balance Birth control planning Preconception counseling starts here Connect with long term follow up care Monitor for postpartum depression and provide support

Oral Agents in Hospital Setting?

Metformin + - Eval GFR DPP-IV + Sitagliptin, linagliptin GLP-1RA + - Eval appetite SGLT-2 - DKA risk TZD's -Fluid retention Sulfonylurea -Hypo risk high

Metformin for Polycystic Ovary Syndrome (PCOS)

Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester.

Considering oral therapy in combination with injectable therapies

Metformin: Continue treatment with metformin TZD: Stop when commencing insulin OR reduce dose Sulfonylurea (SU): -If on SU, stop or reduce dose by 50% when basal insulin is initiated -Consider stopping SU if prandial insulin is initiated OR on a premix regimen DPP-4i: -Stop DPP-4i if GLP-1 RA is initiated SGLT2i: -If on SGLT2i, continue treatment. -Consider adding SGLT2i if, 1) established CVD 2) A1c above target or as weight reduction aid SGLT2i: Beware of euglycemic DKA, instruct on sick-day rules, and DO NOT down-titrate insulin over-aggresively

Meal Time data review

SMBG data before and after breakfast, lunch and dinner Ideally, 2 hour post-meal should not rise above 180mg/dL or 50mg/dL from the pre-meal start By 5 hours, glucose should return to pre-meal level

Pattern Management

Safety 1st!! - Evaluate 3-day patterns Hypo: eval 1st and fix: If possible, decrease medication dose Timing of meals, exercise, medications Hyperglycemia: evaluate 2nd Identify patterns Before increase insulin, make sure not missing something (carbs, exercise, omission)

Safety Pearls

Safety Pearls Back up plan for pump failure - Rx for long acting insulin, insulin pens, syringes - Written insulin pump settings Sick day management Ketone testing Pump rotation Insulin spoilage in high temperatures Always carry back up supplies - Eg: Infusion sets/reservoirs, test strips/meter, insulin, batteries https://www.diabeteseducator.org/docs/default-source/practice/educator-tools/troubleshooting_final.pdf?sfvrsn=4

Screen for Pediatric Celiac Disease - Type 1

Screen for by measuring IgA anti- tissue transglutaminase after 2 years then again at 5 yrs or with symptoms: Consider testing in children with Positive family history of celiac disease Growth failure Failure to gain weight, weight loss Diarrhea, flatulence, abdominal pain, signs of malabsorption Frequent unexplained hypoglycemia or deterioration in glycemic control

PostTransplantation Diabetes Mellitus

Screen using OGTT after organ transplantation for hyperglycemia once person is stable on an immunosuppressive regimen and in the absence of an acute infection. Imunosuppressive regimens shown to provide the best outcomes for survival should be used, irrespective of posttransplantation diabetes risk. Insulin therapy always works

Microvascular complications - Eyes Screening

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 High Quality Fundus Photography to Screen for Retinopathy After initial exam, then... Annual exam Less frequent (every 2-3) yrs can be considered if 1 or more normal eye exam More frequent if retinopathy progressing Refer pts with macular edema, and severe non-proliferative disease to trained specialist

Adult Learners

Self-directed must feel need to learn Problem oriented rather than subject oriented Learn better when own experience is used Prefer active participation

Chronic Sensorimotor Neuropathy (Small Nerve Fiber)

Sensory deficits in distal portions, spreading medially "stocking-glove" Small Nerve Fiber Neuropathy -C-fiber pain = burning and superficial -Allodynia (all stimuli interpreted as painful) -Later, loss of pressure and temp sensation -Decrease blood flow, sweating -Detect w/ Monofilament -High risk for ulceration, Charcot, gangrene

Generalized Symmetrical Polyneuropathy - Acute Sensory Neuropathy

Severe pain, wasting, weight loss, depression and erectile dysfunction Foot pain- burning, unremitting, deep, sharp, stabbing, "shock like"..worse at night, hypersensitive to light touch Associated w/ hyperglycemia or w/ rapid improvement of glucose Goal - improve BG - resolve in year

DKA with associated infection

Signs an symptoms Fever Chills Chest Pain Dyspnea Body aches Diarrhea Make sure to have a sick day plan!

Exercise decreases:

Sleep apnea Diabetic kidney disease, retinopathy Depression Sexual dysfunction Urinary incontinence Knee pain Need for medications Health care costs

Medical Diabetes Identification

Speaks when you cannot Necklace, bracelet or watch band A wallet card is additional identification only

Prolonged bolus

Square/extended None of the bolus is delivered up front Common timing is 1-2 hours after start of meal Can last for up to 8 hours Dual/combo/ combination bolus 30% delivered up front, the rest of bolus over the next several hours. Lasts about 5 hours

Hospital Stay for Insulin Pump Users

Staff to assess: How long using pump? Who adjusts pump settings? What type of insulin is used? How much insulin is in pump now? When is next site change? Who does it? Basal rates? I:C ratios? Correction? Have your supplies? When usually check BG or CGM?

Standard vs prolonged bolus

Standard bolus Delivered within a few minutes Peaks in one hour (rapid acting insulin) Lasts for 3-5 hours (rapid acting insulin) Purpose Match insulin to absorption of food Works well with slowly digested food versus Prolonged bolus Delivered after 1-2 hours and lasts for 8 hours. Peak delay Duration extended Applications Large portions Slow consumption Gastroparesis Use of incretin mimetics

Basal rate testing

Start with glucose 80-180mg/dL with last bolus > 4 hours Wear CGM or check glucose every 2 hours Glucose should not change by more than 30mg/dL if basal is effective Avoid physical activity, stress, and high fat meals before test Start with overnight, and then work on the rest of the day is smaller segments If >30mg/dL rise or fall, make basal rate adjustment, 10-20% increments

What are the two things that are pancreatic stress tests?

Steroids in the hospital Pregnancy in the 2nd and 3rd trimester

Case study example for correction insulin for current BG level: 1700/TDD - target 120

TDD = 40 units BG target is 120. Current BG is 220. Based on her current BG, how much correction insulin does she need to get to target? Correction/sensitivity -1700 divided by TDD -1700 / 40 = 42.5 or 43 Correction: I unit of insulin lowers BG 43 points. 220-120 = 100 over target 100/43 = 2.3 units to correct for hyperglycemia what if her BG is 320? 320-120 = 200 over target 200/43 = 4.65 units to cover for hyperglycemia

Foot Exam - Screening for Neuropathy

Test: -Semmes-Weinstein monofilament 10g -vibration perception threshold testing -tuning fork 128 hz Significant Finding: -lack of perception at one or >sites -vibration perception threshold >24 volts -abnormal vibration perception

Treatment of Chronic Kidney Disease (CKD)

There are four primary treatment options for individuals who experience ESRD: 1. Hemodialysis 2. Peritoneal Dialysis 3. Kidney Transplantation 120, 000 Americans waiting for kidney Only 17,000 receive one each year Every day, 12 people die waiting for a kidney 4. No treatment

SMBG vs CGM

There may be undetected hyperglycemia and hypoglycemia with ONLY SMBG. Although you accept the values of SMBG as more accurate than from CGM

Omega-3 Fatty Acid Ethyl Esters

These are derived from fish oils that are chemically changed and purified. They're used in tandem with dietary changes, to help people with high triglyceride levels (over 200 mg/dL). Lovaza® Vascepa™ Epanova® Omtryg®

Statins

This class of drugs, also known as HMG CoA reductase inhibitors, works in the liver to prevent cholesterol from forming. This reduces the amount of cholesterol circulating in the blood. Statins are most effective at lowering LDL (bad) cholesterol. They also help lower triglycerides (blood fats) and raise HDL (good) cholesterol. Atorvastatin (Lipitor®) Fluvastatin (Lescol®) Lovastatin (Mevacor®, Altoprev™) Pravastatin (Pravachol®) Rosuvastatin Calcium (Crestor®) Simvastatin (Zocor®)

Calcium channel blockers

This drug prevents calcium from entering the smooth muscle cells of the heart and arteries. When calcium enters these cells, it causes a stronger and harder contraction, so by decreasing the calcium, the hearts' contraction is not as forceful. Calcium channel blockers relax and open up narrowed blood vessels, reduce heart rate and lower blood pressure. What the Medication Does Interrupts the movement of calcium into the cells of the heart and blood vessels. May decrease the heart's pumping strength and relax blood vessels. Reason for Medication Used to treat high blood pressure, chest pain (angina) caused by reduced blood supply to the heart muscle and some arrhythmias (abnormal heart rhythms). Amlodipine (Norvasc) Diltiazem (Cardizem, Tiazac) Felodipine (Plendil) Nifedipine (Adalat, Procardia) Nimodipine (Nimotop) Nisoldipine (Sular) Verapamil (Calan, Verelan)

Nerve Disease - Microvascular Complications

Tight glycemic control Screen 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.

Step 5. Bolus insulin timing

Timing of injection is important to consider Generally, best BG results when bolus insulin is given 15 minutes before meal Problem: "When and what am I going to eat"? Premeal bolus timing -if BG above target = 15+ minutes before meal -if BG below target = close to meal -if BG below 70 = treat and get BG to 70+, decrease insulin dose and take with meal -if gastroparesis = depending on meal consent take after meal?, use extended bolus function If Rob's BG is 68 before eating, what is the best insulin adjustment strategy? -Reduce usual bolus insulin dose by 1 unit -Eat 15 gms of carb, then eat meal

Four Critical Times to Eval Self-Care

To promote skills acquisition, medical nutrition therapy, and well-being: 1. At diagnosis 2. Annually (or when not meeting treatment targets) 3. When complicating factors develop 4. With life transitions

Retinopathy Prevention

To reduce the risk or slow the progression of retinopathy Optimize glycemic control Optimize blood pressure control

Glargine U-300

Toujeo Long Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Toujeo Solostar U-300 Pen 300 units insulin/mL

Toujeo Solostar U-300 Pen 300 units insulin/mL Glargine (Lantus) Basal 1.5 mL pen holds 450 units. Max dose 80 units. ---------------------- 3 mL Max Solostar pen holds 900 units. Max dose 160 units. ------------------- Once opened, good for 56 days.

Linagliptin

Tradjenta Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Increases insulin release and decreases glucagon release when blood glucose levels are elevated

Management Goals

Treatment aims at: Fluid resuscitation Reversal of acidosis Replenish electrolytes Replenish fluid loss Identification of underlying cause Pharmacotherapy Rapid acting insulin drip Electrolyte replacement Closely evaluate potassium levels. -If K+ is less than ~ 3.3, starting insulin drip can lower it even further. -May need IV Normal Saline and K+ replacement first - then insulin when K+ is normalized

Dulaglutide

Trulicity Noninsulin Injectables Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon

Case Study

Type 2 - Glimepiride (Amaryl) 4mg AM, 10u Glargine (Lantus) pm Day, Breakfast, Lunch, dinner, HS BG levels Day 1: 164, 94, 66, 162 Day 2: 169, n/a, 59, 195 Day 3: n/a, 84, 81, 242 Day 4: 159, n/a, 43, 211 low BG dinner = likely due to sulfonylrea that lasts 24 hours. consider the following: Half sulfonylrea or hold it. Put person on metformin instead of sulfonylrea. do not tell the person to eat more carbs for lunch because they will gain weight.

Unconditional Positive Regard

Unconditional Positive Regard involves showing complete support and acceptance of a person no matter what that person says or does - Carl Rogers

JR has dry skin cracks in the back of their heel. What is the best action?

Use a pumice stone on area when skin is damp (in bath)

Insulin Pump adjustments

Use calculations as a starting point Fix fasting first Begin with basal rate testing Multiple patterns can be set throughout the day Alternative basal patterns can be set for sick days, menstruation, etc Once basal at goal, focus on bolus settings

Colesevelam Tablets and Oral Suspension

Welchol Bile Acid Sequestrant Binds bile acids in the intestines and increases bile acid production Mechanism of action regarding glucose control not fully understood

Anticoagulants (Also known as Blood Thinners.)

What the Medication Does Decreases the clotting (coagulating) ability of the blood. Sometimes called blood thinners, although they do not actually thin the blood. They do NOT dissolve existing blood clots. Used to treat certain blood vessel, heart and lung conditions. Reason for Medication -Helps to prevent harmful clots from forming in the blood vessels. -May prevent the clots from becoming larger and causing more serious problems. -Often prescribed to prevent first or recurrent stroke. Apixaban (Eliquis) Dabigatran (Pradaxa) Edoxaban (Savaysa) Heparin (various) Rivaroxaban (Xarelto) Warfarin (Coumadin)

Expectancy Theory and Language

When we label people, we form biases. We act out behaviors based on this label. Providers also modify behavior in response to label The person labeled may take on attributes of that label Do our language choices lead to clinical inertia?.

Liraglutide & Insulin Degludec 100/3.6

Xultophy 100/3.6 Injectable Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon AND Long-Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Make A Difference in foot care and outcomes

You Can Make A Difference Assess Nail condition, nail care, in between the toes Who trims your nails Have you ever cut your self? Shoes - type and how often Socks Skin/skin care and vascular health Ability to inspect Loss of protective sensation

Exercise precautions for people with DM

a. Carry some form of ID on you at all times b. Always have a snack if BG <100 c. Look for signs of hypo for up to 24 hrs after exercise d. Carry a snack with you during exercise. e. Let someone know your route

Which of the following changes would you make to alice's regimen?

add empagliflozin (SGLT2)

Mechanisms of tissue injury by hyperglycemia

hyperglycemia > glycation pathway > glycated proteins (eg a1c) > Altered function or turnover hyperglycemia > glycation pathway > glycated proteins (eg a1c) > AGEs > receptor-mediated cytokine effects Sorbitol pathway > sorbitol and fructose > osmotic effects + oxidative stress

Microvascular Disease and Polyol Theory

hyperglycemia increases glucose level in cells sorbitol pathway - glucose reduced to sorbitol by aldose reductase polylol pathway - sorbitol oxidized to fructose by sorbitol dehydrogenase glucose, sorbitol, fructose toxic to cells decreased nerve velocity, oxygenation, increases oxidative stress

Insulin release in individuals without diabetes

insulin bolus occurs in the first 10 minutes after eating basal insulin is released every 12 minutes

Why does diabetes increase ASCVD risk?

insulin resistance hypertension dyslipidemia endothelial dysfunction inflammation procoagulant factors

Alternate Site Testing?

remember finger testing is the most accurate and glucometer readings are superior to CGM readings Yes if -finger fatigue -no risk of hypoglycemia -stable BG levels -if BG <90, recheck on finger No if -pregnant -on intensive insulin therapy -during hypoglycemia -during illness

Lipid monitoring

Obtain a lipid panel at time of diagnosis and every 5 years after if under 40 years old (if not taking lipid lowering therapy) Obtain a lipid panel at initiation of therapy, 4-12 weeks after or a change in dose and annual thereafter Intensify lifestyle therapy and optimize glycemic control in patients with elevated TG ≥150mg/dL) and/or low HDL (<40mg/dL mean, <50mg/dL women)

Atherosclerotic cardiovascular disease (ASCVD) Risk Factors

Smoking Overweight and obesity Physical inactivity Diabetes Hypertension Dyslipidemia Family history of premature coronary disease Chronic kidney disease Presence of albuminuria ***Assess risk factors at least annually***

Anti-platelet agents - Primary Prevention 2

Use aspirin (75-162mg/day) in those with diabetes and a history of ASCVD Dual antiplatelet therapy with a P2Y12 inhibitor for 1 year after acute coronary syndrome and may have benefits beyond

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. ADA Guidelines: Type 1 or on Intensive Insulin Therapy -Self monitor before: meals, snacks, bedtime -Occasional postprandial and before exercise -When suspects low blood glucose -Before critical tasks such as driving Type 2 on orals -No evidence that daily checking improves outcomes. Be practical, no two people or two days are alike

Glucagon Side-Notes

*All raise BG 20+ points. Can cause nausea, vomiting. After admin, roll person on side. Seek medical help. If no response after 1st dose, give 2nd dose in 15 mins. When awake, give oral carbs ASAP when safe to swallow. Please consult package insert for detailed info. Please consult prescribing information for detailed guidelines.

Erectile Dysfunction

-Affects about 50% of men with diabetes -Loss of erections sufficient for intercourse -Due to combo of vascular and nerve damage -Tests: penile tumescence to eval if organic or psychogenic Treatment: -Sildenafil (Viagra), Vardenafil (Levitra), Tadalfil (Cialis) Use caution if taking nitrate drugs. Check w/ MD first -Other meds, vacuum devices, prosthetics -HRT- testosterone gel, patches, injections, pills

Hypoglycemia UNAwareness

-Autonomic symptoms adrenergically based (stress hormones) After 2-5 yrs of type 1 dm, glucagon secretion impaired, epinephrine secretion becomes primary mechanism to restore BG levels Over time, epinephrine response diminished or delayed This decreases awareness of hypoglycemia symptoms = dangerous

Fruit 15 g Carb Servings

-Juice, prune or grape, fruit juice blends, 100% juice (1⁄3 cup) -Juice, unsweetened (1⁄2 cup) -Apple or orange (1 small) -Apricots (4 whole or 8 dried halves) -Banana, extra small (1 or 4 oz) -Blueberries (3⁄4 cup) -Canned fruit in juice (1⁄2 cup) -Cantaloupe (1 cup cubes) -Cherries (12) -Dried fruit (2 tbsp) -Grapefruit, large (1⁄2) -Grapes, small (17) -Kiwi (1) -Mango (1⁄2 small or 1⁄2 cup) -Papaya (1⁄2 of small fruit or 1 cup cubes) -Passion fruit (1⁄4 cup) -Peach (1 medium) -Pear (1⁄2 large) -Pineapple (3⁄4 cup) -Plum (2 small) or 3 dried plums -Raspberries (1 cup) -Strawberries (1 1⁄4 cup) -Watermelon (1 1⁄4 cup)

Metformin (Glucophage) Metformin Extended Release (Glucophage XR, Fortamet, Glumetza) Metformin liquid (Riomet) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1 ) Class = Biguanides 2) MOA = ↓ Hepatic glucose production (gluconeogenesis), ↑ Insulin sensitivity via peripheral glucose update, ↓ Intestinal absorption of glucose 3) Indication = first line for most individuals with DM2, sometimes for DM1 if they require large doses of insulin 4) Administration = Orally with meals 5) Side-Effects = D/N, Ab pain, Metallic taste, Lactic acidosis severe but rare, B12 deficiency from high-dose/long-term use 6) Contraindications = Before starting get eGFR - avoid if eGFR 30-45 ml/min - reduce dose when eGFR <45 ml/min, ↑ risk of lactic acidosis with alcohol use of 2-4 drinks / week 7) Clinical Pearls = A1c ↓ 1-2%, Effective for FPG & PPG, Take with food to ↓ GI side-effects, Slow upward titration MAY ↓ GI side-effects, Periodically measure B12 levels (low levels may contribute to peripheral neuropathy, NO HYPOGLYCEMIA, NO WEIGHT GAIN, ↓ cholesterol & triglycerides / CVD risk, approved for kids age 10 or older, INEXPENSIVE Consider metformin for women with history of GDM, people with BMI 35 or greater, under age 60 For dye study, if GFR <60, liver disease, alcoholism or heart failure, restart metformin after 48 hours if renal function stable.

Glipizide (Glucotrol) Glipizide Extended Release (Glucotrol XL) Glyburide (Diabeta, Glynase PresTabs) Glimepiride (Amaryl) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1 ) Class = Sulfonylureas 2) MOA = ↑ Insulin secretion from pancreatic beta cells (may lose effectiveness as pancreas gets more damaged) 3) Indication = DM2 in addition to meal planning & physical activity to lower BG (never DM1) 4) Administration = Orally 30 minutes before the first meal of the day, Lasts up to 24 hours 5) Side-Effects = Hypoglycemia ( may want to avoid glyburide most likely to cause hypoglycemia), Weight Gain 6) Contraindications = Severe hypoglycemia when calorie intake ↓, avoid XL w/ GI stricture or GI narrowing, may ↑ risk of hypoglycemia in elderly, use caution in individuals with kidney problems (because it's eliminated via kidney) 7) Clinical Pearls = A1c ↓ 1-2%, Inexpensive, DO NOT break/crush/chew XL tablets, Most clinical efficacy occurs at half-max dose, Reduced effect over time (requires pancreatic insulin production), Avoid glyburide in age >65, INEXPENSIVE, WEIGHT GAIN & HYPOGLYCEMIA MAY ACCELERATE BREAKDOWN OF THE PANCREATIC BETA-CELLS BY INCREASING THEIR WORKLOAD

How much Insulin?

1 unit for every 10 gms carbs & 1 unit for every 50 points over 150 60 gms carb. BG 240 -6 units + 2 units 70 gms carb, BG 69 -7 units (but ends up being 6 because blood sugar is below 70) 45 gms carb, BG 148 -4.5 units

Rates of Gestational Diabetes (GDM) and Diabetes in Pregnancy increasing

1% to 2% have type 1 or type 2 during pregnancy 6% to 9% develop GDM From 2000 to 2010 -GDM rates increased 56% -Type 1 or type 2 before pregnancy increased 37%. Asian and Hispanic women have higher rates of GDM Black and Hispanic women have higher rates of type 1 or type 2 diabetes during pregnancy.

What are the Statin Recommendations?

1) Age 2) ASCVD OR 10 yr risk >20% 3) Recommended statin Option 1: 1) <40 years 2) No 3) None + lifestyle Option 2: 1) <40 years 2) Yes 3) High intensity Statin, If LDL >70 despite max statin dose consider adding additional therapy such as ezetimbe or PCSK9 inhibitor Option 3: 1) > 40 years 2) no 3) Moderate Statin Option 4: 1) > 40 yeras 2) Yes 3) If LDL >70, despite max statin dose consider adding additional therapy such as ezetimibe (Zetia) or PCSK9 Inhibitor

Acarbose (Precose) Miglitol (Glyset) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Alpha Glucosidase Inhibitors 2) MOA = DELAYS the breakdown and absorption of certain starches & sugars in the intestines, ↓ PPG 3) Indication = DM2 in addition to meal planning & physical activity to lower BG, rarely for DM1 - May help some who experience elevated blood sugars after carb-rich meals. They don't cause hypoglycemia or diminish between meal appetite, they could help with weight loss. However, the side-effects are more than most people are willing to endure. 4) Administration = At the start of each main meal Start low dose, increase at 4-8 wk intervals to decrease GI effects. Caution with liver or kidney problems. In case of hypo, treat w/ glucose tabs or skimmed milk 5) Side-Effects = Flatulence, Diarrhea, Ab Pain, Bloating 6) Contraindications = Acarbose (Precose) may increase liver transaminase levels especially in females, Avoid if serum creatinine (SCr) >2 mg/dl, Avoid if creatinine clearance (CrCl) <25 ml/min (causes Miglitol-Glyset levels to double). Avoid with any type of bowel disease 7) Clinical Pearls = A1c ↓ 0.5-1%, Increased hypoglycemia risk if also taking sulfonylreas or insulin, HYPOGLYCEMIA TREATMENT SHOULD BE WITH low-fat milk or glucose tablets (foods made of sucrose like table sugar, hard candy, juice or regular soda WILL NOT WORK), Skip medication if not eating, Pt's with low BW are at increased risk of elevated liver enzymes

Colesevelam (Welchol) Tablets and oral suspension 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Bile Acid Sequestrants 2) MOA = Binds bile acids in the intestines & increases bile acid production, MOA regarding BG control NOT fully understood 3) Indication = An adjunct to diet and exercise to reduce elevated low- density lipoprotein cholesterol (LDL-C) in adults with primary hyperlipidemia as monotherapy or in combination with a (statin). Type 2 diabetes in addition to meal planning and physical activity to lower blood glucose 4) Administration = Should be taken with a meal AND liquid 5) Side-Effects = Constipation, Dyspepsia, Nausea 6) Contraindications = AVOID with pt's who have a hx of bowel obstruction, AVOID if serum Triglyceride (TG) > 500, AVOID if hx of TG-induced pancreatitis, May ↓ absorption of fat-soluble vitamins 7) Clinical Pearls = A1c ↓ 0.5%, May ↓ the GI absorption of some drugs, Administer drugs with a known interaction at least 4 hours prior, Postmarketing reports: Increased seizure activity or ↓ phenytoin levels in patients receiving phenytoin, Administer Phenytoin 4 hours prior to Welchol

Liraglutide (Victoza) & Insulin Degludec (IDeg or Tresiba) = Xultophy 100/3.6 (IDegLira) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Combination 2) MOA = Combination of Long-acting Insulin & GLP-1 Receptor Agonist (GLP-1 RA) ***Long-acting Insulin - controls blood sugars between meals / snacks and while asleep ***GLP-1 Receptor Agonist (GLP-1 RA) -increases glucose dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon 3) Indication = Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes 4) Administration = Once daily WITHOUT regard to food Xultophy 100/3.6 pre-filled pen = 100 units IDeg / 3.6 mg liraglutide per mL Once daily injection - Dose range 10 to 50 = 10 - 50 units IDeg + 0.36 -1.8 mg liraglutide Recommended starting dose: 16 IDegLira (= 16 units IDeg + 0.58 mg liraglutide) -Titrate dose up or down by 2 units every 3-4 days to reach target. -Supplied in package of five single-use 3mL pens. 5) Side-Effects = nausea, vomiting, diarrhea, headache, decreased appetite, weight loss, injection site reactions (brusing, pain, irritation, itching, rash), hypoglycemia when combined with insulin or insulin secretagogue, increased heart rate, weight gain, constipation, indigestion, upset stomach, ab pain, GERD, bloating, gas , hypoglycemia, runny or stuffy nose, increased lipase 6) Contraindications = Risk of thyroid C-cell tumors, avoid use of (Bydureon, Ozempic, Trulicity, Victoza) in people with personal or family history of medullary thyroid carcinoma, ↑ risk of pancreatitis and acute gallbladder disease, Not recommended in people with severe GI disease (e.g. gastroparesis), PostMarketing reports of acute renal failure and worsening of chronic renal failure, Contraindicated with hypoglycemia 7) Clinical Pearls = Available as multidose pen Once opened, expires in 21 days

5 most important Foot Care Tips

1) Inspect and apply lotion to your feet every night before you go to bed. 2) Do NOT go barefoot, even in your house. Always wear shoes! 3) Every time you see your doctor, take off your shoes and show your feet. Report any foot problems right away! 4) Do not do bathroom surgery or remove caluses as these can quickly become infected 5) 50% of amputations can be avoided through self-care education and early intervention

Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Alogliptin (Nesina) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Dipeptidyl Peptidase-4 (DPP-4) Inhibitor, -gliptins, INCRETIN ENHANCERS 2) MOA = Works by blocking the enzyme that breaks down GLP-1 (glucagon-like peptide) increasing the amount of GLP-1 which helps ↑ insulin release and ↓ glucagon release when BG levels are elevated, Prolongs action of gut hormones, slows gastric emptying, decrease appetite a bit, promote some growth and duplication of pancreatic beta cells (unique to this medication) 3) Indication = DM2 in addition to meal planning & physical activity to lower BG, Rarely for DM1 4) Administration = With or without food 5) Side-Effects = Upper Respiratory tract infection, Nasopharyngitis, Headache & flu-like symptoms, Allergic reactions like skin rash / itching / hives 6) Contraindications = Reports of pancreatitis, increased hospitalizations for HF w/ Alogliptin (Nesina) & Saxagliptin (Onglyza), Severe and disabling arthralgia (joint pain), Acute renal failure sometimes requiring dialysis 7) Clinical Pearls = A1c ↓ 0.5-0.8%, Renal Dosing required when CrCl is <30 to <60, NO WEIGHT GAIN OR HYPOGLYCEMIA MODEST BLOOD SUGAR REDUCTION (a more direct and robust way to increase GLP-1 levels is to take a GLP-1)

Bromocriptine (Cycloset) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Dopamine Agonists 2) MOA = Dopamine Receptor Agonists: Resets circadian rhythm and leads to ↑ insulin sensitivity AND glucose disposal 3) Indication = Type 2 diabetes in addition to meal planning and physical activity to lower blood glucose 4) Administration = Take within 2 hours after waking in the morning with food 5) Side-Effects = Nausea, Fatigue, Headache, Vomiting, Hallucinations, Somnolence 6) Contraindications = AVOID with syncopal migraines, nursing women (may inhibit lactation), and with severe psychotic disorders, MAY precipitate hypotension (caution in pt's taking anti-hypertensives), 7) Clinical Pearls = A1c ↓ 0.5 - 0.9%, may exacerbate psychotic disorders or reduce the effectiveness of drugs that treat psychosis, Limit dose to 1.6 mg daily during concomitant use of a moderate CYP3A4 inhibitor, Avoid concomitant use with strong CYP3A4 inhibitors.

Semaglutide (Rybelsus) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Glucagon-Like Peptide-1 Receptor Agonist (GLP-1 RA) 2) MOA = ↑ glucose-dependent insulin secretion, Slows gastric emptying, Promotes satiety, Suppresses Glucagon 3) Indication = Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes 4) Administration = Should be taken on an empty stomach with no more than 4 oz of plain water; wait 30-60 minutes to eat, drink, or take other medications. Swallow tablets whole (don't cut or crush). Dosing: Start with 3 mg once daily for 30 days Then increase to 7mg once daily for 30 days If A1c at target, maintain at 7mg daily If A1c not at target, increase to 14 mg once daily 5) Side-Effects = Nausea. Abdominal Pain. Vomiting. Diarrhea. Constipation. Decreased appetite. Hypoglycemia when combined with insulin OR insulin secretagogues, NO WEIGHT GAIN 6) Contraindications = Risk of thyroid C-cell tumors. Avoid in pt's with hx of medullary thyroid carcinoma. ↑ risk of pancreatitis. ↑ risk of diabetic retinopathy. Postmarketing Reports: Acute renal failure AND worsening of chronic renal failure 7) Clinical Pearls = Do not split / crush / chew. Decreases A1c by 1-2% Conversion between formulations: Rybelsus 14 mg daily can be converted to subcutaneous Ozempic 0.5 mg once weekly started the day after the last dose of Rybelsus; Ozempic 0.5 mg subcutaneous injection can be converted to Rybelsus 7 or 14 mg started up to 7 days after the last Ozempic dose.

