DM I & II Flashcards
2 ways we maintain homeostasis of sugar
Glycolysis (insulin)
Gluconeogenesis (glucagon)
The pancreas is always secreting insulin or ____ for sugar homeostasis
glucagon
What is the normal set point for sugar homeostasis?
90mg/100mL
Gluconeogenesis
When does it occur?
Main precursors?
Occurs after ~8hrs of fasting when liver gets low on glycogen
Main precursors: Lactate from anaerobic resp and Glycerol (released from breakdown of triglycerides and amino acids)
____ is one of the major contributors to diabetic hyperglycemia
pts feel starved of nutrients
Gluconeogenesis
The cells feel “starved” of nutrients and send out hormonal signals to incr glucose levels in the blood via gluconeogenesis. This process is due to insulin resistance.
ETOH abuse alters the NAD+/NADH ratio leading to excess NADH. This results in ____
inhibition of fatty acid oxidation -> excess triglycerides.
Recall, glycerol from breakdown of triglycerides is req for gluconeogenesis. So, Alcohol -> depletes precursor for gluconeogenesis -> HYPOGLYCEMIA
Summary:
Alcohol makes it so you cant break down your fat for energy -> hypoglycemia
Does Alcohol abuse lead to hyper or hypo - glucemia?
HYPOGLYCEMIA
two types of insulin secretion
Pulsatile Release (Rapid onset) - used to absorb nutrients from the blood after eating a meal
Protracted Release (Longer) - homeostasis, cell growth, cell division, protein synth, DNA replication
What does insulin do in the body?
Glycolysis > Gluconeogenesis/Glycogneolysis
Only wants to use Glucose for energy (glycolysis). Saves all other resources (fat/glycogen)
- Decr Gluconeogenesis in liver
- Incr Glycolylsis in liver
- Decr Amino Acid Breakdown in liver
- Incr amino acid uptake and protein synthesis in muscle, liver, and adipose tissue
- Decr lipolysis (unable to decr body fat)
- Incr Lipogenesis and esterifications of fatty acids in liver and adipose tissue (adds body fat)
____ is the most common metabolic disease of childhood
Type I DM
What cells are destroyed in Type I DM?
Lymphocytic destruction of insulin-secreting BETA CELLS of the islets of Langerhans in the pancreas
What is Type IA DM?
A = Autimmune
85% of Type I DM pts have islet cell antibodies
Type ____ DM is incr in pts with autoimmune diseases (Graves Dz, Hoshimoto Thyroiditis, Addison Dz)
I
What is the ET of Type 1B DM?
- Non-autoimmune beta cell destruction
- incr risk for child if dad>mom has it
- Viruses, toxic chemicals, exposure to cow’s milk in infancy, cytotoxins
Classic SS of Type I DM?
Polyuria - peeing out Gluc + Water
Polydipsia - Thirsty (peeing a lot dehydrates you)
Polyphagia - Hungry (cells feel starved bc the Gluc can’t get in)
Other: Fatigue, Nausea, Blurred Vision
The body requires at least ____ units of insulin a day to maintain all Cellular Functions
12
What causes Fatigue & Muscle Cramps in Type I DM?
Fatigue is due to Muscle wasting from:
* Gluconeogenesis
* Hypovolemia
* Hypokalemia
Muscle Crmaps is due to e- imbalance
What causes Transient Blurred Vision in Type I DM?
Glucose in the lens (hypotonic) -> Lens swells -> Blurred vision
Type I DM
What should you check during the PE?
