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- A group of metabolic disorders characterized by hyperglycemia due to defects in insulin secretion, action, or both.
- ADA criteria for the diagnosis of DM – a fasting plasma glucose of 126 or higher, a random glucose of 200 or higher with s/s, or a 2 hr post prandial plasma glucose of 200 or higher after a 75 gram oral glucose challenge.
- Fasting (12 hours no food) glucose level is best
- Disorder of carbohydrate metabolism:
- --deficiency of insulin
- --resistance to action of insulin
What does the word "Diabetes" mean?
Diabetes mellitus Greek word “fountain”Latin word “honey”
Scarey stats about diabetes
- Leading cause of blindness in 25-74 year olds
- Leading cause of non-traumatic amputations
- Responsible for 25-30% of all new dialysis pts.
Subclasses of diabetes
- Type 1
- Type 2
- Gestational Diabetes Mellitus
- Malnutrition Related Diabetes Mellitus
- Secondary Diabetes Mellitus
- Impaired Fasting Glucose and Impaired Glucose Tolerance
Type 1 DM
- Insulin dependent (always the treatment)
- --destruction of pancreatic beta cells
- --No insulin production
- Age of onset usually < 30 yrs. Most < 20 yrs.
- SnSs present when 90% of beta cells are destroyed --> severe or complete insulinopenia.
- Ketonuria (DKA prone): Also called metabolic acidosis.
- Rapid weight loss due to breakdown of fat and protien to produce glucose because body thinks it doesn't have any.
- Hyperglycemia per ADA criteria.
Type 2 DM
- Cells are less responsive to insulin
- 90-95% of all DM cases
- Age of onset usually > 30 yrs.
- SnSs mild or absent at time of onset
- Occurs due to defects in insulin function
- Insulin resistance/not islet cell antibodies
- Decreased insulin secretion (rarely DKA)
- Hepatic glucose overproduction
- May be multifactoral
Suspected causes and treatments of DM2
- Suspected causes
- --Genetic predisposition-90% with family hx
- --Strongly associated with obesity (80-90%)
- --Strongly associated with sedentary lifestyle
- --IRS/Syndrome X association
- --Diet (80% of pt will need wt loss)
Actions of Insulin
- Lowers glucose by increasing transport into cells and promoting the conversion of glucose to glycogen
- Promotes the conversion of amino acids to proteins in muscle
- stimulates triglyceride formation
- Inhibits the release of free fatty acids
Properties of Insulins
- 3 main characteristics determine classes of insulin
- --Time of action
- Route- IV or SQ (syringe/jet/or CSII pump)
- --Always indicated in Type 1 DM and in certain situations in Type 2
- SMBG is necessary
- Side Effects
- --Lipodystrophy/lipohypertrophy --> dimples at site of injections.
- --Allergic reactions (local vs systemic)/Resistance. Most insulin is now synthetic, so allergic rxn is not as common as it once was.
- Teaching insulin administration is role of nurse
Forms of Insulin
- Prandial or Mealtime Insulins
- Rapid Acting
- Short Acting
- Basal Insulins
- Intermediate Acting
- Long Acting
- Supplemental or Correctional
- U100 (100 Units/ mL) and U500 (500 Units / mL)
Prandial Rapid Acting Insulins
- Lispro (Humalog)
- Aspart (Novolog)
- Glulisine (Apidra): Duration 1.2.5 hrs.
- All need to be taken within 15 minutes before meals
- --Onset 10-15 minutes
- --Peak 45 min to 1 hour
- --Duration 3-5 hours
- May be mixed with all other insulins if administration is immediate except Lispro.
- Available in mixed formulation of 75/25
Prandial Regular Insulin
(look for the R on the box)
- Natural Insulin
- Humulin R (Novolin R)
- Velosulin (insulin pump)
- Routes of Administration:
- --SQ, IV or IM (rare)
- Onset - 30 minutes to 1 hour
- --Peak - 2-3 hours
- --Duration - 4-6 hours
- Can mix with all except Lispro
Intermediate Basal Insulins
- Insulin isophane (Humulin N and Novulin N)
- ***Technically NPH is no longer made—but you will still hear it referred to as NPH
- Usually taken 1-2x/day in the morning and/or evening
- --Onset 1-4 hours
- --Peak 4-12 hours
- --Duration 16-24 hours
- May be mixed with other insulins
- Only insulin that is cloudy. Typically taken with short acting (for immediate meal) while intermediate will regulate glucose thereafter.
- Available in mixed formulation 70/30
Long Acting Basal Insulins
- Glargine (Lantus)
- Detemir (Levemir)
- Usually dosed once a day
- --Onset 2-4 hours
- --Peaks. Slight peak for Detemir at hour 8-10 (Lantus is peakless. Only one that is.)
