Diabetes

Question 1

What is metabolic syndrome?

Answer 1

A group of metabolic risk factors (must be dx / 3 or more: obesity, hypertension, abnormal lipid levels, high BG) that increase a person’s risk of CVD, stroke, and diabetes. 1/3 adults have it. usually in 60+.

Question 2

What is the main underlying risk factor of metabolic syndrome?

Answer 2

insulin resistance (Cell’s decreased ability to respond to action f insulin, so pancreas secretes more insulin resulting in hyperinsulinemia) related to visceral fat

Question 3

What are the criteria that someone must need 3 of to be dx with metabolic syndrome?

Answer 3

waist circumference over 40in in men, 35in in women

drug treatment for high triglycerides (40mf/dL men, 50mg/dL women)

Drug treatment for high cholesterol

drug treatment for hypertension (130mmHg systolic, 85mmHg diastolic BP)

fasting BG greater than 100mg/dl

Question 4

define diabetes mellitus

Answer 4

hyperglycemia from abnormal insulin production, impaired insulin use, or both

Question 5

insulin is produced by

Answer 5

The B cells in the islets of langerhans of the pancreas

Question 6

How much insulin is naturally secreted daily

Answer 6

40-50U OR 0.6U/kg of body weight

Question 7

What is a normal glucose range?

Answer 7

74-106mg/dL

Question 8

Insulin is a ______ (storage) hormone

Answer 8

anabolic: stops body from using fat/protein as energy source and makes protein/fat storage

Question 9

Two examples of insulin dependent tissues

Answer 9

skeletal and adipose tissue. have receptors specific for insulin so that insulin can unlock transport of glucose into cells for energy use

Question 10

Why is liver function important for diabetics?

Answer 10

Liver isn’t insulin-dependent although it needs insulin to uptake glucose and turn it into glycogen

Question 11

What hormones work against the effects of insulin?

Answer 11

(counterregulatory hormones)

glucagon, epinephrine, growth hormone, cortisol

they stimulate glucose production/release form liver and inhibit glucose from going into the cells

Question 12

T/F; counterregulatory hormones and insulin work together to keep BG levels in range

Answer 12

T

Question 13

Why is measuring C-peptide in the blood serum helpful for diabetic pts

Answer 13

Proinsulin is precursor to insulin. Proinsulin is split by enzymes to form insulin and c-peptide (released in equal amounts). The measure of c-peptide indicated the level of insulin in blood

Question 14

Describe type 1 diabetes

Answer 14

more common in young people

abrupt onset of symptoms

accounts for 5-10% of diabetes

Caused by viruses, toxins, autoimmune reaction to islet cells. HLA-DR3 &4 are exposed to viral infection and kill the pancreas instead of the virus.

characterized by absent/minimal insulin

Symptoms include weight loss without trying, lots of peeing, fatigue

Goes into ketosis with out insulin, needs insulin therapy

Can be thin, normal, or obese

Question 15

Describe type 2 diabetes

Answer 15

more common in adults w/ rise in children. Is gradual and may go undiagnosed for years

90-95% of all diabetes

Insulin levels are initially increased but decrease over time

pts are often asymptomatic aside from polyuria and fatigue. May have recurrent infections

Question 16

Is type 2 diabetes polygenic (passed down from family members)?

Answer 16

yes

Question 17

What is the pathophysiology of type 2 diabetes?

Answer 17

Obesity causes decrease in adiponectin (regulates blood glucose storage in fat) and increase in lectin (hunger hormone) which causes adipose and skeletal muscle cells to become insulin resistant so more glucose in blood so b cells in pancreas secrete more insulin than usual but then b cells get tired and slowly stop making insulin. Glucagon secretion is increased because it always wants to match insulin levels so the liver releases more glucose even though the body doesn’t need it which makes the blood even more sugary. Creates a temporary state of high insulin and high glucose in the blood.

Then pancreas gives up making insulin.

Then the liver releases a ton of glucose whenever it wants and the fat cells forget how to use adipokines to regulate glucose processing and hunger.

type 2 diabetes usually detected when only 50-20% of b cells are working, usually when pt has had it for 6.5 years

Question 18

When would a patient be diagnosed with prediabetes?