- Vital Signs - orthostatic hypotension (due to vol depletion), Tachycardia, Kussmaul breathing + incr RR + metabolic acidosis (DKA)
- Fundoscopic Exam - Annually
- Foot Exam - within 1yr
DDx for Type I DM
- Type II DM
- 2ndary hyperglycemia
- Endocrine DO
- Rx - Thiazide diuretics, Phenytoin (seizures), Steroids (#1)
- Chronic pancreatitis
- Cystic Fibrosis
- Prader-Willi Syndrome - Intellectual disability, muscular hypotonia, obesity, short stature, and hypogonadism
Type I DM WU
- Plasma Gluc (Nonfasting 200+ or Fasting 126+)
- Hgb A1C or Glycohemoglobin (Adults 6.5%)
A single Hgb A1C draw is a ____ month average bc RBC are constantly being replaced
3
A1C % Trmnt goals
< 7% (Avg adult)
< 7.5% (Peds or 65yo+ & healthy)
7.5-8% (65yo+ w/ mod comorbid and gonna die within 10yr)
Once Dx, test A1C q ___ mo if meeting goals & stable sugars
If changing therapy or not meeting goals, test A1C q ____ mo
6 mo (stable)
3 mo (unstable or change therapy)
Pt shows SS of Type I DM. Hx shows iron-deficiency anemia. Can you order a HbA1C?
NO
HbA1C testing doesn’t work well in pts with abnorm RBC turnover (hemolytic or iron-deficiency anemia)
A newborn is showing signs of neonatal DM. Your preceptor orders a HbA1C. Wdyd?
Ask if it will be reliable bc neonates have high levels of fetal hemoglobin (HbF) in their blood for 2yrs
Unsure if its DM Type 1 or 2? Order these 3 things….
1…2…3…
Insulin level
C-peptide levels
Immune markers
Fasting C-Peptide and Insulin ratio
Proinsulin -> ___ insulin + ____ C-Peptide
Proinsulin -> 1 Insulin + 1 C-Peptide
Type ___ DM shows LOW insulin AND C-peptide
Insulin < 5uU/mL (0.6ng/mL)
1
DM pt is on exogenous insulin and has NORM/HIGH fasting insulin and LOW C-Peptide. What is happening?
Type 2 is converting to Type 1
Proinsulin is endogenous (made by the body). This shows the pt is not producing enough of their own insulin.
Type II DM pt is taking exogenous insulin. Fasting labs show C-Peptide is increasing over time. WDYD?
This is a good sign that their body is making insulin on its own. Can start tapering down exogenous insulin.
Proinsulin -> 1 insulin + 1 C-Peptide
labs show (+) Islet-cell (IA2) and Anti-GAD65
Type 1 or 2 DM?
Type I DM
IA2 antibodies titers decr after 6mo
Anti-GAD65 antibodies present at Dx and are persistently (+) over time.
Peds vs adult A1C goal
Peds = 7.5%
Adult = 7%
Blood Glucose goals (mg/dL):
________ preprandial
________ before bed
________ if intellectual disability or frequent hypoglycemic episodes, substance abuse
80-130 = Preprandial
130-150 = B4 Bed
100-150 = Mental disability, frequent hypoglycemia, substance abuse
At the bare minimum, diabetics should check their blood sugars ______ (when?)
Before eating
Before bed
Pt with continuous glucose monitor just ate a donut and should wait _____ min before checking for an accurate glucose reading. Why?
10 min lag b/w plasma and interstitial glucose levels. Do a finger stick if it’s urgent
The first step of Type II DM is _______
Metabolic syndrome
Metabolic Syndrome Dx Criteria
Type II DM pathophysiology
adipose tissue dysfunction -> insulin resistance
Visceral or intra-abdominal fat correlates more with inflammation than subcutaneous fat
Albumin yo creatinine ratio Ranges
Normal?
Microalbuminuria?
Macroalbuminuria?
Normal: < 30mg daily
Micro: 30-300mg daily
Macro: >300mg daily
Microalbuminuria (albumin-to-creatinine ratio 30-300mg daily) must be documented on at least _____ of ____ samples over ____ months
2 of 3 samples
3-6 months
Microalbuminuria is a risk factor for _____ in Type I DM.
However, in Type II DM, it’s more of a risk factor for _____.
Kidney Damage (Type I DM)
CAD (Type II DM)
3 ways glucose enters Glycolysis pathway
Dietary Glucose (GI -> Blood stream)
Glycogenolysis (hepatic stores of glycogen)
Other Monosaccharides (galactose, fructose)
Rx that makes you feel full by decr the hunger stim
GLP-1(glucagonlike peptide 1), DPP-4
GLP-1 is an AGONIST
Rx that slows glucose breakdown in the stomach?
