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5 Pathology > L1 Diabetes > Flashcards

L1 Diabetes Flashcards

1
Q

SOC

A

Standard of Care

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2
Q

Diabetes definition

A

means siphon, describes the large urinary volume excreted by sufferers of this disease

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3
Q

Exocrine component of pancreas

A

-most cells in pancreas
-produce enzymes to digest proteins, carbs, fats in small intestine
-Enzymes flow into ducts

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4
Q

Endocrine component of pancreas

A

only 1-2% of total pancreatic cells
hormones are released into blood

-islands of cells within exocrine that release insulin, glucagon, somatostatin

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5
Q

Diabetes mellitus is characterized by

A

Chronic hyperglycemia
Relative deficiency in insulin (b/c of reduced secretion or action)

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6
Q

Type 1 Diabetes

A

Autoimmune disease
characterized by a lack of insulin production

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7
Q

Type 2 Diabetes

A

Ineffective response to insulin or tissue insulin resistance

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8
Q

In the last 20 years, # of adults diagnosed with diabetes has _______

A

doubled

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9
Q

____ of adults worldwide has diabetes

A

9.3%

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10
Q

annual cost of diabetes

A

327 billion

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11
Q

Diabetes dramatically increases the risk of

A

End-stage renal disease
amputation
heart disease
blindness
pregnancy complications

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12
Q

Type 1 DM Etiology

A

-appears before age 20
-most common in caucasians
-accounts for 5-10% of diabetic population
-not always a genetic component

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13
Q

Onset/treatment of Type 1

A

Generally rapid onset
no prevention and no cure
treatment is exogenous insulin

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14
Q

Classic signs of Type 1 Diabetes

A

RAPID onset of:
Polydipsia
Polyuria
Polyphagia
Weight loss

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15
Q

Polyphagia

A

excessive eating

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16
Q

Polydipsia

A

excessive drinking

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17
Q

Type 2 DM Etiology

A

-Appears mostly in adult population
-Increasingly occurring in children
-accounts for 90-95% of total diabetic population

-older adults and non-caucasians are disproportionately affected

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18
Q

Type 2 DM Risk Factors

A

Increasing age (65+)
Ethnicity (American indians)
Genetics
Overweight/Obesity
Physical inactivity

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19
Q

Type 2 DM Onset/Treatment

A

Onset: SLOW, initial signs present in type 1 are subtle or absent

Tx: weight loss, exercise, diet (which can all delay onset)

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20
Q

What occurs with glucose in an individual with TYPE 2 DIABETES

A
  1. reduced sensitivity of target tissues to respond to insulin
  2. Beta cells secrete more insulin to overcome resistance
  3. Later in disease process, insulin production decreases as beta cells fatigue, signal transduction pathway breaks down
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21
Q

What are possible reasons for insulin resistance?

A

changes in insulin receptors
problems in the signal transduction pathway activated by insulin receptor binding

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22
Q

Insulin sensitivity definition

A

relatively small amount of insulin is needed to maintain normolglycemia and supply cells with glucose they need

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23
Q

Insulin Resistance

A

a lot more insulin is needed to get the same blood glucose lowering effect because insulin’s targets tissues are not as responsive to insulin

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24
Q

Impaired glucose tolerance

A

known as impaired fasting glucose

condition in which individuals have blood glucose levels higher than normal, but not high enough to be called diabetes

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25
Q

Tests used to in diagnosis

A
  1. Fasting plasma glucose (fasting for 8 hrs)
  2. Oral glucose tolerance test
  3. Random plasma glucose level (any time during 24 hr period)
  4. A1C
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26
Q

Fasting plasma glucose levels

A

Normal: 70-99
Prediabetes: 100-125
Diabetes: >126

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27
Q

Fasting Plasma Glucose

A

direct measurement of plasma glucose levels after overnight fast

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28
Q

Oral Glucose Tolerance Test

A

measurement of body’s ability to appropriately handle excess sugar after drinking very high glucose drink

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29
Q

Non-diabetic OGTT Results

A

Plasma glucose level rises after drinking a glucose drink. Peaks within one hour, then falls quickly back to normal level

this is a normal insulin reaction

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30
Q

Diabetic OGTT results

A

glucose level rises higher than normal after drinking glucose drink and comes down in normal levels much slower

occurs with insulin resistance

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31
Q

What occurs with Type 1 Diabetics?

