Diabetes Mellitus

Nursing Implementation

Health Promotion - Identify, monitor, and teach patients at risk - Obesity: primary risk factor - Routine screening for all overweight adults and those older than 45 - Diabetes risk test www.diabetes.org/risk-test.jsp Your role in health promotion relates to the identification, monitoring, and teaching of the patient at risk for the development of diabetes. Obesity is the primary risk factor for type 2 diabetes. The Diabetes Prevention Program found that a modest weight loss of 5% to 7% of body weight and regular exercise of 30 minutes five times a week lowered the risk of developing type 2 diabetes up to 58%. The ADA recommends routine screening for type 2 diabetes for all adults who are overweight or obese (BMI of 25 kg/m2 or higher) or have one or more risk factors. For people who do not have risk factors for diabetes, screening should begin at age 45. If values are normal, repeat screening at 3-year intervals. There are many factors that put an individual at an increased risk for diabetes. These include age, ethnicity (being Native American, Hispanic, African American, Asian, Pacific Islander), obesity, having a baby that weighed more than 9 pounds at birth, history of gestational diabetes, and a family history of diabetes. A diabetes risk test is available at http://www.diabetes.org/risk-test.jsp. The diabetes risk test determines if a person is at risk for prediabetes or diabetes on the basis of the number of risk factors present. Acute Care - Hypoglycemia - Diabetic ketoacidosis - Hyperosmolar hyperglycemic nonketotic syndrome Acute illness and surgery 1. ↑ Blood glucose level secondary to counterregulatory hormones 2. Frequent monitoring of blood glucose - Ketone testing if glucose level exceeds 240 mg/dL - Report glucose levels exceeding 300 mg/dL twice or moderate to high ketone levels 3. Increase insulin for type 1 diabetes 4. Type 2 diabetes may necessitate insulin therapy Both emotional and physical stress can increase the blood glucose level and result in hyperglycemia. Because stress is unavoidable, certain situations may require more intense management, such as extra insulin and more frequent blood glucose monitoring, to maintain glycemic goals and avoid hyperglycemia. Acute illness, injury, and surgery are situations that may evoke a counterregulatory hormone response, resulting in hyperglycemia. Even common illnesses such as a viral upper respiratory infection or the flu can cause this response. Encourage patients with diabetes to check blood glucose at least every 4 hours during times of illness. Acutely ill patients with type 1 diabetes whose blood glucose value is greater than 240 mg/dL (13.3 mmol/L) should also check urine for ketones every 3 to 4 hours. Teach patients to report glucose levels exceeding 300 mg/dL for twice in a row or the presence of moderate to high urine ketone levels to the HCP. A patient with type 1 diabetes may need an increase in insulin to prevent DKA. Elevated blood glucose levels can lead to poor healing and infection. Insulin therapy may be required for a patient with type 2 diabetes to prevent or treat hyperglycemia symptoms and avoid an acute hyperglycemia emergency. In critically ill patients, insulin therapy may be started if the blood glucose is persistently greater than 180 mg/dL. These patients have a higher targeted blood glucose goal, which is usually 140 to 180 mg/dL. Acute illness - Maintain normal diet if able - Increase noncaloric fluids - Continue taking antidiabetic medications - If normal diet not possible, supplement with CHO-containing fluids while continuing medications Food intake is important during times of stress and illness because the body requires extra energy to deal with the stress of the illness. If patients are able to eat normally, they can continue with their regular meal plan while increasing the intake of noncaloric fluids, such as water, sugar-free gelatin, and other decaffeinated beverages, and continue taking oral agents, nonisulin injectable agents, and insulin as prescribed. When illness causes patients to eat less than normal, they can continue to take oral hypoglycemic medications, noninsulin injectable agents, and/or insulin as prescribed while supplementing food intake with carbohydrate-containing fluids, such as low-sodium soups, juices, and regular sugar-sweetened decaffeinated soft drinks. It is important to tell the patient to contact a HCP if he or she is unable to keep down food or fluid. Intraoperative period - IV fluids and insulin - Frequent monitoring of blood glucose During the intraoperative period, adjustments in the diabetes regimen can be planned to ensure safe and healthy blood glucose levels. The patient is given IV fluids and insulin (if needed) immediately before, during, and after surgery when there is no oral intake. Explain to the patient with type 2 diabetes who has been taking oral agents that this is a temporary measure and it should not be interpreted as a worsening of diabetes. When caring for an unconscious surgical patient receiving insulin, be alert for signs of hypoglycemia such as sweating, tachycardia, and tremors. Frequent monitoring of blood glucose can prevent episodes of severe hypoglycemia. Ambulatory Care 1. Overall goal is to enable patient or caregiver to reach an optimal level of independence in self-care activities - Increased risk for other chronic conditions - Successful interaction with interprofessional team Because diabetes is a complex chronic condition, a great deal of patient contact takes