Science of Diabetes and Diabetes Management as it

Relates to Legal Issues and the Need for Accommodations

Daniel Lorber, MD, FACP, CDE

Linda Siminerio, RN, PhD

John Griffin, JD

FIGHTING FOR FAIRNESS

Session Outline

CAUSE/CLASSIFICATIONSCOMPLICATIONSCARECHALLENGES

The prevalence of diabetes - current estimates - world*

Number of people with diabetes:

» 177 million (154 million projected)

Top 10 countries (number of people with diabetes):

» India, China, USA, Indonesia, Russia, Japan, UAE, Pakistan, Brazil, Italy

*Source: WHO Global Burden of Disease

U.S. Diabetes Facts 20% increase in past 20 years 70% increase in diabetes in 30-39 yr. age range

from 1990-1998 1 in 3 children born in 2003 will get diabetes

125,000 in U.S. under the age of 19 Type 2 in children is increasing 14 million lost work days Annual costs -- $132 billion

What is Diabetes?

Ancient Greek: “Diabetes Mellitus”» Diabetes: Copious Urine» Mellitus: Sweet

Lay Definition: » Abnormally High Blood Sugar

American Diabetes Association:» Fasting Blood Glucose above 126 mg/dl » Fasting Blood Glucose above 7 mM

CLASSIFICATIONS/CAUSE

What is the Cause of High Glucose in Diabetes?

Type 1: Failure of the pancreas to make Insulin: cause = autoimmune

Type 2: Resistance of the body to Insulin: cause unknown

Both of these are areas of active research in the U.S. and internationally

What Kinds of Diabetes are There? Type 1 (Juvenile, Insulin-Deficient)

» 10%» Under 40 y.o.» Hereditary

Type 2 (Adult Onset, Insulin-Resistant)» 90%» Strongly Hereditary» Associated with Overweight

Secondary Diabetes» E.g., medications like cortisone; pancreatitis

How is Glucose Regulated?

What is the Cause of High Glucose in Diabetes?

Intestine

BloodFat

Muscle

Liver

Brain

Pancreas

Glucose100 mg/dl

Meet the Cast:

Food

Intestine

BloodFat

Muscle

Liver

Brain

Pancreas

Glucose100 mg/dl

Effects of Eating

Food

Intestine

Glucose

BloodFat

Muscle

Liver

Brain

Pancreas

Glucose100 mg/dl

140 mg/dl

Effects of Eating

Food

Intestine

Glucose

BloodFat

Muscle

Liver

Brain

Pancreas(makes Insulin)

Glucose100 mg/dl

140 mg/dl

Effects of Eating

Food

Intestine

Glucose

BloodFat

Muscle

Liver

Brain

Pancreas(makes Insulin)

Glucose100 mg/dl

140 mg/dl

Effects of Eating

Intestine

BloodFat

Muscle

Liver

Brain

PancreasNo Islets,No Insulin

Glucose100 mg/dl

500 mg/dl

Type 1 Diabetes:

Food

Glucose

BALANCING ACT

Insulin and food must stay in balance» The insulin you inject will work whether you eat

or not» Timing and amounts of food are important» If you do not eat enough, your blood sugar

(glucose) could go LOW» If you eat too much, your blood sugar could go

too HIGH» Physical activity will effect your blood sugar level

HbA1c and Glucose

5% - - - - 906% - - - - 1207% - - - - 1508% - - - - 1809% - - - - 21010% - - - 24011% - - - 27012% - - - 300

GOAL

Take Action

CARE

How Do You Treat Diabetes?

Type 1:

» Glucose Monitoring (fingersticks)

» Insulin Injections or infusion pump therapy (replacement doses)

» Meal Plans

» Physical Activity

How Do You Monitor Blood Glucose Control?

