90-85%

relative insuling deficiency due to insulin resistance and a defect in insulin secretion

Type 1 DM can NOT be cured whereas Type 2 DM can be.

T/F?

False: neither T1 or T2 DM can be cured but both can be treated.

T1 treated by insulin, diet and exercise

T2 by insulin (sometimes), oral agents, diet, exorcise, etc.

o   At 24-28 weeks of gestation

o   As soon as possible after confirmation of pregnancy in women at very high risk for GDM

o   Note: If diabetes is found at first prenatal visit, woman should receive diagnosis of overt, not gestational, diabetes (because it has a good chance of being T2DM)

BMI of > 25 kg/m^2

ONE

Risks for DM include:

AIC _____

HTN _____

HDL levels _____ and/or a TG level _____

Hx of GDM or delivery of a baby _____

> 5.7% IFG or IGT on previous tests

> 140/90

< 35 mg/dl and/or >250 mg/dl

> 9 lbs

·      At any age if overweight plus 1 other risk factor

·      Testing should begin at age 45 in those w/o risk factors

o   After 65 yoa, 25% people will have T2 DM

·      If nl, repeat every 3 years

·      May use A1C, FPB (fasting glucose), or 2 hr 75 g OGTT (oral glucose tolerance test)

·      Polyuria: LOTs of urine

·      Polydipsia

·      Polyphagia

·      Fatigue: not getting energy to tissue

o   Insulin is the key to unlock tissue cells for glucose

o   No insulin = no energy

·      Unexplained weight loss

o   More with T1 DM

o   Eating all the time but still losing weight

·      Elevated serum glucose levels

·      Ketonuria (T1 DM)

o   Trying to break down fat for energy

Criteria for DM diagnosis:

- Fasting (8 hrs) plasma glucose of _____. (Normal = _____)

- AIC _____. (This test measures bs over the last _____).

- 2-hr plasma glucose of _____ during a 75 OGTT.

- Showing S/S of Dm plus a randome plasma glucos of _____.

> 126 mg/dl (Nl = 65-99)

> 6.5% (3 months)

> 200 mg/dl

> 200 mg/dl

A person is not normal but not diagnoses as having DM when their:

- Fasting Glucose is "_____" at _____.

- Glucose tolerance is "_____" at _____ on 2-hr OCTT.

-AIC is _____%

Interventions for at risk pts:

impaired; 100-125 mg/dl

impaired; 140-199

5.7-6.4%

Encourage activity and healthy diet choices

That T2 DM can be almost completely prevented.

The most successful prevention programs must include lifestyle modifications targeted at diet and exercise behaviors.

150 min/week; can be as simple as walking.

Dropping 5-10% of weight is extremely benificial.

Monitoring of glucose levels (how you know where you're at, insulin, oral agents, etc)

Interventions to regulate glucose levels (activity, diet, insulin or oral agents)

Education for self mgmt

ADA recommends keeping A1C under _____%. _____ is completely normal, _____ is in the gray area.

This should be checked ______ or maybe _____ if the pt is not controlling it well.

7% (or more like 6.5%)

Under 5.7%

5.7-6.4% in the gray area

semi-annually

every 3-4 months

70-130 mg/dl

2 hours

< 180 mg/dl

4

6

2

_____ and _____ are the cornerstone for mgmt of both T1 and T2 DM.

DM pts are _____ more likely to have CVA or MI, so this lowers both _____ and _____ while fostering _____ and improving their sense of _____.

Physical activity and diet

3-4

BP and cholesterol 

weight reduction

well being (decreases depression)

150

3

_____ is a risk for persons on insulin or insulin secretagogue (which _____) while exercising.

Interventions include _____ and _____.

Hypoglycemia

causes pancrease to make more insulin

reducing insulin with exercise and adding carbs prior to exercise if blood glucose < 100

Hyperglycemic

requre more energy but not be able to access the glucose because they're insulin deficient.

- Improve glucose and lipid levels

- Facilitate weight mgmt

- Provdie consistent, nutritionally balance intake

determine a insulin:carb ratio

They will then count the carbs theyare eating and match their insulin to this number.

FALSE

The machine does go into the interstitial space, but only gives readings every 5 min. It is only for those who are good at monitoring their blood glucose and is NOT a replacement for finger pricks.

Food/Supplemental

acute elevation

Aspart, Lispro, Glulisne (Nobalog, Humalog)

Starts working in: _____

Peaks at about: _____

Gone completely by: _____

Take this _____ to help _____.

10 min

1 hour

3-4 hours

before eating to help control kick after meals

Starts working in: 10 min

Peaks at about: 1 hour

Gone completely by: 3-4 hours

Take this before meals to help control the kick after meals.

Regular

Starts working: _____

Peaks at: _____

Lasts for: _____

Can be used as _____ insulin and needs to be given _____.

