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Normal fasting glucose

less than 100 mg/dl

Impaired Fasting Glucose (IFG)

100 - 125 mg/dl {Pre-Diabetes}

Impaired Glucose Tolerance (IGT)

OGTT level > 140 - 199 mg/dl
after 2 hrs {Pre-diabetes}

young, thin, requires insulin, prone to ketosis, autoimmune B cell destruction, low fasting C-peptide [conc]

Type 1 diabetes

older, obese, doesn't require insulin, not prone to ketosis, peripheral resistance B cell dysfunction, normal-high fasting C-peptide [conc]

type 2 diabetes

Typically occurs in children and adolescents but may occur at any age

Type 1 DM

Exogenous administration of insulin is necessary for survival in patients with type

Type 1 DM

It is an autoimmune disorder: patients develop an absolute lack of insulin due to destruction of beta cells in the pancreatic islets of Langerhans

Type 1 DM

Usually develops in adults although the incidence in children and adolescents is increasing

Type 2 DM

90-95% of patients with diabetes have type

Type 2 DM

Most patients with type 2 disease do not need insulin initially but require it later because of disease progression

There is tissue insensitivity to insulin:
? genetic factors
Aging, sedentary lifestyle
Abdominal-visceral obesity as well as fat deposition on the neck, face, and chest

Polyuria, Fatigue, weakness, Slow wound healing, Polydipsia, Recurrent blurred vision, Peripheral neuropathy, Frequent infections (candidiasis)

general signs/symptoms of Diabetes Mellitus

signs unique to Type 1 DM

polyphagia
weight loss

patients with type 2 DM may be

asymptomatic

Excess GH, hypercortisolism, glucagons or somatostatin

secondary Hyperglycemia
Disorders that affect insulin action or insulin secretion

High-dose glucocorticoids, diuretics, phenytoin, niacin

secondary Hyperglycemia (medication induced)
Disorders that affect insulin action or insulin secretion

Individuals have IFG and/or IGT
Individuals have an increased risk of developing DM and/or CV disease
Is associated with the metabolic syndrome (insulin resistance syndrome)
Individuals with IFG and/or IGT may have normal HbA1C levels

Pre-Diabetes

______have been demonstrated to prevent or delay the development of type 2 diabetes in persons with IGT

Use of medical nutrition therapy (MNT) to decrease body weight by 5-10% + exercise + pharmacologic agents (selected individuals)

what pharmacologic agents can be helpful in conjunction with medical nutritional therapy for a patient with "pre-diabetes"

statins -> lower lipids

Individuals have an increased risk of developing type 2 DM
Independent risk factor for cardiovascular disease - increases risk of coronary artery disease and stroke

Metabolic Syndrome

for a patient with HTN releated to metabolic syndrome, use

B-blockers and diuretics RAISE LIPID LEVELS

for a patient with dyslipidemia releated to metabolic syndrome, use

Niacin corrects elevated lipids but may increase insulin resistance.

Insulin resistance
Dyslipidemia - elevated triglycerides, decreased HDL, increased LDL (especially small, dense particle LDL)
Hypertension

Metabolic Syndrome - Associated Clinical Abnormalities

Hypercoagulable state (elevated plasminogen activator inhibitor-1, hyperfibrinogenemia, increased platelet aggregation)

Metabolic Syndrome - Associated Clinical Abnormalities

Proinflammatory state (elevated C-reactive protein, endothelial dysfunction)

Metabolic Syndrome - Associated Clinical Abnormalities

Hyperuricemia
Hyperinsulinemia
Abdominal Obesity:
Waist circumference > 40 in. (males) and > 35 in. (females) who have a BMI of 25-34.9 kg/m2

Metabolic Syndrome - Associated Clinical Abnormalities

Abdominal Obesity

There is an increased risk of type 2 DM, HTN, and CV disease
Can be a marker of increased disease risk even in persons of normal weight (BMI 18.5-24.9 kg/m2)
Some men develop metabolic risk factors when waist circumference is only marginally increased

Central adiposity (see waist circumference)
IFG or IGT
Increased triglyceride level
Decreased HDL-C level
Hypertension

3 out of 5 must be present before classifying a patient as having the metabolic syndrome

Hyperinsulinemia, through stimulation of arterial smooth muscle proliferation, has been implicated in the development of

atherosclerotic plaque.

who is most likely to develop metabolic syndrome

Hispanics: men 28%, women 37%

Treating the metabolic syndrome may prevent or improve

CVD and type 2 DM.

