Tag: guidelines

Health

Driving and Diabetes

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NPPossessing a driver’s license is a rite of passage in our society.
A driver’s license is seen as a gateway to independence and is a necessity for survival in many instances since many places in the US don’t have adequate public transportation. Driving is such a huge part of our lives, but there are instances when the ability to drive competently is also at issue. The American Diabetes Association (ADA) published a Position Statement on Diabetes and Driving in the 2014 Clinical Practice Recommendations. I would like to summarize the key points of this Position to provide an overview to help both people with diabetes and their health care providers have the best information about driving with diabetes.

The process for identifying drivers with diabetes varies from state to state, depending on what type of vehicle the driver needs to be licensed for. In some states, questions such as “Do you have any medical condition that may interfere with the safe operation of a motor vehicle?” are asked at the initial application for license. These questions may then prompt the need for further medical evaluation. There is no need for a medical examination just because the driver has diabetes. Most often a medical evaluation would be requested when there has been a documented episode of hypoglycemia while driving. Visit the ADA Website for more information on specific rules for each state.

Drivers with diabetes that are commercial drivers in interstate commerce have different rules and follow a set of uniform federal regulations. ALL drivers are subject to an examination every 2 years to update the driver’s ongoing general fitness. Drivers with diabetes managed with diet, exercise, and oral medications do not have any further requirements. Drivers who use insulin often require a more detailed medical evaluation so an exemption to drive and medical certification can be granted. Drivers for commercial motor vehicles, such as school bus drivers and vehicles that transport passengers or hazardous materials are subjected to more strict evaluations that differ state to state.

There are many factors to consider when caring for the driver with diabetes. I want to be clear: a diagnosis of diabetes or the use of oral medications or insulin does not mean that driving ability is compromised. The ADA has determined that the single most significant factor associated with collisions for drivers with diabetes appears to be a recent history of severe hypoglycemia regardless of diabetes type or treatment. The ADA Workgroup on Hypoglycemia defines severe hypoglycemia as an event that disrupts cognitive motor function and requires the assistance of another person to treat the hypoglycemic event.

The plan of assessment and care of the driver with diabetes needs to be individualized. It is important to not only review hypoglycemia awareness, but to also review the other conditions that could interfere with safe driving. These conditions may include decreased visual acuity due to retinopathy or cataracts, neuropathy that diminishes the sensation of the right foot, or sleep apnea which can result in daytime sleepiness. Drivers that have had a hypoglycemic event will need much closer evaluation and education. The driver may need re-education to address issues with mealtimes and dosing of medications (or medications may need to be adjusted altogether), further education about hypoglycemia awareness, and the best methods of treating low blood sugars. Drivers who have had episodes with severe hypoglycemia may also need to perform additional glucometer testing.

People driving for long distances should have a good supply of glucose tablets easily available in the glove compartment or in the console. A supply of snacks such as packages of cheese and peanut butter crackers or nuts should also be stored in the front of the car with the driver and checked before each trip. Drivers who feel hypoglycemia occurring while driving should pull off the road immediately, put on their blinkers, and treat with a fast acting carbohydrate. Do not resume driving until blood sugar values are normalized.

Finally, I advise that all of my patients with diabetes have a medical ID with them at all times. Symptoms of hypoglycemia may appear as if driving under the influence of alcohol or drugs, which can lead to losing precious treatment time if there is an incident where you are unable to identify yourself as having diabetes.  First responders are trained to look for things like a bracelet or necklace, or a card in the wallet.

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Health

2013 ADA Clinical Practice Recommendations (Part 1)

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen W

Every year the multidisciplinary Professional Practice Committee of the American Diabetes Association (ADA) publishes a set of guidelines and recommendations on the diagnosis and treatment of diabetes for both adults and children. These standards guide us in how and when to screen for, diagnose and treat diabetes; how to monitor for complications; and how to educate patients in their self-management strategies.

These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Rather, they provide a guideline for the care of a person with diabetes;  providers rely on their best clinical judgment for each individual they care for and adapt the guidelines as needed.  Last year I did a review of the ADA Guidelines along with the specific updates published (you can refer to that post here). This year there were 12 revisions published which I will highlight this week and next. Please remember that these are guidelines— always review your personal health care plan with your health care provider(s).

Screening for Type 1 Diabetes

Type 1 Diabetes is generally diagnosed with an acute presentation of hyperglycemia and even ketoacidosis. There is no evidence that screening the general population for Type 1 Diabetes is helpful, but there is valid evidence that measuring islet autoantibodies in relatives of people with Type 1 Diabetes will identify at-risk individuals. Those identified can be referred to clinical studies where they can learn about their potential for developing Type 1 Diabetes and what symptoms to watch for.  Lifestyle education would also be provided and more frequent screening instituted.

Prevention/Delay of Type 2 Diabetes

There are several random controlled studies showing that people at high risk for developing Type 2 Diabetes can decrease their rate of onset with certain interventions. These interventions may include lifestyle changes and even medication in some instances. ADA supports formal education for people with impaired glucose tolerance and an A1C between 5.7 and 6.4%. People who fall into this category also need to be monitored annually for their blood sugar values and assessed for cardiovascular risk factors (obesity, hypertension, and high cholesterol).

