Diabetes Mellitus Flashcards
Epidemiology (6)
- 18 million individuals diagnosed in the US
High risk groups
- African Americans
- Hispanics
- American Indians
- Asian Americans
Complications
6. Leading cause of blindness, end-stage renal disease, amputations, and infection; will be cumulative with duration of uncontrolled blood sugar
Fasting Plasma Glucose (FPG)
No caloric intake for at least 8 hourss
Oral Glucose Tolerance Test (OGTT)
Administration of glucose containing:
75 grams anhydrous glucose
1.75 g/kg of body weight to a maximum of 75 grams
Impaired Glucose Tolerance (IGT) (2)
- Measure of carbohydrate intolerance 2 hours following OGTT
- Also known as ‘Pre Diabetes’
Impaired Fasting Glucose (IFG)
Measure of disturbed carbohydrate metabolism
Classification
Type 1 Diabetes (T1DM) (3)
- Autoimmune destruction of B cells of the pancreas
- Onset usually preschool to teenage (can see neonatal diabetes)
- Antibody formation:
- Islet cells
- Glutamic acid decarboxylase
- Insulin
Classification Type 2 Diabetes (T2DM) (2)
- Insulin resistance and a relative lack of insulin secretion
- Metabolic Syndrome
- Hypertension
- Dyslipidemia
- Elevated plasminogen activator-1 inhibitors (PAI-1)
Miscellaneous Causes (6)
- Pancreatitis
- Cystic Fibrosis (CF-Related Diabetes)
- Cushing syndrome or medication induced
- Hyperthyroidism
- Infections (Congenital rubella or cytomegalovirus)
- Monogenic (Neonatal diabetes)
Associated with genetic syndromes (2) Other syndrome (1)
Associated with some genetic syndromes
- Down’s syndrome
- Prader-Willi syndrome
Other: Gestational diabetes
Screening by American Diabetes Association (5)
- Overweight (BMI > 85% percentile)
With at least two of the following:
- Family history
- Race (Native Americans, African Americans, Hispanic Americans, Asians/South Pacific Islanders)
- Signs of insulin resistance
- Screen every 2 years starting at 10 years of age or onset of puberty
Signs and Symptoms of DM (6)
- Polyuria, Polydipsia, Polyphagia
- Blurred vision
- Weight loss
- Fatigue
- DKA
- Slow healing wounds
Neuropathies (Microvascular) Diabetic (2)
- Sorbitol accumulation
2. Protein glycosylation (thickened basement membrane)
Neuropathies (Microvascular) Peripheral (2)
- Parathesia and pain
2. Begins in distal extremeties but progresses proximally
Neuropathies (Microvascular) Autonomic (6)
- Impotence
- Gastroparesis
- Diarrhea
- Neurogenic bladder
- Orthostatis
- Diminished response to hypoglycemia
Neuropathies (Microvascular) Retinopathy (6)
- Leading cause of new blindness
Retinal changes
- Microaneurysms
- Increased permeability
- Occlusion
- Proliferation of new blood vessels
- Cancers
Nephropathy (microvascular) (5)
- 30-40% of all diabetic patients may develop
- Proteinuria
- Decreased GFR
- Increased arterial blood pressure
- Microalbuminuria
Dyslipidemia (macrovascular) (4)
- Increased risk of coronary artery disease
- Goal LDL < 100 mg/dL
- Dietary intervention needed
- Statins should be considered; Age > 8 years
Hypertension (macrovascular) (4)
- Goal BP determined by age, gender, height
- Lifestyle modifications
- ACE Inhibitors drug of choice
- Renal protective effects
Treatment Goals for Age < 6 years
FBG
Bedtime
HbA1C
Age < 6 years
FBG – 100-180
Bedtime – 110-200
HbA1C –7.5-8.5%
Treatment Goals for Age 6-12 years
FBG
Bedtime
HbA1C
Age 6-12 years
FBG 90-180
Bedtime 100-180
HbA1C <8%
Treatment Goals for Age 13-19 years
FBG
Bedtime
HbA1C
Age 13-19 years
FBG 90-130
Bedtime 90-150
HbA1C <7.5%
Goals for therapy (5)
- Weight loss or maintain appropriate weight & growth (good diet)
- Increase in exercise capacity
- Normalization of glycemia
- Control of comorbidities
- Education is HUGE!!!
