Diabetes mellitus
Thursday, May 27, 2010
MONITORING/TESTS OF GLYCEMIA
Monitoring of CBG is a strategy that allows caregivers and people with diabetes to evaluate diabetes management regimens. The frequency of monitoring will vary by patients’ glycemic control and diabetes regimens. Patients with type 1 diabetes are at risk for hypoglycemia and should have their CBG monitored three or more times daily. Patients with type 2 diabetes on insulin need to monitor at least once daily and more frequently based on their medical plan. Patients treated with oral agents should have CBG monitored with sufficient frequency to facilitate the goals of glycemic control, assuming that there is a program for medical review of these data on an ongoing basis to drive changes in medications. Patients whose diabetes is poorly controlled or whose therapy is changing should have more frequent monitoring. Unexplained hyperglycemia in a patient with type 1 diabetes may suggest impending DKA, and monitoring of ketones should therefore be performed.
Glycated hemoglobin (A1C) is a measure of long-term (2- to 3-month) glycemic control. Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control) and quarterly in patients whose therapy has changed or who are not meeting glycemic goals.
Discrepancies between CBG monitoring results and A1C may indicate a hemoglobinopathy, hemolysis, or need for evaluation of CBG monitoring technique and equipment or initiation of more frequent CBG monitoring to identify when glycemic excursions are occurring and which facet of the diabetes regimen is changing.
Diabetes Management in Correctional Institutions
At any given time, over 2 million people are incarcerated in prisons and jails in the U.S. It is estimated that nearly 80,000 of these inmates have diabetes, a prevalence of 4.8%. In addition, many more people pass through the corrections system in a given year. In 1998 alone, over 11 million people were released from prison to the community . The current estimated prevalence of diabetes in correctional institutions is somewhat lower than the overall U.S. prevalence of diabetes, perhaps because the incarcerated population is younger than the general population. The prevalence of diabetes and its related comorbidities and complications, however, will continue to increase in the prison population as current sentencing guidelines continue to increase the number of aging prisoners and the incidence of diabetes in young people continues to increase.
People with diabetes in correctional facilities should receive care that meets national standards. Correctional institutions have unique circumstances that need to be considered so that all standards of care may be achieved. Correctional institutions should have written policies and procedures for the management of diabetes and for training of medical and correctional staff in diabetes care practices. These policies must take into consideration issues such as security needs, transfer from one facility to another, and access to medical personnel and equipment, so that all appropriate levels of care are provided. Ideally, these policies should encourage or at least allow patients to self-manage their diabetes. Ultimately, diabetes management is dependent upon having access to needed medical personnel and equipment. Ongoing diabetes therapy is important in order to reduce the risk of later complications, including cardiovascular events, visual loss, renal failure, and amputation. Early identification and intervention for people with diabetes is also likely to reduce short-term risks for acute complications requiring transfer out of the facility, thus improving security.
ROUTINE SCREENING FOR AND MANAGEMENT OF DIABETES COMPLICATIONS
All patients with a diagnosis of diabetes should receive routine screening for diabetes-related complications, as detailed in the ADA Standards of Care. Interval chronic disease clinics for persons with diabetes provide an efficient mechanism to monitor patients for complications of diabetes. In this way, appropriate referrals to consultant specialists, such as optometrists/ophthalmologists, nephrologists, and cardiologists, can be made on an as-needed basis and interval laboratory testing can be done.
The following complications should be considered.
* Foot care: Recommendations for foot care for patients with diabetes and no history of an open foot lesion are described in the ADA Standards of Care. A comprehensive foot examination is recommended annually for all patients with diabetes to identify risk factors predictive of ulcers and amputations. Persons with an insensate foot, an open foot lesion, or a history of such a lesion should be referred for evaluation by an appropriate licensed health professional (e.g., podiatrist or vascular surgeon). Special shoes should be provided as recommended by licensed health professionals to aid healing of foot lesions and to prevent development of new lesions.
Diabetes Care in the School and Day Care Setting
INTRODUCTION
Diabetes is one of the most common chronic diseases of childhood. There are about 176,000 individuals <20 years of age with diabetes in the U.S. The majority of these young people attend school and/or some type of day care and need knowledgeable staff to provide a safe school environment. Both parents and the health care team should work together to provide school systems and day care providers with the information necessary to allow children with diabetes to participate fully and safely in the school experience.
