Diabetes Flashcards
Goals for DM Management
- Include the patient’s preferences
- Normalize glycemic control
- Prevent/delay complications
- Preserve/enhance QOL
- Promote psychological well-being
SMBG Goals
- Fasting 70-130mg/dL
- Post-prandial <7%
DM Behavior Change
- Shared goal setting
- SMART goals
- – Specific, Measurable, Attainable, Realistic, Timely
DM Medical Nutrition Therapy Benefits
- Improves glycemic control
- Weight control
- Lowers cholesterol
- improves blood pressure
- Individualized
MNT: General Guidelines
- BMI <200mg/day
Carbohydrate strategies
- Total amount of CHO is more predictive of glycemic control than structure of CHO
- Space CHO throughout the day
- Protein and CHO combinations will decrease likelihood of hypoglycemia and decrease glucose spike
MNT Areas of Indiscretion
- Sodas (10 tsp. sugar)
- Milk, juice, “Kool-Aid,” ETOH, tea
MNT Snacks
- Should be around 100 calories or 15g CHO
- Pre-exercise snacks should be around 30g CHO
Nutrition Basics
- Calorie: the amount of heat required to raise 1g of H2O 1-degree Celsius
- CHO 4kcal/g
- Fat: 4kcal/g
- Protein: 9kcal/g
Basic CHO counting
- CHO serving size=15g
- – CHO = 45-65% of total caloric needs
- Caloric prescription: Based on weight
- – 1800cal/day, 50% CHO
- – Divide CHO calories by 4cal/g
- – 900cal/4cal/g = 225g
- About 45-60g CHO per meal
- Snacks should be around 15g CHO
Benefits of Physical Activity
- Weight loss
- Prevention of weight gain
- Improves overall strength and conditioning
- Promotes sense of well-being
- Improves insulin sensitivity up to 72hrs after
Physical Activity recommendations
- 150min/week of moderate intensity aerobic activity (50%-70% of maximum heart rate)
- 90min/week of vigorous aerobic activity (>70% of maximum heart rate)
- Exercise should be distributed over at least 3 days/week with no more than 2 consecutive days off
- Resistance training 3d/wk
Continuous glucose monitoring
- Can be useful in T1DM
- Useful for patients with hypoglycemia unawareness and/or frequent hypoglycemic episodes
SMBG recommendations (Carrie)
- Multiple insulin injections (2-4x/day)
- Once daily insulin and/or oral agents (daily)
- Fasting glucose at goal and A1C elevated (1 FBS and 1 Post-prandial daily)
- Frequent hypoglycemia (2-4x/day)
- Hypoglycemic unawareness (refer)
- “Diet controlled” (1-3x/wk)
Health Maintenance for DM
- Routine visits: No less than q3mo; monthly until A1C <7.5%
- A1C q3-6mo
- BP and FSBS q visit
- Annual:
- – Foot exam, Lipid assessment (more often if indicated), Microalbuminuria, retinal exam (within 3-5yr of T1DM Dx & 6mo of T2DM Dx)
Conditions associated with increased risk of foot amputation
- Peripheral neuropathy with loss of protective sensation (monofilament)
- Bony deformity (Charcot Foot)
- Hx of ulcers or amputations
- Severe nail pathology
Foot Care Recommendations
- Annual foot exam with tuning fork, 1g monofilament, palpation, and visual assessment
- For individuals with ulcers and high-risk: Refer
- Refer to foot care specialist: Smokers, Hx of neuropathy, Foot deformities, Hx of LE complications
T2DM Key Points
- Diabetes is a progressive disease
- Almost all will require insulin eventually
- Early, aggressive control leads to better outcomes
Biguanides
- Metformin (Glucophage)
Action - Increases insulin sensitivity - Decreases hepatic gluconeogenesis Contraindications/Caution - Eldery, CHF, CKD; GI distress in patients; stop when Cr >1.5
Sulfonylureas
- Glipizide (Glucotrol)
- Glyburide (DiaBeta, Glynase)
- Glimepride (Amaryl)
Action
- Increases insulin secretion from pancreas
Containdications/caution
- Weight gain; hypoglycemia
Thiazoledinediones
- Pioglitazone (Actos)
- Rosiglitasone (Avandia)
Action
- Increases insulin sensitivity in peripheral tissues
Contraindication/Caution
- Fluid retention; CHF; Link to CV Dz
DPP-4 Inhibitor
- Sitagliptin (Januvia)
- Saxagliptin (Onglyza)
- Vildagliptin (Zomelis, Galvus)
Action
- Increases insulin production by breakdown of GLP-1
Contraindication/Cautionl
- Renal dosing
Meglitinides
- Nateglitinide (Starlix)
- Repaglitinide (Prandin)
Action
- Increases insulin secretion from pancreas (short burst)
Contraindication/Caution
- Weight gain; hypoglycemia
Alpha-Glucosidase Inhibitors
- Acarbose (Precose)
Action
- Decrease glucose absorption in gut
Contraindication/Caution
- Faltulence; Complicates hypoglycemia management
Starting Metformin
- Initial DOC for people with normal renal function; does NOT promote weight gain
- Start 500mg qd for 3d, then 500mg BID for 1wk, then 1g BID
Starting Sulfonylurea
Initial DOC for people with contraindications to metformin
Incretin Mimetics
- Exenatide (Byetta)
- Liruglatide (Victoza)
Action
- Increases insulin production; reduces glucagon production;
slows gastric emptying
