DIABETES MELLITUS Rachel S. Natividad RN, MSN, NP

Review A&P Review A&P

Role of Insulin   Insulin: – –Counters metabolic activity that would increase blood glucose levels – –Enhances transport of glucose into body cells – –Lowers blood glucose levels

Physiology Cont: Insulin  Basal (continuous)  Prandial (Bolus) *Blood glucose increases within 10 minutes of the beginning of a meal*

Diabetes Mellitus  A disorder of carbohydrate, protein, and fat metabolism resulting from an imbalance between insulin availability and insulin need. (Porth, 2002)  End Result : HYPERGLYCEMIA

Physiology Cont.:Glucose Control

Patho: DM Type 1

Patho Cont.: DM Type 2

Normal Physiology

Pathophysiology-Cont.:DM Type 2

DM 1&2: The big difference… DM TYPE 1 DM TYPE 2 No endogenous insulin Some endogenous insulin Tx requires insulin injections Tx diet and exercise 1st, then pills and /or insulin Usually < age 30 yrs. Usually over 30 yrs. (peaks at 50) Ketosis prone (DKA) no ketosis Former names: IDDM (Juvenile) Diabetes Type I NIDDM (maturity/adult- onset) Diabetes Type II Thin to normal body weight Usually Overweight Acute metabolic complications (DKA) Chronic vascular complications

Case Study

THE 3 POLYs POLYURIA POLYPHAGIA POLYDYPSIA 14 Diabetes: Clinical Manifestations

Signs and Symptoms Diabetes Clinical Manifestations Cont: Signs and Symptoms Early signs  3 Polys  Weight loss  Fatigue/Always tired  Visual Blurring Late signs  Any of the 3 Polys  Infections  Numbness/ tingling of feet or leg pain  Slow healing wounds  Chronic Complications

Diabetes: Dx Tests Diabetes: Dx Tests  Fasting Blood Glucose (FBG): <100 mg/dL –Iggy: mg/dL *Random/Casual Blood Glucose*:<200 mg/dL  Oral Glucose Tolerance Test (OGTT): < 140 mg/dL  Glycosylated Hemoglobin (HgbA1C): 4-6% Check MD orders or agency protocol for frequency of BS Monitoring In General: AC&HS if pt able to eat; Q4-6 hours if NPO or tube feedings

Diabetes: Diagnostic Tests Cont.   Glycosylated hemoglobin test – Hemoglobin A1C (HbA1c) – –measures the amount of glycosylated hemoglobin (hemoglobin that is chemically linked to glucose) in blood. –Normal -4-6% –Target range DM patient <7%

HbA1C Control

Criteria for the Diagnosis of Diabetes Mellitus Normal –FPG <110 mg per dL –2hr OGTT <140 mg per dL Diabetes- positive findings from any two of the following tests on different days: –Symptoms of diabetes mellitus* plus casual (random) plasma glucose concentration >=200 mg / dL or –FPG >=126 mg per dL or –2hr OGTT >=200 mg per dL after a 75-g glucose load

Diagnostic Tests – Cont. Is it Diabetes Yet? Impaired Fasting Glucose Impaired Glucose Tolerance < <100 <140 >126 >200 >6

Acute Complications  Diabetic Ketoacidosis (DKA)  BS > 300 mg/dL  Classic symptoms  Ketosis  Hyperglycemic- Hyperosmolar Nonketotic Syndrome (HHNS)  BS > 800 mg/dL  Similar symptoms  No Ketosis Check urine for ketones

(ADA)

Chronic Complications of DM

Effects on Blood Vessels Blood Vessel Lumen

Chronic Complications - Macrovascular  Cardiovascular –heart disease  Cerebrovascular –Stroke  Peripheral vascular disease DM pts have heart disease and stroke risks 2 to 4 X higher than non-DM pts

Chronic Complications- Microvascular :  Diabetic Retinopathy The leading cause of new cases of blindness in adults ages

Chronic Complications- Microvascular Nephropathy The leading cause of end-stage renal disease (ESRD), occurs in about % of patients with diabetes

Chronic Complications-Microvascular Diabetic Neuropathy - Diabetic Neuropathy - the poor blood supply will cause the nervous system to malfunction

Chronic Complications- Microvascular Amputation of Toes

Chronic Complications- Microvascular   Sexual problems for men erectile dysfunction retrograde ejaculation   Sexual problems for women decreased vaginal lubrication decreased sexual response   Urologic problems for men and women urinary tract infections neurogenic bladder

Chronic Complications- Microvascular   Gastroparesis Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly

MANAGEMENT OF DM   Regular Blood Glucose Monitoring Diet Exercise Drug Therapy 32

Management: Diet & Exercise

Diet : Diet : Diabetes Food Pyramid

Diet Cont: What to do???

Diet Cont. Carb-Counting

Diet Cont: Diet Cont: Glycemic Index

Diet Cont.: Getting the balance right Get your portions right!!

