Section 13 – Management of Diabetes in Pregnancy
These are the updated guidelines from the 2017 ADA Standards of Care, Section 13 page S115.

Insulin treatment of Choice – insulin was emphasized as the treatment of choice in pregnancy based on the concerns about the concentration of metformin on the fetal side of the placenta and glyburide levels in cord blood.

Glucose testing and goals – based on evidence, more emphasis will be placed on post-prandial targets and less on pre-prandial values.

To simplify, fasting and postprandial targets are now the same for pregnant women with pre-existing diabetes and gestational diabetes.

Pregnancy and Blood Pressure Goals – for pregnant patients with diabetes and chronic hypertension, the new blood pressure target is 120-160/80-105 mmHg. This target is to optimize maternal health without causing fetal harm. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin.

 

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Diabetes Educators often ask for guidelines to manage BG Levels while patients are on parenteral or tube feedings. Here is a handy little chart that I was published in the 2017 Standards of Care, in section 14, Diabetes Care in the Hospital (page s124).  I think if offers some sound, practical guidelines that we can share with our hospital colleagues.

 

 

 

 

 

 

 

 

 

 

 

 

 

From ADA Standards of Care 2017 – Page S12

The rate of progression is dependent on the age at first detection of antibody, number of antibodies, antibody specificity, and antibody titer.
Glucose and A1C levels rise well before the clinical onset of diabetes, making diagnosis feasible well before the onset of DKA.
Three distinct stages of type 1 diabetes can be identified (Table 2.1) and serve as a framework for future research and regulatory decision making (4,5).

iHealth Gluco Pro – A Real-Life Tool for CDCESs^®

iHealth Gluco Pro is a diabetes management application and clinical practice tool that helps Certified Diabetes Care and Education Specialists, (CDCESs®) maintain a real-connection with their patients between visits. It allows patients with diabetes to share their blood sugar levels, physical activity, nutrition intake, and medication with their educator.

“Now CDCESs^® can help their patients where they need it the most – in the real world. Our patients are using mobile phones more than ever. This iHealth Gluco Pro App is a great way to interact with patients and interject snippets of information and coaching when it means the most to them.”   Chuck Newcombe, MS, RD, CDCES –  Diabetes Expert and consultant with iHealth Labs

Pioneering CDCESs^® Needed – Stipend and Supplies included

Gluco Pro is looking for about 20 pioneering CDCESs^® that would like to evaluate the effectiveness of this innovative app in improving the patient – CDCES^® connection. The goal is to enroll 200 – 300 patients to evaluate the effectiveness of this innovative app.  That means, each CDCES^® would need to enroll 10-15 patients.

There is a stipend for CDCESs^® and a Bluetooth meter with test strips for their patients using only iOS devices. With feedback from patients and CDCESs^®, the Human Factor Study will help determine the effectiveness of the app in real life setting.

Yes, I want to help evaluate Gluco Pro >>

iHealth Gluco Pro Screen and Features

The cost of insulin continues to rise dramatically and steadily, especially in the past few years.

The American Diabetes Association just published the 2017 Standards of Care! Section 8 Reviews the average wholesale price per 1000 units of insulin as listed in the chart below.  Thank you ADA for sharing this incredibly useful and powerful information with the diabetes community.

Treating type 2 diabetes is complicated. Supporting behavior change is the foundation of diabetes self-management. Medications are the next line of defense to prevent diabetes complications and get to the best health possible.

As providers and educators we are compelled be familiar with the wide range of medications that are currently available to treat diabetes. As patient advocates, we also perform a cost/benefit analysis to determine which medication would be the best match, considering cost, side effects and complexity.

There have been flurry of updates on existing medications. And many of the newly approved medications offer the hope of decreasing complexity, by combining 2 of different classes of medication in one shot. Plus, there are now four different concentrated insulins. Read on to learn more >>

Important Medication Updates

Metformin – new GFR renal threshold info approved by FDA.

• If GFR <30, do not use
• If GFR <45, don’t start metformin
• If pt on metformin and GFR falls to 30-45, eval risk vs. benefit and consider decreasing dose.

For dye study, if GFR <60, or with liver disease, alcoholism or heart failure, restart metformin after 48 hrs if renal function stable.

DPP-IV Inhibitors – New Warnings

• This class of med can cause disabling joint pain. Stop med, contact provider.
• Saxagliptin (Onglyza) and alogliptin (Nesina) can increase risk of heart failure. Notify provider if patient experiences shortness of breath, edema.

