Maine Physician Assistant Workshop
Intelligent Diabetes : PA’s Pioneering,
Progress, Creativity and Solutions in Outpatient Care
Dana L. Green, PAC, DFAAPA
Ellsworth Internal Medicine
Ellsworth Family Practice
MCMH Geriatrics Services
Tel 207-469-3150 (home)
Cell 207-322-4805 (work)
Goals of Diabetes Treatment
Sustained Normal Blood
Glucose Control
=
No Long Term Diabetes
Complications
Lowest Possible Incidence
No Acute Diabetes
of Hypoglycemia = Complications
Best Quality of Life with a Chronic Disease
New Targets of
Intensive Diabetes Management
Near normal glycemia
HbA1c less than 6.5%
Post prandial: < 140 at 2 hrs.
Heart disease patients 7.0 to 7.5%
Avoid short term crisis
Hypoglycemia
Hyperglycemia and DKA
Minimize long term complications
Improve quality of life
ADA: Clinical Practice Recommendations, 2010
AACE and ESAD
DCCT Research Group, N. Eng J Med
Percentage of Patients with
DM Having HbA1c < 7%
Harris MI, et al Diabetes Care. 1999; 22: 403-408
Relationship between % BG in
Target and HbA1c Level
Brewer K, Chase P, Owen S, Garg S, Diabetes Care 1998, 21: 2
The Facts of Poor Control
Complications
Conventional
Therapy
Intensive
Therapy
Event
Cost
Blindness
Early stage disease
End stage renal
Neuropathy
LL amputation
34%
48%
24%
57%
7%
20%
15%
7%
31%
4%
$$$$$$
$$$$$$
$58,000
$$$$$$
$29,000
Cumulative incidence of diabetes
Related complications Type 1
Age 70 yr.
O’Brien JA, et al., Diabetes Care 2002, 21: 1122-1128
PA Reported Treatment
Choices with Insulin
Patients Using Insulin Pumps
360,000
2014
Most DM Patients Feel That
They Are In Good Control
Satisfied with overall
health…
Are you satisfied with your
diabetes control?

72% non DM…(yes)

19% Needs improvement

86% with Type 1

81% Good Control

71% with Type 2
Key Points
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Diabetes prevalence and cost continue to grow
Lower treatment targets are driving the adoption
of more intensive management
The use of intensive insulin management continues
to grow… due to insulin changes in products
Large increases in insulin pump use and acceptability
barrier to intensive management is patient’s lack of
awareness and perception of good control
Guidelines for Diabetes Care

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Blood Pressure
A1C Goal
Micro albumin
TSH
Lipids
Creatinine
Weight
130/80 (140/90 HD)
under 7.5 to 6.5
Less than 5.0…
0.40 to 4.00
LDL under 100 (70) (40yr)
under 1.4 (f) to 1.6 (m)
10 to 20 lbs wt loss
Guidelines for Diabetes Care
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Smoking
Eye exams
Foot exams
Oral exams
Skin exams
Flu vaccine
Pneumovax
get patients to quit
Annually (Laser age 50-60)
Every office visit (Shoes ?)
Every 6 months
Every 6 months
Annual
Follow guidelines of CDC
Defining the Metabolic Syndrome


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Triglycerides
over 150 mg/dl
HDL cholesterol less 35 (m), 45 (f)
Blood Pressure
>130 (s)/ (d) >85 mg Hg
Obesity
BMI > 30 kg/m2
Glucose
Fasting >110 mg/dl
Micro albumin
Overnight MA excretion
GFR >60
rate >30 mg/g creatinine
or 20 mcg/min
The Links Between Insulin
Resistance and CVD

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Hypertension
Dyslipidemia
Hyperglycemia
Hyperinsulinemia
Inflammation
Impaired Fibrinolysis
Endothelial
Dysfunction


Atherosclerosis
Hypercoagulability
Net Result.
Insulin Resistance
Leads to … or
Equals CVD
Estimated Number of
CHD Events Averted
90
80
70
60
50
40
30
20
10
0
78
58
38
36
20
A
Normal
AIC
B
BP
130/85
16
C
HDL-C
45-50
D
LDL-C
100
A+B+C
A+B+C+D
Meet your destiny head on.
Differences among types of oral
Diabetes Medications

