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  1. What is diabetes?
    What causes it?
    Systemic metab disorder char by inc lev of glucose, improper metab of carbs and fats

    • A lack of insulin production by the beta cells in the Islets of Langerhans
    • Decreased activity of insulin that is secreted
    • Target cells resist the action of insulin
  2. Risks
    • Gen predisp, fam hx
    • viruses (rubella, mumps), agian process, diet and lifestyle, ethnicity, obesity (BMI over 27), elev chol, T lymphocytes may play a role in dev of autoimmune dest of ins producing Beta cells in P
  3. Becoming more common (doubled 80s-2002, will double again by 2030)
    Up to __% of older than 65 have some gluc intol
    In working adults, leading cause of __,__, &__; ___ leading cause of death from disease
    • 50%
    • amputations, blindness, ESRD
  4. What hormones are counter regulatory?
    What is normal gluc lev?
    Released from ___, routed thru___
    Insulin binds w glucose, allows into cell (butler)
    • glucagon, epinephrine, GH, cortisol
    • Beta cells in islets of langerhans, liver
  5. Normal Metab
    Rise in plasma ins after a meal stimulates storage of __ as __. Inhibits __, enhances __, Increases __
    Fall in BG lev facilitates rel of __

    Insulin not needed to enter cells in ___
    • glucose as glycogen
    • glycogenesis
    • fat deposits
    • protein synth
    • kidneys and brain
  6. Lowered or dec insulin (hyperglycemia)
    kidneys__, causing __, causing ___, too much glucose and not any way to let it into cells leads to malnourishment, leads to ___
    Explains clinical sx of ___
    • excrete glucose (glycosuria), excess water to dilute urine (polyuria), excessive thirst (polydipsia), polyphagia
    • inc food intake, excess gluc and weight loss (no way to lose)
  7. When carbs can't be used, protein and fat broken down, and __ used for energy. May develop __. Could cause death in sev cases.
    Tx inc
    • ketone bodies
    • DKA
    • insulin IV (continuous), rehydration, close elyte monitoring (hypokalemia), only tx severe DKA w Sodium Bicarb
  8. Gestational and Pre and Secondary diabetes too
    DM1, usually before __
    ___ of diabetes cases
    Autoimmune, probably caused by virus. Dest of B cells by __
    ____% need to fail before s/s occur. After 5 years of dx all cells are destroyed.
    • 30
    • 10%
    • T-lymphocytes
    • 80-90%
  9. DMII
    __ to __ % overweight
    usual onset is over __, but childhood obesity can dec onset
    • 80-90
    • 30
    • asympt for years, may be nonspec of sim to type I.
  10. GD
    occurs in __% preggos
    week 24-28
    High risk for__
    but returns to normal after 6 w pp
    Higher risk later on for DMII
    • 4
    • C sect, perinatal death, complications
  11. What can cause 2ary DM?
    Usually resolved w cause
    panc issues, cushing's, hyperthyroidism, cystic fibrosis, PPN, TPN, drug induced
  12. glycosylated hemoglobin or A1C?
    • how much glucose has been incorp into hemoglobin?
    • percentage. From prev 3-4 months
    • 4-6% is normal
    • Reduce complications if lower than 7%
    • 8% = average of 200 mg/dL
  13. Insulin therapy probs
    • hypoglycemia
    • allergic reaction (inj site)

    Lipodystrophy (rotate inj sites important, room temp ins helps prev)
  14. If hypglyc, 4 oz soda or juice, a few tsp of jelly or sugar
    if loss of consc
    • inc gluc 25-50 mg/dl
    • 1 mg glucagon inj IM
  15. DKA
    HHNKs (hyperglycemic hyperosmolar nonketotic sx)
    • DKA- most ser dist in DM1
    • in non DM, hyperthyroidism, cushings, pancreatitis, preg, drugs
    • no glucose to cell, hyperglyc to osmotic diuresis to elyte imbal and hypervolemia, inc fat metab to acidosis
    • avg serum G= 600
    • less than pH 7.3
    • kussmauls, fruity breath
    • serum os 295-330
    • low K
    • normal-el Na+
    • BUN up, severe fl def

    • HHNKS
    • absence of ketones
    • most ser disturb in type II DM
    • sim to DKA
    • Avg ser gluc
    • 1100mg/dL
    • normal pH
    • tachypnea
    • greater os than 330
    • low K
    • normal-el
    • Na+BUN up,
    • severe fl def
  16. DMII can be prev
    keep BMI less than 24, red of 7% of body wt,
    ex, healthy LS
    • gluc, lipid, Hgb AiC levs
    • dietition consult
    • each carb has diff glycemic index
    • reduce ETOH intake
    • insulin dept need aft and eve snacks
  17. Dx studies
    • Fasting plasma G lev (8h)
    • greater than 126
    • OGTT (oral gluc tol test
    • greater than 200
    • Random plas gluc meas
    • greater than 200
    • Serum insulin
    • none in T 1
    • normal to high in T 2
    • elyte imbal
    • Ketones in urine
  18. __ tissue responsiveness, ___of insulin (leads to ____)
    Abnormal hepatic glucose reg
    Factors result in periph insulin resistance
    • Decreased
    • overprod
    • beta cell exhaustion, eventual decrease
  19. Rapid Acting Insulins
    • Aspart (novolog), clear Aspart- pain in the Ass
    • 5-10 m
    • 1-3h
    • 3-5h
    • Rapid acting insulins mimic normal meal insulin profile more closely than short; higher, faster peak and shorter per of action. Eat w in 5 min of injecting to get max benefit and reduce risk of hypoglycemia. Can be used with insulin pump.

