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Diabetes Therapeutics > Diabetes Tx and Targets > Flashcards

Diabetes Tx and Targets Flashcards

1
Q

What are the treatment goals of diabetes?

A

Be symptom free (avoid hyper / hypoglycemia)

Achieve personalized target glucose levels

Address modifiable CV risk factors

Prevent or slow the progression of microvascular complications

Empowerment to self-manage ( a lot of management needs to be done by the pt itself)

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2
Q

Is treatment of diabetes the same for everyone?

A

No - Varies from person to person

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3
Q

In regards to glucose levels, we should try to achieve _______ glucose levels. This can be done through…..

A

PERSONALIZED

Hemoglobin A1C –> Longer Term Scenario
Fasting Glucose Levels –> Immediate Feedback
Postprandial Glucose
Time in Range

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4
Q

What is an essential component of diabetes self-management? Examples?

A

Monitoring glucose control is an essential component of diabetes management

Examples include:
Blood glucose lab evaluations

Hemoglobin A1c

Capillary blood glucose (cBG) –> Checking sugars at home

Continuous glucose monitoring (CGM)
–> Intermittently scanned CGM (isCGM)
–> Real-time CGM (rtCGM)

Ketone testing

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5
Q

What is hemoglobin A1C measuring?

A

A1C is a measure of glycemic control over a defined period of time (the previous 3 months)

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6
Q

How does A1C measurement work?

A

Glucose attaches to RBCs when present in high levels in the blood, and A1C is the % of hemoglobin A that has been irreversibly glycosylated

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7
Q

What is indicated by a higher A1C?

A

The more glucose there is in the blood, the more glycated hemoglobin is formed and the higher the A1C will be

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8
Q

What are the normal A1C levels?

A

4-6%

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9
Q

How often should A1C be checked?

A

Should be checked q 3 months (6 months if stable) Depends on person
Newly Diagnosed –> Every 3 months

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10
Q

What can affect A1C?

A

Certain conditions

  • Conditions that effect the life cycle of RBC’s
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11
Q

What are the specific A1C targets?

A

< 6.0 - Selected adults with type 2 diabetes with potential for remission to normoglycemia

< or = 6.5 - Adults with Type-2 diabetes to reduce the risk of CKD and retinopathy if at low risk of hypoglycemia

< or = to 7% –> Most individuals with Type-1 or 2 Diabetes

7.1-8.0% - Functionally dependent
7.1-8.5% - Recurrent severe hypoglycemia and/or hypoglycemia unawareness
- Limited life expectancy
- Frail elderly and/or with dementia

Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acute and chronic complications

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12
Q

How can one achieve an A1C target of less than or equal to 7%? (Other test values)

A

For most patients:
- Pre-prandial glucose (mmol/L) = 4.0-7.0 mmol/L
- 2 hour postprandial glucose (mmol/L) = 5.0-10.0 mmol/L

If A1C of less than or equal to 7.0% is not achieved despite the above PG targets:
- Pre-prandial glucose (mmol/L) = 4.0-5.5 mmol/L
- 2 hour postprandial glucose (mmol/L) = 5.0-8.0 mmol/L

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13
Q

Why is an A1C% target of 7% used?

A

Studies have shown such target:
- decreased risk of retinopathy
- neuropathy
- microalbuminuria

Lower blood sugar, lower these risks

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14
Q

In regards to the studies conducted for an A1C of 7%, what is the effect on macrovascular outcomes?

A

None of them independently confirmed a significant benefit of tight glycemic control on macrovascular outcomes
- Those with more intense tx had a 10-15% decrease in risk of major CV events (M.I. only)

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15
Q

What is the main takeaway of achieving an A1C of less than or equal to 7%?

A

Provides strong benefits for microvascular complications and, if achieved early enough may also provide macrovascular benefit

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16
Q

Is more intensive blood glucose lowering always better? In regards to mortality, what may be the cause?

A

More intensive BG lowering is not always better
Should not be pursued in everyone

Rather than causing CV AEs, severe hypoglycemia may be a marker of vulnerability for such events

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17
Q

What are the limitations of A1C?

A

Cannot tell you what the highs and lows are, only an average
Does not tell you variability from day to day
Does not tell you anything right now –> Tells you about what has happened the last 3 months but not right now
Is a tool that should be used in conjunction with other tools

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18
Q

What is capillary blood glucose (CBG)? What does it tell you?

A

Determines the glucose level in capillary blood via a finger stick

Tells you BG level at a particular point in time –provides immediate feedback

Is a tool – useful when actionable. Hence, the usefulness will differ from person to person

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19
Q

In regards to cBG, what should people with diabetes know?

