Diabetes Mellitus-Dialysis

Diabetes Mellitus

is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion or insulin action.

Type 1 Diabetes

B-cell destruction, leading to absolute insulin deficiency.

Immune-Mediated

only accounts for 5-10% of type 1 diabetes; cell-mediated autoimmune destruction of the B-cells which leads to insulin deficiency.

Ketoacidosis

usually the first manifestation of type 1 diabetes.

Idiopathic Diabetes

no known etiology; some patients have permanent insulinopenia & are prone to DKA but have no evidence of autoimmunity.

Type 2 Diabetes

ranging from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect; accounts for 90-95% of cases.

Gestational Diabetes

diagnosed in the 2nd or 3rd trimester of pregnancy that was not clearly overt diabetes prior to gestation.

Maturity-Onset Diabetes of the Young (MODY)

a heterogeneous disorder identified by non-insulin-dependent diabetes characterized by early onset of hyperglycemia generally under 25 years of age.

Diseases of the Exocrine Pancreas

such as cystic fibrosis and pancreatitis.

Drug or Chemical-Induced Diabetes

such as glucocorticoid use, treatment of HIV/AIDS, or after organ transplantation.

Necrobiosis Lipoidica

skin condition often begins as small raised solid bumps that look like pimples.

Acanthosis Nigricans

often causing darker skin in creases of the neck; may be the first sign that someone has DM.

Digital Sclerosis

tight, waxy skin on the backs of hands; fingers become stiff and difficult to move.

Bullosis Diabetricorum

large blisters can form on the skin of people who have diabetes.

Skin Infections

hot, swollen skin that is painful; an itchy rash and sometimes tiny blisters, dry scaly skin, or white discharge that looks like cottage cheese.

Diabetic Ulcers

caused by poor circulation and nerve damage which makes it hard for body to heal wounds.

Diabetic Dermopathy

skin condition causes spots (sometimes lines) that create a barely noticeable depression in the skin.

Eruptive-Xanthomatosis

bumps that often look like pimples which will soon develop a yellowish color.

Granuloma Annulare

skin condition causes bumps and patches that may be skin-colored, red, pink, or bluish purple.

Extremely Dry, Itchy Skin

high blood sugar can cause this.

Xantholasma

yellowish scaly patches on and around the eyelids.

Skin Tags

which hand from a stalk are most common on the eyelids, neck, armpit, and groin.

1. Polyphagia

2. Polyuria

3. Polydipsia

3P’s of DM.

3.5-6.0% (15-42 mmol/mol)

normal value for HbA1C

5.7-6.4% (39-47 mmol/mol)

pre-diabetes result for HbA1C

> 6.5% (48 mmol/mol)

diabetes result for HbA1C

72-108 mg/dl

normal value for fasting plasma glucose.

100-125 mg/dl

pre-diabetes result of fasting plasma glucose

> 126 mg/dl

diabetes result of fasting plasma glucose

< 140 mg/dl

normal result of oral glucose tolerance test

140-199 mg/dl

pre-diabetes of oral glucose tolerance test

> 200 mg/dl

diabetes result of oral glucose tolerance test

Metformin Therapy

for prevention of type 2 diabetes should be considered in prediabetes.

1-Hour Fasting Glucose Challenge Test

screening between 24-28 weeks AOG.

24-28 weeks

AOG to start the 1-hour fasting glucose challenge test.

3-hours OGTT

to confirm diagnosis if blood glucose is > 140 mg/dl in 1 hour OGTT.

> or = 180 mg/dl

abnormal value for 1-hour OGTT.

> or = 155 mg/dl

abnormal value for fasting 2-hour OGTT.

> or = 140 mg/dl

abnormal value for fasting 3-hour OGTT.

Diabetic Retinopathy

damaged to retina leading to blindness.

Diabetic Nephropathy

persistent proteinuria leading to decreased GFR to end-stage renal disease.

Diabetic Neuropathy

gradual onset of sensory impairment, including burning & numbness in the feet, neuropathic pain, poor wound healing, foot ulcer.

Peripheral Vascular Disease

narrowing of arteries supplying the arms, legs, stomach, & kidneys.

Oral Hypoglycemic or Antidiabetic Agent

usually indicated for type 2 diabetes.

1. Sick

2. Stress

3. Surgery

4. Pregnant

situations when oral hypoglycemics shift to insulin.

Insulin Therapy

often indicated for type 1 diabetes.

50-60%

percentage of complex calories, CHO’s, high fiber.