Answer 18

if the pt has impaired glucose tolerance or impaired fasting glucose

Question 19

What pregnant women are high risk for gestational diabetes?

Answer 19

obese, advanced ag, family hisotry of diabetes

screened at 24-28 weeks

if they had it during pregnancy they have a 63% chance of developing type 2 diabetes w/ in 16 years

Question 20

What are the four methods of diagnosing diabetes

Answer 20

A1C 6.5% or higher

fasting plasma glucose of 126 or higher

a 2 hour plasma glucose level of 200 mg/dL after giving 75g of glucose

symptomatic pt w/ plasma glucose level of 200mg/dL or higher

1-3 need repeat testing to confirm diabetes dx

Question 21

What does A1C measure?

Answer 21

if value if 6.5%, it means that 6.5% of the total Hgb has glucose attached to it. When blood glucose levels are high, overtime the amount of glucose attached to hgb increases. Once attached to Hgb, it stays for 120 days. Therefore, it provides the blood glucose levels of the past 2-3 months

Question 22

How do you calculate the blood glucose from an A1C value?

Answer 22

you use eAG (estimated Average Glucose) formula

eAG=28.7xA1C-46.7

Question 23

What should you measure instead of A1C if pt is anemic?

Answer 23

Fructosamine reflects previous 1-3 weeks

Question 24

how is insulin manufactured nowadays

Answer 24

genetically engineered human insulin made from E-Coli or yeast cells in a lab

Question 25

What are the three things that differentiate insulin types?

Answer 25

onset, peak action, and duration

Question 26

What are the four types of insulin

Answer 26

rapid acting, short acting, intermediate acting, and long acting

Question 27

What insulin approach most closely mimics natural insulin production

Answer 27

basal-bolus plan consists of multiple daily insulin injections (insulin pump) w/ frequent/continue BG monitoring. Includes rapid/short acting bolus insulin before meals and intermediate/long acting background insulin once/twice a day

Question 28

Describe the difference between bolus/basal insulin administration

Answer 28

Bolus means around mealtime. Basal means maintenance of baseline amount

Question 29

RAPID-acting insulin has an onset of action of

Answer 29

15 minutes so should be injected w/ in 15 min of meal time

Aspart (NovoLog), glulisine (apidra), lispro (humalog)

Question 30

SHORT ACTING insulin has an onset of action of

Answer 30

30-60min. Should be injected 30min-hr before meal. More likely to cause hypoglycemia due to long action

usually does not have a peak of action

Question 31

Examples of BOLUS insulin types

Answer 31

RAPID: Aspart (NovoLog), glulisine (apidra), lispro (humalog)

SHORT: regular

Question 32

Examples of BASAL insulin types

Answer 32

degludec (resiba), detemir usuualyl given twice daily (levemir), glargine (lantus, toujeo, basaglar)

Question 33

rapid acting insulin is

Answer 33

aspart

onset 15-30min

peak 30min-2.5hr

duration 3-6hr

Question 34

short acting insulin is

Answer 34

regular (humulin R, novolin R)

onset 30min-1hr

peak 1-5hr

duration 6-10hr

Question 35

intermediate acting insulin is

Answer 35

NPH (humulin N, novolin N)

onset 1-2hr

peak 6-14hr

duration 16-24hr

Question 36

long acting insulin is

Answer 36

degludec (tresiba), detemir (levemir), glargine (basaglar, lantus, toukjeo) insulin glargine (basaglar)

onset 1hr 10min

peak steady levels

duration 18-24hr

Question 37

T/F: Intermediate acting insulin can be used as basal insulin

Answer 37

T. It has a duration of 12-18hrs, peak is 4-12 hrs which can result in hypoglycemia. Never give iV

Question 38

What protein makes insulin cloudy and makes the insulin work longer?

Answer 38

protamine

Question 39

What phenomenon tends to cause morning hyperglycemia in diabetic patients after not eating during a nights sleep?

Answer 39

Somogyi effect: a high dose of insulin during the night causes body to overcompensate conversion of glycogen to glucose. Eat bedtime snack, reduce insulin, or both.

Dawn phenomenon: related to increased secretion of GH and cortisol in the early morning hours. Treat by increasing insulin or giving it in the early morning

Question 40

What are the 3 metabolic functions of the liver.

