Study guide Q Diabetes Mellitus

06/16/26- Not completed

What is the pathophysiology behind DM 1?

• Body’s immune system attacks and destroys cells in the pancreas that make insulin.

• Sometimes, a few remaining beta cells produce insulin just for a temporary (or honeymoon) phase shortly after a type 1 diabetes diagnosis.

• Honeymoon: decreased blood glucose concentration and decreased insulin requirements. Considered temporary remission after initial treatment.

• Patients should be maintained on insulin even if the dose is low.

What is the pathophysiology behind DM 2?

• Most prevalent type (90% to 95%)

• Insulin resistance; impaired insulin secretion

• Many risk factors: overweight, obesity, advanced age, family history

• Usually develops after age 40

• Gradual onset; hyperglycemia may go many years without being detected

• Insulin therapy may be added for some

What characterizes a healthy pancreas?

After meals:

• Insulin facilitates transport of glucose from blood into cells, thus decreasing blood glucose level.

• Insulin allows cells to store and utilize carbohydrates, fat, and proteins.

• Excess glucose gets converted into glycogen to be stored.

During fasting/starvation:

• Glucagon stimulates liver to break down glycogen into glucose (glycogenolysis).

• Fats and amino acids are converted into glucose (gluconeogenesis)

What is the pattern of insulin secretion?

Normal glucose and insulin metabolism:

• Produced by B-cells in islets of Langerhans in pancreas.

• Released continuously into blood stream in small increments with larger amounts released after food.

What are the clinical manifestations of type 1 DM?

• Classic symptoms:

  • Polyuria (frequent urination)

  • Polydipsia (excessive thirst)

  • Polyphagia (excessive hunger)

• Unexplained weight loss

• Weakness

• Fatigue

What are clinical manifestations of type 2 DM?

• Often nonspecific

• Although not common, but possible:

  • Polyuria

  • Polydipsia

  • Polyphagia

• Fatigue

• Recurrent vaginal yeast or urinary tract infections

• Prolonged wound healing

• Vision problems

What are the risk factors for type 2 DM?

Risk factors include:

• Overweight

• Obesity

• Advanced age

• Family history

• Certain ethnicities in this order:

  • 23.5% American indians/Alaskin Natives

  • 22.1% Hispanics

  • 20.4% Non-hispanic blacks

  • 14% Asian Americans

  • 12.1% Non-hispanic whites

What is acanthosis nigricans? What can it signifiy?

• Dark, velvety patches of skin often appear in the armpits, groin, and neck.

• Manifestation of insulin resistance and possible pre-diabetes.

What is metabolic syndrome and what constitutes it?

• This syndrome consists of a cluster of 5 conditions. You need at least 3 of these conditions in order to be diagnosed:

  • Elevated glucose levels-hyperglycemia (fasting glucose >110 mg/dL)

  • Elevated blood pressure (>130/>85 mmHg)

  • Increased triglyceride levels (>150 mg/dL)

  • Abdominal obesity (>40 in for men, >35 in for women)

  • Decreased levels of HDLs (<40 mg/dL in men, <50 mg/dL in women)

• This syndrome increases the risk for DM 2.

Above what BMI is considered obesity?

>30 BMI

What is Hemoglobin A1C? How often is it monitored?

Hemoglobin A1C is a blood test that measures the average blood glucose levels over the past two to three months. It is typically monitored every three to six months to assess diabetes management.

What are the A1C ranges for normal glucose, prediabetes, and diabetes?

Normal: <5.7%

Prediabetes: 5.7%-6.4%

Diabetes: >6.5%

How can diabetes be diagnosed with which tests and values?

• Hemoglobin A1C level > 6.5%

• Fasting plasma glucose level > 126 mg/dL

• Two-hour plasma glucose level during OGTT > 200 mg/dL

• Symptoms of hyperglycemia with random plasma glucose level > 200 mg/dL

What are the treatment goals for A1C, BP, and LDL in DM 1 and 2?

• A: A1C Goal: < 7%

  • Hemoglobin A1C: reflects glucose levels over past 3 months

  • Used to monitor response to therapy

  • For elderly, A1C of 8% is acceptable

• Fasting glucose goal of 80 to 130 mg/dL

• B: Blood pressure

  • BP <130/80 mmHg

• C: Cholesterol

  • LDL <100 mg/dL or even <70 mg/dL

What is the onset, peak, and duration for rapid acting insulin?