30 min

2 hours

8 hours

food 30-60 min before meal

Starts working: 30 min

Peaks at: 2 hours

Lasts for: 8 hours

Can be used as food insulin and needs to be given 30-60 min before meal.

NPH

Starts working: _____

Peaks at: _____

Lasts: _____

Can be used as _____ insulin, but does have a _____.

Note... Use in _____.

2 hours

4-10 hours

10-18 hours

basal a peak

Pregnant women

Starts working: 2 hours

Peaks at: 4-10 hours

Lasts: 10-18 hours

Can be used as basal insulin, but does have a peak.

Note... Use in pregnant women.

Detemir

Peak: _____

Lasts: _____

Use as _____ insulin.

None

21 hours

basal

Peak: None

Lasts: 21 hours

Use as basal insulin.

Glargine (Lantis)

Peak: _____

Lasts: _____

Use as _____ insulin.

None

24 hours

basal

Peak: None

Lasts: 24 hours

Use as basal insulin.

Give the:

ONSET OF ACTION

PEAK ACTION

and

EFFECTIVE DURATION

of

rapid-acting analogs, short-acting, intermediate acting and long-acting.

Rapid-acting analogs: 5-15 min; 30-90 min; 3-5 hours

Short Acting: 30-60 min; 2-3 hours; 5-8 hours

Intermediate Acting: 2-4 hours; 4-10 hours; 10-16 hours

Long-acting (GLARGINE): 2-4 hours; peakless; 20-24 hours

Long-acting (DETEMIR, dose related): 2-4 hours; 6-14 hours; 16-20 hours

·      Humalog Mix 50/50

o   50% lispro protamine and 50% lispro

·      NPH/Regular 70/30 (human)

o   70% NPH and 30% Regular

·      Humalog Mix 75/25 (analog)

o   75% lispro protamine and 25% lispro

·      NovoLog Mix 70/30 (Analog)

o   70% aspart protamine suspension and 30% aspart

rapid-acting

regular 

What is the benefit of taking Regular for food insulin and NPH for basal?

What is the disadvantage?

Benefit: mix regular and NPH - only giving 2 shots per day. Snack throughout the day.

Disadvantage: have to plan how many carbs you will be eating for entire day; NPH peaks in the middle of the night and may cause low.

Lispro/Aspart for food insulin and NPH for basal.

They need to eat more and smaller meals; NEED snack before bedtime; better regiment bc NPH peaks towards breakfast.

What injection site is insulin best absorbed in? 2nd best? 3rd?

Why should you move around the injection sites?

Best: Abdomin, 2 inches away from belly button

2nd: never in front

3rd: outer part of the thigh, one handbrest above the knee

Also can do upper buttocks

Avoid hypertrophied sites (scar tissue) because the insulin isn't absorbed as well

Note: runners do not want to inject into thigh... increased blood flow = increased absorption.

highly motivated pts who are willing to check BS regularly and to check the carbs at each meal.

basal (pre-set) and bolus (on demand programming: this many carbs + my BS = ??? units insulin)

T2DM

functioning (insulin secreting) pancreas

Sulfonylureas (oldes class and all generic meds):

What they do: _________.

Med: _____, _____, _____.

Major SE: _____ 

What they do: improve insulin release from the pancreas.

Med: Glyburide, Glipzide, Glimeprameds.

Major SE: Low BS 

What they do: improve insulin release from the pancreas.

Med: Glyburide, Glipzide, Glimeprameds.

Major SE: Low BS 

What Class??

What they do: improve insulin release from the pancreas. Stimulate the pancreas to make more insulin; just used before meals.

Med: Repaglinde, Nateglinide.

What Class??

Meglitinides (pricey)

What they do: __________.

Meds: _____, _____. 

What they do: improve insulin release from the pancreas. Stimulate the pancreas to make more insulin; just used before meals.

Meds: Repaglinde, Nateglinide.

Biguanides

Med: _____.

What they do: __________.

What must you check before administering? _____ and _____.

SE: _____; _____

Dose: _____

Metformin

Increase tissue response to insulin (helps insulin work better) and decrease hepatic production of glucose

Creatinine and GFR

GI upset; weight loss (great for obese T2 DM pts)

Dose: start slow (500 mg/day) and the max is 1000 mg bid

Med: Metformin

What they do: Increase tissue response to insulin (helps insulin work better) and decrease hepatic production of glucose

Must check FIRST: Creatinine and GFR

SE: GI upset; weight loss (great for obese T2 DM pts)

Dose: start slow (500 mg/day) and the max is 1000 mg bid

Thiazolindinediones (TZD's) (Glitazones) (not generic = pricey)

Meds: _____, _____.

What they do: __________.

