non-insulin-dependent diabetes mellitus

(80-90% of patients)

hyperglycemia

polyuria - due to osmotic diuresis

polydipsia - compensatory

polyphagia

weight loss

usually during childhood or puberty

frequently undernourished

10-20% of diagnosed diabetics

moderate genetics

frequently over age 35

obesity usually present

80-90% diagnosed

very strong genetic

polyuria

polydipsia

polyphagia

a fasting plasma glucose test all patients over 45 years of age every 3 years

earlier and more frequently in patients w/ risk factors

family history

obesity

habitual physical inactivity

race or ethnicity 

history of impaired glucose tolerance

HTN

low HDL < 35, or trig. > 250

history of gestational DM

native americans

hispanic americans

asian americans

african americans

pacific islanders

microvascular

macrovascular

retinopathy

neuropathy and foot problems

nephropathy and microalbuminuria

abdominal obesity

atherogenic dyslipidemia (elevated TG and LDL and low HDL)

high BP

insulin resistance

classical signs and symptoms 

a fasting plasma glucose > 126 mg/dL

failure of oral glucose challenge test

polyuria

polydipsia

ketonuria

rapid weight loss w/ random plasma glucose > 200

insulin admin

control hyperglycemia -blood glucose monitoring (HbA1c)

Diet

exercise

control blood glucose concentrations

diet and exercise

oral hypoglycemic agents

insulin

sulfonylureas

biguanides

glitazones

meglitinides

alpha-glucosidase inhibitors

incretins- GLP- 1

DPP-IV inhibitors

SGLT2

differ in onset times, peaks, and duration

less soluble- longer duration of action

hypoglycemia

hypersensitivity reactions

lipodystrophies (lipohypertrophy, lipatrophy)

patient is conscious   BG <50

tremor, palpitations, sweating and hunger, HA, mood changes, irritability, decreased attention, drowsiness

15-15-15 (carbs, wait 15 min)

2 glucose tabs, 1/3 glass apple juice, 5-6 lifesavers, 2 tsp sugar

patient is unconscious BG about 20

unresponsive, convulsions

outpt w/o IV access - glucagon kit 1 mg SC or IM - feed pt when awake

inpatient - give IV dextrose

IV or IM

6 hours duration

rapid absorption and acting

can be used 15 min prior to meals 

insulin aspart, insulin glulisine

duration up to 4 hrs

all are more effective than regular insulin in controlling postprandial blood sugar

usually given subcu but can be given IV

isophane insulin suspension

NPH (neutral protamine hagedorn)

crystalline zinc insulin is conjugated w/ protamine less soluble (delayed absorption)

insulin detemir (Levimir) - 12-20 hrs

insulin glargine (Lantus) - 22-24 hrs

Humulin 70/30 and 50/50

NPH to regular

Neutral protamine lispro (NPL) to lispro

amylinomimetic agent - naturally relased w/ insulin

slows gastric emptying

increase satiety

suppresses postprandial plasma glucagon & hepatic glucose output

N/V

anorexia

HA 

severe hypoglycemia w/ insulin

standard - insulin x 2 

intensive - insulin x 3,4

better control, less microvascular disease, greater hypoglycemia

stimulation of insulin release from pancreas B cells

block ATP - sensitive K channels

reduction of serum glucagon levels

increase binding of insulin to target tissues & receptors

hypoglycemia and weight gain are more common rxns

rest are rare - allergic skin rxns, anemia, GI problems

take 30 minutes before a meal 

(absorption is delayed when taken with food) 

once daily dosing or divided

minimal transfer across placenta therefore potential alternative to insulin in diabetes of pregnancy

once daily or divided

glipizide

glyburide

glimepiride

repaglinide

nateglinide

similar to sulfonylureas

blod ATP - sensitive K channels, stimulating the release of insulin

take before each meal

omit dose if meal is skipped (will go hypoglycemic)

monotherapy or in combo w/ metformin

consider in patients who have a history of skipping meals or an irregular schedule

decreases hepatic glucose production by inhibiting gluconeogensis

may have a mild anorexia effect - weight loss

only oral hypoglycemic to decrease CVD morality

relative to diet alone or other oral hypoglycemic drugs

positive lipid profil - lowers LDL, TG, and raises HDL

< hypoglycemia compared to sulfonylureas

Polycystic ovary diseases - can result in pregnancy

may need to supplement vitamin B12

GI (diarrhea, N/V, bloating, flatulence)

rare - fatal lactic acidosis, esp. in renal patients

hepatotoxicity (only seen in troglitazone which was pulled)

monitor liver function

potential for increased MI, heart failure, death from CVD

lower TG and raise HDL, evidence they raise LDL

edema and weight gain can occur

acarbose

miglitol

reversibly inhibits enzymes in the mucosa of the small intestine

delays the digestion of carbohydrates decreasing postprandial blood glucose

inflammatory bowel disease

colonic ulceration

intestinal obstruction

abd pain, diarrhea, and flatulence 

alone or in conduction w/ sulfonylureas

can decrease availability of metformin