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Drug-Induced Hyperglycemia  Risk Factors  Presentation  Causative Agents Mallory Linck, Pharm.D

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Drug-Induced Hyperglycemia  Risk Factors  Presentation  Causative Agents Mallory Linck, Pharm.D 9/29/12 Outline Drug-Induced Hyperglycemia Risk Factors Presentation Causative Agents Mallory Linck, Pharm.D. Mechanisms Pharmacy Practice Resident Prevention University of Arkansas for Medical Sciences Management Risk Factors Presentation of Drug-Induced Hyperglycemia Mild-to-Moderate Severe disease General Diabetes risk factors, plus: Blurred vision Abdominal Pain, N/V Pre-existing or underlying Diabetes Excessive thirst Coma Higher doses of thiazides or corticosteroids Fatigue/weakness Dehydration Use of more than one drug that can induce Polydipsia Hypokalemia hyperglycemia Polyphagia Hypotension Polypharmacy Polyuria Kussmaul respiration and Unexplained weight loss fruity breath Increased Blood Glucose Lethargy Metabolic acidosis Causative Agents Mechanisms Atypical antipsychotics Nicotinic acid B-blockers Oral contraceptives Cyclosporine Pentamidine Diazoxide Phenothiazines Thiazide Diuretics Phenytoin Fish oil Protease inhibitors Glucocorticoids Rifampin Growth Hormone Ritodrine Interferons Tacrolimus Megesterol Terbutaline Thalidomide 1 9/29/12 Thiazide Diuretics High doses Hypokalemia “Each 0.5mEq/L decrease in serum potassium was associated with a 45% higher risk of new diabetes” DECREASE INSULIN SECRETION Plan: Use smaller doses (12.5-25mg/day HCTZ) and replace potassium Shafi T. Hypertension. 2009 Feb;53(2):e19. Immunosuppressants Overall incidence 4-46% Pre-disposing factors Genetics Metabolic syndrome Increasing age Most common in the first few months post- transplant Immunosuppressants Immunosuppressants Immunosuppressive Incidence of Diabetes Agent Tacrolimus +++++ Sirolimus ++++ Cyclosporine +++ Azathioprine -- Mycophenolate -- Kasiske BL. American Journal of Transplantation Woodward RS. Value Health. 2011 Jun;14(4): 2003; 3: 178--185 443-9 2 9/29/12 Antipsychotics Beta Blockers Especially non-selective for B1-subtype Propranolol Nadolol ARIC Study Psychiatric Times, MAY 20, 2011 ARIC Study ARIC Study METHODS: Prospective study with 12,550 patients Hypertension, with no diabetes ENDPOINTS: New onset diabetes after three and five years Gress TW. N Engl J Med. 2000 Mar 30;342(13): 905-12 Gress TW. N Engl J Med. 2000 Mar 30;342(13): 905-12 Mechanisms CAUSE INSULIN RESISTANCE 3 9/29/12 Glucocorticoids Oral Contraceptives Agents Hyperglycemic effect Older Agents +++++ Newer Agents +++ Bi- and Tri-phasic + CARDIA trial Gurwitz JHArch Intern Med. 1994 Jan 10;154(1): Kim C. Diabetes Care 25:1027–1032, 2002 97-101. Protease Inhibitors INCREASE HEPATIC GLUCOSE PRODUCTION Noor MA. AIDS. 2006;20(14):1813. AIDS. 1998 Oct 22;12(15):F167-73. Mechanisms Nicotinic acid Niacin ER 2000 mg lead to 5% increase in serum glucose Guyton JR. Am J Cardiol. 1998 Sep 15;82(6):737-43. Baseline Week 16 % HbA1c HbA1c Change Placebo 7.13% (0.12%) 7.1% (0.13%) -0.02% 1000 mg 7.23% (0.14%) 7.4% (0.19%) +0.07% 1500 mg 7.21% (0.11%) 7.5% (0.14%) +0.29% Grundy SM. Arch Intern Med. 2002;162:1568-1576 4 9/29/12 Nicotinic Acid HMG-CoA Reductase Inhibitors Chang AM. J Clin Endocrinol Metab, September Sattar N. Lancet. 2010;375(9716):735 2006, 91(9):3303–3309 Prevention Identify high-risk patients Monitor blood glucose levels Use lowest effective dose for shortest possible duration Alter therapy when necessary and possible PREVENTION OF DRUG- INDUCED DIABETES Management Reduce risk factors Replace causative agent whenever possible Administer anti-diabetic agents if Diabetes develops MANAGEMENT OF DRUG- INDUCED DIABETES 5 9/29/12 Mechanisms QUESTIONS? Outline Patient Education in Diabetes Disease state management Treatment goals Lindsay Coleman, Pharm.D. Lifestyle recommendations Pharmacy Practice Resident University of Arkansas for Medical Sciences Complications Medications Diabetes Overview ADA Position Statement Chronic disease of glucose metabolism At least one in every twelve people has “Diabetes self-management education is a diabetes critical element of care for all people with diabetes and is necessary in order to improve Self-managed and controllable: patient outcomes.” Proper meal planning Exercise Medication, if needed National Diabetes Information Clearinghouse. National Diabetes Statistics 2011. http:// American Diabetes Association: Diabetes Care 2012. http://professional.diabetes.org/. diabetes.niddk.nih.gov/dm/pubs/statistics/. Accessed August 2012 Accessed August 2012 6 9/29/12 Patient Self Management General Treatment Goals Diet Eliminate symptoms Exercise Avoid hypoglycemia Weight Loss Achieve/maintain ideal body weight Medications Normalize growth and development Life Style Changes Prevent long-term