Therapeutic Interventions for Diabetes Mellitus Flashcards
Exocrine function of pancreas
- secretes enzymes into duodenum to support digestion of macromolecules
- secretes bicarbonate into duodenum to raise pH of chyme
Endocrine
- 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
Insulin
- 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
Glucagon
- promotes conversion of glycogen, proteins, and lipids into glucose (gluconeogenesis) and release of glucose into blood
- glucagon secretion increases during fasted state
DM
metabolic disorder characterized by an imbalance between insulin availability and insulin need
- characterized by hyperglycemia, polydipsia, polyuria, polyphagia
Type 1 DM
insulin-dependent. pancreas cannot produce insulin represents 5-10% of all cases of DM usually underweight treated with insulin
Type II
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
DKA
- extreme hyperglycemia
- ketones in blood and urine
- fruity breath
- treated with insulin and fluid replacement
Complications of not treating Type 1 or Type II
- diabetic neuropathy (end-stage renal failure)
- diabetic retinopathy (leading cause of acquired blindness)
- Vascular disease (heart disease, stroke, poor circulation contributes to foot ulcers)
macronutrient intake
- the distribution of Carbs, Fats, and protein is dependent on food preferences and metabolic factors like insulin sensitivity, lipid levels, and kidney function
Glycemic Index
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
low
med
high
glycemic index
low: < 55
medium: 56-69
high: > 70
benefit to eating foods with low glycemic index
- control BG level
- control cholesterol level
- control appetite
- lower your risk of developing heart disease
- lower your risk of developing type 2 diabetes
Sugars, whole grains and fibre, dietary fat, protein
- 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
Body weight:
weight los is encouraged especially early in type 2 diabetes as fat can increase insulin resistance - chronic state of inflammation. inflammation decrease insulin sensitivity
Carb counting
- 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
Most common drugs for treatment of type II diabetes
drugs that promote release of insulin (secretagogues) or increase receptor sensitivity to insulin
Secretagogues
- Sulfonylureas
- meglitinides
promote release of insulin
Biguanides
Thiazolidinediones
drugs that increase sensitivity to insulin
- used to treat DM II
Alpha glucosidase inhibitors (DM II)
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
Incretin Enhancers (DM II)
- 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)
Thiazolidinediones
- reduce blood glucose by decreased insulin resistance and inhibiting hepatic gluconeogenesis
- hypoglycemia does not occur with this class
- ex. Rosiglitazone
Sulfonylureas
- divided into first - and - second generation categories
- stimulate release of insulin from pancreatic islet cells
- increase sensitivity of insulin receptors on target cells
Sulfonylurea Prototype Drug: Glyburide
- therapeutic effects and uses
- mechanism of action
- side effects
- serious side effects
1 . lowers blood glucose levels in patients with type 2 diabetes
- stimulates release of insulin from pancreatic beta cells. increases sensitivity of peripheral tissues to insulin
- nausea & vomiting/heartburn/dizziness/urticaria/pruritis
- hypoglycemia/hepatoxicity/aplastic anemia
Keeping patients safe when they are at risk of dehydration (vomiting/diarrhea) Hold SADMANS
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
Pharmacotherapy for Type I DM (IDDM - insulin dependent DM)
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
Forms of Insulin
Rapid-acting - lispro
Short-acting - regular
Intermediate acting - NPH
Long-acting - zinc
How much insulin is needed
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
Timing of Insulin
- 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
Insulin prototype drug: Regular insulin
- trade names
- therapeutic effects and uses
- mechanism of action
- adverse effects
- Humulin/Novolin ge Toronto
- insulin replacement therapy for type I DM
- insulin produced through recombinant DNA techniques; replacement for endogenous insulin
- hypoglycemia (too much insulin given to a patient/given at wrong time/if a meal is skipped)
Symptoms of Hypoglycemia
tachycardia, confusion, sweating, drowsiness, colvulsions, coma, death if not treated.
- treat with gucagon or a glucose source
Further Adverse effects of Insulin
- irritation at injection site - always rotate injection sites
- hypokalemia because potassium follows glucose into cells
- Somogyi effects
- Dawn effect
Somogyi effect
- 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.
Dawn Effect
- 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
Sliding Scale Insulin
- 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
IV insulin
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)
