PDF: Why, When, and How to Initiate Insulin Therapy

PDF: Why, When, and How to Initiate Insulin Therapy

Supported by an educational grant from Novo Nordisk Inc.

Why, When, and How to Initiate Insulin

Therapy in Elderly Patients with Type 2

Diabetes: A Case-based Approach

PODCAST/MP3 INSTRUCTIONS

1.

Download the Podcast or MP3 audio file to your player.

2.

Listen to the presentation, following along with the slide images contained in this PDF workbook.

It should take approximately 105 minutes to listen to the audio and complete the post-test and evaluation.

3.

To receive CPE or CE credit, use the link to the online test or print the post-test and evaluation pages found at the end of this PDF file.

4.

Follow the provided instructions to complete and submit the CME/CE post-test and evaluation form.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Summary of Need & Program Overview

More than 20 million Americans have diabetes—a number that continues to increase in all age groups and all ethnic groups. Of these, 10 million, or 21%, of older Americans

(>60 years) have diabetes. Based on death certificate data, diabetes contributed to more than 220,000 deaths in 2002. Studies indicate that diabetes is generally under-reported on death certificates, particularly in the cases of older persons with multiple chronic conditions such as heart disease and hypertension. Because of this, the toll of diabetes is believed to be much higher than officially reported.

Type 2 diabetes is the most prevalent form of the disease, accounting for more than 90% of all reported cases. Type 2 diabetes increases the risk of patients developing many serious complications, including cardiovascular disease, retinopathy, neuropathy, and nephropathy. The majority of patients with type 2 diabetes will eventually fail to adequately respond to oral drug therapy alone. Recently, the American Association of

Clinical Endocrinologists reported that 2 out of 3 patients are inadequately treated to reach glycemic targets. Insulin replacement in the form of insulin analogs may be used to reduce glycemic burden and improve outcomes in patients with type 2 diabetes.

This CE activity is designed to enhance the understanding of the progressive nature of type 2 diabetes, the role of insulin analogs, and available treatment options and strategies that can be used to reduce the risk of serious diabetes complications within the elderly population.

Target Audience

This educational activity is intended for pharmacists and nurses involved in the care of elderly patients at risk for the adverse effects of type 2 diabetes.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Learning Objectives

Upon completion of this continuing education activity, the participant should be able to:

1.

Identify elderly patients with type 2 diabetes who are not meeting established treatment goals for glycosylated hemoglobin (A1C), postprandial glucose (PPG) targets, and fasting plasma glucose (FPG) targets

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Describe how to transition elderly patients with type 2 diabetes who are not meeting treatment goals with more intensive and effective therapeutic regimens to attain and maintain A1C, PPG, and FPG targets

3.

Differentiate the benefits and risks of regular insulin mixes, premixed insulin analogs, and basal-bolus insulin treatment strategies for elderly patients

Accreditation & Credit Designation

PHARMACISTS: The American Society of Consultant Pharmacists is accredited by the

Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This program is accredited for 1.75 contact hours (0.175

CEUs) of continuing education credit. Universal Program Number 203-999-06-081-H01.

NURSES: NADONA/LTC is an approved provider of continuing nursing education by Georgia Nurses Association, an accredited approver by the American Nurses

Credentialing Center’s Commission on Accreditation #1087. This program provides 1.75 contact hours by NADONA/LTC.

Participants must pass a post-test and complete a program evaluation to receive credit.

An educational service of...

None of the contents may be reproduced in any form without prior written permission from the publisher. The opinions expressed in this activity are those of the speakers and do not necessarily reflect the opinions or recommendations of their affiliated institutions, the publisher, the

American Society of Consultant Pharmacists, the National Association of Directors of Nursing Administration in Long-Term Care, or Novo Nordisk.

Any medications or other diagnostic or treatment procedures discussed by the program speakers should not be utilized by clinicians without evaluation of their patients’ conditions and possible contraindications or risks, and without a review of any applicable manufacturer’s product information and comparison with the recommendations of other authorities.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Disclosure of Financial Interest

In accordance with the guidelines set forth by the Accreditation Council for Pharmacy

Education, it is the policy of the American Society of Consultant Pharmacists to ensure balance, independence, objectivity, and scientific rigor in all of its educational activities including those which are sponsored and cosponsored. All faculty are expected to disclose any significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation. The intent of this disclosure is not to prevent a presenter with significant financial interest or other relationship from making the presentation, but rather to provide the audience with information with which they can make their own judgments.

