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Wee 8 - Diabetes Mellitus
Terms in this set (49)
What is diabetes mellitus?
Group of metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.
Where are the alpha and beta cells located?
Islets of Langerhans in the pancreas.
What hormone do the alpha cells secrete?
- Glucagon elevates glucose levels in the blood
- It stimulates the conversion of stored glycogen (stored in the liver) to glucose, which can be released into the bloodstream. This process is called glycogenolysis.
What hormone do the beta cells secrete?
- insulin and amylin
- Amylin is a peptide hormone that is cosecreted with insulin from the pancreatic β-cell and is thus deficient in diabetic people. It inhibits glucagon secretion, delays gastric emptying, and acts as a satiety agent. Amylin replacement could therefore possibly improve glycemic control in some people with diabetes.
What is glucose?
►Glucose is the primary source of energy for the human body. Absorbed from the intestine it is metabolized by:
- energy production (by conversion to water and carbon dioxide)
- conversion to amino acids and proteins or keto-acids
- storage as glycogen in the liver
What is insulin?
- Anabolic hormone that promotes not only the uptake of glucose but also the synthesis of proteins, carbohydrates, and nucleic acids.
- Net effect of insulin is to stimulate protein and fat synthesis and decrease blood glucose level
- Facilitates intracellular transport of potassium, phosphate, and magnesium
- Mostly in liver, muscle, adipose tissue
Classification of Diabetes
•Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency)
•Type 2 diabetes (due to a progressive loss of adequate β-cell insulin secretion frequently on the background of insulin resistance)
•Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation)
•Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation)
What is Type 1 Diabetes?
►Previously known as juvenile diabetes, diabetes mellitus type 1 (DMT1), insulin-dependent diabetes (IDDM)
►Little to no insulin is produced by beta cells
Abrupt onset, thirst, hunger, increased UOP, weight loss
Pancreatic beta cell destruction
Frequently none; thirst, fatigue, blurred vision, vascular or neural complications
Insulin resistance; dysfunctional pancreatic beta cell
Gestational Diabetes Mellitus (GDM)
►Diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation.
Other specific types of diabetes
- Genetic defects in beta-cell function, genetic defects in insulin action, disease in exocrine pancreas, endocrinopathies, drug- or chemical induced beta-cell dysfunction, infections, or other uncommon autoimmune and inherited disorders.
•Diseases of the exocrine pancreas, such as cystic fibrosis and pancreatitis
•Drug or chemical-induced diabetes, such as with glucocorticoid use, in the treatment of HIV/AIDS or after organ transplantation
Maturity Onset Diabetes of the Young (MODY)
- Diagnosis and management like those used for type 2 diabetes
►Insulin resistance syndrome or syndrome X
►Cluster of conditions that synergistically increase the risk of cardiovascular disease, T2D, premature mortality
- Abdominal obesity
- Impaired glucose metabolism
T1D Risk Factors
- Parent or sibling with type 1 diabetes
- Likely to develop in childhood/ adolescence
Indications for Testing People for T2D
►BMI >25 with one or more of these additional risk factors
- Have first-degree relative with diabetes
- Physical inactive
- Members of a high-risk ethnic population
- Gave birth to a baby weighing more than 9lb or diagnosed with GDM
- Hypertensive (>140/90)
- HDL <35 and/or triglyceride >250
- Polycystic ovary syndrome
- A1C greater than 5.7% on previous testing
- History of vascular disease
Patient History - Diabetes
►Ask about and record patient history:
- Age and weight
- Birth weight of children or diagnosis of GDM or glucose intolerance during pregnancy
- History of recent illness, infection, or extreme stress
- Omission of insulin or oral diabetic drugs if the patient is known to have DM
- Change in eating habits
- Change in exercise schedule or activity level
- Presence and duration of polyuria, polydipsia, polyphagia, and loss of energy
- Presence of cardiovascular disease such as hyperlipidemia, hypertension, heart failure, or stroke
What is hyperglycemia?
