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1、Update on Diabetes Medications and Guidelines in Cardiopulmonary Rehab Setting,Raja Hanania, R.Ph, CDM, CDE, BCPS Clinical Pharmacy Specialist Critical Care/Diabetes Care IU-Health- Bloomington Hospital Bloomington-Indiana,Objectives,Learn about the impact of diabetes in the United States Review ora
2、l and injectable diabetes medications and their role in diabetes management Review the 2013 ADA general recommendations with special emphasis on physical activity and exercise in the cardiopulmonary rehab setting,National Diabetes Estimates,25.8 million Americans (8.3% of the US population) 7 millio
3、n undiagnosed 79 million American adults aged 20 years or older qualify as being at high risk to develop diabetes (fasting glucose between 100 and 125) If the trend continues, 1-in-3 American adults will have diabetes by 2050 The 7th leading cause of death in the US The leading cause of blindness, r
4、enal failure and nontraumatic amputations between the age of 20-74 Cost: U.S. national economic burden of pre-diabetes and diabetes reached $245 billion in 2012, $218 billion in 2007 , $132 billion in 2002 vs. $44 billion in 1997 CDC National Diabetes Fact Sheet 2011. ADA diabetes Statistics 2013,Ma
5、king the Diagnosis,Fasting Plasma Glucose Test 99 or below = Normal 100 to 125 = Pre-diabetes (impaired fasting glucose (IFG) 126 = Diabetes Oral Glucose Tolerance Test (OGTT) 2 hr plasma glucose result: 139 and below =Normal 140-199 = Pre-diabetes (impaired glucose tolerance (IGT) 200 and above = D
6、iabetes Random Plasma Glucose Test 200 or more plus presence of symptoms (polydypsia/polyuria/polyphagia) = Diabetes Results should be confirmed by repeating the test on another day prior to diagnosis A1c 6.5% (new 2010 criteria for diagnosis),Classification of Diabetes,Insulin-Dependent Diabetes Me
7、llitus (Type I) High anti-beta cell antibodies Low plasma insulin concentration (determined by C-peptide levels) Usually lean and young patients but this trend in changing Non-Insulin-Dependent Diabetes Mellitus (Type II) Serum insulin levels normal or elevated but still have relative insulin defici
8、ency Metabolism does not respond properly to insulin= insulin resistance Usually obese (60-90%) and older but thins trend is changing Losing weight frequently brings glucose levels and insulin sensitivity back under control Strong genetic linkage,Classification of Diabetes (Cont.),Type 1.5 Diabetes
9、(also known as slow onset type I or latent autoimmune diabetes in adults) Patients do not immediately require insulin for treatment Little or no resistance to insulin Antibodies present (especially GAD65) Can be easily misdiagnosed as Type II since patients are older and respond to oral medications
10、except glitazones (since little or no insulin resistance) & usually have good C-peptide levels Gestational Diabetes (GD) In most cases, slender and physically fit patients Approximately 4% of all pregnancies according to ADA 5-10% of women with GD are found to have type 2 diabetes Women with GD have
11、 20-50% chance to develop diabetes in the next 5-10 years,Type 3 Diabetes?,Alzheimers can be associated with low levels of insulin in the brain is the reason why increasing numbers of researchers have taken to calling it Type 3 diabetes, or “Diabetes of the Brain“ In Alzheimers, the brain, especiall
12、y parts that deal with memory and personality, become resistant to insulin. Research is ongoing and there will be more to come on the link between diabetes and the brain.,Risk Factors,Family History Obesity: 20% over IBW or BMI 27 Age: over 45 years old History of impaired glucose tolerance or impai
13、red fasting glucose Hypertension HDL 200 Smoking Race/Ethnicity Pregnancy,Clinical Practice Recommendations,ADA Begin screening at age 45 Preprandial BG 70-130 2 hr postprandial 180 Average bedtime BG 100-140 A1c goal 7% for patients in general, EAG= (28.7x A1c) - 46.7 (6%= 126 mg/dl, 7%= 154, 8%= 1
14、83, 9%= 212, etc.),AACE Begin screening at age 30 Preprandial BG 110 2 hr postprandial 140 A1c goal 6.5%,ADA= American Diabetes Association AACE= American Association of Clinical Endocrinologists,Benefits of Reducing A1c by 1%,Type I diabetes (DCCT) -32% decrease in risk for retinopathy -20% -27% de
15、crease in risk for nephropathy -30% decrease in risk for neuropathy Type II diabetes (UKPDS) -10% decrease in risk in diabetes related death - 6% decrease in all-cause mortality -16% decrease in risk for MI -25% decrease in microvascular complications DCCT= Diabetes Control and Complications Trial U
16、KPDS= United Kingdom Prospective Diabetes Study,A1C Goals Unmet in Majority of Patients With Diabetes,Upper limit of normal range (6%),ACE recommended target (6.5%)4,8.0,9.5,A1C (%),6.0,8.5,10.0,6.5,5.5,9.0,7.0,7.5,1. Data from Saydah SH, et al. JAMA. 2004; 291:335-342 2. Calculated from Koro CE, et al. Diabetes Care. 2004; 27:17-20 3. Data from ADA. Diabetes Care. 2003; 26(suppl 1):S33-S50 4. Data from ACE. Endocrine Practice. 2002,Diabetes Management,Control of A1c, fasting glu