It remains for the audience to determine whether the speaker’s interest or relationships may influence the presentation with regard to exposition or conclusion. Faculty are also expected to openly disclose any off-label, experimental, or investigational use of drugs or devices in their presentations.

Jerry Meece, RPh, FACA, CDM, CDE – Program Chairman

Grant/Research Support:

Consultant:

Stock Shareholder:

Speaker with honorarium:

Pfizer

Eli Lilly, LifeScan, Novartis, Novo Nordisk

Metrika

Eli Lilly, LifeScan, Novo Nordisk, Bayer, Sanofi-Aventis,

Pfizer

Teresa L. Pearson, MS, RN, CDE

Consultant:

Speaker with honorarium:

LifeScan, Novo Nordisk, AmeriSource-Bergen

LifeScan, Roche, Novo Nordisk, Bayer, Abbott, Pfizer

Theresa Plog, PharmD

Speaker with honorarium: Novo Nordisk, Sepracor

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Faculty

Jerry Meece, RPh, FACA, CDM, CDE

Jerry Meece, RPh, FACA, CDM, CDE, is a pharmacist and Certified Diabetes Educator who is owner and Director of Clinical Services of Plaza Pharmacy and Wellness Center in Gainesville, Texas, one of the first freestanding pharmacies in the country to achieve

Provider Education Recognition from the American Diabetes Association.

Mr. Meece has spoken across this country and internationally on the subject of diabetes, disease state management and clinician/patient behavior in the healthcare setting, and has written numerous articles on diabetes care and insulin use in the patient with diabetes.

He is the first practicing community pharmacist ever to be elected to the Board of

Directors for the American Association of Diabetes Educators and to serve on their

Executive Board in the position of Vice President.

In August of this year, Mr. Meece was awarded the Innovative Practice Award by the

Texas Pharmacy Association, and for his work in the legislative field, was awarded the

Legislative Leadership Award by the American Association of Diabetes Educators.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Faculty

Teresa L. Pearson, MS, RN, CDE

Teresa L. Pearson, MS, RN, CDE, is Director of Fairview Diabetes Care for the Fairview

Health System in Minneapolis, Minnesota. She is also co-founder of and a consultant for

Innovative Health Care Designs.

Ms. Pearson received a Bachelor of Science degree from Winona State College–School of Nursing in Winona, Minnesota. Subsequently, she obtained a Master of Science degree from the University of Minnesota–School of Nursing in Minneapolis, and a

Mini-MBA in Health Care Administration from the University of St. Thomas, also in

Minneapolis. In addition, she is a Certified Diabetes Educator and a Certified Trainer in Choices and Changes from the Bayer Institute.

Author or coauthor of 40 journal and newsletter articles, book chapters, and audio and video programs, Ms. Pearson has written about quality improvement intervention in diabetes care, primary care and diabetes self-management, and identifying individuals at risk for developing type 2 diabetes. Her article, “Getting the Most From Health Care

Visits,” was selected as one of the Best of Diabetes Self-Management in 2002.

Additionally, she has delivered presentations to pharmacists, nurses, dietitians, physicians, and diabetes educators nationally and internationally, and serves on several advisory boards and key opinion leader panels.

Ms. Pearson is a member of the American Association of Diabetes Educators, having served as a past First Vice President. Additionally, Ms. Pearson has served the American

Diabetes Association, Professional Section; the European Association for the Study of

Diabetes; and the Minneapolis-St. Paul Diabetes Educators. Since 1979 she has been a member of Sigma Theta Tau–Zeta Chapter (International Honor Society of Nursing).

