Diabetes Mellitus

Barbara S. Hays Winter, 2006

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Inside CNS

◦ Brain uses glucose as primary fuel ◦ Brain cannot store/produce glucose

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Outside CNS

◦ Fatty acids: stored as

 Glycogen (liver/muscles)  Triglycerides (fat cells)

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Outside CNS, continued ◦ Endocrine portion of pancreas: Islets of Langerhans  Alpha cells make glucagon  “counterregulatory”, acts opposite of insulin

 Beta cells make insulin  Allows body cells to store and use carbohydrate, fats, and protein

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When blood glucose becomes high ◦ INSULIN allows glucose to enter cells  Liver  Production /storage of glycogen  Inhibits glycogen breakdown  Increased protein & fat synthesis (VLDL formation)

 Muscles  Promotes protein and glycogen synthesis

 Fat cells  Promotes storage of triglycerides

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Drowsy Flushed Thirsty

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Glucagon: causes release of glucose from liver ◦ “glycogenolysis (breakdown of glycogen to glucose) ◦ “glyconeogenesis of glucose not available  Lipolysis (breakdown of fat)  Proteolysis (breakdown of amino acids)

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Weak, sweaty Confused/irritable/ disoriented

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Major health problem US/worldwide Complications [lousy blood vessels] ◦ ◦ ◦ ◦ ◦

Blindness Renal failure Amputations [heart attacks and strokes] [OB/neonatal complications]

The good news: ◦ Blood glucose control reduces complications of Diabetes!

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Absence (or ineffectiveness of ) insulin Cellular resistance Cells can’t use glucose for energy ◦ Starvation mode  Compensatory breakdown of body fat/protein  Ketone bodies from faulty fat breakdown  Metabolic acidosis, compensatory breathing (Kussmal’s breathing)

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HYPERGLYCEMIA: fluid/electrolyte imbalance. ◦ Polyuria  Sodium, chloride, potassium excreted

◦ Polydipsia from dehydration ◦ Polyphagia: cells are starving, so person feels hungry despite eating huge amounts of food. Starvation state remains until insulin is available.

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Complications of chronic hyperglycemia ◦ Macrovascular complications  Cardiovascular disease (heart attack)  Cerebrovascular disease (strokes)

◦ Microvascular    

Blindness (retinal proliferation, macular degeneration) Amputations Diabetic neuropathy (diffuse, generalized, or focal) Erectile dysfunction

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Type I Diabetes: autoimmune ◦ Beta cell destruction in genetically susceptible person ◦ Some viral infections

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Type II Diabetes ◦ Reduction in ability of most cells to respond to insulin ◦ Poor control of liver glucose output ◦ Decreased beta-cell function (eventual failure)

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Major risk factors

◦ Family history ◦ Obesity ◦ Origin (Afro-American, Hispanic, Native American, Asian-American) ◦ Age (older than 45) ◦ History of gestational diabetes ◦ High cholesterol ◦ Hypertension

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Prevention of effects: combination approach ◦ Increased exercise

 Decreases need for insulin

◦ Reduce calorie intake

 Improves insulin sensitivity

◦ Weight reduction

 Improves insulin action

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Diet

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Medication ◦ Oral hypoglycemics ◦ Insulins

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Exercise

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Exercise ◦ Under physician supervision ◦ Check glucose prior

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Diet ◦ Lower calorie ◦ Fewer foods of “high glycemic index” ◦ Spread meals evenly

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Anti-Diabetic medications

◦ Oral hypoglycemic agents (“Easy” p 297)      

Sulfonylureas Thiazolidinediones Biguanides Alpha-glucosidase inhibitors D-phenylalinine derivatives Combinations

◦ Insulins (“Easy” Prototype Pro p 393)

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Stimulate pancreas to secrete insulin ◦ Glyburide (Diabeta) [Prototype Pro p 393]  Glucotrol (Glipizide)  Diabenese (chlorpropamide)

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Adverse reactions

◦ Hypoglycemia ◦ Water retention/edema ◦ Photosensitivity

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May need to add insulin in times of stress

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Decreases liver production of glucose Decreases intestinal absorption of glucose Improves cell sensitivity to insulin

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Example: Metformin

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◦ GI upset, flatulence ◦ Cardiac (CHF, MI)

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Increase cellular sensitivity to insulin ◦ Pioglitazone (Actos) ◦ Rosiglitazone (Avandia)

Client should have liver enzymes checked periodically

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Nateglinide (Starlix)

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Rapid onset, short half-life ◦ Good for those with rapid post prandial rise in blood glucose

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Glucovance ◦ Glyburide and Metformin

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Avandamet ◦ Avandia and Metformin

[come tell me when you run into this question…]

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Made in beta cells of the pancreas Moves glucose into cells (thus acts like growth hormone in a way) Moves potassium into cells (can buy time in emergencies)

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Rapid acting (lispro, asparte) Short acting (regular) Intermediate acting (NPH) Long acting ◦ Ultralente ◦ [Glargine/Lantus]

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Onset of action

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Peak (blood glucose will be lowest then)

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Duration

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Lispro (Humolog, Novolog Aspart) ◦ Onset of action  “15-30” minutes [may come on in 5 minutes…]

◦ Peak of action  1 - 2 hours

◦ Duration  3 – 4 hours

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Regular (clear so can be given IV) ◦ Onset of action  0.5 to 1 hour

◦ Peak of action  2 – 4 hours

◦ Duration of action  6 – 8 hours

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NPH, Lente (chemicals added. Cloudy) ◦ Onset of action  1 – 4 hours

◦ Peak of action  4 – 12 hours

◦ Duration of action  18 – 24 hours

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Ultralente ◦ Onset of action  4 – 8 hours

◦ Peak of action  18 hours

◦ Duration of action  24 – 36 hours

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Glargine/Lantus ◦ Cannot be diluted or mixed in syringe with any other insulin ◦ Slow, steady release ◦ Daily dosing [usually at bedtime] ◦ Refrigerated or tosses every 14 days

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70/30 (70% NPH and 30% regular) Humolog 70/30 (Humolog and regular) Fewer injections Rotate sites to decrease lipodystrophy

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Byetta for type II Diabetics taking sulfonylureas or combination ◦ Mimics physiologic glucose control  Inhances insulin secretion only in presence of hyperglycemia  Insulin secretion decreases as blood glucose approaches normal

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Neutontin for Diabetic nerve pain

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Insulin moves potassium into cells ◦ Good for emergency situations ◦ Dangerous if potassium level already low

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HHNK (Hyperglycemic Hyperosmolar NonKetotic Coma). Also called ◦ HHNK ◦ HNKS [syndrome]  Like dibetic ketoacidosis, without the ketones  Type II diabetic, makes enough insulin to avoid ketones, but sugar guilds up to dangerous levels -> cellular dehydration

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Dawn Phenomenon vs Somogi’s effect ◦ Dawn phenomenon  Blood sugar rises in early morning

◦ Somogi’s (rebound) effect  Blood sugar rise in morning as reaction to hypoglycemic time during the night

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Diabetic foot care ◦ Dry, cracked skin + poor circulation could = loss of a limb ◦ For the most part nurses don’t trim nails of diabetic clients. Refer to Podiatrist.