Pharmacologic Treatment for DM Type 1
Insulin
Pharmacologic Treatment for DM Type 2 (6)
- Insulin
- Biguanides
- Sulfonylureas
- Meglitinides
- Alpha Glucosidase Inhibitors
- Thiazolidinediones
- … and more
Endogenous Insulin (6)
- Normal Activity
- Increases glucose uptake in tissues
- Increases liver glycogen
- Decreases glycogenolysis
- Increases fatty acid synthesis
- Decreases fatty acid metabolism
Exogenous Insulin (2) Types (4)
- Similar pharmacologic activity as endogenous chemical
- Different types depend on structure changes Pharmacokinetic properties differentiates different types of insulin
Types:
- Rapid-acting
- Short-acting
- Intermediate-acting
- Long-acting
Rapid Acting Insulin - 3 Types
- Insulin Aspart (NovoLog)
- Insulin Lispro (Humalog)
- Insulin Glulisine (Apidra)
Rapid Acting Insulin PK Parameters: Onset, Peak, Duration
- Onset: 15 min
- Peak: 1 – 2 hrs
- Duration: 3 – 4 hrs
Rapid Acting Insulin: Available dosage forms (4)
Insulin vials
Insulin pens
- Prefilled
- Re-usable
Short-Acting Insulin: Available products
Insulin Regular (novolin R, Humalin R)
Short-Acting Insulin PK Parameters: Onset, peak, duration
Onset: 30-60min
Peak: 2 - 4 hrs
Duration: 4-8 hrs
Short-Acting Insulin: Available dosage forms (1)
Insulin Vials
Intermediate Acting Insulin: Available Products
Insulin NPH (Novolin N)
Intermediate Acting Insulin PK Parameters: Onset, Peak, duration
- Onset: 1-2 hrs
- Peak: 4-10 hrs
- Duration: 10-18 hrs
Intermediate Acting Insulin: Available dosage form
Insulin vials
Combo Products (2)
- NovoLIN® 70/30
2. HumaLOG® 70/30
Long Acting Insulin: available agents
Insulin Determir (Levemir)
Long Acting Insulin: onset, peak, duration
Onset: 6 hrs
Peak: 12 – 16 hrs
Duration: 2hrs
Long Acting Insulin Dose Frequency
q12 – q24
Long Acting Insulin, Approved for?
use in pregnancy
Insulin Glargine: onset, peak, duration
Onset: 4 – 5 hrs
No peak
Duration: 22 – 24hrs
Insulin Glargine Dose frequency
Dose freq: q24 (q12)
Insulin Glargine Available dosage forms (2)
- 100 Units/mL
2. Toujeo® 200 Unit/mL
Insulin Pearls (2) Available in...
Most insulin available in U-100
100 units of insulin per mL
Combination preparations available (2)
- Pre-mixed insulin analogs
- 72/25 (75% NPL, 25% lispro)
- 70/30 (70% APS, 30% aspart) - NPH-regular combinations
- 70/30 (70% NPH, 30% regular)
Dose Regimen Basal + Bolus (4)
- Long-acting insulin should be 40-60% of total daily insulin requirement
- Regular or rapid acting is the remainder
- Regular insulin 20-30 minutes prior to eating
- Intermediate or long-acting at bedtime or twice daily
Dose Regimen (2)
- Continuous SC infusion – Insulin pump
2. Twice daily injections with NPH
ADE Insulin (5)
- Hypoglycemia
- Weight gain
- Lipodystrophy
- Lipohypertrophy
- Lipoatrophy
Insulin Techniques (6)
- Rotate injection sites; Abdomen, thigh, buttocks, lateral aspect of arm
- Clean before/after injection
- Examine bottle, roll gently to warm
- Inject air and draw up desired dose
- Pinch skin with one hand
- Pull plunger back to look for blood
Insulin Pearls (4)
- Intravenous administration
- Regular insulin ONLY
- Used in crisis management; DKA, Surgical procedures - Adjust basal insulin dose 1-2 units at a time
- Every unit of insulin may decrease glucose by 25-50 units
- High blood sugar at office visits
- Sick days
Somogyi Effect (2)
- Post-hypoglycemic hyperglycemia
2. Decrease bedtime NPH or give evening NPH later
Dawn Phenomenon (2)
- Rise in glucose in early morning hours
2. Increase evening NPH dose