Among her numerous awards, Ms. Pearson has received special recognition from the

President of HealthPartners for clinical quality improvement work in diabetes care as well as the HealthPartners’ Presidents Award for work in disease management, specifically cardiovascular disease and diabetes. In 2005, Ms. Pearson received a Best Practice

Award for Fairview Diabetes Care from the American Medical Group Association.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Faculty

Theresa Martin Plog, PharmD

Theresa Martin Plog, PharmD, is an Ambulatory Care Clinical Specialist and Antithrombosis

Pharmacist in the Shore Health System of Maryland, and a Clinical Pharmacist at Shore

Health System Memorial Hospital in Easton, Maryland. She is also a Clinical Assistant

Professor at the University of Maryland School of Pharmacy in Baltimore and a Guest

Lecturer (endocrine, respiratory, musculoskeletal) for the Wilmington College Certified

Nurse Practitioner Program in New Castle, Delaware.

Dr. Plog received a Bachelor of Science degree in Pharmacy and a Doctor of Pharmacy degree from the Philadelphia College of Pharmacy and Science in Pennsylvania. She completed training in the Cardiac Anticoagulation Clinic at the Loma Linda VA Medical Center in California, and an ASHP Research and Education Foundation–Type 2 Diabetes Patient

Care Traineeship Program at the Joslin Diabetes Center, and the University of Maryland in

Baltimore. In addition, she is a Certified Smoking Cessation Specialist (University of

Pittsburgh School of Pharmacy) and has received certification for Basic Life Support and Advanced Cardiac Life Support.

Dr. Plog has published journal articles on antibiotic-associated seizures and on patient outcomes at a pharmacist-managed anticoagulation clinic. She has also coauthored a guide for pharmacy-based diabetes screening and education programs.

Dr. Plog participates in grand rounds and gives presentations to nursing and pharmacy staff as well as to diabetes support groups and senior citizen groups on diabetes medications, the role of cholesterol/blood pressure monitoring in diabetic patients, and current therapy for Alzheimer's disease, among other topics. In addition, she has served as a clinical investigator and subinvestigator for several clinical research protocols.

Dr. Plog is a member of the Maryland Society of Health System Pharmacists. She is also a recipient of the Preceptor of the Year Award from the University of Maryland School of Pharmacy and has received a Distinguished Young Pharmacist Award from Pharmacists

Mutual Companies.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

The Current State of Diabetes and Impact of the Aging Process

Teresa L. Pearson, MS, RN, CDE

Regardless of how age is defined, diabetes is an increasingly prevalent condition in the older American. One in 5 Americans 60 years and older has diabetes (equal to slightly more than 10 million patients). Nearly 40% of seniors have pre-diabetes (ie, impaired fasting glucose). Furthermore, the risk for death among people with diabetes is about twice that of people without diabetes of similar age. Clearly, the risk for diabetes-related complications is also greater.

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Corresponding increases in obesity and physical inactivity with aging are contributing to the widespread prevalence of diabetes among older

Americans.

There are unique challenges regarding the diagnosis and treatment of the older population. Due to physiologic changes associated with aging, the elderly patient with diabetes may not present with classic symptoms. In addition, with age, there is an increased prevalence of functional disability and comorbid illness that contributes to the complexity of managing diabetes. Treatment of the older patient with diabetes must take into consideration not only the standard microvascular and macrovascular complications, but also conditions such as cognitive impairment, falls, and impaired function.

Therapeutic interventions can have meaningful outcomes in elderly patients with diabetes.

For example, in over 3 years of study, the Diabetes Prevention Program found that diet and exercise sharply reduced the risk of developing diabetes, especially in patients 60 years and older.

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In patients with diabetes, improving glycemic control by 1% can reduce the risk of developing microvascular complications by 20%-30%.

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The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications

(DCCT/EDIC) study research group showed that intensive therapy for diabetes reduced the risk of cardiovascular events by 42%.

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Benefits were realized as early as 3 years.

Recent studies have shown that good glycemic control improves outcomes for older patients, including increased survival for those on dialysis

6 and decreased hospitalization with exacerbated congestive heart failure.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Treatment goals in the elderly include not only controlling hyperglycemia and avoiding hypoglycemia, but the ability to minimize, delay, and prevent long-term complications.

In addition, special attention should be given to avoiding dehydration with the concomitant risks of hyperosmolar hyperglycemic nonketotic syndrome, or diabetic ketoacidosis.

