AMDA Clinical Practice Guidelines for Treating Type 2 Diabetes in Long-Term Care Residents
Diabetes and long-term care
More than 50% of ß-cell function may have been lost by the time diabetes
has been diagnosed1
- One recent study has suggested that at the time of diagnosis, patients have lost more than 80% of ß-cell function2
- In patients with type 2 diabetes, normal ß-cell function declines, on average, about 5% a year1
- Patients with type 2 diabetes may eventually require insulin therapy to achieve or maintain glycemic control3
The prevalence of type 2 diabetes increases with age, with 20% of individuals over the age of 60 affected.4 The prevalence in long-term care (LTC) facilities may be underestimated, making proper diagnosis and treatment a matter of great concern.
Caution should be exercised when administering insulin to elderly patients. In elderly patients with diabetes, dosing should be conservative to avoid hypoglycemia. Hypoglycemia is the most common adverse effect of insulin, including Lantus®. Hypoglycemia may be difficult to recognize in the elderly.
A tailored approach is recommended
- AGS recommendations for A1C goals are based on life expectancy, frailty, presence of comorbidities, cognitive impairment, and functional disability5
- In many cases, a resident's disease has progressed beyond control with 1 or more oral medications1
- Care is required in prescribing and monitoring treatment regimens. Oral agents may be contraindicated in patients with certain comorbidities4
- According to the AMDA standards of care, glycemic goals should be tailored according to the patient's risk of hypoglycemia4
- Glycemic goals for older adults who are not functional, not cognitively intact, or who do not have significant life expectancy may be relaxed using individual criteria. However, hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients if possible
Consider less stringent glycemic goals for frail older residents or those with the following conditions: 1
- Are dependent on others for feeding or generally have a poor prognosis
- Have anorexia, gangrene, malignancy, or severe dementia
- Have hypoglycemia unawareness or recurrent idiopathic hypoglycemic episodes
- Have a life expectancy of less than 5 years
As type 2 diabetes progresses, many LTC residents will require insulin to manage their disease.
Basal prandial regimen vs SSI Monotherapy
A basal-prandial regimen significantly reduced BG vs SSI monotherapy in the RABBIT 2 Study
Read more
Important Safety Information for Lantus® (insulin glargine [rDNA origin] injection)
Contraindications
Lantus® is contraindicated in patients hypersensitive to insulin glargine or
one of its excipients.
Warnings and Precautions
Monitor blood glucose in all patients treated with insulin. Insulin regimens should
be modified cautiously and only under medical supervision. Changes in insulin strength,
manufacturer, type, or method of administration may result in the need for a change
in insulin dose or an adjustment in concomitant oral antidiabetic treatment.
Do not dilute or mix Lantus® with any other insulin or solution. If mixed or
diluted, the solution may become cloudy, and the onset of action/time to peak effect
may be altered in an unpredictable manner. Do not administer Lantus® via an
insulin pump or intravenously because severe hypoglycemia can occur. Insulin devices
and needles must not be shared between patients.
Hypoglycemia is the most common adverse reaction of insulin therapy, including Lantus®,
and may be life-threatening.
Severe life-threatening, generalized allergy, including anaphylaxis, can occur.
A reduction in the Lantus® dose may be required in patients with renal or hepatic
impairment.
Drug Interactions
Certain drugs may affect glucose metabolism, requiring insulin dose adjustment and
close monitoring of blood glucose. The signs of hypoglycemia may be reduced in patients
taking anti-adrenergic drugs (e.g., beta-blockers, clonidine, guanethidine, and reserpine).
Adverse Reactions
Other adverse reactions commonly associated with Lantus® are injection site
reaction, lipodystrophy, pruritus, and rash.
Important Safety Information for Lantus®
SoloSTAR®
Lantus® SoloSTAR® is a disposable prefilled insulin pen. To help ensure
an accurate dose each time, patients should follow all steps in the Instruction
Leaflet accompanying the pen; otherwise they may not get the correct amount of insulin,
which may affect their blood glucose.
Indications and Usage for Lantus® (insulin glargine [rDNA origin] injection)
Lantus® is a long-acting insulin analog indicated to improve glycemic control
in adults and children (6 years and older) with type 1 diabetes mellitus and in
adults with type 2 diabetes mellitus. Lantus® should be administered once a
day at the same time every day.
Important Limitations of Use: Lantus® is not recommended for the treatment of
diabetic ketoacidosis. Use intravenous short-acting insulin instead.
Lantus® SoloSTAR® is a disposable prefilled insulin pen.
Please click
here for Full Prescribing Information for Lantus®.
References:
- Holman RR. Diab Res Clin Pract.1998;40(suppl):S21-S25.
- DeFronzo RA. Diabetes. 2009;58:773-795.
- Hirsch IB, Bergenstal RM, Parkin CG, Wright E, Buse JB. Clin Diabetes.
2005;23(2):78-86.
- American Medical Directors Association. Diabetes Management in the Long-Term
Care Setting Clinical Practice Guideline. Columbia, MD: AMDA 2008, revised
2010.
- Migdal A, Yarandi SS, Smiley D, Umpierrez GE. J Am Med Dir Assoc. 2011;12:627-632.
- Pandya N, Nathanson E. J Am Med Dir Assoc. 2010;11:171-178.
- American Diabetes Association. Diabetes Care. 2011;34(suppl 1): S11-S61.
- Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American
Geriatrics Society Panel on Improving Care for Older Persons with Diabetes. J Am
Geriatr Soc. 2003;51(5 suppl): S265-S280.
- American Association of Clinical Endocrinologists. Endocr Pract. 2011;17(suppl
2):1-53.
Indications and Usage for Lantus® (insulin glargine
[rDNA origin] injection)
Lantus® is a long-acting insulin analog indicated to improve glycemic control
in adults and children (6 years and older) with type 1 diabetes mellitus and in
adults with type 2 diabetes mellitus. Lantus® should be administered once a
day at the same time every day.
Important Limitations of Use: Lantus® is not recommended for the treatment of
diabetic ketoacidosis. Use intravenous short-acting insulin instead.
Important Safety Information for Lantus® (insulin
glargine [rDNA origin] injection)
Contraindications
Lantus® is contraindicated in patients hypersensitive to insulin glargine or
one of its excipients.
Warnings and Precautions
Monitor blood glucose in all patients treated with insulin. Insulin regimens should
be modified cautiously and only under medical supervision. Changes in insulin strength,
manufacturer, type, or method of administration may result in the need for a change
in insulin dose or an adjustment in concomitant oral antidiabetic treatment.
Important Safety Information for Lantus® SoloSTAR®
Lantus® SoloSTAR® is a disposable prefilled insulin pen. To help ensure
an accurate dose each time, patients should follow all steps in the Instruction
Leaflet accompanying the pen; otherwise they may not get the correct amount of insulin,
which may affect their blood glucose.
Click here for additional Important Safety Information.