Wk 12 DM Flashcards
DM
hyperglycemia
impaired metab
impaired insulin sec, insulin resistance
Type I
5-10% of class, age of onset <30, weak genetic link, absolutely no insulin prod, autoimmune
Type II
90+% of class, >30, strong genetic link, either insulin resistance or defective insulin release or excess glu prod or all the above
diagnosis of DM
confirmed by repeat
HgbA1c >6.5%, FBG >126, S/S’s + RPG >200 and OGTT >200
4 main ft’s of type I DM
long pre-clinical period
hyperglycemia when 80-90% of beta cells are destroyed
transient remission (“honeymoon period”)
established dx
Type I DM tx
individualized to each pt
goal is to mimic normal physiologic levels
basal, bolus or basal-bolus (long acting insulin and short acting insulin)
Insulin types
human insulin (regular, short acting, 100 units/mL, 500 units/mL (U-500) which is error prone) insulin analogs (rapid acting/ultra short and long acting) NPH (intermediate acting) mixtures
insulin route of administration
PO destroys protein, but be given parenterally
usually by SC injection (slow abs)
regular insulin may be given IV
Insulin Requirement 1
total daily dose required - 0.4-1 units/kg/day of actual body weight
dec during “honeymoon period” to 0.2-0.5 units/kg/day
Insulin Requirement 2
basal insulin 24 hr coverage
approximately half total daily insulin dose
may use any intermediate/long acting insulin
NPH usually preferred as it can be mixed
Detemir may req q12 hr/BID dosing
Insulin Requirement 3
other 50% of total daily dose (meal time insulin)
divided between meals based on type of meal, pt characteristics
rapid acting or regular insulin
non-intensive insulin therapy - 2 injections
“split mixed” dosing
2 daily injections (2/3 TDD in morning, 1/3 TDD in evening)
basal insulin should be the 2/3 in am, 1/3 in evening if using NPH
non-intensive insulin therapy - 3 injections
3 daily injections: same dosing as split mixed but moves NPH to bedtime
dec nocturnal hypoglycemia
inc effect at dawn
intensive insulin therapy
multiple self monitored blood glucose (SMBG) checks each day
sliding scale insulin
“tight” control vs “regular” control
institutional specific
SMBG
blood glucose levels evaluate impact of insulin on meals
determined by FBG and PPG (post prandial glucose)
HbA1c
glycosylated Hgb assesses glycemic control over 2-3 mo's 4-6% in non-diabetics AACE recommends <6/5% ADA recommends <7%
interpreting HgbA1c
process is irreversible
lasts the life of the RBC (120 days)
reflects av glu over 3 months
type II DM tx
individualized based on age and comorbidities
lifestyle changes and simultaneously initiate pharm tx
no single algorithm is ideal, consider other factors
most pt’s will require multiple meds eventually
therapeutic lifestyle changes in type II DM
weight reduction through diet and exercise (target >/= 7 kg loss for all, may dec A1c by 1-2%)
tobacco cessation
minimize alc intake
nut counseling
summary of therapy for type II DM
TLCs and mono therapy with metformin at dx
start dual therapy if not at target A1c after 3 mo’s of mono therapy or if baseline A1c >/= 9%
start triple therapy if not at target A1c after 3 mo’s of dual
start combo injections if not at target A1c after 3 mo’s of triple therapy, blood glucose is >/= 300-350 and/or A1c >/= 10-12%
insulin in type II
insulin now used earlier in pharm to minimize micro and microvascular complications
multiple drugs are being used earlier
when to start insulin in type II
not at A1c goal after >/= 2 non-insulin hypoglycemics, severe FBG levels, A1c >10%
DO NOT use as a threat for not reaching A1c goals
starting with basal (long acting) insulin in type II
guidelines recommend long acting because it causes less hypoglycemia
both NPH and LA - analogs are =’ly effective
NPH is available OTC and is much cheaper