Furthermore, because of the likelihood of concomitant medical conditions and, therefore, concomitant medications which may affect diabetes control, special attention is warranted for the older patient.

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Diabetes management also includes attention to nutrition and exercise, as well as the potential need for medication. Diabetes is a progressive disease, and beta-cell function also declines with years of disease; therefore, in these cases, the use of insulin should be considered.

In conclusion, diabetes will be increasingly encountered by consultant pharmacists caring for the elderly. An awareness and appreciation of the special considerations in diagnosis and treatment is warranted, as is the knowledge that interventions can result in improved patient outcomes.

References

1. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States,

2005. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.

2. Diabetes Prevention Program. Prevention or delay of type 2 diabetes.

Diabetes Care. 2004;27(suppl 1):S47-S54.

3. UKPDS Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk for complications in patients with type 2 diabetes. Lancet. 1998;352:837-853.

4. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med.

1993;329:977-986.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

5. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med.

2000;342:381-389.

6. Oomichi T, Emoto M, Tabata T, et al. Impact of glycemic control on survival of diabetic patients on chronic regular hemodialysis: a 7-year observational study.

Diabetes Care. 2006;29:1496-1500.

7. Bhatia et al. Association of poor glycemic control with prolonged hospital stay in patients with diabetes admitted with exacerbation of congestive heart failure.

Endocr. Pract. 2004;10:467-471.

8. Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare

Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51(suppl guidelines 5):S265-S280.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Insulin Analogs Added to Oral Antidiabetic

Therapy for Older Patients

Theresa Martin Plog, PharmD

Pathophysiology of Diabetes: Progression Over Time

Diabetes is a progressive disease characterized by insulin resistance and increasing insulin deficiency over time. Beta-cell deterioration in type 2 diabetes occurs progressively as well; eventually, the pancreas cannot synthesize and secrete sufficient insulin to meet the demands of insulin-resistant patients. Although insulin secretion can be boosted with secretagogues, and the action of endogenous insulin can be enhanced with sensitizers, pancreatic beta-cell failure still occurs over time.

Rationale for Insulin Therapy in Older Patients

It is not surprising that patients seen by consultant pharmacists are those who are likely to have had diabetes for many years and who have greatly diminished beta-cell function.

This may make them less likely to respond to oral therapy or to achieve glycemic targets with oral therapy alone. The majority of patients with type 2 diabetes will eventually require insulin.

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Insulin is used in patients with type 2 diabetes who are not at A1C goal

(those on 2 to 3 oral agents at maximum doses) or in patients unable to tolerate oral medications (due to side effects or drug interactions). Basal or premixed insulin can be added to oral agents, or basal-bolus therapy can be used alone.

Needs for Replacement Insulin: Rationale for Insulin Analogs

The premise of insulin therapy is to mimic the body’s natural insulin production cycle.

Patients need a basal insulin to cover background insulin requirements plus bolus insulin to cover meals and fluctuations.

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There are several types of insulin products that can be used to achieve this. Insulin products are divided into rapid, short, intermediate, and long-acting (each type has different onset, peak, and duration). Insulin analogs are largely replacing older human insulin products. The advantages and rationale for insulin analogs in elderly patients include a lower risk of hypoglycemia and thus the ability to titrate to achieve A1C goals more closely. Better A1C results may delay disease progression and comorbidity development, which may be especially important in the elderly whose organ function is already declining with age. The improved pharmacokinetic profiles of insulin

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

analogs more closely mimic physiologic function. This allows more convenient administration and greater flexibility with meals since the elderly often have declining appetites or skip meals. Insulin analogs also offer the advantages of being better tolerated and causing less weight gain than traditional human insulins. Finally, they are available in convenient administration devices, such as insulin pens, which can deliver reproducible doses with less pain.

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Choosing an Insulin Regimen for Older Patients

What insulin regimens are appropriate for older patients? There are many treatment strategies that can be considered.

Basal Therapy (+ Oral Agents)

Basal therapy consists of a single injection of a long-acting insulin like glargine or detemir that provides simple coverage of basal insulin requirements.

