Diabetes Flashcards
COMPLICATIONS OF DIABETES
LEADING CAUSE OF:
Adult blindness
ESRD (including dialysis and transplantation)
Non-traumatic limb amputations
Other risk factors:
Death from heart disease 2-4x higher
Stroke 2-4x higher
>50% have HTN and hyperlipidemia
NORMAL GLUCOSE AND INSULIN METABOLISM - where is glucose transported to?
Insulin is produced in the β cells of the islets of Langerhans of the pancreas
Function is to regulate blood glucose
When BG is high, insulin promotes transport of glucose into tissues (skeletal muscles and adipose tissue). Excess is stored as glycogen in liver
Released in small increments throughout the day and increased with food intake
DIABETES MELLITUS - what happens to the cells?
YOUR BODY HAS TROUBLE MOVING GLUCOSE FROM BLOOD INTO THE CELL
THIS LEADS TO HIGH LEVEL GLUCOSE IN THE BLOOD AND NOT ENOUGH IN THE CELL
CELL NEEDS GLUCOSE TO PRODUCE ENERGY
NOT LETTING GLUCOSE ENTER THE CELL LEADS THE CELLS TO STAVE FOR ENERGY
what ARE CONSIDERED INSULIN-DEPENDENT TISSUES?
INSULIN
PROMOTES GLUCOSE TRANSPORT FROM THE BLOODSTREAM ACROSS THE CELL MEMBRANE TO THE CYTOPLASM OF THE CELL
CELLS BREAK DOWN GLUCOSE TO MAKE ENERGY
LIVER AND MUSCLE CELLS STORE EXCESS GLUCOSE AS GLYCOGEN
SKELETAL MUSCLE AND ADIPOSE TISSUE ARE CONSIDERED INSULIN-DEPENDENT TISSUES
CLASSIFICATIONS OF DIABETES: TYPE I
TYPE 1 DIABETES: BODY DOES NOT MAKE ENOUGH INSULIN
Formerly known as juvenile-onset diabetes or insulin dependent diabetes
5-10% of diabetics
Generally in people under 40 but can occur at any age
Absence of endogenous insulin
Autoimmune disorder
Exposure to virus
80-90% of β cell destruction before symptom onset
DM I SYMPTOMS (the Ps and one other)
POLYPHAGIA: GLUCOSE CANNOT GET INTO CELL, CELL STARVES FOR ENERGY, WEIGHT LOSS
GLYCOSURIA: BLOOD GETS FILTERED TO THE KIDNEY, GLUCOSE IN THE URINE
POLYURIA: WATER FOLLOWS GLUCOSE
POLYDIPSIA: DEHYDRATION AND THIRST FROM POLYURIA
CLASSIFICATIONS OF DIABETES: TYPE 2 - what ethnic groups?
TYPE 2 DIABETES
Formerly known as Non-insulin dependent diabetes or adult-onset diabetes
Endogenous insulin produced but inadequate amounts, tissue resistance or overproduction of glucose by the liver
90-95% of diabetics
Less frequently in children but incidents rising due to childhood obesity
Contributing risk factors that lead to insulin resistance:
Family hx, obesity, increasing age, certain ethnic groups (Hispanics, Pacific Islanders, Native Americans, African Americans, Asian Americans)
TYPE 2 DIABETES MELLITUS ONSET OF DISEASE - is it fast or slow?
GRADUAL ONSET
HYPERGLYCEMIA MAY GO MANY YEARS WITHOUT BEING DETECTED
OFTEN DISCOVERED WITH ROUTINE LABORATORY TESTING
AT TIME OF DIAGNOSIS
ABOUT 50% TO 80% OF Β CELLS ARE NO LONGER SECRETING INSULIN
AVERAGE PERSON HAS HAD DIABETES FOR 6.5 YEARS
CLASSIFICATION OF DM: PREDIABETES- # for fasting and after oral glucose test
Individuals who are at an ↑ risk for developing diabetes
They have impaired glucose tolerance (IGT), impaired fasting glucose (IFG) or both
Impaired glucose tolerance – 140-200 mg/dL 2 hours after an oral glucose tolerance test (OGTT). Normal is <140
Impaired fasting glucose – 100-125 mg/dL (normal < 100)
Individuals should have BG and HbA1C checked regularly
Watch for symptoms of diabetes (fatigue, frequent infections, non-healing wounds)
Advise to lose weight, exercise and make healthy food choices to prevent diabetes
DIABETES: DIAGNOSIS AND MONITORING - how does Hba1c measure glucose?