• Lispro, aspart, glulisine

• Onset of action 15 minutes

• Injected within 15 minutes of mealtime

• Peak: 1-2 hours

• Duration: 3-4 hours

What is the onset, peak, and duration for short acting (regular) insulin?

• Regular insulin with onset of action 30 to 60 minutes

• Injected 30 to 45 minutes before meal

• Peak: 2-4 hours

• Duration: 5-8 hours

What is the onset, peak, and duration for intermediate-acting insulin?

• NPH (Cloudy; must roll to mix)

• Duration 12 to 18 hours

• Peak 4 to 12 hours

• Onset: 1 to 2 hours

• Can mix with short- and rapid-acting insulins

What is the onset, peak, and duration for long acting insulin?

• Insulin glargine, degludec, and detemir

• Released steadily with no peak action

• Usually given once a day but can be administered twice a day

• Do not mix with any other insulin

• Onset: 1 to 2 hours

• Duration: 24 hours or more

How is insulin administered?

• All insulin can be given SQ; ONLY REGULAR INSULIN CAN BE GIVEN IV!

• Absorption is fastest from abdomen, followed by arm, thigh, and buttock

• Abdomen is often preferred site

• Do not inject in site to be exercised

• Rotate injections sites

• Use only insulin syringes to administer insulin

• Usually available as U100 insulin (1 mL contains 100 U of insulin)

• Inject at 45- to 90-degree angle

• Wash with soap and water to cleanse the site to be used; alcohol swab not necessary for self-injection when at home

What are the implications of insulin?

• Do not heat/freeze; do not administer cold insulin

• In-use vials may be left at room temperature up to 28 days

• Extra insulin should be refrigerated

• When drawing up regular insulin with a NPH insulin, draw up the regular (clear) insulin before the NPH (cloudy) insulin

What are the signs and symptoms of hypoglycemia?

• Autonomic nervous system activated

• Common manifestations

  • Shakiness

  • Irritability

  • Palpitations

  • Nervousness

  • Diaphoresis

  • Dizziness

  • Headache

  • Hunger

  • Pallor

• Altered mental functioning

  • Difficulty speaking/slurred speech

  • Anger

  • Visual disturbances/blurry vision

  • Confusion

  • Drowsiness

  • Coma

• Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death

What can cause hypoglycemia?

Possible reasons:

• Taking too much insulin or wrong insulin.

• Not eating enough carbs for how much insulin was taken.

• Timing of when insulin was administered.

• Being more active than usual.

• Drinking alcohol without eating.

• Eating meals later than usual or skipping meals.

• Older patients or patients who use beta-adrenergic blockers are at risk for hypoglycemia unawareness.

• Symptoms can also occur when high glucose level falls too rapidly.

What is the management for hypoglycemia if the patient is awake?

• Check blood glucose level

  • If < 70 mg/dL, treat with 15 grams of carbohydrate (simple; fast-acting)

• Treatment: rule of 15

  • Consume 15 g of a simple carbohydrate

    • ½ cup orange juice or regular soda, 2-3 glucose tablets, 1 tube glucose gel, 5-8 LifeSavers, 1 Tbsp honey, 8 oz of low-fat milk

  • Recheck glucose level in 15 minutes

    • Repeat if still < 70 gm/dL

  • Avoid high fat foods (cookies, ice cream), which decrease absorption of sugar

  • Eat complex carbohydrates and protein after recovery (turkey sandwich, peanut butter or cheese) to prevent rebound hypoglycemia

What is the management of hypoglycemia if the patient is unconscious?

• Obtain glucose level

• Patient not alert enough to swallow and no IV access:

  • 1 mg of Glucagon IM or SQ

  • Nausea/vomiting are common reaction after injection

  • Turn the patient on the side until patient becomes alert to prevent aspiration

  • Administer a second dose of Glucagon in 15 minutes if patient remains unconscious

  • After regaining consciousness, have patient eat a small meal that has complex carbohydrates and protein (turkey sandwich, peanut butter or cheese)

• Acute care settings with IV access

  • 50% dextrose IV

Which factors predispose elderly to hypoglycemia?

