by Timothy L. Gieseke, MD, CMD

Through my work with the Endocrinology Department in Tirana, Albania, I have developed an interest and expertise in the care of persons with Type 2 Diabetes.  However, this is a rapidly changing field, so I attended the online Webinar from AMDA on 3/7/18 with great interest. Dr. Naushira Pandya is a former President of AMDA and a recognized expert on this subject in the PA/LTC setting.  She was a part of the latest ADA update on diabetes care in our setting, January 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5317234/

I’ll share a few pearls below, but encourage you or your facility to listen to the power point presentation.  It’s available at:  https://paltc.digitellinc.com/amda/sessions/7627/view .  It’s free for AMDA members, but $99 for non-members.  Here are some pearls:

1.     Some of the variability we see in finger-stick glucose measurements is likely due to errors administering insulin by syringe or pen, wrong size needles, wrong angle of injection, & failure to rotate site or injecting into lipodystrophy or atrophy sites.  She has 3 slides with detailed recommendations for reducing these errors. For facility training the FIT UK Forum for Injection Technique UK, is quite helpful. It’s available at  http://www.fit4diabetes.com/files/4514/7946/3482/FIT_UK_Recommendations_4th_Edition.pdf

2.     Sliding Scale Insulin (SSI) without basal insulin coverage is high-risk for poor glycemic control with increased risk for serious hypoglycemic episodes.  Facilities are starting to be cited for this substandard practice. However, basal insulin + SSI without meal rapid acting insulin is permissible since there is no evidence yet for increased risk of hypoglycemia.

3.     Once a person with Type 2 IDDM is stable with finger-stick Glucose in desired target range, the frequency of finger-stick Glucose measurements can be reduced as long as the patient remains medically stable.  This can be safely done by “block testing”. For instance, FS Glucose test a.c. tid + h.s. could be reduced to a.c. breakfast and dinner q M,W,F, Su and a.c. Lunch and bedtime q Tu, Th, Sa. Alternatively, FS Glucose could be measured once a day advancing to the next a.c time or h.s the following day so that each time would be checked twice every 8 days.

4.     Finally, use of injectable incretin receptor agonists (Exenatide - Bydureon, Dulaglutide – Trulicity, Liraglutide – Victoza) may be a desirable intervention after Metformin rather than insulin because of lower risk of hypoglycemia, weight loss potential (rather than gain), and reduction in mortality and macrovascular disease risk (Victoza, NEJM 2016).  The 2018 AACE Guidelines recommend considering incretin receptor agonists and SGL2's after Metformin. See executive summary at: https://www.aace.com/sites/all/files/diabetes-algorithm-executive-summary.pdf

Since diabetes is so prevalent in our facilities and since there are so many advances to be aware of, I highly commend this webinar for your facility.