- --Duration 17-24 hours
- Basal insulin should be given even if the patient is NPO before a test or operative procedure. Regular dose night before and usually ½ dose morning of procedure. Will probably withhold other forms of insulin.
What motion would you use to mix insulins?
- Shaking with cause mixture to foam and you will not be able to draw an accurate dose.
Supplemental or Correctional Insulins
- All of the prandials
- May need to be used in medical setting because stress and upset ADLs will screw up their glucose levels. Stress --> Cortisol release --> glycogenolysis --> increased glucose levels.
- Check glucose 4x/day. May only need a minescule amount to correct levels.
Adverse Reactions to Insulin
- Hypoglycemia caused by:
- Excessive exogenous insulin or oral diabetes medications that increase insulin production
- Excessive alcohol consumption especially w/o adequate food intake
- Impaired hepatic or renal function
- Too little food
- Excessive exercise
- Mentation changes (confusion, LOC, decreased concentration and memory)
- Behavioral changes (nervousness, irrational or combative behavior, emotional changes)
- Neurological changes (poor coordination, seizures, drowsiness, double vision, headache, numbness)
- Trembling, sweating, palpitations, hunger
Treatment of Hypoglycemia
- Mild (40-60 BG)--Ingestion of 15 grams of CHO
- Moderate (20-40)--Ingestion of 15-30 grams of CHO and follow with a meal or snack containing protein
- Severe (< 20)--Ingestion not possible-must use IV glucose or IM glucagon preferably. May use glucose gel, honey, syrup, or jelly inside cheek
- --Follow above with rapid acting CHO liquid and meal containing CHO and protein
Adverse reactions to insulin treatment
- Hyperglycemia (if you didn't get enough insulin)
- Flushed, dry skin
- Fruit-like breath
- Frequent urination
- Loss of appetite
- Unusal thirst
Lipodystrophies: remember the pitting around injection sites.
- A person who is insulin-resistant has cells that respond sluggishly to the action of insulin.
- Following a meal, this person will have elevated glucose circulating in the blood, signaling yet more insulin to be released from the pancreas until the glucose is taken up by the cells.
- Experts suggest that 10 to 25 percent of the adult population may be resistant to insulin to some degree.
- People who are insulin-resistant often have elevated triglycerides.
- Elevated triglycerides usually coincide with low HDL.
- People who are overweight show signs of insulin resistance more often than people who are normal weight
Insulin Resistance Syndrome
- The syndrome is typically characterized by varying degrees of:
- --glucose intolerance
- --abnormal cholesterol and/or triglyceride levels
- --high blood pressure and upper body obesity
- --all independent risk factors for cardiac disease.
Pramlintide Acetate (Symlin)
- Synthetic amylin
- 1) modulation of gastric emptying;
- 2) prevention of the postprandial rise in plasma glucagon; and
- 3) satiety leading to decreased caloric intake and potential weight loss
- Purpose: Improved postprandial glucose control
- Used with both Type 1 and Type 2 taking insulin
- AC (before meals)
- Abdomen, thigh **never upper arm
What is Amylin?
- Amylin is a hormone that partners with insulin to help control blood sugar levels. Just as people with diabetes make little or no insulin, they also make little or no amylin. Without enough amylin and insulin, blood sugar levels can go too high after meals. This is because:
- --Amylin helps control how much sugar gets into the blood and how quickly it gets there
- --Insulin controls how much sugar gets out of your blood and into the muscles and tissues in the body
- --Taking SYMLIN replaces the amylin your body needs to help control blood sugar levels.
Important info about Symlin
- SYMLIN is used with insulin to lower blood sugar, especially high blood sugar that happens after meals.
- SYMLIN is given at mealtimes.
- The use of SYMLIN does not replace daily insulin but may lower the amount of insulin needed, especially before meals.
- Even when SYMLIN is carefully added to a mealtime insulin therapy, blood sugar may drop too low, especially with type 1 diabetes. If this low blood sugar (severe hypoglycemia) happens, it is seen within 3 hours after a SYMLIN injection.
- Severe low blood sugar makes it hard to think clearly, drive a car, use heavy machinery or do other risky activities.
- SYMLIN should only be used by people with type 2 and type 1 diabetes who:
- --already use their insulin as prescribed, but still need better blood sugar control.
- --will follow their doctor's instructions exactly.
- --will follow up with their doctor often.
- --will test their blood sugar levels before and after every meal, and at bedtime.
- --understand how to adjust SYMLIN and insulin doses.
- Self-monitoring of Blood Glucose (SMBG)
- --Before meals - blood glucose 80-120 mg/dL
- --At bedtime - blood glucose 100-140 mg/dL
- Hemoglobin A1C
- --Reflects average glucose levels over extended time (previous 7-10 days)
- Hb A1C - < 7%. Measures glucose bound to hemoglobin. If >7% pt has not managed well recently.
