Finding the Sweet Spot:
DM II treatment in post acute rehabilitation
(& a few crumbs for granny –
the key to treating DM II in frail elders)
Belinda Setters, MD, MS, AGSF
March 6, 2014
Kentucky Cardiopulmonary Rehab Symposium
The Sweet Spot: DM II treatment update
Disclosures
• Acting Associate Chief of Staff , Geriatrics & Extended Care
• Director, Acute Care for Elders & Transitional Care Programs
Robley Rex VAMC, Louisville, Ky
• Associate Clinical Professor
University of Louisville
Depts. of Internal and Family & Geriatric Medicine
No financial (or other) incentives, stock or compensation
The Sweet Spot: DM II treatment update
Learning Objectives
• Review updated guidelines for DM II treatment
• Identify pitfalls of treatment in post acute (rehabilitation) care
• Understand unique features of elderly patients that
complicate treatment
• Understand the importance of individualized care
The Sweet Spot: DM II treatment update
• Just the stats m’am. . .
• 25.8 million diabetics (all ages) = 8.3% of population
• > 65 yo, increases to 27% of population (10.9 million)
o 7 million undx patients
• DM II associated with 2 x
higher disability
• 42% of persons > 65 yo have at least one disability
o = 14 million people
American Diabetes Association: www.diabetes.org
NIH: www.ndep.nih.gov/diabetes-facts
CDC: www.cdc.org/diabetes
The Sweet Spot: DM II treatment update
The Sweet Spot: DM II treatment update
From Dr. Samuel E. Dagogo-Jack: http://www.medscape.org/viewarticle/536351
The Sweet Spot: DM II treatment update
The Sweet Spot: DM II treatment update
The Sweet Spot: DM II treatment update
• Treatment goals . . .
• Fasting blood glucose < 140 mg
• Hemoglobin A1C < 7
• If can push to get better #s, without side effects
(hypoglycemia), then ok to do so in adult patients
• Post acute care (“rehabilitation”) guidelines follow those of
non-critical care acute recommendations
J Clin Endocrinol Metab 2012, 97(1):16-38
The Sweet Spot: DM II treatment update
• Treatment goals . . . Short term concerns
• Minimize adverse effects of high glucose
o
o
o
o
Wound healing & infection
Confusion/MS change
Fatigue = decr. participation in therapy
Falls
• Minimize HYPOglycemia
• Minimize “pill burden”
• Transition patient to home
The Sweet Spot: DM II treatment update
• Treatment goals . . . Options.
Glucose
>140
DX: DM II
No DM II
(+)
Current RX
Adjust RX
Monitor BS
24-48 hrs
( --)
d/c
monitoring
The Sweet Spot: DM II treatment update
• Recommended therapy: Insulin
Long Acting Insulin
(Daily)
OR
Intermediate acting
(Twice Daily)
Short Acting Insulin
(with Meals)
The Sweet Spot: DM II treatment update
• Insulin types
Action
Onset
Peak
Duration
Name
Brand
Rapid
15 min
1 hr
2-4 hrs
Glucine
Lispro
Aspart
Apidra
Humalog
Novolog
Regular /
“short”
30 min
2 hrs
3-6 hrs
Lispro R
Novolin R
Humalog R
Novolgo R
Intermediate
2 -4 hrs
4-12 hours
12-14 hrs
NPH
Humulin N
Novulin N
Long
hrs (aprox
6)
None
24 hrs
Detemir
Glargine
Levemir
Lantus
The Sweet Spot: DM II treatment update
• Insulin types . . . . . “the slide”
• Sliding Scale Insulin
o Good for short term coverage to adjust long acting insulins
o Should not be used as a substitute for long acting or short/regular
insulin regimen.
