glucose regulation

what are macrovascular changes?

• affect large blood vessels » arteries and veins

• increases atherosclerosis » buildup of plaque in blood vessels » plaque narrows and hardens arteries » difficult for blood to flow

what are microvascular changes?

• affect small blood vessels » capillaries » tiny blood vessels that supply oxygen and nutrients to organs and tissues

• changes to structure and function of organs

what are the potential complications of microvascular changes?

• retinopathy » damage to vessels in eyes

• nephropathy » damage to vessels in kidneys

• neuropathy » damage to nerves » tingling, numbness, pain in hands and feet

• gastroparesis » neuropathy in stomach » delays gastric emptying » N/V, bloating

what are the potential complications of macrovascular changes?

• CAD » blood vessel supplying heart become narrowed/blocked » MI

• poor blood flow to brain due to narrowed blood vessels » ischemia » stroke

• PAD » narrowing of blood vessels in legs, arm » reduced blood flow, pain, amputation

what are the positive outcomes when blood glucose levels are controlled?

• fewer hospital days

• fewer incidences of hypoglycemic events/coma

• slow onset of retinopathy

• slow progression of renal failure

• slow progression of peripheral neuropathy

• decrease rates of diabetic ulcers and amputations

• improve health of GI tract by avoiding gastroparesis

what is diabetes?

disease that affects body’s ability to control and utilize its supply of fuel

how is glucose made available to the body?

• diet » eating foods with carbohydrates

• body’s production in the liver

what are the organs involved in regulating and utilizing glucose for the body?

• liver

• pancreas

• skeletal muscle

how does the liver regulate and utilize glucose?

• produces glucose when body needs it » in between meals or during fasting

• stores glucose in form of glycogen » releases to bloodstream when body requires energy

• in diabetes: body produces too much glucose » inappropriate glucose production » liver continues releasing glucose even when body doesn’t need it » high glucose levels

how does the pancreas regulate and utilize glucose?

• produces insulin » helps cells absorb glucose from bloodstream

• in diabetes: type 1 vs type 2 » too much glucose in bloodstream

how does the skeletal muscle tissue regulate and utilize glucose?

• when muscles are active » take up glucose for energy

• in diabetes: process is impaired » high glucose levels

what is pre-diabetes?

BS higher than normal, but not high enough to be diabetic

what is type 1 diabetes?

• insulin dependent » insulin therapy, close monitoring of blood glucose levels

• immune system attacks and destroys insulin producing cells (beta) of pancreas

• juvenile onset » under age of 30

what is type 2 diabetes?

• non insulin dependent » diet, oral meds, insulin, and/or combo

• insulin resistant » over time, pancreas cannot produce enough insulin to maintain normal blood glucose levels

• adult onset, but more common in children now due to increased obesity rates

what is gestational diabetes?

• occurs during pregnancy

• body cannot produce enough insulin to meet extra needs

• usually goes away after delivery » increases risk of developing type 2 in mother and child

what is secondary diabetes?

• occurs in individuals with other medical conditions or often side effect of certain meds

• disease/tumor of liver/pancreas

• meds

  • corticosteroids » promote insulin resistance

  • thyroid preparations » affects glucose metabolism

  • thiazide diuretics » affect insulin sensitivity

  • dilantin

how does HgbA1C diagnose diabetes?

• as serum glucose increases » more glucose becomes bound to hgb

• ≥6.5%

• no fasting » provides average measure of glucose control over 3 month period

how does fasting plasma glucose (FPG) diagnose diabetes?

• fast at least 8 hours

• ≥126 mg/dL

how does random blood glucose level diagnose diabetes?

≥200

how does oral glucose tolerance test (OGTT) diagnose diabetes?

• loading dose of 75g of glucose ingested » plasma glucose level obtained 2 hours later

• ≥200 mg/dL

what are the s/s of hyperglycemia?

• polyuria

• polydipsia

• polyphagia

• warm and dry » sugar’s high

what are the s/s of hypoglycemia?