A

1) how to perform CBG

2) how often and when to perform CBG

3) the meaning of various BG levels
FPG – reflects glucose derived from hepatic production
PPG – how meals affect glucose

4) how behavior and actions affect CBG results
- interpretation of trends

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20
Q

When does cBG become an essential component of self-management in those who use insulin?

A

Those who use insulin > than once per day

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21
Q

How many times should a person perform cBG measurements?

A

Perform at least as many times as insulin is injected

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22
Q

When is less intensive cBG used?

A
  • When not on insulin/stable
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23
Q

When is more intensive CBG monitoring required?

A

When a person is not reaching their targets

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24
Q

What is intermittently scanned CGM (isCGM)? Examples? How often applied?

A

Measures glucose levels in the subcutaneous interstitial fluid via a sensor that is inserted into the skin (sensor-based technology)

FreeStyle Libre: approved for use in adults
FreeStyle Libre 2: approved for those ≥4yo. Also has optional alarms to notify if low or high glucose
Libre 3: forthcoming

Applied to the back of the arm every 14 days – simply scan with a provided device or a smartphone

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25
Q

What does intermittently scanned CGM (isCGM) measure? What can it help with?

A

Does not measure blood glucose –> Measures glucose levels in the interstitial fluid

Can help reduce hypoglycemia and can imporve time-in-range

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26
Q

What is the glucose lag? What does it occur with? Counselling tip?

A

Occurs with capillary glucose measurements
Capillary glucose must diffuse into the interstitial fluid – may lag capillary levels by 5 to 15 minutes
- Lag occurs with all sensor-based technology
- Think of the trend as the important message, not the “point to point” accuracy
“Follow the trend”

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27
Q

What are some examples of real-time continuous glucose monitoring (rtCGM)?

A

Dexcom G6 and Medtronic Guardian Connect

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28
Q

How are real-time continuous glucose monitoring (rtCGM) work available? How do they work? How is the data represented?

A

Are available as stand-alone systems or integrated with insulin pumps

Measure glucose levels in the subcutaneous interstitial fluid via a sensor that is inserted into the skin

Continuous data visibility 24/7
Provides real-time and historical data, as well as information on trends (i.e. where glucose is headed, and how quickly)

“pushes” info to the user/caregiver

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29
Q

Real-time Continuous Glucose Monitoring (rtCGM) Evidence?

A

Evidence supports its beneficial effects on A1c, Time in Range and hypoglycemia in those with T1DM & T2DM on basal-bolus insulin. May also improve QOL

30
Q

How does rtCGM and isCGM differ/similar?
a) Application
b) Information
c) Alerts
d) Measurement of Glucose
e) Sensor
f) System
h) Cost

A

rtCGM:

a) Applied on abdomen, back of upper arm or upper buttocks, depending on age
b) “push” information via a transmitter
c) Sends alerts if outside target range (and before if predicted to go out of range)
d) Measures glucose every 5 minutes – can access any time
e) Sensor replaced up to every 10 days (G6) and 7 days (Guardian)
f) Stand-alone or integrated system
g) More expensive than isCGM

isCGM:

a) Applied on back of arm
b) “pull” information via scanning
c) Libre2 has option to send alerts if outside target range
d) Measures glucose every minute and stores readings every 15 min – the data is downloaded after 14 days
e) Sensor replaced every 14 days
f) Stand-alone system
g) Less expensive than rtCGM

31
Q

When counselling a patient on rtCGM and/or isCGM, a patient should be told…..

A

If readings do not match symptoms/expectations, verify with CBG

32
Q

What is time in range in regards to people with diabetes? How is this possible?

A

The amount of time spent in the target BG range)

Since CGM continually checks glucose levels, PWD are able to know their glucose levels 24/7

33
Q

PWD’s should aim for a TIR of….. This equates to….. A PWD should be in range for how long a day?

A

Most PWD should aim for a TIR (3.9-10.0mmol/L) of >70%

70% TIR equates to about an A1C of 7%

Aim is to be within range ~ 17/24h each day

34
Q

Does TIR vary? If so, how? As pharmacist, we should help the pt to what?

A

YES –> Can vary based on population

To reach an A1C target of 7.0%, the TIR target is > 70%
For older adults or those at high risk from hypoglycemia (A1C target of 8.0%), the TIR target is > 50%
Every 10% increase in TIR (2.4 hours/day) corresponds to a 0.5% decrease in A1C

  • Customize TIR based on A1C target
35
Q

What are ketones?

A

Ketones are formed as a by-product when body’s fat stores have to be accessed for energy

36
Q

Is urine or blood ketone testing a part of self management? If not, what situations is it used in?

