Diabetes: Risk for Cardio-Pulmonary Disease

By Ryan Squire

Naushira Pandya, MD, CMD
Naushira Pandya, MD, CMD

Prof and Chair, Dept of Geriatrics
Nova Southeastern College of Medicine

Dr. Pandya outlined identified the objectives of her talk to review the goals of glycemic control: One size does not fit all, review the current guidelines from several national organizations for cardiovascular risk, and review best practices for diabetes management.

Diabetes is a head to toe disease: Retinal disease, stroke, nephropathy, neuropathy, large and small vessel disease of the extremities and  this emphasizes the range of diabetes impact.

There are many potential barriers to improved management of diabetes: Institutional challenges, staff/practitioner resistance, and complexity of medication regimens and all may negatively impact diabetic control. Yet, there are several basic principles that apply to diabetes management, and must involve an inter professional clinical team:

  • Set a target for glucose control
  • Control pain
  • Maintain nutrition
  • Reduce cardiovascular risks

Maintaining functional status is the over arching goal of all interventions applicable to diabetes management.

A useful way to remember the key concerns in diabetes is the ABCDEFG +S of diabetic care:

  1. A1c : Risk of first cardiovascular event goes up with elevation in HgbA1c.  A goal of 7-8% may be appropriate  if life expectancy under 5 yrs; each 1% rise equates to increase of 35mg/dL in avg. blood glucose. Important to note that A1c may be around .4% higher in blacks, for same levels of glucose.
  2. BP 130/80
  3. Cholesterol: LDL<100 or <70 if evident CV disease;  HDL>40, TG<150
  4. Depression
  5. Eyes: Retinopathy, glaucoma, cataracts
  6. Foot care
  7. Geriatric specific concerns: Geriatric syndromes: dementia, depression, foot ulcers,  polypharmacy are more common in diabetics
  8. Smoking cessation

Dr. Pandya also commented that nutritional concerns still apply to all diabetics, but strict dietary restrictions in the elderly are not recommended.  The American Diabetes Association does not endorse a specific  "diabetic diet". Studies have shown that a "no concentrated sweets" diet doesn't improve control of blood sugar.

Dr. Pandya said the most important concept in glycemic control is to fix the fasting first (FFF) and then the post-prandial level: the basal-bolus concept.

Types of insulin currently used:

  1. Basal insulins: NPH,  glargine, detemir: account for about 50% of daily needs
  2. Prandial (bolus) insulin: regular, lispro, aspart:  account for 10-20% of daily need per meal
  3. Combinations of the above

Major principles of insulin dosing that Dr. Pandya shared:

  1. A correction dose preferred over sliding scale: the sliding scale is reactive to excessive levels of glucose and allows for excessive glucose excursions
  2. Adjust basal insulin primarily based on fasting glucose; adjust prandial insulins based on post-meal readings
  3. Glycemic control in the hospital, long-term acute care hospital, or rehabilitation unit: target a pre meal glucose<140 and random glucose <180

Dr. Pandya concluded with these points regarding treatment of the spectrum of diabetes:

  1. Very intensive therapy does not make sense in the elderly,  It is more important to avoid risk of hypoglycemia; the elderly are  less likely to realize benefits of tight control, given shorter time horizon There is no apparent cardiovascular benefit of lowering A1c from 8.4 to 6.9%.
  2. In diabetic kidney disease: ACE-I and ARB equally effective and provide greatest protection.
  3. Younger diabetics and women are more likely to have atypical symptoms of coronary artery disease.
  4. Hypoglycemia is a very expensive event.  It is more likely to be seen with older age. To treat hypoglycemia, recall the Rule of 15's:  give 15g of glucose: e.g. 1/2 cup juice, wait 15 min, recheck and repeat 15g glucose dose if levels are still low.
  5. How often should blood glucose be checked?  Twice per day, Two-to-three times per week if on oral agents or no treatment. More frequent checks are critical in complex insulin regimens and glycemic trends more important than individual levels.
  6. Do not forget to check the feet and mouth: oral inflammation may worsen glycemic control, and foot infections may lead to severe morbidity.

Contributions from Paul McKinney, MD