Diabetes

Metabolic syndrome

A cluster of conditions that increase the risk of heart disease, stroke, and diabetes.

Treatment of hypoglycemia

Awake and able to swallow? Use the 15-15 rule: 15g of carbs from from glucose tablets or gel. Wait 15 minutes, recheck. Still <70mg give another 15g? Unconscious, majorly altered LOC, or unable to swallow? Emergency: D50 or gel or glucagon, then recheck.

Polydypsia

Excessive thirst due to osmotic diuresis

Long acting insulin

Glargine, detemir onset 1-3 hours, G has no peak, lasts approximately 24 hours

Diabetes type 1

Insulin dependent diabetes mellitus, caused by lack of insulin secretion.

SGLT-2

Invokana Empagliflozin/Jardiance Inhibits sodium glucose lowers the renal threshold for glucose and increase urinary excretion of glucose by interfering with glucose reabsorption in proximal tubules Type 2 only S/E: osmotic diuresis, dehydration, UTI, yeast infections, maybe DKA

Somogyi phenomenon vs Dawn

S: Rebound hyperglycemia Dawn: increased BG in am d/t cortisol release

Anti-DM medications

Sulfonylurea agents Meglitinide analogues Biguanides Alpha-glucosidase inhibitors Thiazolidinediones Combination agents Empagliflozin/Jardiance: sodium glucose co-transporter-2 (SGLT-2)

Thiazolidinediones

Rosiglitazone Pioglitazone Actos improve peripheral insulin sensitivity. ThiazoliDInediones: think DI--Decreases Insulin resistance to increase sensitivity at receptors. S/E: may increase weight. May increase edema in HF.

Pre-diabetes

condition characterized by fasting blood glucose levels that are 100 to 125 mg/dl

DKA

diabetic ketoacidosis

Counter regulatory hormones

glucagon, epinephrine, cortisol, and growth hormone

Rapid Insulin

. Aspart (Novolog) Glulisine (Apidra) Lispro (Humalog) onset 5-15 minutes, peak around 1 hour, lasts until next meal typically used as correction factor (AKA sliding scale)

Latent autoimmune diabetes of adults (LADA) or DM 1.5

Form of diabetes mellitus type 1 that occurs in adulthood, with a slower onset. May be misdiagnosed as type 2 diabetes based on their age, particularly if they have risk factors for type 2 diabetes such as a strong family history or obesity.

Basal insulin

Insulin needed for 24 hour coverage. No relationship to intake of meals

Complications of diabetes

Macrovascular: vascular disease, CAD, CVAs, etc. Microvascular disease: Retinopathy (vision problems) Nephropathy (kidney dysfunction) Neuropathy (nerve dysfunction)

Complications of hyperglycemia

Micro-aneurysms, osmotic stress d/t glucose accumulation, thickened vessels, etc.

Short acting insulin

Regular insulin Regular insulin (human); onset: 30-60min; peak: 2-3 hours; duration until next meal can be given IV

Diabetes type 2

Results from insulin resistance, relative lack of insulin OR receptors no longer sensitive to it.

Treatment of diabetic neuropathy

Seizure meds like neurontin, or trycyclics like Elavil try OTC such as capsacian cream

Alpha glucosidase inhibitors

slow or inhibit absorption of CHO. Acarbose, (precose) Miglitol (glycet) Think ASE--enzyme that delays CHO digestion. So think GI S/E's: GI upset.

Correction factor insulin

taken with meals to return BG to normal level. AKA SSI. Taken regardless of food intake

Nutritional insulin

taken with meals when patient eats/plans to eat at least 50%. Almost always rapid insulin. Not "correction factor or SSI"

Insulin resistance

A decreased ability of some of the cells of the body to respond to insulin. Causes: inactivity, being overweight, steroids, high triglycerides, cortisol, perhaps inflammation

Usual dose of insulin replacement

0.5-1.0 u/kg/day basal is 50% daily dose of insulin (DDI) prandial is 50%

C peptide/Connecting Peptide

Good measure of insulin production. Cannot directly measure insulin secretion in body as it is used up by tissues, so this shows rate of insulin secretion. DM1 have lower levels of C peptide DM2 have higher levels, since they still make some Insulin.

