Chronic Disease Management:
Diabetes Mellitus
Rachel Waite, Pharm.D. Candidate
By the end of this talk you should be
able to…
• Explain the difference between type 1 and
type 2 diabetes mellitus
• List risk factors for DMT2
• Explain the difference between prediabetes,
diabetes, metabolic syndrome
• Describe microvasuclar and macrovasular
complications of diabetes.
• Counsel a patient on hypoglycemia treatment
• Counsel a patient on non-drug diabetes
management tools.
• Counsel a patient on treatment goals of
diabetes.
• List the components of a SOAP note
• Practice writing a SOAP note from an example
case
Impact of DM
• 25.8 million Americans have diabetes (8.3% of
population)
• The number of Americans treated for diabetes
doubled from 1996 to 2007.
• 1 in 3 Americans born in 2000 will have diabetes
in their lifetime
• Annual costs -- $132 billion
• Leading cause of blindness, ESRD, amputations,
MI, strokes
84% of people
with diabetes are
on oral
medication or
insulin
Source: 2007–2009 National
Health Interview Survey
Diabetes Mellitus Type 1
• Results from inability of
islet cells to produce
insulin
• Also known as insulindependent or juvenileonset diabetes
• Cause is unknown, but
likely to have genetic,
autoimmune component
Diabetes Mellitus Type 2
• Results from decreased
insulin sensitivity and
decreased pancreatic
beta-cell function
Gestational Diabetes
• Diabetes that first
presents during
pregnancy
• Occurs in 2-10% of
pregnancies
• 30-60% chance of
developing T2DM
95% of DM patients are Type 2
Source: SEARCH for Diabetes in Youth Study NHW=non-Hispanic whites;
NHB=non-Hispanic blacks; H=Hispanics/Latinos;
API=Asian/Pacific Islander Americans; AI=American Indians
DMT1 v. DMT2
Characteristic Type 1
Age of onset Childhood /
adolescence
Rate of onset Abrupt
Increased prevalence
Family hx
with Fm Hx Type 1
Type 2
> age 40
Islet cell Abs
Body weight
Yes
Thin, undernourished
No
Overweight, obese
Insulin
Marked decrease
Insulin Rx mandatory
Insulin not necessary
initially
Symptoms
Weight loss, thrist,
urination, hunger
May be asymptomatic
Gradual
Increased prevalence
with Fm Hx Type 2
Risk Factors: T2DM
Obesity (BMI >27)
Hypertension
Hx Gestational DM
Family Hx DM
Dyslipidemia
Hx vascular disease
Previous impaired fasting
glucose test, impaired
glucose tolerance
Polycystic ovaries
Inactive lifestyle
Certain ethnicities (African
Americans, Hispanics, Native
Americans, Pacific Islanders).
Metabolic Syndrome
A group of risk factors that occur together that
increase risk for diabetes, coronary artery
disease, and stroke.
Not the same as pre-diabetes
Metabolic Syndrome
• Elevated waist circumference:
Men — Equal to or greater than 40 inches (102 cm)
Women — Equal to or greater than 35 inches (88 cm)
• Elevated triglycerides:
Equal to or greater than 150 mg/dL
• Reduced HDL (“good”) cholesterol:
Men — Less than 40 mg/dL
Women — Less than 50 mg/dL
• Elevated blood pressure:
Equal to or greater than 130/85 mm Hg
• Elevated fasting glucose:
Equal to or greater than 100 mg/dL
Screening
• Fasting Plasma Glucose (mg/dL)
(FPG)
– Check a fasting glucose level
• Oral Glucose Tolerance Test (mg/dL)
(OGTT)
– Check blood glucose 2 hours after a 75g
oral glucose load
•
Hemoglobin A1c
– Shows percentage of glycated
hemoglobin.
– Reflects glucose control over 6-12 week
period.
HbA1c and Average Plasma
Glucose Correlation
HbA1c
6
7
8
9
Etc.
Plasma Glucose
120
150
180
210
Signs and Symptoms
“The Polys”
• Polyuria / polydipsia: Glucose spilled into
urine, leads to osmotic diuresis (polyuria). This
leads to dehydration, and increased thirst
(polydipsia).
• Polyphagia: without insulin function, glucose
cannot be transported into cells. Cells are
“hungry” and hunger sensation is triggered.
• Polys can go unnoticed for years.
