Special population mgmt (soc 7,8 obesity & tech) Flashcards
What is diabetes technology?
Software
Hardware
Devices
to help PWD manage their condition
What are barriers to pt and provider use of DM technology?
- complexity
- rapid change of available tech
What resource is available to help pts/providers make initial device choices?
DiabetesWise.org (nonprofit organization)
What should be considered when deciding to recommend DM tech?
- availability of devise
- pt needs
- pt skills
- pt desire
- cost
When should PWD on intensive insulins be encouraged to SMBG?
- before meals/snacks
- @ bedtime
- b4 exercise
- if suspecting hypo
- after tx low BG
- until normoglycemic
- prior to and possibly during critical tasks (driving)
- occasionally postprandially
- may be 6-10 x/day
When may SMBG in those not on insulin be helpful?
- altering diet
- altering PA
- using oral meds that may cause hypo
Evaluating SMBG
- evaluate technique, results, and pt ability to use the data to adjust tx
What common meds or supplements may interfere with glucometer accuracy?
Vitamin C/ascorbic acid
Acetaminophen
What should patients know about glucometers and test strips?
- only use FDA approved glucometers
- only use unexpired strips that are purchased from pharmacy/licensed distributor
Why should PWD SMBG?
- evaluate response to tx
- assess if glycemic targets are being met
- assess if targets are met safely
What is SMBG helpful for?
- Guiding MNT- how to adjust food intake
- PA
- Preventing hypo
- adjusting meds
What should dictate frequency, timing and consideration for use of CGM?
Pt needs and goals
What is SMBG accuracy impacted by?
- glucometer used
- user technique
Increased frequency of SMBG in T1DM is associated with
lower A1c esp. in kids/adolescents
How often should need for SMBG be evaluated?
Every visit
SMBG in insulin users NOT on intensive insulin regimen
- those on basal benefit from SMBG; lowered A1c
- no set recommendation on frequency
Should PWD on oral meds only SMBG?
Evidence shows limited benefit;SMBG alone does not lower A1c; info must be integrated into practice
What are 2 major factors that affect BG meter readings?
- Glu oxidase rxn- sensitive to oxygen levels. High oxygen (like on oxygen tx or arterial blood oxygen) –> false low. Low oxygen (hypoxia, venous readings, high altitude) –> false highs
- Glu dehydrogenase rxn- not sensitive to oxygen
Does temperature affect glucometer?
Yes
will receive error message if at unacceptable temp
What are common interfering substances for glucose oxidase meters?
Uric acid
Ascorbic acid
L-dopa
Acetaminophen
What are common interfering substance with glu dehydrogenase monitors?
peritoneal dialysis
icodextrin
Just because meter is FDA approved does not mean it’s accurate. Why?
- only has to meet standards of past initial time of approval for FDA (not current standards)
What is the ISO
International Organization of Standardization
Meter must meet current ISO standards
How many meters meet DM tech society BG monitoring system surveillance program standards?
6/18
What is needed for CGM rx?
DM education, training, support. Need to be able to calibrate device and verify readings if they don’t match current s/s
What is useful for lowering A1c & hypo in T1DM?
- Real time CGM + intermittently scanned CGM along with insulin therapy
How often should real time CGM be used?
intermittently scanned?
real time- daily
intermittent- scan at least q 8 hours
Why should pregnant women use real time CGM
improve A1c
improve BG TIR
improve neonatal outcomes
What can blinded CGM do?
- ID and correct HYPER and HYPO
in T1DM + T2DM when used w/ DSME & medication adjustment
What’s the difference b/w finger sticks and CGM?
Finger stick -plasma glucose
CGM- interstitial fluid
What’s the difference b/w adjunctive CGM and non-adjunctive?
Adjunctive- require SMBG confirmation
Non-adjunctive- do not require SMBG
What data does CGM provide?
- TIR
- GLU variability
- Time above & below range
If intermittently scanned CGM is used in T2DM what can it do?
- reduce A1c
- doesn’t reduce hypo
Real time CGM in T1DM effectiveness
- effective in reducing A1c & hypo in adults
- limited research in kids/adolescents
- may be more helpful if kid wore it 6-7 days/week
- parents love it
What is a side effect of CGM use?
dermatitis
associated w/ skin sensitizer isobornyl acrylate
When may insulin pen vs. syringe be helpful?
dexterity issues
needle phobia
vision issues
Insulin syringe
- size
1 ml= up to 100 units 0.5 ml= up to 50 units 0.3 ml=up to 30 units generally meant for 1x/use but may be reused if cleaned well u500 insulin has special syringe
insulin pens
combined syringe & vial in 1 devise
convenient
cartridges may be disposable or reusable
insulin needles
- duller needle= more pain, associated w/ reused needles
- thicker needle= dose given more quickly
- thinner needle= less pain
- size- 22-33 (higher number is thinner)
- length- 4 mm-12 mm
- shorter needles= less risk of injecting IM
Who is a candidate for insulin pump?
All adults, kids, adolescent w/ T1DM who can safely manage the device
Who is most likely to use pumps?
higher socioeconomic status
- race/ethnicity
- private health insurance
- family income
- education
What can pump therapy do?