►Too much glucose production
- Excessive intake
- Food, drink, IVF (D52)
- Excessive production
- Steroids (corticosteroids)
Hyperglycemia - T1D
- Body does not produce enough insulin (T1D)
Hyperglycemia - T2D
- Body produces insulin, cellular insulin receptors do not respond appropriately (insulin resistance - T2D)
Hyperglycemia - The Three "P"s
►Polyuria (Much Urine)
►Polydipsia (Much Thirst/Drinking)
►Polyphagia (Much Eating)
What is Polyuria?
- Frequent and excessive urination
- Osmotic diuresis cause by excess glucose in the urine
What is Polydipsia (Much Thirst/Drinking)?
What is Polyphagia (Much Eating)?
- Cell starvation due to lack of glucose
- Despite eating, remains in metabolic starvation until insulin is available to move glucose in the cells
Assessment of Diabetes
►Polyuria, polydipsia, polyphagia
►Slow wound healing
►Weakness and paresthesia
►Signs of inadequate circulation to the feet
►Signs of accelerated atherosclerosis
- Renal, cerebral, cardiac, peripheral
Laboratory Assessment - Diabetes
►Glycosylated hemoglobin test (A1C or HbA1C)
- Diabetes is diagnosed at an A1C of greater than or equal to 6.5%
►Fasting plasma glucose (FPG)
- Diabetes is diagnosed at fasting blood sugar of greater than or equal to 126 mg/dl
►Oral glucose tolerance test (OGTT)
- Diabetes is diagnosed at 2-hour blood sugar of greater than or equal to 200 mg/dl
- Used in pregnancy
Management of Diabetes
- A1C maintained at 7% or below, premeal BG 70-130mg/dL, peak after meals less than 180mg/Dl
►Process of maintaining optimal blood glucose level
- Glycemic control
- Maintain blood glucose levels in the normal range (euglycemia)
- Hypoglycemia (lower than normal blood glucose)
- Hyperglycemia (higher than normal blood glucose)
What glucose levels determine hypoglycemia?
- <74 mg/dL
- < 4.1 mmol/L
- Nutrition, medication, self-monitoring, and self-management
- A1C -1
- Cardiovascular risk factors: smoking, BP control, reduction of lipids with a statin, diet, exercise, weight loss, ASA for established atherosclerosis
►The ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-care, as well as activities that assist a person in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis, beyond or outside of formal self-management training
►Medical nutrition therapy (MNT)
- Process by which the dietary plan is tailored for people with diabetes, based on medical, lifestyle, and personal factors
- Weight management
- Caloric intake (balanced with caloric expenditure)
- Consistency in day-to-day carbohydrate at meals and snacks
- Nutrition content
- Timing of meals and snacks
1. Carbohydrate intake avoids nutrient-deficient sources ("empty calories") and focuses on sources from vegetables, fruits, whole grains, legumes, and dairy products.
2. Adults with diabetes should eat at least 25 g of fiber daily.
3. Dietary fat and cholesterol intake for adults with DM focuses on the quality of fat rather than on the quantity of fat. Current recommendations from the ADA to limit trans fats, saturated fats, and cholesterol are the same as for the general population (ADA, 2019a; ADA 2019e).
4. Alcohol consumption affects blood glucose levels, especially with high alcohol use or when DM is poorly controlled. Teach patients that two alcoholic beverages for men and one for women can be ingested with, and in addition to, the usual meal plan.