SE: _____

CI: _____

Meds: Rosiglitazone, Pioglitazone

What they do: Increase insulin action at receptors and post receptors in hepatic and peripheral tissue to decrease insulin resistance

Se:

- Both: weight gain, edema

- Rosiglitazone: associated w inc cardiac risks

- Pioglitazone: inc risk of bladder cancer

CI: Stage 3-4 CHF

Meds: Rosiglitazone, Pioglitazone

What they do: Increase insulin action at receptors and post receptors in hepatic and peripheral tissue to decrease insulin resistance

Se:

- Both: weight gain, edema

- Rosiglitazone: associated w inc cardiac risks

- Pioglitazone: inc risk of bladder cancer

CI: Stage 3-4 CHF

Alpha-glucosidase inhibitors (Rare):

Meds: _____, _____.

What they do: __________.

SE: _____, _____.

Meds: Acarbose, Miglitol

What they do: delay digestion of complex carbs and certain sugars to blunt peak of blood glucose and insulin levels after meals... idea is to stop bs spike after eating.

SE: gas, bloating

Meds: Acarbose, Miglitol

What they do: delay digestion of complex carbs and certain sugars to blunt peak of blood glucose and insulin levels after meals... idea is to stop bs spike after eating.

SE: gas, bloating

WHAT CLASS?

Incretin Based Therapies:

What they do: __________.

Use in: _____ and _____.

Meds: _____, _____, _____, _____, _____.

SE: _____, _____.

What they do: mimic GLP 1 (Enhance insulin secretion, suppress glucagon secretion, slow gastric emptying, and promote satieity)

Use in: pt who want to lose weight and in truck drivers

Meds:

- Exanatice (Byetta): IV before meals

- Exanatide extended-rel (Bydureon): IV once/wk

- Liraglutide (Victoza): IV daily

- Sitagliptin (Januvia): PO, keep GLP1 from breaking down

- Saxagliptin (Onglyza): PO, keep GLP 1 from breaking down

SE: GI upset, weight loss

What they do: mimic GLP 1 (Enhance insulin secretion, suppress glucagon secretion, slow gastric emptying, and promote satieity)

Use in: pt who want to lose weight and in truck drivers

Meds:

- Exanatice (Byetta): IV before meals

- Exanatide extended-rel (Bydureon): IV once/wk

- Liraglutide (Victoza): IV daily

- Sitagliptin (Januvia): PO, keep GLP1 from breaking down

- Saxagliptin (Onglyza): PO, keep GLP 1 from breaking down

SE: GI upset, weight loss

Amylin Therapy

What they do: __________.

Med: _____.

Use in: _____ and _____.

What they do: suppress glucagon secretion, slow gastric emptying and promote satiety (used in T1DM along with insulin and T2DM)

Med: Pramlintide (Symlin)

Use in: T1DM with insulin and in T2DM

What they do: suppress glucagon secretion, slow gastric emptying and promote satiety (used in T1DM along with insulin and T2DM)

Med: Pramlintide (Symlin)

Use in: T1DM with insulin and in T2DM

- GLP secreted by gut upon injestion of food

- beta cells: inhance glucose-dependent insulin secretion

- Alpha cells: decrease postprandial glucagon secretion

- Liver: decrease glucagon secretion

- Stomach: helps regulate gastric emptying

- Promotes satiety and reduces appetite

The selection of medications for T2DM is:

First:

Then:

Finally:

First: DIET, EXERCISE, METFORMIN

Then: Generics

Finally: specific, more pricey drugs

Adding evening insulin to T2DM pts while continuing oral agents can allow the pancreas to rest.

T/F?

TRUE

Can give:

- Insulin glargine or insulin determir

- NPH insulin at Bedtime
- 70/30 insulin at supper along with food insulin 

WHAT IS DIABETES?

Then, talk about glucose monitoring, what to do with numbers, goal making, exercising, dieting, et.

Hypoglycemia deprives the brain of glucose and requires immediate intervention to restrore the blood glucose to nl levels.

T/F?

TRUE

Even if the pt does not show symptoms, we need to intevene immediately.

It is bad when patient's experience symptoms of hypoglycemia because it worsens the SE of the acute complication.

T/F?

Hypoglycemia unawareness

A bad thing where the pt is so used to feeling low that they are unable to realize when their bs is dropping to a dangerous number.

Not enough glucose to the brain

Slow thinking, blurred vision, slurred speech, uncoordination, numbness, trouble concentrating, dizziness, fatigue/sleepiness

checking bs every 2 hours and giving doses of insulin on top of each other

acute hypoglycemia

the liver cant multitask (can't put out stored glucose and take care of the alcohal at the same time)

acute hypoglycemia

- Missing a meal after taking insulin

- Taking too much insulin or oral hypoglycemic agent

- stacking insulin doses

- Excessive exercise

- Drinking

- Vomitting or Diarrhea

Insulin peaks

Night time

Exercise

NPO for surgery or a procedure

If a person's blood sugar is less than 70, but they are not showing signs of hypoglycemia, you don't have to treat their low blood sugar.