Frequent Blood Sugar Measurements» Fingersticks, multiple times each day

Hemoglobin A1c (HbA1c)

» Quarterly

MONITORING

Blood Glucose Meters

» Small, lightweight and user friendly

» Many varieties available

» One size does not fit all

» No danger to others

MONITORING

How often? » Some suggestions:

• Before each meal and at bedtime• Fasting and two hours after you eat• Before and after each meal• Once daily before breakfast• Fasting and once more during different times of the

day• More often if you are ill, exercising, having a low blood

sugar, driving.

Always individualized for each person with diabetes!

BACK

MONITORING

How to test?» Wash hands with warm soap and water» Dangle fingers» Prick side of finger» Milk your finger to get a good drop of blood» Do not use the same finger over and over for

testing

URINE TESTING Done to detect ketones

» Ketones are BAD!!» Ketones happen mostly in Type 1 diabetes» Type 1: test in the presence of persistent hyperglycemia » Should test if consistently high or anytime during illness» Moderate or large ketones should be reported to

physician immediately

Urine testing is NOT used to detect glucose levels or as a measure of diabetes control

RAPID-ACTING INSULINS

HUMALOG AND NOVOLOG» Work very quickly» Starts working in 15 minutes» Peak 1-1 1/2 hours» Clear

SHORT-ACTING INSULIN

REGULAR» Works quickly» Starts to work in 1/2 hour» Peaks in 2-4 hours» Should be taken 15-30 minutes before a meal» Clear

INTERMEDIATE-ACTING INSULINS

NPH and LENTE» Work more slowly» Most often taken with oral medicine» Starts to work 1-2 hours after it is given» Peaks in 6-12 hours» Cloudy» Can be mixed with Humalog, Novolog and

Regular

LONG-ACTING INSULIN

ULTRALENTE and LANTUS» Lasts for 24 hours with little or no peak» Usually taken at bed» Ultralente is cloudy» Lantus(Glargine) is clear» Lantus CANNOT be mixed with any other insulin

Insulin Delivery Systems

Injectors Injection Aids Pen delivery

Insulin Pump

Other technology

Other Delivery Systems Being Explored

Closed-loop insulin pumps Lectin-and polymer-bound systems New routes: inhalation, oral, and transdermal Microencapsulation of islet cells Biohybrid artificial pancreas Pump cannula at portal vein (Disetronic)

How Do You Treat Diabetes? Type 2:

» Careful Diet; Weight Reduction; Glucose Monitoring

» Reduce glucose absorption from gut: (alpha-glucosidase inhibitors)

» Increase Sensitivity of Liver, Muscle to Insulin: (Thiazoladinediones, Metformin)

» Stimulate Insulin Secretion: (Sulfonylureas, Repaglinide)

» Insulin: large doses» Physical Activity

INSULIN

INSULIN» Needed to lower blood sugar levels.» Diet alone or diet and oral medicine did not

control your blood sugar levels (type 2)» Does NOT mean your diabetes is worse» What your body needs to keep blood sugar in

control

Kinds of Oral Medicines

Sulfonylureas Biguanides Alpha-glucosidase Inhibitors Insulin-sensitizing agents Meglitinides

Intestine

BloodFat

Muscle

Liver

Brain

Glucose100 mg/dl

500 mg/dl

Type 2 Diabetes:

Food

Glucose

PancreasLiver, Fat, Muscle

Resist Insulin

Oral Medicines

Medicines can be used alone, with each other or with insulin.

Sulfonylureas and meglitinide.

Help the pancreas make more insulin.