Hemoglobin A1C (HbA1C)

Degree to which glucose is bound to the A1C component of hemoglobin

Level of blood glucose is ________ to the level of HbA1C

directly proportional

the goal for HbA1C levels is

< 7%

HbA1C normal concentration is about _______% (average American) but the normal range can vary between labs.

4-6 %

HbA1C reflects the concentration of glucose present in the body over a prolonged time period related to the 60-day half-life of _______

RBCs

HbA1C reflects glucose control over the past ______ weeks

8-12 weeks

Check every ____ months in patients with HbA1C > 7%

3 months >7%

Check every ____ months in patients with HbA1C < 7%

6 months <7%

Measures over 2-3 months instead of day to day
Provides better indicator of severity and presence of disease
Stable value and easy to collect

HgA1C

Hemoglobinopathies may interfere
Conditions that cause RBC turnover can cause false positives
Anemia's, transfusions, pregnancy)
Not useful for acute elevations (Type 1)

HgA1C

Age > 45 years
Low HDL cholesterol (< 35 mg/dl) and/or high triglyceride (> 250 mg/dl)
Family history of diabetes
Obesity (BMI > 25 kg/m2)
Ethnicity: Native-Americans, African-Americans, Hispanics
History of Vascular disease

Risk Factors for Type 2 DM

Low HDL-C and/or high triglycerides as well as obesity (especially abdominal obesity) are 2 of 5 criteria for

the metabolic syndrome

Previously identified impaired fasting glucose (FBS: 100-125 mg/dl) or impaired glucose tolerance
Hypertension
Habitual physical inactivity
History of gestational diabetes mellitus or delivery of a baby weighing > 9 lbs.
Polycystic Ovarian Syndrome

Risk Factors for Type 2 DM

Previously identified IFG and hypertension are 2 of the 5 criteria for

metabolic syndrome

who is at an increased risk for macrovascular complications

fasting glucose is 100-125 mg/dl (Impaired Fasting Glucose)

who should be screened for Type 2 DM

All adults over age 45 years every 3 years
Especially those with BMI > 25 kg/m2

if result of the initial fasting glucose is 100-125 mg/dl (Impaired Fasting Glucose) how frequently should you repeat the screening test for Type 2 DM

annually

if the individual is overweight and has one or more risk factors for DM

screen at a younger age
Test every 2 years starting at age 10 or at onset of puberty

You should begin screening for _____ if a teen is OVERWEIGHT, has HTN, high serum triglycerides, and low a HDL level

Diabetes Mellitus

Fasting blood sugar
Random glucose level with symptoms of DM
Oral Glucose Tolerance Test

3 tests used for the diagnosis of DM

hopw do you confirm a Dx of DM

Any of the 3 diagnostic criteria must be confirmed on a different day to make the diagnosis of diabetes mellitus
The fasting blood sugar test is recommended as the confirmatory test

Fasting

no caloric intake for at least 8 hrs before testing

glucose tolerance test (GTT)

draw a FBS, have patient drink a measured amount of sugar (75 gms) as a very sweet drink, and then test glucose at least 2 hours later. DM is diagnosed if the 2 hour glucose is >200

GTT may be utilized for patients with a FBS ______ if diabetes is suspected

< 126 mg/dl

FBS >126 mg/dl (no caloric intake for at least 8 hrs)
HbA1c >6.5% (Repeated unless random glucose >200 with symtoms)
Random glucose >200mg/dl with symptoms of diabetes
OGTT: 2hrs plasma glucose >200mg/dl

Diagnosis - Diabetes Mellitus

what is recommended as the confirmatory test for DM Dx

fasting blood sugar test

if HbA1c is >6.5% when do you NOT need to repeat this test

random glucose >200 with symtoms

blood glucose monitoring
diabetes education

patient self monitoring

this test is not reliable for patient self-monitoring

urine tests
The concentration of urine also makes a big difference - if you drink 2 glasses of water the glucose level in your urine will be diluted but the blood glucose will remain stable.

