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
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)