Insulin Human Inhalation Powder (Afrezza) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Inhaled Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Oral inhalation at the start of meal 5) Adverse-Effects = low blood sugar (hypoglycemia), cough, sore thterm-19roat, headache, diarrhea, fatigue, nausea, bronchitis, urinary tract infection, and weight gain. 6) Contraindications = Assess lung function. Avoid in lung disease - bronchospam risk. Side effects: hypoglycemia, cough, throat irritation. 7) Clinical Pearls = Not recommended in lung disease, smokers, or recently quit smoking. Expiration is 3 days 8) Onset is 12 minutes 9) Peak Effect is 36 to 54 minutes 10) Duration of Action is 1.5 to 4.5 hours

Humulin N (NPH) Novolin N (NPH) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Intermediate Acting, Neutral Protamine Hagedorn (NPH) Insulin 2) MOC = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM2 4) Administration = inject 30-60 minutes before a meal Administered in 2 divided doses daily (either as equally divided doses, or as ~2/3 of the dose before the morning meal and ~1/3 of the dose before the evening meal or at bedtime) 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = This formulation is a suspension and should appear uniformly cloudy after gently mixing or "rolling" the vial or pen. 8) Onset is 1-4 hours 9) Peak Effect is 4-12 hours 10) Duration of Action is 10-24 hours

Glargine U-100 (Lantus, Basaglar, Semglee) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Long Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = If requiring one dose, administer at evening meal or at bed-time. If requiring two doses, administer the evening dose with the evening meal, at bedtime, or 12 hours after the morning dose. 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = DO NOT MIX IN SAME SYRINGE WITH OTHER INSULINS. Insulin Naive Patients (not meeting BG targets on oral drugs) In DM 2, the recommended starting dose is 10 units of long-acting insulin (0.1-0.2 units /kg). In DM 1 Recommended starting dose is 0.2-0.4 units /kg. Expiration upon opening is 28 days. 8) Onset is 2-4 hours 9) Peak Effect N/A 10) Duration of Action is 10.8 hours to >24 hours

Basal insulin

Drip of rapid insulin very few minutes If basal rate is set correctly, stable BG between meals and hs -Can skip or delay meals if set correctly Delivered auto on 24 hour cycle Temporary adjustments may include: -lower basal insulin during exercise -increase during sick days

Detemir (Levemir) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Long Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = If requiring one dose, administer at evening meal or at bed-time. If requiring two doses, administer the evening dose with the evening meal, at bedtime, or 12 hours after the morning dose. 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = DO NOT MIX IN SAME SYRINGE WITH OTHER INSULINS. Insulin Naive Patients (not meeting BG targets on oral drugs) In DM 2, the recommended starting dose is 10 units of long-acting insulin (0.1-0.2 units /kg). In DM 1 Recommended starting dose is 0.2-0.4 units /kg. Expiration upon opening is 42 days. 8) Onset is 3-4 hours 9) Peak Effect is 3-9 hours (also N/A) 10) Duration of Action is dose-dependent: 6-24 hours

Glargine U-300 (Toujeo) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Long Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = If requiring one dose, administer at evening meal or at bed-time. If requiring two doses, administer the evening dose with the evening meal, at bedtime, or 12 hours after the morning dose. 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = DO NOT MIX IN SAME SYRINGE WITH OTHER INSULINS. Insulin Naive Patients (not meeting BG targets on oral drugs) In DM 2, the recommended starting dose is 10 units of long-acting insulin (0.1-0.2 units /kg). In DM 1 Recommended starting dose is 0.2-0.4 units /kg. Expiration upon opening is 56 days. 8) Onset is 6 hours 9) Peak Effect N/A 10) Duration of Action is 24 to 36 hours

Degludec U-100 and U200 (Tresiba) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Long Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Tresiba can be taken at any time throughout the day - for example, 8 am on Monday, 12 pm on Tuesday, and 7 am on Wednesday. The insulin lasts for an impressive 42 hours (at least), and doses must be taken at least eight hours apart. 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = DO NOT MIX IN SAME SYRINGE WITH OTHER INSULINS. Insulin Naive Patients (not meeting BG targets on oral drugs) In DM 2, the recommended starting dose is 10 units of long-acting insulin (0.1-0.2 units /kg). In DM 1 Recommended starting dose is 0.2-0.4 units /kg. Expiration upon opening is 56 days. 8) Onset is 1 hour 9) Peak Effect is 9 hours (also N/A) 10) Duration of Action is >42 hours

Repaglinide (Prandin) Nateglinide (Starlix) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Meglitinides, -glinides 2) MOA = ↑ Stimulates the pancreas to release insulin from pancreatic beta cells 3) Indication = DM2 in addition to meal planning & physical activity to lower BG (Never DM1) 4) Administration = Orally 15-30 minutes before the first meal of the day 5) Side-Effects = Hypoglycemia, Weight Gain 6) Contraindications = Co-administration of clopidogrel, cyclosporine, gemfibrozil, and ketoconazole may increase Repaglinide (Prandin) levels, increasing risk of hypoglycemia. 7) Clinical Pearls = A1c ↓ 0.5-2%, Lowers post meal blood glucose ONLY, Skip the dose if skipping the meal, May have reduced effect over time (requires pancreatic insulin production, Prandin is more effective at lowering A1c than Starlix, DO NOT USE WITH SULFONYLREAS MAY ACCELERATE BREAKDOWN OF THE PANCREATIC BETA-CELLS BY INCREASING THEIR WORKLOAD

Pramlintide (Symlin) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Non-insulin Injectables 2) MOA = Amylin Mimetic: -slows gastric emptying and slows digestion -suppresses glucagon -promotes satiety / decrease appetite *Amylin is normally secreted by beta cells of the pancreas along with insulin. People with DM1 secrete little to no amylin since they have little to no beta-cells depending on the individual. Ironically, people with DM1 secrete extra glucagon right after meals 3) Indication = Adjunct therapy for people with DM1 and DM2 using meal-time insulin and having high post-meal blood sugars (nothing is more powerful at limiting these than Pramlintide) 4) Administration = Inject under skin prior to meals 5) Side-Effects = Nausea, anorexia, vomiting, fatigue, ab pain, dizziness, WEIGHT LOSS & HYPOGLYCEMIA RISK (MUST EAT) 6) Contraindications = AVOID use in people with hypoglycemic unawareness or gastroparesis 7) Clinical Pearls = Meals should contain at least 250 kcal or 30g CHO, Reduce prandial insulin dose by 50% when starting and monitor BG frequently Because of it's acidity, DO NOT MIX with insulin. It's effects only last a few hours. Not only helps with post meal blood sugars, but also with 3 kg weight loss over a 6-month period. Nausea, usually experienced 30 minutes after injecting, dissipates entirely after a few weeks as the body becomes accustomed to having the amylin present. Because digestion of carbohydrates is delayed when pramlintide is taken, insulin doses may need to be reduced and/or delayed. Pramlintide can make it easier to avoid extra snacking

Lispro Protamine and Lispro (Humalog 50/50) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Premixed Combinations 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM2 4) Administration = 15 minutes before breakfast and dinner 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = Expiration upon opening is 28 days. 8) Onset is 15-30 minutes 9) Peak Effect is 1-5 hours 10) Duration of Action is 11-22 hours

NPH and Regular (Novolin 70/30)

1) Class = Premixed Combinations 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM2 4) Administration = 30 minutes before breakfast and dinner 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = Expiration upon opening is 28 days. 8) Onset is 30 minutes 9) Peak Effect: Based on individual components: Regular = 2-4 hours, NPH = 4-12 hours 10) Duration of Action is 18-24 hours

NPH & Regular Insulin (Humulin 70/30) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Premixed Combinations 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM2 4) Administration = 30-45 minutes before a meal. 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = Expiration upon opening is 31 days. 8) Onset is 30 minutes 9) Peak Effect: Based on individual components: Regular = 2-4 hours, NPH = 4-10 hours 10) Duration of Action is 18-24 hours

Lispro Protamine and Lispro (Humalog 75/25) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Premixed Combinations 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM2 4) Administration = 5-15 minutes before breakfast and dinner 5) Side-Effects = 6) Contraindications = 7) Clinical Pearls = Expiration upon opening is 28 days. 8) Onset is 15-30 minutes 9) Peak Effect is 1-6.5 hours 10) Duration of Action is 13-22 hours

Lispro U-100 (Humalog, Admelog) Lispro U-200 (Humalog) U-100 is standard insulin concentration. U-200 is two times more concentrated than U-100. U-500 is 5 times more than U-100. When insulin is concentrated, it takes less liquid per dose than standard U-100 insulin to help reduce your blood sugar levels. 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Rapid Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Inject 5-15 minutes before meal 5) Adverse-Effects = Monitor closely for hypoglycemia, Monitor for Hypokalemia, especially in patients who are using potassium-lowering drugs or taking drugs sensitive to serum potassium level. Hypertrophy at the injection site, Injection Site Reaction, Lipodystrophy at the Injection Site, Hypersensitivity and Allergic Reactions, Weight Gain, Immune Response 6) Contraindications = Patients experiencing hypoglycemia or are sensitive to insulin or one of the inactive substances utilized to create the drug 7) Clinical Pearls = These insulins can cause low blood glucose if they are injected before a meal and the patient doesn't eat as much as expected. Low blood glucose can also result if too much insulin is injected in a short period of time. Always give the medication time to start working before injecting any additional insulin. Expires 28 days after opening 8) Onset is 5 to 15 minutes 9) Peak Effect is 1 to 3 hours 10) Duration of Action is 3 to 5 hours

Glulisine (Apidra) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Rapid Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Inject 5-15 minutes before meal 5) Adverse-Effects = Monitor closely for hypoglycemia, Monitor for Hypokalemia, especially in patients who are using potassium-lowering drugs or taking drugs sensitive to serum term-19potassium level. Hypertrophy at the injection site, Injection Site Reaction, Lipodystrophy at the Injection Site, Hypersensitivity and Allergic Reactions, Weight Gain, Immune Response 6) Contraindications = Patients experiencing hypoglycemia or are sensitive to insulin or one of the inactive substances utilized to create the drug 7) Clinical Pearls = These insulins can cause low blood glucose if they are injected before a meal and the patient doesn't eat as much as expected. Low blood glucose can also result if too much insulin is injected in a short period of time. Always give the medication time to start working before injecting any additional insulin. Expires 28 days after opening 8) Onset is 5 to 15 minutes 9) Peak Effect is 1 to 3 hours 10) Duration of Action is 3 to 5 hours

Aspart (Novolog) 1) Class 2) MOA 3) Indication 4) Administration 5) Adverse-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Rapid Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Inject 5-15 minutes before meal 5) Adverse-Effects = Monitor closely for hypoglycemia, Monitor for Hypokalemia, especially in patients who are using potassium-lowering drugs or taking drugs sensitive to serum term-19potassium level. Hypertrophy at the injection site, Injection Site Reaction, Lipodystrophy at the Injection Site, Hypersensitivity and Allergic Reactions, Weight Gain, Immune Response 6) Contraindications = Patients experiencing hypoglycemia or are sensitive to insulin or one of the inactive substances utilized to create the drug 7) Clinical Pearls = These insulins can cause low blood glucose if they are injected before a meal and the patient doesn't eat as much as expected. Low blood glucose can also result if too much insulin is injected in a short period of time. Always give the medication time to start working before injecting any additional insulin. Expires 28 days after opening 8) Onset is 5 to 15 minutes 9) Peak Effect is 1 to 3 hours 10) Duration of Action is 3 to 6 hours

Hypoglycemia: Identify, Treat & Prevent

1) Identify your unique symptoms of low blood sugars: Sweaty Shaky Hungry Can't think straight Headache Irritated, grouchy Other 2) Symptoms of hypoglycemia, treat with carbs until glucose reaches 70+, then eat usual meal or large snack. -4-8oz sugary drink, -Piece of fruit -2 tbsp or handful Raisins -Glucose tabs 4+ (each has 4g carb each), -Honey or glucose gel (1 tbsp), -Skittles candy, 15+ (each with 1 g carb) 3) Have glucagon rescue meds available. In case of severe hypo, identify someone (ahead of time) who can get medical help & give a glucagon rescue medication. Notify your provider of lowblood sugar events. Level 1 Hypo = glucose < 70 Level 2 Hypo = glucose < 54 Level 3 Hypo = severe, needs assistance IDENTIFY CAUSES OF HYPO & RESOLVE TO PREVENT FUTURE EPISODES: -low carb meal -extra activity -drinking alcohol -delayed or missed meal -too much insulin / meds -insulin timing

Humulin R (regular insulin) Novolin R (regular insulin) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = Short Acting Regular 2) MOC = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Inject 30 minutes before meal 5) Adverse-Effects = Monitor closely for hypoglycemia, Monitor for Hypokalemia, especially in patients who are using potassium-lowering drugs or taking drugs sensitive to serum potassium level. Hypertrophy at the injection site, Injection Site Reaction, Lipodystrophy at the Injection Site, Hypersensitivity and Allergic Reactions, Weight Gain, Immune Response 6) Contraindications = Patients experiencing hypoglycemia or are sensitive to this insulin or one of the inactive substances utilized to create the drug 7) Clinical Pearls = These insulins can cause low blood glucose if they are injected before a meal and the patient doesn't eat as much as expected. Low blood glucose can also result if too much insulin is injected in a short period of time. Always give the medication time to start working before injecting any additional insulin. Expires 31 (Humulin) and 42 (Novolin) days after opening 8) Onset is 30 to 60 minutes 9) Peak Effect is 2 to 4 hours 10) Duration of Action is 6 to 10 hours

Canagliflozin (Invokana) Empagliflozin (Jardiance) Dapagliflozin (Farxiga) Ertugliflozin (Steglatro) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Sodium-Glucose CoTransporter 2 (SGLT-2) Inhibitor, -Glifozins, "GLUCORETICS" 2) MOA = Inhibits SGLT-2 in the proximal convoluted tubules of the kidney => Reducing glucose reabsorption and increasing urinary glucose excretion **In the body, blood sugar levels above approximately 180 mg/dl (10 mmol/l) result in the spillage of sugar into the urine, along with extra water, thus increasing urination. SGLT-2s excrete blood sugar at about any blood sugar level. 3) Indication = Treatment of type 2 diabetes in addition to meal planning and physical activity to lower blood glucose, Potentially for DM1 4) Administration = Taken with or without food 5) Side-Effects = genital mycotic infections, UTIs, and ↑ urination and dehydration, hypersensitivity reactions, ↑ LDL, ↑ risk of acute kidney injury and pyelonephritis for all agents, orthostatic hypotension (dizziness when standing up), WEIGHT LOSS 6) Contraindications = ↑ risk of bone fracture for Canagliflozin, ↑ risk of lower extremity amputations for Ertugliflozin & Canagliflozin 7) Clinical Pearls = A1c ↓ 0.7-1%, Advise pt to ↑ H20 intake, ↑ risk of euglycemic DKA in DM2 pt's using insulin and DM1 pt's, Recommend good hygiene practices to ↓ risk of genital mycotic infections, NO WEIGHT GAIN, NO HYPOGLYCEMIA Empagliflozin, Dapagliflozin, Canagliflozin decreases risk of CV death, heart attack, and stroke, and preserves long-term kidney function

Pioglitazone (Actos) Rosiglitazone (Avandia) 1) Class 2) MOA 3) Indication 4) Administration 5) Side-Effects 6) Contraindications/Warnings 7) Clinical Pearls

1) Class = Thiazoledinedione (TZD), -glitazones 2) MOA = Selective agonist for peroxisome proliferator activated receptor gamma, Improves glucose uptake in the muscle and fat by improving insulin sensitivity, Decreases free fatty acids 3) Indication = DM2 in addition to meal planning & physical activity to lower BG, Rarely for DM1 4) Administration = orally with or without meals 5) Side-Effects = MONITOR FOR WEIGHT GAIN & EDEMA, Edema due to sodium and water retention, Increased risk of fractures 6) Contraindications = Fluid retention may occur and worsen / cause CHF, Use w/ insulin & use in pt's with CHF NYHA Class 1 & 2 may increase risk, NOT RECOMMENDED in symptomatic HF or NYHA Class 3 or 4 HF, Obtain Liver Enzymes before starting Pioglitazone - use with caution if Abnormal Enzymes, ↑ risk of bladder cancer & macular edema, Increased peripheral fracture risk 7) Clinical Pearls = A1c ↓ 1-2%, Takes up to 12 weeks to see full benefit PEOPLE WITH DIABETES CAN IMPROVE INSULIN SENSITIVITY BY LOSING WEIGHT, EXERCISING AND IMPROVING THEIR DIET.

Lispro-AABC (Lyumjev) 1) Class 2) MOA 3) Indication 4) Administration 5) Adverse-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = VERY Rapid Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Inject 1-15 minutes before a meal 5) Adverse-Effects = Monitor closely for hypoglycemia, Monitor for Hypokalemia, especially in patients who are using potassium-lowering drugs or taking drugs sensitive to serum potassium level. Hypertrophy at the injection site, Injection Site Reaction, Lipodystrophy at the Injection Site, Hypersensitivity and Allergic Reactions, Weight Gain, Immune Response 6) Contraindications = Patients experiencing hypoglycemia or are sensitive to Lyumjev or one of the inactive substances utilized to create the drug 7) Clinical Pearls = These insulins can cause low blood glucose if they are injected before a meal and the patient doesn't eat as much as expected. Low blood glucose can also result if too much insulin is injected in a short period of time. Always give the medication time to start working before injecting any additional insulin. Expires 28 days after opening 8) Onset is 1 to 15 minutes 9) Peak Effect is 1 hour 10) Duration of Action is 4 to 5 hours

Aspart Recombivant (Fiasp) 1) Class 2) MOA 3) Indication 4) Administration 5) Adverse-Effects 6) Contraindications/Warnings 7) Clinical Pearls 8) Onset 9) Peak Effect 10) Duration of Action

1) Class = VERY Rapid Acting Insulin 2) MOA = Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway. 3) Indication = DM1 and DM2 4) Administration = Inject 2.5-15 minutes before a meal 5) Adverse-Effects = Monitor closely for hypoglycemia, Monitor for Hypokalemia, especially in patients who are using potassium-lowering drugs or taking drugs sensitive to serum potassium level. Hypertrophy at the injection site, Injection Site Reaction, Lipodystrophy at the Injection Site, Hypersensitivity and Allergic Reactions, Weight Gain, Immune Response 6) Contraindications = Patients experiencing hypoglycemia or are sensitive to Fiasp or one of the inactive substances utilized to create the drug 7) Clinical Pearls = These insulins can cause low blood glucose if they are injected before a meal and the patient doesn't eat as much as expected. Low blood glucose can also result if too much insulin is injected in a short period of time. Always give the medication time to start working before injecting any additional insulin. Expires 28 days after opening 8) Onset is 2.5 to 18 minutes 9) Peak Effect is 1 hour 10) Duration of Action is 3 to 7 hours

No one is unmotivated

No one is unmotivated to lead a long and healthy life 3 usual Critical Barriers: -Perceived worthlessness -too many personal obstacles -absence of support and resources

Transtheoretical Model

1.Precontemplation (the stage at which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or underaware of their problems.) 2.Contemplation (the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action.) 3.Preparation (the stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year.) 4.Action (the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy.) 5.Maintenance (the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors this stage extends from six months to an indeterminate period past the initial action.) 6.Termination (relapse, recycle)

Dexcom G6

10 day wear 2 hour warm-up FDA approved ages 2 and over No calibrations required-optional 1 press inserter, must attach transmitter Reusable transmitter-3 months FDA approved for dosing decisions Choice of receiver or smart phone (iphone, android) Insulin pump integration with T:Slim X2 FDA approved sites: abdomen (ages 2+), Upper buttocks (ages 2-17) MARD 9% Has Alarms High, low, predictive low alert Hydroxyurea drug interference Dexcom G6, Clarity, and Dexcom follow apps (up to 10 followers) iCGM Status

Type 1 Diabetes Features

10% of all diabetes Most commonly expressed at age 10-14 Insulin sensitive (require 0.5 to 1 unit/kg/day) Expression due to a combo of genes and environment -Autoimmunity tends to run in families -Exposure to virus or other environmental factors Signs can include: -increased thirst and hunger -frequent urination or new-bed wetting at night (hs) -unintended weight loss -fatigue and irritability Autoantibodies Associated with DM1 Panel of autoantibodies -GAD65 ‐ Glutamic acid decarboxylase - -ICA ‐ Islet Cell Cytoplasmic Autoantibodies -IAA ‐ Insulin Autoantibodies

Insulin Drip Recommendation

100 units insulin in 100 cc NS Bag 1 cc = 1unit of insulin Rate based on body wt: 0.05 units/kg per hour 100kg x 0.05 = 5 units insulin /hr Rate based on BG / 100 BG 400 / 100 4 units insulin / hr Monitor BG q 1-2 hr and adjust per protocol

Units of insulin in a vial

1000 units per vial (10 ml total insulin) -u-100 is standard so 1000/100 units/ml = 10 ml total vial If a person takes 100 units of insulin daily, they need 3 vials per month (1000 units per vial/100 units daily = 10 days * 3 vials

Freestyle Libre

14 day wear 1 hour warm-up FDA approved for insulin dosing except for the first 12 hours after insertion Must scan every 8 hours to avoid data gaps Salicylic acid and high dose vitamin C interference 1 press inserter, disposable transmitter included with sensor No real time alerts receiver is phone or reader. phone to scan with LibreLink mobile app no pump integration no calibrations required FDA approved sites: upper arm FDA approved ages >18 years MARD 9.4% LibreLinkUp allows up to 20 followers

Sweets 15 g & 30 g Carb Servings

15 g Carb Servings -Brownie, unfrosted (1 1⁄4-inch square—1 oz) -Cake, unfrosted (2-inch square—1 oz) -Cookies (2 small, sandwich type) -Fruit juice bars (1 bar—3 oz) -Ice cream (1⁄2 cup) -Jam/jelly (1 tbsp) -Muffin (1⁄4 of 4-oz muffin) -Pancake syrup (1 tbsp) -Regular gelatin (1⁄2 cup) -Regular soda (1⁄2 cup) -Sports drinks (1 cup) -Yogurt, frozen, fat-free (1⁄3 cup) 30 g Carb Servings -Cupcake, small, frosted (1 3⁄4 oz) -Doughnut, glazed (2-3 oz) -Milk, chocolate (1 cup) -Pie, pumpkin (1⁄8 pie) -Pudding (1⁄2 cup) -Rice pudding, sweet rice with milk (1⁄2 cup) -Sherbet (1⁄2 cup) Please note that this has more carbs: Pie, fruit, 2 crusts (1⁄8 pie is 45 g carbs)

Psychosocial Issues "Integrity vs. Despair" + drug use

15-20% of older adults with diabetes live with depression Assess other factors that may impact QOL lack of income isolation loss of partner, family, friends limited mobility alcohol or substance use (1 million adults 65 years+ live with substance use disorder) -alcohol increases risk of pancreatitis (hyperglycemia) high blood pressure, triglycerides hypoglycemia, malnutrition liver and bone problems neuropathic pain memory issues and mood disorders. opiod and heroin use on the rise

Case Study 70/30 insulin

16u 70/30 am, 8u 70/30 pm Patterns? Changes needed? Day, Breakfast, Lunch, Dinner, at HS BG levels Day 1: 102,63, 92, 181 Day 2: 112, 67, 106, 185 Day 3: 98, 56, 112, 201 Day 4: 99, 71, 132, 211 1) Address hypoglycemia first: Decrease breakfast dose by 20% 2) Address hyperglycemia second: decrease carb intake for dinner to decrease before bedtime blood sugar. Don't increase PM insulin dose because breakfast blood sugars are fine.

1700 rule for insulin sensitivity

1700 divided by total daily insulin dose = insulin sensitivity 1700/30 units total daily insulin = 56 1 unit insulin drops BG 56 points

Sexual Functions as We Age

20-30 years trice daily 30-40 years tri weekly 40-50 years try weekly 50-60 years try weakly 60-70 years try oysters 70-80 years try anything 80-90 years try to remember A touch of humor from AADE-New Perspectives on Erectile Dysfunction, 1999

Screening for Pediatric Hypothyroidism - DM Type 1

25% positive for thyroid disease at diagnosis of type 1 Screen for anti-thyroid peroxidase, anti-thyroglobulin antibodies soon after diagnosis Measure Thyroid-stimulating hormone (TSH) concentrations after metabolic control established. If normal, consider rechecking every 1-2 years Recheck if develops symptoms of thyroid dysfunction: thyromegaly, abnormal growth rate, or unusual BG variation

How a Pump Delivers Insulin

3 parts - insulin pump (holds insulin) + infusion set (transfers insulin from the pump) + glucose sensor & transmitter An insulin pump delivers insulin continuously (basal) and on demand (bolus) to account for carbohydrates in meals or high blood glucose levels

Mr J Started with 70/30

35 units am and 15 units pm Glucose levels in 300s After 2 months 120 units am and 100 units pm Total 220 units a day Time to switch to U-500 insulin (once exceed 200 units switch to U-500 insulin) couldn't tolerate SGLT-2 due to bladder infections started on semaglutide and increased to 1 mg weekly

15-20 g carb sources for hypoglycemia

4 ounces apple juice 4 glucose tablets 2 tbsp raisins 4-6 ounces of non-diet (regular) soda 4-6 ounces of regular fruit juices 8 ounces of non-fat/skim milk

Composition of the Pancreas

60% of the Pancreas is composed of insulin-producing beta cells. 30% of the pancreas is composed of glucagon-producing alpha cells. 10% of the pancreas is composed of somatostatin-producing delta cells.

DKA Precipitating Factors

40% - illness and infection- increases stress hormone release 25% - inadequate insulin dosage 15% - New diagnosis type 1 Emotional stress - especially with teens, neglect, mismanagement Disordered eating Pregnancy Hyperglycemia inducing medications Insulin omission due to fear of hypo Stress of chronic condition Can't afford insulin Cocaine or marijuana use

Insulin to Carb Ratio I :C

450 Rule I:C 450/TDD • 450 divided by total daily insulin dose. • Equals Gms of carb covered by 1unit insulin. • Example: Pt takes 45 units daily. 450 / 45 = 10 • 1 unit for 10 grams carb JR TDD is 90 units 450/90 = 5 = 1 unit for 5 gm carbs Ate 60 grams = 60/5 = 12 units insulin for meal (not including bolus for current blood sugar) ML TDD is 15 units 450/15 units = 30 = 1 unit for 30 gm carbs Ate 45 gram carbs = 45/30 = 1.5 units of insulin for meal (not including bolus for current blood sugar)

Case Study RT

48-year-old with type 2 diabetes on insulin for over 18 years. Most recent A1c 8.4, LDL cholesterol 112, HDL 37, triglycerides 324, GFR 110. TSH in 2017 was 4.4 Very upset about her blood sugars and weight, because she says "she is trying to do everything correctly and her blood sugars are always above 200." Current medications for diabetes include: Detemir (Levemir) 80 units BID and Semaglutide (Ozempic) 0.5 mg once a week. She is also on atorvastatin (Lipitor) 10 mg daily. Nutrition, rarely eats at breakfast because she is not hungry, her first meal is usually at noon and she has a subway sandwich. At 3 PM she has a snack bar, around six or seven she eat dinner. Dinner usually includes either rice or beans and six corn tortillas plus meat. Monitoring: has Freestyle Libre meter, but often doesn't swipe it every eight hours to gather that data. Plan: RT is very focused on getting blood sugars to target. Will focus first on managing hyperglycemia. 1. Add empagliflozin 25 mg daily - instructed on potential side effects. 2. Increase semaglutide to 1.0 mg once weekly 3. Once start these two medications, decrease detemir in morning to 40 units and continue 80 units of detemir at bedtime. Eventual goal is to get her on one injection of detemir at night. 4. Increase atorvastatin as needed 5. Keep on eye on carbs per meal 6. Check TSH with next lab draw. 7. Return in one week for evaluation and coaching. 2 weeks Later Since making changes in her medications last week, she is feeling a lot better about her diabetes. Blood sugars in the 80 -130 range and she is happy she is taking less insulin. Nutrition: due to semaglutide increased dose, she experienced some nausea and decreased appetite, especially the first few days after injection. She has been eating less. However, she is not able to weigh herself since she does not have a scale. Monitoring: has a freestyle libre meter and is swiping it regularly to evaluate her blood sugar management. She stated last night she noticed her blood sugar was running in the 60s, but she did not feel it. Reviewed signs and symptoms of hypoglycemia and the importance of having a 15 g snack on her person at all times. Updated Plan 1. Keep semaglutide at 1.0 mg once weekly. Inject on Fridays, so that the nausea doesn't cause her to miss work. 2. Decrease detemir in morning to 40 units and 40 units of detemir at bedtime to prevent nighttime lows.

DKA and HHS

5 most important interventions Fluids (NS, 0.45 NS, D51/2 NS once glucose 300mg/dl) Insulin (.05 - 0.1unit/kg per hour) Potassium / lyte replacement (K+, Mg, Ca, Phos) Determine, treat precipitating cause Education to prevent future episodes

Consider U-500 High Potency Insulin

5 x's the concentration of u100 500 units per mL vs 100 units per mL 20 mL a vial. 500 units per mL= 10,000 units/vial Costs ~ $400 $1,200 per vial Less volume no conversion required if using U-500 insulin- use a U-500 syringe

"DAN" Diabetic Autonomic Neuropathy

50% of ind's with peripheral neuropathy also have DAN DAN increases Mortality and Morbidity rates -neurogenic bladder, sexual dysfunction -GI related disorders / gastroparesis -orthostatic hypotension -fixed heart rate, silent MI, sudden death -hypoglycemia unawareness -sudomotor, pupillary

Psychological Insulin Resistance (PIR)

50% of providers in study threatened participants "with the needle". Less than 50% of providers realized insulins' positive effect on type 2 dm Most participants don't believe that insulin would "help them better manage their diabetes". Solutions: Find the root of PIR and address it, use more insulin pens Use language and images that promotes the benefit of insulin therapy. Ideas include: "Your pancreas can't make enough insulin, so we need to help it". "Insulin is just hormone replacement therapy". "It's not your fault you need insulin, your pancreas just can't make enough".