Answer 40

Glucose: Primary form of energy for cells
Glycogen: Storage form of glucose
Glycogenesis: Conversion of glucose to glycogen

Question 41

What is Amylin (from beta cells)

Answer 41

Decreases gastric motility, decreases glucagon secretion, decreases endogenous glucose release from liver, increases satiety

Question 42

What is Glucagon (from alpha cells)

Answer 42

Stimulates glycogenolysis and gluconeogenesis

Question 43

What is Somatostatin (from delta cells)

Answer 43

Inhibits insulin and glucagon secretion

Question 44

Describe normal endogenous insulin secretion

Answer 44

Normal endogenous insulin secretion. In the first hour or two after meals, insulin concentrations rise rapidly in blood and peak at about 1 hour. After meals, insulin concentrations promptly decline toward preprandial (before a meal) values as carbohydrate absorption from the gastrointestinal tract declines. After carbohydrate absorption from the gastrointestinal tract is complete and during the night, insulin concentrations are low and fairly constant, with a slight increase at dawn.

Question 45

What are the function of Counterregulatory Hormones

Answer 45

Oppose effects of insulin
Increase blood glucose levels
Provide regulated release of glucose for energy
Help maintain normal blood glucose levels
Examples
Glucagon, epinephrine, growth hormone, cortisol

Question 46

What additives affect insulin’s onset, peak, and duration?

Answer 46

zinc, acetate buffers, and protamine are added to insulin in various ways to manipulate onset, peak, and duration.

Question 47

What is the function of metformin (glucophage)

Answer 47

Is a Biguanide
Reduce glucose production by liver
Enhance insulin sensitivity at tissues
Improve glucose transport into cells
Do not promote weight gain

Question 48

What is the function of Sulfonylureas

Answer 48

↑ insulin production from pancreas
Major side effect: Hypoglycemia
Examples
Glipizide (Glucotrol)
Glimepiride (Amaryl)
Glyburide (DiaBeta)

Side effect (other): Weight gain
When insulin is secreted, glucose is able to enter the cells, and glucose levels drop. This is the desired therapeutic goal. However, if the number of calories taken in and activity level result in more calories than the person needs to maintain a healthy weight, the cells will get more glucose than they need. Glucose that cells don’t use accumulates as fat.

Question 49

What is the function of Dipeptidyl peptidase-4 (DPP-4) inhibitor

Answer 49

AKA “gliptins”
These medications increase insulin release from the pancreas, decrease glucagon secretion, and decrease hepatic glucose production.
These medications are glucose dependent, so there is less risk of hypoglycemia, weight gain.
Examples
Sitagliptin (Januvia)
Saxagliptin (Onglyza)

used for obese pts b/c The main benefit of these drugs over other medications with similar effects is the absence of weight gain as a side effect.

Question 50

Examples of drugs that may cause diabetic complications

Answer 50

-adrenergic blockers (Beta-adrenergic blocking agents are a class of medicines that bind to beta-adrenoreceptors and prevent the binding of norepinephrine and epinephrine at these receptors. This prevents sympathetic stimulation of the heart and reduces heart rate, cardiac contractility, conduction velocity, and relaxation rate which decreases myocardial oxygen demand and increases exercise tolerance. Beta-adrenergic blocking agents are commonly referred to as beta-blockers.)
Mask symptoms of hypoglycemia
Prolong hypoglycemic effects of insulin

Corticosteroids (First, they increase insulin resistance, causing insulin to work less effectively in the body. Second, steroids can trigger the liver to release extra glucose, also leading to high blood glucose levels.)
Can increase blood glucose levels in people who already have and people who don’t have DM

Thiazide and loop diuretics
Can worsen hyperglycemia by inducing potassium loss

Question 51

What is the function of Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

Answer 51

These drugs block the reabsorption of glucose by the kidney, increasing urinary glucose excretion.
Examples
canagliflozin (Invokana)
dapagliflozin (Farxiga)
empagliflozin (Jardiance).

Question 52

T/F: Diabetic patients would benefit from immediately starting low carb, high protien diet immediately upon Dx

Answer 52

F: Guidelines from the ADA state that, within the context of an overall healthy eating plan, a person with diabetes can eat the same foods as a person who does not have diabetes. This means that the same principles of healthy nutrition that apply to the general population also apply to the person with diabetes.

