Chapter 36 Diabetes Mellitus

Front 1

Diabetes mellitus

Back 1

a group of diseases characterized by hyperglycemia

Front 2

Hyperglycemia

Back 2

(fasting glucose level>100 mg/dL) and abnormalities in fat, carbs, and protein metabolism that lead to micro-vascular,macro-vascular, and and neuropathic complications

Front 3

Development of Diabetes

Back 3

patients often have impairment of insulin secretion as well as defects in insulin action resulting in Hyperglycemia.

Front 4

Diabetes mellitus occurs

Back 4

with increasing frequency in the United States as the population increases in weight and age. In the United states estimated that the prevalence in diabetes in the general population is estimated that 7.8% (23.6 million people. 5.7 million of whom are undiagnosed.)

Front 5

Diabetes Mellitus Pathophysiology

Back 5

cells do not absorb glucose the way they should, pancreas is not making enough insulin to metabolize glucose, liver is making to much sugar, and specific genetic syndromes,surgery,drugs, malnutrition, and infections

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glucose

Back 6

cells need glucose for energy, glucose is the main fuel for CNS, brain cannot produce nor store glucose, and alpha cells (a cells) on pancreas produce glucogen.

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diabetes

Back 7

is listed as the sixth leading cause of death in the United states.

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The risk of heart disease and stroke in diabetes patients

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two to four times greater in patients with diabetes compared to those without the disease.

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The incidence of diabetes

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is higher in African Americans, Hispanics, American indians, native Alaskans and women.

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Type 1 Diabetes mellitus

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formerly known as insulin-dependent diabetes mellitus (IDDM), is present in 5 to 10%of the diabetic population. its is caused by an autoimmune destruction of the beta cells in the pancreas. It occurs more often in juveniles, but patients can become symtomatic for the first time at any age.

Front 11

DM type 1 risk factors

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type 1 diabetes usually starts in childhood, genetics and family history, *Primary risk factor:diseases of the pancreas and infection or illness.

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"honeymoon" period

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a patient with type 1 diabetes going into remission in the early stages of the disease, requiring little or no exogenous insulin. This condition may last for a few months.

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Type 2 diabetes mellitus

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formerly known as non-insulin- dependent Diabetes Mellitus (NIDDM) is present in about 90% in the diabetic population.

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Type 2 diabetes is characterized by

Back 14

a decrease in beta cell activity (insulin deficiency) , insulin resistance (reduced uptake of insulin by peripheral muscle cells.) or an increase glucose production by the liver.

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syndrome X

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most people with type 2 DM also have a metabolic syndrome also known as insulin resistance syndrome.

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risk factors for type 2 DM

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obesity (single most predictor of DM type 2 ), sedentary lifestyle, HTN= hypertension, triglycerides above 250mg/dL, Low HDL below 35mg/DL, and impaired glucose tolerance.

Front 17

type 2 diabetes onset

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is usually more insidious than that of type 1 diabetes. the pancreas still maintains some capability to produce and secrete insulin. consequently the symptoms (polyphagia, polydipsia, polyuria) are minimal or absent for a prolonged period.

Front 18

fasting hyperglycemia

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can be controlled by diet in some patients, but most patients require the use of supplemental insulin or oral anti-diabetic agents, such as metformin or glyburide .

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the third subclass of diabetes mellitus

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includes additional types of diabetes that are part other diseases having features not generally associated with with the diabetic state.

Front 20

Diseases that might have a diabetic component with the third subclass

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pheochromocytoma, acromegaly, and crushing's syndrome. other disorders included in this category include: malnutrition, infection, drugs and chemicals that induce hyperglycemia, defects in insulin receptors, and certain genetic syndromes.

Front 21

look up box 36-1 on pg 551 pharmacology book

Back 21

its over classification of diabetes mellitus by pathologic cause

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Fourth category classification known as Gestational diabetes Mellitus (GDM)

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is reserved for woman who show abnormal glucose tolerance during pregnancy; this happens in about 4% of all pregnancies in the U.S. resulting in about 135,000 cases a year,

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gestational diabetic patients

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have to be reclassified within 6 weeks after delivery into one of these categories: diabetes mellitus, impaired fasting glucose ,impaired fasting glucose tolerance, or normoglycemia.

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woman with gestational diabetes are

Back 24

at a greater risk of developing diabetes mellitus 5 to 10 years after pregnancy.

Front 25

Impaired glucose tolerance(IGT)
Impaired fasting glucose(IFG)

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these patients are often normally euglycemic, but develop hyperglycemia when challenged with an oral glucose tolerance test. (in many of these patients the glucose tolerance level returns to normal or persists in the intermediate range for years.)

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prediabetes

Back 26

intermediate stage between normal glucose homeostasis and diabetes.

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Prediabetes in American adults

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57 million people have this

Front 28

Categories of fasting plasma glucose

Back 28

FPG CATEGORIES:
FPG less than 100 mg/dL=normal fasting glucose
FPG greater than or equal to 100mg/dL or greater than but less than 126 mg/dL=IFG(impaired fasting glucose)
2-hour plasma glucose level at 140 or greater but less than 199mg/dL=IGT (impaired glucose tolerance)

Front 29

Microvascular complications

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are those that arise from destruction of capillaries in the eyes, kidneys, and peripheral tissues.