A

Is no longer part of standard self-management, but may still be used in certain situations:
- During times of acute illness or stress
- When preprandial readings >14mmol/L (Type 1)
- DKA symptoms present (nausea, vomiting, abdominal pain, dehydration)
- Pregnancy

37
Q

What are some common reasons why ketones may occur?

A

Ketones usually occur because you are either: not eating enough total calories, going too long between meals, skipping meals/snacks, nauseous, not eating well/throwing up

38
Q

What is the cornerstone of diabetes care?

A

DIET

39
Q

How can diet be vital to diabetes?

A

The cornerstone of diabetes care
Can effectively lower BG
Can be 1st line treatment (with exercise) for T2DM

40
Q

In type 1/type 2 diabetes, what does non-pharmacological diet education focus on?

A

TYPE 1: nutritional education is vital to understand the relationship between carbohydrates, insulin, and blood glucose to maintain euglycemia

TYPE 1 and 2: nutritional education is vital to understand the relationship between food & its effects on body weight, BG, BP, and lipids (i.e. CV risk)

41
Q

In regards to diet, is there one specific one that diabetics must follow?

A
  • There is no such thing as a diabetic diet
  • INDIVIDUALIZED NUTRITION THERAPY –> What may work for one, may not work for another
42
Q

What are some important points in regards to diet as pharmacists?

A

Access to a dietitian if possible ✔

Individualize diet based on patient goals and preferences
–> Be mindful of cultural importance of food

If weight loss is a goal, 5-10% weight loss may provide health benefits

“Everything in moderation”

43
Q

What are some available forms of carbohydrates?

A

Available as starches, sugars, and fibre

44
Q

According to Health Canada, what should one’s diet consist of?

A

Generally, people should consume 45-60% of total energy from CHO (Health Canada recommendation)

10-35% protein

20-35% fat

45
Q

For people using insulin, what is paramount in regards to carbohydrates?

A

For people using insulin, knowing the relationship between carbohydrates, insulin, and blood sugar is paramount

Carb counting takes time and practice, but allows for insulin doses to be adjusted according to meal content, and leads to improved flexibility

46
Q

What is the difference between high and low glycemic index foods?

A

Carbohydrates that break down quickly during digestion have a higher glycaemic index. These high GI carbohydrates, such as a baked potato, release their glucose into the blood quickly.

Carbohydrates that break down slowly, such as oats, release glucose gradually into the bloodstream. They have low glycaemic indexes.

47
Q

In regards to low and high glycemic index foods, how is it distinguished? What foods are preferred?

A

The GI assesses the quality of CHO foods based on ability to increase BG

Whole foods and less refined foods over processed foods

Fast food and sugar drinks are not preferred

48
Q

Diabetics should be referred to use _______ in regards to their diet. Such resource does…..

A

Beyond the Basics: Meal Planning for Diabetes

Provides a list of CHO containing foods

Foods are grouped according to: grains & starches, fruits, milks and alternatives, other, vegetables, meats and alternatives, fats

Distinguishes foods as “Choose more often” or “choose less often” based on their glycemic index (GI)

Breaks food down into serving sizes
1 serving = 15g CHO or 1 CHO choice

49
Q

What foods have little or no CHO?

A

Meat and Alternatives
Vegetables
Fats

50
Q

What are the DRI’s for fibre?

A

19-50 yo: 25g/d (women) 38g/d (men)
≥51yo: 21g/d (women) and 30g/d (men)

51
Q

Is soluble fibre beneficial? if so, how?

A

Soluble fibre slows gastric emptying and delays sugar absorption in small intestine

52
Q

What type of CHO is fibre? When calculating CHO, it should be ______ from total CHO

A

It is a type of CHO the body cant digest, so it should be subtracted from total CHO

53
Q

In regards to Canada’s Food Guide, what are the 9 recommendations?

A

Make water your drink of choice
Have plenty of vegetables and fruit
Eat protein foods
Choose whole grains
Eat a variety of healthy foods each day
Choose protein foods that come from plants more often
Limit highly processed foods
Use food labels
Healthy eating Habits

54
Q

In regards to Ramadan, a pt should….

A

Encourage consultation with dietitians/diabetes educators 2 months before –> Plan how to keep sugars in safe levels

SEEK HELP FROM HCP’S WHO ARE KNOWLEDGEABLE IN THIS AREA

55
Q

What are some basic dietary tips pharmacists can share with pt’s?