Complications
Microvasuclar: damage
to eyes, kidneys, nerves
(retinopathy,
nephropathy,
neuropathy)
Macrovascular: 2X risk
for heart attack and
stroke, peripheral
vascular disease
Hypoglycemia
Definition: plasma glucose <70
A complication of treatment!
Normal plasma glucose 70-150
40 is the minimum for brain function
<40 = Risk for diabetic coma, seizures
Symptoms of Hypoglycemia
• Heat
palpitations
• Confusion
• Tremor
• Sweating
• Anxiety
• Hunger
• Visual
disturbances
• Seizure
• Loss of
Consciousness
Hypoglycemia Treatment
• Glucose
– 15 grams of simple carbohydrates
•
•
•
•
8oz. fruit juice
Half can regular soda
3 glucose tabs
1 tablespoon honey
• Glucagon injection
– Stimulates glycogen breakdown
Patient Education
Diabetes Survival Skills:
Food, exercise, meds
Treatment plan
Goals / targets
Self-monitored blood
glucose
Hypoglycemia
Emergency numbers
If insulin: injection
technique, syringe
disposal, storage, etc.
Foot care
Ophthalmic exams
Target Goals
Glycemic Control:
A1c
≤ 7%
Fasting (preprandial)
Plasma Glucose
70-130 mg/dL
Postprandial or HS
Plasma Glucose
<180 mg/dL
Target Goals
Blood pressure:
<130/80
Lipids:
LDL < 100mg/dL (if CAD <70)
What if your patient doesn’t make goals?
It is okay. Any decline = decline in risk
Non-Drug Management Tools
Diet
Exercise
Smoking cessation
Alcohol in moderation
Education
Monitoring
Questions
?
A Case
Mr. Smith came to the pharmacy this morning to pick up his refill prescription for lisinopril 10mg
once daily, metformin 1000mg twice daily, and lispro insulin. This is the second time he has filled
his insulin prescription. He did not receive diabetes education. He said that he often gets dizzy
about 20 minutes after taking his lispro, especially when he hasn’t eaten recently. He uses the
insulin at 8am, noon, and 6pm, but his prescription says that he should take 15units 15min. before
meals. He does not eat regular meals. His injection technique is good and I observed his technique
in the pharmacy. He takes a baby aspirin every day. He was diagnosed with type 2 diabetes and
hypertension 1 year ago at a routine physical. His last visit with his PMD was 2 months ago and at
that time he had a blood glucose of 245, an A1c of 9.5%, BP of 145/92 and a serum creatinine of
1.8. At this visit he got a prescription for insulin. He describes his hypoglycemia reaction as getting
dizzy, shaky, and he sometimes feels lightheaded, like he might pass out. He pulled out his blood
glucose meter and the last 5 readings were 65, 138, 142, 95, 112. He checks his blood glucose
before giving his insulin. I think that he should only use the insulin after meals, and I told him that if
he has symptoms of hypoglycemia he should have a small sugar snack like 8 oz. of juice or 3 glucose
tabs. Mr. Smith works as a construction worker and eats a lot of fast food on the run. He does not
smoke or drink and he plays in a church softball league on the weekends. He is 57 years old and he
weighs 220lbs and he is 5foot9. I think Mr. Smith should go to a diabetes education class and I
called his physician to get a prescription for glucagon, just in case. I also sold him a roll of glucose
tabs. His dad had T2DM and also came to this pharmacy. I told Mr. Smith to eat less fast food.
Written Communication
• Useful tool to pass along information when
transitioning patient care from one person to
another:
– Shift changes
– From one healthcare field to another
– Guidance for future encounters
SOAP Format
Subjective
Objective
Assessment
Plan
Subjective
Information the pt tells you about him/herself
Includes:
•
•
•
•
•
•
ID & Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
Drug History (DH)
Family History (FH)
Social History (SH
Objective
Observable/factual information obtained from
or verified by a healthcare provider
•
•
•
•
•
Vital signs (BP, HR, RR, temp, wt, ht)
Physical Exam
Labs (blood tests, urine tests, microbiology, etc)
Diagnostic tests (x-rays, CT/MRI, EKG, EEG)
Medications (from profile or chart)
Active Learning
1. Find a partner
2. With your partner, circle all of the subjective
information in the case.
3. With your partner, underline all of the
objective information in the case.
Use your handout to decide what information is
subjective, and what is objective.