- modestly lower A1c
- reduce severe hypo
aspects of pump therapy
- assess pt/family readiness
- select pump type & settings
- education for pump complications- DKA,infusion set failure
- transition from multiple daily injections
- advanced pump settings
complications of pumps
- pump can get dislodged or occluded –> DKA
- lipohypertrophy
- lipoatrophy (not common)
- pump site infection
Common reasons pumps are d/c
- $$
- wearability
- dislike of pump
- suboptimal glycemic control
- mood disorders
barriers to using pump in kids
- physical interference
- physical discomfort
- financial burden
- effectiveness?
sensor augmented pumps
suspend insulin when glu is low or predicted to go low within 30 minutes
- reduced nocturnal hypo without increasing A1c
automated insulin delivery systems
- increase and decrease insulin delivery based on sensor derived glu level/trends
- consist of 3 parts:
- insulin pump, continuous glu sensor, algorithm that determines insulin delivery
- requires user bolus for meals;must announce meals
DIY insulin delivery system
- not FDA approved yet
- contains pump, real time CGM w/ controller, algorithm to automate insulin delivery
- insulin doses adjusted based on set basal rate, CHO ratio, correction dose, insulin activity
- ensure pt has back up plan if system fails
Insulin pump calculations
CHO to carb ratio
correction factor
1:15 insulin:CHO ratio to start
1 unit of insulin needed for every 30-50 pts above target
calculating insulin needs
1/2 TDD as bolus; other 1/2 basal
0.5 x kg in body weight= TDD/day
1/2 as bolus, 1/2 as basal
for basal rate/24 hours
Insulin drip in hospital
- usually 60-80% for basal dose
- 1cc= 1 unit of insulin; 100 cc bags
- rate based on BW- 0.05 units/kg/hr
- monitor BG q 1-2 H
- inject insulin subq 2-4 hours before stopping the insulin drip
insulin sensitivity factor (ISF)
AKA correction factor
ISF= how much 1 unit of insulin drops BG
NOT reliable for T2DM
1500 rule
Used for those on short acting insulin (regular insulin)
1500/TDD
ex: 1500/50= 30. 1 unit of regular insulin would drop this person’s BG by 30 pts
1800 rule
for those on rapid acting insulin
1800/TDD
ex: 1800/30= 60. 1 unit rapid would lower BG by 60 pts
500 rule
500/TDD= insulin:CHO ratio
500/50 units (this persons TDD)= 1:10. 1 unit of insulin covers 10 g CHO
Insulin:CHO ratio
how many g CHO 1 unit insulin covers
higher ratio= more insulin sensitive
1:15 common, sometimes 1:10
1:15, ate 45 g CHO= 3 units to cover it
Asian overweight
Asian obesity
OV- 23-27.4
OB-27.5 or higher
VLCD for T2DM
<800 kcal, 3 month intervention, medically supervised for carefully selected pts
decrease A1c <6.5% & FPG <126 w/o meds
modest & sustained WL in T2DM –>
improve glycemic control, reduces need for DM meds
5% WL
high intensity intervention for WL
> /=16 sessions x 6 months; once wt loss achieved, offer at least 1 year of weight maintenance
wt maintenance
weigh at least weekly
200-300 mins/PA per week
modest WL in T2DM
improve BG, A1c, TG
greater WL in T2DM
improve BP, LDL, HDL, reduce need for meds to control BG/BP/lipids
when to recommend WL meds
- BMI >27 + DM
- BMI >25 + DM in Asians
When to recommend bariatric surgery
BMI 30+ DM
BMI27.5 or more + DM + Asian
Look AHEAD
- population- OV/OB T2DM
- outcome: did not reduce CV events
- at 8 years 1/2 maintained 5%, 1/4 maintained 10% WL; mean WL 5%
- median WL 5%
- improved QOL- physical and sexual function, mobility
- reduced risk factors w/ less meds
Need what % WL for minimum clinical benefit
3-5%
energy deficit for WL
500-750
When to d/c WL med
- <5% loss x 3 months
- tolerability issues
A1c goal achievement
NOT BMI dependent
wt neutral DM meds
DPP4i
Metformin
weight loss DM meds
Metformin? GLP1-RA SGLT2-i a-glucosidase inhibitor amylin mimetics
weight gain DM meds
insulin
sulfonylureas/meglinitides
TZD
other wt gain meds
- antipsychotic (end in ine), antidepressant (SSRI, triclyclic, MAOI), anticonvulsant, glucocorticoids/steroids, injectable progestins
WL meds in DM- efficacy
nearly all prescription WL meds delay progression from pre-DM –> T2DM & improve glycemic control in T2DM
prescription WL meds- how often to assess pt response?
assess monthly 1st 3 months
medical devices for WL
$$$$$$
limited insurance coverage
lack of research in T2DM
metabolic surgery to treat T2DM
- Morbid obesity or >37.5 in Asians
- class II obesity or 32.5-37.4 in Asians who did not lose weight or improve co-morbidities w/ nonsurgical methods
- class I Obesity or >27.5 Asian American if they tried all other options and didn’t work
why bariatric surgery in T2DM?
superior glycemic control and reduction in CV risk factors
reduce microvascular dz
better QOL
cost effective
T2DM remission after bariatric surgery
30-60% 1-5 years
erosion of remission over time
35-50% remission pts experience recurrence
median dz free years is 8
most have improved glycemia for 5-15 years or more
who is most likely to experience T2DM remission and reduced risk of regain following bariatric surgery?
younger age shorter duration DM (<8 years) non-insulin user maintained WL better baseline BG
mortality rate w/ bariatric surgery
0.1-0.5%
LT s/s of bariatric surgery
dumping syndrome vitamin/mineral deficiencies anemia osteoporosis rare- severe hypo (Roux en Y) MH issues, alcoholism additional surgery/revision suicidal ideation