ABCs of Diabetes
- A: A1c Test <7%
- B: Blood Pressure < 120/80 mmhg
- C: Cholesterol Levels for LDL <100 mg/dl
Drug Therapy - Diabetes
- Insulin stimulators (secretagogues) stimulate insulin release from pancreatic beta cells
- Sulfonylurea triggers release of insulin from beta -> glipidize
- Biguanide decreased live glucose production and decrease intestinal absortion of glucose - metformin
- Insulin sensitizers - decrease blood glucose production adn improving the sensitivity of insulin receptors = TZDs thiazolidinediones
- Alpha-glucosidase - inhibit enzymes in intestinal tract from breaking down starches into glucose (GI symptoms)
- Act like gut hormones by reducing pancreatic glucagon secretion, reducing luver glucose rpoduction, delaying gastric emptying
- DDP-4 inhibitors - DDP-4 break down GLP-1/GLP which work with insulin to lower glucagon secertion from pancreas, delay gastric emptying
- Amylin - simliar to amylin that co-secreted with insulin to lowe BG
- SGLT-2: prevent kidney reaborpption of lgucose and sodium to excrete urine
When to give drug therapy?
•Diet and weight control have failed to maintain satisfactory blood glucose levels
•Not a substitute for dietary midficaitons and exercise
•Severe categories may be used to lower BG
•Started at the lowest effectve dose and icnrease over time until reaches desired blood glucose control or maximum dosages
•May require the use of more than one category of drug
Oral hypoglycemic medications
►Diet and weight control have failed to maintain satisfactory blood glucose levels
►Drug selection based on cost, patient's ability to manage multiple drug dosages, associated risks of side effects, and response to drugs
- Types: Rapid, short, intermediate, long-acting
- Administration considerations
- Illness, infection
- when to hold
- Peak action time
Rapid acting insulin
- lispro, aspart, glulisine
- Starts: 5 -10 minutes
- Peaks: 30-90 minutes
Short acting insulin
- Regular (Humulin R, Novolin R)
- Starts: 30 minutes - 1 hour
- Peaks: 2-3 hours
Intermediate acting insulin
- Starts: 1-3 hours
- Peaks: 4-12 hours
Long acting insulin
- glargine (Lantus)
- detemir (Levemir)
- Starts: 1-2 hours
- No peaks
- Hyperglycemia upon morning awakening that results from excessive morning release of GH and cortisol
- Increase insulin dose or change time of insulin administration
- Normal or elevated BG at bedtime, hypoglycemia around 2-3AM which causes an increase in the production of counterregulatory hormones
- By 7am, BG rebounds to hyperglycemic range
- Treatment includes decrease insulin dose or increase in bedtime snack or both
- May complain of early morning headaches, night sweats, or nightmares cause by early morning hypoglycemia
continuous subcutaneous insulin infusion (CSII)
►Insulin pump for T1D
►Emulate the pancreas
- Release basal level of insulin and additional insulin after meals
- Can adjust insulin requirement based on activity/carbs consumed
self-monitoring of blood glucose (SMBG)
1. Meter systems now require a very small blood sample, which allows for alternate testing sites (e.g., arm, thigh, hand).
2. Accuracy of the blood glucose monitor is ensured when the manufacturer's directions are followed. If the meter requires calibration, teach patients to properly calibrate the machine.
3. Teach the patient how to clean the equipment to prevent infection. The chance of becoming infected from blood glucose monitoring processes is reduced by handwashing before monitoring and by not reusing lancets.
Continuous blood glucose monitoring (CGM)
- Monitor glucose levels in interstitial fluid to provide real-time glucose information to the user. The system consists of three parts: a disposable sensor that measures glucose levels, a transmitter that is attached to the sensor, and a receiver that displays and stores glucose information.
- After an initiation or warm-up period, the sensor gives glucose values every 1 to 5 minutes. Sensors may be used for 3 to 7 days, depending on the manufacturer.
- CGM provides information about the current blood glucose level, provides short-term feedback about results of treatment, and provides warnings when glucose readings become dangerously high or low.
►Usually done with kidney transplantation
►Requires life-long immunosuppressants
►Eliminates need for insulin injections, blood glucose monitoring, and many dietary restrictions
►Complications of DM increase the risk for surgical problems
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