A
  1. High plasma glucose occurs because of reduced uptake of glucose to insulin’s target tissues
  2. Liver continues to produce glucose
  3. Accelerated lipolysis leads to high plasma levels of FFA and glycerol
  4. Liver produces excessive amounts of ketones
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32
Q

Diabetic Ketoacidosis

A

Major life-threatening complication mainly occurring in type 1

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33
Q

Processes of diabetic ketoacidosis

A
  1. Increased plasma glucose filtered by kidney cells overloads tubular reabsorption of glucose -> glucose and ketones are spilled into urine
  2. Increased nutrient concentration in kidney tubules leads to an osmotic diuresis and increased loss of water/sodium > causes decreased plasma volume and blood pressure
  3. Increased ketone production results in blood acidosis > causes coma and death
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34
Q

Insulin Therapy Goals

A
  1. Achieve optimal glycemic control
  2. minimize risk of severe hypo/hyper glycemia (acute)
  3. delay or prevent late vascular and neuropathic complications (chronic)
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35
Q

Hyperglycemia

A

patient not receiving enough insulin
greater than 250

S/s: polyuria, polydipsia, polyphagia, fatigue, nausea, blurred vision

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36
Q

Hypoglycemia

A

less than 50

S/S: weakness, hunger, profuse sweating, headaches, shaking confusion

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37
Q

Acute diabetic complications

A
  1. Hyperglycemia
  2. Hypoglycemia
  3. Ketoacidosis
  4. Surface infections and abscesses
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38
Q

Situations that increase diabetics’ risk of hypoglycemia

A

Fasting
delayed meals
alcohol consumption
intense physical activity
sleep

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38
Q

Insulin therapy and type 1 DM

A

insulin is required for life

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39
Q

Insulin therapy and type 2 DM

A

insulin use is reserved for those that are unable to control glucose levels with diet/exercise

most type 2 diabetics will eventually need insulin

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39
Q

Multiple daily insulin injections

A

has rapid, short, intermediate, long acting types

onset of action, peak response, duration of action determines what type of insulin you would need

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40
Q

Methods of insulin therapy

A
  1. Multiple daily insulin injections
  2. Continuous subcutaneous insulin infusion
  3. Inhaled insulin
41
Q

Continuous subcutaneous insulin infusion

A

-driven by mechanical force and delivered via needle
-uses only rapid acting insulin
-programmable, helps to optimize glycemic control
-lowers HbA(1c) levels

42
Q

Rapid-acting insulin

A

onset is in 5 min, with a peak at 30-90 min
Humalog

43
Q

Intermediate acting insulin

A

onset is 1.5 hours, peak is at 4-12 hrs
Insulin NPH

44
Q

Long-acting insulin

A

onset in 1 hr, with no peak
Insulin glargine

45
Q

Insulin injection sites

A
  1. make sure to rotate sites
  2. areas with more subcutaneous fat may absorb insulin more slowly
  3. exercise/massage/heat will increase absorption rate
46
Q

Insulin absorption rates vary in tissues…

A

abdomen > arm > leg and buttock

47
Q

Common insulin ADRs

A

Hypoglycemia
weight gain
injection site bruising/lipodystrophy

48
Q

How are blood glucose levels measured?

A

ACUTE: capillary pin prick and test with glucometer
instant and accurate snapshot

49
Q

Capillary blood glucose (CBG)

A

measured with a glucometer

50
Q

Glucometer and therapy

A

patients should bring their glucometer to therapy sessions

they should prick their own skin

51
Q

Continuous Glucose Monitors

A

-inserted under skin that measures glucose levels in the INTERSTITIAL FLUID

does not replace daily CBGs

used to identify trends in glucose levels

52
Q

Acute measurements of glucose levels

A

Glucometer
Continuous glucose monitors

53
Q

Long term measurement of blood glucose

A

best measure of glycemic control
HbA(1c)

54
Q

Glycemic Control

A

target goal of diabetes care

maintenance of stable blood glucose levels as close to normal as possible over time

helps to decrease the risk of chronic diabetic complications

55
Q

What is the HbA(1c)?