DIABETES AND THE LAW
Federal laws that protect children with diabetes include Section 504 of the Rehabilitation Act of 1973, the Individuals with Disabilities Education Act of 1991 (originally the Education for All Handicapped Children Act of 1975), and the Americans with Disabilities Act. Under these laws, diabetes has been considered to be a disability, and it is illegal for schools and/or day care centers to discriminate against children with disabilities. In addition, any school that receives federal funding or any facility considered open to the public must reasonably accommodate the special needs of children with diabetes. Indeed, federal law requires an individualized assessment of any child with diabetes. The required accommodations should be provided within the child’s usual school setting with as little disruption to the school’s and the child’s routine as possible and allowing the child full participation in all school activities.
Despite these protections, children in the school and day care setting still face discrimination. For example, some day care centers may refuse admission to children with diabetes, and children in the classroom may not be provided the assistance necessary to monitor blood glucose and may be prohibited from eating needed snacks. The American Diabetes Association works to ensure the safe and fair treatment of children with diabetes in the school and day care setting (http://www.diabetes.org/schooldiscrimination).
Strategies For Improving Diabetes Care
The implementation of the standards of care for diabetes has been suboptimal in most clinical settings. A recent report (24) indicated that only 37% of adults with diagnosed diabetes achieved an A1C of <7%, only 36% had a blood pressure <130/80 mmHg, and just 48% had a cholesterol <200 mg/dl. Most distressing was that only 7.3% of diabetes subjects achieved all three treatment goals.
While numerous interventions to improve adherence to the recommended standards have been implemented, the challenge of providing uniformly effective diabetes care has thus far defied a simple solution. A major contributor to suboptimal care is a delivery system that too often is fragmented, lacks clinical information capabilities, often duplicates services, and is poorly designed for the delivery of chronic care. The Institute of Medicine has called for changes so that delivery systems provide care that is evidence based, patient centered, and systems oriented and takes advantage of information technologies that foster continuous quality improvement. Collaborative, multidisciplinary teams should be best suited to provide such care for people with chronic conditions like diabetes and to empower patients’ performance of appropriate self-management. Alterations in reimbursement that reward the provision of quality care, as defined by the attainment of quality measures developed by such activities as the ADA/National Committee for Quality Assurance Diabetes Provider Recognition Program will also be required to achieve desired outcome goals.
The National Diabetes Education Program recently launched a new online resource to help health care professionals better organize their diabetes care. The http://www.betterdiabetescare.nih.gov website should help users design and implement more effective health care delivery systems for those with diabetes.
Diabetes care at diabetes camps
Recommendations
* Each camper should have a standardized medical form completed by his/her family and the physician managing the diabetes. (E)
* It is imperative that the medical staff is led by someone with expertise in managing type 1 and type 2 diabetes and includes a nursing staff (including diabetes educators and diabetes clinical nurse specialists) and registered dietitians with expertise in diabetes. (E)
* All camp staff, including medical, nursing, nutrition, and volunteer, should undergo background testing to ensure appropriateness in working with children. (E)
The concept of specialized residential and day camps for children with diabetes has become widespread throughout the U.S. and many other parts of the world. The mission of camps specialized for children and youth with diabetes is to allow for a camping experience in a safe environment. An equally important goal is to enable children with diabetes to meet and share their experiences with one another while they learn to be more personally responsible for their disease. For this to occur, a skilled medical and camping staff must be available to ensure optimal safety and an integrated camping/educational experience.
