CB

Diabetes M 4/7

Diabetes 4/7/25


Normal blood glucose

  • 70-100mg/lm

  • Fasting


Hypoglyemia

  • Less than 70mg

  • Brain functioning 


Hyperglyemia

  • Bg more than 200

Fasting BG

  • 100–125 mg/dL

    • Impaired glucose tolerance

(IGT) = “prediabetes”

  • Greater than 126 mg/dL = diabetes


 Postprandial BG

  • Glucose after eating

  • Greater than 200 mg/dL = diabetes


Oral glucose + urine if high x2= DIABETES

A1c- 3 months of blood sugar


a1c= should be below 6



Fasting and random BG tests

 Oral glucose tolerance test(OGTT)

  •  75 g of glucose ingested, measure BG following


 Glycated hemoglobin (A1c)

  •  Diagnose diabetes and assess BG levels over the preceding 3 months

  • Use may be limited due to variability in results

  • Pair with fasting BG on the same day


If values of both are in diabetic range, diagnosis of DM confirmed


Tests

  • EAG

    • Average bg over few mionths

  • Glugcouria

    • Glucose in nepthrons

  • Keorurnia

    • Ketones in urine test

    • t1dm


Complications of DM

  • Acute and long term

  • Hyper and hypoglyemia

  • Acute

    • dKA - t1dm

    • Hhs - t2dm

  • Long term systemic

    • BLINDNESS, kidney failure, neuropathy (autonominal and peripheral neuropathy), CV disease >>> amputation


Hypoglyemia

  • BG less thqan 70

  • Excessive exogenous insulin

  • Food intake is low

  • Too much physical activity

  • Infection, illness, drug interaction

COMpensatoryt response to raise bg

  • Epinepthrin, glucgon, SNS

  • Activates SNS for many signs and symptoms

    • SWEATING, HUNGER, DIZZINESS, HEART PALPATION, CONFUSSION

      • LEADS TO COMA = TOO LITTLE GLUCOSE/FOOD FOR BRAIN

    • Need action plan

      • Fast acting carbs (15g) x4

      • Avoid fats (delays glucose

      • Transient response 

        • Meal and snack with glucose

  • IV glucose

  • Glucangon by subcutaneous injections

    • Accelerating breakdown of glycogen to glucose

    • Good for unconscious

    • IV DEXTROSE

      • Severe hypoglyemia

    • Repeated episodes of hypoglycemia can blunt compensatory response

    •  Autonomic neuropathy may cause patients to miss warning signs of hypoglycemia

    •  Hypoglycemia is a medical emergency


Somogyi effect

  • Morning Hyperglyemia due to hypoglemia at night

  • Insulin peaking wrong time


Dawn effect

  • Morning hyperglycemia

  • Nocturnal elevation of growth hormone GH




Classic Signs of DM

  • Polydipsia

    • THIRST

    • High blood sugar increases plasma osmlarity

    • ICF to ECF causes cells to DEHYDRATE

    • INCREASED THRIST

  • Polyuria

    • Increased pissing

    • Osmotic duireis

    • Glucose appears in urine

    • Water follows glucose

  • Polyphagia

    • Body cant use glucose

    • Fat and muscle breakdown

    • Weight loss with increased appreciate

    • Ketones levels ↗

  • Glyconeolysis and glyconegenesi

    • Increases bg further

    • Inability to use bg is bad


Signs of dm

  • Blurred vision

    • Glucose accumulation in fluid of eye

    • Changes refraction of light

  • Electrolyte imbalance

    • Fluid shifts

      • Icf to ecf cause delusional HYPOnatremia (low sodium)

        • Sodium supplements needed

    • False hyperkalemia

      • Serum levels of K potassium are high but body is okay



Fuel utilization in DM

  •  


Hyperosmolar hyperglyemic syndrome (HHS)

  • Common in T2DM

  • SEVEVE HYPERGLYEMIA AND INCREASED PLASMA OSMOLARITY

  • NO KETONES, insulin present

    • Bg more than 600 mg/dl

    • Blood ph more than 7.3

    • Hco3 more than 18

    • Blood osmolarity more than 320 mossm/L

  • CAUSES

    • Triggered by infection or illness

  • Signs

    • DEHYRDRATION!!!