Postpartum after GDM

50% risk of getting diabetes in 5 years Screen with 75gm OGTT at 4-12 wks post partum Repeat at 1-3 yr intervals or signs of DM Encourage Breast Feeding (reduces future GDM Risk by 50%) Encourage weight control Encourage exercise Make sure connected with health care Lipid profile/ follow BP Preconception counseling

Calculate Carb-to-Insulin Ratio (450 rule / 500 rule)

500 Rule - Humalog and Novolog -Divide 500 by total daily insulin dose -equals = grams of carbs covered by one unit of Humalog or Novolog -EXAMPLE: KP takes 33 units / day total insulin. 500/33 (total dose) = 15 -1 unit insulin covers 15 grams of carbs 450 Rule - Regular insulin -Divide 450 by total daily insulin dose -equals = grams of carbs covered by one unit of Regular insulin -EXAMPLE: OC takes 45 units / day total insulin. 450/45 (total dose) = 10 -1 unit insulin covers 10 grams of carbs

Case Study

54 year old, smokes, hx of heart failure. GFR in 48. Not checking BG, even though he has glucose meter. On Metformin 500mg BID for past 4 months. Had bad experience with hypoglycemia on glyburide. Most recent A1c 8.9% ADA / AACE - Insurance coverage Big deductible Solution: • Change to Metformin XR and double dose • Add SGLT-2 or • Add GLP-1 • If $ an issue, consider adding SU or insulin • ASA, Statin, B/P meds? • Referral to RD/DSME

Mrs. Jones Insulin Case Study

60kg, 70 year old patient, normal kidney function Determine insulin dose: 50/50 rule 0.3-1.0 units/kg example: 60 kg * 0.3 = 18 units of insulin per day Basal = 50% of total insulin for the day -glargine at HS -NPH or detemir BID *Basal dose : 9 units -Glargine: 9 units HS -NPH/Detemir 4 units BID (only use half of total daily dose for entire day split into two doses) Bolus = 50% of total insulin for the day Bolus dose: 9 units example: 3 units regular, novolog, apidra, humalog each meal

Case Study

61 year old woman with BMI of 28 and type 2 diabetes 3 months. Has been trying to manage diabetes with diet and exercise. GFR in 90s. Worried about weight gain. Most recent A1c 7.2% ADA - metformin AACE - metformin Cash pay - metformin

Case Study

65 year old male, BMI 25, on Metformin 1000mg BID and Exenatide 10mcg before breakfast and dinner. History of a cardiac event. A1c 8.9%. Creat 1.2 BMI 29, 11 yr history of diabetes 1) Refer to RD and DSME 2) Consider starting basal insulin 3) Consider SGLT-2 inhibtor

Case study JR

68 yr old, avid walker BMI 24, Weighs 90kg, GFR >60 History of Congestive heart failure A1c - 9.6%, BG 270s during day for past mos Insulin - 50 units Lantus Oral Meds: glyburide 20mg, metformin 2,000mg What medication changes, additions? Add SGLT-2 Inhibitor? YES Help with CHF and BG, $$ Add GLP1 Agonist? YES Help with A1c, affect appetite? BMI 24, $$ Add DPP-IV? Not Sure Lowers A1c by less than 1%, $$ Is he on right basal dose? Should be 23 units not 50 units since he weighs 90 kg (90 *.5 = 45 units *.5 = 22.5 units) What insulin changes? Insulin Not Sure Add Bolus Insulin or switch to 70/30 May be most affordable, but higher risk for hypoglycemia

Case Study

69 year old male, BMI 28, on Metformin 2000mg a day, Glipizide 40mg a day and Empagliflozin 25mg a day. A1c 10.1%. GFR 50s. Solutions Insurance - Add Basal + GLP-1 combo or Start basal insulin, then add GLP-1, then bolus insulin (stop glipizide) No insurance - Stop Glipizide, keep metformin, add 70/30 insulin Add 70/30 insulin 1-2 times a day 100kg x 0.5 = 50 units daily * 0.5 units = 25 units total for NPH (16units am/ 8units dinner)

Women, DM, CVD

6x's rate of CVD than non-DM women 4xs risk of CVD & mortality compared to men w/ diabetes who have 2xs the risk Women with diabetes present 10 years earlier with CVD than women without diabetes (same as men). Lose female protection. Why? Elevated BG, HTN, dyslipidemia, excess wt, PCOS, depression, lower income, later detection

Guardian Connect and Guardian 3

7 day wear Up to 2 hour warm-up Not FDA approved for dosing decisions Calibrations required 2-4 times/day Acetaminophen and Hydroxyurea interference Guardian 3 sensor -compatible with 670G and 770G insulin pumps Guardian Connect- compatible with smart phone (no separate receiver) Reusable transmitter -Charge every 7 days, transmitter lasts for ~1 year Guardian Connect, Sugar IQ apps -Sugar IQ provides predictive glycemic patterns based on user input Ability to have followers through carelink website Carelink Connect Mobile app for 770G users 2 calibrations required per day FDA approved site: upper arm, abdomen FDA approved ages: Guardian 3 = >2 years Guardian Connect = >7 years MARD 9.64%

Case Study

70 yr old, weighs 100kg, GFR 58 History of CABG, foot ulcer, smokes A1c - 11.3%, BG 400-500 for past weeks Insulin - 120 units Lantus at hs (solostar). Metformin 1000mg BID & canagliflozin What is max basal insulin should he be on? 100 kg * .5 units/kg = 50 units Given his history, what diabetes meds would benefit him? -SGLT-2 (-gliflozin) for heart disease, CHF -GLP RA for heart disease, weight loss -GLP RA + basal insulin combo -add bolus insulin = 4 units bolus insulin to largest meal (or 10% of basal = 12 units) switch to 70/30 insulin AC -total previous basal dose - 120 units -use full dose instead of 80% of dose because he has a high A1c -2/3 am = 80 units AM -1/3 pm = 40 units PM What will inform you of how to proceed? Insurance coverage His willingness to stick to a complex regimen His ability to self-monitor His social support and connection to his medical team PLAN: -Professional CGM -GLP RA -Referral to diabetes care % education specialists -Build rapport - discussion on medication taking barriers

Case Study

71 year old woman with type 2 diabetes for past year. BMI 27. Has been trying to control diabetes by limiting carbs and exercise. Creat 1.6, GFR high 30s with CKD. Good social support. Most recent A1c 7.9% Insurance - Canaglifozin or GLP-1 RA Cash pay - Sulfonylurea Other referrals?

Case Study

72 yr old, BMI 24, lives alone, A1c 7.3%. History of stroke. DM for 12 yrs, "diet controlled". Good insurance. Creat 1.4. GFR in 50s -Start Metformin -Consider SGLT-1 inhibitor -Start low dose glipizide -consider DPP-IV Inhibitor (sitagliptin or linagliptin)

Rob 30 Years with Type 1, Celiac Disease Injects Glargine (Lantus) and Humalog

80kg, BMI 23, Target BG 130 Insulin dosing Glargine (Lantus) 22 units AM Humalog (bolus) Before breakfast 9-14 units Lunch 2-4 units Dinner 2-6 units Bedtime 1-2 units if > 200 2. Not keeping any type of log 3. Not counting carbs - "ball parking" 4. A1c 7.9 - no Endo TDD = 38 to 48 units = 43 units Wt based dosing: 80 kg * .5 = 40 units insulin daily 40 units * 0.5 = 20 units for basal and bolus (50%/50%) 20 units basal 6+7+7 units bolus for breakfast, lunch, and dinner Plan - Keep BG log for 1 week (prevent hypos as much as possible - circle numbers they're concerned about)

Natural History of Diabetes

<---Development of DM2 happens over years or decades----> Healthy: FBG <100 Random BG <140 A1c <5.7% Prediabetes: FBG 100-125 Random BG NA A1c ~5.7 - 6.4% 50% of working pancreas (50% of cells lost) Diabetes: FBG 126+ Random BG >200 A1c >6.5% 20% of working pancreas (80% of cells lost) ***Development of DM2 happens over years or decades

Basal insulin key points - Type 2

ADA Standards of Care 2021 Keep metformin and other oral agent if appropriate Next agent is based on profile: CHF? CVD? Kidney Disease? Cost? Weight? When is it too much basal insulin? If basal insulin is >0.5units/kg day or FBG on target, advance to combination injectable therapy If possible, consider GLP1-RA first (before basal) Once start bolus insulin, stop sulfonylureas

The ABC's of Diabetes Management

A - A1c less than 7% B - Blood pressure less than 140/90 C - Cholesterol HDL > 40, Triglycerides < 150 D - Drugs- Keep list for emergencies/ MD E - Exercise and Eyes F - Food and Feet G - Glucose checks and goals H- Healthy Coping - Hoorah for your hard work!

Medicare Parts and Coverage

A = Hospital Insurance Program B = Supplemental Medical Insurance Elective program (95% participate) Covers 80% - Outpt services, durable medical equipment, DSMT, MNT C = Medicare Advantage = A + B + D D = Prescription Drug Coverage

Diabetes in Pregnancy or (Pre-existing DM)

A woman with pre-existing type 1 or 2 becomes pregnant Elevated BG discovered in first 13 weeks of pregnancy Preconception A1c goal < 6.5% -2/3 of all pregnancies w/ diabetes not planned Involve and empower to help prevent complications

Pediatric A1c Goals for Type 1

A1C of <7% appropriate for many peds. <6.5% without significant hypoglycemia, negative impacts on well-being, or undue burden of care <7.5% if cannot articulate symptoms of hypoglycemia or at high risk <8.0% may be appropriate for some • Individualize Goals ~ goals adjusted based on benefit-risk assessment. • Blood glucose goals are higher in children with frequent hypoglycemia or hypoglycemia unawareness. • Measure postprandial blood glucose when there is a discrepancy between preprandial blood glucose values and A1C levels

Discharge plan insulin algorithm

A1c <8% -restart outpatient treatment regimen A1c 8-9.9% -re-start outpatient oral agents and discharge on glargine once daily at 50% of hospital dose A1c >10% -discharge on basal-bolus at same hospital dose -alternative re-start oral agents and discharge on glargine once daily at 80% of hospital dose Also perform medication reconiliation

What are the ABCs of Diabetes

A1c less than 7% (avg 3 month BG) Pre‐meal BG 80‐130 Post meal BG <180 Blood Pressure < 140/90 BP target <130/80 = ASCVD or If 10‐year CVD Risk > 15% Cholesterol Statin therapy indicated?

Diabetes Care in the Hospital - ADA

A1c on all patients with Diabetes or new hyperglycemia (if not done in past 3 mo's) Insulin dosing based on standard protocols that allow for predefined adjustments based on BG fluctuations Consider consulting with glucose mgmt. team Have hypoglycemia protocol. Ongoing quality improvement to keep BG > 70. Create structured discharge plan based on individual.

The Ankle-Brachial Index

ABI = Lower extremity systolic pressure divided by Brachial artery systolic pressure • The ankle-brachial index is 95% sensitive and 99% specific for PAD • Establishes the PAD diagnosis • Identifies a population at high risk of CV ischemic events • The "population at risk" can be clinically and epidemiologically defined Use highest pressures from the DP=dorsalis pedis & PT=posterior tibial 1-1.29 = normal 0.91-0.99 = borderline 0.41-0.90 = mild-to-moderate disease <0.40 = severe disease >1.30 = non compressible.

Adenosine triphosphate-citrate lyase (ACL) inhibitors*

ACL inhibitors work in the liver to block the production of cholesterol. They are used in combination with lifestyle changes and statins to further decrease LDL cholesterol in adults with familial heterozygous hypercholesterolemia and patients with heart disease that need to further lower their LDL. Bempedoic acid (Nexletol) Bempedoic acid and ezetimibe (Nexlizet)

Causes of Hospital Hypoglycemia - Main Categories

Admitted with hypo Poor PO intake Too much basal On oral meds + Insulin Insulin Scale Mismatch Hypo due to other causes

Case Study: AL

AL returns home from the hospital and monitors glucose. He denies any low blood glucose events. FBG: 160-190mg/dL Pre-lunch: 160-180 mg/dL Pre-dinner: 200-220mg/dL Pre-bedtime: 200-220mg/dL Should the long-acting or meal time insulin be increased? Fix fasting first: Titrate basal insulin to achieve fasting and pre-meal glucose targets In the case of AL, all of the pre-meal glucose levels are above target Therefore, basal insulin should be increased How to titrate? Increase by 2 units every 3 days until fasting or pre-meal is 80-130mg/dL Stop or reduce dose if hypoglycemia develops

Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)

ARNIs are a drug combination of a neprilysin inhibitor and an ARB. What the Medication Does Neprilysin is an enzyme that breaks down natural substances in the body that open narrowed arteries. By limiting the effect of neprilysin, it increases the effects of these substances and improves artery opening and blood flow, reduces sodium (salt) retention, and decreases strain on the heart. Reason for Medication For the treatment of heart failure Sacubitril/valsartan (Entresto)

Atherosclerotic cardiovascular disease (ASCVD)

ASCVD is defined as: Coronary heart disease Cerebrovascular disease Peripheral arterial disease ASCVD is the leading cause of morbidity and mortality in people with diabetes Largest contributor to direct and indirect costs $37.3 billion/year Rates of heart failure hospitalization are 2x higher in people with diabetes

DKA action

Action maintain insulin drip until ketone negative, anion gap closes, and glucose <200 maintain hydration check BG q1 hour assess lytes (esp K+) give sub-Q insulin before d/c IV insulin teach, teach, teach

Basal Insulin Dosing - Beyond Basics

Active, healthy 35-45% of total daily insulin Less active, lower carb intake 45-55% of total daily insulin Percentage may increase during puberty Tends to decrease with advanced age Sleep and growth patterns have major influence

Piolglitazone

Actos Thiazoledinediones (TZDs) Selective agonist for peroxisome proliferator activated receptor gamma; improves glucose uptake in muscle and fat by improving insulin sensitivity

Add Other Med / Insulin Changes

Add SGLT-2 Inhibitor? YES Help with CHF and BG, $$ Add GLP1 Agonist? YES Help with A1c, affect appetite? BMI 24, $$ Add DPP-IV? Not Sure Lowers A1c by less than 1%, $$ Insulin Not Sure Add Bolus Insulin or switch to 70/30 May be most affordable, but higher risk for hypoglycemia

JR Next Step - OR add bolus

Add bolus insulin to largest meal. -Dose - 5 units or 10% of basal -50 units Glargine x 10% = 5 units. When is largest meal (most carbs)? Meal Plan - how is food intake impacting blood glucose? What are there usual eating habits? How can we match the plan to their lifestyle? What are JR's values and goals? Carbs need to be matched with insulin - use the 450-500 rule/ total daily insulin dose

Next step - OR Carb Counting

Add bolus insulin to largest meal. 50 units Lantus x 10% = 5 units. Dose - 5 units or 10% of basal When is largest meal (most carbs)? Breakfast How many carbs is JR eating at meals? How much insulin needed?

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

Hypoglycemia Prevention Strategies for Insulin/Secretagogues

Adjust carbohydrate prior to planned activity: If using insulin and /or secretagogues BG < 90, consume 15 -30 gms Carry carb snack/ glucagon ER Kit Extra Carb in post exercise period Caution with alcohol post exercise

Lixisenatide

Adlyxin Noninsulin Injectables Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon

Tandem T:Slim X2 with Control-IQ

Advanced hybrid-closed loop system Algorithm adjusts insulin delivery from programed "manual" settings Automatic correction doses - Up to 1 every hour - Calculated at 60% of programmed correction factor (target of 110) User must still bolus for carbs (and additional correction doses) FDA approved 6+ years Basal-IQ users who update to Control-IQ cannot switch back to Basal-IQ mode Control-IQ technology helps increase time in range* using Dexcom G6 continuous glucose monitoring (CGM)† values to predict glucose levels 30 minutes ahead and adjust insulin delivery accordingly, including delivery of automatic correction boluses as needed.‡ Basal IQ- suspends basal if CGM predicted to decrease to < 80 mg/dl within 30 minutes

"How to think like a pancreas"

Advise patients: We are going to try and imitate the work of your pancreas. Your pancreas releases little doses of insulin through out the day and night. This is called basal insulin Your pancreas also releases a squirt of insulin with meals or if your blood sugars are running above target. This is called bolus insulin

Insulin Human Inhalation Powder

Afrezza Rapid Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Safety Features

Alarms for occlusion or low insulin reservoir Active insulin to prevent stacking Keypad lock Waterproof or watertight Communication with CGM for auto-suspend, auto adjustment of basal Reminders to bolus, change infusion set, etc

Alice case study

Alice's lipid panel is as follows: Total cholesterol: 204mg/dL LDL: 120mg/dL HDL: 34mg/dL Triglycerides: 250mg/dL Which ASCVD risk factors does Alice have? Low HDL, smokes, obesity, HTN, albuminuria 10 year ASCVD risk=42% best recommendation: Lifestyle + initiate a high intensity statin + fibrate

Statin Recommendations

All ages - DM + ASCVD 10 year risk >20% > High intensity statin Under age 40 with CV Risk Factors > Consider moderate intensity statin Age 40-75 without CV Disease > Moderate intensity statin ASCVD Risk include: LDL >100, HTN, Smoke, CKD, albuminuria, family hx ACSVD

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. Benefits: -improves knowledge -lowers a1c -improve quality of life -reduced all cause mortality -reduced healthcare costs -increased primary care and preventative services -less frequent use of acute care and inpatient admissions -more likely to follow best practice recommendations (esp those with Medicare) **only 5-7% of medicare pt's received DSME

Other Hypertension Meds 2

Alpha 1 blockers (Doxazosin, Prazosin, Terazosin) -Vasodilator, risk of orthostatic hypotension -Often used for people with DM + benign prostatic hypertrophy (BPH) Alpha 2 agonists (Clonidine, Methyldopa) -Centrally acting -Administer with a diuretic -Side effects: sedation, dry mouth, orthostatic hypotension, impotence -Avoid abrupt discontinuation

At what point is BP meds started?

Always consider lifestyle management: initial BP >140/90 and under <160/100 mgHg (start one agent) -if patient does not have albuminuria or CAD start ACEI, ARB, CCB, diuretic -if patient has albuminuria or CAD start ACEI or ARB OR Initial BP >160/100 mgHg (start two agents) -if patient does not have albuminuria or CAD start drug from 2 of 3 options: ACEI or ARB, CCB, diuretic -if patient has albuminuria or CAD, start ACEI or ARB and CCB or diuretic **Calcium channel blockers (CCBs), Angiotensin receptor blockers (ARBs), Angiotensin-converting enzyme inhibitors (ACEIs) **for best effect, administer at least one at bed time **avoid ACEi and ARB at the same time

Glimepriide

Amaryl Sulfonylureas Increases insulin secretion from pancreatic beta cells

Ambulatory Glucose Profile (AGP)

Ambulatory Glucose Profile (AGP)

Disaster Readiness

American Red Cross Shelters: Contact the American Red Cross directly at 1-800-RED- CROSS. Resource For Health Care Providers: Insulin Supply Hotline: During a disaster, call the emergency diabetes supply hotline 314-INSULIN (314-467-8546) if you know of diabetes supply shortages in your community (i.e. shelter, community center). Hotline is for health care providers only.

Blood pressure treatment strategies

Assess BP at every office visit If BP >120/80 encourage lifestyle changes to reduce blood pressure Lifestyle changes -weight loss -DASH style diet (fresh fruit, veggies, whole grains, reducing sodium and increasing potassium intake) -moderation of alcohol intake -increased physical activity

Psychosocial Issues - Youth with diabetes

Assess for diabetes-related distress, generally starting at 7-8 years of age Offer appts by themselves with provider(s) starting at age 12 years Begin screening youth with type 1 diabetes for distress and eating disorders between 10 -12 years of age. The Diabetes Eating Problems Survey- Revised (DEPS-R) Problem Areas in Diabetes-Teen (PAID-T) and Parent (P-PAID-T) Both reliable, valid, and brief screening tools

Hypoglycemia considerations

Assess hypoglycemic episodes at each visit 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 may need to increase BG thresholds -Assess cognitive function and safety

Medtronic 670G & 770G

Auto Mode adjusts basal rates every 5 min. based on sensor glucose Indicated ages ≥ 7 years (670G) and ages ≥ 2 years (770G) with TDD ≥ 8 units Guardian 3 continuous glucose monitor (CGM) - 7 day wear time - Requires charging between use - 2-4 calibrations/day Suspend before/on low options (in manual mode) Additional BG checks to stay in auto mode BG target=120 Temp target of 150 available 300 unit reservoir Connected contour meter (670G) or Accu-check Guide (770G) Mobile app for data sharing/viewing with 770G

Hybrid-Close Loop (HCL)

Automates insulin delivery based on CGM readings All systems auto-adjust basal rates Some systems give auto-corrections All systems require the user to bolus for carbohydrates Requires user to use CGM and maximize time spent in HCL to get most benefits Current systems: Medtronic 670G/770G, Tandem Control IQ Up-coming: Medtronic 780G, Omnipod 5, Beta bionics ilet

Hypoglycemia symptoms

Autonomic: -Anxiety -Palpitations -Sweating -Tingling -Trembling -Hypoglycemic Unawareness Neuroglyopenia -Neuroglycopenia is a shortage of glucose (glycopenia) in the brain, usually due to hypoglycemia. Glycopenia affects the function of neurons, and alters brain function and behavior. Prolonged or recurrent neuroglycopenia can result in loss of consciousness, damage to the brain, and eventual death. -Irritability -Drowsiness -Dizziness -Blurred Vision -Difficulty with speech -Confusion -Feeling faint

Rosiglitazone

Avandia Thiazoledinediones (TZDs) Selective agonist for peroxisome proliferator activated receptor gamma; improves glucose uptake in muscle and fat by improving insulin sensitivity

Management of Diabetes in Pregnancy

Avoid teratogenic meds (ACE Inhibitors, ARBs, Statins) in sexually active women not using reliable contraception Women with pregestational diabetes need baseline eye exam in first trimester, monitor every trimester See Stds of Care for complete listing of labs to monitor

Mr. J Clinical picture after getting to right insulin dose

BEFORE Triglycerides 780 46 years old Fatty liver disease BMI 34,Weighs 100kg Stopped insulin a month ago Metformin 1000 mg BID A1c 11.9% AFTER Triglycerides 140 A1c 7.0 - 7.5% No hypos Requires 4.0 units/kg Feels more hopeful

Hypoglycemia Level Actions

BG <70mg/dl - level 1 -follow 15/15 rule (15g carbs > 15 min > check BG > repeat PRN if not 80+ > meal) and contact provider to make needed changes** BG <54 mg/dl - level 2 -indicates serious hypo. Contact provider for medication change. Use Glucagon emergency kit).** Severe Hypoglycemia - Level 3 -requires external assistance - no threshold **If BG less than 40, allow recovery time. Gives carbs after treating wtih glucagon.

Adjusting Robs Bolus Insulin With Ratios - You Try 2

BG before breakfast 61, plans to eat 45 gms of carbohydrate. 45 g carbs / 13 g carb to insulin ratio = 3.46 units 61 - 130 = -69 /50 = -1.38 units insulin 3.46 -1.38 = 2.08 units insulin

Adjusting Robs Bolus Insulin With Ratios - You Try 1

BG before lunch 230, plans to eat 75 gms of carbohydrate. 75 g carbs / 13 g / unit insulin = 5.77 unit insulin 230 - 130 = 100 mg/dl BG / 50 (insulin sensitivity factor = 1 unit brings down BG by 50 points) = 2 7.77 units = 8 units insulin for that meal

Cindy continued: Adjusting Cindy's Bolus Insulin With Ratios

BG before lunch 285, she plans to eat 60 gms of carbohydrate 165 over target 1700/30 = 55 points decreased by 1 unit insulin 450/45 = 15 carbs to 1 unit of insulin 120 (target) + 165 (over target) = 285-120 = 165/55 = 3 units of insulin for correction of current blood sugar Ate 60 g carb for meal = 60g/15g per 1 unit insulin = 4 units of insulin for carbs Take 7 units humalog bolus 15 minutes before meal

PrePregnancy BMI and risk of GDM

BMI determines odds ratio of GDM and dose-dependently increases risk of GDM <20 = 0.75 25-29 = 1.97 30-35 = 3.01 >35 = 5.55 55% of women enter pregnancy at BMI >25 less than 30% of women gain recommended gestational wt

Blood pressure goals

BP goal <140/90 -if 10 year ASCVD risk <15% (ADA) BP goal <130/80 (AACE, ACC/AHA) -if ASCVD risk >15% (ADA) BP target based on individual assessment and shared decision making that addresses CV risk and potential adverse effects of BP meds. Prompt initiation of drug therapy when BP is above target

BP and diabetes targets

BP target <140/90 if ASCVD risk <15% BP target <130/80 if 10-year ASCVD risk >15% During pregnancy, with previous history of HTN B/P Target of 110 ‐135/85

Hospital Stay - Need orders

Backup plan in case pump can't be used Don't stop pump without administering rapid insulin first (or IV insulin). Designate surrogate programmer(s) Specify frequency and carb count for meals/snacks Keep pump and programmer outside room during MRI, CT Scan, Xray. Don't aim Echo/US transducer at pump CGM - Remove infusion set and sensor for MRI -Hospital meter to determine BG levels

Risk of Future Diabetes after Gestational Diabetes

Immediately after birth = 5-10% have DM2 6-12 weeks later = 10% dx'd with DM, 20% have pre-diabetes 36 months later = 30% have metabolic syndrome 5 years later = 50% have DM2

Case study continued

Basal + Metformin 2000mg daily, DM, 60kg, 10.1% Day, Breakfast, Lunch, Dinner, HS Day 1: 170s, n/a, n/a, 298 10uLantus Day 2: 160s, n/a, n/a, 233 20u Lantus Day 3: 140s, 303, 335, 206 30u Lantus Add on changes? PM Lantus Dose 15 units Max Add GLP-1 RA or basal insulin/GLP combo (iGlarlixi or IDegLira) Add 1 bolus injection at largest meal Switch to 70/30 30 x 0.8 = 24 units total (16 units am and 8 units pm) Consider adding SGLT2 to preserve kidney function

Basal Bolus - Using 50/50 Rule - Participant weighs 80kg. Adjustments?

Basal Bolus - Using 50/50 Rule - Participant weighs 80kg. Adjustments? Day, Breakfast, Lunch, Dinner, HS insulin dose of Humalog and Detemir Day 1: 84, 89, 145, 190 Day 1: 6H, 7H, 7H, 20u Det Day 2: 81, 97, 107, 133 Day 2: 6H, 7H, 7H, 20u Det Day 3: 79, 104, 124, 110 Day 3: 6H, 7H, 7H, 20u Det Day 4: 69, 103, 208, 193 Day 4: 6H, 7H, 7H, 20u Det 1) decrease Detemir by 20% to 16 units. (20 * .80 = 16) This will increase morning blood sugars and lunch blood sugars a bit as well titrate insulin over 2-4 days because you may see lower blood sugars over time when insulin is in the sweet spot for controlling bloood sugars optimally.

Case Study 3

Basal Bolus - What Adjustments? Participant weighs 80kg Day, Breakfast, Lunch, Dinner, HS units of insulin Day 1: 69, 79, 245, 190 Day 1: 7H, 5H, 8H, 22u Det Day 2: 81, 87, 170, 133 Day 2: 7H, 5H, 8H, 22u Det Day 3: 73, 94, 194, 110 Day 3: 7H, 5H, 8H, 22u Det Day 4: 62, 83, 211, 127 Day 4: 7H, 5H, 8H, 22u Det Decrease detemir by 20% to 18 units 50/50 Rule (0.4-1 units/kg / day)g: -80kg *0.5 = 40 units of total insulin per day Basal = 50% of total insulin (Glargine QD, NPH or Detemir BID) -Glargine 20 units 1x daily -NPH/Detemir 10 units BID (also consider 2/3s for breakfast, 1/3 for dinner) Bolus dose = 50% of total, divided into 3 meals 20/3 = 6.67 units = 6 units for breakfast, 7 units for lunch, 7 units for dinner (assuming lunch/dinner are large) of rapid acting insulin

Insulin Therapy Components

Basal insulin - long acting insulin covers between meals and through night Prandial or meal insulin - a bolus insulin that covers food, IV dextrose, enteral nutrition, TPN or other nutritional supplements Correction insulin - bolus insulin dosed to correct for hyperglycemia that occurs despite use of basal and prandial insulin Usually given before meals w/ prandial insulin

Bolus vs Basal/background insulin coverage

Basal insulin covers blood sugars in between meals and through the night Bolus insulin covers post-meal blood sugars

Insulin Terminology

Basal rate - a continuous 24-hour delivery of insulin, "background" insulin Bolus dose - used for carbohydrate and correction doses Insulin-to-carb ratio - how many grams of carbs will be covered by 1 unit of insulin Insulin sensitivity factor (aka correction bolus or ISF) - how much 1 unit of insulin is expected to lower glucose Target - the goal glucose level Insulin-on-board (aka active insulin time or IOB) - a pump feature that keeps track of a previous bolus

Adjusting Bolus and Correction Doses Carbohydrate-to-Insulin Ratio

Based on three questions before meals: 1. How much carbohydrate am I going to eat? 2. What is my insulin dose for this amount of carbohydrate? 3. Should I lower the dose because I plan to be very active or have recently been active?

How often to check BG level

Be realistic!! Type 2 on orals - Medicare covers 100 strips for 3 months Based on individual - Consider: Types and timing of meds Goals Ability (physical and emotional) Finances / Insurance ***User error is the most common reason for inaccurate results

How Often Should I Check blood sugar levels?

Be realistic!! Type 2 on orals - Medicare covers 100 strips for 3 months Based on individual - Consider: Types and timing of meds Goals Ability (physical and emotional) Finances / Insurance

Alternate Method for ICR based on pre and post prandial blood sugar readings.

