Endocrine Lecture #6: Diabetes Part II

Who produced the "Standard of Care in Diabetes"?

American Diabetes Association

How often is the "Standards of Care in Diabetes" updated?

Annually or more frequently if new evidence merits immediate incorporation

What is the handbook or "bible" of diabetes?

Standards of Care in Diabetes

What does gestational diabetes do for a child?

Risk of macrosomia, hypoglycemia at birth, and risk of obesity and Type II diabetes later in life

Classifications of Diabetes (5)

1. Type 1

2. Type 2

3. Gestational

4. Disease

5. Chemical/Drugs

Characteristics of Type 1 (2)

1. Due to autoimmune beta cell destruction

2. Leading to absolute deficiency of insulin

Characteristics of Type 2 (2)

1. Due to insulin resistance

2. May lead to progressive loss of beta cell insulin secretion

Characteristics of Gestational (2)

1. Dx in 2nd or 3rd trimester

2. Not clearly over diabetes prior to gestation

Disease causing diabetes (3)

1. Cystic fibrosis

2. Cushing's syndrome/disease

3. Surgical removal of the pancreas (induces Type 1 automatically)

Chemical/drug causing diabetes (3)

1. Glucocorticoids

2. HIV meds

3. Transplant meds

Lab tests for diabetes (4)

1. A1C

2. FPG

3. OGTT

4. Random plasma glucose

A1C meaning

Hemoglobin A1C

What does A1C measure?

Average blood glucose levels over the last 3 months

Why is A1C taken every 3 months?

RBCs are routinely destroyed every 3 months

How does A1C testing work? (3 steps)

1. Glucose in body sticks to hemoglobin A

2. Glucose remains stuck to hemoglobin for up to 120 days

3. Test measures percent of hemoglobin A with glucose

FPG meaning

Fasting plasma glucose

Is FPG routinely done?

Yes

When is fasting recommended and for how long?

Overnight for 8-12 hours

OGTT meaning

Oral glucose tolerance test

How is OGTT done?

2 hour plasma glucose during 75g oral glucose tolerance test

What diabetes is OGTT used to Dx?

Gestational

Dx Criteria for A1C, FPG, OGTT, and random plasma glucose with PREdiabetes

A1C: 5.7-6.4%

FPG: 100-125mg/dL

OGTT: 140-199mg/dL

Random plasma glucose: None

Why is there no Dx criteria for prediabetes with random plasma glucose?

There is no prediabetes value. If you are over a certain amount, you have diabetes.

Dx Criteria for A1C, FPG, OGTT, and random plasma glucose with DIABETES

A1C: >/= 6.5%

FPG: >/= 126mg/dL

OGTT: >/= 200mg/dL

Random plasma glucose: >/= 200mg/dL

Screening Criteria Categories for Asymptomatic Adults (6)

1. Overweight or obese with risk factors

2. Prediabetes

3. GDM lifelong testing every 3 years

4. Begin at 35 for others

5. Normal results = testing every 3 years

6. HIV

Screening Criteria Categories for Asymptomatic Children and Adolescents Risk Factors (4)

Children that are overweight or obese with 1+:

1. Maternal Hx of DM or GDM

2. FHx of DM2

3. Race

4. Signs of insulin resistance

Pathologic effects of diabetes (general idea)

DM is important to treat because it can affect many bodily systems

What does high blood glucose do? (3)

1. Damages capillaries

2. Decreases tissue perfusion

3. Damages cells

DM damages capillaries (small arteries). Where are these small arteries anatomically located? (3)

1. Eyes

2. Kidneys

3. Around nerves

4 complications of DM

1. Diabetic neuropathy (nerves)

2. Diabetic nephropathy (kidneys)

3. Diabetic retinopathy (eyes)

4. Cardiovascular disease

What is the most common complication of DM?

Diabetic neuropathy

What may Pts experience with diabetic neuropathy?

Numbness and tingling

What are 2 manifestations of diabetic neuropathy?

1. Infection

2. Diabetic foot disease

Cardiovascular disease is a ____________ complication of DM.

Macrovascular

2 other macrovascular complications of DM

1. Stroke

2. Extremities

Diabetic neuropathy causes a decrease in what function?

Nerve via reduced blood flow to them

TRUE OR FALSE: Diabetic food ulcers can kill the Pt.

True; Due to the spread of bacteria

What happens if a Pt progresses to a Grade 5 diabetic foot ulcer?

Need to amputate foot

Why would a Pt progress to a Grade 5 diabetic foot ulcer?

Pt may not feel the wound due to diabetic neuropathy

Diabetic foot ulcer (photo)

Diabetic foot ulcer grade scale (6 grades; briefly describe)

Grade 0: No ulcer, pain present

Grade 1: Superficial ulcer

Grade 2: Ulcer is deep (affects tendons and ligaments)

Grade 3: Ulcer is deep enough to affect bone

Grade 4: Half of foot is gangrenous

Grade 5: Whole foot is gangrenous (amputate this)

Diabetic retinopathy characteristics (5)

1. Hemorrhages

2. Abnormal growth of blood vessels

3. Aneurysm

4. "Cotton wool" spots

5. Hard exudates

Summary of recommendations for Most Nonpregnant Adults for A1C, preprandial capillary plasma glucose, and peak postprandial capillary plasma glucose

A1C: < 7.0%

Preprandial: 80-130 mg/dL

Postpradial:

Preprandial capillary plasma glucose

Blood glucose before eating a meal

Peak postprandial capillary plasma glucose

Peak blood glucose after eating a meal

What are the 3 assessments of glycemic targets for diabetic Pts?

1. A1C

2. CGM

3. Blood glucose monitoring

How often should a diabetic Pt be getting their A1C checked? Why?