    • Super hyperglyemia 

    • Extreme pissing

    • Polyuria

    • Days- weeks development

    • WEAKENESS, POOR SKIN TURGOR, TACHYCARDIA, RAPID WEAK PULSE, CONFUSION

  • TREATMENT

    • FLUIDS FIRST

    • IV insulin

    • Rehydration very important

    • Electrolyte replacement



Diabeteic ketoacidosis (DKA)

  • Those with NO INSULIN

  • High levels of KETONES

  • ⅓ of children with t1dm first present with dka

  • MEDICAL EMERGENCY

  • Blood is ACID!

  • labs

    • Glucose =250mg

    • KETONES

    • Blood ph LESS than 7.3

    • Hco3 LESS than 18

    • Anion gap!!!!

    • BUN ↗

    • acidosis

Signs and symptoms of DKA

  • Polyuria, polydipsia

    • Dehydration

  • Tachycardia

  • Abdominal pain

  • FRUITY BREATH

    • acetone

  • Kussmaul breath

    • Slow weird breaths

  • Mental status changes


Treatment

  • IV insulin


Long term complications of DM

  • Cerevascular  diseases

    • Glucose in arteries = ateroscerloris

  • Retinopathy

  • Cardiovascular

    • Atherosclerosis, htn 

    • High MI risk

  • Nephropathy

  • Autonomic neuropathy

    • SNS and PSNS dysfunction

    • Bowel dysfunction

    • Always feeling bad

  • Poor WBC function

    • Immusupression

    • Poor wound healing

  • peripheral neuropathy

    • Burning sensation

    • Motor weakness

    • Distal extremities low sensation



DM and atherosclerosis

  • Acute cardiac events x2-4 times more likely in DM

  • Vascular damage from hyperglyemia leading to OXIDATIVE STRESS


Peripheral neuropathy

  • Distal, symmetric neuropathy

    • Neural arteries damage

    • Feet first

  • Sensiormotor nerves

    • Burning and tingling sensation

    • Pain sensation blunted

    • Signs of diseases are BLUNTED

      • SILENT MI

  • Motor weakness > gait admornalities


Automonic neuropathy

  • Cardiac system affected

    • Tachycardia > hypotension

    • Hypotension

  • GI system

    • Bowel dysfunction

    • anorexia

  • Bladder problems

    • UTI risk

    • incontinence

  • Erectile dysfunction

  • Hypoglycemia?

    • Signs not present

  • Decreated sweating


Suspecibility to infection

  • WBC function ↘

  • Increased colonization of S aures

  • Canada (YEAST)

    • Due to high PH of glucose

    • Yeast loves sugar

    • Especially in the vagina

    • Sugar pussy


Amputation in DM

  • Diabetes foot complication

    • Common cause of non traumatic lower extremity am

    • Poor circulation

    • Increased infection suspsective

    • Gangre!

    • Bone infection = amputation


Diabetic Foot care

  • Foot senation with light touch

  • Toe perspection

    • Up or down?

  • Achilles tendon reflection

  • Examine for injuries


Diabetic nephropathy

  • Renal failure

  • Glomerular capillary damage

    • microABLUMINuria

  • Glomercular membrane THICKENS

  • RAAS system be wilding >>> BP elevates


Retinopathy and blindness in DM

  • Leading cause of blinding

  • Microanyerusms in eye

  • COTTON WOOL SPOTS

  • blurred vision

  • Proliferative retinopathy

    • New vessel growth> fragile



Treating DM

  • Indivisual with DM more susceptible to hypogleymia and hyperglyemias

    • Insulin excess causes hypogleymia

  • STRICT GLYEMENIC CONTROL IS GOAL OF ALL TREATMENT OF DM

    • BETTER CONTROL = DECREASED RISK OF LONG-TERM COMPLICATIONS


Lifestyle changes

  • Maintain ideal body weight

  • Diabetic educator may assist with lifestyle changes

  • General recommendations

    • 40-50% are carbs

    • Fats 25-30%

    • Low fat low salt low sugar

    • Fruit increase ( low gi carbs)

    • Veggie increase

  • Daily exercise!