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A fact about diabetes is

Back 30

has become the leading cause of end-stage renal disease and adult blindness.

Front 31

Macrovascular compliacations

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are those associated with atherosclerosis of middle to large arteries, such as those in the heart and brain. macro-vascular complications,strokes,myocardial infractions, and peripheral disease account for 75 to 80% of mortality in patients with diabetes.

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neuropathies

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may first be observed as numbness or tingling of these extremities (paresthesia), loss of sensation, orthostatic hypotension, impotence, or vaginal yeast (candidiasis) infections, and difficulty in controlling urination (neurogenic bladder).

Front 33

nonhealing ulcers

Back 33

of the lower extremities may indicate chronic vascular disease.

Front 34

diabetic conditions can be delayed or prevented by

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continuous normoglycemia accomplished by monitoring blood glucose levels, drug therapy, and treatment of comorbid conditions as they arise.

Front 35

look at charts 36-1 and 36-2 on pg 552 in pharm book

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36-1: features of type 1 and type 2 DM
36-2: criteria for diagnosis of DM

Front 36

A cure for DM

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a cure for DM is still unknown at present time, the minimal purpose of treatment is to prevent ketoacidosis and symptoms resulting from the hyperglycemia

Front 37

Major determinants of success in treatment of DM is

Back 37

a balanced diet, insulin or oral antidiabetic therapy, routine exercise, and good hygiene.

Front 38

people with type 1 diabetes

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will always require exogenous insulin as well as dietary control because the pancreas has lost the capacity to produce and secrete insulin.

Front 39

hypoglycemia

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blood glucose level less than 60mg/dL

Front 40

To help maintain adherence to dietary restrictions the diet should be planned

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using the american diabetes association(ADA) MNT recommendations in relation to the patient's food preferences, economic status, occupation, and physical activity.

Front 41

Infection

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is a common precipitating cause of ketosis and acidosis and must be treated promptly .

Front 42

intensive therapy

Back 42

a comprehensive program of diabetes of care that includes self-monitoring of blood glucose four or more times daily, MNT, exercise and for those patients with type 1 diabetes, three or more insulin injections daily or use of an insulin for continuous insulin infusion.

Front 43

table 36-3 pg 554 in pharm book

Back 43

treatment goals for diabetes and comorbid diseases.

Front 44

Type 1 diabetes

Back 44

absolute Insulin deficiency; they do not make any at all!!!

Front 45

insulin is

Back 45

facilitates normal glucose range of 70 to 100 mg/dL; pancreas secretes 40 to 50 units of insulin/day directly into liver circulation

Front 46

basal insulin

Back 46

low level during fasting

Front 47

prandial insulin

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high after eating (within 10 minutes)

Front 48

insulin after a meal

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stimulates storage of glucose as glycogen by liver, inhibits gluconeogenesis, enhances fat deposition in adipose tissue, and protein synthesis

Front 49

normal insulin metabolism

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normally 0.6units/kg/day of insulin are produced by adults

* 40 to 50 units per day

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incretins peptides

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are proteins release from L cells of distal ileum&colon in response to CHO& fat ingestion

Front 51

GLP-1(glucagon-like peptide-1)

Back 51

secreted in response to food

Front 52

GIP

Back 52

glucose dependent insulinotropic polypeptide

Front 53

DPP-IV

Back 53

is an enzyme which causes breakdown of incretins.

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incretins control blood glucose levels by

Back 54

enhancing insulin secretion, suppress glucagon secretion from liver, delay gastric emptying , thus slowing CHO and lipid absorption, reducing post prandial hyperglycemia, and reduce appetite and maintain b cell function.

Front 55

glucogon

Back 55

produced in alpha cells of islets of langerhans,counter regulatory hormone to insulin, has actions opposite of insulin, causes release of glucose from cell storage when blood glucose is low, breaks down glycogen in liver(gluconeogenesis) into glucose.

Front 56

DM pathophysiology, three key defects

Back 56

1. insulin resistance of the cells
2.pancreas is not making enough or inadequate insulin
3.liver makes too much sugar

Front 57

diagnosis of DM1

Back 57

2 of the following test in any combo 24 hours apart
1.fasting plasma glucose greater then 126mg/dL
2. Sx+casual plasma glucose above 200mg/dL
3. 2hr post prandial(after meal or glucose) or oral glucose tolerance test above 200mg/dL

Front 58

diagnosis of prediabetes

Back 58

fasting plasma glucose (100-125mg/dL)
2hr post prandial(after meal or glucose tolerance test(140-199mg/dL)

Front 59

insulin resistance

Back 59

blood sugar is normal,but insulin levels may be 2-3 times higher than normal

Front 60

Impaired fasting glucose (IFG)

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fasting blood sugar (110-126)

Front 61

Impaired glucose tolerance

Back 61

oral glucose tolerance test (140-200)

Front 62

diabetes mellitus type 2

Back 62

progressive disorder in which the pancreas makes less insulin over time
1. reduced ability of cells to respond to insulin(insulin resistance)
2. poor control of liver glucose metabolism.
3. decreased beta cell function leading to beta call failure

Front 63

symptoms of DM

Back 63

increased thirst, excessive hunger, extreme weakness or fatigue, slow heal, blurred vision,tingling/numbness of feet and hand, frequent urination, vaginal infections in women, impotence,acanthosis Nigricans(darkening of the skin folds especially back of neck.