place in outpatient and home settings. The major goal of patient care in these settings is to enable the patient or caregiver to reach an optimal level of independence in self-care activities. Unfortunately, many patients with diabetes face challenges in reaching these goals. Diabetes increases the risk for other chronic conditions that can affect self-care activities. These include visual impairment, lower extremity problems that affect mobility, and other functional limitations related to stroke. Successful management of diabetes requires ongoing interaction among the patient, the caregiver, and the health care team. Ambulatory Care 1. Assess patient's ability to perform SMBG and insulin injection - Use assistive devices as needed 2. Assess patient/caregiver knowledge and ability to manage diet, medication, and exercise 3. Teach manifestations and how to treat hypoglycemia and hyperglycemia Important nursing functions are to assess the ability of patients and caregivers in performing activities such as SMBG and insulin injection. Assistive devices for self-administration of insulin include syringe magnifiers, vial stabilizers, and dosing aids for the visually impaired. In some cases, referrals are made to help the patient achieve the self-care goal. These may include an occupational therapist, a social worker, a home health aide, or a dietitian. Assessment of the patient must include an evaluation of his or her ability to safely manage this therapy. This includes the ability to understand the interaction of medication, diet, and activity and to be able to recognize and treat the symptoms of hypoglycemia appropriately. If the patient does not have the cognitive skills to do these things, identify and teach another responsible person. Emotional support and encouragement to deal with this chronic disease is important. Ambulatory Care 1. Frequent oral care 2. Foot care - Inspect daily - Avoid going barefoot - Proper footwear - How to treat cuts 3. Travel needs - Medication, supplies, food, activity The potential for infection necessitates diligent skin and dental hygiene practices. Because of the susceptibility to periodontal disease, encourage daily brushing and flossing in addition to regular visits to the dentist. When dental work is done, have the patient inform the dentist that he or she has diabetes. Teach patients regarding the importance of informing dentists and other health care professionals of their diagnosis. Routine care should include regular bathing, with particular emphasis given to foot care. Advise patients to inspect their feet daily, avoid going barefoot, and wear shoes that are supportive and comfortable. If cuts, scrapes, or burns occur, treat them promptly and monitor them carefully. Patients should wash the area, apply a nonabrasive or nonirritating antiseptic ointment, and cover the area with a dry, sterile pad. Teach patients to notify the HCP immediately if the injury does not begin to heal within 24 hours or if signs of infection develop. Travel for a patient with diabetes requires advance planning. Being sedentary for long periods of time may raise the person's glucose level. Encourage the patient to get up and walk at least every 2 hours to prevent the risk for deep vein thrombosis and to prevent elevation of glucose levels. Teach the patient to have a full set of diabetes care supplies in the carry-on luggage when traveling by plane, train, or bus. This includes blood glucose monitoring equipment, insulin and/or oral medications, and syringes or insulin pens. When equipment such as syringes, lancing devices, insulin vials or pens, and insulin pumps are taken onto a commercial airliner, it is a good idea to have the professional printed pharmaceutical labels that accompany them. A letter from the prescribing HCP indicating medical necessity may prevent delays at security checkpoints. Notify screeners if an insulin pump is used so they can inspect it while it is on the patient's body, rather than removing it. For patients who use insulin, OAs, or noninsulin injectable agents that can cause hypoglycemia, keep snack items and a quick-acting carbohydrate source for treating hypoglycemia in the carry-on luggage. Keep extra insulin available in case a bottle breaks or is lost. For longer trips, carry a full day's supply of food in the event of canceled flights, delayed meals, or closed restaurants. If the patient is planning a trip out of the country, it is wise to have a letter from the HCP explaining that the patient has diabetes and requires all the materials, particularly syringes, for ongoing health care. When travel involves time changes such as traveling coast to coast or across the International Date Line, the patient can contact the HCP to plan an appropriate insulin schedule. During travel, most patients find it helpful to keep watches set to the time of the city of origin until they reach their destination. The key to travel when taking insulin is to know the type of insulin being taken, its onset of action, the anticipated peak time, and mealtimes. Medical Alert - Instruct the patient to carry medical identification at all times that indicates that he or she has diabetes. Police, paramedics, and many private citizens are aware of the need to look for this identification when working with sick or unconscious persons. Every person with diabetes is encouraged to wear a MedicAlert bracelet or necklace. An identification card can supply valuable information, such as the name of the HCP, the type of diabetes, and the type and dose of insulin or OA.