FBG >126 mg/dL
OGTT >200 mg/dL
HbA1c >6.5
In 2010, the ADA recommended the use of *HbA1c for diagnosing diabetes. Advantages: fasting is not required. More accurate picture of glucose control over time (normal Hba1c < 6.55)
Classic Sx of hyperglycemia + random plasma glucose => 200 mg/dl
Hyperglycemia with 3 Ps (polyuria, polydipsia, polyphagia) & a FBG > 126, confirmed by repeat testing x1 = usually no more tests are needed
- Hba1c (glycohemoglobin) measures the % of hg on a RBC that is coated with glucose. Measures the average BG over the past 2 to 3 months. The higher the number, the poorer the BG control
GOOD GLUCOSE CONTROL - what should BG and HbA1c be?
Euglycemia can delay the onset and slow the progression of retinopathy, nephropathy, neuropathy.
Maintain a mean BG of 155 and a HbA1c of <7.0 will reduce risk of developing micro and macrovascular diseases
For every % point ↓ in Hba1c, there was a 35% reduction in risk for kidney and eye complications, but not cardiac
METABOLIC SYNDROME
A collection of risk factors that increases an individual’s chance of developing HTN, cardiovascular disease, stroke and diabetes.
EDUCATION ON NUTRITION
Can use the food pyramid but new method is “myplate” introduced by Michelle Obama
For every Kg lost, a diabetic gains 3 months of life.
Avoid alcohol
high in calories and no nutritional value
leads to hypertriglyceridemia
liver damage
Etoh consumption during fasting state:
Inhibits gluconeogenesis
Altered CNS further contributes to hypoglycemia unawareness
Delayed recovery from hypoglycemia in DMI
Lifestyle change – Difficult to make changes after years old habits
Drug therapy
TYPES OF INSULIN - Rapid acting - ex (a rapid lisp is novel)
Rapid acting
Aspart (Novolog), Lispro (Humalog)
INSULIN FACTOIDS
Regular insulin and ..logs = always clear solution
NPH and protamine containing insulins are cloudy; preparations have additives of zinc, protamine and acetate buffer
Premixed insulin (short/rapid acting with intermediate acting) What are the benefits vs drawbacks?
MIXING AND ADMINISTERING - clear before cloudy
Mixing
Which do you draw up first and why?
Rapid or short-acting first (clear solution) then intermediate (cloudy) or long-acting
This is to prevent contamination of intermediate/long acting from contaminating short acting
Administering
Sites – Rotate injection sites within a particular area ½ to 1” apart. Fastest absorption is from the FAT in the abdomen (not muscle), then arm, then thigh and last buttock.
INSULIN REGIMEN: THINKING LIKE A PANCREAS- Basal-bolus regime (just rapid at meals and long acting all day)
Basal-bolus regimen
Regimen that closely mimics endogenous insulin production
Uses rapid or short acting (bolus dose) insulin at meal time and intermediate or long acting (basal dose)
CONSIDERATIONS - TSA
If exercising, do NOT inject in the thigh
Assess insulin administration barriers:
Neuropathies
Visual and motor deficits
When injecting prefilled insulin syringe, gently roll in palm 10-20x to warm insulin and resuspend particles
Alcohol swabs – not necessary at home
What about traveling with insulin?
***on test - According to TSA website, notify TSA officer that you have diabetes and are carrying insulin. Insulin pumps and supplies must be accompanied with insulin, and must be clearly labeled.
INSULIN STORAGE - temp, and how long?
Insulin vials and pens may be kept at room temperature up to 4 weeks as long as it’s not < 0 degrees or >86F degrees
INSULIN
ADMINISTRATION OF INSULIN
ABSORPTION IS FASTEST FROM ABDOMEN, FOLLOWED BY ARM, THIGH, AND BUTTOCK
ABDOMEN IS OFTEN PREFERRED SITE
DO NOT INJECT IN SITE TO BE EXERCISED
ROTATE INJECTIONS WITHIN AND BETWEEN SITES
PROBLEMS WITH INSULIN THERAPY - what about fat?
HYPOGLYCEMIA
ALLERGIC REACTION
LIPODYSTROPHY
INSULIN COMPLICATION: SOMOGYI EFFECT
A unique combination of hypoglycemia early morning (2am to 4am) and rebound hyperglycemia upon waking up
Due to too much evening insulin causing counterregulatory hormones (epinephrine, GH, cortisol, glucagon) release which stimulate lipolysis, gluconeogenesis, glycogenolysis → hyperglycemia
DAWN PHENOMENON - and what hormones cause it?
(dawn grows)
Hyperglycemia also present upon awakening
Due to 2 counterregulatory hormones (growth hormone and cortisol). GH & cortisol oppose insulin causing glucose to rise
DRUG THERAPY: ORAL AGENTS - Sulfonylureas - what do they do? (cooking)
(sulfur pancakes)
Know major classifications, where they work and timing of the oral agents
Sulfonylureas – stimulates pancreas to produce more insulin
ORAL AGENTS - Meglitinides- fast or slow? (mega lit, mega fast)
Rapid and short lived release of insulin from the pancreas.