Below is your patient's food diary and blood glucose log: Pre-breakfast=6.8 Had 2 slices of white toast and a glass of diet coke. Took 5 units of Humalog. 2-hour PC BG= 70 2 white toast = 30 carbs. Diet coke = 0 carbs. Total carbs= 30/5 Humalog= 1:6 ICR. Pt went low so too much Pre-lunch= 5.2 Had 2 cups of salad, 2 medium apples and 3 boiled eggs. Took 2 units of Humalog. 2 hr PC BG= 142 Salad= 0 carbs, 2 medium apples= 32 gram of carbs, 3 boiled egg= 0 carbs. Total carbs= 30/2 Humalog= 1:16 ICR. Pt was on target after meal, so this is a good ICR Pre-supper= 5.8 Had a 6 oz steak, 1 cup of mashed potatoes, 1 cup of salad, 1 cup of boiled rice and a cup of unsweetened tea. Took 5 units of Humalog. 2 hr PC BG= 229 Steak=0 carbs, mashed potatoes= 57 gram, salad= 0 carbs, boiled rice= 39 gram, tea= 0 gram. Total carbs= 96 grams/5 Humalog= 1:20 ICR. Pt was above target so not enough. Comparing all the different ICR the patient used it seems that the 1:15 ratio is best.

Other cholesterol medications

Bempedoic acid (Nexletol): indicated as adjunct to diet and max tolerated statin for treatment of familiar hypercholesterolemia or established ASCVD who require additional LDL lower Dose: 180mg PO daily

Beta-blockers (-ols)

Beta-blockers reduce the heart rate, the heart's workload and the heart's output of blood, which lowers blood pressure. What the Medication Does Decreases the heart rate and force of contraction, which lowers blood pressure and makes the heart beat more slowly and with less force. Reason for Medication Used to lower blood pressure. Used for cardiac arrhythmias (abnormal heart rhythms) Used to treat chest pain (angina) Used to help prevent future heart attacks in patients who have had a heart attack. Acebutolol (Sectral) Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol/hydrochlorothiazide (Ziac) Bisoprolol (Zebeta) Metoprolol (Lopressor, Toprol XL) Nadolol (Corgard) Propranolol (Inderal) Sotalol (Betapace)

What is binge drinking?

Binge drinking is 4 or more drinks in 2 hours. 1 drink equals: • 1 oz spirits • 5 oz wine • 12 oz beer

Blood vessel dilators (vasodilators)

Blood vessel dilators, or vasodilators, can cause the muscle in the walls of the blood vessels (especially the arterioles) to relax, allowing the vessel to dilate (widen). This allows blood to flow through better. What the Medication Does Relaxes blood vessels and decreases blood pressure. A category of vasodilators called nitrates increases the supply of blood and oxygen to the heart while reducing its workload which can ease chest pain (angina). Nitroglycerin is available as a pill to be swallowed or absorbed under the tongue (sublingual), a spray, and as a topical application (cream). Reason for Medication Used to ease chest pain (angina) Isosorbide dinitrate (Isordil) Isosorbide mononitrate (Imdur) Hydralazine (Apresoline) Nitroglycerin (Nitro Bid, Nitro Stat) Minoxidil

Bread, Cereal, Grain, Pasta, and Rice 15 g Carb Servings

Bread: -Bagel (1⁄3 large bagel or 1 oz) -Biscuit (21⁄2 inches across) -Bread, white or whole wheat, pumpernickel, rye (1 slice or 1 oz) -Bun, hamburger/hot dog (1⁄2 bun or 1 oz) -Crackers, saltine or round butter (4 to 6) -English muffin (1⁄2) -Melba toast (4 slices) -Oyster crackers (20) -Pancake or waffle (4 inches across) -Stuffing (1⁄3 cup) -Tortilla, corn or flour (6 inches across) Cereals: -Bran cereal, flakes (1⁄2 cup) -Cold cereal, unsweetened (3⁄4 cup) -Cold cereal, sugar-coated (1⁄2 cup) -Cooked cereal, oatmeal, grits (1⁄2 cup) -Granola (1⁄4 cup) -Puffed cereal (11⁄2 cups) Grains (cooked): -Barley (1⁄3 cup) -Couscous (1⁄3 cup) -Pasta (1⁄3 cup) -Quinoa (1⁄2 cup) -Rice, white or brown (1⁄3 cup)

The Type 1 Honeymoon

By diagnosis, 15-40% of beta cell function remains Positive antibodies: GAD, ICA, IAA Length of honeymoon varies -10-15% of teens and adults still have clinically significant insulin production > 5 yrs after DM onset (DCCT, NEJM 1993) -Rate of beta cell loss is correlated with age Younger patients tend to have shorter honeymoons

Exenatide Extended Release

Bydureon, Bydureon BCise Noninsulin Injectables Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon

Exenatide Immediate Release

Byetta Noninsulin Injectables Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon

Bolus Rates - Same for each meal to start

CHO Ratio -Start with 1:15 or -450 divided by TDD= I:C Ratio Correction/sensitivity 1700 divided by TDD Active insulin/insulin On Board -3-6 hours Time in Range target: 70-180 mg/dl

Diabetes and Chronic Kidney Disease (CKD) Considerations

CVD leading cause of death in CKD microalbuminuria = increased risk of CVD 1/4 to 1/3 of insulin cleared by kidney renal retinal syndrome 70 - 80% of people with diabetes DON'T get kidney disease Early and aggressive intervention crucial

If on insulin or sulfonylurea - special precautions required

Carb source on person, car, by bed at all times (4 glucose tablets, 2 tbsp raisins, 2 honey packets) Identification -phone in case of emergency -wallet card -bracelet If pattern of lows, medication adjustment Premeal target / fasting 80-130 mg/dl (or <110) Post meal less than 180 (or < 140) Bed time 110-180

Bolus Basics

Carbohydrate/ Prandial Coverage -Match the insulin to the carbohydrates -1 unit insulin for 15 gms - Common starting point -Or can use Carb/Insulin ratio formula Correction Bolus - targets hyperglycemia -1 unit for every 30-50 points over target -Use 1500 - 1800 rule Adjust ratios depending on sensitivity and response

Hypoglycemia Prevention Strategies for Insulin/Secretagogues

Carry carb snack/ glucagon ER Kit Extra Carb in post exercise period Caution with alcohol post exercise Adjust carbohydrate prior to planned activity: If using insulin and /or secretagogues BG < 90, consume 15 -30 gms BG 90-150, may need ~ 15gms

Cataracts

Cataracts - elevated glucose levels glycosylate lens, decreasing permeability Treatment = surgery

Effect of Corticosteroids

Cause insulin resistance Promote glucose production inliver Decrease insulin production Cause post meal hyperglycemia (esp late afternoons) Impair immune system Steroid Induced Hyperglycemia (SIH) Situations No prior history of diabetes / started on steroid BG levels may increase during steroid, but normalize when stopped (still at future risk) BG levels may increase and stay elevated even after steroid stopped (now has diabetes) Either situation requires treatment Has diabetes / started on steroid Monitor BG, can become very hyperglycemic Practical points for SIH No prior history of diabetes Oral agents may work, may need insulin History of DM Insulin needs may increase 2-3 fold Insulin will always lower glucose AM Steroid causes BG to rise post lunch/dinner (lowers overnight) Consider am 70/30 or am NPH Meal time bolus Avoid over night insulin Keep it flexible - adjust insulin to match steroid dose

Central agonists

Central agonists also help decrease the blood vessels' ability to tense up or contract. The central agonists follow a different nerve pathway than the alpha and beta-blockers, but accomplish the same goal of blood pressure reduction. alpha methyldopa Aldomet* clonidine hydrochloride Catapres* guanabenz acetate Wytensin* guanfacine hydrochloride Tenex*

Diabetes and Charcot Foot

Characterized by damaged nerves, blocked blood vessels, shifting bones, and collapsed arch joints. Neurotraumatic theory: bony destruction due to loss of pain sensation and proprioception + repetitive and mechanical trauma to foot. Neurovascular theory: joint destruction secondary to autonomically stimulated hyperemia and periarticular osteopenia associated with trauma.

Discuss these symptoms with provider before starting exercise or during

Chest pain and/or shortness of breath Leg cramps that go away with rest Head, shoulder, neck and or back aches. Any unexplained pain above the belt line should be considered cardiac in origin until proven otherwise.

Taking an accurate Blood Pressure

Choosing the correct blood pressure cuff size -measure the circumference of your upper arm with a cloth measure tape midway between elbow and shoulder. Choose a cuff size that includes this measurement Conditions for taking your blood pressure at home. 1) rest for 5 minutes before measuring your blood pressure 2) sit in a chair with both feet flat on the ground and back straight 3) place your arm at the level of your heart or chest ***Measure your blood pressure right after you wake up or in the evening before you go to bed. ***Measure your blood pressure at the same time every day

Aspart

Novolog Rapid Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Onychomycosis

Chronic Infection 50% of nail problems We treat on skin but reluctant in nails Mean duration of > 10 years Rarely resolves spontaneously Spreads to other nails, skin, other people May be source of more serious infections Affects quality of life Vicks Vapor Rub? Topical or oral antifungal?

Periodontal Disease

Chronic inflammatory disorder by the anaerobic bacteria invasion into periodontal tissues including gingival connective tissue, periodontal ligament, and alveolar bone. Periodontal disease major stages- gingivitis - inflammation of the gums Periodontitis inflammation and infection of the ligaments and bones that support the teeth

Type 1 and a Teen - 1700 Rule

Cindy is trying to carb count and adjust her insulin, but is still having trouble. She weighs 60kg. 1. Pre meal target BG is 120 2. Post meal goal < 180. 3. Carb ratio: 1 unit for every 15 gms (450/30 units insulin) 4. Hyperglycemic correction factor is one unit for every 55 above goal (she uses Humalog = 1700 rule/30 units insulin) What is her daily dose of insulin? 60kg * 0.5 unit/kg = 30 units What is her basal dose? 60kg * 0.5 unit/kg * 0.5 unit bolus / 24 hours = 0.625 units / hour USE INSULIN SENSITIVITY OF 55 FROM 1700 rule FOR INDIVIDUALIZED CORRECTION BOLUS SCALE correction bolus for cindy: less than 70 = subtract 1 unit 70-120 = 0 units 121-175 = 1 unit 176-230 = 2 units 231-285 = 3 units 286-340 = 4 units 341-395 = 5 units

Type 1 and a Teen case study

Cindy is trying to carb count and adjust her insulin, but is still having trouble. She weighs 60kg. What is her daily dose of insulin? 30 units What is her basal dose? 15 units 1. Pre meal target BG is 120 2. Post meal goal < 180. 3. Carb ratio: 1 unit for every 15 gms 4. Hyperglycemic correction factor is one unit for every 55 above goal (she uses Humalog and 1700 rule) Correction bolus for Cindy less than 70 = subtract 1 unit 70-119 = 0 units 120-175 = 1 unit 176-230 = 2 units 231-285 = 3 units 286-340 = 4 units 341-395 = 5 units adjust cindy's bolus insulin with ratios BG before lunch 285, she plans to get 45 grams of carbs 285-120 = 165 mg/dl over target, 165/55 = 3 units 45 gms / 15 = 3 units 3 units bolus insulin to correct to target 3 units bolus insulin to cover carbs in meal Total adjusted dose: 6 units humalog insulin

Cindy, 60kg, Carb (1u/15gms) Target 120, pre meal, Hyper 1 for 55

Cindy, 60kg, Carb (1u/15gms) Target 120, pre meal, Hyper 1 for 55 blood sugars before meals and at night with humalog insulin day > breakfast (carbs, insulin) > lunch (carbs, insulin) > dinner (carbs, insulin) > HS (carbs, insulin) day 1: 99 (30g, 2 units), 154 (75g 6 units), 128 (60g, 5 units), 69 (15 gm) Takeaway - pattern management is a learning process!

Glycemic threshold values

Classification > BG > physical response lower euglycemia > 80-90s > endogenous insulin Hypoglycemia S/S > 70s > glucagon, adrenaline Hypoglycemia S/S > 60s > growth hormone, cortisol Hypoglycemia S/S > 50s > cognitive deterioration Neuroglycopenia > 30-40s Severe Hypoglycemia > 20s > coma, seizures

Proliferative Diabetic Retinopathy (PDR)

Clinical Findings Ischemia induced neovascularization at the optic disk (NVD) elsewhere in the retina (NVE) Vitreous hemorrhage Retinal traction, tears, and detachment Diabetes Macular Edema must also be evaluated Signs: Blurred central or side vision (left, blurred side vision) or a blind spot in central vision (right) may indicate diabetic retinopathy

Combined Alpha and Beta-Blockers

Combined alpha and beta-blockers are used to treat high blood pressure and heart failure. Carvedilol (Coreg, Coreg CR) Labetalol hydrochloride (Normodyne, Trandate) A noted possible side effect of combined alpha and beta-blockers: May cause a drop in blood pressure when you stand up

Marine-Derived Omega-3 Polyunsaturated Fatty Acids (PUFA)

Commonly referred to as omega-3 fish oils or omega-3 fatty acids, are used in large doses to lower high blood triglyceride levels. They help decrease triglyceride secretion and clear triglycerides. The amount of marine-derived omega-3 PUFAs needed to significantly lower triglyceride (2 to 4 g) is hard to get from a daily diet alone, so supplementing with capsules may be needed. Use these supplements only under a doctor's direction and care, because large doses may cause serious side effects. These can include increased bleeding, hemorrhagic stroke and reduced blood sugar control in diabetics. Negative interactions with other medications, herbal preparations and nutritional supplements are also possible. People with allergies to fish, shellfish or both may have a severe adverse reaction to using these supplements.

Insulin to Carb Ratio Adjustments

Compare pre-meal BG to 2 hour post-meal BG Goal post-meal BG should be 30-60mg/dL higher than pre-meal BG If the 2 hour PPG is >60mg/dL above pre-meal Decrease carb ratio by 10-20% If the 2 hour PPG is <30mg/dL above pre-meal Increase the carb ratio by 10-20%

United kingdom Prospective Diabetes Study - 1998 (UKPDS)

Conducted over 20 years involving over 5,100 patients with Type 2 diabetes 1% decrease in A1c reduces microvascular complications by 35% 1% decrease in A1c reduces diabetes related deaths by 25% B/P control (144/82) reduced risk of: Heart failure (56%) Stroke (44%) Death from diabetes (32%)

Initial Calculations for Continuous Subcutaneous Insulin Infusion (CSII)

Consensus Statement by AACE/ACE insulin pump management task force. Endocr Pract. 2014 May; 20(5):463-89 TDD = total daily dose for insulin TDI = total daily insulin Hypoglycemia patients = start at lower value of method 1 & 2 hyperglycemic, elevated A1c or pregnant - start at high value of method 1 and 2 Method 1: Prepump TDD Prepump TDD * .75 Method 2: Patient weight weight (kg) * .50 ***Starting Pump TDD = Average method 1 and 2 After method 1 & 2 do the following: 1) basal rate = Pump TDD * 0.5 / 24 -start with 1 basal rate, adjust according to glucose trends over 2-3 days -adjust to maintain stability in fasting state (between meals and sleep) -add additional basal according to diurnal variation (dawn phenomenon) 2) carb ratio = 450 (regular insulin) or 500 (rapid insulin) divided by pump TDD -adjust based on low-fat meals with known carb content -acceptable 2-hour post-prandial rise is ~60 mg/dl above pre-prandial BG -adjust carb ratio in 10-20% increments based on post-prandial BG 3) correction ratio = 1700 / pump TDD -sensitivity factor is correct if BG is within 30 mg/dL of target range within 2 hours after correction -make adjustments in 10-20% increments if 2-hr post-correction BGs are consistenlty above or below target Methods to use based on their CURRENT A1c: A1c 6.3% - Method 1 A1c 9.2% - Method 2 A1c 7.5% - Take avg 1 & 2

Intensifying Injectable Therapy - DM2 (IMPORTANT)

Consider GLP-1 RA first Start basal insulin 10 units or 0.1 to 0.2 units/kg day =Titrate up 2 units every 3 days, until FBG at goal If AM hypo, decrease basal insulin 20% Overbasalization if basal >0.5 unit/kg day, add bolus insulin Adding bolus -Start with 10% basal insulin dose or 4 units bolus at largest meal (titration: increase dose by 1-2 units or 10-15% twice weekly) or -Start 1-2 injections bolus with 10% of basal and stepwise increase (then 3 total injections) or -Switch to basal-bolus combo (like 70/30 insulin) - Able to switch NPH to twice daily = 80% of total bedtime NPH dose converted into 2/3's given in the morning and 1/3 given at bed time.(80% if good BG control, 100% if poor BG control)

Lipid Management

Consider fibrates or fish oil when TG>500mg/dL and definitely when TG>1000mg/dL High TG puts people at increased pancreatitis risk Rule out secondary causes In People with ASCVD on a statin with controlled LDL but elevated TG (135-499mg/dL), adding icosapent ethyl can be considered to reduce CV risk (REDUCE-IT trial) In patients with DM + ASCVD, if LDL ≥70mg/dL on maximum tolerated statin, consider adding ezetimibe or PCSK9 inhibitor

Metabolic (Bariatric) Surgery

Consider for adults with: BMI 30-34.9 (27.5 -32.4 for Asian Americans) if hyperglycemia is inadequately controlled despite optimal medical control by either oral or injectable medications. BMI 35 - 39.9 (32.5 -37.4 Asian Americans) when hyperglycemia is inadequately controlled despite lifestyle and optimal therapy BMI 40 + (37.5 for Asian Americans) regardless of BG control Perform metabolic surgery at high volume center with an experienced team Need life long support and monitoring Provide comprehensive mental health assessment prior to surgery and ongoing mental health support

Intensifying Injectable Footnotes

Consider insulin as the first injectable if evidence of ongoing catabolism when A1C levels >10%, BG levels ≥300mg/dL or a diagnosis of type 1 diabetes is a possibility. -can also try adding a sulfonylurea if patient doesn't want insulin Once insulin is started, gradually decrease then stop: -Sulfonylureas -DPP-IV Inhibitors.

Cost vs Benefit of Treating HTN

Consider potential adverse effects of antihypertensive therapy Hypotension, syncope, falls, acute kidney injury, and electrolyte abnormalities Older people, those with chronic kidney disease, and frailty have been shown to be at higher risk People with orthostatic hypotension, substantial comorbidity, functional limitations, or polypharmacy higher risk and may prefer relaxed B/P targets to enhance quality of life.

Glycemic Management of the Patient Receiving Enteral Nutrition

Continuous enteral nutrition (EN) • Basal insulin: 50% of daily dose twice daily • Prandial bolus insulin: 50% given q6h Cycled enteral nutrition • Combination basal/bolus insulin (ie 70/30) given at the start of each tube feeding • Bolus insulin administered q4 to 6 hours for duration of EN administration • Correctional insulin given for BG above goal Bolus enteral nutrition • Rapid acting analog or short acting insulin given prior to each bolus

What is his Carb to Insulin Ratio? Total Daily Dose is 40 units a day

Current Carb ratio: 1 unit for every 10 gms at breakfast 1 unit for every 15 gm at lunch and dinner What should insulin to carb ratio be? Based on current TDD insulin calculation, 1 unit for every 13gms of carb Evaluate post meal glucose levels to evaluate if on target

Rob: What is his Carb to Insulin Ratio? Takes 40 units a day

Current Carb ratio: 1 unit for every 10 gms at breakfast 1 unit for every 15 gm at lunch and dinner What should it be? (also check accuracing with carb counting)

Would you change alice's diabetes regimen?

Current meds Metformin1000mg PO bid Glipizide 10mg PO qam Chlorthalidone 25mg PO daily Escitalopram 10mg PO daily Home monitoring FBG and pre-meal: 110-130mg/dL Denies s/sx hypoglycemia. A1C=6.9%

Assessment for Rob- Decrease Basal

Currently 22 units long-acting insulin -decrease by 10-20% which is 2.2 to 4.4 units because he's having low fasted blood sugars -Rob wants to try 20 units at first -What about considering an insulin pump / CGM? Not ready Provided info Insulin pump calculations -20 units basal / 24 hours = .0833 per hour.

Mr. J started on U-500

Currently taking 120 units 70/30 in am and 100 units in pm Glucose levels in 300 range Started U-500 (decrease by 20%, give 80% of 70/30 dose) -100 units in am -80 units before dinner -Glucose still 300s -Kept increasing 10 units at a time over next 3 months (10 units about once per week) Final dose 180 units am 165 units lunch 140 units dinner = 485 units a day Discovered Milk Intolerance By cutting out milk, blood sugars dropped substantially. Cut evening dose by 2/3rds and decrease breakfast and lunch by 20 units

Bromocriptine

Cycloset Dopamine Agonists Dopamine receptor agonist; affects circadian rhythm and leads to increased insulin sensitivity and glucose disposal

Cystic Fibrosis-Related Diabetes (CFRD)

Cystic Fibrosis-Related Diabetes (CFRD) Annual screening starting at age 10 Use oral glucose tolerance test A1C is not recommended as a screening test for CFRD. Treat with insulin to attain individualized glycemic goals. Beginning 5 years after the diagnosis of CFRD, annual monitoring for complications of diabetes is recommended

Review of CGM - DATAA acronym

D - download data -key metrics, ambulatory glucose profile (AGP), day by day or spaghetti graph -start with global overview: what AGP, key metrics mean, ask what the person learned, what is going well with self-management A - assess safety -hypoglycemia - identify times below range, % time in hypoglycemia, #events -interactive discussion: possible causes and solutions T - Time in Range -focus on the positive - identify days or times when time in range in the highest -interactive discussion: how to replicate what is working well A - areas to improve -hyperglycemia - identify times above range, % time in hyperglycemia, # events -interactive discussion: possible causes, solutions, and adjustments to self-management A - Action Plan -develop collaboratively with the person with diabetes **At each step, express this information is a process and is just that, information to improve upon Isaacs D, Cox C, Schwab K, et al. Technology Integration: The Role of the Diabetes Care and Education Specialist in Practice. The Diabetes Educator. 2020;46(4):323-334. doi:10.1177/0145721720935123

Extreme Hyperglycemia - DKA = Severe Catabolic State

DKA - profound insulin deficiency Cells can't use glucose for fuel Excess counter regulatory hormones: glucagon, epinephrine, and cortisol render insulin less effective Lipolysis leads to FFA's and ketones Osmotic diuresis, dehydration, electrolyte imbalances, acidosis, Lipogenesis, hyperosmolarity Liver increases glucose release and cells become more insulin resistance *glycogenolysis *gluconeogenesis (muscle tissue) *lipolysis

Diagnosis Criteria for DKA vs HHS

DKA vs HHS plasma glucose: >250 versus >600 mg/dl arterial pH: <7.0-7.3 versus >7.3 serum bicarbonate: <10-18 versus >18 mEq/L Urine or serum ketones: postive versus negative urine or serum B-hydroxybutyrate (mmol/L): >3.0 versus <3.0 effective serum osmolality: variable versus >320 mOsm/kg Anion gap: >12 versus variable Mental status: alert, drowsy, stupor/coma (with worsening DKA severity) vs stupor coma Other charateristics: DKA: usually <40 years old, <2 day symptoms, usually DM1, 3-10% mortality HHS: usually >60 years old, >5 day symptoms, usually DM2, 10-20% mortality

Treatment of DKA vs HHS

DKA: 1. Insulin - correct glucose, pH, ketosis 2. Fluids-rehydrate 3. Correct lyte imbalances 4. Prevent complications 5. Provide Glucose 6. Pt and family ed HHS: 1. Fluids-rehydrate 2. Insulin - correct glucose 3. Correct lyte imbalances 4. Prevent complications 5. Treat underlying medical condition 6. Pt and family ed

DKA (diabetic ketoacidosis) vs HHS (hyperglycemic hyperosmolar crisis)

DKA= absolute insulin deprivation HHS = severe dehydration, usually occurs in older people with comorbidities

Hypoglycemic Risk for DM1 and DM2 during exercise

DM1 -Activity increases exogenous insulin sensitivity and may block glycogenolysis DM2 -Same concern as above if on insulin and sulfonylureas, meglitinides -Low risk if treated by diet, exercise or medications that do not cause hypoglycemia.

Path to DM2

DM2 is a complex metabolic disorder characterized by insulin resistance and deficiency with social, behavioral, and environmental risk factors revealing the effects of genetic susceptibility Ominous octet 1) decreased satiation, neuro-transmission 2) decreased amylin & beta-cell secretion (80% loss at diagnosis) 3) increased renal glucose reabsorption 4) increased glucagon secretion 5) decreased gut hormones (GLP-1, etc) 6) increased lipolysis (breakdown of fat) 7) increased glucose production in the liver (glycogenolysis) 8) decreased glucose uptake (disposal) excessive body weight and abdominal/visceral fat Factors linked with insulin resistance: -abdominal obesity -sedentary lifestyle -genetics/ethnicity -polycystic ovary syndrome -acanthosis nigricans (high insulin levels in blood stream) -obstructive sleep apnea -cancer of the pancreas, liver, and breast -Alzheimer's disease -depression -fatty liver disease

Diabetes Prevention Program (DPP)

DPP reduced risk by 58% for those with prediabetes moving to diabetes Lost 7% of body weight (1-2 lbs a week) -Intervention included: Includes food diary, weekly weighing, coaching, high fiber, low fat, avoid sugar sweetened beverages, reduce total caloric intake Attain 150 mins exercise a week (Exercise without wt loss reduced risk by 44%) 16 group lifestyle sessions in 24 weeks Then monthly for next 6 months Ongoing follow-up and data collection Taught by certified DPP Lifestyle coaches

Diabetes Related Emotional Distress=DRED

DRED - unique emotional issues directly related to the burdens and worries of living with a chronic disease. (embarrassed, guilty) More than worry: can overlap with depression, anxiety and stress. Normal-to some extent Associated with stress of living with diabetes Express high levels stress and depressive symptoms; but not clinical depression Not rare: linked to poor health outcomes How to handle DRED: -take things slowly -set easy goals

What to teach

Daily foot care Visual inspection of feet, including in between toes. As for help if needed. Keep feet dry by regularly changing shoes and socks Report any new sores, discolorations or swelling Inspect and apply lotion to feet every night before bed Shoes Don't walk barefoot, even when indoors. always wear shoes Use good fitting footwear Replace shoes yearly Every time you see your doctor, take off your shoes and show your feet. Report any foot problems right away!

Empowerment Based, Self-Directed Behavior Change Protocol

Define problem -What part of living with diabetes is most difficult or unsatisfying for you? Identify feelings -How does the situation make you feel? Identify long term-goal -How would this situation have to change for you to feel better about it? -What barriers will you face? -How important is it for you to address this issue? -What are the costs and benefits of addressing or not addressing this problem? Identify short-term behavior change experiment -What are some steps that you could take to bring you closer to where you want to be? -Is there on thing that you will do when you leave to improve things for yourself? Implement and evaluate plan -How diet the plan we discussed at your last visit work out? -What did you learn? -What would you do differently next time? -What will you do when you leave here today?