A

also known as glycated hemoglobin

glucose sticks to hemoglobin, forming it. The more glucose in the blood, the more HbA(1c) will be in the blood

56
Q

What does HbA(1c) measure?

A

estimates the mean blood glucose level over previous 4 weeks

A1C is tested at diagnosis and at least 2 times/year

57
Q

What measurements are used to diagnose diabetes?

A

A1C > 6.5%
FBG >126

58
Q

Prediabetes A1C

A

5.7% to 6.4%

59
Q

Normal A1C levels

A

<5.7%

60
Q

ADA’s goal for diabetics is to keep A1C…

A

<7%

61
Q

A1C is correlated with…

A

estimated average glucose

using EAG is better with patients when talking about glucemic control

its not a percentage, its the same units as daily CBG values

62
Q

Why should we care about A1C levels?

A

higher A1C indicates poor glycemic control, which is associated with a higher risk of chronic diabetic complications

63
Q

Chronic diabetic complications fall into 2 main categories…

A

Neuropathies
Vascular diseases

64
Q

Neuropathic complications

A

ALL nerves are affected, mechanisms unknown

S/S: numbness, insensitivity, muscle atrophy, altered thermoregulation, tachycardia, erectile dysfunction

65
Q

Charcot joint disease

A

loss of sensation leading to joint dysfunction

most frequently affects the weightbearing joints, and occurs after minor injury

Muscle atrophy–> arch collapses –> weight bearing differently –> ulcer

66
Q

What is optimal treatment for charcot foot?

A

subject of ongoing debate

options of conservative limb salvage, surgical conservation, CROW, amputation

67
Q

Conservative limb salvage

A

involves offloading, casting, therapeutic footwear

goal is slow down and minimize degree of joint pathology

does not entail return normal jt structure

68
Q

Disadvantages of conservative limb salvage

A

bones can heal in deformed positions
CROW device can limit activity
hard to be NWB

69
Q

CROW

A

Charcot restrain orthotic walker
custom made rigid boot that completely immobilizes foot and ankle
worn for 6-12 months

70
Q

Other off-loading devices

A

Traditional, roll-on, removable, CROW

don’t use wedge or post-op shoe

71
Q

Diabetic Foot Exam

A

Vascular
Infection/Inflammation
Pressure
Sensation

72
Q

Vascular (diabetic foot exam)

A

Vital signs
Foot pulses
ABI

73
Q

Infection (diabetic foot exam)

A

For each ulceration note…
Location, size, depth, debride, probe to bone

74
Q

Pressure

A

also look for deformity
look for toes, ankles, calluses

75
Q

What is protective sensation?

A

light touch perception that corresponds to the ability to sense trauma to the foot and cease weightbearing

76
Q

How do you test protective sensation?

A

with semmes-weinstein 5.07 monofilament
calibrated to apply 10 grams of force

77
Q

Don’ts of diabetic foot care

A

Smoke
Wash in very hot or cold water
use heating pads
razors/scissors to cut corns
cross legs
wear girdles/garters
walk barefoot

78
Q

Do’s of diabetic foot care

A

heave regular exams
inspect feet daily
wash feet daily
dry feet carefully
apply cream to dry areas
cut nails straight across
wear wide toe-box shoes
inspect shoes before putting them on

79
Q

Macrovascular complications

A

affects large vessels of heart and peripheral arterial vessels

leads to CAD, MI, CVA, PVD

80
Q

Microvascular Complications

A

smaller blood vessels of retina, kidneys, peripheral nerves

leads to blindness, renal failure, neuropathy

81
Q

Why is long-term hyperglycemia toxic to blood vessels?