When glucose is elevated, patients c/o being thirsty, dry, and tired but not until the glucose is at

200 mg/dl

some patients get used to the symptoms of elevated glucose levels and may not notice them, even when the levels reach

200s-300s mg/dl

When glucose is low patients become shaky and sweaty but not until the glucose

< 60 mg/dl

the diet of a patient with DM should strive for

Saturated fats should be < 7% , carb intake must be monitored

first line therapies for DM

diet and exercise

If you can get a patient to lose as little as _____% of their body weight, they may get decreased insulin resistance with improved glycemic control.

10-15%
They may even be able to stop drug therapy at that time. Added benefits of weight loss are lower lipid levels and decreased blood pressure.

Alcohol is not metabolized to glucose and it also inhibits

gluconeogenesis in the liver. Too much may result in hypoglycemia as late as 8-12 hours after consumption. Alcohol should not be a substitute for food and should always be taken with food

Has beneficial effects on carbohydrate metabolism and insulin sensitivity
Decreases triglycerides
Decreases blood pressure
May enhance weight loss
May be helpful in preventing or delaying the onset of type 2 DM

Exercise

exercise

Ideally 150 minutes per week aerobic + resistance training 3 time per week
Beneficial for dealing with carbs, increasing insulin sensitivity, decrease triglycerides, decreases BP, decreases weight

Type 1 DM treatment

Educate patient about the risk of hypoglycemia
Exercise alone decreases blood glucose. The combination of exercise + insulin significantly increases the risk of hypoglycemia

you should order what test on these types of patients:
Diabetic patients > 35 years old
Those w/ Type 2 disease for > 10 years
Those w/ Type 1 disease for > 15 years
Those with any other risk factor for CAD
+ presence of microvascular disease
+ presence of peripheral vascular disease
+ presence of autonomic neuropathy

Order a graded exercise stress test or radionuclide stress test for the following

what medications are used in the treatment of DM

Glycemic controlling agents
ASA
Lipid lowering agents
Blood pressure lowering agents

Oral agents:
-Stimulate insulin secretion
-Alter insulin action
-Affect absorption of glucose
Insulin

glycemic controlling agents

Primary preventive strategy for all diabetics men > 50, women > 60 years old, or all diabetics with any one of the following risk factors for CAD:
Hypertension
Increased lipid levels
Family history of premature CAD
Micro/macroalbuminuria
Smoking

ASA therapy: 75-162 mg daily (EC)

Secondary preventive strategy for all diabetics with a history of any of the following conditions:
Transient ischemic attacks (TIA)
Peripheral vascular disease (PVD)
Non-hemorrhagic stroke
MI, angina, or documented CAD

ASA therapy: 75 - 162 mg daily (EC)

Contraindications to use of ASA

ASA allergy, bleeding tendency, anticoagulant therapy, recent GI bleed, hepatic disease

add these (regardless of labs) to those patients who have
Overt CVD
Without overt CVD, < 40 with 1 or more CVD risk factors

Statins

lipid control goal for LDL is____
what if overt CVD is present

< 100
<70 if overt CVD present

lipid control goal for HDL is

> 50

lipid control goal for triglycerides is

<150

blood pressure goal

<130/<80
Lifestyle modifications acceptable for first 3 months only
If BP 130-139/80-89
If BP <140/<90 needs mods + meds

if BP is <140/<90 you need

mods + meds
Treat with ACE/ARB FIRST
Use multiple drugs if needed

a diabetic pt with HTN, what is your first line medication for the HTN

ACE/ARB FIRST

recommended vaccines for DM pts

Flu Vaccine annually
Pneumococcal Vaccine
At time of diagnosis
Repeat dose at age 65 if received prior to 65

when should you consider bariatric surgery for a diabetic pt

Consider if BMI > 35

when should you provide your diabetic pt with DSME (diabetes self monitoring education)

Done at time of diagnosis
Done at least annually
Can be done by you, nurse educator, diabetic educator

tobacco cessation is important and you should

Encourage at each visit, assess and document readiness to quit

Average FPG (mg/dl)
Or Preprandial - goal

90 - 130

Avg Postprandial 2 hr
(mg/dl) - goal

< 160

Avg Bedtime Glucose
(mg/dl) - goal

110 - 150

sustained HbA1C - goal

<7%

you should initiate action when Average FPG (mg/dl)
Or Preprandial is

<80 or >140

you should initiate action when Avg Postprandial 2 hr
(mg/dl) is

>180

you should initiate action when Avg Bedtime Glucose
(mg/dl) is

<110 or >160

you should initiate action when sustained HbA1C is

greater than or equal to 7%

Sulfonylureas, Meglitinide analogs &
D-Phenylalanine derivative

stimulate insulin secretion

Metformin, Thiazolidinediones

alter insulin action

Alpha-glucosidase inhibitors

affect absorption of glucose

increases pancreatic insulin secretion (secretagogues)

