Module 3 - Diabetes Mellitus Flashcards
What is diabetes mellitus and what signs & symptoms are expected?
- It is a condition which affects your body’s ability to produce or use insulin and characterized by hyperglycemia
- Signs & symptoms include: polyuria, polydipsia, polyphagia, unexplained weight loss
What conditions can cause diabetes?
- Cushing’s syndrome
- Acromegaly
- Hyperthyroidism
- Pheochromocytoma
- Medication use: Glucocorticoids, Diuretics, Phenytoin, Oral Contraceptives, Statins
- Pancreatic Disease: pancreatitis, pancreatectomy, cystic fibrosis
- Other genetic factors: B cell defects, Neoplasia, Down’s syndrome, Turner’s syndrome, Klinefelter syndrome and Wolfram syndrome
What labs should be obtained annually to rule out developing diabetes?
- Fasting lipid profile
- Liver function tests
- Urine albumin excretion
- Serum creatinine
- Serum thyroid stimulating hormone (TSH) in type 1 DM
According to the American Diabetes Association (ADA) how is diabetes mellitus diagnosed?
Positivefindings of any of the following tests results:
- Random plasma glucose of 200mg/dL or above
- 2-hour post oral glucose tolerance test with 75gms glucose load and result of 200mg/dL or above
- Glycosylated hemoglobin (HbA1c) 6.5% or above
- Fasting plasma glucose = 126 mg/dL or above on two separate occasions
According to the American Diabetes Association (ADA) how is pre-diabetes diagnosed?
- Fasting plasma glucose = 110-125mg/dL
- 2 hour plasma glucose after a 75gm glucose load = 140-199 mg/dL
- HbA1c = 5.7% - 6.4%
What is HbA1c and how is it used to diagnose/manage diabetes?
- Indicative of patient’s glycemic control over past 2-3 months
- Now used for initial diagnosis
- For patients not under optimal glycemic control, practitioner should follow HgA1c at least quarterly.
- Once patient under glycemic control, can measure every 6 months
- Normal 5.5-6.4%
- Goal: <7%
What are the 10 complications associated with diabetes mellitus?
1. Diabetes Retinopathy:
- Most common cause of blindness
- Annual ophthalmology examinations
2. Cardiovascular Disease:
- Diabetes add an independent risk factor for cardiovascular disease
- HTN prevalence is 2 times greater in type 2 diabetes patients.
3. Cataracts:
- Increased prevalence in diabetics
4. Glaucoma:
- Prevalence 6% in diabetics
5. Neuropathy:
- Most common complication
- Loss of sensation a/w pain along autonomic and peripheral nerve tracks
6. Nephropathy:
- End-stage renal disease prevalence 40% for type 1 diabetics and <20% for type 2 diabetics
- First indication of diabetic nephropathy is the finding of microalbuminuria (also known as the albumin – to – creatinine ratio) on urinalysis
- Microalbuminuria is defined as urinary albumin excretion of 30-300mg/day and is an early sign of vascular damage and diabetic kidney disease.
7. Neuropathic Osteoarthropathy
- Commonly referred to as ‘Charcot foot’
- Conditions affecting bones, joints and soft tissues of foot and ankle
- Characterized by inflammatory conditions that may lead to varying degrees and patterns of bone destruction, subluxation, dislocation and deformity
- Hallmark deformity is midfoot collapse, described as a ‘rocker bottom’ foot
8. Infections:
- Yeast infections common
- Lower extremity skin infections
9. Gangrene of feet:
- 20 times higher incidence in patients with diabetes
10. DKA & HHNKS
What are the predisposing factors for type I diabetes?
- Predominantly affects Caucasians, males and females affected equally
- African Americans with the lowest incidence of Type 1 DM
- Genetic predisposition exists
- Most (70%) acquire Type I DM prior to age 20
- Virtual absence of circulating insulin
- Islet cell antibodies may be found in 90% of patients within 1st year of diagnosis
- Ketone development usually occurs
- Type I DM strongly associated with human leukocyte antigens HLA-DR3 and HLA-DR4
- Absence of C-peptides
What are the 4 types of insulin?
- Rapid acting (i.e. insulin lispro, brand name Humalog; insulin aspart, brand name Novolog, and insulin glulisine, brand name Apidral)
- Short acting (i.e. insulin Regular)
- Intermediate acting (i.e. insulin NPH)
- Long acting (i.e. insulin glargine, brand names Lantus and Basaglar; insulin detemir, brand name Levemir and insulin degludec, brand name Tresida)
How is the initial insulin dosage calculated?
The initiation of insulin commonly begins by prescribing 0.5units/kg/day, with 2/3 of the dosage given in the a.m. and the remaining 1/3 given in the p.m.
What is the Somogyi effect and how do you treat this?
- Somogyi effect -nocturnal hypoglycemia develops, stimulating a surge of counter regulatory hormones that raise blood sugar, resulting in elevated early morning glucose levels
- Treatment - reduce or omit bedtime dose of insulin
What is the dawn phenomenon and how is it treated?
- Dawn phenomenon - decreased sensitivity to insulin occurs nocturnally, owing to the presence of growth hormone, which spikes at night
- Blood sugar becomes progressively elevated thoughout night, resulting in elevated glucose by 7am
- Treatment: Increase amount of intermediate acting insulin at bedtime
What are the predisposing factors for type II diabetes?
- 90% of patients with diabetes have Type 2 DM
- Usually diagnosed in adults, after age 45
- Circulating insulin is sufficient to prevent ketoacidosis but is inadequate to meet the patient’s insulin needs
- 75-80% of type 2 DM patients in U.S. are obese
- Ketone production does not usually occur in type 2 DM patients.
- C-peptides are usually present.
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Associated with Metabolic Syndrome
- Central obesity (waist circumference > 40 inches in men and > 35 inches in women)
- Hypertension
- Abnormal HDL (< 40 mg/dL in men and < 50 mg/dL in women)
- Abnormal triglycerides > 150mg/dL
- Fasting blood glucose of 100mg/dL or greater
- Develops insidiously
- Frequently patient is asymptomatic
- Sedentary lifestyle
What is the MOA, S/x, and contraindications associated with metformin?
MOA: Reduces gluconeogenesis; increase glucose utilization
S/x: Lactic acidosis, nausea, anorexia, diarrhea, GI Effects
Contraindications: Hepatic or renal impairment, advanced age, alcoholism
This is the preferred initial pharmacologic agent for type 2 DM
What is the MOA, S/x, and contraindications associated with Sulfonylureas (Glyburide/Glipizide)?
MOA: Stimulates release of endogenous insulin chronically
S/x: Hypoglycemia, nausea, GI discomfort
Contraindications: Hypersensitivity, DKA
Describe the medication management for patients with diabetes
1. Start newly diagnosed patients with Metformin unless:
- HgA1c _>_9%, consider dual therapy
- HgA1c _>_10%, blood glucose >300mg/dL, or patient is markedly symptomatic, consider combination injectable therapy
2. If HgA1c target not achieved in approx 3 months, proceed to dual therapy:
- Metformin + (Sulfonylura/Insulin/Gliptin Hypoglycemic/)
3. If HgA1c target not achieved in approx 3 months, proceed to tripple therapy
4. IF HgA1c t arget not acheived after 3 months, move to basal insulin. Maintain metformin therapy.