T/F?

FALSE

If a person is below 70, treat, with or without symptoms.

How many carbs are necessary to give a person who's bs is below 70? below 50?

What are some good carbs to give someone for an acute hypoglycemic event?

15 g Carbs

20-30 g Carbs

Fruit Juice (1/3-1/2 C); Non-diet soft drink (4-6 oz); skin milk (1 C); Honey/jelly/corn syrup (1 Tbs); Sugar (3-4 tsp); glucose tabs

Retest blood sugar 15 min after supplemental carbs.

Provide snack (complex carb ie 6 saltines, 3 graham crackers, 1 slice of bread, etc.; or protein before bed) if a meal/snack is not within the next 30-60 min

If unconcious due to sever hypoglycemia, what should be administered?

Following administration, what steps should be taken and how long will it be till they are woken up?

Glucagon

Turn on side; most likely will vomit

- D50 IV (25ml) – ½ amp probably enough to wake them up and then treat them PO to continue to get bs up

 = D5 (300 ml for 15 g) or D10 (150ml for 15 g) IV if hanging already (Push slowly over 3-5 min; make sure you have a good vein bc it can be irritating to tissue)

Will wake in 15-20 min

Diabetic Ketoacidosis is a life threatening complication with a mortality rate < 5%

T/F?

GI Symptoms (throwing up and not eating - still important to take basal insulin)

Weight loss: s/s new DM pts; can't get the glucose into the cells for energy so the body begins breaking down fat

Psychological problems

Insulin deficiency causes (inc/dec) uptake of glucose in the tissues, (inc/dec) glucose production by the liver, and protein breakdown resulting in (inc/dec) amino acids for glucose production in the liver, leading to (Hyper/Hypo)glycemia.

This proufound insulin deficiency is characterized by _____.

decreased

increased

increased

hyperglycemia

DKA

§  Insulin deficiency increases counter regulatory hormones

ú  Fat breakdown leading to increased fatty acids and glycerol

·      Glycerol leads to increased glucose production by the liver

·      Excessive ketone bodies formed in the liver (betahydroxybuturic acid and acetoacetic acid)

DKA

CO2

Ketones

A patient with DKA may be delerious or in an acute confusional state.

T/F?

TRUE

Along with these other Clinical manifestations:

o   Metabolic acidosis

o   Usually Elevated serum K level (initially)

o   Usually High serum glucose

o   Dehydration

o   Fruity breath (ketones, smells like they are drunk)

§  Very specific to acidosis

o   Rapid, deep respirations to get rid of CO2

REHYDRATE

IV infusion of isotonic saline; rapidly unless contraindicated

POTASSIUM; if hypokalemic, need to replace K+ 1-2 hours before insulin.

Do NOT give insulin if K+ is < 3.3 mEq/L because it will continue to drop and the pt will experience severe hypokalemia

What does checking the ABG in a pt with DKA look for?

How should you correct this number?

pH levels

low-dose insulint (5-10 units/hr, IV)

monitor blood glucose every hour

in ICU, dilute sodium bicarb only if pH < 7.0

SE of high bs

abdominal pain, N/V

55-70

2

Diet

Oral Agents

15%

The most common precipitating factor of pt's with Hyperosmolar Hyperglycemia Syndrom is:

Others include:

INFECTIONS (30-50% have UTI or pneumonia)

Massive fluid loss from prolonged osmotic diuresis, MI, GI hemorrhage, arterial thrombisis, hypertonic feeding, and certain drug therapy

Patients with HHS may have focal neurological signs that mimic a CVA.

T/F?

What is the most common SE to pt's with HHS?

What are the differences between pt's with HHS and DKA? (3 things...)

Decreased Mentation (lethary and mild confusion)

Pt's with HHS have milder GI symptoms, seldom have kussmaul respirations, and may have neuro deficits that mimic CVA.

Rehydration

Insulin (dec when bs is at about 300 mg/dl)

Prevent complications

treat underlying med conditions

educate about DM and follow up

Pt diagnosed with DM should have an eye exam to check for retinopathy. If negative for retinopathy, you don't need to test again.

T/F?

FALSE!

Should have eye exam once/year

How often should DM pt's have a urine/albumin exam to check for Nephropathy?

What are ways to treat nephropathy?

Once per year if nl

If abnl, check in 3 months

If abnl again, monitor for 24 hours

Possibly put on ACEI or ARG and protect kidney

Walking! It will hurt at first but will get better with exercise...

Also, support hose can be beneficial.