• Headache

• Irritiability

• Weakness

• Anxiety

• Sweating/shaking

• Hunger

• Tremors/tachycardia

• cold and clammy » need some candy

what is the dawn phenomenon?

• early morning increase in blood glucose levels due to natural hormone secretion

• caused by release of growth hormone, cortisol, and catecholamines

• 4-8 am

what effect does the dawn phenomenon have?

increases insulin resistance and glucose production by the liver

how do you manage dawn phenomenon?

• adjust insulin timing, dose or meal timing

• consider increasing bedtime insulin

what is the somogyi effect?

• rebound hyperglycemia following an episode of hypoglycemia

• caused by overcompensation by the body due to low blood glucose during the night » releases counter regulatory hormones » epinephrine, cortisol

what effect does the somogyi effect have?

increases blood glucose levels after hypoglycemic event

how do you manage somogyi effect?

lower insulin dose or adjust meal/snack timing » prevent hypogylcemia

what is the treatment plan for type 2 diabetes?

• diabetic education

• nutritionist

• improve activity levels

• weight loss

• control comorbidities

• oral hypoglycemic agents

• possible insulin/oral agent combo

• screen for DM complication onset » retinal exam, urine microalbuminuria, neuropathy, vascular changes, wounds

what is the treatment plan for type 1 diabetes?

insulin replacement

what are the goals in managing diabetes?

• tight glycemic control

  • maintain blood glucose levels 70-110 mg/dL

  • HgbA1C <6%

  • may be slightly individualized for each pt

• reduce symptoms/ severity of symptoms

• improve overall feeling of wellness

• prevent diabetic complications

• maintain desirable weight, regular activity, proper diet

what are the oral medications to treat type 2 diabetes?

• thiazolidinediones and biguanides

• sulfonylureas and meglitinides

• alpha glucosidase inhibitors

how do you mix insulins?

1. air to cloudy

2. air to clear

3. draw clear

4. draw cloudy

• regular to NPH

what are combination insulins?

• contains 2 types of insulin

• ex: 70/30 = 70% NPH and 30% regular

• 7 units NPH

• 3 units regular

what is a sliding scale insulin?

• used to adjust pt blood sugar levels at specific time » typically before meals

• provides flexibility in insulin dosing » real time corrections of high blood sugar levels

• used during hospitalization

• provides higher glycemic control vs PO

• administered to type 1 and 2

• rapid and short acting most commonly used with sliding scale

what should you know about insulin syringes?

• read syringe correctly

• different syringe sizes » U-30, U-50, U-100

• U-50 = 50 units of insulin per mL

• U-100 = 100 units of insulin per mL

what are multidose insulin pens?

• prescribed for various insulins » common in rapid/long acting

• prefilled with range of insulin options

• color branded for insulin identification

• single pt use only and replace needles

what are the lifespan considerations in elderly with insulin administration?

• increased risk of insulin related hypoglycemia » falls, confusion, hospitalization

• improper insulin administration, incorrect dosing, missed meals » dangerous low blood sugar episodes

• more likely to experience delayed symptoms » difficult to detect and treat in time

why should you watch kidney function when administering insulin?

• diabetics can develop kidney dysfunction

• elderly lose kidney function rapidly

• as serum creatinine rises » gfr decreasing » medications cannot clear system as readily » toxicity

• as kidney function decreases » pt needs less insulin » higher risk for insulin toxicity and hypoglycemia

how do you treat mild/moderate hypoglycemia in patients that are alert?

• give simple carb snack

  • crackers

  • piece of hard candy

  • fruit juice

  • soda

  • sugar tablets

• or/and IV dextrose (D-50)

• re-evaluate blood sugar 15-20 mins after each intervention until blood sugar returns to normal

how do you treat severe hypoglycemia if a patient is unresponsive?

• administer IV dextrose (D-50)

• IV not available » administer glucagon IM/SQ

• re-evaluate blood sugar 15-20 mins after each intervention until blood sugar returns to normal