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Medications that increase insulin production
(sulfonylureas) Dosed QD or BID
1. (chlorpropamide) Diabinese x 50 yrs.
2. (glipizide) Gluctrol, Gluctrol XL
3. (glyburide) Micronase, Diabeta, Glynase
4. (glimepride) Amaryl
--stimulate the pancreas to produce more
insulin --
Differences among types of oral
Diabetes Medications
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Meglitnides = stimulate release of more
insulin from beta cells (dosing TID/meals)
1. (repaglinlide) Prandin
2. (nateglinide) Starlix
Differences among types of oral
Diabetes Medications
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Biguamides = Medications that decrease
glucose production & increase insulin
sensitivity
1. (metformin) Glucophage, XR, Glumetza
Riomet (liquid).
Decrease liver glucose release and
increase muscle uptake (sensitivity)
Differences among types of oral
Diabetes Medications

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Thiazolidinediones
1. (rosiglitazone) Avandia
2. (pioglitazone) Actos
Differences among types of oral
Diabetes Medications
Alpha-glucosidase inhibitors
Medications that slow the breakdown of
carbohydrates. Slow down the breakdown
of starches in the intestines during the post
meal period.
1. (acarbose) Precose
1. (megitol) Glyset
Differences among types of oral
Diabetes Medications
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DPP-4 inhibitors = Medications that
increase insulin production & decrease
glucose production in the liver
1. (sitagliptin) Januvia
2. (saxagliptin) Onglyza
3. (linagliptin) Tradjenta
Differences among types of oral
Diabetes Medications

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GLP-1 = non insulin injectables
(exenatide) Byetta (pens), used with oral
meds. Trigger the release of insulin from
the pancreas when BS rise. BID dosing
and newer versions are used weekly.
2. Bydureon (pens)
3. Victoza (pens)
4. Trulicity (pens)
Differences among types of oral
Diabetes Medications
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SGLT-2 = Na glucose co-transport 2
Stops BS (glucose) from getting
reabsorbed by the kidneys, ?? helps with
wt loss (single use medication with metformin)
1. (canagliflozin) Invokana
2. (dapagliflozin) Farxiga
3. (empagliflozin) Jardiance
--concerns with dehydration and low BP,
dizziness and impaired renal function--
With age comes wrinkles
but also wisdom.
Insulin vs. the Resistance Dilemma
Patient
Occupation 36+ hrs. wkly
Things that matter:
fisherman & wrangler,
fiddle player, travel,
hockey and good food.
Insulin vs. The Resistance Dilemma
Patient

Blood pressure… 136/88 (ACE)

A1C
8.9
A1C history = 8.8, 10.2, 9.5
 TSH 3.50…(Synthroid 112mcg)
Stats:
5‘l0.75” (in skates 6’!) wt.
 Renal
GFR 60
204
Microalbul. 35 (Altace 10mg)
(highest wt last 3 yrs. 232,
lowest 200)
 Chol results Total 200/
TG 255/HDL 45/LDL 105
(Lipitor 10mg)
Insulin vs. The Resistance Dilemma
Other labs results:
Bun = 20 creat.= 1.3
Cal+ = 8.9, K+ = 4.8
Mg+ = 1.9, Na = 138
Uric Acid = 4.8
Insulin Level 5.5
C-peptide Level 2.5
Fructosamine level 362…equals
... A1C 9.0 or daily avg of 210mg/dl
1. BS mg/dl = 30 (A1C – 6) + 120
B12= 270, Iron 60/413/20%
Hgb = 13 and Hct = 35
AST = 19, ALT= 22
2. BS mg/dl = 30 ( 9.0 – 6) + 120
3. BS mg/dl = 30 (3) + 120
4. BS mg/dl = 90 + 120
5. BS = 210 mg/dl
Insulin vs. The Resistance Dilemma
Medical Dx:
Medications
Diabetes Type 2
hypertension
hyperlipidemia
microabluminuria
hypothyroidism,
neuropathy
1. Metformin ER 500 mg, 2 tabs
AM and PM meals (max. dose)
3. Amaryl 4 mg AM and PM meals
(max dose)
4. Januvia 100mg after supper
5. Lisinopril 10mg,
6. Lipitor 10mg,
7. Synthroid 112mcg,
8. Alphabetic Mvit
9. Lyrica 75mg AM and PM (bedtime)
10. Zoloft 100mg daily AM
11. Cialis 20mg prn
12. Vit D 3, 1000 IU
13. B12 500 mcg
(leg pain/restless leg syndrome)
anxiety
impotence
Types & Actions of Insulin
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Rapid - Acting

Humalog-Novolog-Apidra

Short - Acting

Humulin R (?...with whom)

Intermediate - Acting

Humulin NPH (best choice?)
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Long – Acting
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Combinations insulin

Lantus & Levemir
Humulin L/U (gone)
75/25 & 50/50 Humalog Mix
70/30 Novolog Mix

Clinical Experience with
Insulin
How do you define oral agent failure?