A

Endothelial cell dysfunction
Lipoprotein dysfunction
Thickening of basement membrane
Thrombogenesis
Arterial wall calcification

82
Q

Endothelial cell dysfunction

A

normal/healthy endothelial cells modulates vascular tone, permeability, coagulation

leads to atherosclerosis

83
Q

What factors contribute to hyperglycemia?

A
  1. Exogenous systemic glucocorticoids
  2. Stress
  3. Onset of new illness/infection
  4. Meals
84
Q

Exogenous systemic glucocorticoids and hyperglycemia

A

induce a state of insulin resistance

85
Q

Stress and hyperglycemia

A

hormones released during stress induce hyperglycemia

86
Q

Meals and hyperglycemia

A

POSTPRANDIAL HYPERGLYCEMIA is a predominant feature in patients with type 2 DM and is a risk factor for development of CV complications

87
Q

Recommendations for diabetes

A

Increasing PA
Nutritional management
Weight loss
Intense glycemic control
blood pressure
control dyslipidemia
Antiplatelet therapy
daily foot care, smoking cessation

88
Q

Children and Adolescent exercise recommendations

A

should engage in 60 min/day of moderate to vigorous activity, strengthening 3 days a week, for either diabetes type

89
Q

Adult exercise recommendations

A
  1. Exercise more than 150 minutes of aerobic activity
  2. No more than 2 consecutive days missed
  3. 2-3 sessions of resistance exercise
  4. Reduce daily sedentary time. Prolonged sitting should be interrupted every 30 min
90
Q

How does exercise improve glycemic control?

A

Muscle contraction moves glut4 to the surface of muscle fibers and insulin is not needed for this

trained muscle can act like a sponge to suck up some of the glucose from the blood, decreasing blood glucose

the insulin sensitivity created can last 24 hours after the exercise

glut4 expression is enhanced with training only in those fibers recruited during exercise training

slow twitch fibers do better at this

more muscle mass, bigger sponges to suck up more glucose

91
Q

Cornerstone treatment for Type 2 DM

A
  1. Weight loss
  2. Exercise
  3. Glucose-lowering meds
  4. Insulin
92
Q

Weight loss benefits for diabetics

A

clinical benefits begin with 3-5% body weight loss

93
Q

Lifestyle vs med treatments

A

Lifestyle intervention reduced the incidence of diabetes more than metaformin

94
Q

Less sitting =

A

less risk of Type 2 DM
every hour spent watching TV there was a 3.4% increased risk of diabetes

95
Q

General exercise prescription guidelines for diabetic

A

Warm up fro 5-10 min
30 min of continuous moderate intensity
Cool-down for 5-10 min

use RPE as a predictor of exercise intensity (12-14)

96
Q

Postprandial hyperglycemia and exercise

A

aerobic exercise works better after a meal

97
Q

Exercise contraindications and precautions

A

NEED to assess before: VS, vision, balance, foot exam, shoes

Monitor CBG pre and post exercise

Adjust insulin/food intake as needed

Hypoglycemia may occur during or after exercise

Evening exercise increases risk of nocturnal hypoglycemia

Neuropathy may lead to hyperthermia, ischemia, painless trauma

Don’t exercise during peak insulin

98
Q

CBG and exercise

A

No exercise if CBG >300 mg/dl
No exercise if CBG > 240 mg/dl w/ketones

99
Q

Metformin

A

MOA: decrease liver gluconeogenesis

ADRS: nausea, vomiting, diarrhea, flatulence, abdominal discomfort, asthenia

individuals with abnormal kidney/liver function: lactic acidosis may occur

100
Q

5 Regulators of Insulin Secretion

A

Food intake
Increased amino acids
GLP1 and GIP (ff regulation)
Exercise (inhibits)
Parasympathetic Activity (ff regulation)

101
Q

Stress management of diabetes

A

approaches to reduce stress are key components of diabetes management

psychological intervention can help to lower A1C levels

102
Q
A

5 Pathology (9 decks)

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