complications Blood Glucose Monitoring Obtain glycemic goals Education!! American Diabetes Association: Diabetes Care 2012. http://professional.diabetes.org/. Accessed August 2012 Glycemic Goals of Therapy Recommended Glycemic Goals More intensive: In frail, older adults: Expected shorter American Geriatrics Goal ADA AACE duration of diabetes Society A1C < 8% A1c% < 7% < 6.5% Long life expectancy Veterans Affairs and Premeal Plasma glucose Less intensive Department of Defense (mg/dL) 70-130 < 110 A1C 8-9% Greater risk of Post-prandial plasma glucose American Diabetes hypoglycemia (mg/dL) <180 <140 Association “less Longer duration of stringent glycemic diabetes goals” Shorter life expectancy Nathan DM, et al. Diabetes Care. 2006;29:1963-72. American Association of Clinical Brown AF et al. J Am GeriatrSoc. 2003;51(Suppl):S265-S280. American Diabetes Association. Endocrinologists. EndocrPract. 2007;13 (suppl1):3-68. Diabetes Care. 2007;30(suppl 1):S4-S41. A1c% Correlation A1c% and Average Blood Glucose 6.0% = 126 mg/dL 10.0% = 240 mg/dL 7.0% = 154 mg/dL 11.0% = 269 mg/dL 8.0% = 183 mg/dL 12.0% = 298 mg/dL 9.0% = 212 mg/dL Nathan DM et al. Diabetes Care. 2006;29:1963-72. 7 9/29/12 Hypoglycemia Treatment: 15 grams of carbohydrates 4 oz (1/2 cup) of juice or regular soda 2 tablespoons of raisins 4 or 5 saltine crackers 4 teaspoons of sugar 1 tablespoon of honey or corn syrup Glucose tablets American Diabetes Association: Diabetes Basics. http://www.diabetes.org/diabetes-basics/. Accessed August 2012 Severe Hyperglycemia Self-Monitoring Blood Glucose Similar Symptoms, Plus: Three or more times daily for Nausea patients using multiple insulin injections Stomach cramps Before breakfast, lunch, and Fruity breath dinner Ketones in urine Before bedtime Weight loss Useful guide to therapy Different site options for Heavy breathing different devices Unconsciousness American Diabetes Association: Diabetes Basics. http://www.diabetes.org/diabetes-basics/. American Diabetes Association: Diabetes Care 2012. http://professional.diabetes.org/. Accessed August 2012 Accessed August 2012 Healthy Eating General Guidelines: Eat at least 3 meals per day LIFESTYLE MANAGEMENT Avoid sweets Limit milk to one 8 oz. serving at a time TECHNIQUES Limit fruit juice Watch fats Make at least half of grains whole grains Fill ½ plate with non-starchy vegetables at each meal American Diabetes Association: Diabetes Basics. http://www.diabetes.org/diabetes-basics/. Accessed August 2012 8 9/29/12 The Plate Method Carb Counting 1 serving = 15 grams of carbohydrates 45-60 grams per meal 15 grams per snack Serving size! Always include protein and fat to balance out meals American Diabetes Association: Diabetes Basics. http://www.diabetes.org/diabetes-basics/. Accessed August 2012 Serving Size Medical Nutrition Therapy 1 Serving or 15 grams of Carbohydrates: 4 kcal/gram, 60-70% of daily Carbohydrates: calories 1 slice of bread Sugars, starch, fiber 4-6 small crackers Proteins: 4 kcal/gram, 15-20% of daily calories 1 cup of low-fat milk Recommended 1g/kg for adults, 1.2g/kg for kids 1/4 large baked potato Fat: 9 kcal/gram, 10-20% of daily calories 1 small piece of fruit Recommendations: 1/3 cup pasta or rice Saturated fat < 10% (cooked) Cholesterol < 300mg 1 tablespoon honey Trans minimal ADA. Standards of Medical Care in Diabetes. Diabetes Care 2012;35(S1):S11-S63 Limit Alcohol Intake Physical Activity Hypoglycemia shortly after drinking and for up to Recommended: 8-12 hours Daily light activity through normal routine Too much alcohol vs. hypoglycemia: similar 30 minutes of moderate activity, 5 days per symptoms week Limited amount and with food OR, 25 minutes of vigorous activity, 3 days per week Women < 1 drink/day; Men < 2 drinks/day Strength and endurance 3 times weekly Check blood glucose before drinking and before going to bed American Diabetes Association: Diabetes Basics. http://www.diabetes.org/diabetes-basics/. American Diabetes Association: Diabetes Basics. http://www.diabetes.org/diabetes-basics/. Accessed August 2012 Accessed August 2012 9 9/29/12 Physical Activity Physical Activity Check blood glucose before activity Chair exercises If < 100, may need carbohydrate snack Patients with limited mobility due to weight issues and/or comorbidities If extremely high, postpone activity If working out for > 30 minutes, check again halfway through Always have a fast-acting carbohydrate snack on hand Sick Day Plan Check blood glucose every 2-4 hours Eat same amount of carbohydrates as usual, or drink fluids with carbohydrates COMPLICATIONS Do NOT skip insulin! Take oral hypoglycemic medications as usual If glucose > 250 mg/dL, drink sugar-free liquids; may need extra regular insulin American Diabetes Association: Diabetes Care 2012. http://professional.diabetes.org/. Accessed August 2012
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