Unit 4: Diabetes Objectives

Etiology of Type I diabetes?

an autoimmune disorder in which the body’s immune system mistakenly attacks and destroys the insulin producing beta cells in the pancreas

Pathophysiology of Type I diabetes?

a gradual, chronic process that typically involves genetic predisposition and is triggered by environmental factors.

Etiology of Type 2 diabetes?

a complex interplay of genetic, environmental, and lifestyle factors; involves the development of insulin resistance in which the body’s cells don’t respond properly to insulin, combined with the gradual failure of the pancreatic beta cells to produce enough insulin to overcome this resistance.

Pathophysiology of Type 2 diabetes?

a chronic condition characterized by high blood sugar levels (hyperglycemia) due to a combination of factors that impair the body’s ability to use glucose effectively; The body’s “key” (insulin) stops working effectively, and the “lock” (cells) stops opening for glucose

Differences in etiologies of type 1 and type 2?

• Type 1 is an autoimmune disorder resulting from body’s self-destruction of its insulin-producing cells

• Type 2 is a metabolic disorder caused by insulin resistance and relative insulin deficiency

Pathophysiology difference between type 1 and type 2 diabetes?

• Type 1 diabetes body produces no insulin because immune system destroys insulin producing cells in the pancreas

• Type 2 diabetes the body’s cells resist insulin’s effects, and the pancreas can’t produce enough extra insulin to compensate

Describe receptor desensitization

a.     Process by which a cell’s response to an agonist diminishes after repeated or prolonged exposure; protective regulatory mechanism that prevents overstimulation of the cell

Describe the physiology associated with blood glucose regulation. (1a) 

a.     The body regulates blood glucose through a complex system of hormones, organs, and physiological processes; goal is to maintain a tight balance known as glucose homeostasis, ensuring the cells have a steady supply of energy while preventing toxic levels of sugar in the bloodstream

risk factors for Type 1 diabetes?

a.     Type 1 risk factors include genetics, family history, and environmental factors like certain viruses

risk factors for Type 2 diabetes?

a.     Type 2 risk factors include obesity, physical inactivity, family history, certain race and ethnic groups, age 45+, history of gestational diabetes, prediabetes, and a sedentary lifestyle

Describe the common clinical presentation of type 1 diabetes. (1c) 

• frequent urination (polyuria),

• thirst (polydipsia), polyphagia,

• weight loss,

• N/V, abdominal pain, fatigue, absence of menstruation;

• life threatening diabetic ketoacidosis (DKA) is a common initial presentation

Describe the common clinical presentation of type 2 diabetes. (1c) 

• Symptoms often develop slowly over many years and can be subtle or even absent in the early stages;

• the disease may be discovered by a routine health check;

• polydipsia, polyuria, polyphagia (feeling very hungry), losing weight,

• having sores heal slowly, dry itchy skin,

• neuropathy (losing feeling in the feet or having tingling in the feet, ocular pathologies (blurred vision)

Type 1 vs Type 2 Diabetes clinical presentation

• less than 30 years (childhood or puberty); greater than 30 years

• abrupt onset/ lean body; gradual onset/ obesity

• absent insulin resistance; present insulin resistance

• Autoantibodies often present; autoantibodies rarely present

• Symptomatic; asymptomatic

•  Ketones present; absent ketones

• Immediate need to insulin; insulin needed years after diag.

• Acute complication: DKA; acute complication: HHS

• No microvascular complications at diagnosis; yes at diagnosis

• Rare macrovascular complications before diagnosis; yes

• 5-10% diagnosed diabetics; 90-95% of diabetics

• Moderate genetic disposition; strong genetic disposition

• Beta cells destroyed eliminating the production of insulin; inability of beta cells to produce appropriate amounts of insulin

• Treated with insulin injections; managed with drugs and lifestyle changes

What are some complications for type 1 diabetes?

• Retinopathy, neuropathy, nephropathy, heart disease, stroke, increased susceptibility to infections;

• acute complications like diabetic ketoacidosis (DKA) can occur

What are some common complications for for type 2 diabetes?