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However, it does not provide mealtime (prandial) coverage and may require addition of bolus doses of a rapidacting analog such as aspart, lispro, or glulisine.

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Insulin detemir is the most recent addition to longer-acting insulin analogs and may have the advantage of less weight gain than other basal insulins.

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Basal therapy may be appropriate for elderly patients who do not have advanced diabetes (ie, limited beta-cell function) or do not have significant postprandial hyperglycemia.

Premixed Insulin Analogs (+ Oral Agents)

Another simple starting regimen is to use a premixed insulin analog, such as insulin aspart

70/30 or insulin lispro 75/25.

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Premixed insulin analogs provide basal and prandial coverage in one injection.1

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This strategy may be started with a single daily dose given at one meal and increased up to 3 injections per day if needed.

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With this approach, a fairly regular meal pattern is recommended. This strategy is appropriate for elderly patients with elevations in both fasting plasma glucose (FPG) and postprandial glucose

(PPG) who desire a simple regimen. In all cases, family member assistance and education must also be included regarding symptoms of hypoglycemia and injection techniques.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Basal-Bolus Therapy (Multiple Daily Injections)

Finally, there is basal-bolus therapy (or multiple daily injections, MDI), as a way to progress from a single basal injection.

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Basal-bolus therapy offers flexibility in meal patterns (including number, timing, and content of meals) as well as more flexibility in activity patterns, including more opportunity for sporadic exercise. Long-acting insulin is used to cover basal insulin requirements, and rapid-acting insulin is used to cover mealtime carbohydrates.

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However, this method requires that patients (or care providers) clearly understand advanced carbohydrate counting. This strategy may be appropriate in the following elderly patients: the

“well-ederly” (those who are very physically active, who travel, and can make appropriate dose adjustments themselves), and also suitable for patients under supervision (eg, nursing home) where food intake, blood glucose (BG) results, and injection times are supervised by health care providers. Other reasons for using basal-bolus therapy in hospitals and nursing homes include meal delivery times, which do not always correlate with scheduled medication administration times. Also, patients may be “nothing by mouth” (NPO) for procedures where there is then a need to hold doses/injections.

Choosing the Right Regimen

For elderly patients with type 2 diabetes, consultant pharmacists should conduct a thorough assessment of charts, nurses and dietician notes, or assess patient home BG monitoring logbooks. Review recent laboratory results against the current regimen and ask yourself, “Are they at the maximum dose of their oral medications?”, “Are there contraindications or significant comorbidities to any diabetes medications or to insulin?”, and “Have they been getting

A1C levels at appropriate intervals, or do we need more labs before deciding on regimen?”

Pharmacists should be able to identify and interpret glycemic patterns (correlate BG values with time of day, identify eating patterns, missed meals, and identify lack of participation in group exercise or activities) and offer recommendations on how to adjust therapy to achieve the best response possible for the patient. Dose adjustments may be required if the patient is taking certain medications that affect carbohydrate metabolism or responses to insulin.

Liver or renal disease can also affect the pharmacokinetics of insulin. Exercise, illness, stress, aberrant eating patterns, alcohol, and travel may also necessitate dose adjustments.

Regardless of which insulin regimen is chosen, insulin remains one of our most powerful tools with which to achieve glycemic control in elderly patients. Appropriate titration and dose adjustment can improve glycemic control and patient outcome.

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Patients with Type 2 Diabetes: A Case-based Approach

References

1. Wright A, Burden AC, Paisey RB, et al. Sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the U.K.

Prospective Diabetes Study (UKPDS 57). Diabetes Care. 2002;25:330-336.

2. Polonsky KS, Given BD, Hirsch LJ, et al. Abnormal patterns of insulin secretion in non-insulin-dependent diabetes mellitus. N Engl J Med. 1988;318:1231-1239.

3. Hirsch IB. Insulin analogues. N Engl J Med. 2005;352:174-183.

4. Stoneking K. Initiating basal insulin therapy in patients with type 2 diabetes mellitus. Am J Health Syst Pharm. 2005;62:510-518.

