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Diabetes Core Update
Diabetes Core Update Special Edition - Diabetes is Primary 2015 Part 3
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Diabetes Core Update is a monthly podcast that presents and discusses the latest clinically relevant articles from the American Diabetes Association’s four science and medical journals – Diabetes, Diabetes Care, Clinical Diabetes, and...
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Hello, I'm Dr. Neal Skolnick and I'd like to welcome you to this special edition of Diabetes Corps. Update on this special series of podcasts. We will be interviewing faculty who presented during the American Diabetes Association's Scientific Sessions Diabetes is primary conference on June 6, 2015. In part one of this series, we heard Dr. Andrew Reinhardt discussing and updating us on the standards of Care and Dr. John Buesse discussing new medications for diabetes. In part two last month, we heard Dr. Charles Schaefer discussing what to do after basal insulin is no longer sufficient and Dr. Jim Chamberlain discussing data on the importance of and the management of hypoglycemia. Today, in part three of this series, we will hear Dr. Jay Shubrook discussing atypical diabetes, Dr. Henry Rodriguez discussing diabetes in adolescence, and Dr. Eric Johnson discussing continuous glucose monitoring and insulin pump therapy for primary care. Please visit www.professional.diabetes.org CE to access the full webcasts of the full versions of these lectures. Our next speaker is Jay Shubrook, who.
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A professor in primary care and director.
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Of clinical research and Diabetes services at.
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Touro university in California. Dr. Shubrook just gave a fantastic talk on atypical diabetes. Welcome, Dr. Shubrook, welcome.
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Yeah, happy to be here.
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If you would just give our listeners an overview of the most important information from your talk on atypical diabetes.
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Sure. So I think a lot of people recognize that there's type 1 diabetes and type 2 diabetes and there's gestational, but I think that there's not a recognition of the many other subtypes and other types of diabetes. So we did a case based approach where we talked about other forms of diabetes, including lata, which is latent autoimmune diabetes of the adult. It's a form of type 1 diabetes seen in adulthood. We talked about Modi monogenic diabetes. So it's a form of genetic diabetes typically seen in youth but sometimes is not diagnosed until adulthood. We talked about ketosis prone type 2 diabetes. So there's a subgroup of people with type 2 diabetes that actually can go into diabetic ketoacidosis. And then finally we talked about double diabetes. And this is particularly challenging because as our population has become more obese, we're actually seeing more people who have both insulin resistance and the autoimmunity associated with type 1 diabetes. And so it gets quite hard to distinguish between them. And really we focused on these cases to highlight when you should suspect atypical form of diabetes.
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So let's focus for this talk on lada, because I think that's the one that the tough case that our listeners will most frequently encounter. When should we think about LADA?
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So LADA is a form of type 1 diabetes diagnosed in adulthood, typically between the age of 35 and 50. And it's someone who presents as an adult with diabetes but doesn't have the metabolic signals that you would see. So they're typically less likely to be obese. They're less likely to have acanthosis as we typically see with type 2. They also are less likely to have a family history of diabetes and they're less likely to have diabetic dyslipidemia. And so there's actually been a scoring sheet where you can find no personal history of diabetes, but a personal history of autoimmunity, no presence of diabetic dyslipidemia, but present with the age of diabetes between 35 and 50. And if they don't have physical signs of type 2, you really should consider LADA, which is really present in 10% of people who think they have type 2.
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So that's a larger percentage than we used to think to be the case. Why is it important to make that diagnosis?
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Well, it's very important because, you know, with lada, it's really a form of type one. And so the treatment is really insulin. And so often people who might be misdiagnosed as type 2 initially may be put on medications, oral tablets, metformin, sulfonyas, and some of the medications like sulfonylureas might actually destroy the beta cell faster and actually has a worse prognosis. The earlier you can put someone with LADA on insulin, the better the long term prognosis and glucose control.
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So we've talked about how to identify those people, we've talked about what to do and why it's important. How do you confirm the diagnosis?
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So because LADA is a form of type 1, they will have markers that we use for type 1. So one of the the kind of testing protocols we'd use is we order a C peptide in glucose. People with type 1 typically have low C peptide or low endogenous insulin production in the face of a high glucose. And they may have autoimmune markers. So the GAD antibodies, islet cell antibodies or insulin antibodies.
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That's fantastic. So thanks so much for going over that. I think those are some important pearls for our listeners. Thank you, Dr. Shubra. Our next speaker is Henry Rodriguez, who is a professor of pediatrics and clinical director of the University of South Florida Diabetes center, who just gave A fantastic talk on diabetes in special populations, discussing diabetes in type 1 adolescents and gestational diabetes, and who is now going to give us a bit of an overview of that talk. Welcome, Dr. Rodriguez.
