Diabetes Flashcards
What characterizes diabetes mellitus?
Abnormal insulin production
Impaired insulin utilization
Or both
What can diabetes cause?
End-stage renal disease
Adult blindness
Non-traumatic lower limb amputations
What are theories behind the causation of diabetes?
Genetics
Autoimmune (Type 1)
Viral
Environmental
How is insulin normally metabolized?
Produced by the β cells of pancreas
Released continuously into bloodstream in small increments and released after food
How does insulin secretion change throughout the day?
Small, steady secretion throughout the day
Spike after eating
Fall during the night time, facilitating the release of glucose from the liver, protein from muscle, and fat from adipose tissue
What is the role of insulin?
Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell
Decreases glucose in the bloodstream
What does insulin do?
Stimulates storage of glucose as glycogen in liver and muscle
Inhibits gluconeogenesis
Enhances fat deposition
↑ protein synthesis
What tissues are insulin-dependent?
Skeletal muscle and adipose tissue
What do counter-regulatory hormones do?
Increase blood glucose levels
Provide regulated release of glucose for energy
Maintain normal blood glucose levels
Ex: glucagon, epinephrine, growth hormone, cortisol
What happens during the onset of DM1?
Long preclinical period
Manifestations develop when pancreas no longer produces insulin
Rapid onset of symptoms
Present at ED with ketoacidosis
What is the etiology and pathophysiology of DM2?
Pancreas continues to produce some endogenous insulin.
Insulin produced is insufficient or poorly utilized by tissues.
Body becomes insulin resistant - receptors are unresponsive or insufficient in number -> hyperglycemia
Pancreas decreases ability to produce insulin
- Beta cells fatigued
- Beta cell mass lost
What happens during the onset of DM2?
Gradual onset
Person may go many years with undetected hyperglycemia.
Osmotic fluid/electrolyte loss from hyperglycemia may become severe -> hyperosmolar coma -> fluid pulled from cells
What are symptoms of DM1?
3 polys
Weight loss
Weakness
Fatigue
What are symptoms of DM2?
Nonspecific symptoms (May have classic symptoms of type 1) Fatigue Recurrent infections Recurrent vaginal yeast or candida infections Prolonged wound healing Visual changes
What is the impaired fasting glucose of prediabetics?
100-125 mg/dL
What is the healthy fasting glucose?
70-100 mg/dL
What is the impaired glucose tolerance of prediabetics?
2 hour glucose between 140-199 mg/dL
What is a healthy, prediabetic, and diabetic A1C?
4-5.7%
5.7-6.4%
>6.5%
What is A1C?
Average glucose level for the past 120 days
What is the four method diagnosis?
A1C >6.5%
Fasting plasma glucose level >126 mg/dL
Random plasma glucose >200 mg/dL plus symptoms
Two hour OGTT level >200 mg/dL when a glucose load of 75g is used
What is the preferred method of diagnosis?
Fasting plasma glucose
What is the ideal A1C goal for diabetics? Fair control? Poor control?
<7.0%
8-9%
>9%
What does abnormal A1C increase the risk of?
Retinopathy, nephropathy, neuropathy
What are the goals of diabetes management?
Decrease symptoms
Promote well-being
Prevent acute complications
Delay onset and progression of long-term complications
What is included in diabetes management?
Patient teaching - Self-monitoring of blood glucose, etc. Drug Therapy - Insulin, oral agents, non-insulin injectable agents Nutritional Therapy - Counseling, education, monitoring - Exercise/Physical activity Regular, consistent exercise
Which are the rapid acting insulins?
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
What are the short acting insulins?
Regular (Humulin R, Novolin R, ReliOn R)
What are the intermediate acting insulins?
NPH (Humulin N, Novolin N, ReliOn N)
What are the long-acting insulines?
Glargine (Lantus)
Determir (Levemir)
What is the onset, peak, and duration for rapid-acting insulins?
O: 10-30 min
P: 30min-3hours
D: 3-6 hours
What is the onset, peak, and duration for short-acting insulins?
O: 30-60 min
P: 1-5 hours
D: 6-10 hours
What is the onset, peak, and duration for intermediate-acting insulins?
O: 60-120 min
P: 6-14 hours
D: 16-24 hours
What is the onset, peak, and duration for long-acting insulins?
O: 70 min
P: none
D: 18-24 hours
How do you mix insulins?
Squirt 14 units of air into first bottle without touching insulin
Wipe bottle top and squirt 4 units of air into the regular insulin bottle to be drawn up first
Draw up 4 units of regular insulin before the other
Swab second top and draw up 14 units of the other insulin and recap to give to patient
Rotate bottle between hands - don’t shake
What regimen most closely mimics endogenous insulin production?
Basal-bolus
- Long acting (basal) once a day
- Rapid/short-acting (bolus) before meals
How should insulin be stored?
In-use vials may be left at room temperature up to 4 weeks
Extra insulin should be refrigerated.
Avoid exposure to direct sunlight.
Do not use expired insulin.
How can insulin be administered?
Subq or IV
In what order is insulin absorbed the quickest?
Abdomen, arm, thigh, butt
Which is the preferred site for insulin?
Abdomen
How many units is in 1 mL?
100 units
What are oral used for in DM2?
Insulin resistance
Decreased insulin production
Increased hepatic glucose production
What are the types of oral agents?
Biguanides – metformin (Glucophage)
Sulfonylureas - glipizide (Glucotrol), glyburide (Micronase)
Meglitinides – repaglinide (Prandin), nateglinide (Starlix)
Thiazolidinediones – rosiglitazone (Avandia)
What is nutritional therapy like for the DM1 patient?
Meal plan based on individual’s usual food intake and is balanced with insulin and exercise patterns.
Insulin regimen is managed day to day.
What is nutritional therapy like for the DM2 patient?
Meal plan is based on achieving glucose, lipid, and blood pressure goals.
Emphasis placed on calorie reduction for weight loss
How should carbs and fats be distributed for the DM patient?
130g of carbs per day
<200mg of cholesterol and trans fats
<7% from saturated fats
How does alcohol affect glucose levels?
Can cause hypoglycemia from diuresing
Why is exercise important?
↑ insulin receptor sites
Lowers blood glucose levels
Contributes to weight loss
(Monitor blood glucose levels before, during and after exercise)
How should a diabetic patient be treated if they’re acting weird and are diaphoretic?
Give sugar first because there may not be sugar in the blood
What is hypoglycemia and when does it occur?
Blood glucose <70 mg/dL
Too much insulin in proportion to glucose in the blood
(Rapid drop in blood glucose level can also cause symptoms even if actual level is not less than 70)
How does hypoglycemia manifest?
Confusion Irritability Weakness Diaphoresis Tremors Hunger Visual disturbances Can progress to loss of consciousness, seizures, coma and death
What is the rule of 15?
Give 15g of a simple carb
Wait 15 min then recheck blood glucose
Repeat with another 15g until blood sugar is >70 mg/dL
Have pt eat regularly scheduled meal to prevent rebound hypoglycemia
How do you treat a hypoglycemic patient that can’t swallow?
1 mg glucagon IM or subq
Have patient ingest a complex carb
What are symptoms of hyperglycemia?
Increased urination Weakness Fatigue Blurred vision Headache Nausea Vomiting Stomach cramps
What are pharmacologic treatments of hyperlgycemia?
Insulin PO meds Non-insulin injectables IV fluids Electrolyte replacement In monitored settings, pt may be placed on insulin IV drip
What should you do with a patient who can’t produce insulin and is hypoglycemic?
Give insulin because the body produces more glucose when hypoglycemic
