Finding the Sweet Spot DM II treatment in

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 treatment • Understand the importance of individualized care complicate

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 A 1 C < 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 noncritical 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 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 2448 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 A 1 C < 7 o Mean plasma glucose 154 mg/dl (2 -3 months) o Healthy adults with > 10 year life expectancy • Hemoglobin A 1 C 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): S 11 -S 66

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): S 11 -S 66

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 A 1 C < 7 • Control vascular, other risk factors • Consider QOL, pt preferences/GOC & life expectancy • For most elders, especially frail elders, A 1 C = 8 is target 8 at 80 honey!

Belinda. Setters@va. gov Geriatrics & Extended Care http: //vaww. louisville. va. gov/ @Belinda. Setters 502 -287 -5995