Sulfonylureas (glipizide, glyburide)
Meglitinide analogs (repaglinide)
D-phenylalanine derivative (nateglinide)

what patient population are secretagogues useful in

non-obese/mildly obese

the first class of pills used to treat DM

sulfonylureas

useful for patients with postprandial hyperglycemia
secretagogues

Repaglinide and nateglinide

Repaglinide and nateglinide

Advantages: long use history, inexpensive, addresses FPG
Disadvantages: hypoglycemia, weight gain
Contraindications: sulfonylureas in severe liver or renal disease

Suppresses hepatic gluconeogenesis; increases hepatic insulin sensitivity

Metformin (a biguanide)

Metformin (a biguanide) is useful in what patient population

obese, normal renal/liver function

Improves lipid profile, no hypoglycemia, inexpensive, weight neutral

Metformin

metformin

Disadvantages:
dose-related GI side-effects
lactic acidosis occurs in the setting of renal insufficiency or after use of IV contrast agents (50% mortality rate)
Contraindications:
serum creatinine > 1.4 mg/dl (females),
> 1.5 mg/dl (males)
concurrent use of IV contrast agents
alcoholics, > 80 years old (unless creatinine clearance is normal), congestive heart failure (CHF)

when you put a patient on these drugs to sensitize their peripheral tissues to insulin you Must monitor liver function by LFTs as mandated by the FDA

thiazoladinesdiones:
rosiglitazone, pioglitazone

MOA of thiazoladinesdiones:
rosiglitazone, pioglitazone

sensitizes peripheral tissues to insulin

in obese, signs of insulin resistance, normal liver function, renal impairment type patients, you can use

thiazoladinesdiones:
rosiglitazone, pioglitazone

how long can it take before you see benefit from thiazoladinesdiones:
rosiglitazone, pioglitazone

2-4 months
can cause fluid retention

thiazoladinesdiones:
rosiglitazone, pioglitazone are contraindicated in

NYHA Class III or IV CHF
LFTs > 2.5 times normal

when presrcibing oral therapy agents for DM usually one agent is used, when would two agents be called for (initial therapy)

if there is evidence of MARKED hyperglycemia after medical nutrition therapy and physical activity (failure to meet target goal)

titration of oral therapy agents is done over

2-4 months, reinforce medical nutrition therapy and exercise

after the 2-4 month titration period of oral therapy for DM what do you do

recheck plasma glucose or post-prandial glucose or HbA1C:
If the FBS > 140 mg/dl OR
If the post-prandial glucose > 180 mg/dl OR
HbA1C > 7.0%
ADD a drug in a different class

you have begun your patient on a second oral therapy agent, how long is the titration period

Titrate the dose over 2-4 months, reinforce medical nutrition therapy and exercise
(it's the same as when you initially started them on therapy)

after the 2-4 month titration period of oral therapy for DM of two medications what do you do

After 2-4 more months, recheck the FBS, post-prandial glucose, or HbA1C. If values meet the criteria noted (not in target range yet/goals not met) ADD A THIRD ORAL AGENT OR ADD INSULIN
The third oral agent should be of a different class
There is no benefit of adding 2 different secretagogues in combination

Very-rapid acting:
(Ultra short acting)
Short duration INSULIN

Humalog (lispro)
Novolog (aspart)
Apidra (glulisine)

Rapid-acting:
(short acting) INSULIN

Humulin R (regular)
Not used as often, hypoglycemia, variable absorption

Intermediate acting: INSULIN

Humulin N (NPH)
Lente
Not used as often, peak at 9 hours

Long-acting:
(Ultra-lente) INSULIN

Lantus (glargine)
Detemir (Levemir)
Becoming initial choice, bedtime, titrated 1-3U every 2-3 days

what are the Usual sites for insulin injection?

