Therapeutic Interventions for Diabetes Mellitus

Question 1

Exocrine function of pancreas

Answer 1

• secretes enzymes into duodenum to support digestion of macromolecules
• secretes bicarbonate into duodenum to raise pH of chyme

Question 2

Endocrine

Answer 2

• islets of langerhan includes two types of cells that secrete hormones
• alpha cells: secrete glucagon in response to low blood glucose and to activity of sympathetic nervous system
• beta cells: secrete insulin in response to high blood glucose and to activity of parasympathetic nervous system

Question 3

Insulin

Answer 3

• promotes formation of glucose transporters that bring glucose from body into cells, thereby lowering blood glucose
• promotes conversion of monosaccharides, lipids, and amino acids into storage forms of polysaccharides, triglycerides, and proteins
• insulin secretion increases during fed state

Question 4

Glucagon

Answer 4

• promotes conversion of glycogen, proteins, and lipids into glucose (gluconeogenesis) and release of glucose into blood
• glucagon secretion increases during fasted state

Question 5

DM

Answer 5

metabolic disorder characterized by an imbalance between insulin availability and insulin need
- characterized by hyperglycemia, polydipsia, polyuria, polyphagia

Question 6

Type 1 DM

Answer 6

insulin-dependent. 
pancreas cannot produce insulin 
represents 5-10% of all cases of DM
usually underweight 
treated with insulin

Question 7

Type II

Answer 7

pancreas does not produce enough insulin to meed needs of body or insulin receptors are not sensitive to insulin that is produced

• 90-95% of cases
• patients are usually overweight
• treated with appropriate diet and exercise then with oral antihyperglycemic drugs, then finally insulin.
• disease usually appears in middle adulthood

Question 8

DKA

Answer 8

• extreme hyperglycemia
• ketones in blood and urine
• fruity breath
• treated with insulin and fluid replacement

Question 9

Complications of not treating Type 1 or Type II

Answer 9

• diabetic neuropathy (end-stage renal failure)
• diabetic retinopathy (leading cause of acquired blindness)
• Vascular disease (heart disease, stroke, poor circulation contributes to foot ulcers)

Question 10

macronutrient intake

Answer 10

• the distribution of Carbs, Fats, and protein is dependent on food preferences and metabolic factors like insulin sensitivity, lipid levels, and kidney function

Question 11

Glycemic Index

Answer 11

a scale that ranks carbohydrates by how much they raise blood glucose levels compared to a standard food like glucose or white bread

• foods low on glycemic index scale tend to release glucose slowly. foods high on he glycemic index release glucose rapidly
• the slow and steady release of glucose in low-glucose in low-glycemic foods is helpful in keeping blood glucose under control

Question 12

low
med
high
glycemic index

Answer 12

low: < 55
medium: 56-69
high: > 70

Question 13

benefit to eating foods with low glycemic index

Answer 13

• control BG level
• control cholesterol level
• control appetite
• lower your risk of developing heart disease
• lower your risk of developing type 2 diabetes

Question 14

Sugars, whole grains and fibre, dietary fat, protein

Answer 14

• sugar consumed moderately
• fibre rich food encouraged
• dietary fat intake is similar to general population - monosaturated fats and omega 3s are engouraged
• protein intake similar to general population

Question 15

Body weight:

Answer 15

weight los is encouraged especially early in type 2 diabetes as fat can increase insulin resistance - chronic state of inflammation. inflammation decrease insulin sensitivity

Question 16

Carb counting

Answer 16

• management of carb intake and insulin administration
• need to know how to read nutritional info on food packages to determine how much insulin to give to account for the carbs
• insulin to carb ration (ICR)
  Ex. 1 unit of insulin for every 10 carbs. 1:10 ratio

Question 17

Most common drugs for treatment of type II diabetes

Answer 17

drugs that promote release of insulin (secretagogues) or increase receptor sensitivity to insulin

Question 18

Secretagogues

Answer 18

• Sulfonylureas
• meglitinides
  promote release of insulin

Question 19

Biguanides

Thiazolidinediones

Answer 19

drugs that increase sensitivity to insulin

- used to treat DM II

Question 20

Alpha glucosidase inhibitors (DM II)

Answer 20

reduce absorption of glucose by preventing digestion of carbohydrates

• block enzymes in the small intestine responsible for breaking down complex carbs into monosaccharies.
• hypoglycemia may occur when combined with insulin or a sulfonylurea
• cause flatulence, diarrhea, abdominal distension
• ex. Acarbose

Question 21

Incretin Enhancers (DM II)