- --Index of blood glucose of 1-2 weeks
- --Want 30 mmol/L or less
Injection sites for insulin
Check facility protocol for acceptible sites. Just probably not around the umbilicus.
Insulin Pump Info
- Pump delivers insulin through an “infusion set”
- 24-48” length of pastic tubing with a needle or cannula on the end
- Inserted just under the skin (usually abdomen)
- Usually changed q36-48 hrs
- Very expensive ($10-30K)
- Good for "brittle" diabetics who have self-care deficit.
- Refrigerate if unopen. Will extend its viability until expiration date.
- If opened, refrigeration will not make a difference (will expire 28 days after opening.
- Two RNs must verify dose. Hand other RN vial, syringe , and orders and ask, "I have this order, have I filled it properly?"
Type II DM
- Sulfonylureas work by stimulating the pancreas to release more insulin and are only effective when there is some pancreatic beta-cell activity still present.
- Non-obese patients with Type 2 diabetes are usually started on sulfonylureas.
- A common side effect is hypoglycemia.
- It may cause weight gain and is therefore not suitable for obese patients.
- 1st Generation Sulfonylureas
- Rarely prescribed due to increases in side effects
- Example—only one still available
- Tolazamide (Tolinase ) --The only one still on the market
- 2nd Generation Sulfonylureas
- Most commonly prescribed sulfonylureas
- Glimepiride (Amaryl): FDA approval in combination tx with insulin
- **Glipizide (Glucotrol and Glucotrol XL). Used in mild hepatic and renal failure safely
- 2nd Generation Sulfonylureas
- Glyburide (Glynase Prestab, Micronase, and Diabeta)
- Metformin is the only available biguanide.
- It inhibits the amount of glucose produced by the liver, increases the insulin-receptor binding and stimulates tissue uptake of glucose. Metformin does not stimulate the pancreas to make or release more insulin.
- Increases insulin sensitivity.
- It does not cause hypoglycaemia or weight gain therefore obese patients with Type 2 diabetes are usually started on biguanides.
- Common side effects include abdominal discomfort, diarrhea, nausea or vomiting, loss of appetite, and metallic taste.
Methods of Action of Biguanides
Suppresses hepatic glucose productionIncreases peripheral glucose uptakeFrequently prescribed d/t action-excellent choice for obese patients with Type 2 DMSide EffectsGI disturbances – usually dose relatedLactic Acidosis – creatinine clearance level must be known prior to tx
Biguanides' side effects
- GI disturbances – usually dose related
- Lactic Acidosis – creatinine clearance level must be known prior to tx
- slow the digestion of carbohydrates and delay glucose absorption. They work by inhibiting intestinal enzymes that digest carbohydrates, thereby reducing carbohydrate digestion after a meal, which lowers postprandial blood glucose elevation in diabetics.
- Common side effects include abdominal pain, diarrhea and flatulence.
- Stimulate pancreatic insulin secretion but uses a fast action with short duration
- Must be taken at the beginning of each meal and avoided if meal is missed. If not, will --> hypoglycemic.
- Side Effects:
- Hypoglycemia – rare with monotherapy
- Wt gain
- work by making the body's cells more sensitive to insulin, so less insulin is needed to move glucose from the blood into the cells. This leads to a reduction of blood glucose levels.
- They should be taken in combination with metformin or a sulphonylurea.Act to reduce effects of insulin resistence.
TZD Side Effects
- Peripheral Edema
- Wt gain
- Caution in use with patients in advanced CHF
- Caution with liver failure-monitoring liver fxn imperative.
- Very effective, but ***BLACK BOX WARNING*** need to monitor for heart disease and possibly bladder cancer.
- Newest Rx for DM2
- Increases the level of incretin hormone – Increases insulin secretion and decreases glucagon secretion that reduces glucose production.
- Incretin will stimulate insulin production and inhibit glucagon.
- When given with other oral diabetic Rx, --> better glucose control.
Side Effects of Incretin modifiers
- Upper respiratory infection
- Runny nose, sore throat
- Swelling of face and hands
- Elevated liver enzymes
- Improves beta cell responsiveness—improves glucose control
- Suppresses glucagon secretion
- Slows gastric emptying
- Reduces food uptake
- Administered SubQ
Educational points on Incretin Mimetics
- DO NOT administer to Type 1 diabetics
- Is not a treatment for ketoacidosis
- Is NOT a substitute for Insulin
Side Effects of Incretin mimetics
- HA, dizziness, jitteriness, NV, diarrhea
- Stephens-Johnson Syndrome
Long Term complications of diabetes
- Macrovascular disease
- --Heart disease
- Microvascular disease
- --Gastroparesis: Decreased emptying of the stomach.