• MS is a 57 y.o. male who presented at the pharmacy
today to pick up refill prescriptions, complaining of
symptoms of hypoglycemia.
• CC: He describes feeling dizzy, shaky, lightheaded when
he takes his insulin and does not eat.
• DH: Lisinopril 10mg Qday, Metformin 1000mg BID,
Insulin Lispro 15 units 15 min. before meals, Aspirin
81mg daily.
• PMH: He was recently diagnosed with T2DM and HTN
1 year ago at a routine physical.
• FH: Father had T2DM.
• SH: He works as a construction worker and frequently
eats fast food. He does not smoke or drink. He did not
receive diabetes education.
From PMD visit 2 mo. ago: Blood Pressure:
145/92, Serum Cr: 1.8, BG 245, HA1c 9.5%,
Wt. 220lb. Ht. 5’9.’’
Calculated BMI is 32.5.
The patient demonstrated good insulin
injection technique at home.
His last 5 self-monitored blood glucose
readings were 65, 138, 142, 95, 112. He
monitors his blood glucose 3 times daily
before administering his insulin.
Assessment
Your clinical judgment of the patient’s drugrelated problems
• Problem list (numbered)
• Each item should include
– problem, solution, evidence/reason for your solution
• Prioritize problems
– start with most urgent (usually relates to CC)
– end with least urgent
Plan
Specific solution for each problem outlined in
the assessment
• Numbered list to match the Assessment
• Recommendations for drug dose, frequency,
duration
• Monitoring
• Follow-up
Find another partner
• For the practice case, pick out the parts of the
pharmacist’s assessment and plan with your
partner.
– Is there any assessment in the note as written?
• Discuss what things go in Assessment, and
what goes in Plan
1. Insulin use: Lispro is a rapid-acting insulin and can cause hypoglycemia.
It should be given 15 minutes before meals.
2. Hypoglycemia: The patient is experiencing hypoglycemia symptoms
approximately 3 times a week when he skips meals. He should be
counseled on preventing hypoglycemia, recognizing signs and
symptoms of hypoglycemia, and how to treat hypoglycemia.
3. Education: This patient does not eat regular meals. He could benefit
from a diabetes education class to learn carbohydrate counting and
other diabetes survival skills. Diabetes education has been shown to
improve outcomes.
4. Lifestyle changes: Increasing exercise to most days of the week,
reducing fast food consumption, and increasing complex carbohydrates
and lean protein in the diet are non-pharm strategies this patient can
implement to manage his diabetes. Weight loss to a BMI ≤ 25 can
increase insulin sensitivity.
1. Administer insulin 15 minutes before meals. Encourage regular
meal. If skipping a meal, do not administer insulin.
2. If SMBG reading is <70 have a small meal or snack of 15g simple
carbohydrates. Examples are 8oz. juice or half a can of regular soda.
Counsel the patient that dizziness, shaking, anxiety, and
lightheadedness are symptoms of hypoglycemia. If the experiencing
these symptoms check blood sugar and have a snack if necessary.
15 min. after a snack, recheck blood sugar. Get a prescription for
glucagon pen, 1mg IM if unresponsive due to hypoglycemia.
Counsel friends and family members to use pen if patient
unresponsive.
3. Recommend a diabetes education class at the community hospital
next week.
4. Recommend 150 min. aerobic exercise per week and resistance
training 3 times per week. Increase consumption of complex
carbohydrates and lean protein. Encourage a “Mediterranean diet”
and less fast food. Recommend weight loss to a goal of <170lbs
(BMI ≤ 25).
• Will follow up with patient at next refill in one month.
Questions
?
References
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Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34 Suppl
1:S11-61.
Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national
estimates and general information on diabetes and prediabetes in the United
States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, 2011.
Triplitt Curtis L, Reasner Charles A, Isley William L, "Chapter 77. Diabetes Mellitus"
(Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara
G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 7e:
http://www.accesspharmacy.com.offcampus.lib.washington.edu/content.aspx?aID
=3207048.
Odegard, P. Diabetes Mellitus: Type I. Pharm 561. University of Washington School
of Pharmacy, Seattle, WA. Feb 22 2010 Lecture.
Ellsworth A. Pharmacotherapy, Diabetes Type 2. Pharm 561. University of
Washington School of Pharmacy, Seattle, WA. Feb 24 2010 Lecture.
Mayoclinic.com/health/hypoglycemia