Diabetes Care In Specific Settings
A. Diabetes care in the hospital
Recommendations
* All patients with diabetes admitted to the hospital should be identified in the medical record as having diabetes. (E)
* All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E)
* Goals for blood glucose levels:
Critically ill patients: blood glucose levels should be kept as close to 110 mg/dl (6.1 mmol/l) as possible and generally <180 mg/dl (10 mmol/l). These patients will usually require intravenous insulin. (B)
Non–critically ill patients: premeal blood glucose levels should be kept as close to 90–130 mg/dl (5.0–7.2 mmol/l; midpoint of range 110 mg/dl) as possible given the clinical situation and postprandial blood glucose levels <180 mg/dl. Insulin should be used as necessary. (E)
Diabetes Care In Specific Populations
A. Children and adolescents
1. Type 1 diabetes
Although approximately three-quarters of all cases of type 1 diabetes are diagnosed in individuals <18 years of age, historically, ADA recommendations for management of type 1 diabetes have pertained most directly to adults with type 1 diabetes. Because children are not simply “small adults,” it is appropriate to consider the unique aspects of care and management of children and adolescents with type 1 diabetes. Children with diabetes differ from adults in many respects, including insulin sensitivity related to sexual maturity, physical growth, ability to provide self-care, and unique neurologic vulnerability to hypoglycemia. Attention to such issues as family dynamics, developmental stages, and physiologic differences related to sexual maturity all are essential in developing and implementing an optimal diabetes regimen. Although current recommendations for children and adolescents are less likely to be based on evidence derived from rigorous research because of current and historical restraints placed on conducting research in children, expert opinion and a review of available and relevant experimental data are summarized in a recent ADA Statement. The following represents a summary of recommendations and guidelines pertaining specifically to the care and management of children and adolescents that are included in that document.
Ideally, the care of a child or adolescent with type 1 diabetes should be provided by a multidisciplinary team of specialists trained in the care of children with pediatric diabetes, although this may not always be possible. At the very least, education of the child and family should be provided by health care providers trained and experienced in childhood diabetes and sensitive to the challenges posed by diabetes in this age-group. At the time of initial diagnosis, it is essential that diabetes education be provided in a timely fashion, with the expectation that the balance between adult supervision and self-care should be defined by, and will evolve according to, physical, psychologic, and emotional maturity. MNT should be provided at diagnosis, and at least annually thereafter, by an individual experienced with the nutritional needs of the growing child and the behavioral issues that have an impact on adolescent diets.
Diabetic autonomic neuropathy
The symptoms of autonomic dysfunction should be elicited carefully during the history and review of systems, particularly since many of these symptoms are potentially treatable. Major clinical manifestations of diabetic autonomic neuropathy include resting Tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, “brittle diabetes,” and hypoglycemic autonomic failure.
Cardiovascular autonomic neuropathy is the most studied and clinically important form of diabetic autonomic neuropathy. Cardiac autonomic neuropathy may be indicated by resting Tachycardia (>100 bpm), orthostasis (a fall in systolic blood pressure >20 mmHg upon standing), or other disturbances in autonomic nervous system function involving the skin, pupils, or gastrointestinal and genitourinary systems.
Gastrointestinal disturbances (e.g., esophageal enteropathy, gastroparesis, constipation, diarrhea, fecal incontinence) are common, and any section of the gastrointestinal tract may be affected. Gastroparesis should be suspected in individuals with erratic glucose control. Upper gastrointestinal symptoms should lead to consideration of all possible causes, including autonomic dysfunction. Evaluation of solid-phase gastric emptying using double-isotope scintigraphy may be done if symptoms are suggestive, but test results often correlate poorly with symptoms. Barium studies or referral for endoscopy may be required to rule out structural abnormalities. Constipation is the most common lower gastrointestinal symptom but can alternate with episodes of diarrhea. Endoscopy may be required to rule out other causes.
Neuropathy screening and treatment
Recommendations
* All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests. (A)
* Electrophysiological testing is rarely ever needed, except in situations where the clinical features are atypical. (E)
* Once the diagnosis of DPN is established, special foot care is appropriate for insensate feet to decrease the risk of amputation. (B)
* Simple inspection of insensate feet should be performed at 3- to 6-month intervals. An abnormality should trigger referral for special footwear, preventive specialist, or podiatric care. (B)
* Screening for autonomic neuropathy should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes. Special electrophysiological testing for autonomic neuropathy is rarely needed and may not affect management and outcomes. (E)
* Education of patients about self-care of the feet and referral for special shoes/inserts are vital components of patient management. (B)
* A wide variety of medications is recommended for the relief of specific symptoms related to autonomic neuropathy and are recommended, as they improve the quality of life of the patient. (E)
The diabetic neuropathies are heterogeneous with diverse clinical manifestations. They may be focal or diffuse. Most common among the neuropathies are chronic sensorimotor DPN and autonomic neuropathy. Although DPN is a diagnosis of exclusion, complex investigations to exclude other conditions are rarely needed.