• Poor or erratic nutritional intake

• Changes in mental status that impair the perception or response to hypoglycemia

• Dependence or isolation that limits early treatment for hypoglycemia

• Presence of comorbid conditions that can mask or lead to misdiagnosis of hypoglycemic symptoms (dementia, delirium, depression, sleep abnormalities, myocardial infarction, cerebrovascular accident)

• Need to monitor vital signs: blood pressure, respiration rates, blood glucose levels

What is the medical management for type 2 DM?

• Glycemic control (diet & exercise) – In type 2 diabetes, diet & exercise can normalize insulin release & decrease insulin resistance

• Glycemic control with drug treatment – oral drugs, other injectables, insulin

• Initiate diet, exercise

  • Add drug (metformin – first line)

  • Add second drug

  • Insulin therapy

• Oral drugs are for type 2 only; never type 1 DM

• First line: metformin (Glucophage), a biguanide.

• Other oral drugs, injectables, insulin.

• Some patients with Type 2 DM may take insulin if they cannot manage blood glucose levels by other means.

What is Metformin?

A biguanide medication used primarily to treat type 2 diabetes by improving insulin sensitivity and inhibiting hepatic glucose production. Also called Glucophage.

What are care guidelines for patients taking metformin and undergoing diagnostic studies? What are the contraindications to this medication?

• Monitor serum creatinine (normal: 0.8 to 1.2 mg/dL) and BUN levels

• Hold metformin if patient is undergoing diagnostic studies requiring IV iodine contrast media (such as coronary angiogram)

  • Hold 48 hours before and after

• Give with a meal; does not cause hypoglycemia if used alone

• Contraindications:

  • Renal impairment (high creatinine, low glomerular filtration rate)

  • Excessive alcohol intake

What are sulfonylureas and its major side effect?

• A medication that increases insulin production from the pancreas.

• Major side effect: hypoglycemia.

• Examples:

  • Glipizide (Glucotrol)

  • Glyburide (Glynase)

  • Glimepiride (Amaryl)

What are the names of thiazolidinedione medications? How do they work? What needs to be monitored?

• Drugs: pioglitazone (Actos), rosiglitazone (Avandia)

• MOA: enhance cellular response to insulin by decreasing insulin resistance.

• Adverse effects (AKA monitor for):

  • Peripheral edema (fluid retention), monitor weight

  • May cause or exacerbate heart failure (↑BNP)

  • Hepatotoxicity; monitor LFTs, report jaundice, dark urine

What are the SGLT2 inhibitors? How do they work and what are they called?

• Drugs: canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance)

• MOA: excrete glucose through the urine by preventing its reabsorption in kidney; promotes weight loss

• Side effects:

  • Genital yeast infections (Candidiasis)

  • Urinary tract infections – need to obtain urine dipstick

  • Increased urination

• Adverse Effects:

  • Hypotension

How does nutrition therapy look like for diabetics? What are healthy food choices?

• Food composition

  • Healthy balance of nutrients is essential – “Heart Healthy”

    • Carbohydrates (whole grains, fruits, vegetables; low-fat dairy; legumes) 45-50%

      • Fiber intake at 25-30 g/day

      • Avoid fruit juices

    • Fat (reduced saturated and trans fat; cholesterol <200 mg/day) <30%

      • Healthy fats: olives, nuts, avocados, fish

      • Avoid cheese

    • Protein (lean protein) 15-20%

• Carbs: fruits, vegetables, whole grains, legumes, low-fat dairy

• Carb counting for those on complex insulin regimens:

  • Serving size is 15 g of carbohydrates (45-60 g per meal)

  • Insulin dose based on number consumed

  • Fiber intake at 25-30 g/day

• Nutritive and nonnutritive sweeteners may be used in moderation

• Carbohydrate counting

  • Complex carbs: whole wheat, multigrain bread, brown rice, barley, quinoa

• Exchange lists

  • Starches, fruits, meats, vegetables, fats, free foods

• USDA MyPlate method

  • Non-starchy vegetable (1/2), starch (1/4), and protein (1/4), 8 oz of nonfat milk, small fresh fruit

  • 9-inch plate

What are the effects of alcohol in a diabetic?

• Excessive alcohol intake can decrease blood sugar level – sometimes causing it to drop into dangerous levels.

