DIABETES

MEDICATION
& INPATIENT
DIABETES CARE
RELATED TO
GLYCEMIC CONTROL
Professional Research Presentation
Eva Yip

September 2, 2015

OBJECTIVES
Review DM medications
Review insulin use in clinical setting
Medication associated with disease
progression
Impact of inpatient care on glycemic
control

ICE BREAKER: FILL IN THE

BLANK
Word Bank

Medical Costs
2.3
29.1

1.

Nearly ____ million people in the U.S. have diabetes

2.

8.1 million
7 people with diabetes are undiagnosed
Amputation
Diabetes is the
leading cause of new blindness among adults, kidney
3
failure and non-traumatic
lower limb ___________.

3.

____th/rd leading cause of death

4.

If current trend continues, at least 1 in __ US adults will have

diabetes by 2050

5.

Total cost (direct or indirect) of diabetes in 2012 was $245 billion of

which $176 billion was direct _____________.

6.

Medical expenditure for those with diabetes is ____ times higher

than for those without diabetes.

ICE BREAKER: ANSWERS

Word Bank

1.

2.

3.

Medical Costs
2.3
29.1

Nearly 29.1 million people in the U.S. have diabetes

8.1 million people with diabetes are undiagnosed

7
Diabetes is theAmputation
leading cause of new blindness among adults, kidney
3
failure and non-traumatic
lower limb amputation.

7th leading cause of death

4.

If current trend continues, at least 1 in 3 US adults will have diabetes by

2050

5.

Total cost (direct or indirect) of diabetes in 2012 was $245 billion of which

6.

Medical expenditure for those with diabetes is 2.3 times higher than for
those without diabetes

$176 billion was direct medical

costs.

GOALS OF TREATMENT

HbgA1C: <7%
Minimize incidence of abnormally high or low blood
glucose swings
Delay disease progression

ASSESS

Lifestyle

changes (diet/exercise)
Medications

Stress:

Glycemic goals

Assess adherence issues

Other reasons for increased glucose

psychosocial, infection
Started medication that can worsen glucose (such
as prednisone or antipsychotic agent)

Stage of disease and progression

SULFONYLREAS
Glyburide, Glipizide, Glimepiride
Mechanism of action

Stimulates

pancreas to release insulin

Considerations:
Type

2 DM without dyslipidemia and who is

not overweight

Contraindications:
T1DM,

ketoacidosis, allergy, or documented

hypersensitivity to these agents

Side Effects:

Hypoglycemia
Weight

gain (secondary to increase insulin

secretion)
Mild GI disturbances
(Tolbutamide and Chlorpropamide) associated
with abnormal hepatic function tests,
thrombocytopenia, agranulocytosis and
hemolytic anemia

MEGLITINIDES (GLINIDES)
Repaglinide, Nateglinide
Mechanism of action:

Stimulates pancreas to release insulin

Short acting compared to Sulfonylureas.

Take 3x/d instead of 1x/d

Taken 1-30 minutes before meals

Considerations:

Meglitinides is often used in combinations with other oral

agents
Candidates are often those who experience
hypoglycemia on sulfonylurea, are without dyslipidemia,
not over weight
Medication is better suited for those with inconsistent
eating patterns

Contraindications

T1DM, diabetic ketoacidosis, severe infection, surgery, trauma,

other severe stressor

Side Effects

GI disturbances, hypoglycemia

BIGUANIDES (METFORMIN)
First choice of therapy (in additional to lifestyle changes)
Mechanism of action:

Considerations:

Decreases sugar release from the liver (no effect on the

pancreas)

Ideal candidate: T2DM with dyslipidemia, obesity or genetic factors

favoring insulin resistance and elevated fasting plasma glucose

Contraindications:

Decreased renal function

Presence of hepatic dysfunction
Hx of hypoxic conditions
Hx of alcoholism

Side Effects:

Weight loss,
Improve lipid profile
Used in combination with sulfonyureas, meglitinides or insulin may
result in hypoglycemia
GI disturbances (abd bloating, nausea, cramping, feeling fullness,
diarrhea)
Metallic taste in mouth

Dosing:

Therapeutic max is 2000mg

THIAZOLIDIONES (TZDS)
Rosiglitazone, pioglitazone
Mechanism of action

Decreased

insulin resistance and increases glucose

uptake by muscle and fat tissue

Considerations:
Slow

onset to effect: 4-6 weeks to have an effect on BG

Twice daily
Liver function should also be tested before starting and
then periodically after, every 6 months

Side Effects
Fluid

retention and edema

Weight gain
Rosiglitazone may increase relative risk of MI by 30-40%

Contraindications:
Class

3 and 4 heart failure and active liver disease

Discontinue use with jaundice, edema, shortness of breath, rapid
weight gain and other signs and symptoms of heart failure

ALPHA-GLUCOSIDASE INHIBITORS
Acarbose, Migitol
Mechanism of action

Delays

carbohydrate digestion and slows glucose absorption

from gut

Considerations:
Ideal

candidate: T2DM with dyslipidemia or obesity and symptoms

or blood glucose levels demonstrating significant post prandial
hyperglycemia
Not commonly used a monotherapy
Hypoglycemia is best managed with oral glucose or IV
glucose or glucagon