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Well, thank you.
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We're real interested and thanks for joining us to give an overview of your talk for our listeners.
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Well, yeah, it's a pleasure to have participated. I think, you know, the adolescent population in particular is a challenging group and it's a challenging group irrespective of whether, you know, you're a subspecialist in pediatric diabetes, as I am, or a generalist. And, you know, I've got the wisdom now of two children that are now adolescents, young adults, and it is a very difficult proposition because at that age they obviously want to be like everybody else. And so a chronic disease, particularly like diabetes, particularly type 1 diabetes, which is really quite burdensome on the individual in terms of all the tasks that they need to master and the responsibility they need to have. When you layer that on top of a developmental stage where they really want to conform to their peer group, the demands of monitoring, of making insulin dosing decisions, counting carbohydrates, that kind of thing becomes a major challenge both to the individual, to their family. There's a source of lots of potential conflict and the provider as well.
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What are some of your suggestions about how we can recognize when there are particular issues and how to overcome those challenges?
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Well, I think the recognition is kind of in your face, quite honestly. You're going to know for that patient that becomes very non adherent, their hemoglobin A1C may go up dramatically many times. As I frequently explained to families at that age, there tends to be disagreement about curfew, screen time, all the rest of it. And although we might in our ideal world say, well, there's going to be those disagreements, that's normal development. But when it comes to the diabetes, you know, we're all going to be one happy family and cooperate and things will be wonderful. The challenge is for most parents, and I think almost universally, they're more concerned obviously about the diabetes than they are about the amount of time they play, they spend playing video games. So that's where the conflict many times really, really focuses. And so to be able to work with families and I think quite honestly, having a multidisciplinary team is very helpful. You know, at my institution, we're actually very fortunate. We've got a clinical social worker, we've got a clinical psychologist. And so you don't have to have all those people at your particular institution. But knowing what resources are available I think is very important because to be able to provide that degree of support to the family and to the young adult I think is really important, particularly in very difficult cases.
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I have to imagine another piece is probably also just listening to the concerns of the adolescent. There's no question that adolescents ultimately determine what they are going to do, so enlist their cooperation is critical.
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Oh, there's critical question. As an example, increasingly individuals with type 1 diabetes are used utilizing insulin pump therapy. And there are parents that come in and say I want Johnny on that pump. And I always tell them, listen, there are two non negotiable conditions for going on a pump. One is that the individual has to be monitoring frequently and I think that's fairly straightforward. But, but the second is particularly in this age group that they're willing and interested to use a pump because if the parents think it's a great idea, but the individual is not really keen on it, I always tell them it's a topic for future discussion because that young adult, that adolescent is going to be utilizing that device pretty much 24 7. So if they don't have buy in, if they're not motivated, they're almost doomed to failure.
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That makes a lot of sense. And I suspect that a lot of adolescents, when it ultimately comes to using the pump, are the ones who understand the technology, can use it a lot more fastly than the parents do.
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Absolutely, absolutely. So it shouldn't be overlooked that you know, educating the parents as well as certainly at this age, many times our primary focus is the adolescent because they're the one increasingly that's taking responsibility. But particularly in those cases where the road is getting a little rough, having parents supervise I think is tremendously important. And so as an example, I've got adolescent patients who many times are in the care of their grandparents and parents will come in and say, well Johnny, I keep picking on Johnny, but Johnny just pulls the wool over his grandparents eyes. So he tells them, oh yeah, I'm taking care of it. And then obviously when he comes into an appointment you find he's not monitoring or he's not bolusing, that kind of thing. So I think again it's coming back to that team approach and the individual in this case the adolescent and the family are really the key players on that team.
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That makes a lot of sense. That was a great overview for our listeners. If you go to the American Diabetes website and we'll give you the exact address at the end of this podcast, you can hear the Complete lecture and the webinar of this lecture will be available and it is really worth seeing. Dr. Rodriguez, thank you so much.
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You're very welcome.
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Our next speaker is Eric Johnson. Dr. Johnson is the assistant medical director and is an associate professor at the All True Diabetes center at the University of North Dakota School of Medicine and Health Sciences in Grand Fork, North Dakota. Dr. Johnson just gave a fantastic talk on technology in the treatment of diabetes and particularly on the place and the use of insulin pumps and continuous glucose monitoring and sensors and their relevance for primary care. Welcome, Dr. Johnson.
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Yeah, thank you. Great to be here.
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If you could go over some of the highlights of that talk for our listeners. Sure.