Combination agents in diabetes

Incretin and Pramlitide: Incretin increases insulin secretion. Use with PO's. Pramlitide is an amylin mimic so mimics insulin. Can be used with insulin. Incretin and amylin are GI hormones that slow the rate of gastric absorption and emptying.

Complications of insulin therapy

Local allergic reactions Insulin lipodystrophy Lipohypertrophy Dawn Somogyi

Biguanides

Metformin (Glucophage) 2 functions: reduce glucose production by the liver and enhance insulin sensitivity (metformin - Glucophage). Not for ESRF; also check LFTs. Must NOT be given with contrast.

Diabetic Neuropathy

Most Common cause of Neuropathy; 50-60% of people with diabetes; prevalence increases with duration is primarily a symmetrical sensory polyneuropathy, initially affecting the distal lower extremities.

DKA , pH and K

Burning ketones for energy d/t lack of insulin. These are acidic and leads to acidic pH. Body tries to compensate by shifting H out of serum into cells. So K is driven from cells into serum. Pt is hyperkalemic. Give insulin? Drag K into cells. Now pt is hypokalemic.

Main concepts

glucose regulation F/E balance and regulation

HHNK

hyperglycemia hyperosmolar nonketotic coma

Polyphagia

increased hunger due to "starving cells"

Sulfonylurea

increases insulin secretion from pancreas. oral hypoglycemic agent. Stimulate Secretion of insulin. Amyryl, glucotrol, etc. S/E: weight gain, hypoglycemia

Insulin

made in the pancreas that regulates the level of glucose in the blood. hormone that lowers glucose and stores energy as fat

Insulin and K

moves K into cells via Na/K pump

Polyuria

production of abnormally large volumes of dilute urine due to osmotic diuresis

DPP4 inhibitors

sitagliptin saxagliuptin linagliptin alogliptin Increase or prolongs incretin (GI hormone) to increase insulin secretion and decrease release of glucagon

Meglitinides

Repaglinide (Prandin) Nateglinide (Starlix) Similar to Sulfas...Stimulate insulin. Short duration of action. Make Insulin.

Insulin produced by normal pancreas

Amount of insulin normally produced by the pancreas; usually 40-50 u/day as basal (long acting) and prandial (for food intake) Why we use SSI--it mimics what our bodies do

Ketone bodies

An acid by-product of fat metabolism that the body produces when it does not have enough insulin in the blood. Cannot be excreted so leads to acidosis.

Hypoglycemia

Abnormally low blood sugar level, < 70.

Ultrafast insulin

Afrezza :insulin human inhaled powder. Ultra Rapid--onset 2.5 minutes. This graphic says onset is much slower--ignore that.) FIAsp/insulin aspart with vitamin B3/Ultra rapid, SQ, onset 2.5 minutes For use as correction factor and nutritional insulin

DKA vs HHNK

DM 1: no insulin so pt becomes acidic d/t burning of ketones. DM 2: lack of insulin, so no to minimal ketones used. But DM2 are often older and sicker.

Principles of nutrition in diabetes

Healthy fats CHOs: 45-65% of calories; aim for whole grain, high fiber, fresh fruit and veggies increase protein to 20% of calories unless renal failure, then only 10% ETOH counts as fat and carb 1 CHO/carb = 15 grams of carbohydrate use carb counting method

What does insulin do in body

Transports and metabolizes GLU (glucose) for energy Stimulates storage of GLU as glycogen in liver and muscle cells Signals liver to stop release of GLU Enhances storage of fat Accelerates transport of amino acids into cells Helps move K (potassium) into cells Inhibits breakdown of store GLU, PRO/protein, fat