• Cardiovascular diseases (heart attacks/strokes), kidney disease, neuropathy, eye problems including vision loss, and foot problems like ulcers and infections that can lead to amputations;

• hyperosmolar hyperglycemic state (HHS) – blood sugar levels are too high for a long period of time leading to severe dehydration and confusion

What are efficacy monitoring parameters for diabetes?

• tracking treatments’ impact on blood glucose, using A1C tests and CGM

• self monitoring of blood glucose (SMBG)

What are safety monitoring parameters for diabetes?

• managing medications and infections

• watching for long term complications

• foot exams, kidney function, eye exams, cholesterol and BP checks

Describe the role of lifestyle modifications for diabetes mellitus (diet, exercise).

• Diet: control carbohydrate intake, reduce added sugars and processed foods, manage portion sizes, eat at regular times

• Exercise: increases glucose uptake into muscles through both insulin dependent and non-insulin dependent pathways (for type 2 helps body become more responsive to own insulin); lowers blood sugar, weight management); aerobic (walking at least 150 minutes per week), strength training (2-3 times per week), and reduced sedentary time

• Manage stress, get enough sleep, quit smoking

Identify efficacy monitoring parameters for biguanides.

• A1C

• FPG

Identify efficacy monitoring parameters for GLP-1 RA and GIP/GLP-1 RA..

• A1C

• FPG (fasting plasma glucose)

• PPG (postprandial glucose)

• weight

Identify efficacy monitoring parameters for SGLT2i.

• A1C

• FPG

• PPG

• weight

Identify the criteria for the diagnosis of type 1 and type 2 diabetes

• Diabetes is diagnosed with any blood test or symptoms on two separate occasions: (any of the following tests with symptoms indicates diagnosis); (no symptoms - need 2 tests)

  • Random plasma glucose greater than or equal to 200 mg/dL with hyperglycemia symptoms - could be diagnosis

  • A fasting plasma glucose greater than or equal to 126 mg/dL

  • A1C greater than or equal to 6.5%

  • Two hour plasma glucose greater than or equal to 200 mg/dL during an oral glucose tolerance test

Identify goal laboratory values for blood glucose based on the American Diabetes Association (ADA) for a patient with type 1 and type 2 diabetes.

• preprandial (before meal) blood glucose between 80-130 mg/dL

• peak postprandial (after meal) blood glucose under 180 mg/dL

Identify goal laboratory values for A1C based on the American Diabetes Association (ADA) for a patient with type 1 and type 2 diabetes.

• Type 1 and 2 diabetes: A1C less than 7%

• Less than 6.5% for patients with short duration of diabetes and who are not on insulin or for those with life long expectancies and no significant cardiovascular disease

• Less than 8% for patients with a history of severe hypoglycemia, limited life expectancy, significant CV or other complications, or long-standing diabetes that has been difficult to control

Describe symptoms of hypoglycemia.

• Mild to moderate: shaky, nervous, sweating, chills, irritability, rapid/irregular heartbeat, hunger/nausea, dizziness, pale skin, headache, weakness, difficulty concentrating, tingling/numbness in the lips, tongue, cheeks

• Severe: confusion, slurred speech, blurred vision, loss of coordination, difficulty eating, drowsiness, seizures, coma

• Nocturnal (while sleeping): restless sleep, nightmares, waking up tired, sweats while sleeping

When do you treat hypoglycemia?

• As soon as the blood glucose drops below 70 mg/dL or if you experience symptoms of low blood sugar

Describe the rationale for treating a patient experiencing hypoglycemia.

• To quickly restore the brain’s glucose supply to prevent serious and potentially fatal complications and alleviate a patient’s distressing symptoms

Describe the rationale for the first-line medication used in type 1 diabetes (insulin) based on the ADA guidelines.

• ADA mandates insulin therapy for all individuals with Type 1 diabetes as it is the only effective way to replace the missing insulin and to manage blood glucose levels.

Describe the rationale for the first-line medication used in type 2 diabetes (metformin, glucagon-like peptide-1 receptor agonists, glucagon-like peptide-1/glucose-dependent insulinotropic polypeptide, sodium-glucose transporter-2 inhibitors) based on the ADA guidelines.