    • Lispro (Humalog), clear
    • 5m
    • 1/2h-1 1/2h
    • 3-4h
  20. Short acting insulin
    • Regular (Humulin R, Novolin R), clear
    • Short- used the be the REGULAR course of tx
    • 30m-1h
    • 2-3h
    • 3-6h
    • Inject 30-60 m before meals. Increases risk of hypo g 3-5h after meals because of longer action. Used to be only one avail IV, but now can mix lispro w normal saline or dextrose to do IV too.

    • Regular (iletin-pork) clear
    • 30m-2h
    • 3-4h
    • 3-6h
  21. Intermediate acting
    • NPH (Humulin N, Novolon N) cloudy
    • 2-4h, 4-10h, 10-16h
    • Longer acting cuz of addition of protamine and zinc
    • THINK-Non extreme, INTERMEDIATE weather, CLOUDY,
    • Lente (Humulin L, Novolin L) cloudy
    • 3-4h, 4-12h, 12-18h
    • NPH (iletin-pork) cloudy
    • 2-4h, 8-14h, 10-16
  22. 70/30 NPH/regular
    • (Humulin 70/30, Novolin 70/30), cloudy
    • 70/30 aspart protamine/aspart
    • (NovoLog Mix 70/30), cloudy
    • Closely mimic normal insulin sec at mealtime and afterward, but aren't appropriate for most ppl w diabetes; can promote inconsistent BG lev and inc risk of hyperglycemia. Rapid onset, intermediate dur of action. Can result in lower postprandial BG readings and decrese risk of hyper G after meals. Not w IV, not w pump, not w other insulin product.
  23. Long Acting Insulin
    • Ultralente (Humulin U), cloudy
    • 6-10h, 10-16h, 18-20h
    • Insulin Glargine (Lantus) clear
    • 1h, peakless, 24h
    • Similar to slow, steady (basal) sec of insulin from pancreas. Often at bedtime. May get more independence w less risk of hypoglycemia because it has no peak, tho, need bolus of short acting before each meal. Don't miss in syringe.
  24. Premixed Insulin
    30m-1h, depends on mix, 10-16
  25. Replacement therapy for hypothyroidism
    • Levothyroxine (Synthroid)-synthetic form of T5. Monitor B levs till stable, IV, IM, PO
    • DDs- can alter BG, adjust meds, can alter PT (coags)
    • Nervous, insomnia, tremor, tach, palps, arrhythmias, cardiac arrest, weight loss, haet into, fever
    • ctn in card dis (esp post MI, renal insuff), DM, take once a day
    • Liothyronine
    • Synthetic T3
    • Similar risks, SE, caution as in Synthroid
  26. Hyperthyroidism
    • Propylthiouracil (Propacil) (PTU)
    • sometimes given before surgery
    • Interferes w T3 & 4 synthesis
    • Monitor B levs, CBC
    • drowsy, depression, nephritis, leukopenia, agranulocytosis, aplastic anemia
    • take w food, watch for hypo T
  27. Drugs for adrenal insufficiency
    • Hydrocortisone (Cortef, solu-cortef)
    • Synthetic glucocorticoid (systemic)
    • also tx for inflamm, allergic dis, other uses
    • PO, IV, intra joint, IM
    • psychotic beh, insom, seiz, moon face, HF, arrhyth, thromboembolism, pancreatitis, peptic ulcerization, inc app, hypo K, hyper G, monitor elytes. Acute adrenal insuffic after sudden wdrawal of therapy (can be fatal), or inc stress, DDIs- risk for bleed w ASA, NSAIDS
    • Prednisone (deltasone)
    • Methylprednisone (solu-medrol)
  28. (Adrenal drugs) Testosterone xdernal
    • Stim targ tiss to dev normally. Can also be used in pts w FTT or extreme muscle weakness.
    • depression, stroke, itching, rash, bleeding, HGcemia, prostate abnmorms, breats tenderness, insulin may need starting or changing. W anticoags monitor PT
  29. (Pituitary) Given for Diabetes insipidus, and to increase factor 8.
    • DDAVP
    • inc perm of ren tubules
    • Promotes reabsorption of water, produces concentrated urine,
    • headache, inc BP, nasal irritation, ETOH may increase SEs
  30. Oral hypoglycemics
    • Biguanides
    • Sulfonylureas (2nd gen)
    • Combination drugs, many others

    • (DM II still cap of secreting insulin)
    • targets insulin resistant cells, used when diet and ex fail. When 2 oral hypo.s fail, usually need insulin.
  31. Oral hyoglycemics (B_____)
    • Biguanides
    • Metformin (glucophage)
    • dec hep glucose production
    • Dec intestinal absorp of glucose
    • Improves insulin sens
    • Metallic taste, renal failure, lactic acid. Contrast dye can inc Met levs in blood, inc risk of RF
  32. Oral hypoglycemics (S____)
    • Sulfonylureas (Glipizide (Glucotrol)
    • probably stims insulin rel from B cells, reduces gluc output by liver, inc in sens
    • dizzy, drowsy, can't poop, leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia, alt chol, increased LFTs
    • DDIs corticosteroids, anticoags, ETOH
    • Also, glyburide (Diabeta)
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