diabetesmanager.pbworks.com
The Sweet Spot: DM II treatment update
The Sweet Spot: DM II treatment update
• Oral agents
www.medscape.org
Class
Pharm
Limitations
Name
Brand
Sulfonylureas
Stimulates
pancreas to
release insulin
Hypoglycemia
CV risks
Liver/renal
Glimeprimide
Glyburide
Glipizide
Gliclazide
Amaryl
Micronase
Gluctorol
Diamicron
Biguanide
Reduces
glucose
production
Lactic acidosis
Metformin
Glucophage
Alpha-glucosidase
inhibitor
Reduces
glucose
absorption
GI side effects
/ take with
meals
Acarbase
Precose, Glucobay
Glyset
Basen
Thiazolidinedione
Reduces
insulin
resistance
Edema
Heart failure
Wt gain
Liver fxn
Rosiglitazone
Pioglitazone
Avandia
Actos
Prandial glucose
regulators
Incr. insulin
secretion
Hypoglycemia
Repaglinide
Nateglinide
Prandin
Starlix
Incretin mimetics
Incr. insulin
sensitivity
hypoglycemia,
Fatigue,
anorexia
Pramlinitide
Sitagliptin
Exenatide
Symlin
Januvia
Byetta
Miglitol
Voglibose
The Sweet Spot: DM II treatment update
• Nutrition therapy
Rec:
“Consistent Carb” diet
+
Education & Accountability
• Exercise
Therapy, activities, walking
American Diabetes Association: www.communitydiabetes.org
The Sweet Spot: DM II treatment update
• Control Vascular Risk Factors
o Tobacco cessation
o Nutrition
o Weight Loss
o HTN management
o HLD management / statins
o Anti-inflammatory therapies
o Mental & physical activity
The Sweet Spot: DM II in elders
• Treatment Considerations
Micro-vascular
Injury (in Years)
Macro-vascular
Injuries (in Years)
Control of -Glucose
Blood Pressure
Cholesterol
8
--
2-3
3
--
3-6
(CHF/AGS, presented at AGS Symposium, May 2003)
The Sweet Spot: DM II in elders
The Sweet Spot: DM II treatment update
• DM in The Elderly: Unique Concerns
o Erratic eating (or dependency on being fed)
o Inability to report symptoms (dementia, vague symptoms)
o Polypharmacy: multiple meds – competition for clearance
o Slowed metabolism / impaired clearance
o Shift in water-fat body content
o Low reserve, can’t respond to hypoglycemia
Med Care 2006 Apr;44(4):373-7
JAMA 2006 Oct 18;296(15):1858-66.
J Am Coll Cardiol 2009 Jan 20;53(3):298-304
The Sweet Spot: DM II treatment updates
• DM in Elders: Frailty
o Loss of functional reserve
o Slowed response to stress / pathologic illness
o Multisystem organ involvement
o Estimated prognosis (life expectancy)1-2 years
Lancet 2013; 381(9868): 752-762.
JAGS 2006; 54(6): 991-100.
Clin Geriatr Med 2011; 27(1): 1-15.
The Sweet Spot: DM II treatment updates
• DM in Elders: Frailty
Philosophy, Ethics, and Humanities in Medicine 2009 4:3 doi:10.1186/1747-5341-4-3
The Sweet Spot: DM II in elders
• Treatment Considerations
• Hemoglobin A1C < 7
o Mean plasma glucose 154 mg/dl (2-3 months)
o Healthy adults with > 10 year life expectancy
• Hemoglobin A1C between 7 – 8.5
o Mean plasma glucose 180 mg/dl (2-3 months)
o Adults with limited life expectancy, history of severe
hypoglycemia, or advanced micro-vascular or macro-vascular
disease
DIABETES CARE, 2013; 36(1): S11-S66
The Sweet Spot: DM II in elders
• Treatment Considerations
• Blood Pressure & Lipid Goals
•
•
•
•
Blood pressure < 140/80
LDL < 100 mg/dl or 70 with CVD
HDL > 40 mg/dl
Triglycerides < 150 mg/dl
DIABETES CARE, 2013; 36(1): S11-S66
The Sweet Spot: DM II in elders
• The “Sweet Spot” for Frail Elders
J Am Geriatr Soc 60:1215–1221, 2012.
The Sweet Spot: DM II in elders
• Other thoughts:
Hypoglycemia
• 2 episodes = 80% increased risk for Dementia
development
• 3 episodes = 94% increased risk for dementia
development
The Sweet Spot: DM II in elders
• Other thoughts
• Life Expectancy
o Changes w/ comorbidity
o Changes w/ frailty
• Goals of Care
o Pt Preferences
The Sweet Spot: DM II treatment update
• Wrap up
• Blood glucose < 140 or Hg A1C < 7
• Control vascular, other risk factors
• Consider QOL, pt preferences/GOC & life expectancy
• For most elders, especially frail elders, A1C = 8 is target
8 at 80
honey!
[email protected]
Geriatrics & Extended Care
http://vaww.louisville.va.gov/
@BelindaSetters
502-287-5995