A

Consistency in spacing of meals (i.e. 3 well balanced meals/day) and CHO intake may help with BG control and weight

Snacks between meals may or may not be necessary

Sugar: acceptable part of a healthy diet (up to 10% of daily energy intake)

Artificial sweeteners are fine to use within the ADI values from Health Canada

Routine vitamin supplementation: not necessary

Coffee: fine in moderation

56
Q

Are pharmacists equipped to provide dietary advice? Exception?

A

YES; however, in addition with a dietitian

57
Q

Why is alcohol a worry in people with diabetes?

A

Can decrease hepatic production of glucose and mask the symptoms of hypoglycemia

58
Q

When is alcohol worrying? Why?

A

For people with T1DM, or those with T2DM on insulin or sulfonylureas, alcohol can cause delayed hypoglycemia

Hypoglycemia can occur at blood alcohol levels of mild intoxication and persist for up to 24 hours following the last drink

59
Q

What strategies should be taken when a diabetic consumes alcohol?

A

Check glucose levels, take with food, adjust insulin, let your friends know

60
Q

What are the current alcohol recommendations?

A

New alcohol recommendations: no amount is safe – it’s a continuum of risk

2 drinks per week (low risk)

61
Q

In regards to physical activity, diabetics should be informed….. such as……

A

PWD should be informed of the health benefits of physical activity, beyond the goals of weight loss and glycemic control that people also set for themselves:

  • Increased cardio / respiratory fitness
  • Decreased insulin resistance
  • Improves lipids, BP
  • Psychological
62
Q

Physical Activity and A1C Levels

A

Physical activity has been proven to improve A1C in T2 and kids with T1, but evidence on A1C less clear in adults with T1

Nevertheless, it ↓’s risk of CVD and stroke, and can prevent onset of microvascular disease

63
Q

What are the recommendations for exercise?

A

≥150 mins of moderate to vigorous intensity aerobic exercise/week

Spread over ≥ 3 days/week

No more than 2 consecutive days of no activity

Resistance training ≥ 2x/week

64
Q

What are some tips a pharmacist can tell a pt in regards to exercise?

A
  • Smaller amounts are still beneficial
  • Aim for ≥10 min at a time (aerobic)
  • Moderate intensity is -50-70% max HR (bike, brisk walk, swim)
  • Resistance: 3 sets of 8
  • Limit sedentary activity
65
Q

How should exercise be initiated?

A

Be realistic; it is OK to start slow!

Brisk walking easiest to initiate

Assess for conditions that can predispose to injury before beginning i.e. neuropathy, retinopathy, CAD

Screening by a physician with ECG beforehand may be necessary (E.g. chest discomfort, previous MI, TIAs)

66
Q

How does exercise affect blood glucose?

A
  • Depends on the intensity of the activity
  • People with diabetes routinely experience rapid changes in BG during and after exercise, so it is important to monitor for signs of low/high BG; particularly for those on insulin
67
Q

How does low-moderate intensity exercise affect blood glucose?

A
  • Aerobic Exercise

↓’s BG during & after exercise due to increased insulin sensitivity (uses glucose as fuel)

30 minutes of exercise can improve insulin sensitivity for the next 48hrs

68
Q

How does very intense exercise affect blood glucose?

A

↑’s BG during & after exercise due to increased glucose production that > increases in glucose disposal (↑’ed secretion of stress hormones) –> glucagon production

69
Q

In regards to exercising with Type-1 Diabetes, what is the goal?
What are some strategies to avoid hypoglycemia?

A

Goal is safety: minimize risk of hypoglycemia

Some strategies:
Inject insulin at a non-exercise site

Consume extra CHO before/during/after exercise

↓ dose of bolus insulin that is most active at time of exercise
E.g. going to do 60 min of moderate exercise: ↓ pre-meal insulin by 25 - 75%
E.g. if exercise is mild and <30min, likely no adjustment

Reducing basal insulin overnight by 20% after exercise
Similarly, careful with exercise late in the evening (overnight lows…)

Perform resistance or max intensity exercise before aerobic exercise or intermittently

70
Q

What are some other critical points in regards to exercising with diabetes?

A
  • Self-monitoring glucose levels is important
  • Maintaining hydration is important
  • Always carry a fast-acting glucose source just in case
  • Avoid exercise if BG < 4 mmol/L
71
Q

In regards to type-2 and type-1, what is the relation between BG levels and exercise?

A

T2DM: Ok to exercise if BG is high as long as no signs of dehydration and person feels fine

T1DM: If BG> 16.7 mmol/L + feel unwell, check ketones
- If present, postpone vigorous exercise until insulin given and ketones resolved
- If sugar is high but feel fine and no ketones, exercise is fine

Diabetes Therapeutics (4 decks)

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