What are the obstacles to insulin initiation?

What strategies do you use to overcome “insulin
resistance” in your patients?

What do your patients believe once they have initiated
insulin therapy?

Who has experience with Mix 70/30 or 75/25?

Who has experience with Lantus/Levemir?
Why Start Insulin in Type 2 Diabetes?

Blood glucose not at goal

Serum triglycerides out of control
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Timely initiation of insulin replaces failing
beta-cell function
After OAD failure = combination insulin + OAD may
improve glycemic control with less weight gain
than insulin alone
Patients with severe glucose toxicity may benefit
from immediate insulin therapy
Basal/Bolus Insulin Concept
• Basal Insulin
• Suppresses glucose production between meals and
overnight
• 40% to 50% of daily needs
• Bolus insulin
• Limits hyperglycemia after meals
• Immediate rise and sharp peak at 1 hour
10% to 20% of total daily insulin requirement
each meal
Solutions to the Insulin resistance dilemma
Step One ( patients with A1C 8.0 to 8.5 )
1. Basal Insulin Treatment method
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Lantus start 20 unit 3 hrs after supper…then…
Continue Metformin, Amaryl, Glipizide/Glyburide
Get bedtime readings to 100-150
Get AM (before breakfast 100-150)
Pre meal level should initially be 100-150
Solutions to the Insulin resistance dilemma
Step Two (patients with A1C 8.5 or higher)
2. Basal Insulin + fast acting + orals
 Lantus 60 PM or Levemir 60 PM or try 40 PM + 20 AM
Guide dose on PM and AM readings (goal 80-150)

Novolog/Humalog/Apidra (fast acting mealtime insulin)
4 to 10 units with meals initially
0 to 4 units at bedtime if BS are above 175 to 200s

Continue Metformin if no renal disease
Discontinue Amaryl,

Solutions to the Insulin resistance dilemma
Step Three (patients with A1C 8.0 or higher)
3. 75/25 Humalog Mix or 70/30 or 50/50
 Start: 8 units meals and 4 units bedtime
Dose up to ranges: Breakfast 8-15 u, Lunch 4-8 u,
Supper 10-16 u, Bedtime if BS 170 or higher 4-8 u

Goals BS always 80-180 initially
… then get them to 80-150 pre meal and bedtime
…may use Metformin with this method to reduce
insulin resistance
Solutions to the Insulin resistance dilemma
Step Four (patients who ……. scratch your head?)
4. 75/25 Humalog Mix + Humalog (difficult patients with 300+ BS)

Patients using 35 to 50 units of 75/25 at meals and
failing to keep Blood Sugar levels under 180 pre meal

Add Humalog to syringe…start with 5 units at meals & bed
Keep adding novolog…until results desired are achieved
Example: 50u (75/25 Humalog Mix) + 15u Humalog = 65u meals
…for Bedtime use only 75/25 Humalog Mix 20-25units
Solutions to the Insulin resistance dilemma
Step Five (you tried everything…but something is missing)
5. When Lantus and Levemir are at high doses in the PM
and your mornings are still high (above 160 – 200)
 Add NPH single dose in PM at bed (around 10-20 units)
 Problem solved.
5. New thoughts…Humalog 50/50 Mixture
 Can be used in those heavy obese patients…
 Try starting those patients out with either 25 or 35 or 50
units with meals. And use a dose of 20-25 at bedtime.
 Continue Metformin
Solutions to the Insulin resistance dilemma
Step Five (you tried everything…but something is missing)
5. Prednisone patients (temporal arthritis, rheumatoid,
COPD, ?)
 Amaryl 0.5 to 1 mg with often times cure this high
 Amaryl and NPH at noontime in combination work well
 Small dose needed of each.
5. Prednisone patients who are on insulin already and get ill
 Increase the fast acting insulin by 5-8 with meals and
bedtime for 3 days then reduce…and go back to prior
dosing levels.
Solutions to the Insulin resistance dilemma
Step Five (you tried everything…but something is missing)
5. Changing Medicare/Medicaid patients over from
Lantus to Levemir…or Levemir to Lantus.
 Example:Lantus dose PM was 60
or Levemir 40 PM and 20 AM
…Goal PM BS 80 to 150
…Goal AM BS 80 to 150
…Goal pre meal (especially supper under 150)
Keep mooving forward.
Glucose logs review. These are
patients examples that can
teach us what to discuss and
help with our next adventure.
Diabetes Food & Soul Therapy: Secrets
Revealed for Everyone Living with Diabetes
By Dana & Eileen Green
Publication date: March 6, 2013 as Book 1
(Released iTunes April 2013)
Diabetes Food & Soul Therapy
offers you solutions and guidance for how to live a life of
joy and happiness while facing the daily challenges of
dealing with diabetes related concerns. Suggestions on
eating, cooking, dealing with sick days, blood control
solutions for insulin and non-insulin diabetes
patients. [The book contains: shopping list, medication
information, charts, glucose logs, tools to help with meal
planning tools and dietary requirements.]