    • Helps with glucose uipdate in muscles

    • Increases hdl

    • Collateral blood vessel growth

    • ALERT- TOO MUCH EXERCISE CAUSES SEVERE HYPOGLYCEMIA

      • Reduce insulin before physical activity

      • Carb source available

      • Diabetic id card or braclet

Self moninoring of glucose

  • Glucometer

    • Measure bg  before meals and after meals

    • Bedtime


Antidiabetic Non Insulin Agents

  • T2dm stepwise approach

  • Lifestyle modifications to begin

  • METFORMIN

    • Inital medication choice

  • COmbinations for more effective contonl

    • Oral and injections


Types of meds for DM

  • Insulintropic

    • Stimulation of pancreas to secrete insulin

    • GLIPIZIDE/GLUCOTROL

  • Biguanides

    • Reduces bg by increasing cell sensitivity to insulin and lowering hepatic glucose prodcution

      • Ex: MEDFORMIN

        • DECREASE


METFORMIN

  • ACTIONS

    •  Decreases heptaic glucose producrtion

    • Decreases intestinal absorption of glucose

    • Improves glucose senstivity

  • Indication

    • Type 2 diabetics

  • Contraindications

    • Kidney failure

    • Acidosis

    • DKA

  • Caution

    • Hepatic disease

    • Substance abuse

    • dehydration

  • Adverse effects

    • Gi disturbance

    • Metallic taste

    • B12 definecny sometimes

  • Drug to drug interactions

    • No contrast dyes!

  • Assess

    • Monintor glucose regularly

    • Renal tests often

  • Teach

    • No contrast dyes!

    • Take with meals

    • Signs and symptoms of hypoglyemia


Dulaglutide

  • Action

    • Supress glucagon secretion

  • Indication

    • t2dm

  • Contraindication

    • cancers

  • Caution

    • Pancreas or renal impairment

  • Adverse

    • GI distrubances

  • Assess

    • Hypogylemia

    • A1c

  • Teach

    • GIVE AT SAME TIME SAME DAY OF WEEK REGULARLY


Insulin

  • Indications

    • Treatment of diabetes, hyperkelmia, hypergleymia

  • Adverse

    • Hypogylemia

    • Ketoacidis

    • Local reactoons

  • Drug to drug interactions

    • MAOI, beta blockas


Regular insulin lasts ___ and peaks ___


NPH insulin lasts ___ and peaks ___


Lispro insulin lasts ___ and peaks ___


Aspart insulin lasts ___ and peaks ___


Glargine insulin lasts ___ and peaks ___

—----------------------

Regular insulin lasts 6-12hr and peaks 2-4 hr (Clear)


NPH insulin lasts 24hr and peaks 4-12hr (LONG ACTING)


Lispro insulin lasts 2-5hr and peaks 1-2 hrs(short acting)


Aspart insulin lasts 2-5hr and peaks 1-3hr (short acting


Glargine insulin lasts ___ and peaks ___



Regular FIRST
CLEAR TO CLOUDY


Cloudy regular insulin  is BAD


  • Treatment regime is individualized

  •  Insulin therapy is the best choice for diabetics during pregnancy and lactation

  •  Always required in type 1 DM

  • Cannot mix: Insulin glargine and insulin detemir with any other drug

  •  Regular insulin can be given IV or IM in emergency situations 

  •  Food intake



USE UNIT/ INSULIN SERINGE

  • Check insulin doses x2 people


  • Added to normal