Front 64

hypoglycemia

Back 64

or low blood sugar can occur from too much insulin and not enough glucose , symptoms are nervousness, tremors, headache apprehension , sweating, cold and clammy skin , and hunger.
It can progress to blurring of vision , lack of coordination,incoherence, coma, and death.

Front 65

hyperglycemia

Back 65

elevated blood sugar occurs when glucose available available in the body cannot be transported into the cells because of a lack of insulin. it can be caused by adherence, overeating, acute illness, or acute infection.

Front 66

symptoms of hyperglycemia

Back 66

headache, nausea and vomitting, abdominal pain, dizziness, rapid pulse, rapid shallow respirations, and a fruity odor to the breath from acetone. If untreated can cause death or coma.

Front 67

treatment of DM

Back 67

medical nutritional Therapy, exercise, lifestyle modifications, aggressive control of co-morbid conditions, and medications

Front 68

lifestyle modifications

Back 68

Low CHO, low fat, low cholesterol diet ,exercise 30 min a day, weight management,stop smoking,limit alcohol,get adequate sleep, and regular check ups

Front 69

The pancreas secretes insulin

Back 69

at a steady rate of 0.5 to 1 unit /hr. It is released in greater quantities when the blood glucose level rises above 100 mg/dL, such as after a meal. The average rate of insulin secretion in an adult is 30 to 50 units daily.

Front 70

Biosynthetic human insulin

Back 70

now used by most patients, especially people newly diagnosed with diabetes. It has fewer allergic reactions associated with it than beef and pork insulins.

Front 71

rapid acting insulins

Back 71

such as lispro, aspart, and glulisine , are clear solutions that may be injected separately or mixed in the same syringe with an intermediate acting insulin.

Front 72

shorter acting insulins are used

Back 72

to control hyperglycemia associated with meals having longer lasting effects with the potential for for hyperglycemia. (these insulins can be used alone without any other insulin in patients with type 2 diabetes who only have hyperglycemia associated with digestion of meals)

Front 73

regular insulin

Back 73

is the only dosage form of insulin that is approved to be injected by both IV and subcutaneous routes of administration. Is usually administered 30 to 60 minutes before meals.

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HgbA1c=4.0% to 6.0%

Back 74

used to access long term glycemic control, as well as predict risk for long term CXS

Front 75

glucose

Back 75

permanently attaches to hgb for the 120 day life span of RBC's

Front 76

Sulfonylureas side effects and contradictions &interactions

Back 76

Hypoglycemia/
hepatic disease, sulfa allergy, pregnancy, alcohol (antabuse effect severe N&V), beta blockers may induce or mask hypoglycemia

Front 77

Thiazolidineiones(TZD)

Back 77

Action: high tissue sensitivity to insulin causing high glucose uptake in muscles, adipose and liver tissue& decreased glucose production in the liver.

Front 78

Thiazolidineiones(TZD)

Back 78

are usually used for add on therapy
effectiveness is gradual "4-6" weeks, to months, Positive effects on triglycerides,HDL,&LDL
Side effects: weight gain 4-6 pounds,edema,
NOT susceptible to hypoglycemia unless taking another hypoglycemic meds, Black box warning for people with Heart failure

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onset

Back 79

time required for initial action of effects

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Peak

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when maximum effect occurs

Front 81

Duration

Back 81

length of time insulin( medicine) remains active in body.

Front 82

Basal insulin

Back 82

cannot not be mixed or diluted

Front 83

Novolog Mix 70/30

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Insulin aspart protamine susp /Aspart 70/30

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Humalog Mix 75/25

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Insulin lispro protamine susp /Lispro

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Humulin or Novolin 70/30

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Humulin or Novolin 70/30 - NPH/Reg

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Humulin 50/50 – NPH/Reg

Back 86

NPH/Reg

Front 87

Insulin Regimens

Back 87

Single daily injection protocol
Two-dose protocol
Three-dose protocol
Four-dose protocol
Combination therapy
Intensified therapy regimens

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Insulin Guidelines

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Insulin is measured in units
Usually U-100 (insulin syringe)

Front 89

always check vial for

Back 89

“Right” drug
Clarity (for Regular)
“Right” client (name)
Expiration date & date opened

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Mixing insulins

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Mix clear to cloudy

Front 91

Blood sugar and regular insulin

Back 91

Blood sugar Regular Insulin
61-200 = No insulin, monitor
201-250 = 2 units
251-300 = 4 units
301-350 = 8 units
351-400 = 10 units
Recheck blood sugar in 90 minutes if above 400 call the physician

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If blood sugar is under 60 or no LOC or inability to tolerate PO

Back 92

give Glucogon 1 mg IM
Notify MD