Abdomen - except for circular area within 2 inches of navel
Thighs - medial, anterior or lateral
Upper arms near triceps or deltoid

where is an insulin injection most rapidly absorbed

the abdomen

where is an insulin injection absorbed slowest

the buttocks

It's a good idea to have patient rotate the site but keep the same site for the same time each day

AM in abdomen, PM in arm or leg, the bedtime shot in the buttocks

what effects does exercise have on insulin absorption

increases insulin absorption so don't have patient inject insulin into the thigh and then go for a run

Type 2 DM: Guidelines for ADDING Insulin to Oral Therapy

Continue oral agent(s) at the same dose
Add a single evening insulin dose (~10 U):
Suggested starting dose 0.1-0.2 U/kg of IDEAL body weight
NPH insulin or Lantus (glargine) (at bedtime)

when adding insulin to oral therapy, what should you do to the oral therapy agents

Continue oral agent(s) at the same dose

when adding insulin to oral therapy, when should the insulin be injected and how many times daily

Add a single evening insulin dose (~10 U):
Suggested starting dose 0.1-0.2 U/kg of IDEAL body weight
NPH insulin or Lantus (glargine) (at bedtime)

Insulin NPH/Regular Insulin (Humulin 70/30)

70% of dose is NPH/30% is Regular***(this is the one referred to above)
[Another example of 70/30: Insulin LISPRO (short-acting) - 70% of dose is lispro PROTAMINE/30% is just lispro]

if needed how frequently should you increase insulin doses

Increase insulin dose weekly as needed:
Increase 4 U if FBS > 140 mg/dl
Increase 2 U if FBS = 120-140 mg/dl

70/30 insulin (evening meal) (OBESE)

Adjust dose by monitoring fasting SMBG (self-monitored blood glucose)

Type 2 DM: Guidelines for ADVANCING Insulin + Oral Therapy
indicated when

the FBS is acceptable but:
The HbA1C > 7% and/or
SMBG before dinner > 180 mg/dl

Type 2 DM: Guidelines for ADVANCING Insulin + Oral Therapy
insulin options

To bedtime NPH, add AM NPH and mealtime regular or lispro
To suppertime 70/30, add morning 70/30

Type 2 DM: Guidelines for ADVANCING Insulin + Oral Therapy
options for the oral therapy agents

Usually discontinue the sulfonylurea agent
Continue metformin for weight control (if applicable)

Regulate dose after conditions of normal daily activity and optimal diet have been achieved

Type 1 DM: Insulin Therapy

Once-daily and split-dose regimens (traditional dosing) are INEFFECTIVE for patients with type 1 DM

Results in nighttime hypoglycemia
3 or 4 dose intensive regimens are recommended

what type of insulin would you want to give a type 1 diabetic before meals

Ultra-short acting insulin analogs (lispro) are recommended as more safe and convenient than Regular insulin before meals

an example of insulin doing for a 70 kg adult

5U(breakfast), 4U(lunch), 6U(dinner) Humalog (lispro) before meals;
8-14 U of Lantus (glargine) at bedtime

what is the insulin of choice for an insulin pump

Lispro (ultra short-acting insulin)

Dawn Phenomenon

Slightly elevated or markedly elevated 0200-0300 glucose
Reduced tissue sensitivity to insulin that develops between 0500 and 0800
Attributed to nocturnal rise in GH secretion

treatment for dawn phenomenon

increase bedtime insulin dose

Somogyi Phenomenon

Low 0200-0300 glucose
Nocturnal hypoglycemia stimulates a surge of epinephrine that produces high glucose levels by 0700 (increases glucose release by the liver)

what is the treatment for Somogyi phenomenon

reduce bedtime insulin

Hypoglycemia
Diabetic ketoacidosis
Hyperosmolar nonketotic syndrome

acute diabetic complications

Microvascular (retina, kidney, peripheral nerves)
Macrovascular (coronary arteries, peripheral vasculature)

chronic diabetic complications

at what glucose level would you start seeing s/s of hypoglycemia

Glucose < 55 mg/dl

Hunger, diaphoresis, anxiety, tremors, tachycardia, palpitations, Behavior/cognitive changes, drowsiness, confusion, blurred vision, headaches, amnesia, seizures, coma

Hypoglycemia Symptoms (Glucose < 55 mg/dl)

Common Causes of Hypoglycemia

Too much insulin - most common complication of insulin therapy
In otherwise healthy individuals, suspect the presence of an insulinoma
Too little food
Too much activity
Alcohol-suppresses glucose release from the liver
Oral hypoglycemic agents
Other medications
Menstrual cycle
Gastroparesis: nerve damage delays stomach emptying and food is absorbed slower

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