Contraindications
Inflammatory

bowel disease, colonic ulceration, obstructive bowel

disorders, or chronic intestinal disorders of digestion or absorption
(Acarbose) Cirrhosis of liver and Creat levels of >2.0 mg/dL or creat
clearance <25 mL/min

Side Effects
GI

disturbances (diarrhea, abd pain, flatulence)

DOPAMINE RECEPTOR AGONIST

Bromocroptinemesylate
0.8mg

taken 2 hours after waking with first meal of

the day

Mechanism of action is unknown

Contraindications

T1DM,

diabetic ketoacidosis
Patients with syncopal migraines or those with sever
psychotic disorders

Side effects:

Somnolence,

headache

nausea, fatigue, dizziness, vomiting and

INCRETIN-BASED THERAPIES
Incretin = group of metabolic hormones that
stimulate a decrease in blood glucose levels
Glucose Dependent Insulinotropic Peptide (GIP)
& Glucagon-like Peptide-1 (GLP-1)

Promote

satiety in the brain

Decrease or slow gastric emptying rate
Increase glucose dependent insulin release from beta
cells
Decrease glucagon release from pancreatic alpha cells

GLP-1 is quickly inactivated by Dipeptidyl

Peptidase-4 (DPP-4)

GLP-1 RECEPTOR AGONISTS (GLP-1R)

Exendatide & Liraglutide

Administered

by subcutaneous injections within 60

minutes before morning and evening meals

Contraindications:
(Exenatide)

Severe renal impairment

Avoided in patients with severe GI disorders

Side Effects
Primarily

nausea, but vomiting, diarrhea, headache,

dyspepsia are also noted
May cause hypoglycemia when used with a
hypoglycemic agent should monitor BG well

Administered by subcutaneous injections

within 60 minutes before morning and
evening meals

DIPEPTIDYL PEPTIDASE-4 INHIBITOR (DPP-4I)

Sitagliptin, Saxagliptin
Competitive

inhibition of the enzyme

responsible for GLP-1 inactivation
prolonging the effects of endogenous GLP-1.
Advantage: oral formulation

Side effects:
Upper

GI tract infection and headache, UTI

Sitagliptin is associated with acute pancreatitis
May cause hypoglycemia when used with a
hypoglycemic agent should monitor BG well

AT
DIAGNOSIS:
LIFESTYLE
AND
METFORMIN
Step 1
Tier 2: less
well
validated
therapies

Lifestyle+Metfor
min
+Basal insulin

Lifestyle
+Metformin
+Intensive insulin

Lifestyle
+Metformin
+Sulfonyurea
Step 2

Step 3

Lifestyle
+Metformin
+Pioglitazone
(no hypoglycemia,
oedema/CHF, bone
loss

Lifestyle
+Metformin
+Pioglitazone
+Sulfonyrea

Lifestyle
+Metformin +GLP1Agonist
(no hypoglycemia,
weight loss, N/V

Lifestyle
+Metformin
+Basal insulin

Circumstance

Avoid

Consider

Renal dysfunction

Metformin, certain
SFUs

Glipizide, glinides, DPP4 inhibitors

Severe liver dysfunction

Most agents

Insulin

Overweight/obese

TZD

Metformin, GLOP-1
agonist, DPP-4 inhibitor

Heart failure

TZD, metformin (only

unstable/severe)

Most other agents

Reduced bone density

TZD

Most other agents

History of pancreatitis

GLP-A agonist, DPP-4

inhibitor

Most other agents

History of bladder
cancer

Pioglitazone

Most other agents

Pre-existing edema

TZD

Most other agents

DiabetesCare,Diabetologia.
19April2012[Epubaheadofprint]

MEDICATION THERAPY IN ACUTE

SETTINGS:

Oral agents are not used within acute settings

Metformin

cannot be used with renal insufficiency

Sulfonyureas and Metaglinides can cause
unpredictable hypoglycemia in patients who are not
eating reliably
TZDs can cause fluid retention
Common side effect: Nausea

Insulin is more reliable and can be adjusted

depending on changes in glucose levels and food
intake

INSULIN THERAPY
Type of
Insulin

Onset

Peak

Short-acting
Regular
30-60 minutes 2-4 hours
Lispro/Aspar 5-15 minutes
1-2 hours
t/Glulisine

Duration

Appearance

6-8 hours
3-5 hours

Clear
Clear

Intermediate
-acting
NPH

1-2 hours

6-10 hours

12+ hours

Cloudy

Long-Aciting
Detemir
Glargine

1 hour
1.5 hour

Flat
Flat

12-24 hours
24 hours

Clear
Clear

HTTP://PROFESSIONAL.DIABETES.ORG/

BASAL/BOLUS INSULIN REGIMEN

Basal/Bolus insulin
Regimen
Scheduled

basal

insulin
Meal time insulin
Correction insulin

Desirable ranges
Non

critically ill: <140

mg/dl
Acute critical illness:
140-180mg/dL
Avoid severe
hypoglycemia (<40
mg/dL)