• ADA recommends a personalized approach to medication with type 2 diabetes with metformin as the preferred initial therapy due to its effectiveness, safety, and benefits against complications;

• GLP-1 RAs (GLP-1 receptor agonists), GLP-1/GIP receptor agonists, and SGLT-2 inhibitors are now considered first line options particularly for individuals with established atherosclerotic CV disease (ASCVD), as these agents provide additional cardioprotective, renoprotective, and weight loss benefits alongside glucose control

How do you calculate basal/bolus insulin regimen?

• TDD = weight (kg) times 0.5 units/kg

• basal = ½ TDD; bolus = ½ TDD (long acting/intermediate)

• bolus is divided between 3 meals each day unless counting carbs (rapid acting/short acting)

Describe how to calculate an insulin sensitivity factor

• ISF = 1800 / TDD (mg/dL) – for rapid acting insulin (Humalog, Novolog)

• ISF = 1500 / TDD (mg/Dl) – for regular insulin (Humulin R, Novolin R)

What is the insulin to carbohydrate ration (I:CHO)?

• 500 rule

  • 500/TDD = the # of grams of carbs 1 unit of bolus insulin will cover

Describe the dose titration for initially starting metformin in a patient with type 2 diabetes.

• For initially starting metformin in a patient with type 2 diabetes, the dose is gradually increased, or titrated, to minimized common GI side effects like nausea, bloating, diarrhea.

• Titration depends on whether an IR or ER formula is used; eGFR will be monitor to assess kidney function

Why would a diabetic patient be hypoglycemic?

• hypoglycemia < 70 mg/dL

• taking too much medication or insulin

• skipping a meal or snack

• more exercise than usual

Readings that make a person hyperglycemic?

• fasting reading consistency over 130 mg/dL

• Postprandial reading over 180 mg/dL

• A reading of 200 mg/dL or higher at any random time especially if accompanied by symptoms like increased thirst or frequent urination

• Factors to look at: skipping or taking too little medication or insulin, eating larger meals or more carbs than usual, being ill or stressed, little or no physical activity

Describe how to treat hypoglycemia.

• Treated based on its severity

  • Mild to moderate when a person is conscious and can swallow are managed with fast-acting carbohydrates

    • Consume 15 g of fast acting carbohydrates to raise blood sugar quickly; wait 15 minutes then recheck blood sugar; repeat is blood sugar is still below 70 mg/dL

    • severe hypoglycemia: administer glucagon, position the person on their side, call 911 (if glucagon is not available or the person doesn’t respond after 15 minutes)

  • Severe episodes, when a person is unable to eat or is unconscious, require emergency glucagon or IV glucose

What is a high alert medication?

• medications that are most likely to cause significant harm to the patient even when used as indicated.

What is the MOA for metformin? (pollev)

• decrease hepatic gluconeogenesis (glucose production in liver)

• increase insulin sensitivity

• decrease intestinal glucose absorption (from foods you eat)

What is the MOA for GLP-1 receptor agonists and GLP-1/GIP RA?

• increase glucose-dependent insulin secretion

• decrease glucagon secretion

• slow gastric emptying

• increase satiety

What is the MOA for SGLT2i?

• decrease kidney glucose reabsorption

• increase glycosuria (glucose in the urine)

What comorbidities impact initial therapy selection for a person with type 2 diabetes?

• atherosclerotic cardiovascular disease (ASCVD)

• heart failure (HF)

• Chronic kidney disease (CKD)

Which medication are considered first line if a patient has type 2 diabetes and a history of myocardial infarction (heart attack)?

• GLP-1 RA

• SGLT2i

What medication class is preferred in people with T2D and HF?

• SGLT2i specifically dapagliflozin and empagliflozin

Which medications would be appropriate for a person with T2D and CKD?

• empagliflozin

• semaglutide

Rank the medications from highest to lowest for their efficacy for weight loss? Metformin, Dulaglutide, Emagliflozin, Tirzepatide

Tirzepatide (best), dulaglutide, emagliflozin, metformin

Which medication would be appropriate for a patient with MASLD?

• dulaglutide

• tirzepatide