Block 3: Diabetes IV-T1DM Flashcards
What are the treatment options of T1DM?
Lifestyle mod: diet and exercise
Insulin due to inability to produce insulin
How do you iniitiate multi-dose insulin?
Total daily dose: 0.6 units/kg
Basal dose = 50% of total daily insulin dose
Pre-breakfast = 20% of total daily insulin dose
Pre-lunch = 15% of total daily insulin dose
Pre-supper = 15% of total daily insulin dose
What is basal insulin?
Controls hepatic glucose production
What is prandial/bous insulin?
- Based on meal carb content
- Controls post-prandial glucose levels
What is correction insulin?
- Treats acute elevations in blood glucose
- Amount of insulin needed to correct a high blood glucose level
- Change in insulin dose based on a single event such as Thanksgiving dinner or a single out of target glucose level
What is the carb:insulin ratio?
Amount of rapid or short acting insulin needed to cover the carb content of a meal
What are the methods of calculating carb:insulin ratio?
Rule of 450 (Regular Insulin)
450/Total daily insulin dose in units = carb : insulin ratio
Rule of 500 (Rapid Acting Insulin):
500/Total daily insulin dose in units = carb : insulin ratio
What do you do if carb:insulin ratio is correct?
PPG will be in target range by 2 hours after the meal
What do you do if a patient has too frequent lows?
Too much insulin
Solution: increase the carb: insulin ratio
What do you do if a patient has too frequent high?
Too little insulin
Solution: decrease the carb : insulin ratio
What are the methods of using a correction dose?
Consistent carbohydrate intake:
1. Pre-meal insulin dose determined by algorithm based on pre-meal blood glucose values
2. Fixed pre-meal insulin dose with algorithm to determine additional (correction/supplemental) insulin dose based on pre-meal blood glucose level
3. Fixed pre-meal insulin dose with ISF used to determine additional (correction/supplemental) insulin dose
Flexible carbohydrate intake:
Carb:insulin ratio used to determine pre-meal insulin dose AND ISF used to determine additional (supplemental) insulin dose
How do you calculate correction dose?
What is ISF?
The amount that one unit of rapid- or short-acting insulin will lower blood glucose
Used to calculate correction dose
What is the insulin/blood glocose formula?
One unit of rapid or short acting insulin per 50 mg/dl increase or decrease in blood glucose level from goal (ISF = 50)
What do you do in pattern management?
- Make insulin adjustments using a least a 3 day average
- Determine if dietary intake or insulin dose is affecting blood glucose levels or if something else is causing the alteration
- Change one thing at a time
Insulin dose adjustment is based on?
A1C and BGM taking into account the peak and duration of the insulins used
What factors do you need to consider prior to insulin adjustment?
- Compliance
- Technique
- Timing of meals and exercise
- Rotation of injection site
- Over insulization
How do you manage diabetes in adolescents?
Obesity is on the rise in adolescents and children
Treatment options:
1. Lifestyle mod
2. Metformin, SU
3. Injectables: GLP1 (>10YO), insulin
What is the preconception care for diabetes?
Need to have glood glucose control prior to pregnancy to help prevent problems
Use insulin for control during pregnancy:
1. No PO
2. Need more diet and exercise
Eliminate potentially teratogenic medications prior to conception, i.e., ACE, ARB, Statin
How do you treat gestational diabetes?
Important for the health of both infant and mother:
1. Diet
2. Insulin
How does diabetes affect elderly?
Renal function decreases with age:
1. Increased risk of hypoglycemia
2. Increased risk of lactic acidosis
Higher blood glucose and A1c goals may be appropriate in some elderly patients.
What are the diabetes tx for eldrely?
- Low dose sulfonylureas, short-acting insulin secretagogues, alpha-glucosidases, TZDs, etc.
- Simple insulin regimens
- Less aggressive, simplified regimens in certain situations
What are sick days in T1DM?
More insulin is needed to control blood sugar during illness
What are tips to overcome T1DM sick days?
- Take usual insulin dose
- Monitor blood glucose levels and use rapid-acting insulin based on the results
- Monitor for ketones when FSBS > 250
- Additional insulin may be needed for ketonuria
- Gatorade (sports drinks)
What are sick days in T2DM?
Usually not a major problem because most patients with Type 2 DM have some insulin production
How do you overcome T2DM sick days?
- Monitor BG levels closely
- Sugar free drinks
What are the BG levels of hospitalized patients?
Hyperglycemia: >140 mg/dl
Hypoglycemia: <70 mg/dl
Severe Hypoglycemia: <40 mg/dl
How do you manage hospitalized patients on insulin?
Scheduled insulin plus additional short-acting as needed
Avoid reactionary dosing
How do you manage hospitalized patients on PO diabetes agents?
May need insulin to control blood sugar during hospitalization
Avoid reactionary dosing
What are the diabetic goals in crit ill patients?
140-180 mg/dl for most critically ill patients
110-140 mg/dl if tolerated
Targets <110 mg/dl NOT recommended
How do you manage crit ill diabetics?
Treat hyperglycemia if > 180 mg/dl
Once insulin is started, goal 140-180 mg/dl
What are the diabetic goals in non-crit ill hospitalized patients?
Target fasting <140 mg/dl
Target random <180 mg/dl
How do you manage diabetes in surgeries?
- May need to give reduced doses of insulin until eating normally
- On insulin: scheduled or continuous
- On PO: May need insulin temporailty to control blood sugar
What are the risk factors of fasting?
- Hypoglycemia
- Hyperglycemia
- Diabetic ketoacidosis
- Dehydration and thrombosis
How do you manage diabetes in religious or cultural fastings?
Frequently monitor glucose and breakfast immediately if:
Hypoglycemia
* SMBG <70 mg/dL while taking insulin or sulfonylureas
* SMBG <60 mg/dL while on other therapies
Hyperglycemia: >300 mg/dL
Healthful eating before and after each fasting period:
* Complex carbohydrates prior to fast
* Avoid ingesting high-carbohydrate, high-fat foods when breaking fast
Avoid excessive physical activity but maintain normal exercise routines
Avoid fasting while ill