Alpha-glucosidase inhibitors, GLP-1
Rx that slow glucose absorption in the stomach and small intestine?
Alpha-glucosidase inhibitors
Biguanides
Rx that decr the amount of glucose from gluconeogenesis that enters the bloodstream?
Biguanides
Rx that increases insulin secretion?
Sulfonylureas
DPP-4 (Dipeptidyl peptidase-4)
Meglitinides
Rx that open cellular channels help glucose enter the cells
Insulin
Biguanides
Rx that make you pee out glucose
SGLT-2 Inhibitors
GLP-1 Receptor Agonists (Incretins)
Med: Tanzeum, Trulicity, Byetta, Bydureon, Victoza, Ozempic (inject), Rybelsius (oral)
MOA: incretins are naturally released after eating due to gastric stretching. They make you feel full, stim insulin release, and inhibit glucagon release. Thus, lowering blood gluc
USE: can’t take Metformin, A1C >1.5% over target, don’t reach A1C target within 3mo, comorbid (atherosclerosis, HF, CKD), especially if OVERWEIGHT/OBESE
SE: Nausea
Pro: unlike other drugs, this won’t cause hypoglycemia Bc it only works to stop additional glucose ingestion and continues to use the body’s current glucose supplies.
Blood glucose 130mg/dL and A1C 6.6%
Prediabetes or DM?
DM
What are the A1C values for healthy, Prediabetes, and DM?
Healthy <5.7%
Prediabetes 5.7 - 6.4%
DM 6.5%+
Fasting plasma glucose values: Healthy, Prediabetes, DM?
Healthy <100mg/dL
Pre-diabetes 100 - 125 mg/dL
DM 126+ mg/dL
A single random plasma glucose (non-fasting) of _____ or greater is diagnostic for DM
200 mg/dL
Pt is taking mixed insulin - fasting acting and intermediate acting. Do they need to add on basal insulin?
NO
Dawn Phenomenon vs Somogyi Effect
Both: hyperglycemia in morning
Dawn Phenomenon: due to Type II insulin resistance
Somogyi Effect: rebound hyperglycemia due to late-night hypoglycemia
Trmnts: Dawn Phenomenon vs Somogyi Effect
Dawn Phenomenon -> take insulin at night
Somogyi Effect -> eat before bed or back off insulin at night
Pt with DM should get their A1C to ____ before pregnancy and try to maintain an A1C of _____ during pregnancy
6.5% before preg
6 - 6.5% during preg
Max weight a pt with DM should gain during pregnancy:
Normal weight -> ____ lbs
Overweight -> _____ lbs
Obese -> _____ lbs
Norm Wt -> 25-30 lbs
Overweight -> 15-25 lbs
Obese -> 11-20 lbs
What can a pregnant DM pt do reduce postprandial sugars?
Moderate walking after meals (use the sugar)
How often should a pregnant DM pt have their A1C checked?
Every trimester
DM pregnancy: Blood Glucose goals
1hr postprandial -> ____ mg/dL
2hr postprandial -> _____ mg/dL
Fasting -> _____ mg/dL
1hr -> 140
2hr -> 120
Fasting -> 90
What types of insulin do pregnant DM pts get?
Treat as type I for insulin
Long-acting insulin qday + short acting at mealtime
Metformin and Glyburide are safe
What causes Morning hyperglycemia in Somogyi phenomenon?
Usu due to too much insulin at night or not eating enough before bed
Insulin too high -> stress release of glucagon and cortisol -> triggers Gluconeogenesis -> high AM glucose
Dawn Phenomenon pathophysiology
It is normal to have high insulin levels in the morning. However, in Type II DM there is insulin resistance -> High gluc in the morning
Summary: hyperglycemia in morning due to Type II DM insulin resistance. Trmnt is wt loss/diet or incr evening insulin dose