Available free on iTunes
30 Chapters (current 2013 edition)
4 new chapters coming in 2016 (2nd edition)
3,999 downloads in its first 21 months of availability (April 1 2013):
2,940 in US and Canada
449 in Australia and Asia Pacific
528 in United Kingdom and Europe
67 in Latin America and Caribbean
136 downloads in other countries
Downloads in Italy, New Zealand, Ireland, Mexico, Brazil, Denmark,
Bolivia, Belgium, Chile, Colombia, Costa Rica, Dominica Republic,
Estonia, Greece, Lithuania, Malta, Slovenia
Averaging 190 downloads per month (ranges from 123 to 438)

https://itunes.apple.com/us/book/diabetes-food-soultherapy/id631859806?mt=11
https://itunes.apple.com/us/book/diabetesfood-soul-therapy/id631859806?mt=11
Dana’s Endo-diabetes ROS List
Endocrine (new since last
office visit)
Polyphagia (increase sx hunger)
Polyuria (increase urine output)
Polydipsia (increase thirst)
Diaphoresis (increase sweating)
Appetite changes
Weight change (loss or gain
5+lbs)
Sx of malaise
Sx of fatigue (rate 1 to 10)
Sx of hair loss
Decreased libido
ENT and diabetic eye
disease
Vision changes
Cataracts, glaucoma, macula
degen.
Diabetic Retinopathy hx (OD
exam?)
Tinnitus (ringing in ears)
Hearing loss or changes
Allergies
Difficultly in swallowing
Voice changes
Cardio vascular
Chest pains or discomfort
Shortness of breathe with
activities
Edema of lower extremities or
hands
Leg cramps or leg pain walking
Respiratory
Cough
Shortness of breathe sx
Sleep disturbances due to
breathing
Snoring (with/without sleep
apnea)
Asthma hx
COPD hx
Smoking hx
Gastro System
Heartburn or Reflux
Nausea
Vomiting
Abdominal pain
Abdominal bloating
Hemorrhoids
Diarrhea
Constipation
Urinary
Changes in urinary patterns
Nocturia
Incontinence
Metabolic & Endocrine
Disorder History
Type 1 diabetes (age of
onset)
Type 2 diabetes (age dx)
Dermatology
Hyperglycemia
Suspicious skin changes or
Hypoglycemia
lesions
Osteo arthritis or Osteoporosis
Dry skin (itching)
Lumbar disc disease
Poor lesion healing
Chronic pain hx and treatment
Nail changes
w/meds
Vit. D def. & Calcium def.
Neurological changes and
B12 def. or Iron def. (anemia)
Neuropathy
Mg+ def.
Memory or concentration
Hyperlipidemia
changes
Nephropathy
Balance and gait changes
Kidney disease mild (stage 1-3)
Headaches
Renal failure (dialysis patient)
Numbness or tingling sensations Renal transplant (age or year)
Shoulder, Wrist or hand, foot
Thyroid disease
pain
Hypo K+ or hyperK+ hx
Pain (myalgia or arthralgia = 1 Hypothyroidism or
to 10)
Hyperthyroidism
Seizure hx or Tremors hx
CAD, GI, vascular
Weakness or loss of strength
Prior heart attack (MI)
Anxiety or stress (rate 1 to 10) CABG (prior bypass)
Depression
Gastric Bypass (date)
Bipolar disorder, PTSD,
EOTH use
Schizophrenia
Gout hx
Can you say Moo?