Question 53

T/F: Alcohol can cause potentially dangerous levels of BG

Answer 53

F: Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver. This can cause severe hypoglycemia in patients on insulin or OAs that increase insulin secretion. A patient can reduce the risk for alcohol-induced hypoglycemia by eating carbohydrates when drinking alcohol. On the other hand, mixed drinks often contain sweetened mixers and can increase blood glucose levels

Question 54

How many grams of carbs are in a recommended serving

Answer 54

15g

Question 55

What is the effect of exercise on diabetic patients?

Answer 55

Essential part of diabetes management
↑ insulin receptor sites
Lowers blood glucose levels
Contributes to weight loss

A small carbohydrate snack can be taken every 30 minutes during exercise to prevent hypoglycemia.
Best done 1 hour after meals

Exercise plans should be started
After medical clearance
Slowly with gradual progression
Monitor blood glucose levels before, during, and after exercise.

The ADA recommends that people with diabetes engage in at least 150 min/wk (30 minutes, 5 days/week) of a moderate-intensity aerobic physical activity.
The ADA encourages people with type 2 diabetes to perform resistance training 3 times a week unless contraindicated.

Question 56

A pt is considered hypoglycemic if Blood glucose level is less than

Answer 56

70 mg/dL

Question 57

Describe the 15-15 rule in the midst of a hypoglycemic episode

Answer 57

The 15-15 rule—have 15 grams ofcarbohydrateto raise your blood sugar and check it after 15 minutes. If it’s still below 70 mg/dL, have another serving.

Avoid treatment with carbohydrates that contain fat, such as candy bars, cookies, whole milk, and ice cream. The fat in those foods will slow the absorption of the glucose and delay the response to treatment. Do not overtreat with large quantities of quick-acting carbohydrates because a rapid fluctuation to hyperglycemia can occur.

Question 58

What are two ways to treat hypoglycemia in an acute care setting if the pt is NOT ALERT ENOUGH TO SWALLOW

Answer 58

Administer 1 mg of glucagon IM or subcutaneously. PRN order required
Side effect: nausea
In acute care settings *PRN order required
20 to 50 mL of 50% dextrose IV push
Have patient ingest a complex carbohydrate after recovery.

Question 59

How does diabetes affect a patient long term?

Answer 59

Chronic complications associated with diabetes are primarily those of end-organ disease from damage to blood vessels(angiopathy)from chronic hyperglycemia.

Angiopathy is a leading cause of diabetes-related deaths, with about 68% of deaths caused by CVD and 16% caused by strokes for those ages 65 or older.

retinopathy, cataracts, glaucoma, blindness, ED infections, peripheral vascular disease, peripheral neuropathy, anything to do with perfusion of blood

Question 60

What meds can a diabetic pt take to avoid long term complications from diabetes?

Answer 60

Capsaicin is a moderately effective topical cream made from chili peppers. It depletes the accumulation of pain-mediating chemicals in the peripheral sensory neurons. The cream is applied 3 or 4 times a day.
Tricyclic antidepressants are moderately effective in treating diabetes-related neuropathy. They work by inhibiting the reuptake of norepinephrine and serotonin, which are neurotransmitters thought to play a role in the transmission of pain through the spinal cord.
Duloxetine may relieve pain by increasing the levels of serotonin and norepinephrine, which improves the body’s ability to regulate pain.
Antiseizure drugs decrease the release of neurotransmitters that transmit pain.

Question 61

Describe autonomic neuropathy

Answer 61

Can affect nearly all body systems
Complications:
Delayed gastric emptying can produce anorexia, nausea, vomiting, gastroesophageal reflux, and persistent feelings of fullness.
Cardiovascular abnormalities associated with autonomic neuropathy include postural hypotension, resting tachycardia, and painless myocardial infarction.
Erectile dysfunction (ED) in diabetic men is well recognized and common, often being the first manifestation of autonomic failure.
A neurogenic bladder may develop as sensation in the inner bladder wall decreases, causing urinary retention. A patient with retention has infrequent voiding, difficulty when voiding, and a weak stream of urine.