5. Riddle MC, Rosenstock J, Gerich JE; Insulin Glargine 4002 Study Investigators.

The treat-to-target trial randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26:3080–3086.

6. Karl DM. The use of bolus insulin and advancing insulin therapy in type 2 diabetes. Curr Diab Rep. 2004;4:352-357.

7. Soran H, Younis N. Insulin detemir: a new basal insulin analogue. Diabetes Obes

Metab.

2006;8:26-30.

8. Raskin P, Allen E, Hollander P; INITIATE Study Group. Initiating insulin therapy in type 2 diabetes: a comparison of biphasic and basal insulin analogs.

Diabetes Care. 2005;28:260-265.

9. Garber AJ, Wahlen J, Wahl T, et al. .Attainment of glycaemic goals in type 2 diabetes with once-, twice-, or thrice-daily dosing with biphasic insulin aspart

70/30 (The 1-2-3 study). Diabetes Obes Metab. 2006;8:58-66.

10. Rolla AR, Rakel RE. Practical approaches to insulin therapy for type 2 diabetes mellitus with premixed insulin analogues. Clin Ther. 2005;27:1113-1125.

11. Garber AJ. Premixed insulin analogues for the treatment of diabetes mellitus.

Drugs. 2006;66:31-49.

12. Monnier L, Colette C. Addition of rapid-acting insulin to basal insulin therapy in type 2 diabetes: indications and modalities. Diabetes Metab. 2006;32:7-13.

13. Raslova K, Bogoev M, Raz I, et al. Insulin detemir and insulin aspart: a promising basal-bolus regimen for type 2 diabetes. Diabetes Res Clin Pract.

2004;66:193-201.

14. Davidson JA. Treatment of the patient with diabetes: importance of maintaining

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Counseling the Elderly and Strategies for Improving

Adherence, Safety, and Health Literacy

Jerry Meece, RPh, FACA, CDM, CDE

A growing body of evidence suggests that patients with chronic diseases, such as diabetes, who are engaged and active participants in their health care have better health outcomes. However, a recent study showed that a majority of patients with diabetes polled did not know their last A1C level, while only a quarter accurately reported that value.

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Health literacy measures a patient’s ability to read, comprehend, and act on medical instructions. Poor health literacy is common among elderly persons and patients with chronic conditions. Among primary care patients with type 2 diabetes, inadequate health literacy has been shown to be independently associated with worse glycemic control and higher rates of retinopathy.

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Communication skills in discussing treatment regimens are important for all patients, but there are specific nuances when it comes to the elderly. Communication can be hindered by the normal aging process, which may involve sensory loss, decline in memory, slower processing of information, lessening of power and influence over their own lives, and separation from family and friends.

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Some simple recommendations include allowing extra time for older patients and avoiding visual and auditory distractions such as other people and background noise. Verbal behaviors that are positively associated with health outcomes in patients with diabetes include empathy, reassurance and support, various patient-centered questioning techniques, encounter length, history taking, explanations, positive reinforcement, humor, friendliness, courtesy, and summarization and clarification.

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Simplifying information and speaking in a manner that can be easily understood is one of the best ways to ensure that your patients will follow your instructions. Speak clearly and loudly enough for your patients to hear you, but do not shout.

Avoid medical jargon or technical terms that are difficult for the layperson to understand.

Repeating statements and summarizing frequently is also helpful.

Writing is a more permanent form of communication than speaking and provides the opportunity for the patient to later review what you have said in a less stressful environment.

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Providing graphical information to patients about their A1C and other laboratory values has been found to improve glycemic control and other diabetes outcomes.

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Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

Nonverbal behaviors are also important in communication. Nonverbal behaviors positively associated with outcomes include head nodding, leaning forward, and uncrossed legs and arms.

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Other suggestions are to sit face-to-face and to maintain eye contact while providing health information. Some older patients have vision and hearing loss, and reading your lips may be crucial for them to receive the information correctly.

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Finally, counseling elderly patients with diabetes requires an assessment of the individual patient regarding their level of skills, abilities, understanding, and willingness to participate in their health care.

References

1. Heisler M, Piette JD, Spencer M, et al. The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management.

Diabetes Care. 2005;28:816-822.