Answer 21

• simulate amount of insulin produced by the pancreas
• reduce the destruction of incretins
• decreases rate of digestion of carbs
  Two Classes
  1. activating GLP -1 receptor
• increased amount of insulin secreted by pancreas
• decreased amount of glucagon secreted by pancreas
• delayed gastric emptying
• decreased food intake
• ex. Sitagliptin
  2. Inhibiting dipeptidyl peptidase (DPP-4)

Question 22

Thiazolidinediones

Answer 22

• reduce blood glucose by decreased insulin resistance and inhibiting hepatic gluconeogenesis
• hypoglycemia does not occur with this class
• ex. Rosiglitazone

Question 23

Sulfonylureas

Answer 23

• divided into first - and - second generation categories
• stimulate release of insulin from pancreatic islet cells
• increase sensitivity of insulin receptors on target cells

Question 24

Sulfonylurea Prototype Drug: Glyburide

1. therapeutic effects and uses
2. mechanism of action
3. side effects
4. serious side effects

Answer 24

1 . lowers blood glucose levels in patients with type 2 diabetes

2. stimulates release of insulin from pancreatic beta cells. increases sensitivity of peripheral tissues to insulin
3. nausea & vomiting/heartburn/dizziness/urticaria/pruritis
4. hypoglycemia/hepatoxicity/aplastic anemia

Question 25

Keeping patients safe when they are at risk of dehydration (vomiting/diarrhea) Hold SADMANS

Answer 25

s: sulfonylureas, other secretagogues a: ace-inhibitors d: diuretics, direct renin inhibitors m: metformin a: angiotensin receptor blockers n: non-steroidal anti-inflammatory drugs s: SGLT2 inhibitors

Question 26

Pharmacotherapy for Type I DM (IDDM - insulin dependent DM)

Answer 26

treated with insulin replacement. - insulin is given through subcutaneous route can be given IV - insulin available in many preparations categorized by time to onset, time to peak, concentration, and duration of action

Question 27

Forms of Insulin

Answer 27

Rapid-acting - lispro Short-acting - regular Intermediate acting - NPH Long-acting - zinc

Question 28

How much insulin is needed

Answer 28

insulin administration is planned in conjunction with current blood glucose levels, nutrient intake, and exercise because there is increased glucose in the body and exercise increases sensitivity to insulin

Question 29

Timing of Insulin

Answer 29

- the fundamental principle of insulin administration is that the right amount of it must be available to the cells when glucose is present in the blood - without insulin after a meal glucose can build up in the blood and cause hyperglycemia - if insulin is taken when food has not been eaten and there is little to no glucose in the blood hypoglycemia can occur - during heavy or prolonged exercise periods, hypoglycemia may occur

Question 30

Insulin prototype drug: Regular insulin 1. trade names 2. therapeutic effects and uses 3. mechanism of action 4. adverse effects

Answer 30

1. Humulin/Novolin ge Toronto 2. insulin replacement therapy for type I DM 3. insulin produced through recombinant DNA techniques; replacement for endogenous insulin 4. hypoglycemia (too much insulin given to a patient/given at wrong time/if a meal is skipped)

Question 31

Symptoms of Hypoglycemia

Answer 31

tachycardia, confusion, sweating, drowsiness, colvulsions, coma, death if not treated. - treat with gucagon or a glucose source

Question 32

Further Adverse effects of Insulin

Answer 32

- irritation at injection site - always rotate injection sites - hypokalemia because potassium follows glucose into cells - Somogyi effects - Dawn effect

Question 33

Somogyi effect

Answer 33

- the tendency of the body to react to an extremely low BS to overcompensate and result in a high BS - Releases compensatory hormones - growth hormones, catecholemies - the liver reduces glucose - saves the person from dying from hypoglycemia, but it results in a hyperglycemic event - should set an alarm for 3 am and check their blood sugars.

Question 34

Dawn Effect

Answer 34

- natural 'wake up' response - between 2 and 8 am, the body releases normal waking up hormones , causes BS to rise. - diabetics will wake up with hyperglycemia - avoid carbs at bedtime - adjust dose of med or insulin give more - change time you take med or insulin from dinnertime to bedtime - use an insulin pump

Question 35

Sliding Scale Insulin

Answer 35

- doses of short-acting insulin can be adjusted depending on the individuals blood glucose levels. - typically used in hospitalized diabetic patients - subcutaneous regular insulin ordered in an amount that increases as the BG decreases - check BS, check chart and depending on the range they are falling into, give the appropriate amount of insulin

Question 36

IV insulin

Answer 36

used in critical care perioperatively in-patient setting during delivery goal of BS 6-10 (high goals because it has such an immediate onset of action we want to create a buffer zone for ourselves to keep them from going into hypoglycemia)