L1 Diabetes Flashcards
1
Q
SOC
A
Standard of Care
2
Q
Diabetes definition
A
means siphon, describes the large urinary volume excreted by sufferers of this disease
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
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
5
Q
Diabetes mellitus is characterized by
A
Chronic hyperglycemia
Relative deficiency in insulin (b/c of reduced secretion or action)
6
Q
Type 1 Diabetes
A
Autoimmune disease
characterized by a lack of insulin production
7
Q
Type 2 Diabetes
A
Ineffective response to insulin or tissue insulin resistance
8
Q
In the last 20 years, # of adults diagnosed with diabetes has _______
A
doubled
9
Q
____ of adults worldwide has diabetes
A
9.3%
10
Q
annual cost of diabetes
A
327 billion
11
Q
Diabetes dramatically increases the risk of
A
End-stage renal disease
amputation
heart disease
blindness
pregnancy complications
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
13
Q
Onset/treatment of Type 1
A
Generally rapid onset
no prevention and no cure
treatment is exogenous insulin
14
Q
Classic signs of Type 1 Diabetes
A
RAPID onset of:
Polydipsia
Polyuria
Polyphagia
Weight loss
15
Q
Polyphagia
A
excessive eating
16
Q
Polydipsia
A
excessive drinking
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
18
Q
Type 2 DM Risk Factors
A
Increasing age (65+)
Ethnicity (American indians)
Genetics
Overweight/Obesity
Physical inactivity
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)
20
Q
What occurs with glucose in an individual with TYPE 2 DIABETES
A
- reduced sensitivity of target tissues to respond to insulin
- Beta cells secrete more insulin to overcome resistance
- Later in disease process, insulin production decreases as beta cells fatigue, signal transduction pathway breaks down
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
22
Q
Insulin sensitivity definition
A
relatively small amount of insulin is needed to maintain normolglycemia and supply cells with glucose they need
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
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
25
Tests used to in diagnosis
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
26
Fasting plasma glucose levels
Normal: 70-99
Prediabetes: 100-125
Diabetes: >126
27
Fasting Plasma Glucose
direct measurement of plasma glucose levels after overnight fast
28
Oral Glucose Tolerance Test
measurement of body's ability to appropriately handle excess sugar after drinking very high glucose drink
29
Non-diabetic OGTT Results
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
30
Diabetic OGTT results
glucose level rises higher than normal after drinking glucose drink and comes down in normal levels much slower
occurs with insulin resistance
31
What occurs with Type 1 Diabetics?
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
32
Diabetic Ketoacidosis
Major life-threatening complication mainly occurring in type 1
33
Processes of diabetic ketoacidosis
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
34
Insulin Therapy Goals
1. Achieve optimal glycemic control
2. minimize risk of severe hypo/hyper glycemia (acute)
3. delay or prevent late vascular and neuropathic complications (chronic)
35
Hyperglycemia
patient not receiving enough insulin
greater than 250
S/s: polyuria, polydipsia, polyphagia, fatigue, nausea, blurred vision
36
Hypoglycemia
less than 50
S/S: weakness, hunger, profuse sweating, headaches, shaking confusion
37
Acute diabetic complications
1. Hyperglycemia
2. Hypoglycemia
3. Ketoacidosis
4. Surface infections and abscesses
38
Situations that increase diabetics' risk of hypoglycemia
Fasting
delayed meals
alcohol consumption
intense physical activity
sleep
38
Insulin therapy and type 1 DM
insulin is required for life
39
Insulin therapy and type 2 DM
insulin use is reserved for those that are unable to control glucose levels with diet/exercise
most type 2 diabetics will eventually need insulin
39
Multiple daily insulin injections
has rapid, short, intermediate, long acting types
onset of action, peak response, duration of action determines what type of insulin you would need
40
Methods of insulin therapy
1. Multiple daily insulin injections
2. Continuous subcutaneous insulin infusion
3. Inhaled insulin
41
Continuous subcutaneous insulin infusion
-driven by mechanical force and delivered via needle
-uses only rapid acting insulin
-programmable, helps to optimize glycemic control
-lowers HbA(1c) levels
42
Rapid-acting insulin
onset is in 5 min, with a peak at 30-90 min
Humalog
43
Intermediate acting insulin
onset is 1.5 hours, peak is at 4-12 hrs
Insulin NPH
44
Long-acting insulin
onset in 1 hr, with no peak
Insulin glargine
45
Insulin injection sites
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
Insulin absorption rates vary in tissues...
abdomen > arm > leg and buttock
47
Common insulin ADRs
Hypoglycemia
weight gain
injection site bruising/lipodystrophy
48
How are blood glucose levels measured?
ACUTE: capillary pin prick and test with glucometer
instant and accurate snapshot
49
Capillary blood glucose (CBG)
measured with a glucometer
50
Glucometer and therapy
patients should bring their glucometer to therapy sessions
they should prick their own skin
51
Continuous Glucose Monitors
-inserted under skin that measures glucose levels in the INTERSTITIAL FLUID
does not replace daily CBGs
used to identify trends in glucose levels
52
Acute measurements of glucose levels
Glucometer
Continuous glucose monitors
53
Long term measurement of blood glucose
best measure of glycemic control
HbA(1c)
54
Glycemic Control
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
What is the HbA(1c)?