2. Heisler M, Smith DM, Hayward RA, et al. How well do patients' assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services? Diabetes Care. 2003;26:738-743.

3. Robinson TE, White GL, Houchins C. Improving communication with older patients: tips from the literature. Fam Pract Manag. 2006;13:73-78.

Available at: http://www.aafp.org/fpm/20060900/73impr.html#refs. Accessed

September 29, 2006.

4. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educ. 2000;26:597-604.

5. Cagliero E, Levina EV, Nathan DM. Immediate feedback of HbA1c levels improves glycemic control in type 1 and insulin-treated type 2 diabetic patients.

Diabetes Care. 1999;22:1785-1789.

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Case Studies

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Suggested Readings

Ashkenazy R, Abrahamson MJ. Medicare coverage for patients with diabetes.

A national plan with individual consequences. J Gen Intern Med. 2006;21:386-392.

Aubry W. Reimbursement and coverage implications for CGM.

Diabetes Technol Ther. 2005;7:797-800.

Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716-724.

Campbell RK. Role of the pharmacist in diabetes management.

Am J Health Syst Pharm. 2002;59(suppl 9):S18-S21.

Choe HM, Mitrovich S, Dubay D, et al. Proactive case management of high-risk patients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005;11:253-260.

Doucet J. Use of antidiabetic drugs in elderly patients. Diabetes Metab.

2005;31(spec no 2):5S98-5S104.

Garg SK. New insulin analogues. Diabetes Technol Ther. 2005;7:813-817.

Kuo S, Fleming BB, Gittings NS, et al. Trends in care practices and outcomes among Medicare beneficiaries with diabetes. Am J Prev Med. 2005;29:396-403.

McCord AD. Clinical impact of a pharmacist-managed diabetes mellitus drug therapy management service. Pharmacotherapy. 2006;26:248-253.

Merin M. New Medicare benefits for people with diabetes. The new year brings new Medicare benefits and services for people with diabetes. Diabetes Forecast.

2005;58:77.

Meyer BM. A first step... toward full Medicare recognition of pharmacists as providers. Am J Health Syst Pharm. 2004;61:991.

Miller CD, Barnes CS, Phillips LS, et al. Rapid A1c availability improves clinical decision-making in an urban primary care clinic. Diabetes Care.

2003;26:1158-1163.

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Patients with Type 2 Diabetes: A Case-based Approach

Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycaemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy.

A consensus statement from the American Diabetes Association and the European

Association for the Study of Diabetes. Diabetes Care. 2006;29:1963-1972.

Shetty S, Secnik K, Oglesby AK. Relationship of glycemic control to total diabetes-related costs for managed care health plan members with type 2 diabetes. J Manag Care Pharm. 2005;11:559-564.

Strum MW, Hopkins R, West DS, et al. Effects of a medication assistance program on health outcomes in patients with type 2 diabetes mellitus. Am J Health Syst

Pharm. 2005;62:1048-1052.

Zarowitz BJ, Tangalos EG, Hollenack K, et al. The application of evidence-based principles of care in older persons (issue 3): management of diabetes mellitus.

J Am Med Dir Assoc. 2006;7:234-240.

65

Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

ACPE #203-999-06-081-H01 • Release Date: November 18, 2006 • Credit Expiration Date: February 1, 2008

CPE/CE Post-Test

Please complete the post-test and evaluation online by clicking here. Please use the printed forms if you do not have an internet connection.

If you do not have internet access:

To receive credit, please print or type the required information below, complete the following post-test and evaluation, remove the form and mail it in an envelope to: Medical Communications Media, 2288 Second Street Pike,

Wrightstown, PA 18940. A CPE/CE statement of credit will be awarded for a score of 70% or better and will be mailed within 4-6 weeks. There is no charge for CPE/CE credit.

Please check which type of credit you are applying for: r

Pharmacist CPE r

Nursing CE

Name__________________________________________________________________________________________ Degree/title__________________________

(last) (first) (middle)

Specialty __________________________________ Hospital or Practice Name __________________________________________________________________

Address ____________________________________________________________________________________________________________________________

City ______________________________________________________________________________________ State ______ Zip ________________________

Phone ______________________________ FAX______________________________________ E-mail ____________________________________________

Circle your selected answer.