Adaptation to the emotional stress of chronic disease (Kubler-Ross, Rubin RR, WHPolonsky)

Denial: -don't agree but listen -acknowledge -survival skills only! Anger: indicates awareness, -learning begins -be clear, concise, instruct -no long WHY answers Bargaining -identify with others -group classes are good -educate the pt on what he wants to know Depression & frustration: -realize permanence of dsc treatment -psycho-social support referral -emphasize + change made Accept & adapt -sense of responsibility for self-care

Gvoke 1) description 2) supplied 3) dosage range for adults / pediatrics 4) Age / Route / Storage

Description: Injectable liquid stable glucagon solution Supplied: 0.5 mg/1 mg prefilled syringe OR 0.5 mg/1 mg HypoPen auto-injector DOSE RANGE: Adult: 1 mg Peds/Age Wt Dosing: <2 years: NOT RECOMMENDED 2-12 years: <45 kg = 0.5 mg >45 kg = 1 mg 12 years or older = 1 mg Age / Route / Storage: Approved Age 2+ SubQ administration in arm, thigh, abdomen Expires 2 years at room temp (keep in foil pouch)

Baqsimi 1) description 2) supplied 3) dosage range for adults / pediatrics 4) Age / Route / Storage

Description: Nasal glucagon powder Supplied: 3 mg intranasal device DOSE RANGE: Adult: 3 mg Peds/Age Wt Dosing: <4 years: NOT RECOMMENDED >4 years: 3 mg dose Age / Route / Storage: Approved Age 4+ Nasal admin Expires 2 years at room temp (keep in shrink-wrapped tube)

Dasiglucagon (Zegalogue) 1) description 2) supplied 3) dosage range for adults / pediatrics 4) Age / Route / Storage

Description: Stable liquid glucagon analog Supplied: 0.6 mg/0.6 ml prefilled syringe auto-injector DOSE RANGE: Adult: 0.6 mg Peds/Age Wt Dosing: <6 years: NOT RECOMMENDED 6 years or older = 0.6 mg Age / Route / Storage: Approved Age 6+ SubQ administration in outer upper arm, thigh, abdomen, and buttocks Expires 1 year at room temp (store in red protective case)

Hospital Hypoglycemia Prevention

Develop Hypoglycemia protocol Include treatment and Prevention strategies Common causes of hypo: Too much basal insulin (am hypo) Insulin correction scale mismatch Frail, older person with reduced appetite and low GFR Pt is improving - needs less insulin due to less insulin resistance (after surgery recovery for example) Action required when hypoglycemic Determine cause Reduce insulin dose

CGM in the Hospital

Dexcom G6 and Freestyle Libre available for inpatient remote monitoring - FDA has temporarily approved due to the public health crisis of COVID-19 and the need to preserve PPE and reduce hospital staff exposure to coronavirus

Integrated Continuous Glucose Monitoring: The Future

Dexcom G6 and Libre 2 are integrated CGM (iCGM) Integration with digitally connected devices (eg, pumps, pens, automated insulin dosing [AID] systems)

Glyburide

Diabeta, Glynase, Prestabs Sulfonylureas Increases insulin secretion from pancreatic beta cells

Tests to Dx Diabetes

Diabetes 1) A1c >= 6.5%, 2) Fasting Plasma glucose (FPG) >= 126 mg/dl 3) Random Plasma Glucose (RPG) >=200 mg/dl 4) Oral Glucose Tolerance Test (OGTT) 75g - 2 hour plasma glucose (2hPG) >=200 mg/dl *Random = any time of day w/out regard to time since last meal; symptoms include usual polyuria, polydipsia, and unexplained wt loss. Prediabetes 1) A1c = 5.7-6.4%, 2) Fasting Plasma glucose (FPG) >= 100-125 mg/dl 3) N/A 4) Oral Glucose Tolerance Test (OGTT) 75g - 2 hour plasma glucose (2hPG) >=140-199 mg/dl NORMAL 1) A1c < 5.7%, 2) Fasting Plasma glucose (FPG) < 100 mg/dl 3) N/A 4) Oral Glucose Tolerance Test (OGTT) 75g - 2 hour plasma glucose (2hPG) <140 mg/dl

PCOS and related issues

Diabetes 50% of women with PCOS will have diabetes or pre-diabetes by age 40. High blood pressure Greater risk of HTN Cholesterol. Elevated LDL cholesterol and low HDL cholesterol. Sleep apnea. If BMI 25+, increased sleep apnea risk. Depression and anxiety more common Endometrial cancer. PCOS, excess wt, insulin resistance, diabetes, increase risk of developing endometrium cancer

CGM resources

Diabetes Advanced Network Access (DANAtech) danatech.org Association of Diabetes Care and Education Specialists (ADCES) glucose monitoring resources diabeteseducator.org/practice/educator- tools/diabetes-management-tools/self- monitoring-of-blood-glucose diaTribe diatribe.org Senseonics Eversense eversensediabetes.com Medtronic Guardian Connect hcp.medtronic-diabetes.com.au/guardian- connect Dexcom G6 dexcom.com/g6-cgm-system Abbott FreeStyle Libre freestylelibre.us

When to consider referral to mental health provider for evaluation and treatment

Diabetes distress even after tailored education Screens positive for depression, anxiety, Fear of Hypoglycemia (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

Diabetes & Cancer

Diabetes is associated with immunosuppression, chronic inflammation and lymphocyte dysfunction all of which are implicated in hematological malignancies. Other mechanisms for increased risk may include: hyperinsulinemia, IGF overproduction and upregulation of IGF-1 receptor Excess weight also a contributor. However, the extent diabetes independently contributes to risk of hematological malignancy has not been determined. Both type 1 and type 2 have increased risk of cancer, but type 1s a little less Studies indicate that metformin can decrease cancer risk

Aspart Protamine and Aspart 70/30

Novolog 70/30 Premixed Insulin Combinations Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Diabetes tablet/non-insulin injectables considerations

Diabetes medications can be used as monotherapy, in combo or with insulin Meds reduce A1c 0.5 - 2.0% Each new added class drops A1c an additional 0.7- 1.0% Not to be used during preconception, pregnancy or when breastfeeding Factors important to consider matching meds to individuals: insurance coverage, ability to self-manage, willingness to take meds, and glucose history

Diabetic Neuropathy (DN)

Diabetic Neuropathy (DN) = demonstrable nerve disorder and destruction, either clinical or subclinical- that occurs w/ diabetes, w/out other causes (10% of neuropathy due to other causes) 2 abnormalities present (symptoms, signs, abnormal quantitative test results)

DM1 new dx in children

Diagnosis in infancy rare 75% new cases diagnosed before age 18 30% of new diagnosis present in DKA Complaints include: Nocturia, enuresis, weeks of polyuria, polydipsia, wt loss, tired, infections. Polyphagia is rare. Labs indicate hyperglycemia, glycosuria, ketonemia and ketonuria when someone is diagnosed with DM1 about 15-40% of pancreas function remains

Nutrition for Pregnancy

Dietary Reference Daily Intake 175 gms carb /day 71 gms of protein /day 28 gms of fiber /day Avoid ketonemia from ketoacidosis or starvation ketosis -Make sure consuming sufficient carbs -Monitor urine ketones

Other Hypertension Meds 1

Direct renin inhibitors (Alsikiren-Tekturna®) -Similar side effects to ACEi/ARB, rarely used in clinical practice Combined alpha and beta blockers (ex. Carvedilol) -Similar precautions as beta blockers Loop diuretics (Furosemide, Torsemide, Bumetanide) -Use when eGFR<30 or if greater diuresis is needed, monitor electrolytes Potassium sparing diuretics (ex. Amiloride, Triamterene) -Use in combination with thiazide to retain potassium, minimal effect on BP

Thiazide diuretics (-ones, -ides)

Diuretics help the body get rid of excess sodium (salt) and water and help control blood pressure. They are often used in combination with additional prescription therapies. What the Medication Does Causes the body to rid itself of excess fluids and sodium through urination. Helps to reduce the heart's workload. Also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods. Reason for Medication -Used to help lower blood pressure. -Used to help reduce swelling (edema) from excess buildup of fluid in the body. Acetazolamide (Diamox) Amiloride (Midamor) Bumetanide (Bumex) Chlorothiazide (Diuril) Chlorthalidone (Hygroton) Furosemide (Lasix) Hydro-chlorothiazide (Esidrix, Hydrodiuril) Indapamide (Lozol) Metalozone (Zaroxolyn) Spironolactone (Aldactone) Torsemide (Demadex)

Potassium-sparing diuretics

Diuretics help the body get rid of excess sodium (salt) and water and help control blood pressureDiuretics help the body get rid of excess sodium (salt) and water and help control blood pressure. They are often used in combination with additional prescription therapies.. They are often used in combination with additional prescription therapies. Diuretics help the body get rid of excess sodium (salt) and water and help control blood pressure. They are often used in combination with additional prescription therapies. amiloride hydrochloride (Midamar*) spironolactone (Aldactone*) triamterene (Dyrenium*)

What to ask in 1 minute for foot assessment

Do they have a history of: Diabetes - what is A1c? Previous leg/foot ulcer or LE amputation Prior angioplasty, stent or leg bypass surgery Foot wound that took > 3 wks to heal Smoking or nicotine use Do they have: Burning or tingling in feet Leg or foot pain with activity or at rest Changes in skin color or skin lesions Loss of lower extremity sensation? Also: "If there is ANY foot problems, take off your shoes and socks and show your feet!" with providers Complete foot exam annually More frequent checks on those at high risk Keep close eye if loss of protective sensation, foot deformities, or a history of foot ulcers

Bolus Pattern Management

Does glucose go low after a correction dose? May need a higher sensitivity e.g. 1:60 instead of 1:50 Does glucose remain high after a correction dose? May need a lower sensitivity e.g.. 1:40 instead of 1:50 Often people are more sensitive overnight (less insulin needed) Does the person spike high after eating? Is the person bolusing BEFORE the meal Counting carbs correctly? May need a more intensive carb ratio e.g.. 1:6 instead of 1:8 Does the person go low after eating? Counting carbs correctly? May need a less intensive carb ratio e.g. 1:10 instead of 1:8 Adjustments typically made 10-20% at a time for insulin-to-carb ratio AND insulin in general

Ranges of Insulin Dosing for DM1 and DM2

Dose = units of insulin/kg/day DM1 = 0.25 to 1 units of insulin/kg/day (median is .6 units/kg/day) DM2 = .75 to 2.25 units of insulin/kg/day Other outliers: 2.25 to 3+ units of insulin/kg/day **If taking more than 200 units per day consider higher concentration insulin U-500 (u-500 contains 5 times the concentration of insulin than u-100 per ml.) U-100 insulin = 100 units of insulin per mL U-500 insulin = 500 units of insulin per mL U-500 insulin 20 ml per vial * 500 units per ml = 10,000 units/vial

Covering Carbs with Insulin

Dose based on: Grams of carb in meal Insulin carb ratio or fixed dose? Right dose? Brings glucose to prebolus glucose level within 3-4 hours If BG rises more than 60 - 80 points 2 hours post meal, needs adjustment If BG falls more than 30 points 2 hours post meal, may need adjustment Adjust in small increments (10-20% ideal) <<<< if glucose rising post-meal <<<< 1:3, 1:4, 1:5, 1:6, 1:7, 1:8, 1:9, 1:10, 1:12, 1:14, 1:16, 1:18, 1:20, 1:25, 1:30, 1:35, 1:40, 1:50 >>>> if glucose dropping post-meal >>>>

Dosing Strategies u-500

Dosing - take total daily needs and split into 2-3 doses -2 doses: 60% am / 40% pm or -3 doses: 40/30/30 or 40/40/20 No basal insulin needed, because U-500 has bolus and basal action Needs careful monitoring/ education Example - Pt on 240 units of insulin a day 140 units am / 100 units pm (2 doses) 100 / 70 / 70 or 100 / 100/ 40 (3 doses)

A1c in Pregnancy

Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy A1C represents an integrated measure of glucose, may not fully capture postprandial hyperglycemia, which drives macrosomia. Thus, A1c is a secondary measure of glycemic after self-monitoring of blood glucose. May need to measure monthly Or use fructosamine (measures 2-3 week albumin glycosylation)

Older Adults at Risk for Malnutrition

Due to: Altered taste and smell Swallowing difficulties Oral/dental issues Functional difficulties shopping for/preparing food Anorexia Overly restrictive eating patterns -carb deprivation Self-imposed or provider/partner directed

Signs and Symptoms of Hyperglycemia

Early signs and symptoms Recognizing early signs and symptoms of hyperglycemia can help you treat the condition promptly. Watch for: Frequent urination Increased thirst Blurred vision Fatigue Headache Later signs and symptoms If hyperglycemia goes untreated, it can cause toxic acids (ketones) to build up in your blood and urine (ketoacidosis). Signs and symptoms include: Fruity-smelling breath Nausea and vomiting Shortness of breath Dry mouth Weakness Confusion Coma Abdominal pain

Signs and Symptoms of Hypoglycemia

Early warning signs and symptoms Initial signs and symptoms of diabetic hypoglycemia include: Shakiness Dizziness Sweating Hunger Fast heartbeat Inability to concentrate Confusion Irritability or moodiness Anxiety or nervousness Headache Nighttime signs and symptoms If diabetic hypoglycemia occurs when you're sleeping, signs and symptoms that may awaken you include: Damp sheets or nightclothes due to perspiration Nightmares Tiredness, irritability or confusion upon waking Severe signs and symptoms If diabetic hypoglycemia isn't treated, signs and symptoms of severe hypoglycemia can occur. These include: Clumsiness or jerky movements Inability to eat or drink Muscle weakness Difficulty speaking or slurred speech Blurry or double vision Drowsiness Confusion Convulsions or seizures Unconsciousness Death, rarely

Infant and Toddler Educational Approaches

Education directed toward parents/primary caregivers Provide child with limited choices teach parents signs of hypoglycemia pallor, listlessness, crying, clammy skin, sleepy, hunger, restless, shakiness

Preschool children (3 - 5) Educational Approaches

Engage in magical thinking play therapy helpful to express concerns Concerned about intactness of body Reassure them that body will remain intact, use Band-Aids after injection Give limited choices Would you like your injection on your right side or left side? Can identify s/s hypo and alert adults Provide education to staff in preschool/daycare

Insulin Pump Canditates: lifestyle indicatiosn and attributes

Erratic schedule Varied work shifts Frequent travel Desire for flexibility Tired of MDI Athletes -temporary basal adjust -disconnect options -waterproof options

Pre Insulin Pump Knowledge / Education

Establishment of Goals Competence in Carb counting Insulin Carb Ratios (ICR) & Correction or sensitivity factor (CF) Ability to manage hyper and hypoglycemia Self-adjust insulin Carbs Correction Physical activity Alcohol intake Ability to fill and insert cartridge/reservoir and insert and change infusion sets Ability to detect infusion set and site issues Manage sick days, exercise and travel Trouble shoot and ability to solve pump issues Understand BG Data Hypo prevention and treatment Basic of basal bolus therapy and how to switch back to injections if needed

Prevent DKA and Hyperglycemia

Eval sites for malabsorption, make sure to change site and infusion sets every 2-3 days Protect insulin from overheating Tubing or infusion set clogs - change site Check for leaks, smell for insulin, use angled sets Make sure to purge air bubbles before priming tube Inspect daily for dislodgement Correct priming technique when changing infusion set Extended pump suspension or disconnect? Limit suspension to one hour, always have back- up syringes

Reducing Risk of Hypo

Evaluate Kidney function If creat >1.4, GFR < 60 Give long acting insulin in morning Made need lower dinner bolus insulin Avoid long acting sulfonylureas - - glipizide best choice in am Evaluation Hypoglycemia awareness and action Assess food access and timing Ongoing monitoring and problem solving

insulin calculation practice example

Example - JR weighs 70 kg, TDD 30 units, A1c 7.5% Which method would you use? Figure out the average first because his A1c is in the 7% range method 1 - based on TDD -30 units * .75 * .5 / 24 =.47 method 2 - based on body weight -70 kg * .5 * .5 / 24 = .73 Average both because his A1c is ~7 = 0.6 units per hour (basal rate)

Basal rate calculation case study 2

Example - KL weighs 40 kg, TDD 20 units, A1c 6.2% Method 1 - Based on TDD 20 x.75 = 15 units total daily dose 15 x 0.5 = 7.5 units for basal 7.5 divided by 24 hrs = .31 units/hr (basal rate) Method 2 - Based on body wt 40kg x 0.5 = 20 units 20 x 0.5 = 10 units for basal 10 divided by 24 hours = .416 (.42) units/hr (basal rate) Which method would you use? Method 1 due to lower A1c

Basal rate calculation case study 1

Example - LS weighs 80 kg, TDD 50 units, A1c 8.2% Method 1 - Based on TDD 50 x.75 = 37.5 units total daily dose 37.5 x 0.5 = 18.75 units for basal 8.75 divided by 24 hrs = 0.78 units/hr (Basal rate) Method 2 - Based on body wt 80kg x 0.5 = 40 units 40 x 0.5 = 20 units for basal 20 divided by 24 hours = 0.83 units/hr (Basal rate) Which method would you use? Method 2 because her A1c is high

Insulin Approach Post Insulin Drip - SQ Basal Bolus or Usual Dose

Example: Pt weighs 100 kg 100 kg x 0.5 = 50 units total daily dose 50% basal = 25 units basal Plus correction bolus insulin or 25 / 3 meals = 8 units per meal + correction if needed Give Sub-q insulin at least 2 hours before stopping insulin drip **If frail elderly may consider just basal insulin. If already on insulin therapy, can resume usual dose. Watch for hypoglycemia.

AM Hyperglycemic Issue and Solutions

Excessive Glucose Production = solve with exercise, metformin or HS basal insulin Rebound Hyperglycemia or Somogyi Effect = prevent PM hypoglycemia check meds Dawn phenomena = solve with HS basal insulin or insulin pump

Washington Post - Heavy Drinking has been normalized for women. That's dangerous. 2016

Excessive drinking for women in US is defined as anything more than one drink a day. Women have smaller bodies than men, blood- alcohol levels climb faster and stay elevated longer. Women make less alcohol dehydrogenase enzymes than men to break down alcohol. According to CDC, women are more prone to suffer brain atrophy, heart disease and liver damage from heavy drinking. Women who drink have an increased risk of breast cancer. Females more susceptible to the unwanted biological effects of alcohol than men, even when adjusted for weight.

Exercise: A hard truth

Exercise alone doesn't cause weight loss But.... It helps keep weight off Decreases visceral fat Decreases CV Risk To combat obesity, we need to change the food environment "You cannot outrun a bad diet"

Hormone Response in DM1

Exogenous insulin remains high Increased insulin sensitivity Increased insulin absorption hyperglycemia risk is high due to too little insulin on board and excess stress hormones Problem solving: -inadequate insulin -high intensity exercise -competitive sports

Referrals for Initial Care Mgmt

Eye professional - dilated eye exam Family planning if reproductive age RD for nutrition therapy DSMES - Diabetes Self-Management Education and support Dentist for comprehensive dental and periodontal examination Mental health professional, if indicated Audiology if indicated

At least 42 factors that affect blood sugar

FOOD 1. ↑↑ carbohydrate quantity 2. →↑ carbohydrate type 3. →↑ fat 4. →↑ protein 5. →↑ caffeine 6. ↓↑ alcohol 7. ↓↑ meal timing 8. ↑ dehydration 9. ? Personal microbiome MEDICATIONS 10. →↑ Dose 11. ↓↑ Timing 12. ↓↑ Interactions 13. ↑↑ Steroids 14. ↑ Niacin (Vitamin B3) PHYSICAL ACTIVITY 15. →↓ Light exercise 16. ↓↑ High/ moderate exercise 17. →↓ Level of fitness/training 18. ↓↑ Time of day 19. ↓↑ Food and insulin timing BIOLOGICAL 20. ↑ Insufficient sleep 21. ↑ Stress and illness 22. ↓ Recent hypoglycemia 23. →↑ During-sleep blood sugars 24. ↑ Dawn phenomenon 25. ↑ Infusion set issues 26. ↑ Scar tissue and lipodystrophy 27. ↓↓ Intramuscular insulin delivery 28. ↑ Allergies 29. ↑ A higher glucose level 30. ↓↑ Menstruation 31. ↑↑ Puberty 32. ↓ Celiac disease 33. ↑ Smoking ENVIRONMENT: 34. ↑ Expired insulin 35. ↑ Inaccurate BG reading 36. ↓↑ Outside temperature 37. ↑ Sunburn 38. ? Altitude DECISION MAKING 39. ↓ Frequency of glucose checks 40. ↓↑ Default options and choices 41. ↓↑ Decision-making biases 42. ↓↑ Family relationships and social pressures

Spot a Stroke : Fast Acronym

Face drooping Arm weakness Speech difficulty Time to call 911

Blood Glucose Goals for GDM and Pre-existing type 1 or 2

Fasting < 95 mg/dl One hour post meal < 140 mg/dl Two hour post meal < 120 mg/dl *A1c < 6 - 6.5% *may need to be relaxed to < 7% if excessive hypoglycemia - A1c lower during pregnancy due to increases RBC turnover rate.

Know these Facts

Fat - 9 cals per gm Carb - 4 cals per gm Protein - 4 cal per gm Alcohol - 7cals per gm Common food carb count Milk is 12 gms of carb 1 lb = 3,500 cals 7,500 to 10,000 steps recommended a day 2000-2300 steps - 1 mile Alcohol serving sizes Women- 1 or fewer alcoholic drinks a day Men 2 or fewer alcoholic drinks a day 1 alcoholic drink equals 12 oz beer 5 oz glass of wine 1.5 oz distilled spirits (vodka, gin etc.) If drink, limit amount and drink w/ food. Can cause hypoglycemia and worsen neuropathy

Special Focus on Hypo

Fear of hypo big barrier to control In 10 - 20% of peds, extra exercise responsible for hypo events At high risk for nocturnal hypo, even if hs BG > 130 Exercise can lower BG 1 - 16 hrs post event Prevention critical: Extra carb to cover extra activity 3 am checks if worried / Continuous Glucose Monitoring May need insulin adjustment

BG Self-monitoring - Why should I do it?

Feel better everyday - sense of control Avoid hospital admissions Fewer missed work /school days Avoid hypoglycemia situations - safety Avoid unwanted weight gain Enhanced athletic performance

Aspart Recombivant

Fiasp Rapid Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Not using insulin/carb bolus ratios?

Fixed dosing -Take half of total daily dose, divide by number of meals to get fixed dose per meal Calculate insulin sensitivity correction factor -1700 by total daily insulin No target BG - choose acceptable target range example: 40 units x 0.5 for basal and bolus 20 units/24 for basal = 0.83 hr 20 units for bolus 20 units/3 meals 6, 6, 7 units per meal plus correction Correction 1700/40 units = 1:43 1 unit insulin decreases BG 43 points

Ambulatory Glucose Report Targets / Time in Range

For most people with type 1 or type 2 diabetes: >70% of readings within BG range of 80-180 mg/d <25% of readings >180 mg/dl <5% of readings >250 mg/dl <4% of readings <70 mg/dl <1% of readings <54 mg/dl

CGM Time in Range Recommendations

For most with type 1 or type 2 diabetes > 70% of readings within BG range of 70-180mg/dL < 4% of readings < 70 mg/dL < 1% of readings < 54 mg/dL < 25% of readings > 180 mg/dL < 5% of readings > 250 mg/dL For under 25 years, with A1c goal is < 7.5%, time-in-range target is set to about 60%.

Time in Range | Older Adults

For older adults or those at high risk for hypoglycemia (ie, hypoglycemic unawareness, cognitive impairment, or comorbidities): > 50% of BG within 70-180 mg/dL < 1% of readings < 70 mg/dL < 10% of readings > 250 mg/dL

Time in Range | Pregnancy

For those with type 1 diabetes and pregnant: > 70% of BG readings within 63-140 mg/dL < 4% of readings < 63 mg/dL < 1% of readings < 54 mg/dL < 25% of readings > 140 mg/dL

Management of Hyperglycemia in Type 2 or GDM 14.14

For type 2s or GDM, oral meds may not be sufficient to get BG to target. Glyburide, Metformin not recommended. -Both cross the placenta to the fetus -Glyburide found in umbilical cord blood at 50-70% of maternal blood level, which is Associated with increased risk of neonatal hypoglycemia and macrosomia

Fried Frailty Index - "Compromised energetics"

Frailty Meeting 3 out of 5phenotypic criteria low grip strength, low energy, slowed waking speed, low physical activity, unintentional weight loss Pre-Frail Stage 1 or 2 criteria are present Identifies a subset at high risk of progressing to frailty

Glucose Monitoring in Pregnancy

GDM - check fasting blood glucose and post prandial BG -Pre-existing type 1 or type 2, may need to also check premeal BG Continuous glucose monitoring (CGM) can help to achieve A1C targets when used in addition to pre- and postprandial glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. not be used as a substitute for monitoring blood glucose to achieve optimal pre- and postprandial glycemic targets CGM Estimated A1C and glucose management indicator calculations not to be used in pregnancy as estimates of A1C.

GDM

GDM affects ~7% of all women GDM prevalence increased 10-100% during the past 10 years Native Americans, Asians, Hispanics, African-American women at the highest risk Immediately after pregnancy, 5 to 10% of GDM diagnosed with DM2 Within 5 years, 50% of developing DM in the next 5 years. Body weight before and during pregnancy influences risk of GDM and future DM. Children born to women with GDM at greater risk of diabetes. Focus on prevention. Encourage breast feeding decrease risk of diabetes in mom 50% encourage weight control encourage exercise make sure connected with health care lipid profile / follow BP preconception counseling

gastroparesis

Gastroparesis: affects 20 - 30% w/ longstanding diabetes Delayed emptying of stomach contents due to nerve damage S/S include early satiety, fullness, postprandial hypoglycemia, vomiting Diagnosis: gastric emptying studies, post-prandial hypoglycemia Tx: improve BG, small, low fat & fiber meals meds: reglan, erythromycin

3 Types of Neuropathy

Generalized Symmetrical Polyneuropathy -Acute sensory -Chronic sensory (distal) - (Small fiber & Large fiber) Autonomic Neuropathy Focal and Multifocal Neuropathy

Exercise Standards

Get up and move every 30 minutes! Encourage to limit sit time to 30 minutes and to accumulate 150 minutes of exercise a week. Flexibility and balance training 2-3 xs weekly for older adults. Yoga and tai chi are good options to increase flexibility, strength and balance. Physical Activity - Kids Children should be encouraged to engage in at least 60 minutes of moderate/vigorous physical activity a day. Plus bone/muscle strengthening 3 times a week Only about 50% of people get adequate exercise

Hormone effects on Blood sugars

Glucagon (pancreas beta-cells) ↑ BG levels Growth hormone ↑ BG levels Epinephrine (kidney) ↑ BG levels Cortisol (kidney) ↑ BG levels Insulin (pancreas beta-cells) ↓ BG levels Amylin (pancreas) ↓ BG levels Gut hormones - incretins (GLP-1) - released by L cells of intestinal mucosa, beta cells have receptors ↓ BG levels

Pancreas Hormone - Glucagon

Glucagon is produced by the alpha cells in the pancreas -opposes action of insulin at the liver -stimulated in response to low BG levels -stimulates liver to convert glycogen to glucose -inhibits liver from glucose uptake -causes hyperglycemia

Metformin

Glucophage Biguanides Decreases hepatic glucose production; also improves insulin sensitivity by increasing peripheral glucose uptake and utilization

Labs to evaluate

Glucose Electrolytes CBC Count BUN and Creatinine Beta-hydroxybutyrate levels Ketone levels in urine and blood Calculate anion gap ABGs pH - acidosis Bicarb Amylase and lipase Urine and blood cultures (if infection suspected) ECG if warranted

Glipizide Extended Release

Glucotrol XL Sulfonylureas Increases insulin secretion from pancreatic beta cells

Metformin Extended Release

Glucphage XR, Fortamet, Glumetza Biguanides Decreases hepatic glucose production; also improves insulin sensitivity by increasing peripheral glucose uptake and utilization

Miglitol

Glyset Alpha Glucoside Inhibitors (AGIs) Delays the breakdown of starches and certain sugars in the intestines; decreases postprandial glucose

When goal is to minimize cost.

Go generic. Metformin and Sulfonylureas Walmart, Target others offers 3 month supply of following meds for ~ $10 Metformin and Metformin XR (avoid 1000mg ER $$) Glipizide, Glyburide, Glimepiride Other generics include: AWP - average wholesale price Pioglitazone $5 a month Acarbose, Nateglinide, Repaglinide $30 More cost info - ADA Standards 2021

Extended Boluses

Great for high-fat foods or gastroparesis 3 times of bolus insulin 1) normal bolus - a lot of insulin in a short amount of time 2) square-wave bolus - evenly distributed insulin over an intermediate period of time (looks like a square when plotted on amount of insulin given (y) over time (x) 3) dual-wave bolus - hybrid of 1 and 2 - a lot in insulin in a short amount of time plus a more even distribution of insulin given over a longer period of time e.g. 4 units at 8 am and 3.5 units over 2 hours

Cardiovascular Disease and Risk Management

Heart disease is the leading cause of mortality and morbidity in diabetes Large benefits are seen when multiple risk factors are addressed globally Assess ASCVD and Heart Failure Risk Yearly via: BMI 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

Periodontal disease and Heart Disease

Heart disease link: oral bacteria enter the blood stream, attach to fatty plaques in coronary arteries increasing clot formation inflammation increases plaque build up, which may contribute to arterial inflammation Hyperglycemia = Gingivitis = Heart Disease

Define Empowerment

Helping people discover and develop their inherent capacity to be responsible for their own lives and gain mastery over their diabetes -posits choices made by the person (not HCPs) have greatest impact -PWD are in control of their self-management -the consequences of self-management decision affect PWD the most. It is their right and responsibility to be the primary decision makers.

Statin Dosing

High Intensity: Lowers LDL ≥50% -Lipitor (atorvastatin) 40-80mg -Crestor (rosuvastatin) 20-40mg Moderate Intensity: Lower LDL 30-<50% - Lipitor (atorvastatin) 10-20mg -Crestor (rosuvastatin) 5-10mg -Zocor (Simvastatin) 20-40mg -Pravachol (pravastatin) 40 - 80mg -Mevacor (lovastatin) 40 mg -Lescol (fluvastatin) XL 80mg -Livalo (pitavastatin) 2-4mg ***If person can't tolerate intended statin dose, use maximally tolerated dose

Pancreas hormones that lower blood sugar

Hormones that lower blood sugar: pancreas beta cells - insulin: -anabolic - helps store glucose as glycogen in the muscle and the liver -secreted in response to elevated glucose -halts breakdown of glycogen in the liver -increases protein synthesis in liver -increases protein synthesis, fat storage -powerful hypoglycemic pancreas beta cells - amylin -secreted in 1:1 ratio with insulin -causes satiety -lowers post-prandial glucagon response -slows gastric empyting -DM1 makes none -DM2 makes less than normal amounts

Bolus Insulin Timing - How is the effectiveness of bolus insulin determined?

How is the effectiveness of bolus insulin determined? -2 hour post meal (if you can get it) -before next meal blood glucose

Lispro Protamine and Lispro 75/25

Humalog Mix 75/25 Premixed Insulin Combinations Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Insulin Human Regular U-500

Humulin R U-500 Long Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

BG Above Normal = Trouble

Hyperglycemia in Hospital BG 140 or greater (check A1c) If A1c 6.5% or above, indicates preexisting diabetes Requires adjustment of therapy If BG 180 + (persistent), start insulin therapy Check A1c on all pts admitted with diabetes not checked in past 3 months Blood glucose goal for hospitalized patients is 140-180 Individualize based on pt status Avoid hypo and hyper Goal of 110 -140 for selected ind's Start subq insulin if BG > 180 Stop oral meds Basal bolus therapy if eating Basal + correction scale if higher risk for hypo Critical Care: Basal-bolus or Insulin drip Sliding scale insulin use is discouraged -monitor BG before meal and at night if eating. -Every 4-6 hours if on TPN or tube feeding Start Insulin therapy Basal therapy for all Add correction or bolus as indicated If conscious, consider insulin pump therapy? • Basal plus correction may be considered if frail. • In certain situations, it may be appropriate to continue home regimens, including oral therapy (with caution). • If oral meds are stopped in hospital, they should be resumed 1-2 days before discharge

INTERHEART Study

Identified 9 Risk Factors for CV Disease in Women Diabetes Dyslipidemia Hypertension Smoking Psychosocial stress Obesity—especially abdominal fat Physical inactivity Poor eating habits with too little fruit High alcohol intake Diabetes increases the risk of CVD and mortality 2-4 xs However, diabetes has a different impact in women and men; it increases the risk by about four times in women and about twofold in men

Special Medication Notes

If A1c 1.5% - 2% or more than goal, dual therapy may be required Adding GLP-1s as or more effective as adding basal insulin, causes less hypo + weight loss.- Avoid exenatide, lixisenatide is GFR < 30 If BG 300+, A1C 10% + or person has symptoms of hyperglycemia: Consider starting insulin or sulfonylurea (in addition to metformin or other meds). Basal insulin = hypoglycemia risk; least risk to most risk of hypoglycemia risk: Degludec /glargine U300 > glargine U100 > detemir > NPH As glucose toxicity resolves, insulin and sulfonylurea dose may be reduced or stopped.