Biguanides and insulin sensitizers

Help the insulin to work better

Oral Medicines

Sulfonylureas

Lower pre-meal blood sugar levels

Carbohydrate Inhibitors and Meglitinides

Lower after meal blood sugar levels

SULFONYLUREAS

Help pancreas make more insulin Several different types Do not exchange one for another Side effects

» Low blood sugar» Weight gain» Upset stomach

BIGUANIDES

GLUGOPHAGE» Help keep the liver from putting out too much sugar» Help insulin to work better» Lower cholesterol» Do not cause weight gain» Side effects: diarrhea, nausea and loss of appetite» Do NOT take is liver, kidney problems or heart failure

ALPHA-GLUCOSIDASE INHIBITORS

PRECOSE AND GLYCET» Work in digestive tract» Block enzymes that break down carbohydrates to

sugar» Prevent blood sugar from going up after meal» Side Effects: Bloating, gas, diarrhea» Side effects usually go away after a few months

INSULIN SENSITIZERS

ACTOS AND AVANDIA

» Help your body to use insulin better» May take 2-12 weeks to work» Give medicine a fair trial» Monitor liver functions

MEGLITINIDES

PRANDIN AND STARLIX

» Help pancreas make more insulin» Work in response to blood sugar levels» Take before each meal and snack

Oral Medicine

Most pills should be taken at mealtime Glucotrol (Glipizide) works best if taken 1/2

hour before a meal Prandin should be taken 15 minutes before a

meal Precose and Glycet should only be taken

with the first bite of food

Benefits of Oral Medicine Lower blood sugar will mean you will feel better Remember not a cure for diabetes

The Person with Diabetes must Take medicine every day, eat at planned times, eat

meals per appropriate diet. Stay in touch with his/her health team Test blood sugar level to see if the medicine is working

COMPLICATIONS

Acute

Chronic

Hypoglycemia

Sudden Onset Staggering, Poor

Coordination Anger, Bad Temper Pale Color Confusion,

Disorientation Sudden Hunger Sweating Eventual Stupor or

Unconsciousness

Gradual Onset Drowsiness Extreme Thirst Very Frequent

Urination Flushed Skin Vomiting Fruity or Wine-Like

Breath Odor Heavy Breathing Eventual Stupor or

Unconsciousness

Hyperglycemia

Why Do We Care? Chronic Complications:

(Years, Decades)

Diabetic Nephropathy: Kidney Failure, Dialysis, Kidney Transplant

Diabetic Retinopathy: Blindness

Diabetic Neuropathy: Numbness, Impotence, GI Probs, and more

Accelerated Cardiovascular Disease:

Stroke, Heart Attack, Impotence, Peripheral Vascular Disease (Amputations)

Are These Chronic Complications Preventable?

Absolutely!

» Tight Glucose Control Prevents or Delays Complications.

Proven Studies“benefits of intensified control”DCCT (type 1)

HbA1c = 1.9% Complications in the DCCT

Trial showed profound reduction

» Retinopathy 76%» Nephropathy 56%» Neuropathy 60%

UKPDS (type 2)

HbA1c = 0.9% Intensive therapy… reduced overall

microvascular complications by 25% and decreased risk of » retinopathy 21%» microalbuminuria 33%

Reduction in microvascular complications seen regardless of primary treatment modality for intensive therapy» insulin, sulfonylureas, or metformin

HbA1c and Glucose

5% - - - - 906% - - - - 1207% - - - - 1508% - - - - 1809% - - - - 21010% - - - 24011% - - - 27012% - - - 300

GOAL

Take Action

Decision SupportADA Standards of Medical Care

A1C <7% Blood pressure <130/80 mmHg Lipids

» LDL <100 mg/dl» Triglycerides <150mg/dl» HDL >40mg/dl

Dilated eye exams Foot exam (Monofilament) Microalbumin

CHALLENGES

CHALLENGES at SCHOOL

•Meet both the student’s health and educational needs one at the expense of the other

•Blood glucose testing: assistance as appropriate, right to carry equipment•Eating: meals, snacks, treat low blood sugar•Medication: assistance as needed per individual child, right to carry, •Field trips•Extra-curricular activities•Treatment of severe low blood sugar•Testing accommodations

at WORK

•Right to a job for which the person with diabetes is qualified

•Individual assessments not blanket bans•Reasonable accommodation for testing, eating other care needs•Access to supplies and equipment•Modified work schedule