• Alcohol may affect the liver’s ability to release stored glucose and result in hypoglycemia

• It is recommended that men consume no more than two alcoholic beverages per day. Women should consume only one alcoholic beverage per day.

What parameters of exercise is ok for diabetics? When is the best time to exercise and when to snack?

• Parameters:

  • Minimum 150 minutes/week aerobic (30 minutes 5 days/week)

  • Brisk walking

  • Resistance training 2-3 times/week

• Assess blood glucose levels before, during, and after exercise.

• Exercise 1 hour after a meal.

• If needed, eat small snacks every 30 minutes during exercise.

• If blood glucose < 100 mg/dL, eat a 15 g of carbohydrate snack before starting. After 15-30 minutes, recheck glucose levels. Delay exercise if <100 mg/dL. Talk to provider about lowering drug dose(s) if hypoglycemia occurs consistently.

• Before exercise, if glucose >250 mg/dL in type 1 and ketones are present in the urine, delay vigorous activity until ketones are gone. Drink fluids.

What is sick day management for diabetics overall?

• Any illness, injury, surgery results in hyperglycemia

• Continuing medications important!

• Maintain regular food intake

• Frequent monitoring of blood glucose

What are the specifics of sick day management for diabetics in terms of food intake, role of fluids, how often to monitor BG, and when to call HCP?

• Do not to eliminate insulin doses when nausea and vomiting occur.

• Take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates (low-sodium soups, juices, regular sports drinks)

• In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL

• Increase monitoring of serum glucose while ill:

  • Check blood glucose every 2-3 hours!!!

• If not able to eat normally, substitute with soft foods such a gelatin, soup, and pudding.

• If vomiting, diarrhea, intake of liquids every 30 to 60 minutes to prevent dehydration.

Patient should contact provider if:

• Blood sugar stays higher than 300 mg/dL or lower than 70 mg/dL

• Urine ketones moderate or high

• Vomiting, diarrhea, or fever persists

What are the general guidelines for checking ketones for type 1 DM?

• For type 1 DM, Check urine dipstick for ketones every 3-4 hours if the blood glucose >240 mg/dL.

• Ketones: Intermediate products of fat metabolism.

  • Urine testing only detects acetoacetic acid, not other ketones, acetone, or beta-hydroxybutyric acid.

• Normal= Negative or trace amounts.

• Ketonuria= ketones in urine.

What is Diabetes ketoacidosis (DKA)? S/S? who is at risk?

• Most likely to occur in type 1 diabetes

  • Without enough insulin, body begins to break down fat and protein as energy sources.

  • Metabolism of fat results in the production of fatty acids, which are converted to ketone bodies.

  • An increase in circulating ketone bodies precipitates the state of acidosis.

• Caused by profound deficiency of insulin

• Characterized by

  • Hyperglycemia (> 250 mg/dL)

  • Dehydration

  • Fat breakdown, ketone production

  • Acidosis

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• Clinical manifestations:

  • First, polydipsia (thirst), polyuria

  • Later, dehydration:

    • Poor skin turgor

    • Dry mouth/dry skin

    • Tachycardia

    • Orthostatic hypotension

  • Restlessness, lethargy, and weakness early

  • Nausea/vomiting

  • Ketonuria (ketone production)

  • Kussmaul (fasting, deep) breathing

  • Fruity breath (from ketones)

  • Blood glucose level of ≥ 250 mg/dL

  • Glucosuria

  • Rapid deterioration in LOC to coma

What is the treatment of Diabetic Ketoacidosis (DKA)? What are the possible complications of treatment?

Treatment:

• Establish IV access

• Begin fluid resuscitation to restore fluid balance with 0.9% NaCl solution

• Once urine output is established, address electrolyte imbalances:

  • (normal serum potassium is 3.5-5.0 mEq/L); insulin lowers serum potassium. pt will need K replacement.

• Begin continuous regular insulin IV drip 0.1 U/kg/hr to lower glucose gradually

• Monitor serum glucose and potassium, cardiac monitoring, and I&O

• When blood glucose levels approach 250 mg/dL, 5% to 10% dextrose is added to fluid regimen to prevent hypoglycemia

• Assess breath sounds for fluid overload

Complications of treatment:

What is Hyperosmolar Hyperglycemic nonketotic syndrome (HHNS)? S/S? Who is at risk?

What is the treatment of HHNS? What are possible complications of treatment?