Management: Exercise  Helps regulate blood glucose  Increases insulin effectiveness and sensitivity in the body.  Must monitor insulin and food intake to match exercise regimen.

Drug Therapy Insulin& Oral Antidiabetic Agents

Drug Therapy: Insulin Types   Fast-acting insulin – –Rapid Acting Insulin AnalogsRapid Acting Insulin Analogs   Aspart, Lispro, Glulisine – –Regular Human InsulinRegular Human Insulin   Intermediate-acting insulin – –NPH Human InsulinNPH Human Insulin – –Pre-Mixed InsulinPre-Mixed Insulin   Humulin 70/30, Humalog 75/25   Long-acting insulin – –Insulin Glargine, Insulin Detemir BASAL Used to lower blood sugar throughout the day and night BOLUS Used to lower blood sugar after eating a meal

Drug Therapy Cont.: Insulin  Onset - how soon it starts to work in the blood  Peak - when the insulin has the greatest effect on blood sugar levels  Duration – how long it keeps working

Drug Therapy Cont: Goal of Insulin Therapy Basal and Bolus Insulin Coverage

Drug Therapy Cont: Sample Insulin Regimen (NPH & Regular insulin)

Drug Therapy-Insulin Cont: Rapid Acting “Logs” Humalog (insulin lispro) Novolog (insulin aspart)  Bolus insulin  Onset 15 min; peaks 1-2 hrs; lasts 4-6 hours  Ideal for meal coverage “Give the shot while the plate is hot!”

Drug Therapy-Insulin Cont: Short Acting: Regular Insulin Regs   Bolus insulin   Onset ½-1 hr; peaks 2-4 hrs; lasts 6-8 hrs Give 30 minutes to 1 hour before a meal

Drug Therapy-Insulin Cont: Short Acting: Regular Insulin ♪ It’s time give you your regular insulin ♪ ♪ It’s time to give it 30 minutes before your plate is in ♪ ♪ Come back to check you in 2 (hours) ♪ ♪ Watch out for shakes and sweats too ♪ ♪ If your lucky you’ll have no clue!!!! ♪

Drug Therapy-Insulin Cont: Drug Therapy-Insulin Cont: Rapid Acting (Humalog/Novolog) VS. Short Acting (Regular Insulin) Rapid onset 1-2 hour peak Limited duration Delayed onset Peaks in 2-4 hr Lasts 6-8 hours

Drug Therapy-Insulin Cont: Intermediate acting: NPH Insulin   Basal insulin: covers blood sugar between meals   Satisfies overnight insulin requirement   Onset 1-2 hrs, peaks 6-10 hrs, lasts 12+ hrs   Need snack if NPH given at 5 pm (only)   Ideal to be given at 9 pm (HS) to address Dawn Phenomenon

Drug Therapy-Insulin Cont: L ong-Acting: Peakless Insulins!!! L antus (insulin glargine) L evimir (insulin detimir)  Basal Insulin  Onset 1.5 hrs; no peak (max effect in 5 hrs); lasts 24 hours  No risk for hypoglycemia  Do not mix with other insulins – becomes inactivated when mixed with other insulins

Lantus

Drug Therapy- Insulin Cont: Hypoglycemia  BS < mg/dL  An acute complication of insulin administration  Tx: (15/15 or 20/20 Rule) –Give 15/20 g simple carb and recheck BG in 15/20 minutes

Synthetic injectables   Byetta: Synthetic incretin mimetic hormone – –Indicated for patients with type 2 diabetes who don’t use insulin   Symlin: Synthetic analogue of human amylin – –Approved for use with insulin in adults with type 1 and type 2 diabetes

Drug Therapy Cont: Other Methods of Administration For Uncontrolled DM 1 0r 2 Rapid-acting insulin

Continuous IV insulin infusion   Used to maintain glycemic control in hospitalized patients with high blood glucose levels; in DKA and HHNS   Regular insulin may be used IV   May also be given preoperatively or postoperatively   More frequent BS monitoring ( q1- 2 hours per agency protocol)

Drug Therapy Cont: Drug Therapy Cont: Oral Antidiabetic agents (see handout)

New Oral Med   Januvia (Sitagliptin) – –An oral drug that reduces blood sugar levels in patients with type 2 diabetes.diabetes – – Sitagliptin is the first approved member of a class of drugs that inhibit the enzyme, dipeptidyl peptidase-4 (DPP-4).

Oral Agents: How do they work?

Acute Complication of Insulin and (some) Oral Meds Hypoglycemia Acute Complication of Insulin and (some) Oral Meds Hypoglycemia

Hyperglycemia

Critical Thinking Exercises Course Packet pp

Diabetic Teaching Needs Disease process S/S of hyperglycemia and hypoglycemia Blood sugar monitoring DietExercise Drug therapy Sick Day Rules Complications (acute and chronic) Prevention: Foot care, eye exam etc.

DIABETES can be controlled!!!