Glucose Monitoring

I think one of the most important things we do as diabetes providers is helping people learn how to monitor their blood sugars at home and follow these patterns for better control. However, there has been some discussion in the literature about the clinical utility and expense for self-monitoring of blood glucose (SMBG) in people who aren’t on aggressive insulin or not on insulin at all. ADA has approached this issue by stating that frequency and timing of SMBG should be decided on an individual basis based on the person’s needs and goals for treatment. People using MDI or an insulin pump need frequent SMBG to assess for control and monitor for hypoglycemia. People using less frequent insulin or non-insulin therapies may check SMBG on a more variable schedule that should be determined with the health care provider. It’s also important to review testing technique at times to be sure the results are accurate.

DSME and Support Groups

ADA has always advocated for education and support for people with diabetes, and now is supporting formal education for pre-diabetic patients. ADA supports third-party payer reimbursement for both these services.

Hypoglycemia

Hypoglycemia awareness and management should be frequently reviewed with patients. The self-management plan should always be re-evaluated if there have been one (1) or more episodes of severe hypoglycemia (inability to handle the episode on your own).  People with severe hypoglycemia or hypoglycemia unawareness may need the targets for glycemic control raised. People with declining cognition need to be assessed frequently for hypoglycemia by their providers and family members.  Adjustments in their glycemic management plan will also need to be made.

To view the full set of Clinical Practice Recommendations for 2013, click here.

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Uncategorized

2012 ADA Clinical Practice Recommendations

Posted on by mghdiabeteseducation

By Eileen B. Wyner, NP
Bulfinch Medical GroupEileen W

Every year the American Diabetes Association publishes a set of guidelines and recommendations on the diagnosis and treatment of Diabetes for both adults and children. These standards guide us in how and when to screen for Diabetes, how to diagnose, how to monitor for complications, how to treat Diabetes and how to educate patients in their self-management strategies. A large body of evidence-based data is reviewed by the experts annually to provide the best possible information.

These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Providers rely on their best clinical judgment for each individual they care for.  Although well controlled Diabetes may lessen the instance of complications across the lifespan, there may be associated adverse affects in the process.  Some patients simply can’t tolerate tight control for example; or medications have side affects, the most concerning of which is hypoglycemia (which can be life threatening). While we all fall back on these guidelines, we also have to adapt them as needed.

There are many aspects of these Guidelines, but I want to discuss a few points a little more closely. The ADA Standards not only addresses medical management but strongly emphasizes the importance of Diabetes self –management education, or DSME. The ADA supports all patients receiving education with diagnosis of disease and ongoing education as needed. Education and knowledge about this chronic disease has been shown to improve physical and emotional health.  People with Diabetes who have ongoing educational updates—either in a group or one-to-one—have better control of their disease, better ability to prevent/manage complications, and have better quality of life.

The Standards also identify some other medical conditions that occur in the Diabetic population more so than in the general population. This doesn’t mean that everyone will get these conditions, but it is important to be aware of them:

  • Hearing impairment is more common —this may be due to neuropathy
  • Sleep apnea, especially in obese men, is common and is a risk factor for cardiovascular disease
  • Low testosterone in men, especially if they are obese, is more prevalent in the Diabetic population and may present with symptoms of fatigue and decreased libido (routine screening isn’t done for this condition, but if you are having any concerns it’s a good idea to bring this up with your health care provider)
  • Gum disease is more serious (not necessarily more common)
  • Poor blood sugar control and noncompliance are real concerns
  • People with Diabetes have a higher risk of cognitive impairment (this is an area that needs to be studied more closely, but long-term hyperglycemia seems to be a factor)

A Note about Driving

This year the ADA added a section on Diabetes and driving.  Driving with Diabetes is a topic I try to bring up often with my patients, especially if they’re older, have known visual problems, or have had frequent hypoglycemia. While there is data to show a small increase in the risk of motor vehicle accidents due to hypoglycemia and hypoglycemia unawareness, it’s a much smaller risk than those associated with teenage male drivers. The ADA is against blanket restrictions for people with Diabetes and advises health care providers to make individual assessments as needed.  Everyone who has a license is expected to drive with caution and care; Diabetes doesn’t mean you can’t drive, but it may mean that you need to be a little more cautious.

I tell all of my patients to wear medical identification. I prefer it be a bracelet or necklace, something that hangs off the body and is easily seen— a wallet card can’t be easily accessed in an emergency. Hypoglycemia can resemble drunk driving and valuable time for your health will be lost if you are involved in a driving incident and not acting yourself.  First responders will not think “hypoglycemia”; they will think “cocktails”.

And here are some other considerations to be aware of:  You may have neuropathy, so feeling the brake and gas pedals may be difficult. That may mean you will have to stop driving. Retinopathy may diminish your nighttime or peripheral vision. You may need to curtail your driving from dusk to dawn or stop driving altogether. If you have experienced hypoglycemia frequently or to extremes, you should discuss it with your health care provider. You may need to develop a detailed plan for driving such as checking your blood sugar before you get in the car and checking frequently on the road. And, always be sure to have glucose tablets in the car.

I encourage you to think about your own circumstances.  Do you need a refresher on your self-management care?  Talk to your health care provider and see about education opportunities. Is driving a little more challenging (aside from the normal challenge of maneuvering Boston’s roads)? Set up an appointment to see the eye doctor. Use this New Year as a chance to give yourself good care. You deserve it.

To view the full standards, click here.

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