Trends in Diabetes Care Management

Ann Margarett Lapuz

Cathy Roxas

Trends in Diabetes Care Management

Healthcare workers primarily focus on prevention of DM thru lifestyle modification
DIET EXERCISE

It reveals 58% decrease in developing DM and slows the rate of the disease in pt. with DM. ABCs of DM

Trends in Diabetes Care Management

A = A1c ( <6.5% - <7% ) B = blood pressure ( 130/80 ) C = Cholesterol LDL cholesterol < 2.6 mmol/l - < 3.0 HDL cholesterol Men > 1.1 mmol/ l - > 1.1 Women > 1.3 mmol/ l - > 1.3 Triglycerides < 1.7 mmol/ l < 1.5

Trends in Diabetes Care Management

Prevent complications of DM
Patient Centered Approach early DM Dx; effective control of glycaemia, BP, etc.

Prevention of severe sequel of DM complications

Cx screening & its management

Trends in Diabetes Care Management

Emphasis on patient self-care
Empowerment / patient education Education on self management of diabetes mellitus is important since more than 95% of diabetes care is self-care.

Pharmacological Treatment
New Emerging Theraphies Incretin-Based Hormones (Exenatide, Liraglutide)
Regulates blood glucose, and to a lesser extent, insulin and glucagon secretion. Usually given SQ

Amylin Agonist
Pramlintide - inhibit postprandial glucagon secretion, slow the rate of gastric emptying, enhance satiety, and reduce food intake Given pre-meals SQ Highly associated with hypoglycaemia if used with other drugs

Pharmacological Treatment
New Diabetes Indication for EstablishedDrugs Colesevelam
used for the treatment of hyperlipidemia, is thought to delay or alter absorption of glucose from the intestines shown to provide an A1C reduction of 0.41% and an LDL reduction of 12.8% SE: constipation, dyspepsia, nausea

Pharmacological Treatment
Bromocriptine
shown in a 1-year study to reduce A1C level by approximately 0.6% as monotherapy and 1.2% in combination with insulin or a sulfonylurea. lowered plasma triglycerides and free fatty acids by approximately 30% Decreased cardiovascular events SE: nausea, vomiting, fatigue, dizziness, and hypotension.

Pharmacological Treatment
Sodium-Glucose Transporter 2 Blockers
Dapagliflozin - prevent renal glucose reabsorption and lower serum glucose by increasing urinary excretion of glucose. shown to lower A1C by 0.58% to 0.89% SE: may lead to cancer, hepatoxicity

Pharmacological Treatment
New modes of Insulin Delivery

Pharmacological Treatment

Journal
Neonatal Diabetes: Current Trends in Diagnosis and Management Abstract
The purpose of this article is to describe diabetes diagnosed during the first 6 months of life also known as congenital diabetes Neonatal diabetes is not type 1 diabetes. While the etiology of type 1 diabetes is multifactorial and includes genetic and environmental factors, neonatal diabetes is strictly a genetic condition.

Neonatal Diabetes: Current Trends in Diagnosis and Management

Neonatal Diabetes
defined as uncontrolled hyperglycemia that requires treatment with insulin and has an onset in the first 6 months of life. occurs in approximately 1 in 300,000 to 500,000 live births can be either permanent or transient. term as "congenital diabetes" because some of these cases occur after the 4-week neonatal period. majority of cases of neonatal diabetes are genetically determined by a gene mutation and are, therefore, not autoimmune.

Neonatal Diabetes: Current Trends in Diagnosis and Management

Diagnosis of Diabetes in Infancy

small for gestational age (SGA) increased thirst polyuria ( soaking the diaper suddenly ) dehydration failure to thrive rarely suspected, misdiagnosed which may lead to diabetic ketoacidosis Presence of ketones in the urine Persistent elevated blood sugar of >150 200mg/dl

Neonatal Diabetes: Current Trends in Diagnosis and Management

Neonatal Diabetes Type 1 Diabetes Mellitus

Genetic Condition

Autoimmune disorder

Diagnosed during neonatal period

Diagnosed after neonatal period In children and young adults Polygenic Genetic predisposition but associated with environmental factors ( viruses, cows milk nitrosamines ) With autoantibodies, insulin antibodies etc.

