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Potentially fatal side effect of diabetes type 1
Body type indicative of metabolic syndrome
- Hemoglobin saturation with relative sugar. This reading tells how diabetes has been controlled over past 3 months. Strive to keep this number below 8% at worst and 6% at best. Above 8% they start to have microvascular complications.
- Aftenoon & evening plasma glucose levels show higher correlations with A1c than morning measurements.
Microvascular complications of diabetes
- Related to increased glucose at the capillary level which leads to spilling of microalbumin into urine once kidneys are damaged
- -Leads to retinopathy, neuropathy & nephropathy
Macrovascular complications of diabetes
- Related to low HDL, high LDL, high BP & hyperlipidemia
- -Stroke, MI, amputation due to peripheral disease and/or blood clots.
- Theses complications occur earlier in people with type 2 diabetes
Standard of care for diabetes pts
Yearly urine microalbumin, eye check-up, BP and lipid check with HbA1c q 3 months
- Fasting glucose > 126 mg/dL
- HbA1c > 6.5%
Treatments for Type 2 diabetes
- Sulfonylureas, Metformin, TZDs, GLP1 stimulator, DPP4 inhibitor, dopamine receptor agonist, maglinitide & Amylin.
- Insulin if all else fails and pancreas isn't producing insulin.
Metformin (500 mg BID)
- Improves insulin resistance at liver so pt. doesn't leak glucose.
- Metabolized in kidneys so pts w/ renal disease can get lactic acidosis. Withhold for 24 hrs before CT scan.
- Contraindications in late HF and liver disease.
- Take on full stomach - diarrhea & gas otherwise
Sulfonylureas (glyburide, glipizide, glimepiride)
Stimulate pancreas at times of food. Can cause weight gain. Most likely of these drugs to cause hypoglycemia.
TZDs (Pioglitazone - Actos, Avandia not used anymore due to increased risk for heart disease)
- Improve insulin resistance throughout body & at liver too, but not as much as Metformin. Actos increases risk of bladder cancer & weight gain w/ fluid retention which can precipitate HF in people with known CHF.
- One has been shown to regenerate beta cells in the pancreas at low doses.
- Require endogenous insulin to work so don't use with type 1 diabetes.
GLP1 stimulator (Byetta) (IM q12h currently, one coming that is injected bi-weekly)
- GLP1 agonist that leads to more uniformity in gastric emptying with less severe spikes in glucose after meals. Also decreases glucagon levels and stimulates insulin secretion.
- Can lead to weight loss. Can be combined with Metformi & sulfonylureas.
- Side-effects - PANCREATITIS
DPP4 inhibitor (things that end in -gliptin)
- GLP1 is broken down by DPP4, by knocking out DPP4, GLP1 isn't metabolized as quickly.
- Alternative for pts who are opposed to injections in Byetta.
Dopamine receptor agonist (Cyclocet)
Similar t drug used in Parkinson's pts. Has an effect on brain that can impove insulin resistance. Expensive.
Don't use with sulfonylureas. Good for pts who skip meals.
Damps down glucagon & mildly stimulates pancreas. Almost like GLP1. Works even if pancreas doesn't make insulin where other drugs won't.
After unexplained severe hypoglycemic episode..
Relax trx. for several weeks.
TZDs & biguanides
decrease glucose production in the liver & increase insulin sensitivity in peripheral body tissues
Sulfonylureas & meglitinides
stimulate the pancreatic beta cells to make more insulin
- Regular insulin - lasts 4 hours
- NPH - lasts 12 hours
- Long-acting analog - Novalog (Aspart or Lispro)
- Short-acting bolus - Lantus (Glargin or Detemir)
- Novolog mix for people who can't tolerate 4 injections per day (70/30)
Hyperglycemia leads to insulin resistance. After initial treatment with insulin, resistance will improve leading to "honeymoon effect."
During dawn hours (5-8am), the pituitary produced trophic hormones that stimulate target organs to release more cortisol. This causes increased insulin resistance that may lead to AM hyperglycemia. A dose of NPH at bedtime may control this. Presents a problem with Lantus (Glargine)
- Glucose 150-200 = 3 units
- Glucose 201-250 = 5 units
- Glucose 251-300 = 7 units
- Glucose 301-350 = 9 units
- Glucose 351-400 = 11 units
- Above that, call help