12-20% (60-85 g/day)

percentage of daily calories of CHON

30%

percentage of fat which should not be exceeded.

Sulfonylureas

promotes increased insulin secretion from pancreatic beta cells through direct stimulation (requires at least 30% normally functioning beta cells).

1. Tolazamide (Tolinase)

2. Tolbutamide (Orinase)

examples of first generation sulfonylureas.

1. Glipizide (Glucatrol)

2. Glyburide (Micronase)

examples of second-generation sulfonylureas.

Biguanides

reduces hepatic production of glucose by inhibiting glycogenolysis; decrease the intestinal absorption of glucose & improving lipid profile.

1. Metformin (Glucophage)

2. Metformin with Glyburide (Glucovance)

examples of biguanides.

30 ml/min

glomerular filtration rate which is contraindicated in biguanides.

Renal Disease & D/C

conditions in which biguanides should be used with caution.

Alpha-Glucosidase Inhibitors

inhibits alpha-glucosidase enzymes in the small intestine & alpha amylase in the pancreas; decreased rate of complex CHO metabolism resulting to a reduced rate postprandially.

1. Acarbose (Precose)

2. Miglitol (Glyset)

examples of alpha-glucosidase inhibitors.

Thiazolidinediones

enhances insulin action at the cell and post-receptor site & decreasing insulin resistance.

1. Pioglitazone (Actos)

2. Rosiglitazone (Avandia)

examples of thiazolidinediones.

Meglitinides

inhibit adenosine triphosphate-dependent K+ channels in pancreatic ß-cells, which results in membrane depolarization and subsequent calcium influx.

1. Repaglinide (Prandin)

2. Nateglinide (Starix)

examples of meglitinides.

1. Aspirin

2. Alcohol

3. Oral hypoglycemics

increase the hypoglycemic effect of insulin.

1. Glucocorticoids

2. Thiazide diuretics

3. Thyroid agents

increase the blood glucose level.

Hypokalemia

rare electrolyte imbalance of insulin administration.

Lipodystrophy

results in non-rotation of insulin injection sites.

15-30C

temperature in which insulin should be stored to prevent irritation from “cold insulin”.

1. Lispro (Humalog)

2. Aspart (Novolog)

examples of rapid-acting insulin.

5-15 minutes

onset of rapid-acting insulin.

30 minutes

peak of rapid-acting insulin.

2-3 hours

duration of Lispro (Humalog).

3-5 hours

duration of Aspart (Novolog).

Regular (Humalog R)

example of short-acting insulin.

30-40 minutes

onset of short-acting insulin.

90-120 minutes

peak of short-acting insulin.

6-8 hours

duration of short-acting insulin.

1. Novolin L (Lente)

2. Novolin N (NPH)

examples of intermediate-acting insulin.

1-4 hours

onset of intermediate-acting insulin.

4-8 hours

peak of intermediate-acting insulin.

16-20 hours

duration of intermediate-acting insulin.

1. Ultralente (“UL”)

2. Glargine (Lantus)

examples of long-acting insulin.

6-8 hours

onset of Ultralente (“UL”).

12-16 hours

peak of Ultralente (“UL”).

36 hours

duration of Ultralente (“UL”).

1-2 hours

onset of Glargine (Lantus).

Continuous

peak of Glargine (Lantus).

24 hours

duration of Glargine (Lantus).

Dawn Phenomenon

increase in blood sugar due to inadequate insulin and release of growth hormone at around 4-8 AM.

Somogyi Effect

some patients who take insulin before bed wake up with rebound hyperglycemia at 7 AM after a bout of hypoglycemia at around 2-3 AM.

1. Give at 10 PM

2. Intermediate-acting insulin

3. Increase bedtime dose of insulin

treatment of dawn phenomenon.

Decrease evening dose of intermediate-acting insulin

treatment of somogyi effect.

Hypoglycemia

blood glucose falls to < 50-60 mg/dl; can be caused by too much insulin or hypoglycemic agents, too little food, or excessive physical activity.

15 g of fast-acting simple carbohydrate

treatment of hypoglycemia if patient is awake.

Glucagon SQ or IM

treatment of hypoglycemia if the patient is unconscious.

25-50 cc of D50%

treatment of hypoglycemia in the hospital.

1. Serum Creatinine

2. Urine Albumin

may indicate heart failure.

5-20 mg/dl

normal value of BUN.

0.6-1.2 mg/dl

serum crea for males.

0.5-1.1 mg/dl

serum crea for females.

110-150 ml/min

creatinine clearance for males.