1. Which of the following is not true about elderly patients and diabetes?

A.

Diabetes is common in patients over 65 years of age

B.

Obesity plays a central role in the etiology and pathogenesis of type 2 diabetes

C.

Diagnosis is more difficult because classic symptoms may be absent or may be attributed to the aging process

D.

Glucose control in older patients with longstanding diabetes is not that important

2. The Diabetes Prevention Project showed all of the following except:

A.

Lifestyle interventions decreased the development of diabetes by >50%

B.

Metformin decreased the development of diabetes by >30% and worked particularly well in older, more overweight individuals

C.

Lifestyle intervention worked in all groups but worked particularly well in people 60 and older (reducing the development of diabetes by >70%)

3. Which of the following is not true about insulin therapy in patients with diabetes:

A.

Insulin is always indicated in patients with type 1 diabetes

B.

Insulin is often necessary for patients with type 2 diabetes to optimize glycemic control

C.

Insulin can be rapid, fast, intermediate, or long acting

D.

Insulin cannot be used with oral agents

4. Adding insulin to oral agents is more effective at reaching target A1C values than oral agents alone

A.

True

B.

False

5. An elderly patient who is experiencing loss of appetite and skipping meals should NOT take their insulin glargine.

A.

True

B.

False

6. An elderly patient should NOT be on both metformin and insulin at the same time.

A.

True

B.

False

7. Insulin analogs may be preferred to regular insulin in elderly patients with diabetes for all of the following reasons EXCEPT:

A.

Their more physiologic profiles decrease the risk of hypoglycemia as compared to human insulin

B.

Associated with increased weight gain, which can be beneficial for thin, elderly patients

C.

Can be given at mealtimes rather than 30 minutes prior to meals

D.

Accurate dosing devices available, which take into account dexterity and visual acuity

8. The main reason patients do not tell their physicians that they stopped taking their medication was they:

A.

Didn’t think it was important

B.

Didn’t think he cared

C.

Were never asked

D.

Didn’t have enough time

9. 50% of all patients on long term regimens fail to follow directions.

A.

True

B.

False

10. Prevention of hypoglycemia in the elderly requires all of the following except:

A.

Reinforced education for the patient and caregiver

B.

Knowledge of signs of hypoglycemia and appropriate treatment

C.

Self-monitoring of blood glucose by the patient when possible, or by a familial or medical caregiver, should be encouraged

D.

Discontinuation of insulin therapy if the patient becomes hospitalized

66

07 NN DIAB POD

Why, When, and How to Initiate Insulin Therapy in Elderly

Patients with Type 2 Diabetes: A Case-based Approach

ACPE #203-999-06-081-H01 • Release Date: November 18, 2006 • Credit Expiration Date: February 1, 2008

Post-Program Evaluation

I am a:

r Pharmacist r Nurse r Other

Indicate your answer by circling the appropriate number.

STRONGLY AGREE STRONGLY DISAGREE

1.

As a result of my participation in this activity, I am better able to:

Identify elderly patients with type 2 diabetes who are not meeting established treatment goals for glycosylated hemoglobin (A1C), postprandial glucose (PPG) targets, and fasting plasma glucose (FPG) targets.

Describe how to transition elderly patients with type 2 diabetes who are not meeting treatment goals to more intensive and effective therapeutic regimens to attain and maintain A1C, PPG, and FPG targets.

Differentiate the benefits and risks of regular insulin mixes, premixed insulin analogs, and basal-bolus insulin treatment strategies for elderly patients.

4

4

4

3

3

3

2

2

2

1

1

1

2.

3.

This activity increased my awareness and understanding of the subject matter.

The program was clear and well organized.

4

4

4.

The program was objective, scientifically balanced, and free of commercial bias.

4

5.

The speakers were prepared, clear, and well organized.

4

3

3

3

3

2

2

2

2

1

1

1

1

6.

About which clinical problems related to the therapeutic area covered in this activity would you or your colleagues like to learn more?

7.

Additional comments or suggestions:

67

07 NN DIAB POD

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