Endocrine Flashcards
Type 1 DM: What is it?
- a chronic autoimmune disease of insulin deficiency and secondary hyperglycemia due to destruction of the beta cells in the pancreas
- most common type of diabetes in those younger than 20
- may develop as late as 3rd or 4th decade of life
Type 1 DM: Risk Factors
- genetics
- more common in whites and men
Type 1 DM: Assessment Findings
- polyuria
- polydipsia
- polyphagia
- weight loss
- confusion
- blurry vision
- ketoacidosis
- paresthesia
- altered LOC
Type 1 DM: Diagnostic Tests
- fasting plasma glucose (greater than or equal to 126)
- A1C (greater than or equal to 6.5%)
- random plasma glucose (greater than or equal to 200 with symptoms or 2-hr plasma glucose greater than or equal to 200 after a 75-gram glucose load)
Type 1 DM: Prevention
- daily exercise
- maintenance of ideal body weight
- limit dietary fat intake
- look at social determinants of health (such as access to healthy foods, fod insecurity, and community support)
Type 1 DM: Non-Pharmacological Management
- multidisciplinary treatment
- assessments
- nutrition
- exercise
Type 1 DM: Glycemic Targets
- A1C for healthy adults less than 7%
- A1C for older adults less than 8%
Types of Insulin
- Rapid Acting
- Short Acting
- Intermediate Acting
- Long Acting
Rapid Acting Insulin Medications
- Lispro (humalog)
- Aspart (Novolog)
Rapid Acting Insulin - Onset, Peak, Duration
Onset: 15 minutes
Peak: 30-90 minutes
Duration: 3-5 hours
** can be given 10-15 minutes before a meal or right after a meal (this is better for those with erratic eating habits because it can be given right after the meal)
Short Acting Insulin Medications
- Regular (Humulin R and Novolin R)
Short Acting Insulin - Onset, Peak, Duration
Onset: 30-60 minutes
Peak: 2-4 hours
Duration: 5-8 hours
** can be given 30-45 minutes before a meal
Intermediate Acting Insulin Medications
- NPH (Humulin N or Novolin N)
Intermediate Acting Insulin - Onset, Peak, Duration
Onset: 1-3 hours
Peak: 8 hours
Duration: 12-16 hours
** may not need a prandial dose at lunch if NPH given in the morning
Long Acting Insulin Medications
- Glargine (Lantus, Levemir)
Long Acting Insulin - Onset, Peak, Duration
Onset: 1 hour
Peak: peakless (basal dose)
Duration: 20-26 hours
** usually given at night
Type 1 DM: Calculation of Insulin Dosage
Start at 0.2-0.5 units/kg/day divided into 50% basal (long acting/intermediate) in the morning and/or at night AND 50% prandial (short acting/rapid acting) before meals
Dawn Phenomenon
- The Dawn phenomenon happens when hormones your body naturally makes in the early morning (cortisol and growth hormone) increase your blood sugar
- The best way to diagnose this is by using a CGM. If not using a CGM, check blood glucose by fingerstick at bedtime, about 3 AM, and again in the morning when waking up
- The best way to treat this is by using an insulin pump that automatically adjusts your insulin dose depending on the blood glucose level. If this is not an option, it will take significant time and effort to get the insulin doses, evening exercise routines, and foods right
- Some options might be to increase the evening exercise and/or increase the protein-to-carb ratio of the evening meal.
Somogyi Effect
- The Somogyi effect also occurs because of a surge in hormones but is actually due to a low blood sugar episode overnight that has rebounded
- Recent research with CGM devices has shown that it may not actually be a cause of high blood sugar in the morning
- If the patient does not have a CGM device, get them to check their blood glucose 2 hours after their evening meal or before they go to bed (one or both, depending on when they eat) in the middle of the night and when they wake up
- Also, ask about what kinds and how much food they eat for the evening meal and what kind of exercise they may do in the evening
- Possible options for treatment include adjusting insulin dose, adjusting what you eat for your evening meal and/or snack, changing the time of your evening exercise, and/or switching to a CGM device.
Type 2 DM: What is it?
- a complex, chronic, polygenic metabolic disease characterized by progressive beta cell decline and insulin resistance
- influenced by genetics as well as environmental factors
- approximately 10% of the U.S. population has type 2 DM
Type 2 DM: Risk Factors
- BMI > 25
- history of GDM
- delivery of large infant
- family history of DM
- PCOS
- HDL < 35 and/or triglycerides > 250
- HTN or CVD
- physically active less than 3 days/wk
- more common in Asians, Native Americans, African American, Hispanic, and Pacific Islanders
** Affects men and women equally
Type 2 DM: Screening Recommendations
- Overweight or obese (BMI 25 or above) with one or more risk factors
- Prediabetes (A1C 5.7) test yearly
- History of GDM requires lifelong testing every 3 years
** At age 10 or puberty if overweight or obese with one or more risk factors
Type 2 DM: Assessment Findings
- Similar to type 1 DM
- obesity
- glycosuria
- proteinuria
- hyperglycemia
- acanthosis nigricans
- chronic candidal vulvovaginitis in women
- may present with hyperosmolar state or coma
Type 2 DM: Diagnostic Tests
- fasting plasma glucose (greater than or equal to 126)
- A1C (greater than or equal to 6.5%)
- random plasma glucose (greater than or equal to 200 with symptoms or 2-hr plasma glucose greater than or equal to 200 after a 75-gram glucose load)
Prediabetes Diagnostic Tests
- Fasting glucose of 100-125
OR - A1C 5.7-6.4%
OR - oral glucose tolerance test 140-199
Type 2 DM: Prevention
** Same as type 1 but, reach and maintain a normal BMI
- daily exercise
- maintenance of ideal body weight
- limit dietary fat intake
- look at social determinants of health (such as access to healthy foods, fod insecurity, and community support)
Type 2 DM: Non-Pharmacological Management
- weight loss is primary goal for all obese patients with type 2 DM
- prefer to diabetes educator at diagnosis and annually or more often if needed
- nutrition plan
- avoid alcohol
- assess medication regimen, etc.
- assess technology use
- avoid smoking and vaping
- exercise (150 minutes per week)
- physical examinations with lab tests
Type 2 DM: Glucose Recommendations
- A1C 7% or less
- Preprandial glucose 80-130
- 2-hour post-prandial less than 180
Type 2 DM: Classifications of Medications
- Biguanides
- Thiazolidinediones (tzd)
- Alpha-glucosidase inhibitors
- Dipeptidyl peptidase-4 inhibitors (DP4-i)
- Sodium glucose cotransporter 2 inhibitors
- Glucagon-like peptide-1 receptor antagonists (GLP-1)
- Sulfonylureas
- Combination drugs
Type 2 DM: 1st Line therapy
Biguanides (Metformin)
Type 2 DM: When to consider dual therapy
If A1C is 1.5% or higher than goal A1C
Type 2 DM: ASCVD History
Consider GLP-1 or SGLT2 inhibitors (if adequate GFR)
Type 2 DM: HF or CKD History
- Consider SGLT2 inhibitor (if adequate GFR)
- If not tolerated or not adequate GFR, add GLP-1 with proven CKD benefit
Type 2 DM: When is insulin considered?
- insulin is usually considered only after oral meds have not worked
- early introduction of insulin IF A1C 8-10%, but is individualized to the patient
Biguanides
- Metformin
- do not give with those with CKD, liver failure, or alcoholism
- avoid in pregnancy and children
- hold meds if doing a test that requires contrast media and restart in 24-48 hours to prevent acute kidney injury
- may produce weight loss and improve lipid profiles