Diabetes Mellitus

- A chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both - Affects 29.1 million people - Seventh leading cause of death Diabetes mellitus (DM) is a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both. Diabetes mellitus is a serious health problem throughout the world, and its prevalence is rapidly increasing. Currently in the United States, an estimated 29.1 million people, or 9.3% of the population, have diabetes mellitus, and 86 million more people have prediabetes. In approximately 8.1 million people with diabetes mellitus, the disease has not been diagnosed, and they are unaware that they have the disease. Diabetes mellitus is the seventh leading cause of death in the United States, but it is likely to be underreported. Leading cause of - Adult blindness - End-stage renal disease - Nontraumatic lower limb amputations Major contributing factor - Heart disease - Stroke The long-term complications associated with diabetes can make it a devastating disease. Diabetes is the leading cause of adult blindness, end-stage kidney disease, and nontraumatic lower limb amputations. It is also a major factor contributing to heart disease and stroke. Adults with diabetes have heart disease death rates two to four times higher than adults without diabetes. The risk for stroke is also two to four times higher among people with diabetes. In addition, more than half of adults with diabetes have hypertension and high cholesterol levels.

Nursing Diagnoses

- Ineffective health management - Risk for unstable blood glucose levels - Risk for injury - Risk for peripheral neurovascular dysfunction Nursing diagnoses related to diabetes mellitus may include, but are not limited to Ineffective health management related to deficient knowledge of diabetes management and lack of understanding of diabetes management plan Risk for unstable blood glucose levels related to infrequent blood glucose monitoring and lack of following diabetes management plan Risk for injury related to decreased tactile sensation, episodes of hypoglycemia Risk for peripheral neurovascular dysfunction related to vascular effects of diabetes Additional information on nursing diagnoses for the patient with diabetes is presented in eNCP 48-1 available on the website.