Every 3 months; RBC lifespan

CGM

Continuous glucose monitoring

How is CGM recorded?

Via sensor measuring glucose in interstitial fluid

How often does CGM record glucose levels?

Every 5-6 minutes

How is blood glucose monitoring done?

Via pin stick

What does blood glucose monitoring require?

Significant Pt compliance

Non-Pharmacologic Tx for DM (6)

1. Medical nutrition therapy (refer to nutrition)

2. Routine physical activity (assess activity level)

3. Weight loss for Type II

4. Tobacco cessation counseling

5. Psychosocial care

6. Attitudes about diabetes

What should a discussion of attitude towards DM include? (2)

1. Expectations for Tx and outcomes (Ex. commitment to lifestyle changes)

2. Mood, stress, QOL, resources ($, social, family, emotional)

Pharmacologic Tx for Type I

Insulin

What types of insulin are there? (2)

1. Short-acting

2. Long-acting

Delivery systems for insulin (2)

1. SQ needles/pens (long-acting)

2. Pumps (short-acting ONLY)

What do the delivery systems mimic the natural function of?

The pancreas

TRUE OR FALSE: Pumps also produce glucagon.

False, they only produce insulin.

Hypoglycemia can occur if you give too much..

Insulin

Hypoglycemia

Abnormally low plasma glucose concentration

Levels of abnormally low plasma glucose concentration (3 levels)

Level 1:

Causes of hypoglycemia (3)

1. Overuse of exogenous insulin

2. Delayed or inadequate carbohydrate intake following insulin injection

3. Insulinoma (not DM related)

TRUE OR FALSE: Some Pts with hypoglycemia may be asymptomatic.

True

Signs and Sx of hypoglycemia affect what bodily system?

Autonomic sympathetic neural system

Why does this system cause an activation of when a Pt is hypoglycemic?

Raising blood glucose

What happens to the brain when it does not have enough glucose? The body then goes into what "mode"?

The brain panics; the body goes into "fight or flight"

Signs and Sx of hypoglycemia (6)

1. Shaking/trembling

2. Faster HR

3. Extreme hunger

4. Sweating

5. Confusion/difficulty concentrating

6. Dizziness

Pts ______ being hypoglycemic.

HATE

Tx of hypoglycemia (3)

1. Oral glucose

2. Glucagon pen

3. Nasal spray

When should you Tx with oral glucose?

Only if Pt is conscious and can swallow (Level 1 maybe 2)

How would you Tx a Pt with oral glucose?

Give the Pt crackers, juice, anything with glucose

Glucagon pen requires what? Should a Pt ever self administer?

Requires an injection; Pt should NEVER administer

Nasal spray Tx

Same function as pen, easier to administer

When should you use the glucagon pen and nasal spray to Tx hypoglycemia?

ONLY when Pt is LEVEL 3!!!!!

The Pt cannot eat and is unable to voluntarily raise their blood glucose (via eating). Pt should not be able to administer either of these Tx to themselves.

When should the glucagon pen and nasal spray Tx be avoided?

For Pts that are awake and alert

What's worse high blood sugar description (3)

1. Emergency cases of DKA

2. Damages blood vessels over time (years/decades)

3. Pts are not always aware of high blood sugar

What's worse low blood sugar description (3)

1. Things go bad quickly -> Won't regain consciousness without intervention b/c brain is starved of fuel

2. Frequent severe hypoglycemia has cumulative effects on the Pt's brain

3. Pts do NOT like the feeling of being hypoglycemic (often fearful and avoid at ALL costs)

Type II diabetes can progress from insulin __(1)__ to __(2)__ of insulin.

1. Resistance

2. Absence

What is primary Tx for Type II diabetes guided by? (2)

1. Comorbidities

2. Treatment goals

What are some comorbidities Type II Tx is guided by? (3)

1. Established atherosclerotic disease

2. Heart failure

3. Chronic renal disease

What is a super secret endocrinology tip?

Measure a Pt's C-peptide via blood test to help choose the best medical therapy

What therapies do a high C-peptide best respond to?

Non-insulin therapies

What therapies do low C-peptide patients require?

Insulin

1st line of treatment for Type II diabetes

Metformin (Biguanide therapy)

TRUE OR FALSE: Metformin is a plant based medication.

True

MOA for Metformin (2)

1. Inhibits hepatic gluconeogenesis (prevent liver from making glucose)

2. Opposes actions of glucagon

What body system does Metformin effect in terms of adverse effect?

GI system

What type of unpleasant adverse effect of the GI system may a Pt experience?

Loose, frequent bowel movements

How should you start a Pt on Metformin in terms of dosage?

Start low and titrate slowly

What form of Metformin is better tolerated? Up to what % of Pts is this better for?

-Metformin XR (extended release)

-50%

Metformin is contraindicated when a Pt has a GFR of.......? What does this indicate?

-

When would addition of a second therapy be needed for Type II?

If A1C does not improve on single therapy

What kind of comorbidities may require specific drugs? (4)

1. Atherosclerotic cardiovascular disease or increased risk of heart failure

2. Chronic renal disease

3. Fixed income, not elderly, and no history of risk of hypoglycemia

4. Need for weight loss

What specific drug do Pts with atherosclerotic CV disease require?

GLP-1

GLP-1

Glucagon-like peptide receptor agonist

What specific drugs do Pts with chronic renal disease or increased risk of heart failure require? Why is it beneficial for the kidneys?

-SGLT-2

-Protects the kidneys

SGLT-2

Sodium-glucose co-transporter 2 inhibitor

What specific drugs do Pts with fixed income, not elderly, and no Hx or risk of hypoglycemia? (2)

1. Sulfonylurea

2. Thiazolidinedione

What specific drug do Pts need for weight loss?

GLP-1 RA