Biguanides - how do they work?
(big liver)
Biguanides – Work at the liver to inhibit glucose release, enhances insulin sensitivity and glucose transport to tissues, esp muscles
⍺-Glucosidase inhibitors - how do they work?
(a gluc is blocking my starch)
(starch blockers) delays the absorption of carbs from the small intestine
Thiazolidinediones (TZDS) - how does it work?
(Thia is sensitive)
“insulin sensitizers”
Work at the muscle cells to ↑ insulin sensitivity and glucose transport and ↓ endogenous glucose production
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS - how does it work?
dip into creatin to release insulin)
Enhances incretin activity (inhibits the enzyme that inactivates incretin)
Result
↑ insulin release from pancreatic β-cells when BG is normal or high esp in response to a meal
COMBINATION THERAPY
Combination therapy: combination of OAS classes to target different sites for optimal blood glucose control
Refer to Lewis, p 1131, table 48-7. There are more now than are listed there.
NON INSULIN INJECTABLES = peptide-1- what is it made from?
(1 peptide is a monster)
***Glucagon like peptide-1 (GLP-1) receptor agonists
Made from synthetic Gila monster saliva
BYETTA - side effects (bye headache)
Sides effects:
Mild to moderate nausea in 44% of the people. Dose-dependent and ↓ over time but some can’t tolerate this.
Headache, diarrhea, hypoglycemia (Risk of hypoglycemia increases with adjunct therapy such as sulfonylureas)
Acute pancreatitis and kidney problems are associated with this drug
GOAL IS EUGLYCEMIA
Goal is to aggressively control blood sugar and minimize side effects
Patient should have an endocrinologist in charge for the best and update to date interventions. 85% of diabetics in this country are managed by their PCP. Most generalists are not experts in Diabetes and are not current on the latest therapies
EXERCISE - how often?
Regular exercise decreases insulin resistance
which lowers BG, contributes to weight loss
and may reduce the need for medication
ADA recommends moderate aerobic exercise 30min 5x/wk with resistance training when cleared by PCP
MONITORING
Makes sure your client knows how to check BG properly
Keep log of BG levels when starting or optimizing treatment
Assess knowledge by return demonstration
Assess patient for barriers to learning
Teach patient S&S of hypo and hyperglycemia
FOOT CARE - water temp?
Instruct patient to:
Wash feet in warm water every
day, ensuring water is not too hot
Do not soak feet
Dry feet well. Especially between toes
Apply lotion on feet after washing and drying
File corns and calluses gently with emery board or pumice stone; do not cut
TEACHING - what to do if you can’t eat?
Meds
Insulin storage
Self care, foot care & hygiene
Medical identification
Sick day management
Continue to take insulin and oral agents
Check BG more frequently (every 3-4 hrs)
Notify care provider
Drink fluids if cannot eat
Traveling: travelling across time zones be sure to have more than adequate supplies.
Meds with carry-on or store with check in luggage?
Follow-up care (assess for barriers)
is hypoglycemai fast or slow? (fast and low)
There is usually a gradual onset of symptoms in hyperglycemia, but a rapid onset with hypoglycemia.
GESTATIONAL DIABETES - how to give birth?
DEVELOPS DURING PREGNANCY
INCREASES RISK OF NEED FOR CESAREAN DELIVERY AND OF PERINATAL COMPLICATIONS
OTHER SPECIFIC TYPES OF DIABETES (just injury to b-cells)
RESULTS FROM INJURY TO, INTERFERENCE WITH, OR DESTRUCTION OF Β-CELL FUNCTION IN THE PANCREAS
FROM MEDICAL CONDITIONS AND/OR MEDICATIONS
RESOLVES WHEN UNDERLYING CONDITION IS TREATED OR MEDICATION IS DISCONTINUED
HDL
good - H for happy
how many drinks per week for women?
3
synthetic insulin is made from
ecoli or yeast
we usually only give IV insulin if
the pt has hypercalcemia
need to know
slide 35
wont test us on
slide 39
if someone’s sugar is in the 200s
ask the pt about their lifestyle and check insulin
dont inject insulin
in thigh, because you exercise and lose the insulin, become hypoglycemic
insulin needle
prime w/ 2 needles
slide 54
some will drop sugar, some will not.
Exenatide (Byetta) on test -
what is it?
(bi creatures are high)
An incretin mimetic that enhances insulin secretion when BG is high
slide 65 on test
don’t need to know the time, just whether nyou take it before or after
