Diabetes (management + glucose monitoring)

Lecture Objectives:

1. ID factors that influence insulin absorption in diabetes pts; analyze how this impacts therapeutic outcomes

2. Treatment Pathway for hypoglycemia

3. CC advan/disadvan for insulin delivery devices to support individualized pt care

4. ID indications for aspirin therapy

5. ID lifestyle treatment goals (nutrition, exercise, smoking cessation, CV)

How does insulin work?

1. stimulates glucose uptake & storage as glycogen in muscles and liver

2. decreases hepatic glucose output & ketone production

CC T1DM and T2DM

1. T1: no insulin production, immune attack

2. T2: insufficient or resistance to insulin production

When is exogenous insulin treatment indicated?

inadequate production or increase insuling demands in the body

What is the difference between bolus/prandial insulin and basal insulin?

1. bolus/prandial: short acting forms of insulin to control rise in blood glucose when eating, before meals

2. basal: longer acting forms of insuling to keep blood glucose stable throughout the day

What is the total insulin dosing per day for T1DM? How should we divide the TDD in pts?

0.3-0.5 units/kg; 1 unit of rapid acting insulin covers 10-15 grams of carbs

What is the total insulin dosing per day for T2DM? How should we divide the TDD in pts?

0.5-1.2 units/kg; once or twice daily dosing of basal insulin

What are the 3 most common side effects of insulin therapy?

1. hypoglycemia

2. dose-dependent weight gain

3. injection site reactions

Synringes can be plastic or glass. CC length vs gauge of syringe

1. length: 5/16 is short and less painfaul than ½ inch; when switching lengths, make sure to INC blood glucose monitoring frequency

2. Gauge: higher the gauge, thinner the needle

What is the insulin units to mL ratio?

1 unit is 0.01mL; 100 units = 1 mL, 50 units = 0.5mL

What are the advantages of insulin injection devices?

1. dexterity

2. ease of use

3. convenience

4. accurate dosing.

5. privacy

What are the disadvantagees of insulin injection devices?

1. units per pen & vial

2. varying expiration dates

3. limited uses per administration

4. cost

Where should a patient administer insulin?

1. lower abdomen

2. upper outer thighs

3. upper outer arms

4. butt

Describe the administration technique for insulin

1. clean site w alcohol swab, pinch the skin using dominant hand

2. rotate injection sites to prevent lipoatrophy

should you use an alcohol swab for glucose monitors?

NO because it can dry their hands and lead to infection

What are the 5 pain reduction strategies to teach patients injecting insulin?

1. room temp insulin

2. relax muscles

3. ensure no air bubbles in syring

4. quick penetration of needle

5. using new needle for each injection

What factors INC/DEC insulin absorption?

1. INC: exercise and massaging injection site

2. DEC: cold skin temp and smoking

What location of injection has the most absorption?

Abdomen > arm > thigh > buttock

Which type of injection has the highest absorption rate?

IV > IM > SQ

The potency of insulin ____ as temperature increases

decreases

what are general storage tips for insulin?

1. keep vial/pen currently in use at room temperature

2. keep extra vials/pens in fridge NOT FREEZER

3. store away from heaters, radiators, glove compartments, or sunny windows

4. travel: insulated container w ice/cooling agent, pack in carry on

diabetic pt on new diabetes medications presents with sweating, trembling, confusion/tiredness, and tachycardia/palpitations. What do they have and what should you give them?

hypoglycemia <60mg/dL; give 15g of carbohydrates, repeat if it’s still under 60mg

What is the alternative treatment for hypoglycemia if they are on an alpha glucosidase inhibitor (acarbose, miglitol, voglibose)

use glucose tablets or gel

patient is experiencing hypoglycemia and becomes unconscious. What should be given?

glucagon emergency kit, should be conscious within 5-10 mins but if not must re inject

• ADE: n+v up to 24hrs

What are the treatment goals for T2DM? DOUBLE CHECK

1. A1c:

when is a diabetes pt considered a candidate for aspiring for primary prevention of CV problems?

1. 50-69 yrs old PLUS 1 additional ASCVD risk factor:

   1. family ho premature ASCVD

   2. HT

   3. dyslipidemia

   4. smoking

   5. CKD/albuminuria

when is a diabetes pt considered a candidate for aspiring for secondary prevention of CV problems?

if pt has history of ASCVD: 75-162mg/d

What are the non-pharmacologic therapies for T2DM?

1. medical nutrition therapy

2. alcohol use

3. smoking cessation

4. physical activity

When is medical nutrition therapy given in diabetes pts? What are its effects?

to maintain glycemic control and when >5% weight loss is needed.

• lose 1-2 lbs/wk

• A1C DEC 1-1.9% in T1, DEC 0.3-2% in T2DM

What are the nutrition recommendations in MNT?

1. carbs: no specific requirements

2. protein: 15-20% total calories (1-1.5g/kg/d)

3. fat: limit saturated fat

goal: nutrient dense foods w high protein/fiber to improve satiety and glycemic control

Define glycemic index (GI)

1. ranking system 1-100 that rates how quickly a food raises blood sugr

• Low GI: food break down SLOWLY

• High GI: food break down FAST

Define Glycemic Load

1. calculation that incorporates GI and amount of carbs consumed

• bc low GI can cause large blood sugar spikes

• typical diet: 100GL units/day

CC between free, reduced, and no added/low(sugar/fat)

1. free: <0.5g

2. reduced: 25% less than original product

3. no added/low/lite

What is the difference between nonnutritive and nutritive sweeteners?

1. nonnutritive: few/no calories, FDA approved, may INC appetite and energy intake

2. nutritive: contain calories than need to be counted, sugar alcohols (sorbitol, etc) SIDE EFFECT DIARRHEA

What supplements are NOT recommended for diabetes?

1. antioxidants: vitamin E and C

2. herbal supplements/micronutrients: cinnamon, curcumin, vitamin D, aloe vera, chromium

DUE B-CAROTENE

What are the risks associated with alcohol usage in diabetes? What is recommended instead?

1. weight gain; hyperglycemia; delayed hypoglycemia

2. recommendation: abstain from alcohol; consume in moderate amts

   1. women: 1/day; men: 2/day

   2. 1.5 oz shot, 12 oz beer, 5 oz wine

What are the risks associated with smoking?

1. macro: CVD and PVD

2. micro: retino and nephropathy

3. other: bad glycemic outcomes, INC BP and LDL, DEC HDL

4. QUIT SMOKING EVEN E-CIGS

How much physical activity is recommended in adults pts with diabetes?

1. atleast 150 min of mod-high intense aerobic activity per week AND 2-3 sessions of resistance training per week

   1. insulin users: consume extra carbs (esp if <90mg/dL prior to exercise); T1DM may have delayed hypoglycemia 8-15 hrs

What is a physical activity tips for diabetes pts?

try to break up the time spent being sedentary w light activity esp during extended periods (>30mins)

What type of physical activity is recommended for young diabetes pts? for prediabetes, or diabetes

1. atleast 60 min of mod to high aerboic activity daily

2. strength training at least 3 days/week

REVIEW IMMUNIZATIONS RECOMMENDED IN DIABETES PTS

ADD GLUCOSE MONITORING LATER