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I feel a primary care audience is more and more likely to encounter patients using pumps and sensors in the technological management of their diabetes. And I just wanted them to be familiar with some of the concepts and some things like how we select patients to go on these devices, some basic operation principles of pumps and sensors and what they should be looking for if they would encounter one of these patients in their clinic.
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That's fantastic. So kind of taking those areas in hand, what patients should we think about when we are thinking about, in our case, referring someone on for consideration of pumps and sensors? What's the right patient look like?
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Yeah, we talked a little bit about usually younger, motivated patients with type 1 are good candidates for pumps. People who are technologically engaged already who have a good understanding of other everyday technology like their smartphone or their computer. We feel that those are the candidates who are more successful. Quite often they're people who really are doing a pretty good job with their diabetes, but we're just not achieving their goals.
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That makes a lot of sense. And then when we think about what pumps and sensors do, what are they doing that multiple shots a day don't.
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Do well with multiple daily injections, you have two kinds of insulin. One is a basal insulin and when you inject that, then your background insulin dose is pretty fixed for the next 24 hours. You really can't vary it after you've injected it. Then rapid acting insulin is used for meals and that can be dosed based on blood sugar or food. Pumps allow a little bit more manipulation of insulin, particularly with the basal insulin element. I can have a basal insulin at one rate for part of the day and maybe decreased for another part of the day where I'm more active. Can't do that with injections.
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That makes a lot of sense. You shared a wonderful example of how when you flew here to Boston from North to Dakota, you were sitting on a plane. And during that period of time, you were able to increase your basal rate because you were inactive in order to maintain control of your blood sugar. But then when you got to Boston, you walked around more than you have in a long time, and you were able then to actually decrease the basal rate in real time.
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Yeah, I really can. People might understand this, like with an IV insulin drip in the hospital, but you can actually have a lot more control over it with timers and settings and what your anticipated activity is going to be.
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And I think that idea for many of us in primary care is really a novel idea and it's not something we've thought about a lot. But the minute it is made clear by clear example or discussion, it sort of becomes obvious. And it's one of those things that, wow, I didn't realize how important that could be day to day.
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It really is. We can sculpt the insulin to the person's activity, which is much better than the person having to feel the need of the insulin.
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So that's a wonderful point. I think you also made the point that for many people on standing basal doses, if they're going to go exercise, they need to eat more, which is the opposite of what we often recommend our type 2 patients to do in general in order to sustain their blood sugars during exercise. But this allows you to change your basal insulin rate during the period of exercise.
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Yeah, it's ideal. I often tell patients to anticipate that by about 15 minutes and maybe extend it for another hour beyond the exercise period. And that can really reduce the chance of hypoglycemia during or after an exercise period.
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So the potential advantages are the ability, as you said, to sculpt the insulin dose and therefore have better blood sugar control on the one hand. And then you also mentioned that there.
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Tends to be less hypoglycemia overall, less variability in general. And we can really target the percentage of time less than 70 by doing this as well, particularly when combined with the sensor device that's giving us a blood sugar reading of every five minutes.
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Yeah. So potentially very advantageous for the right patient for the devices. And then lastly, you mentioned some things for us to be aware of as patients come in and might be having problems. What are some of those problems that we might encounter and what we might do about them?
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What I really wanted to emphasize here for our primary care audience was to know the basics. How insulin is dosed with a pump, units per carb, a correction factor, but also things that go wrong when patients are ill or they're having a problem with high blood sugar, they probably need to change the insulin infusion site. If they haven't done that, they need to do things like remember to protect their insulin from heat and cold. The insulin is in the pump. So if they're out on 105 degree day, their insulin, insulin is also 105 degrees. So some kind of basic operational things that I want primary care to be thinking of and they should be asking the patient, well, what is your usual units per carb? What are your basal rates? Do you use these temporary basal features? I think if the primary care audience knows a few of these questions, they can actually help these patients do some problem solving.
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That's fantastic. I think in a really nice concise summary, I think most of us have learned a lot just now. Thanks so much for joining us for our listeners.
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Yeah, thank you.
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That was an excellent summary of these lectures where we heard Dr. Jay Shubrook discussing atypical diabetes, Dr. Rodriguez discussing diabetes in adolescence, and Dr. Johnson discussing continuous glucose monitoring and insulin pump therapy for primary care. Remember in primary, in part one we heard Dr. Rinehart discussing an update on the standards of Care and Dr. Buce discussing new medicines for diabetes. In part two we heard Dr. Charles Schaefer discussing what to do after basal insulin is no longer sufficient and Dr. James Chamberlain discussing data on the importance of and management of Hypoglycemia. Please visit www.professional.diabetes.org ce to access the full version of these webcasts available for cme. Thank you.
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Sam.