BG Goals For Hospitalized Patients - Individualize approach

If BG 180 + Start subq insulin ADA Blood glucose goals 140-180 = general 110-140 goal can be considered for critically ill or post CABG pts as long as avoid hypoglycemia 180 - 250 if severe comorbidities 250 + okay for short life expectancy AACE BG goals for Non critical patients: AACE Goals: Before meal < 140 After meal <180 Basal /bolus Insulin or Insulin drip preferred (Critical Care)

Treatment of Hypoglycemia

If BG 70mg/dl or less and eating: 15 gms of carb (gel, glucose tabs, juice) If BG 70mg/dl or less, NOT eating Amp of D50 if IV access (25 grams of glucose in a 50 ml prefilled syringe (50% glucose) Glucagon if no IV access Recheck BG every 15 minutes Reassess insulin dosing Switch to basal + correction only? Give bolus after meal? Too much basal?

Vial insulin quick calculation

If a patient takes: 20 units of Humalog at breakfast, lunch and dinner Also has correction factor: 2 units for every 50 over 150 (up to 10 extra units/meal) A1c 8.7 20+20+20+10+10+10 = 90 units 1000 units in a vial 1000 units / 90 units / day = 11 days per vial 3 bottles a month 1 box of pens = 1500 units 1500/90units = 16.5 days per box 2 boxes per month

Pre-exercise evaluation DM2

If asymptomatic, routine screening for CAD is not recommended. -Does not improve outcome as long as CVD risk factors are treated. Assess CV risk factors annually Dyslipidemia, HTN, smoking, positive family history of premature coronary disease, and + albuminuria Candidates for advanced or invasive cardiac testing include: Typical or atypical cardiac symptoms Abnormal resting ECG

Which diabetes meds help cardiovascular disease?

If diabetes plus ASCVD risk factors, or CKD, -SGLT‐2s reduce the risk of major adverse cardiovascular events and heart failure hospitalization. If type 2 diabetes and established ASCVD or multiple risk factors for ASCVD, -GLP‐1 receptor agonist demonstrated reduces the risk of major adverse cardiovascular events. If type 2 diabetes and established heart failure, -SGLT‐2s reduce risk of heart failure and hospitalization.

Hypoglycemia Caution

If lowering steroid dose, down regulate diabetes meds/insulin If loses weight, diabetes meds may need dose reduction Elevated GFR associated with increased hypo risk Assess for nocturnal hypo Headache, vivid dreams, sweats

Hypoglycemia Prevention Strategies

If planned activity, adjust insulin in anticipation of activities Reduce insulin in post exercise period Frequent monitoring in post exercise period Keep log to determine how responds to different activities, duration and intensity.

Depression assessment

If they say yes to either of these, action is required such as the PHQ-9. Over the last 2 weeks, have you felt down, depressed or hopeless? Over the last 2 weeks, have you felt little pleasure in doing things?

Backup Plan if pump isn't working

Immediate basal insulin injection Mealtime rapid insulin injection Keep written log of I:C ratios, correction and meal boluses Keep log of off-pump activity Resume pump when basal insulin wears off

Eversense

Implantable CGM Sensor lasts 90 days Sensor is MRI safe FDA approved for insulin dosing 24 hour warm-up, dressing stays on 2 days after insertion Requires calibrations every 12 hours Rechargeable transmitter taped above sensor -Communicates to smart phone (no separate receiver) -On-body vibe alerts Eversense CGM Mobile app that uses iphone and android as receiver with predictive alerts -no insulin pump integration Eversense Now app allows 5 followers FDA approved for upper arm FDA approved for >18 years of age Drug interactions: tetracycline MARD 8.5%

CGM Counseling Points

Important to check glucose when indicated • Symptoms do not match sensor value • During warm-up period • When making dosing decisions for select devices Sensors are waterproof • Showering, bathing, swimming OK • Preferable to avoid hot tubs, saunas Avoid with MRI, CT, diathermy • Exception: Eversense implantable, transmitter should be removed Not FDA approved • Pregnancy, dialysis, critically ill • If people choose to use, it is important they know it is off-label and discuss potential risks

Treating Neuropathy

Improve glycemic control Control pain Relief from depression from chronic pain -Massage, stretching, pain control clinic, Transcutaneous Electrical Nerve Stimulation (TENS), avoiding alcohol, relaxation exercises....

Diabetes Control and Complications Trial (DCCT)

In June, 1993 the New England Journal of Medicine published the results of the landmark DCCT. The largest, most comprehensive diabetes study ever conducted. 10 year study involved more than 1400 subjects with Type 1 DM. Compared the effects of two treatment regimens: standard therapy and intensive control on the complications of diabetes. Conclusions: By maintaining A1C < 7%: Eye disease - 76% reduced risk Kidney disease - 50% reduced risk Nerve disease - 60% reduced risk Management elements included: SMBG 4 or more times a day 4 daily insulin injections or insulin pump Greater risk of hypoglycemia

Nonstarchy Vegetables 5 g Carb Servings

In general, 1 serving = 1 cup raw, 1⁄2 cup cooked, 1⁄2 cup juice, or 1⁄2 cup tomato sauce. -Beans (wax or green); bean sprouts; beets; broccoli; brussel sprouts; cabbage; carrots; cauliflower; celery; cucumber; eggplant; greens; mushrooms; lettuce; nopales; okra; onions; pea pods; peppers; radishes; rutabaga; spinach; tomatoes; zucchini.

Oral Meds during Hospitalization?

In non-critical care settings -Continuing DPP-IV inhibitors is an option (avoid saxagliptin & alogliptin for those who develop heart failure). -Avoid SGLT-2s due to ketosis -Stop SGLT-2s three days prior to surgery (4 days for ertugliflozin) If oral meds are stopped in hospital, they should be resumed 1-2 days before discharge

Diabetes and Coronary Vessel Disease considerations

In those with known CVD, use: -Aspirin -Statin -B/P Med (if hypertensive) In pts with prior MI, Beta Blockers should be continued at least 2 years after the event -Don't use Actos or Avandia in those with CHF -Diabetes Meds that significantly decrease CV events: =SGLT‐2i's = Empagliflozin (Jardiance), canagliflozin (Invokana) =GLP‐1 RA's =Semaglutide (Ozempic), liraglutide (Victoza), dulaglutide (Trulicity)

The Evidence for CGMs

Increased BG Monitoring Leads to Lower A1C in T1DM in the DM1 exchange of 20,555 individuals Diamond trial resulted in 0.5% A1c reduction in 6 months for individuals with DM1 Diamond trial resulted in 0.3% A1c reduction in 6 months for individuals with DM2 -greater benefit with higher baseline A1c Flash CGM in DM1 - reduction of 0.8% A1c, 38% reduction in hypoglycemia, 19% in hyperglycemia

Type 1 and Hypoglycemia

Increased risk of hypoglycemia in first trimester -Due to altered counterregulatory response in pregnancy that may decrease hypoglycemia awareness. Education about prevention, recognition, and treatment of hypoglycemia is important before, during, and after pregnancy to help to decrease and manage the risk of hypoglycemia. Insulin resistance drops rapidly with delivery of the placenta (leads to hypo post delivery)

Metabolic Surgery Benefits

Increases gut hormone availability More likely to cause remission (remission = BG levels normal without meds) with recently diagnosed diabetes (more beta cell mass) -30 - 63% remission over 1-5 years -35 - 50% redeveloped diabetes -Average remission time 8.3 years -Most pts who undergo surgery maintain substantial improvement of BG control from baseline for ~5 yrs Trials demonstrate metabolic surgery achieves superior BG control CV reductions in type 2 obese pts compared to lifestyle/medical intervention Improvements in micro and macro disease and cancer have been observed. Procedure may reduce long term mortality

A1c Target in Pregnancy

Individualize A1c target at 6- 7% In early gestation, lowest rates of adverse fetal outcomes with A1C <6-6.5% In 2-3rd trimester, A1c <6%, has lowest rates of macrosomia, preterm deliver and preeclampsia. An A1c < 6% is optimal during pregnancy, if it can be achieved with out significant hypo. Evaluate for and avoid hypoglycemia - increases risk of low birth wt

Health Belief Model - Cost vs Benefit

Individuals perceived risk and seriousness of illness determines the likelihood of adopting preventive behaviors. The more perceived risk, the more likely to take make necessary changes. Influencing factors: Level of personal vulnerability about developing illness How serious person believes the illness is Efficacy of behavior in preventing or minimizing consequences of illness Costs or deterrents associated with making changes

What vaccines should DM2 patients receive?

Influenza vaccine - Annual not live attenuated vaccine every year starting at age 6 months People with diabetes have higher Hep B due to lancing devices/ glucose meter exposure Hepatitis B Vaccine 18 - 59 years. Administer 2-3 dose series to unvaccinated adults with diabetes age 60 years+ administer 3 dose series to unvaccinated adults with diabetes based on risk Pneumonia Vaccinations: Before age 15 mos PCV13 or 13-valent [Prevnar] 4-dose series vaccine is recommended for children Children 6-18 yrs also need one dose of PPSV23 [Pneumovax] Adults with diabetes 19-64 those over 65 unless need one dose PPSV23 or 23-valent pneumococcal polysaccharide vaccine. At age ≥65 years regardless of vaccination history, additional PPSV23 vaccination is necessary. Other DM2 vaccines: Human Papilloma Virus (HPV) Under 27 years, if 27-45 discuss with provider Tetanus, diptheria, pertussis (TDAP) All adults with booster every 10 years Pregnant women need extra dose Zoster 50 years old or more Two-dose Shingrix, even if previously vaccinated

Strategies for Type 1 Management

Initiate intensive insulin regimens, either via multiple daily injections or insulin pump Monitor blood glucose levels 6-8x including premeal, post meal, pre bedtime, and as needed for safety Continuous glucose monitoring improves glycemic control and reduces hypo -CGM approved for 2 yrs + -Intermittent CGM approved for 4 yrs + Automated insulin delivery systems improve glycemic control and reduce hypoglycemia

JR Next steps - 70/30?*

Insulin - Basal dose is 50 units -Fasting BG on target -Daytime BG above target Next step - Switch to 70/30 (70% basal, 30% bolus) CONSIDERATION: pre-mixed difficult to fine tune therapy -Reduce total daily dose (TDD) by 80% if good control but if poor control use full dose -Give 2/3 in am & 1/3 before dinner TDD is 50 units -Give 70% am - 0.66 x 50 ~ 35 units -Give 30% pm - 0.33 x 50 ~ 15 units

Humulin R

Insulin Regular Insulin Regular Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Novolin R

Insulin Regular Insulin Regular Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

More detailed Insulin Plan - Correction scale Takes ACTUAL 35 units a day

Insulin Sensitivity Calculation - Correction How much does 1 unit of insulin drop BG? 1700 Rule for Analog Insulins 1700 / Total Daily Dose = insulin sensitivity 1700 / 35 = 48.5 (50) 1 unit drops BG 50 points - "Correction" Glucose Target is 130. -Correction plus carb coverage = total mealtime bolus dose Correction Bolus for Rob Analog Insulin (1 unit:50 mg/dl>130) less than 70 = subtract 1 unit 70-130 = 0 units 130-180 = 1 unit 181-230 = 2 units 231-280 = 3 units 281-330 = 4 units 331-380 = 5 units

Insulin Sliding Scales (ISS)

Insulin Sliding Scales (SSI) for bolus insulin are discouraged as they are not effective. Starts at 150 mg/dl, 2 units for every 50 mg/dl BG greater than 150 mg/dl

Exercise effects on BG - No Diabetes

Insulin action suppressed Counter regulatory hormones Release stored glycogen from muscle and liver Increase gluconeogenesis To replace glycogen stores Glucose uptake continues for up to 48 hours

Step 1: Start with Toolkit

Insulin and Meds Storage Quantity Types Syringes /Pens Med organizer Injection sites Meter /strips Medic Alert bracelet Back up energy source Get away bag Healthy snacks

Step 1: Start with Toolkit

Insulin and Meds Storage Quantity Types Syringes Injection Sites Meter/strips Medic Alert bracelet Glucagon Rescue Meds Back up energy source Get away bag Pump supplies CGM supplies

Insulin Approach Depends on Individual

Insulin dosing is relative to body weight • Kidney function • Other meds • Activity level • Social support • Goals of care • Person's ability

Management of Diabetes in Pregnancy

Insulin is preferred for DM1 and DM2 Does not cross placenta Can overcome insulin resistance associated w/ type 2 Either daily injections for insulin pump technology Refer to specialized center

Management of GDM

Insulin is preferred for type 1 and 2 -does not cross the placenta -can overcome insulin resistance associated with DM2 Either daily injections or insulin pump technology All insulins are pregnancy category B, except: -glargine, glulisine, degludec - Category C -Category C means more data needed Refer to specialized center

Assess Hypoglycemia Risk

Insulin or secretagogues Impaired kidney or liver function Longer duration of diabetes Physical or intellectual disability Hypoglycemia unawareness Frailty and older age Cognitive impairment Polypharmacy Alcohol use

Insulins that go in insulin pumps

Insulin pumps use rapid-acting insulins such as lispro, aspart and glulisine. Because the pump delivers tiny amounts of insulin every few minutes, longer-acting insulins are not necessary.

Factors that can interfere with glucose accuracy in Glucose oxidase monitors

Interfering substances for glucose readings Glucose oxidase monitors: -uric acid -ascorbic acid -galatose -xylose -L-Dopa -acetaminophen Glucose dehydrogenase monitors: -lcodextrin (used in peritoneal dialysis)

Novolin N

Intermediate Acting Neutral Protamine Hagedorn (NPH) Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Canagliflozin

Invokana Sodium-Glucose CoTransporter-2 (SGLT-2) Inhibits sodium-glucose cotransporter 2 (SGLT2) in the proximal convoluted tubules of the kidney, reducing glucose reabsorption, and increasing urinary glucose excretion

Generalized Symmetrical Polyneuropathy Chronic Sensorimotor Neuropathy - Large Nerve Fiber

Involve sensory and/or motor nerves Fibers are myelinated, rapid conductors Can detect destruction w/ nerve testing Symptoms may be minimal: Impaired vibration perception/position sense Ataxia "moon-walking", in-coordination Pain described as deep-seated gnawing Shortening of Achilles tendon and claw foot Increased blood flow "hot foot"

Omnipod Dash

No tubing Pod (pump) includes infusion set All programming done via PDM - Locked Android smartphone -Bluetooth connection Rechargeable battery Food database 200 unit reservoir Dash blue tooth connected with contour meter Omnipod 5 (hybrid closed loop) on the horizon

How Much Insulin Does a Patient Need?

It depends, based on: Body weight BMI < 25 or more than 25 Frail, elderly (0.3 units/kg/day) Eating status (Normal, poor intake or NPO) Renal or hepatic insufficiency (less insulin with renal disease) Type of Diabetes Current meds; steroids, insulin, oral DM agents Infected or Septic

How accurate are BG meters?

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. 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. Meters are sensitive to oxygen available. ONLY USE WITH NORMAL OXYGEN LEVELS. -if high oxygen levels = false low BG readings (i.e. arterial blood or oxygen therapy) -if low oxygen levels = false high BG readings (i.e. high altitude, hypoxia, or venous blood readings ***Glucose dehydrogenase-based monitors are not sensitive to oxygen.

Case Study: Convert a patient to 70/30 insulin

JR is on metformin 2000mg, empagliflozin 25mg, semaglutide 1.0mg and 100 units of glargine insulin. A1C is 8.9% and JR weighs 100kg. What best describes this clinical picture? (overbasalization due to >0.5 units/kg) Starting 70/30? Consider 4 factors: - Current insulin dose - Insulin dose based on wt - Current BG /A1C - Risk of hypoglycemia Convert to 70/30 insulin: Option A: 1) Current dose x 80% 2) 100 units x 0.8 = 80 units 3) 2/3 am and 1/3 pm 4) 80*.66 = 53 units am 80*.34 = 27 units pm 5) Simplify = 50 units am and 30 units pm Option B: 1) Weight recommendation: (0.4 - 1 unit/insulin/kg) 2) By wt: 100 kg x 0.5 units/insulin/kg = 50 units a day 3) 2/3 am and 1/3 pm 4) 50 * .66 = 33 units 50*.34 = 17 units 5) simplify = 30 units am and 20 units pm *Be conservative to keep patient safe from hypoglycemia. You can always increase the dose later. Use lower dose Option B or take the average of the AM and PM from other options (e.g. use 40 units am and 25 units pm). By doing this, you will KEEP the patient safe and KEEP their trust (lose trust if they have hypoglycemia episodes)

Basal insulin feedback

Keep glucose steady -On average, 5 different basal segments needed Basal insulin rate not correct IF: -Glucose rises or falls even when not eating -Fasting glucose is elevated or low -Correction bolus does not get glucose to target -To prevent hypoglycemia, not covering for snacks -If person is eating to cover for in-between meal hypoglycemia

Step 2 - Data needed

Keep records and look for patterns 7 point log helpful Fasting glucose Before meals - Break, lunch, dinner 2 hours after meal Bedtime or 2am 3 days worth of data with notes Meter or CGM reports

Step 2 - Data needed

Keep records and look for patterns BG log helpful Fasting glucose Before meals - Break, lunch, dinner Bedtime 3 days worth of data with notes Meter or CGM reports A1c helpful

Niacin (nicotinic acid)

Niacin is a B vitamin that limits the production of blood fats in the liver. Take this only if your doctor has prescribed it. It lowers triglycerides and has mild LDL-lowering action. Niacin side effects may include flushing, itching and upset stomach. Your liver functions may be closely monitored because niacin can cause toxicity. Nonprescription immediate-release forms of niacin usually have the most side effects, especially at higher doses. Niacin is used cautiously in diabetic patients because it can raise blood sugar levels.

Standardized CGM Metrics for Clinical Care

Key Metrics: # of days CGM is worn = 14+ days recommended Percentage of Time CGM is active = >70% of data recommended Mean Glucose Glucose Management Indicator (GMI) - CGM-derived estimated of current A1c level Co-efficient of Variation (CV) -measure of glycemic variability (standard deviation divided by the mean) -CV <=36% is considered acceptable) >250 mg/dl = level 2 hyperglycemia >180 mg/dl = level 1 hyperglycemia Time above range (TAR) 70-180 mg/dl (in target range) Time in Range (TIR) >= 70% for most DM1 and DM2 <70 mg/dl - level 1 hypoglycemia <54 mg/dl level 2 hypoglycemia Time below range (TBR)

Glargine U-100

Lantus, Basaglar Long Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Case Study: Larry

Larry takes metformin 1000mg BID, insulin glargine 50 units once daily, empagliflozin 10mg daily. His A1C is 7.8%. He weights 90kg. FBG averages 100mg/dL. PP breakfast=190mg/dL, PP lunch=210mg/dL, and PP dinner is 240mg/dL. What is the best recommendation for an agent to add to the regimen to achieve A1C target? B. Initiate insulin aspart 5 units with all meals, decrease insulin glargine to 35 units daily (subtract bolus from long-acting by 30% and add 10% basal to each meal = 5 units per meal so total insulin remains 50 units)

Eye Disease Overview

Leading cause of adult blindness Retinopathy and Diabetic Macular Edema DM = 25x's risk of ocular complications Including cataracts 20% of type 2 have retinopathy at diagnosis Only 60% of individuals receive appropriate treatment

Salivary Dysfunction and Xerostomia (dry mouth) in DM

Less saliva uptake and excretion = less protection against bacteria Hyperglycemia increases glucose levels in saliva, providing medium for bacterial growth- also promotes dry mouth Dry mouth increases risk of infection and can alter nutritional intake (due to chewing, swallowing difficulties)

Detemir

Levemir Long Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Case Study

Life Study 67 year old man with type 2 on metformin 2000mg daily for past 6 months. Had stroke last year. GFR >60. Most recent A1c 8.1%. What is next step? ADA / AACE Insured - Either SGLT2 or GLP -1 ADA / AACE Big Copay - Sulfonylurea? Insulin (NPH, Reg, 70/30)?

Biosimilar insulins

Lispro (admelog) - bolus insulin Glargine (basaglar/semglee - basal/background insulin -copycat insulins -can't use the term generics (which are man-made) for insulin which is a large molecule biological because they are manufactured in living organisms (bacteria and yeast) therefore they are called biosimilars -each batch may be slightly different -currently - pharmacist to contact provider before switching to biosimilar -in the future, biosimilar may be the same as generics examples of biosimilar insulins are Lispro (admelog), glargine (basaglar), glargine (semglee

Risks associated w/ elevated BG -GDM Second and Third Trimester

Macrosomia: fetal wt > 4000g (~ 9lbs) -Birth trauma, shoulder dystocia, clavicular fracture -Increased risk of C-section -Still birth -Polyhydramnios (excess amniotic fluid) -Pre-eclampsia: edema, HTN, proteinuria -Neonatal hypoglycemia (should be >40)

Macular Edema

Macular swelling caused by leaking microaneurisms with exudates (in yellow). Most common cause of visual loss among type 2 diabetes Risk 10-15% for ind's with diabetes 15yrs + macula responsible for central vision retinal thickening w/in 3mm from the macula can impair central vision - causing blurring to blindness Tx: focal laser treatment or Lucentis, Avastin or Eylea, injected into eye

Blood pressure drug treatment

No albuminuria - Use any of 4 classes of meds -Includes ACE Inhibitors, ARBs, thiazide-like diuretics or calcium channel blockers With albuminuria or ASCVD- Start ACE Inhibitor or ARB -(Avoid ACEi and ARB at same time) -Multiple Drug Therapy often required -If BP≥160/100 start 2 drug combo

Ketosis Prone Type 2 Diabetes

Marked insulin deficiency at diagnosis Severe ketosis or ketoacidosis in the absence of a precipitating event Severe but transient defect in insulin secretion and insulin action Near-glycemic remission that may last for months to years Other names; Flatbush diabetes, Atypical diabetes

Hospital BG above target - insulin adjustment strategies

Meal Blood glucose above target? -Increase prandial dose by 2 units and /or -Increase correction scale by 1-2 units Morning blood glucose > 140? -Increase evening basal by 10% Identify cause Consider insulin drip

BG too high in the hospital? insulin adjustment strategies

Meal Blood glucose too high? Increase prandial dose by 2 units and /or Increase correction scale by 1-2 units Morning blood glucose > 140? Increase evening basal by 10% Identify cause Consider insulin drip

Time in Range & A1c Correlation

Measured TIR > A1c > 95% Confidence Interval 40% > 8.4% > 7.1-9.7% 50% > 7.9% > 6.6-9.2% 60% > 7.4% > 6.1-8.8% 70% > 7.0% > 5.6-8.3% 80% > 6.5% > 5.2-7.8%

A1c Test

Measures glycation of RBC's over 2-3 months Weighted mean (50% preceding month) Each 1% ~ 29mg/dl Accuracy: affected by some anemias, hemoglobinopathies, blood transfusion (consider fructosamine test) A measurement of glucose in fasting and postprandial states

Continuous Glucose Monitors

Measures interstitial fluid to determine BG - correlates with plasma glucose, Report glucose in real time or intermittent "flash" scanning (isCGM - Freestyle Libre) Tiny sensor under skin sends BG levels wirelessly to a pump, smartphone or other device Lowers A1c ~0.26% (compared to SMBG) Consider CGM 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 individual readiness Significant reductions in hypoglycemia Type 1 38% reduction of overall hypo 40% reduction of nighttime hypo Type 2 less hypo too 43% reduction overall hypo 54% reduction in nighttime hypo

Professional CGM Comparison

Medtronic iPro2 1) blinded 2) 6 days maximum wear time of sensor 3) 3-4 calibrations per day 4) download reports with CareLink 5) clean and disinfect transmitter between transmitter use 6) no alarms for high/low BG alerts 7) acetaminophen is an interfering substance Dexcom G6 Pro 1) blinded and unblined 2) 10 days maximum wear time of sensor 3) no calibrations required 4) download reports with CLARITY 5) disposable 1-time use (care for between transmitter use) 6) it has alarms for high/low BG alerts 7) hydroxyurea interfering substance LibrePro 1) blinded 2) 14 day maximum wear time of sensor 3) no calibrations required 4) download reports with LibreView 5) Disposable 1-time use (care for between transmitter use 6) no alarms for high/low glucose alerts 7) salicylic acid and high dose vitamin C interfering substances

3 Categories of Diabetes Complications in Older Adults - Reciprocal & Synergistic Relationships

Mental dysfunction: -dementia -depression -behavioral and anxiety disorders physical and neuropathic complications -sarcopenia -frailty -proximal motor neuropathy vascular disease -microvascular -retinopathy -nephropathy -sensory neuropathy -lower extremity complications -macrovascular -cardiovascular -cerebrovascular -peripheral vascular

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) Each 38 mg/dl LDL reduction reduces relative risk of death and CVD by 9-13%.

JR BG log 3

Metformin + 28 plus 12 units 70/30 Type 2, 90kg - A1c 7.2% Week 1: 130s (28 unit 70/30), 130s, 130s (12 unit 70/30), 160s Week 2: 110s (28 unit 70/30), 120s, 130s (28 unit 70/30), 150s Week 3: 100s (28 unit 70/30), 110s, 120s (28 unit 70/30), 140s week 4: 90s (28 unit 70/30), 110s, 120s (12 unit 70/30), 140s

Oral Meds in Pregnancy

Metformin found in umbilical cord blood at equal or higher levels than maternal blood. 50% of pts on metformin, needed insulin Lower risk of neonatal hypo, less wt gain. May slightly increase risk smaller neonates Offspring heavier in some studies Not recommended if woman hypertensive, or at risk for uterine growth restriction Other oral and noninsulin injectable diabetes meds lack long-term safety data. Long term studies underway- MiTY and MOMPOD

What factors determine optimal glycemic targets?

More Stringent -------A1c 7%---------Less Stringent Risks potentially associated with hypoglycemia and other drug adverse effects (low vs high) disease duration (newly dx'd vs long-standing) life expectancy (long vs short) Important comorbidities (absent vs few/mild vs severe) established vascular complications (absent vs few/mild vs severe *These above are usually not modifiable.* *These below are potentially modifiable* Patient preference (highly, motivated, excellent self-care capabilities VERSUS preference for less burdensome therapy Resources and support system (readily available vs limited)

Time in Range (TIR) Goals: International Consensus

Most DM2 & DM1: >250 mg/dl = <5% target >180 mg/dl = <25% target 70-180 mg/dl = >70% target <70 mg/dl = <4% target <54 mg/dl = <1% target Older/High-risk DM1 & DM2 >250 mg/dl = <10% target >180 mg/dl = <50% target 70-180 mg/dl = >50% target <70 mg/dl = <1% target Pregnancy: DM1 >140 mg/dl = <25% target 63-140 mg/dl = >70% target <63 mg/dl = <4% target <54 mg/dl = <1% target *Pregnancy: Gestation & DM2 >140 mg/dl = <5% target 63-140 mg/dl = >90% target <63 mg/dl = <4% target <54 mg/dl = <1% target *not enough evidence for this category Battelino T, et al. Diabetes Care. 2019;42(8):1593-1603

Facilitating Self-Care - Specific Skills Training

Most effective education includes: demo of skills practice direct practical feedback for efforts Didactic: less effective Provides knowledge without skill Talk Less - Encourage more participation Make the Behavior Real for that person

Insulin coverage for protein?

Most of time, protein won't affect glucose If person on low carb diet, protein may start impacting blood glucose levels -bolus for 50% of protein grams (for every 30 g protein give 1 unit insulin - compare this to standard carb to insulin ratio of 15:1) If large protein portion consider extended bolus

glycemic targets

Most people: American Diabetes Association: fasted or before meals: 80-130 mg/dl 1-2 hours after meals <180 mg/dl A1c <7% for most adults A1c <6.5% - may be appropriate for those without significant risk of hypoglycemia A1c <8% - history of hypoglycemia, limited life expectancy, or those with longstanding diabetes and vascular complications American College of Clinical Endocrinologists: fasted or before meals: 80-110 mg/dl after meals: 80-140 mg/dl A1c of 6.5% Check A1c 2x per year if stable Check A1c 4x per year if above target Pregnant Preexisting Diabetes: ***fasting and before meals: 70-95mg/dl ***1 hour after meal: 110-140 mg/dl ***2 hour after meal: 100-120 mg/dl ***A1c <6% GDM: fasting and before meals: <95 mg/dl 1 hour after meals: <140 mg/dl 2 hours after meals: <120 mg/dl Type 2 and Kids Goals -A1c goal of 7% if on oral meds alone -A1c goal of 7.5% if at risk for hypoglycemia -Some children may benefit from A1c of 6.5% or less

Atypical antipsychotics Linked to Hyperglycemia

Most risky Clozapine - Clozaril Olanzapine - Zyprexa Intermediate Paliperidone - Invega Quetiapine - Seroquel Risperidone - Risperdal Least Risky Aripiprazole - Abilify Ziprasidone - Geodon

Ideal patients for insulin pumps

Motivated Checking BG 4+ times/day or wearing CGM A1c<10% Carb counting Ability to learn pump programming Willing to follow up regularly with health care team Can afford the pump/supplies Counting carb grams - Accuracy matters Following hyperglycemia treatment instructions

Other strategies to help ease neuropathy pain

Music Podcasts Movies Pet's Massage Touch Topical creams Lidocaine patches Mineral salts baths Tylenol / Ibuprofen Earthing Sleep Hobbies Aromatherapy Time with special people Work / volunteering

Choice of Basal insulin

NPH = lowest cost = shortest duration Levemir & Glargine = medium duration Glargine U300, Degludec U-100, Degludec U200

Nancy - 78 yr old on 4 injections a day

Nancy - 78 yr old on 4 injections a day A1c 9.3%, BMI 27 - Wt 70kg BG levels consistently above 200 Checks BG 3-4 xs a day, keeps log. Starting to have dementia, husband primary care giver Insulin dose: 5 units bolus at each meal 6 units basal at bedtime 70 kg * 0.5 = 35 units of insulin per day basal dose = 18 units bolus dose = 17 units - 5-6-6 meals Other issues In am, injects insulin at 6am and eats at 8am Rest of day, takes insulin after meals Husband needs to assist with all BG checks, logs and insulin administration Husband tells you, morning BG is often above 200 and I don't know how to adjust insulin. MD just says to increase. ASSESSMENT: Given situation, is this a realistic plan or is it too intensive? Keep things safe and don't make too many changes at once. Husband needs framework to adjust insulin based on BG levels. When leaving, husband mentions that the insulin are very expensive. They are having difficulty affording it. Husband is getting tired. PLAN: What A1c and BG targets are realistic? -A1c < 8% (now 9.3%). Want to drop BG by 40 points -BG premeal 100-140, post meal <180 Keep checking BG 3-4 times a day Increase basal by 1 unit every 3 days - Goal 100-140 BG Give bolus 5 units plus correction scale BEFORE each meal PIE - Poke Inject and Eat within 5 mins of injecting insulin Call with glucose results in one week

Characteristics of an Ideal Diabetes Med

No hypoglycemia No weight gain Affordable Lowers CV/ CKD/HF risk Most people can tolerate /use?