- Can be used as adjunct to oral therapy or with Lantus, NOT with bolus insulin therapy
- Useful in T2DM, not meeting glycemic targets, would benefit from appetite suppression
Contraindications/Caution
- N/V, excessive weight loss
- Cost, 1-2 injections daily
Amylin Analogues
- Pramlintide (Symlin)
Action
- Delays gastric transit, decreases glucagon production, increases satiety
- Used in T1 and T2DM as an adjunct to insulin, basal and bolus
- Useful in those failing to meet glycemic targets despite intensive insulin therapy
Contraindications/Caution
- Cost; 2 daily injections
- N/V, anorexia, hypoglycemia
- Contraindicated in hypoglycemic unawareness and gastroparesis
Insulin: Basal vs. Bolus
- Basal: Background insulin
- Bolus: Mealtime insulin
How to start insulin therapy
- When fasting hyperglycemia, A1C within 1-2 points of target: initiate bolus therapy
- – Advantages are 1 shot, less weight gain
- Extremely high A1C, comorbidities that require discontinuation of oral agents, significant post-prandial hyperglycemia:
- – Initiate basal-bolus therapy
- – Flexible pattern, multiple injections, more weight gain
Starting Lantus
- Initiation of an arbitrary low dose
- – Weight based dosing: 0.2 units/kg/day
NPH (70/30) vs. Lantus
NPH may be more appropriate when insulin requirements from day to night differ
- i.e. fasting glucoses are much higher than daytime glucoses
Adding prandial coverage:
When:
- Fasting glucoses are near goal, but post-prandial glucose remains elevated
- The patient is on 1unit/kg of basal insulin and still not achieving glycemic goals
- The patient is experiencing fasting and/or pre-meal hypoglycemia, but still not achieving glycemic goals
Options:
- Rapid-acting insulin with largest meal
- rapid acting insulin with all meals
Dosage:
Arbitrary dose based on how insulin resistant you think they are and/or level of hyperglycemia (2-5units, generally)
How to monitor: Check 2-hr post-prandial SMBG
Titrating Basal-Bolus Regimen (T2DM)
Decrease basal when starting bolus:
- If fasting glucose is at goal or there is a propensity for hypoglycemia, then decrease basal dose by 5-10%
Most adults have fairly predictable basal-bolus requirements:
- 1/3-1/2: Bolus
- 1/2-2/3: Basal
Changing oral meds when starting insulin
- ** Do NOT stop metformin because insulin started!!!
* ** Wean from sulfonylureas
Adjust insulin based on patterns
- Fix fasting SMBG 1st!!!
- Adjust insulin from a minimum of 3-day pattern
- Hypoglycemia is a priority
- Do NOT adjust based on one bad reading
- Make adjustments to TOTAL daily insulin dose: Usually 10-20% adjustment
- ** Fasting Glucose at goal, A1c elevated: Monitor 2hr post-prandial SMBG; Add prandial insulin
- ** Nocturnal, fasting hypoglycemia: reduce basal
- ** Post-prandial hypoglycemia: reduce bolus
- ** Pre-meal hypoglycemia: Reduce basal OR bolus
T1DM Key Points
1) Options for management:
* Conventional insulin therapy
* Basal/Bolus therapy
* Insulin pump
2) SMBG: Minimum of 4x/day (AC, HS, and 1x post-prandial)
3) May need to check at 3am: Somogyi Effect (nocturnal hypoglycemia) vs. Dawn Phenomenon (Fasting hyperglycemia)
4) There may be a “Honeymoon period”
5) LADA: Latent Autoimmune Diabetes in Adulthood
T1 vs. T2 Insulin doses
- T1DM
- Usual dose is 0.2-0.6 units/kg/day
- insulin requirements are absolute
- Insulin resistance is NOT an issue
- T2DM
- Lower dose if on oral agents (0.3-0.5 units/kg/day)
- Higher dose if no oral agents (may be >1 unit/kg/day)
- Insulin requirements are relative not absolute
- Insulin resistance is a MAJOR issue
Insulin therapy in T1DM
- Basal-Bolus
- Long-acting insulin q day
- Rapid- or short-acting insulin AC and with snacks
- Split-Mixed Insulin
- Rapid- or short-acting insulin + NPH at breakfast
- Rapid- or short-acting insulin at supper
- NPH qhs (or 12hrs after 1st dose)
Correction Factor with Supplemental Insulin
- Correction factor determines how much 1 unit of of prandial insulin will decrease SMBG
- Used to determine how many supplemental units of insulin are needed above the patient’s usual bolus dose
- Check SMBG and determine:
- ** Dose of insulin needed depending on CHO intake planned (Insulin-to-CHO ratio)
- ** Develop chart for patient to use
- 1800 Rule for adult using rapid-acting insulin
- ** 1800/TDD=CF
- 1500 Rule for adults using regular insulin
- ** 1500/TDD=CF
Rule of 15 - treating hypoglycemia
- 15g of QUICK CHO will raise FSBS ~30mg/dL
Management of DM Complications - Goals
- BP: <150 mg/dL
Treatment of BP in DM
With normal renal Fx:
- ACE or ARB should be used
- Thiazide-diuretic can be added
Treatment of dyslipidemia in DM
Statin should be added to therapy REGARDLESS of baseline lipids if:
- ** Overt CVD
- ** No CVD, but are >40yo with 1+ CVD risk factors