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
What does HbA(1c) measure?
estimates the mean blood glucose level over previous 4 weeks
A1C is tested at diagnosis and at least 2 times/year
57
What measurements are used to diagnose diabetes?
A1C > 6.5%
FBG >126
58
Prediabetes A1C
5.7% to 6.4%
59
Normal A1C levels
<5.7%
60
ADA's goal for diabetics is to keep A1C...
<7%
61
A1C is correlated with...
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
Why should we care about A1C levels?
higher A1C indicates poor glycemic control, which is associated with a higher risk of chronic diabetic complications
63
Chronic diabetic complications fall into 2 main categories...
Neuropathies
Vascular diseases
64
Neuropathic complications
ALL nerves are affected, mechanisms unknown
S/S: numbness, insensitivity, muscle atrophy, altered thermoregulation, tachycardia, erectile dysfunction
65
Charcot joint disease
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
What is optimal treatment for charcot foot?
subject of ongoing debate
options of conservative limb salvage, surgical conservation, CROW, amputation
67
Conservative limb salvage
involves offloading, casting, therapeutic footwear
goal is slow down and minimize degree of joint pathology
does not entail return normal jt structure
68
Disadvantages of conservative limb salvage
bones can heal in deformed positions
CROW device can limit activity
hard to be NWB
69
CROW
Charcot restrain orthotic walker
custom made rigid boot that completely immobilizes foot and ankle
worn for 6-12 months
70
Other off-loading devices
Traditional, roll-on, removable, CROW
don't use wedge or post-op shoe
71
Diabetic Foot Exam
Vascular
Infection/Inflammation
Pressure
Sensation
72
Vascular (diabetic foot exam)
Vital signs
Foot pulses
ABI
73
Infection (diabetic foot exam)
For each ulceration note...
Location, size, depth, debride, probe to bone
74
Pressure
also look for deformity
look for toes, ankles, calluses
75
What is protective sensation?
light touch perception that corresponds to the ability to sense trauma to the foot and cease weightbearing
76
How do you test protective sensation?
with semmes-weinstein 5.07 monofilament
calibrated to apply 10 grams of force
77
Don'ts of diabetic foot care
Smoke
Wash in very hot or cold water
use heating pads
razors/scissors to cut corns
cross legs
wear girdles/garters
walk barefoot
78
Do's of diabetic foot care
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
Macrovascular complications
affects large vessels of heart and peripheral arterial vessels
leads to CAD, MI, CVA, PVD
80
Microvascular Complications
smaller blood vessels of retina, kidneys, peripheral nerves
leads to blindness, renal failure, neuropathy
81
Why is long-term hyperglycemia toxic to blood vessels?
Endothelial cell dysfunction
Lipoprotein dysfunction
Thickening of basement membrane
Thrombogenesis
Arterial wall calcification
82
Endothelial cell dysfunction
normal/healthy endothelial cells modulates vascular tone, permeability, coagulation
leads to atherosclerosis
83
What factors contribute to hyperglycemia?
1. Exogenous systemic glucocorticoids
2. Stress
3. Onset of new illness/infection
4. Meals
84
Exogenous systemic glucocorticoids and hyperglycemia
induce a state of insulin resistance
85
Stress and hyperglycemia
hormones released during stress induce hyperglycemia
86
Meals and hyperglycemia
POSTPRANDIAL HYPERGLYCEMIA is a predominant feature in patients with type 2 DM and is a risk factor for development of CV complications
87
Recommendations for diabetes
Increasing PA
Nutritional management
Weight loss
Intense glycemic control
blood pressure
control dyslipidemia
Antiplatelet therapy
daily foot care, smoking cessation
88
Children and Adolescent exercise recommendations
should engage in 60 min/day of moderate to vigorous activity, strengthening 3 days a week, for either diabetes type
89
Adult exercise recommendations
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
How does exercise improve glycemic control?
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
Cornerstone treatment for Type 2 DM
1. Weight loss
2. Exercise
3. Glucose-lowering meds
4. Insulin
92
Weight loss benefits for diabetics
clinical benefits begin with 3-5% body weight loss
93
Lifestyle vs med treatments
Lifestyle intervention reduced the incidence of diabetes more than metaformin
94
Less sitting =
less risk of Type 2 DM
every hour spent watching TV there was a 3.4% increased risk of diabetes
95
General exercise prescription guidelines for diabetic
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
Postprandial hyperglycemia and exercise
aerobic exercise works better after a meal
97
Exercise contraindications and precautions
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
CBG and exercise
No exercise if CBG >300 mg/dl
No exercise if CBG > 240 mg/dl w/ketones
99
Metformin
MOA: decrease liver gluconeogenesis
ADRS: nausea, vomiting, diarrhea, flatulence, abdominal discomfort, asthenia
individuals with abnormal kidney/liver function: lactic acidosis may occur
100
5 Regulators of Insulin Secretion
Food intake
Increased amino acids
GLP1 and GIP (ff regulation)
Exercise (inhibits)
Parasympathetic Activity (ff regulation)
101
Stress management of diabetes
approaches to reduce stress are key components of diabetes management
psychological intervention can help to lower A1C levels
102
