Diabetes Care: A Paradigm Shift is Underway

Tracey Pierce RPh, CGP, FASCP, Consultant Pharmacist 
In a recent publication of “Diabetes Care” (Diabetes Care 2016;39:308-311) the American Diabetes Association released a position statement for strategies and goals of diabetes management in LTC. Three specific patient populations seen in long term care were identified: 1)Transitional care/rehab; 2) general LTC; and  3) hospice/palliative care. Each of the 3 areas have unique problems, goals, and treatment strategies. A truly patient specific approach is necessary due to the complexities of the patients, complicating comorbidities, and transitions in care. A change in approach to diabetes management is underway in LTC. The tight glycemic control that is the goal of treatment in younger patients and hospitalized patients is not appropriate for the frail elderly due to the risk of hypoglycemia and the complications that occur.
The risk for hypoglycemia is greater in the elderly due to decreased renal function, variable appetites, cognitive impairment, altered GI motility, and  altered GI absorption. This risk is compounded by recent hospitalization, advanced age, medication changes, and polypharmacy.
Some general guidelines for diabetes care in the elderly residing in LTC include:
  • Avoiding HYPOGLYCEMIA
  • MINIMIZING severe Hyperglycemia
  • Avoid Sliding Scale insulin use as the only strategy for glucose management
  • Avoiding sliding scales insulin  - transition to basal insulin
  • Simplifying diabetes regimen
  • Avoiding “diabetic”, “no concentrated sweets”, ” no sugar“ diets
  • Developing facility protocols for management of HYPO and HYPER glycemia 
  • Avoiding dehydration
 
Treatment goals for diabetics on hospice and/or near end of life (residing at home or in a LTC facility include:
  • Avoiding symptomatic hyperglycemia
  • Not checking HgbA1c levels, there are no benefits
  • Fasting glucose readings of 200-300, if asymptomatic, are appropriate
  • Checking blood sugar only if symptomatic (either hyper or hypo glycemic)
  • Simplify medication regimens to avoid hypoglycemia
  • Avoiding dehydration
  • Consider discontinuing medications not providing comfort
 
Tight glycemic control in younger persons will improve and increase longevity along with decreasing complications of diabetes. However, in the frail elderly, this risk of hypoglycemia outweighs any benefits of tight control due the frequency of hypoglycemia and to the potential increased costs of care due to complications of hypoglycemia and its management. Signs of hypoglycemia in the elderly may not be typical (palpitations, sweating, tremors), but more likely can include confusion, delirium, and dizziness. Change in mental status in diabetics might also include checking a blood sugar to check for hypoglycemia   in addition to the urine dip to rule out a UTI.
Residents and families of persons on hospice services may be resistant to changing diabetes regimens and tightly managing glucose levels because health care has done a good job of educating them on the benefits of this practice. Education of families and in some cases providers may be necessary to explain the risks and lack of evidence of more aggressive glucose management at the end of life.
Persons in transition are at greatest risk of problems with diabetes care due to lack of adequate communication between providers and a distinct plan of care with goals of therapy. The ADA position statement recognizes the American Medication Directors Association (AMDA) Guidelines for management of safe transitions in care of diabetes. The AMDA guidelines include:
  • CAREFUL medication reconciliation between providers, PCP, Specialists
  • Considering living arrangement goalsonce acute treatment/ therapy is completed. Living arrangements and caregiver support may be significant in successful safe outpatient management
  • Considering comorbidities
  • Considering cognitive status
 
All too frequently insulin is initiated during hospitalization and inadvertently ordered at discharge in persons not receiving any medication for diabetes, and discharged home with an insulin pen and no instructions for use. Other diabetes related medication issues at transitions of care include holding metformin during hospitalization due to test interactions, and not restarting at discharge, or therapeutic substitutions made during inpatient stay for oral agents, discharging with prescriptions for the substituted medications resulting in duplicate therapy and overuse at home leading to hypoglycemia and readmission. Inaccurate medication histories on hospital admission get compounded and confused when specialists are involved in care and the different providers do not keep accurate updated medication lists which can results in medication misadventures not only related to diabetes, but many other conditions.
So, how can LTC facility jump on the pendulum and join the paradigm shift?
Avoid sliding scale insulin as the only treatment of diabetes
Establish protocols regarding when to call a physician regarding a hypo/hyperglycemia event
Establish protocols for management of a hypoglycemic event
Develops resident specific goals for diabetes management with A1c goals documented and specific to each resident based on comorbidities and functional status.
 
There are now 8 different classes of medications available for management of glucose, each with advantages and disadvantages to use, along with a multitude of combination products with the classes below.  The categories of agents include:
Insulin:
5 types of insulin: short acting, rapid acting, intermediate acting, long acting, and combination products
GLP-1 agonists:
These include Dulaglutide (Trulicity), albiglutide, (Tanzeum),   Exenatide, (Byetta / Bydureon ), Liraglutide (Saxenda, Victoza)
SGLT2 inhibitors: 
Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)
DPP4 inhibitors: 
Alogliptin (Nesina),  Linagliptin (Tradjenta),  Saxagliptin (Onglyza),  Sitagliptin (Januvia)
Thiazolidinediones (TZD’s): 
rosiglitazone (Avandia), Pioglitazone (Actos)
Meglitinides: 
These include Nateglinide (Starlix), Repaglinide (Prandin)
Sulfonylureas:
These include chlorporpamide,  glimepiride (Amaryl), glipizide (Glucotrol),  glyburide (Diabeta) , tolazamide, tolbutamide
Biguanides:
Metformin (Glucophage)
 
Factors contributing to medication regimen selection might include, but not limited to:
  • Renal function
  • A1c Goals
  • Duration of disease
  • Level of insulin resistance
  • Ability to comply with medication regimen
  • Insurance coverage of medication / payment ability
  • Concurrent comorbidities: Drug / disease interactions
 
The drug selection has become complicated, the patient is more complex, and the risk of untoward effects and hypoglycemia have increased, all of which are contributing to the shift in strategies for management of the diabetic across all levels of care.

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