Lifestyle Modications

Nutrition Recommendations: -Maintain optimal weight -Calorie restriction -Plant based diet-high in polyunsaturated and monounsaturated fats -Avoid trans fats, limit saturated fats -Consider DASH/Mediterranean meal plans -Increase omega-3 fatty acids, viscous fiber, plant stanols/sterols (lipids) Physical Activity Recommendations: -150 minutes/week moderate exertion -2-3 days strength training per week Sleep -7-9 hours per night Alcohol -2 drinks/day for men -1 drink/day for women tobacco cessation -avoid tobacco products salt intake -less than 2300mg/d Diabetes Care 2020;43(Suppl. 1):S111-134 ENDOCRINE PRACTICE Vol 26 No. 1 January 2020

Focal Neuropathies

Often occurs in middle aged pt's or those w/ polyneuropathy 4 major focal neuro mono - compression or entrapment carpal tunnel most common plexopathy- femoral neuropathy pain from hip to ant and lat aspects of thigh radioculopathy - intercostal neuropathy cranial - abrupt onset, HA, eye pain

Extreme Hyperglycemia - Hyperosmolar Hyperglycemic State (HHS)

Older type 2 at high risk Often precipitated by illness or stress Symptoms may go unrecognized for weeks HHS Due to: massive fluid loss from osmotic diuresis burns, hyperglycemia, diarrhea, hemodialysis, diuretics, steroids MI, infections, hypertonic feedings, medications

Peripheral Vascular Disease - Venous Disease

On exam Skin brownish, reddish, mottled Skin warm to touch, may have pitting edema May have stasis ulcers on lower leg Pulses difficult to locate due to edema may get a venous leg ulcer Treatment Support hose, elevate feet, avoid constriction Shoes that can accommodate feet

Filling the Pump

Only fill with how much insulin you expect to use in 3 days + ~30 units Each pump is different -Tandem takes the longest to fill Caution with air bubbles Fill cannula amount -Steel needle (0 units) -6mm cannula (0.3 units) -9mm cannula (0.5 units) If cannula overfilled, can lead to lows If cannula under-filled or air bubbles, can lead to highs

Eyes - Microvascular Complications

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 people with macular edema, severe non‐proliferative disease to trained specialist

General Rules of Insulin Management

Optimize basal dose (stay within 30mg/dL when not eating) 4 constituents: -optimize basal insulin -fix hypoglycemia -fix hyperglycemia -check basal/bolus ratio -fine tune bolus settings

CKD - Microvascular Complications

Optimize glucose and BP control to protect kidneys Screen for albumin-creatinine ratio and GFR -DM2 at dx then yearly -DM1 with DM for 5 years then yearly Treat HTN with ACE or ARB and for elevated albumin-to-creatinine ratio of 30-299 mg/dl Use SGLT2 to slow CKD progression Monitor serum creatinine and K+ if on ACe, ARB or diruretics

screening for kidney disease

Optimize glucose, lipids and B/P to protect kidneys Screen for urinary Albumin-Creatinine ratio (UACR) and GFR Type 2 at dx then yearly Type 1 with diabetes for 5 years, then yearly More often if UACR is more than 30 gm/g (30-299 abnormal, >300 severely abnormal) Treat hypertension with ACE or ARB if albumin-to-creatinine ratio is > 30 mg/g Consider use of SGLT2 or GLP1 to slow CKD progression Monitor serum creat and K+ if on ACE, ARB or diuretics

Keeping Oral Healthy

Oral disease linked with heart disease Dental exams (every 6 mo's) Metabolic control critical Quit smoking Pts may not understand importance of dental hygiene. Treat infections with ATB'x, can lower A1c by 1-2%. Lowering BG shortens infection.

Adjusting insulin doses in a Basal/Bolus regimen

Out of Range BG > Insulin to Adjust 1) fasting > adjust long acting insulin or evening NPH 2) post-breakfast/pre-lunch > adjust pre-breakfast rapid/regular insulins 3) post lunch/pre-dinner > adjust pre-lunch rapid/regular insulin or morning NPH 4) Post-dinner/before bedtime > adjust pre-dinner/regular insulin

When should ADA anti-platelet agents be given?

Over age 50 with Diabetes and 1 additional risk factor: Family history of premature CV disease Hypertension Dyslipidemia Smoking Chronic kidney disease or albuminuria ***Who are not at increased risk of bleeding Use aspirin therapy (75-162 mg/day) Aspirin allergy, use clopidogrel (Plavix) 75 mg/day)

Treatment for Retinopathy

Pan Retinal Photocoagulation Decreases risk of severe vision loss by 50% or more Destroys 12% of retina and loss of visual field but maintains central vision Once stabilized, can achieve excellent control of PDR if B/P and BG well controlled. Injections with Vascular Endothelial Growth Factor (VEGF) Inhibitors may also be considered

LifeStyle Indications for Candidate or Parents of Pump Wearer

Parents and caretakers must have a thorough understanding and willingness and time to understand the pump and work with team to problem solve Willingness to work with healthcare provider during pre-pump training Adequate insurance benefits or personal resources Physical ability -View pump -Fill and replace insulin cartridge -Insert an infusion set -Wear the pump -Perform technical functions Emotional stability and adequate emotional support from family or others

"Digiceuticals"

People are turning to the internet for advice, coaching, connection, and health care. The FDA approves and monitors clinically validated, digital, usually online, health technologies intended to treat a medical or psychological condition—these are known as digital therapeutics or "digiceuticals"

Social Cognitive Theory

People learn from own AND observing "others" behaviors and consequences. Health behavior is a constantly changing and evolving interaction between their environment. Environment Behavioral capability Expectations Observational Learning Reinforcement, Self-efficacy

Diabetes and Oral Health

People w/ DM 2-3x's more likely to have periodontal disease (gingivitis and periodontitis) People with periodontal disease are more likely to be hyperglycemic Both groups may have excess RAGE (receptors for Advanced Glycation Endproducts = inflammation)

Functional Considerations - Older Adults with Diabetes

Peripheral Neuropathy in 50-70% Postural instability which limits physical activity Falls and Fractures -higher risk w/ diabetes Women at risk for hip and humeral fractures Consider physical therapy, balance practice Polypharmacy - 6 or more drugs daily Affordability, interactions, increased risk of falling Visual impairment in 20% Hearing impairment twice as common

Physical Activity vs Exercise

Physical activity -Bodily movement produced by the contraction of skeletal muscle that requires more energy than when resting Exercise -Subset of physical activity that is planned, structured and includes repetitive body movements -Performed to improve or maintain physical fitness Sedentary behavior -Little on no movement or physical activity

What are the suggested insulin teaching keys?

Poke, inject, eat (PIE) abdomen is preferred injection site Use a sharps container to dispose of needles/lancets always have treatment for hypo available

DKA Clinical Signs - Hours-Days

Polydipsia Polyuria Weakness Weight loss Nausea / Vomiting Abdominal pain Ileus Kussmaul breating Acetone breath Hypothermia Tachypnea Tachycardia Altered Sensorium

BG running low?

Possible Causes Too much insulin (Premeal bolus, Basal) Glucose toxicity improving Infection improving Stopped/lowered steroids Poor kidney function Skipped meal, poor PO intake Not eating enough carbs

Insulin Therapy Components

Prandial or meal insulin - a bolus insulin that covers food, IV dextrose, enteral nutrition, TPN or other nutritional supplements Correction insulin - bolus insulin dosed to correct for hyperglycemia that occurs despite use of basal and nutritional insulin. Usually given before meals w/ prandial insulin Basal insulin - long acting insulin covers between meals and through night

When to Consider Stress Testing Prior to physical activity

Pre-exercise medical clearance is generally unnecessary for asymptomatic individuals prior to beginning low- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living.

Causes of Inpatient Hyperglycemia

Pre-existing Type 1 or Type 2 Discovered diabetes / prediabetes Holding of usual diabetes med(s) Infection, Cardiac events Admin of agents that cause hyperglycemia -Steroids -Enteral or parenteral nutrition -Vasopressors (epi)

Acarbose

Precarbose Alpha Glucoside Inhibitors (AGIs) Delays the breakdown of starches and certain sugars in the intestines; decreases postprandial glucose

Exercise Guidelines Type 1 | Hypo

Preexercise glucose target 90-250 mg/dL Strategies to prevent exercise related hypo: Reduce prandial insulin dosing for the meal/snack preceding (and, if needed, following) exercise Reduce basal insulin dose on heavy exercise days Decrease pump basal rate by 10-50% during and a few hours after exercise, put pump on exercise or suspend mode Increase peri exercise carb intake, eating bedtime snacks, and/or using continuous glucose monitoring. Carb coverage before or during activity If fasting, 10-15 g of carb for low-to-moderate intensity aerobic activities (30-60 min) Consider 0.5-1.0 g of carbohydrates/kg per minute of exercise (30-60 g)

Blood Glucose and Pregnancy

Pregnancy in women with normal BG metabolism is characterized by: -lower fasting BG levels due to insulin-dependent glucose uptake by the fetus and placenta -mild post-prandial hyperglycemia and carb intolerance as a result of diabetogenic placental hormones Non-diabetes usual glucose ranges -mean fasting BG (61-75 mg/d) -peak post-prandial (rearely exceeds 126 mg/dl) -maximal post prandial excursions 60-90 mins after start of meal Pregnancy normally associated with lower fasting glucose and higher post meal glucose Early pregnancy, more insulin sensitive = Insulin needs may drop 2nd, 3rd trimester increased insulin resistance = Insulin needs may increase by 2-3x's pre-pregnancy needs After delivery - insulin needs drop dramatically

Problem solving for insulin

Prevent missed boluses 1 missed meal bolus over a month raises A1c 0.5% Get in habit of pre-bolusing - 15 minutes before meal works best Use reminder alerts on pumps If basal or bolus is more than 65% of total daily dose, usually indicates need to recalculate ratios

Anti-platelet agents - Primary Prevention

Primary Prevention Consider aspirin therapy (75-162 mg/day) for most men or women w DM age ≥ 50 years, with 1 additional CVD risk factor and not at increased risk of bleeding Caution in patients over 70 (higher bleeding risk) In patients who can't tolerate, use Plavix, (clopidogrel) CVD risk factors: family history of premature ASCVD, hypertension, smoking, dyslipidemia, CKD/albuminuria

JR BG log 2

Pt on Metformin, Glargine + Bolus at meals Type 2, 90kg - A1c 7.6% Breakfast, Lunch, Dinner, HS Week 1: 130s (8 unit Regular), 130s (5 unit regular), 130s, 180s (40 unit glargine) Week 2: 110s (8 unit regular), 170s (5 unit regular), 160s, 170s (35 unit glargine) Week 3: 100s (8 units regular), 110s (5 unit regular), 120s, 140s (30 unit glargine) week 4: 90s (8 unit regular), 110s (5 unit regular), 120s, 140s (25 unit glargine)

Pump Basics

Rapid acting insulin has the lowest intrapatient variability at 16% compared to long-acting insulin 36% and intermediate acting insulin 46% 1.Pumps use rapid-acting insulin • Minimizes insulin variability 2. Pumps deliver insulin in two ways • Basal: - Replaces long-acting insulin - Covers hepatic glucose production/maintains glycemic stability in fasting stages - Automatically delivers precise programmed dose - Adjust to match diurnal variations • Bolus: Covers glucose consumption and corrects hyperglycemia 3. Pumps use Bolus Calculator

Nocturnal Hypoglycemia

Signs include: Vivid dreams Waking up with headache Night sweats Waking up hungry Elevated (rebound) or low morning blood glucose

Choice of Bolus Insulin

Regular (lowest cost) = slowest lispro (Humalog, Admelog) & Aspart (Novolog) = medium speed Glulisine (Apidra), Aspart (Fiasp), Lispro (Lyumjev), Inhaled (Afreeza) = quickest

Polycystic Ovarian Syndrome (PCOS)

Reproductive disorder of hyperandrogenism, ovulatory dysfunction, polycystic ovaries About 40% have prediabetes (10% DM) Clinical findings -Infertility, amenorrhea, irregular menses, acne, obesity, dyslipidemia, acanthosis nigricans. -hirsutism (a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern — face, chest and back. With hirsutism, extra hair growth often arises from excess male hormones (androgens), primarily testosterone -PCOS is the 5 o clock shadow of metabolic syhdrome Treatment: -lifestyle changes (lose weight, exercise, healthy eating) -meds (metformin and others) -monitor BG for prediabetes/diabetes

Safety guidelines

Review signs and treatment of hypo If frequent lows, may want to set pump alarm at 90 Try not to suspend pump when low, unless no treatment available Diabetes Ketoacidosis Those with negative c-peptide at higher risk Insulin pump interruption for 2-3 hours can lead to DKA Provide education to prevent, detect and reverse

Liquid Metformin

Riomet Biguanides Decreases hepatic glucose production; also improves insulin sensitivity by increasing peripheral glucose uptake and utilization

Diabetes in Pregnancy - Preconception Counseling Critical

Risk of malformation associated w/ degree of hyperglycemia during first trimester 1st Trimester potential complications directly proportional to A1c levels 5-8 weeks is organogenesis. Elevated BG can lead to: Spina bifida, anencephaly, microcephaly, heart defects, organ position reversal

Gestational Diabetes (GDM)

SCREENING At the first prenatal visit, screen for undiagnosed type 2 in those w/ risk factors as listed in Table 1 Screen for GDM at 24-28 weeks (most insulin resistance phase of gestation for all pregnant women not known to have diabetes. Screen women w/ GDM for diabetes 6- 12 wks postpartum TEST: Standard Diagnostic Testing and Criteria as listed in Diagnosing Diabetes 1) Can use either The International Association of Diabetes and Pregnancy Study Groups (IADPSG) consensus: "One Step" 75-g OGTT fasting and at 1 and 2 h (perform after overnight fast of at least 8 h) OR 2) "Two step" NIH Consensus DIAGNOSTIC CRITERIA: Standard Diagnostic Testing and Criteria as listed in Diagnosing Diabetes 1) One Step: GDM diagnosis when ANY of following BG values are exceeded: • Fasting ≥92 mg/dl, • 1 h ≥180 mg/dl • 2 h ≥153 mg/dl OR 2) NIH Two Step - Step 1: 50gm glucose load (non fasting) w/ plasma BG test at 1 hr. If BG ≥ 130-140*, go to Step 2 > - Step 2: 100g OGTT (fasting) GDM diagnosis if at least 2 of 4 plasma BG measured fasting, 1h, 2h, 3h after OGTT are met or exceeded. Fasting: 95 mg/dL (5.3 mmol/L) 1 h: 180 mg/dL (10.0 mmol/L) 2 h: 155 mg/dL (8.6 mmol/L) 3 h: 140 mg/dL (7.8 mmol/L)

Counting Carbs Accurately

Scales Measuring Cups Labels Recipes Practice helps Food composition tables Carb counting books Cook books Fast food and chain restaurant brochures Websites

Nerve disease Screening

Screen all patients for nerve disease using simple tests, such as a monofilament or tuning fork Type 2 at diagnosis, then annually Type 1 diabetes at 5 years, then annually Tight glycemic control is the only strategy shown to prevent or delay the development and progression of neuropathy. Assess and treat patients to reduce pain and symptoms to improve quality of life. use skin biopsy to assess neuropathy

Problem Solving Tips for more comfortable injections

Short, fine needles hurt less 4 mm (5/92") to 12.7 mm (1/2") Make sure they are injecting subcutaneously, not in muscle If participant thin, inject at an angle Avoid areas with scar tissue Use needle once and toss in sharps container Needle gets duller with each injections To avoid leakage, count to 5-10 before withdrawing needle from skin Use pen needles and injectors

Kidney Physiology

Size and shape of Idaho potato - retroperitoneal Filter entire blood volume every 30 minutes excretory organ: removes water, urea, waste maintains blood volume acid base balance and lytes regulates B/P synthesizes erythropoietin - RBC Maintains calcium /phosphorus levels, activates vitamin D - helps absorb calcium Risk Factors of Kidney Disease 2 leading risk factors: hyperglycemia then HTN Other risk factors: Kidney stones, obesity, smoking and CV disease Family history of kidney disease and age 60 or older Kidney disease often has no symptoms, can undetected until very late

What to look for in feet (1 minute)

Skin exam Discolored, ingrown, or elongated nails Signs of fungal infection Dry or discolored skin, lesions, calluses or corns Open wounds or fissure Cleanliness Interdigital maceration Neurological Exam Monofilament or Ipswich Touch Test Tuning fork Musculoskeletal exam Full range of joints Obvious foot deformities? If yes, how long? Midfoot hot, red or inflamed Vascular Exam Hair growth normal or decreased Dorsalis pedis and posterior tibial pulses palpable Temperature difference between calves and feet? Left and right foot?

Very low calorie diets - <800 cals/day

Small studies have demonstrated with type 2 and obesity, extreme dietary restriction Can lead to diabetes remission (normal BG range without medications) A1c <6.5% and FPG <126 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

Lixisenatide & Insulin Glargine 100/33

Soliqua 100/33 Injectable Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon AND Long-Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Dual Antiplatelet Therapy (DAPT)

Some patients who have heart attacks, that have stents placed in their coronary arteries, or undergo coronary artery bypass graft surgery (CABG) are treated with two types of antiplatelet agents at the same time to prevent blood clotting. This is called dual antiplatelet therapy (DAPT). One antiplatelet agent is aspirin. Almost everyone with coronary artery disease, including those who have had a heart attack, stent, or CABG are treated with aspirin for the rest of their lives. A second type of antiplatelet agent, called a P2Y12 inhibitor, is usually prescribed for months or years in addition to the aspirin therapy. The type of medication and the duration of your treatment will vary based on your condition and other risk factors. The risks and benefits of DAPT should be discussed with your health care provider.

School-Age Child (6 - 12) Educational Approaches

Speaks fluently, able to share and cooperate -games good teaching tools Power, protection of parent very important -Parent needs to assume most of responsibility -Child can participate in self-care Try to fit diabetes management into normal routine

Elevated Blood Sugars in Pregnancy - Potential Complications

Spontaneous abortion Fetal anomalies Pre-eclampsia Intrauterine fetal demise Macrosomia Neonatal hypoglycemia Neonatal hyperbilirubinemia Increased risk of type 2 and excess wt in offspring

Nateglinide

Starlix Meglitinides Stimulates the pancreas to release insulin from pancreatic beta cells

Type 2s- New Diagnosis

Start lifestyle modification program and Metformin therapy. Since fewer than 10% of children with T2DM will attain BG goals with lifestyle changes alone, initiate metformin alongside to exercise and healthy eating Start metformin at low dose to mitigate GI side effects. If BG not at target, add liraglutide (after age 10) or insulin

Step 3 - Basal Insulin Check

Start with assessing basal insulin Is basal insulin dose (22 units) correct? How do we know? Morning blood sugar on target (80- 130)? Below target - decrease basal 10-20% Above target - increase basal 10-20% every 3 days Does glucose overnight drift down or up? Does BG drift up or down in between meals?

Clinical Trials Showing CVD Reduction

Statins: -CTT meta-analysis (high intensity vs standard) -Meal LDL achieved: 66 vs 50 mg/dl -outcome: MI, CHD death, stroke, coronary revasc -RR (95% CI): 0.71 (0.56,0.91) -median duration years: 5.1 years Ezetimibe -IMPROVE IT (ezetimibe plus statin vs statin) -Mean LDL achieved: 70 vs 54 mg/dl -outcome: CV death, MI, stroke, UA, coronary revasc -RR (95% CI): 0.94 (0.89, 0.99) -median duration years: 6 PSCK9 monoclonal antibodies: -FOURIER (evolocumab vs placebo on background moderate-to-high intensity statin +/- ezetimibe) -mean LDL achieved: 92 vs 30 mg/dl -outcome: CV death, MI, stroke, UA, coronary revasc -RR (95% CI): 0.85 (0.79, 0.92) -median duration years: 2.2 years -ODYSSEY OUTCOMES (alirocurnab vs placebo on background moderate-to-high intensity statin +/- ezetimibe -mean LDL achieved: 92 vs 53 mg/dl -outcome: MI, CHD death, stroke, UA -RR (95% CI): 0.85 (0.78, 0.93) -median duration: 2.2 years

Ertugliflozin

Steglatro Sodium-Glucose CoTransporter-2 (SGLT-2) Inhibits sodium-glucose cotransporter 2 (SGLT2) in the proximal convoluted tubules of the kidney, reducing glucose reabsorption, and increasing urinary glucose excretion

ADA Step Wise Approach to Hyperglycemia 2021

Step 1 - Metformin + Lifestyle -If A1c 1.5-2% above goal, consider dual therapy. -If A1c 10% plus with symptoms, consider adding insulin or sulfonylurea Step 2 - If A1c target not achieved after 3 months, Metformin + another med -If ASCVD, CHF, or CKD, consider adding a second agent to reduce risk based on drug effects and individual factors. 1) SGLT-2i for ASCVD- Empagliflozin (Jardiance), canagliflozin (Invokana) 2) SGLT-2i for CHF and CKD (if eGFR is adequate - 30-60) - Empagliflozin (Jardiance, canagliflozin (invokana), dapagliflozin (Farxiga) 3) GLP-1 RA for ASCVD or CKD*- Semaglutide (Ozempic), liraglutide (Victoza) dulaglutide (Trulicity) *if SGLT-2 not indicated or tolerated. Step 3 - If A1c not at target after 3 mos, Metformin plus two other drugs (3 drugs) Step 4 - If A1c target not at target after 3 months, add injectable therapy (GLP-1 RA or Basal insulin) to drug combination.

Steroids Impact on BG

Steroids cause insulin resistance Most notable after lunch and dinner Need bolus insulin at lunch/dinner Can also try 70/30 in am Oral agents alone might work Decadron causes highest blood glucose levels BG trends down through night Give basal insulin in am Avoid basal at night Assess kidney function/eating habits

Hospital Glucose Insulin Targets

Subq insulin therapy (oral agents stopped) Determine insulin needs based on wt/BG -0.3 units kg/day if insulin naïve or GFR less than 60 or elderly -0.4 units kg/day if BG 140-200mg/dl -0.5 units kg/day if BG 201-400mg/dl also DM with BG > 140mg/dl -0.2-0.25 units/kg/day if NPO, uncertain oral intake, or poor oral intake, correction doses with rapid-acting insulin before meals -0.4-0.5 units/kg/day, 50% basal, 50% bolus 50% of total dose - Basal Insulin (eg Lantus, NPH) Increase by 20% if fasting BG elevated Reduced for fasting BG <70mg/dl 50% of total dose Bolus Insulin (eg Reg, Lispro) divided evenly into 3 meals If premeal BG elevated, increase bolus dose ***Person treated with insulin prior to admission Take total daily insulin dose at home: -reduce dose by 20-25% to prevent hypoglycemia, particularly in those with poor or uncertain calorie intake -give half as long-acting basal insulin -give half as prandial insulin

Topics to Cover in Hospital

Survival Skills Diabetes, self-monitoring, BG Goals Hypo & Hyper - recognition, treatment and prevention Healthy eating Meds- how to take, potential side effects and action Proper use and disposal of needles and syringes ID of health care provider for post d/c care Schedule for f/u visit within 1 month Parameters of when to call for help Sick days, N/V, if BG < 70 or > 300

Pramlintide

Symylin Noninsulin Injectables Amylin Mimetic -Slows gastric emptying -suppresses glucagon -promotes satiety

Devices to inject insulin

Syringe Pen Injector Pump Choice of device is person-centered and based on 1) Preference 2) Cost 3) Convenience

Toddlers to Teens Benefit

TODDLERS Delayed bolusing for fussy eaters Dosing precision 10ths 20ths and 40ths of a unit Reduced hypo risk Lockout features TEENS Basal patterns for hormonal swings Historical data records/downloading / app sharing Easy snack coverage Greater independence Technical coolness

Adjusting basal rates - think ahead

Takes time for basal rate to affect glucose -for children: change in basal rate 1 hour prior to rising or falling glucose -for adults: change in basal rate 2 hour prior to rise or falling glucose -repeat basal test after adjustment CHART Current Basal level (units/hour) 0-0.45, 0.50, 1.20 >1.20 0.05, 0.10, 0.20 (Modest rise/fall (30-60mg/dl) 0.10, 0.15, 0.3 (large rise/fall (>60mg/dl)

Meds and Blood Pressure Target During Pregnancy

Target B/P < 135/85 = Not lower than 120/80 Meds contraindicated during pregnancy -ACE inhibitors and Angiotensin Renin Blockers (ARB) -Statins B/P Meds approved -Methyldopa, nifedipine, labetalol, diltiazem, clonidine, prazosin. -Other beta blockers except atenolol can be used

When should a provider consider discontinuing an insulin pump during hospitalization?

Technology in the Hospital Several inpatient studies have shown that CGM detected a greater number of hypoglycemic events than POC glucose testing - Overall, did not improve glucose control Patients who are comfortable using their diabetes devices (insulin pumps, sensor) should be given the chance to use them in an inpatient setting if they are competent to do so. Health care institutions must have clear policies and procedures to maximize safety and to comply with existing regulations related to self-management of medication.

Neuropathy Key Considerations

Very common long-term complication often not recognized and treated Management / treatment complex Thorough history /assessment critical Treatment based on underlying process, presentation, and cost effectiveness Treatable condition with new therapies on horizon.

Temporary Basals

Temporarily increase or decrease basal settings A great option for high stress, sick days, steroid bursts, exercise, etc. Start the temp basal 1-2 hours prior to exercise or activity requiring the change If patient is using a lot of temp basals, it's more difficult to make adjustments Not apparent on some pump reports Medtronic 670G: temp target option of 150 vs usual target of 120 in auto mode Control IQ Exercise mode (target of 140-160)

Foot Exam - Vascular Exam

Test: -Palpation of pulses -dorsalis pedis -tibial ankle-brachial Index (ABI) Significant finding: -absent pulses -ABI <0.90, consistent with peripheral arterial disease Vascular status assessment -posterior tibial pulse (inner part of foot next to malleolus) -dorsalis pedis pulse (top middle part of foot) -temperature -appearance

Biomechanical Foot Assessment

Test: -Plantarflexion & dorsiflexion of ankles, great toes -watch ambulation -inspect shoes -inspect for deformity Significant Finding: -diminished joint mobility -decreased vision, gain imbalance, need for assistive devices -ability to see / reach feet -corn calluses, bunions, prominent metatarsal heads, hammertoes, claw toes

What are the AADE 7 & outcomes continuum??

The American Association of Diabetes Educators (AADE) has defined the AADE 7 Self-Care BehaviorsTM as a framework for patient centered diabetes self-management education and training (DSME/T) and care. The seven self-care behaviors essential for successful and effective diabetes self management are 1) healthy eating, 2) being active, 3) monitoring, 4) taking medication, 5) problem solving, 6) healthy coping, and 7) reducing risks. AADE 7 Self-Care BehaviorsTM (AADE7TM) provide an evidenced-based framework for assessment, intervention and outcome (evaluation) measurement of the diabetes patient, program, and population. DSME/T outcomes contiuum Measure Monitor & Manage (repeat) Outcomes phases 1) IMMEDIATE = LEARNING knowledge skills 2) INTERMEDIATE = Behavior Change -being active -eating -medication taking -monitoring BG -problem-solving for BG and sick days -reducing risk -living with diabetes 3) POST-INTERMEDIATE = Clinical Improvement -A1c -BP -Lipids -Weight Process measures (eye exam, foot exam) Other measures (smoking cessation, ASA use, pre-pregnancy counseling) 4) LONG-TERM = IMPROVED HEALTH STATUS -overall health status -quality of life -days lost from work or school -diabetes complications -health care costs

Rabbit 2 Trial

The Rabbit 2 trial showed that BG levels and postoperative complications were lower on basal-bolus regimen than sliding scale insulin

Fructosamine Test

The level of fructosamine reflects protein glycation over the previous 2-3 weeks Can be used to eval: Effects of rapid changes in diabetes treatment Pregnancy - to help monitor and accommodate shifting glucose, insulin, or other medication requirements. Glucose for those with shortened RBC life span - such as anemia or blood loss. In these situations, A1c result is falsely low. Abnormal forms of hemoglobin such as in sickle cell anemia.