SGLT-2 Inhibitors – Considerations

• Can increase risk of ketoacidosis
• Empagliflozin (Jardiance) lowers all cause mortality 32%

To keep up with the latest medication updates, download our FREE Medication Pocket Cards

Our body responds to stress by releasing hormones that increase glucose levels to provide muscles with the fuel they need to engage in battle. This system works well if you don’t have diabetes. However, for people living with insulin deficiency and /or resistance, chronic stress can make glycemic control even more challenging. In addition, stress can cause a detour in the best laid plans to eat healthier and exercise more. Hence, the “Double Whammy” of diabetes and stress.

We asked our special guest contributor to share her expertise on stress and provide us with some coping strategies we can pass along to our patients. Thanks Cathy!

How does daily stress impact people?
Most adults experience some level of stress on a daily basis.  Everything from the minor annoyance of a traffic jam to the life-altering commitment of caring for a chronically ill family member can lead to the familiar feelings of uneasiness, muscle tension, difficulty concentrating, changes in sleep and appetite, irritability, headaches, gastrointestinal problems, increased heart rate, trembling, and even feeling faint.  Stress affects the physical functioning of the body as well as common behaviors, making it particularly challenging for people with diabetes.

How does stress increase blood glucose levels?

When faced with a stress or danger, the body initiates an immediate and well-coordinated fight or flight response that allows 
a person to fight the danger or flee it.  Stress hormones, like adrenaline and cortisol, are released causing an elevation in glucose levels. In people without diabetes, this glucose surge is beneficial; it provides energy for muscles to fight off the danger or to outrun it. The system is based on the assumption that the extra glucose will be spent while conquering the dangerous situation, allowing the body to return to a normal (baseline) state. For centuries this system has allowed humans to always be ready to handle threats to their survival.

How have the effects on stress impacted human’s overtime?

It’s rare for modern stressors to require physical fighting or fleeing.  Stressors are more often encountered while sitting still — paying bills, sitting in traffic, working at a desk, or having a difficult conversation. Unfortunately the fight or flight response is so ingrained and automatic that it does not allow for differentiation between stress that requires action and stress that requires other types of responses. If the stressor does not necessitate the use of muscles, glucose levels can climb in the bloodstream stimulating the pancreas to increase insulin release.

What is the impact of stress on people with diabetes?

Stress has a dual effect on diabetes. Life stressors can affect behavior by influencing decision-making abilities (such as snacking on unintended foods or skipping exercise). Plus, stress activates the body’s fight or flight response increasing glucose levels circulating in the blood. Recognition of the double impact of stress on individuals with diabetes highlights the need for effective stress management as an integral part of diabetes management programs. 

What are some tools that Diabetes Educators can share?

Several techniques can be employed to help alleviate stress. Perhaps the most important skill is to learn to identify stressors. Often individuals report feeling weighed down and stressed out.  It can be surprisingly difficult to pinpoint the causes of those feelings.  However, taking some time to discuss them with another person can be helpful in naming the stress-causing demands on their lives.  Once identified, one can work to lessen or eliminate the stress or to increase their ability to manage the stress.

There are numerous effective ways to reduce feelings of stress, making it possible to find a technique that fits into the lifestyle and values of the individual who will be using it. An active, energetic person might find that exercise is a great stress-reducer. Alternatively, a person who values calm and quiet may prefer taking several slow, deep breaths to encourage relaxation.

Several relaxation techniques, such as progressive muscle relaxation (PMR), meditation, journaling and guided imagery, have actually been shown to reduce glucose levels in people with diabetes in addition to reducing feelings of stress.  There are many books and internet resources available that can provide more detail or instruction on these techniques.  In some cases, individuals find it helpful to enlist the help of a therapist who is trained in ways to help reduce stress and change thought patterns.

While no one likes the feeling of stress, it’s clear that it is especially detrimental to those with diabetes.  Featuring stress management in diabetes management programs can bring about positive changes psychologically as well as physically.

Special thanks to our guest contributor, Cathy A. Bykowski, from Tampa, Florida. Her research and clinical interests revolve around the relationship between mental and physical health, and in particular, how psychological factors affect diabetes outcomes. She is actively recruiting participants for her FREE Stress and Mood Management Program to complete her PhD. Please share this valuable resource with your patients.