Caused by gene mutation Monogenic No presence of antibodies

Neonatal Diabetes: Current Trends in Diagnosis and Management

Transient Neonatal Diabetes
Result from mutation of chromosome 6

Permanent Neonatal Diabetes

Mutation in the potassium (KATP)

channel of the insulin-producing cells early onset but normalized by 18 months of age
SGA but can catch up later on Diagnosed during 1st 6mos and does not resolve have neurological complications such as Developmental delay mild to severe, Epilepsy, etc Absence of C-peptide levels Requires insulin daily in increasing dosage

Decrease C-peptide levels (not enough secretion of insulin) Resolves during Infancy but possible relapse during adolescence, pregnancy and stressful events. Insulin management

Insulin management and oral

sulfonylureas

Neonatal Diabetes: Current Trends in Diagnosis and Management

Treatment Options for Neonatal Diabetes Insulin

Treatment begins immediately after diabetes is diagnosed by an elevated hemoglobin A1c or persistent hyperglycemia Insulin is often delivered initially by an insulin infusion that gives healthcare providers the ability to titrate doses depending on blood glucose levels. Once transitioned from the initial insulin infusion, injections of a basal insulin may be started often divided into twice-daily dosing in young children and infants to provide an adequate basal effect

Neonatal Diabetes: Current Trends in Diagnosis and Management

Dilute insulin
utilized to ease measurement of insulin doses for small children usual dilution used for insulin is a 1unit/10ml concentration Insulin usually given in 0.2 units allowing for more specificity with measurement should be prepared by a pharmacist who is familiar with the dilution technique should be discarded 30 days after preparation

Neonatal Diabetes: Current Trends in Diagnosis and Management

Feeding and insulin

important that insulin boluses be paired with feedings Counting carbohydrates and planning dietary intake must be carefully managed by healthcare team a common rule for evaluating the insulin-to-carbohydrate ratio is to divide 500 by the total daily insulin dose. If the infant is requiring about 3 units of insulin in a 24-hour period, divide 500 by 3. This results in 166-the insulin-to-carbohydrate ratio would be 1 unit of insulin for 166 g of carbohydrate. U-10 dilution of insulin, each 0.1 unit of insulin would then cover 16 g of carbohydrate-the total carbohydrate in 10 oz of milk. For blood glucose correction, the 1,800 rule is applied: divide 1,800 by the total daily insulin dose. In this case, divide 1,800 by 3 and get 600. Each unit of insulin would decrease the blood glucose by 600 mg/dl. Using U-10 dilute insulin, each 0.1 unit would decrease the blood glucose by 60 mg/dl.

Neonatal Diabetes: Current Trends in Diagnosis and Management

Assessment of Blood Glucose Control

safe target range for glucose levels for infants is 100 to 180 mg/dl before feeding and 110 to 200 mg/dl at sleep times ( ADA ) Trends can be seen at specific times of the day, after specific meals or feeding times or in relation to illness or other change in the daily activity Monitor accordingly Hemoglobin A1c measures long-term glucose control and should be measured every 3 months. (ADA) 7.5% and 8.5% to optimize good blood glucose control Always watch out for episodes of hypoglycaemia

Neonatal Diabetes: Current Trends in Diagnosis and Management

Oral Sulfonylureas
Sulfonylurea drugs bind to the channel, resulting in closure and release of endogenous insulin Given if after 4-8 weeks infant is confirmed to have PND Substitution of insulin with the sulfonylurea should take place gradually under the direction of a experienced medical team sulfonylureas in infancy is currently off-label, and parents should be fully informed and sign consent for the change in treatment

Neonatal Diabetes: Current Trends in Diagnosis and Management

Clinical Implications
great deal for nurses to learn about diagnosis and management of neonatal diabetes Nurses play a significant role in supporting families as they learn about the disease, and struggle to manage the stress, which accompanies having a sick infant. Educate parents in handling their sick infant, (giving insulin as needed and monitoring blood glucose throughout the day and night ) dangers of hypoglycemia and hyperglycemia in their infants Infants have varying sleep/wake and eating schedules, adding to the complications of trying to achieve consistently safe blood glucose levels

Neonatal Diabetes: Current Trends in Diagnosis and Management

Fussiness can be correctly interpreted as normal in the infant, but it may also be caused by hypoglycemia or hyperglycemia, requiring more frequent blood glucose testing than might be necessary in an older child. Managing infants with diabetes requires a skilled pediatric endocrine team with experience in diagnosis and management of diabetes in this young age group, with professional nurses who are both learned and compassionate in their care.