1500 (severe insulin resistance), 1700 (standard), 2000 (insulin sensitive) Correctiosn insulin example

The lower the total daily insulin they take the more insulin sensitive they are 1500/40 TDI = 37.5 mg/dl decrease with 1 unit insulin 1700/40 TDI = 42.5 mg/dl decrease with 1 unit insulin 2000/40 TDI = 50 mg/dl decrease with 1 unit insulin

Liraglutide

Victoza Noninsulin Injectables Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) -Increases glucose-dependent insulin secretion -slows gastric emptying -promotes satiety -suppresses glucagon

Angiotensin II receptor blockers (ARBs)

These drugs block the effects of angiotensin, a chemical that causes the arteries to become narrow. Angiotensin needs a receptor- like a chemical "slot" to fit into or bind with- in order to constrict the blood vessel. ARBs block the receptors so the angiotensin fails to constrict the blood vessel. This means blood vessels stay open and blood pressure is reduced. What the Medication Does Rather than lowering levels of angiotensin II (as ACE inhibitors do) angiotensin II receptor blockers prevent this chemical from having any effect on the heart and blood vessels. This keeps blood pressure from rising. Reason for Medication Used to treat or improve symptoms of cardiovascular conditions including high blood pressure and heart failure. Azilsartan (Edarbi) Candesartan (Atacand) Eprosartan (Teveten) Irbesartan (Avapro) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan)

Alpha-2 Receptor Agonists

These drugs reduce blood pressure by decreasing the activity of the sympathetic (adrenaline-producing) portion of the involuntary nervous system. Methyldopa is considered a first line antihypertensive during pregnancy because adverse effects are infrequent for the pregnant woman or the developing fetus. methyldopa

Peripheral adrenergic inhibitors

These medications reduce blood pressure by blocking neurotransmitters in the brain. This blocks the smooth muscles from getting the "message" to constrict. These drugs are rarely used unless other medications don't help. guanadrel Hylorel* guanethidine monosulfate Ismelin* reserpine Serpasil*

Tandem T:Slim X2 with Basal IQ

Touch screen Lithium rechargeable battery 300-unit reservoir Indicated ages ≥ 6 years 0.001 unit basal increment Integration with Dexcom G6 Basal IQ- suspends basal if CGM predicted to decrease to < 80 mg/dl within 30 minutes For pregnancy

Traditional vs Empowerment

Traditional DM is a physical illness HCP is viewed as teacher responsible for outcomes Emotional issues are separate components Lack of goal attainment is viewed as failure Behavior change is externally motivated Empowerment DM is biopsychosocial PWD is viewed as problem solver /self manager Experiences are integral with clinical content Lack of goal attainment is a learning experience Behavior change is internally motivated

Degludec U-100 & U-200

Tresiba Long Acting Insulin Insulin is an anabolic hormone that promotes glucose uptake, glycogenesis, lipogenesis, and protein synthesis of skeletal muscle and fat tissue through the tyrosine kinase receptor pathway.

Tresiba FlexTouch U-200 Pen 200 units insulin/mL

Tresiba FlexTouch U-200 Pen 200 units insulin/mL Tresiba Ultra basal 3 mL pen holds 600 units. Max dose 160 units. Once opened good for 56 days.

Based on Mr. J Clinical picture

Triglycerides 780 46 years old Fatty liver disease BMI 34,Weighs 100kg Stopped insulin a month ago Metformin 1000 mg BID A1c 11.9% calculate insulin needs 100kg * 0.5 = 50 units daily basal = 25 units bolus = 25 units /3 meal = 8 units each meal 70/30 insulin - 35 units am and 15 units per dinner (2/3 am, 1/3 pm)

Pharmacologic Therapy for Neuropathy

Try Alpha lipoic acid: 600 - 1,800mg /day. B12 deficiency? Prescription Therapy 1st line •Tricyclic antidepressants (ie amitriptyline, nortriptyline) • Calcium channel modulators (ie gabapentin, pregabalin) •Serotonin Norepinephrine Reuptake Inhibitors (SNRI) 2nd line •Topical Capsaicin Cream • Opioids (tramadol, oxycodone) Reasons for treatment failure: •Dose too low, inadequate trial, pt expecting elimination of symptoms, not changing class when no response Other strategies to help ease pain: music, podcasts, movies, pets, massage, touch, topical creams, lidocaine patches, mineral salts baths, tylenol/ibuprofen, earthing, sleep, hobbies, aromatherapy, time with special people, volunteering/work

Preparation for Surgery

Try to schedule surgery in am, resume meds/insulin when eating and stable. Target perioperative glucose target (80-180) Hold metformin day of surgery Hold any other glycemic meds morning of surgery Basal Insulin injection or pump: NPH - cut dose by 50% (type 2) Long acting insulin analog or pump- give 60 - 80% (individualize, type 1 may need 100% of basal) Bolus insulin: Monitor BG every 4-6 hours while NPO Use mild insulin bolus coverage as needed

Coronary Vessel Disease

With known CVD and HTN, use: Aspirin Statin B/P Med -If prior MI, continue Beta Blockers for at least 2 years after the event Don't use Actos or Avandia with CHF Diabetes Meds that decrease CV events: SGLT2 Inhibitors (CVD, CKD, CHF) - empagliflozin, canagliflozin, dapagliflozin GLP-1 RAs (CVD, CKD - use if SGLT-2 isn't tolerated) - liraglutide, dulaglutide, semaglutide

Celiac Disease

Type 1 - Affects ~10 % Immune reaction to gluten - affects function of villi in intestine, decreasing nutrient absorption S/S: bloating, malabsorption, wt loss, fatty stools, diarrhea, muscle tenderness, failure to thrive Diagnosis: measure either anti-endomysial antibodies (EMA) titers or tissue transglutaminase. If positive, refer to GI specialist for endoscopy and biopsy of small intestine to confirm diagnosis. Avoid gluten for life Wheat (einkorn, durum, faro, graham, kamut, semolina, spelt), Rye Barley Refer to a dietitian ASSOCIATED AUTOIMMUNE DISORDERS Insulin-dependent Type 1 Diabetes Mellitus, Liver diseases, Thyroid Disease-Hashimoto's Thyroiditis, Lupus (SLE), Addison's Disease, Chronic Active Hepatitis, Rheumatoid Arthritis

Ketone Testing

Type 1 - BG > 240 mg/dl Type 2 - BG > 300 mg/d Plus Positive ketones Exercise NOT recommended Can worsen hyperglycemia and ketosis Negative ketones Not necessary to postpone exercise if feels well and is adequately hydrated

DKA - always type 1 diabetes?

Type 1 DM most affected (Absolute insulin deficiency) Type 2 DM can also experience under extreme conditions such as: Serious infection Trauma Cardiovascular or other emergencies Ketosis-prone type 2 diabetes

Criteria for testing for Diabetes in Asymptomatic Adults and Children

Type 1 diabetes: Screening for type 1 diabetes risk with a panel of islet autoantibodies is currently recommended in the setting of a research trial or can be offered for relatives of those with type 1 diabetes (www.trialnet.org) Type 2 diabetes: Screen all adults for prediabetes and diabetes starting at age 45 and all adults of any age who are overweight (BMI ≥ 25) or BMI ≥ 23 in Asian Americans with 1 or > additional risk factor: • History of cardiovascular disease • habitual physical inactivity • first degree relative with diabetes • History of GDM* • polycystic ovary syndrome • HTN ≥ 140/90 or on meds • HDL ≤ 35 mg/dl or triglyceride ≥ 250 mg/dl • A1c ≥ 5.7%, IGT or IFG* • Other clinical conditions associated with insulin resistance (obesity, Acanthosis Nigricans) • high risk ethnic population (African American, Latino, Native American, Asian American, Pacific Islanders) 2. If results normal, repeat test at 3-year intervals or more frequently based on risk status 3. *Lifelong annual testing if diagnosed with Prediabetes, at least every 3 years with GDM 4. Test children with excess weight -BMI >85% for age and sex, -weight for height >85% -greater than 120% of ideal weight for height -PLUS one of the following risk factors: Signs of insulin resistance (acanthosis nigricans, HTN, dyslipidemia, Polycystic Ovary Syndrome - PCOS or small for gestational age birth weight Maternal diabetes or GDM during child's gestation Family history American Indian, African American, Hispanic, Asian, South Pacific Islander Test at 10 yrs or puberty and every 3 yrs

Concentrated insulin key points

U-100 insulin = 100 units of insulin per mL U-500 insulin = 500 units of insulin per mL U-500 insulin 20 ml per vial * 500 units per ml = 10,000 units/vial Never withdraw concentrated insulin from a pen into a syringe All concentrated insulin pens and U-500 insulin syringe automatically deliver the correct dose in less volume No conversion, calculation, or adjustment required

Definitions of Abnormalities in Albumin Excretion

UACR | Urine albumin - creatinine ratio (spot collection) Normal = <30 mg/g creatinine moderately increased urinary albumin excretion = 30-299 severely increased urinary albumin = >300 2 of 3 tests w/in 3-6 mo abnormal to confirm if greater than 30 with elevated B/P consider treatment with ACe or ARB Also consider using SGLT-2 or GLP-1 to protect kidney Exercise within 24 h, infection, fever, CHF, marked hyperglycemia, and marked hypertension may elevate urinary excretion over baseline values.

Pregnancy and weight gain

Underweight (BMI <18.5) = 28 lbs min, 40 lbs max normal weight (BMI 18.5-24.9) = 25 lbs min, 35 lbs max overweight (BMI 25-29.9) = 15 lbs min, 25 lb max obese (BMI >30) = 15 lbs

Action in Case of Hyperglycemia for Pump Users

Unexplained hyperglycemia = check for ketones ketone negative = bolus with pump ketgone positive = inject insulin, drink water, change out pump

Ketone Testing Options

Urine ketostix or diastix More than 15 mg/dl = positive ketones Blood sampling Novamax or Precision Xtra blood meter More than 0.5 mmol/l β - hydroxybutyrate indicates action and insulin needed

ADA Stepwise Approach CONSIDERATIONS

Usually, start one medication at a time However, evidence supports initial combo therapy to quickly reach goals and slow decline of glucose control. Other Factors CVD, Heart failure or Kidney Disease Minimize Hypoglycemia Minimize wt gain or promote wt loss Consider Cost

Benefits of Smart Pens

Utilize bolus calculator similar to insulin pumps (enter BG and/or CHO intake) for dose calculations Customized settings for insulin calculators Monitor insulin on board (IOB) Dosing reminders Improved data aggregation linked to glucose or CGM Monitor insulin viability (temperature and expiration) Reduced diabetes burden

ACE inhibitors (-prils)

What the Medication Does Angiotensin is a chemical that causes the arteries to become narrow, especially in the kidneys but also throughout the body. ACE stands for Angiotensin-converting enzyme. ACE inhibitors help the body produce less angiotensin, which helps the blood vessels relax and open up, which, in turn, lowers blood pressure. Expands blood vessels and decreases resistance by lowering levels of angiotensin II. Allows blood to flow more easily and makes the heart's work easier or more efficient. Reason for Medication Used to treat or improve symptoms of cardiovascular conditions including high blood pressure and heart failure. Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik)

Antiplatelet Agents and Dual Antiplatelet Therapy (DAPT)

What the Medication Does -Keeps blood clots from forming by preventing blood platelets from sticking together. Reason for Medication -Helps prevent clotting in patients who have had a heart attack, unstable angina, ischemic strokes, TIA (transient ischemic attacks) and other forms of cardiovascular disease. -Can also be prescribed preventively when plaque buildup is evident but there is not yet a major blockage in the artery. -Certain patients will be prescribed aspirin combined with another antiplatelet drug - also known as dual antiplatelet therapy (DAPT). acetylsalicylic acid - ASA (Aspirin) Clopidogrel (Plavix) Dipyridamole (Persantine) Prasugrel (Effient) Ticagrelor (Brilinta)

Digitalis Preparations

What the Medication Does Increases the force of the heart's contractions. Can be beneficial in treating heart failure and irregular heartbeats. Reason for Medication Used to relieve heart failure symptoms, especially when the patient isn't responding to other standard treatments including ACE inhibitors, ARBs and diuretics. Also slows certain types of irregular heartbeat (arrhythmias), particularly atrial fibrillation. Digoxin (Lanoxin)

Insulin Sensitivity adjustments

When BG is above target and correction dose is taken (without food), does glucose return to target within 3-4 hours? If BG is low at 3-4 hours, the ISF is likely too strong Increase by 10-20% Example: 50 > 55 or 60 If BG is high after 3-4 hours, the ISF is too weak Decrease by 10-20% Example: 50 > 45 or 40

Step 7 - We need Exercise Plan

When exercising: - Always have carb snacks - Identification - Phone or way to get help - If possible, let someone know - Exercise can impact glucose later or the same day 30 minutes of exercise is roughly equal to one unit of insulin which brings down blood sugar ~30-50 points So consider taking 1 unit less of insulin if going on a 30 minute brisk walk after meal

Consulin for DM1

When working with people with Type 1 Focus on success Reinforce their expertise Engage them in problem solving Acknowledge hard work Make sure the toolkit is in good working order Start with basal, then double check carb and correction Plan to prevent and treat lows Exercise strategies Focus on collaboration

Strength based approach

When working with people with Type 1 Focus on success Reinforce their expertise Engage them in problem solving Acknowledge hard work Make sure the toolkit is in good working order Start with basal, then double check carb and correction Plan to prevent and treat lows Exercise strategies. Discover what they want to work on!

Low Carb Meal Plan Not Recommended for:

Women who are pregnant or lactating People with or at risk for disordered eating People who have renal disease Use with caution if taking SGLT-2 Inhibitor due to potential risk of ketoacidosis There is inadequate research in type 1 diabetes to support one eating pattern over another at this time.

Improving Sex Life for Women

Women with diabetes get more vaginal and bladder infections Difficulty achieving orgasm due to neuropathy Painful intercourse due to lack of vaginal lubrication treatment: -lower blood glucose / blood pressure -treat vaginal infections and UTIs. -water based lubricants for vaginal dryness -hormone replacement therapy -eat to prevent lows during intimacy -allow time, touching and romance

Type 1 or 2 - Aspirin Therapy for Preeclampsia?

Women with type 1 or 2 preexisting diabetes have 2-4x's increased risk of preeclampsia Signs: HTN, Proteinuria, edema Associated with decrease blood flow to fetus. Start aspirin therapy 81mg starting at the end of the first trimester until birth US Preventive Task Force 2018 recommendations Taking ASA reduces morbidity, saves lives and lowers health care costs

Alcohol Intake on Rise

Women, older adults, racial/ethnic minorities, and socioeconomically disadvantaged Associated with increased alcohol use, high-risk drinking, and DSM-IV Alcohol Use Disorder These findings portend increases in many chronic comorbidities in which alcohol use has a substantial role.

InPen by Companion Medical

Works with lispro(Humalog), aspart (Novolog, Fiasp) 3.0 mL pre-filled cartridges Doses: 1⁄2 - 30 units Bluetooth connects to an app in smartphone Works with Android and Apple products Dose calculator (up to 4 timed settings throughout the day), tracks IOB, insulin dose reminders Non-rechargeable battery (1 year use) Glooko and Dexcom Clarity integration Monitors insulin temperature Requires rx to pharmacy

Insulin Dosing in Children

Younger children Dose may be low during honeymoon period After honey moon - dose is 0.5 - 1.0 unit/kg/day Basal / bolus combo If difficulty injecting bolus at lunch, consider NPH pre breakfast Pubertal hormones increase insulin required up to 1.5 units/kg/day Keep it flexible, may need to inject after meals Insulin pump therapy coupled with CGM recommended

Data Management Tools

aGlooko > glooko.com > glooko > it downloads data from insulin pumps (omnipod, tandem, dexcom, eversense, many glucose meters) CLARITY > clarity.dexcom.com, Dexcom G6, Clarity, Dexcom Follow, it downloads data from Dexcom CGM Libreview > libreview.com > librelink + librelinkup > it downloads data from Librestyle Libre 14 days, Libre 2 Carelink > carelink.medtronic.com > Guardian Connect + Carelink + Sugar IQ diabetes assistant > it downloads data from medtronic insulin pump and medtronic CGM Tidepool > tidepool.org > tidepool mobile > insulin pumps (medtronic, tandem, omnipod) + freestyle libre 14 days, dexcom, guardian connect + many glucose meters Eversense Data management system > eversensedms.com > eversense > eversense

Insulin teaching key points

abdomen is the preferred injection site stay 1" away from previous site don't re-use syringes keep unopened insulin in refrigerator Look for lipoatrophy (fat wasting) or lipohypertrophy (fat growth) decrease insulin dose if member is going to start injecting insulin in a new area that doesn't have scar tissue or excessive fat tissue (decrease insulin by 40%).Bev gave example of 50 units basal to 30 units.

Hyperglycemia / DM2 on hospital admission

any blood sugar above 140 = check A1c If BG >180 start insulin therapy -stop oral meds -basal-bolus therapy if eating -basal + correction scale if higher risk for hypoglycemia. -Critical care - IV insulin drop or basal-bolus BG goal is 140-180 although it should be individualized and hypoglycemia and hyperglycemia should be avoided. More relaxed BG goals Terminally ill At risk of hypo due to other health issues In setting where intensive checks not feasible When setting goals consider: Clinical status especially renal function Severity of illness Nutritional status Glucose variability and trends Usual management plan and individual's expertise **sole use of sliding scale insulin is discouraged - must take into account both at meal blood sugar AND carbs -monitor BG before meal and hs if eating -monitor BG q4-6 hours if on TPN or tube feeding. If BG <100, consider adjusting insulin / meds If BG <70, insulin change required If renal failure, conservative insulin dose if patient has N/V or not consistent eater - give bolus after meals or use hs scale *basal insulin causes 78% of hypoglycemia Anticipate hypoglycemia events: NPO for sugery, decreasing steroid dose, improving infection, recovering after cardiac event Give the least amount of insulin necessary to reach glycemic targets Point of care BG monitors have a 20% error margin for blood sugars just like regular glucometers

When choosing an insulin consider:

cost onset of action duration of action volume per injection adherence hypoglycemia technology formulary duration of action patient preference

Psychosocial Issues associated with Chronic Kidney Failure

depression stress anxiety support groups, counseling and coping skills

screening children: DM1 vs DM2

distinguishing between DM1 and DM2 excess weight is common in children with DM1 -auto antibodies and ketosis maybe be present in pediatrics with features of DM2 (including excess weight and acanthosis nigricans) -positive islet autoantibodies is associated with faster progression to insulin deficiency -with new DM2 in youth DKA occurs in 6% of youth

Alpha blockers These drugs reduce the arteries' resistance, relaxing the muscle tone of the vascular walls.

doxazosin mesylate Cardura* prazosin hydrochloride Minipress* terazosin hydrochloride Hytrin*

How do you calcualted estimated average glucose (eAG) from A1c AND A1c from BG?

eAG = 28.7 * A1c - 46.7 A1c = eAG + 46.7 / 28.7

Calculating ASCVD risk

http://tools.acc.org/ASCVD-Risk-Estimator- Plus/#!/calculate/estimate/

Carbs, Diabetes & Exercise recommendations #2

https://pubmed.ncbi.nlm.nih.gov/28126459/ Key Specific Circumstance 1) Endurance exercise performance in athletes with and without diabetes 2) Hypoglycaemia prevention under low insulin conditions 3) Hypoglycaemia prevention under high insulin conditions Meal (low fat, low glycaemic index) consumed before exercise 1) A minimum of 1 g carbohydrate per kg bodyweight according to exercise intensity and type 2) A minimum of 1 g carbohydrate per kg bodyweight according to exercise intensity and type 3) A minimum of 1 g carbohydrate per kg bodyweight according to exercise intensity and type Meal or snack consumed immediately before exercise (high glycaemic index) 1) No carbohydrate required for performance 2) If blood glucose concentration is less than 5 mmol/L (<90 mg/dL), ingest 10-20 g carbohydrate 3) If blood glucose concentration is less than 5 mmol/L (<90 mg/dL), ingest 20-30 g carbohydrate Meal consumed after exercise 1) 1·0-1·2 g carbohydrate per kg bodyweight 2) Follow sports nutrition guidelines to maximise recovery with appropriate insulin adjustment for glycaemic management 3) Follow sports nutrition guidelines to maximise recovery with appropriate insulin adjustment for glycaemic management Exercise (up to 30 minute duration) 1) No carbohydrate required for performance 2) If blood glucose concentration is less than 5 mmol/L (<90 mg/dL), ingest 10-20 g carbohydrate 3) Might require 15-30 g carbohydrate to prevent or treat hypoglycaemia Exercise (30-60 min duration) 1) Small amounts of carbohydrate (10-15 g/h) could enhance performance 2) 30-60 g carbohydrate per h to prevent hypoglycaemia and enhance performance 3) Up to 75 g carbohydrate per h to prevent hypoglycaemia and enhance performance* Exercise (>150 min duration); mixture of carbohydrate sources 1) 60-90 g carbohydrate per h spread across the activity (e.g. 20-30 g carbohydrate every 20 min). Use carbohydrate sources that use different gut transporters (eg, glucose and fructose) 2) Follow sports nutrition guidelines (60-90 g/h) with appropriate insulin adjustment for glycaemic management 3) Follow sports nutrition guidelines (60-90 g/h) with appropriate insulin adjustment for glycaemic management ****Carbohydrate consumption at a high rate might cause gastric upset in some individuals and might contribute to hyperglycaemia during and after the activity. To increase the rate of carbohydrate absorption during exercise, and maintain hydration status, sports beverages containing glucose and fructose might be preferable.

Carbs, Diabetes & Exercise recommendations #1

https://pubmed.ncbi.nlm.nih.gov/28126459/ Panel 1: Blood glucose concentrations before exercise commencement and recommended glucose management strategies The carbohydrate intakes shown here aim to stabilise glycaemia at the start of exercise. Blood glucose at the start of exercise must also be viewed within a wider context. Factors to consider include directional trends in glucose and insulin concentrations, patient safety, and individual patient preferences based on experience. Carbohydrate intake will need to be higher if circulating insulin concentrations are high at the onset of exercise. Starting glycaemia below target (<5 mmol/L; <90 mg/dL) • Ingest 10-20 g of glucose before starting exercise. • Delay exercise until blood glucose is more than 5 mmol/L (>90 mg/dL) and monitor closely for hypoglycaemia. Starting glycaemia near target (5-6·9 mmol/L; 90-124 mg/dL) • Ingest 10 g of glucose before starting aerobic exercise. • Anaerobic exercise and high intensity interval training sessions can be started. Starting glycaemia slightly above target (10·1-15·0 mmol/L; 182-270 mg/dL) • Aerobic exercise can be started. • Anaerobic exercise can be started, but glucose concentrations could rise. Starting glycaemia above target (>15 mmol/L; >270 mg/dL) • If the hyperglycaemia is unexplained (not associated with a recent meal), check blood ketones. If blood ketones are modestly elevated (up to 1·4 mmol/L), exercise should be restricted to a light intensity for only a brief duration (<30 min) and a small corrective insulin dose might be needed before starting exercise. If blood ketones are elevated (≥1·5 mmol/L), exercise is contraindicated and glucose management should be initiated rapidly as per the advice of the health-care professional team. • Mild to moderate aerobic exercise can be started if blood ketones are low (<0·6 mmol/L) or the urine ketone dipstick is less than 2+ (or <4·0 mmol/L). Blood glucose concentrations should be monitored during exercise to help detect whether glucose concentrations increase further. Intense exercise should be initiated only with caution as it could promote further hyperglycaemia.

Correction Bolus common scale

less than 70 = subtract 1 unit 70-150 = 0 units 151-200 = 1 unit 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units 351-400 = 5 units

hypoglycemia

level 1 - Bg less than 70 level 2 - Bg less than 54 level 3- severe, needs assistance 50% of episodes occur during the night Mortality with severe hypoglycemia secondary to sulfonylureas especially glyburide, Micronase, Diabeta Risk factors of hypoglycemia: -DM medication -intensive insulin therapies -Impaired kidney or liver function -Advanced age, poor nutrition -Near normal A1c -History of frequent hypoglycemic episodes -Neuropathy typical causes: -low-carb meal -extra activity -drinking alcohol -delayed, missed meal -too much insulin/meds -insulin timing (taking after meal vs before meal - too late)

Loop Diuretics (-ides)

loop diuretics inhibit resorption of water and sodium from the loop of Henle. Diuretics help the body get rid of excess sodium (salt) and water and help control blood pressure. They are often used in combination with additional prescription therapies. furosemide (Lasix) Bumetanide (Bumex)

non-proliferative BECOMES proliferative diabetic retinopathy OVER TIME

non-proliferative retinopathy: aneurysm, hemorrhage, hard exudate proliferative diabetic retinopathy: growth of abnormal blood vessels -new blood vessel formation on surface of retina or the optic nerve. Severe visual loss can occur due to vitreous hemorrhage and retinal detachment. Note fine network of new blood vessels on the surface of the optic nerve

Language of diabetes education

old way > new way control DM > manage DM test BG > check BG patient > participant normal BG > BG in target range non-adherent / compliant > focus on what they are accomplishing refuse > decided, chose For people with BMI >30 preferred terms. Person with elevated BMI Person with obesity Person with excess weight For descriptions of BMI >40 class 3 obesity severe BMI extreme BMI Use language that -imparts hope, -is neutral and non-judgemental, -based on fact, actions or biology -respectful and inclusive -fosters collaboration between person and provider -avoids shame and blame

Heart Attack signs and symptoms

pain or discomfort in arms, back, jaw, neck or stomach shortness of breathe sweating nausea light-headedness Make sure people with diabetes know the signs and seek immediate People with diabetes may not experience intense chest or jaw pain during heart attack due to neuropathy

Factors that increase risk for amputation in diabetes

socioeconomic status cigarette smoking previous amputation age and ethnicity race age Other high risk factors: elevated blood sugars peripheral neuropathy foot deformity (charot foot, claw foot, etc) pre-ulcerative callus or corn peripheral arterial disease previous foot ulcer history vision impairment CKD (especially if on dialysis loss of protective function **Over 50% of ampuations could have been avoided

Other causes of hyperglycemia

steroids agent orange tube feedings/TPN cystic fibrosis Regardless of cause, requires treatment -insulin always works -sign of pancreatic malfunction *Stressors are a test of pancreatic function and might expose insulin resistance and deficiency.

If children have Autoimmune Disease Type 1 diabetes, what else should you screen form?

thyroid antibodies soon after diabetes (TSH at diagnosis when stable then every 1-2 years or if symptoms) screen for celiac disease by tissue transglutaminase antibodies (repeat within 2 years of diagnosis - may check more frequently if symptoms or if have first degree relative with celiac)

Common causes of ulcers

tight shoe and minor trauma Neuropathy and peripheral vascular disease

Types of CGM

types: professional VS personal owned by clinic VS owned by patient blinded and unblinded (real-time feedback) options VS real-time feedback or scan for feedback (flash device) short-term use (3-14 days) VS long-term use insulin coverage for most people with type 1 diabetes or type 2 diabetes VERSUS insurance coverage more focused on type 1 diabetes or those on intensive insulin regimens Not compatible with insulin pumps VS compatible with smartphones and insulin pumps with select devices

Medications to consider when goal is to avoid weight gain & those that cause weight gain:

weight neutral meds: -metformin -DPP-IV inhibitors (-gliptins) = saxagliptin, linagliptin, alogliptin) -AGIs - acarbose weight loss meds: -GLP1-RAs = exenatide, liraglutide, dulaglutide, lixisenatide, semaglutide) -SGLT-2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) -Symlin (pramlintide weight gain meds: -insulins -sulfonylreas -TZDs -meglitinides -steroids -atypical antipsychotics

How Does Continuous Glucose Monitoring (CGM) Work?

what are they? Continuous glucose monitors (CGMs) are small devices that have a tiny hair like wire that goes under the skin. Many people with diabetes refer to a CGM as a 'sensor' because it's sensing the glucose in your body. Sensors show your current sugar level and how it's changing - whether it's staying the same, going high, or going low. You can also set alarms if you want. Most CGMs come with automatic inserters that make it easy and virtually pain-free, to put in place on your own. How do they work? Measures glucose from interstitial fluid (ISF) every 1-5 minutes and records glucose every 5-15 minutes (96 readins/15 min, 288 readings/5 min) Slight delay compared with whole blood glucose (lag time) The CGM data is real-time

Freestyle Libre 2

• 14 day wear • 1 hour warm-up • FDA approved ages ≥ 4 years • Real time alerts (hypo, hyper, out of range) - must scan for actual number • FDA approved for insulin dosing except for the first 12 hours after insertion • Must scan every 8 hours to avoid data gaps • Vitamin C interference (>500mg) • 1 press inserter, disposable transmitter included with sensor no pump integration receiver is reader no calibrations required FDA approved site: upper arm MARD 9.2% • iCGM status

Meet Karen

• 66 year old woman with T2DM, HTN, osteoarthritis, HF Medications •Dapagliflozin 10mg daily •Metformin 1000mg ER twice daily •Insulin glargine 60 units qpm •Insulin aspart 12 units TID a.c. •Eats 2 meals/day •Walks the dog 10 min/day •Sometimes forgets to take glargine, falls asleep •A1C=7.1% D - download data, questions to ask? A - assess safety "I'm sometimes afraid to give myself insulin because I go low." T - time in range "I notice overall when I take my meds like I am supposed to, my numbers are more in range. I think I also exercised that day." A - Areas to improve "I fall asleep and forget to take my insulin glargine a few times per week." A - action plan Switch glargine to QAM, decrease aspart to 10 units BID with 2 main meals, consider future addition of GLP-1 agonist .

COMISAIR Study

••••••Prospective, non-randomized trial with T1D (N=94) rtCGM+MDI vs rtCGM+CSII vs SMBG+MDI vs SMBG+CSII Primary endpoint: A1C, Baseline=8.2% Other endpoints: hypoglycemia, time in range, hyperglycemia CGM groups - A1C: 6.9% (pump), 7.0% (MDI) Non CGM groups - A1C: 7.7% (pump), 8.0% (MDI) CGM groups resulted in a 0.8 to 1% A1c difference compared to non-CGM groups Soupal J et al. Diabetes Care 2019 Sep; dc190888.

Multiple, Complex Pathophysiological Abnormalities in T2DM Adapted from: Inzucchi SE, Sherwin R

↓ pancreatic insulin secretion ↓ incretin effect ↑ pancreatic glucagon secretion ↑ lipolysis ↑ hepatic glucose production ↑ renal glucose reabsoption ↓ renal glucose excretion ↓ peripheral muscular glucose uptake neutrotransmitter dysfunction