TOTAL DAILY DOSE

INSULIN DOSING

Glycemic goals
Assess adherence issues

Lifestyle

changes (diet/exercise)
Medications

Other reasons for increased glucose

Stress:

psychosocial, infection
Started medication that can worsen glucose (such as
prednisone or antipsychotic agent)

Stage of disease and progression

Study

About

Variable

Observed/ti Results
meframe

Group based
DM
education for
intensive
insulin
therapy
(2010)

Retro/long
study;
81 pts (59
T1DM, 14
T2DM, 8
other forms)

Structure inpatient HbgA1c, LDL, Long term benefit

Inpatient DM
education on
readmission 3
or 6 mo post
d/c (2012)

Retro; 2,265
pts for 30
day analysis
and 2,069
for 180 day
analysis

Whether DM
Of those
consult was ordered educated and
and completed
not educated,
% readmitted
after 30 and
180 days

Patients that received DM

education had
significantly lower
frequency of readmission
compared to those that
did not have DM
education.

Inpatient DM
mgmt, ed, d/c
transition on
glycemic
controll 12

Non-blind
randomized
trial; 31
participants

Diabetes
management, CDE
education and
discharge
transition vs Usual

Among naive pts, HbgA1C

decline of 2.35% over 12
mo following hospital d/c

education program
for intensive insulin
therapy; 8 days, 56
hours

HDL and
BMI; f/u 5, 12
and 20
months

HbgA1c,
weight, BP
and incidence
of
hypoglycemia

observed in pts with

T2DM(reduced HbgA1c
1.07%); no improvement
of long term glycemic
control in pts with T1DM

INPATIENT DIABETES EDUCATIONS RESULTS IN

1.

Long term benefits to T2DM

2.

Decreased readmission rates.

Reflects quality of care

Among patients with diabetes who had been hospitalized, 30% of
these patient were hospitalized more than once within 1 year and
these patients accounted for a majority of the inpatients costs for
patients with diabetes.

Decrease in HbgA1c 2.35% in 12 months among nave

patients.

3.

Initiating insulin therapy in the primary care setting is resource

intensive and remains challenging for both patients and providers
Hospital admission may serve as a window of opportunity to
improve long-term diabetes care

WHAT SHOULD WE DO?

1 in 3 adults in 2050
Advantageous to

Implement

patients

a discharge transition regimen for diabetic

Reinforces lifestyle/medication pattern

Provides concrete instructions to follow
Acknowledges disease

SUMMARY AND CONCLUSION

___ classes diabetes medication.
Insulin is administered on a _______/_______
regimen in acute care settings
________________ should not replace meal time
insulin but should be used as a corrective
measurement.
Studies show inpatient diabetes education
(does/does not) have an effect on glycemic control
after discharge.

SUMMARY AND CONCLUSION

7 classes diabetes medication.

Insulin is administered on a basal/bolus

regimen in acute care settings

Sliding

scale should not replace meal time

insulin but should be used as a corrective

measurement.
Studies show inpatient diabetes education

(does/does not) have an effect on glycemic

control after discharge.

THANK YOU
for everything!

REFERENCES

http://clinical.diabetesjournals.org/content/20/1/11.

http://piediabeticoceped.com/hyperg2011jan%20cd.pdf

http://www.ada.org/professional.aspx

http://www.diabetes.ucsf.edu/

http://www.medscape.com/viewarticle/740378_2

The Art and Science of Diabetes Self Management Education Desk Reference

Magaji, V., and J. M. Johnston. "Inpatient Management of Hyperglycemia and Diabetes."

Clinical Diabetes 29.1 (2011): 3-9. Web. 30 Aug. 2015.
Healy, S. J., D. Black, C. Harris, A. Lorenz, and K. M. Dungan. "Inpatient Diabetes
Education Is Associated With Less Frequent Hospital Readmission Among Patients With
Poor Glycemic Control."Diabetes Care36.10 (2013): 2960-967.Pubmed. Web. 30 Aug. 2015.
Gbl, Christian S., Barbara Dobes, Anton Luger, Martin G. Bischof, and Michael Krebs.
"Long-term Impact of a Structured Group-based Inpatient-education Program for Intensive
Insulin Therapy in Patients with Diabetes Mellitus."Wiener Klinische Wochenschrift Wien
Klin Wochenschr122.11-12 (2010): 341-45.Pubmed. Web. 30 Aug. 2015.
Wexler, Deborah J., Catherine C. Beauharnais, Susan Regan, David M. Nathan, Enrico
Cagliero, and Mary E. Larkin. "Impact of Inpatient Diabetes Management, Education, and
Improved Discharge Transition on Glycemic Control 12 Months after Discharge."Diabetes
Research and Clinical Practice98.2 (2012): 249-56.Pubmed. Web. 30 Aug. 2015.