Diabetes Nutritional Therapy

1. Counseling 2. Education 3. Ongoing monitoring 4. Interprofessional team - Registered dietitian with expertise in diabetes management Individualized nutritional therapy, consisting of counseling, education, and ongoing monitoring, is a cornerstone of care for person with diabetes and prediabetes. Changing eating habits can be challenging for many people. Achieving nutrition goals requires a coordinated team effort that takes into account the behavioral, cognitive, socioeconomic, cultural, and religious aspects of the patient. Because of these complexities, it is recommended that a registered dietitian with expertise in diabetes management work with the person who has diabetes. The dietitian starts with a nutrition assessment and develops an individualized food plan. Additional team members may include nurses, certified diabetes educators, clinical nurse specialists, HCPs, and social workers. ADA healthy food choices - Maintain blood glucose levels to as close to normal as safely possible - Normal lipid profiles and blood pressure - Prevent or slow complications - Individual needs; personal, cultural preferences - Maintain pleasure of eating Guidelines from the ADA indicate that within the context of an overall healthy eating plan, a person with diabetes can eat the same foods as a person who does not have diabetes. This means that the same principles of health nutrition that apply to the general population also apply to the person with diabetes. According to the ADA, the overall goal is to assist people with diabetes in making healthy nutritional choices that will lead to achieving and/or maintaining safe and healthy blood glucose levels. Additional specific goals include the following: 1. Maintain blood glucose levels to as close to normal as safely possible to prevent or reduce the risk for complications of diabetes. 2. Achieve lipid profiles and blood pressure levels that reduce the risk for cardiovascular disease. 3. Prevent or slow the rate of development of chronic complications of diabetes by modifying nutrient intake and lifestyle. 4. Address individual nutrition needs while taking into account personal and cultural preferences and respecting the individual's willingness or ability to change eating and dietary habits. 5. Maintain the pleasure of eating by encouraging a variety of health food choices. Diabetes Nutritional Therapy: Type 1 DM 1. Meal planning - Based on usual food intake and preferences - Balanced with insulin and exercise patterns 2. Day-to-day consistency makes it easier to manage blood glucose levels 3. More flexibility with rapid-acting insulin, multiple daily injections, and insulin pump People with type 1 diabetes base their meal planning on usual food intake and preferences balanced with insulin and exercise patterns. The patient coordinates insulin dosing with eating habits and activity pattern in mind. Day-to-day consistency in timing and amount of food eaten makes it much easier to manage blood glucose levels, especially for those individuals using conventional, fixed insulin regimens. Patients using rapid-acting insulin can adjust the dose before each meal based on the current blood glucose level and the carbohydrate content of the meal. Intensified insulin therapy, such as multiple daily injections or the use of an insulin pump, allows considerable flexibility in food selection, and can be adjusted for alterations from usual eating and exercise habits. Diabetes Nutritional Therapy: Type 2 DM 1. Emphasis on achieving glucose, lipid, and BP goals 2. Weight loss - Nutritionally adequate meal plan with ↓ fat and CHO - Spacing meals - Regular exercise Nutrition therapy in type 2 diabetes emphasizes achieving glucose, lipid, and BP goals. Modest weight loss has been associated with improved insulin resistance. Therefore, weight loss is recommended for all individuals with diabetes who are overweight or obese. There is no one proven strategy or method that can be uniformly recommended. A nutritionally adequate meal plan with appropriate serving sizes, a reduction of saturated and trans fats, and low carbohydrates can decrease calorie consumption. Spacing meals is another strategy that spreads nutrient intake throughout the day. A weight loss of 5% to 7% of body weight often improves blood glucose levels, even if desirable body weight is not achieved. Weight loss is best attempted by a moderate decrease in calories and an increase in caloric expenditure. Regular exercise and adopting new behaviors and attitudes can help facilitate long-term lifestyle changes. Monitoring of blood glucose levels, hemoglobin A1C, lipids, and blood pressure provide feedback on how well the goals of nutritional therapy are being met. Diabetes Nutritional Therapy 1. Food composition - Healthy balance of nutrients is essential to maintain blood glucose levels and overall health - Energy from food intake can be balanced with energy output - Individualized to lifestyle and health goals 2. Carbohydrates - Minimum of 130 g/day - Fruits, vegetables, whole grains, legumes, low-fat dairy - All benefit from including dietary fiber - Nutritive and nonnutritive sweeteners may be used in moderation 3. Fats - Limit saturated fats to < 7% of total calories - Limit cholesterol to < 200 mg/day - Minimize trans fat - Healthy fats come from plants - Olives, nuts, avocados 4. Protein - Should make up 15% to 20% of total calories - High-protein diets not recommended 5. Alcohol - Limit to moderate amount 1 drink/day for women; 2 drinks/day for men - Inhibits gluconeogenesis by liver Can cause severe hypoglycemia - Blood glucose levels must be monitored 6. Diet teaching - Dietitian initially provides instruction 7. Carbohydrate counting - Serving size is 15 g of CHO - Typically 45 to 60 g per meal - Insulin dose based on number of CHOs consumed - Patient teaching essential 8. Exchange lists - Starches, fruits, milk, meat, vegetables, fats, free foods 9. Consistent CHO diet 10. USDA MyPlate method A healthy balance of nutrients is essential to maintain blood glucose levels and overall health. Energy from food intake can be balanced with the patient's energy output. Patients plan their individual meal plan with their lifestyle and health goals in mind. Carbohydrates include sugars, starches, and fiber. Carbohydrates provide important sources of energy, fiber, vitamins, and minerals and are therefore important to all people, including those with diabetes. Foods containing carbohydrates from whole grains, fruits, vegetables, and low-fat dairy are part of a healthy meal plan. The recommended dietary allowance for carbohydrates is a minimum of 130 g/day. All individuals benefit from including dietary fiber as part of a healthy meal plan. The current recommendation for the general population is 25 to 30 g/day. Nutritive and nonnutritive sweeteners may be included in a healthy meal plan in moderation. Nonnutritive sweeteners include the sugar substitutes saccharine, aspartame, sucralose, neotame, and acesulfame-K. Dietary fat provides energy, carries fat-soluble vitamins, and provides essential fatty acids. The ADA recommends limiting saturated fat to less than 7% of total calories. Less than 200 mg/day of cholesterol and limited trans fats are also recommended as part of a healthy meal plan. Decreasing fat and cholesterol intake assists in reducing the risk for cardiovascular disease. The amount of daily protein in the diet for people with diabetes and normal renal function is the same as for the general population. • 15% to 20% of total calories. • High-protein diets are not recommended for weight loss for people with diabetes. Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver. This can cause severe hypoglycemia in patients on insulin or oral hypoglycemic medications that increase insulin secretion. Create a trusting environment where patients feel comfortable being honest about their use of alcohol because its use can make blood glucose more difficult to manage. Moderate alcohol consumption can be safely incorporated into the meal plan if the person is monitoring blood glucose levels and if the patient is not at risk for other alcohol-related problems. Moderate consumption is defined as one drink per day for women and two drinks per day for men. A patient can reduce the risk for alcohol-induced hypoglycemia by eating carbohydrates when drinking alcohol. On the other hand, mixed drinks often contain sweetened mixers and can lead to elevated blood glucose levels. To decrease the carbohydrate content, recommend using sugar-free mixes and drinking dry, light wines. Most often the dietitian initially teaches the principles of nutrition management. Whenever possible, be prepared to work with dietitians as part of an interprofessional diabetes care team. In some instances, access to a dietitian is not possible for patients with limited insurance coverage or who live in remote areas. In these cases, you may need to assume responsibility for teaching basic nutrition principles to patients with diabetes. Carbohydrate counting is a meal planning technique that people with diabetes use to keep track of the amount of carbohydrates they eat with each meal and per day. Advise patients to keep carbohydrates within a healthy range. The amount of total carbohydrates per day depends on blood glucose levels, age, weight, activity level, patient preference, and prescribed medications. A serving size of carbohydrates is 15 g. A typical adult usually starts with 45 to 60 g of carbohydrate per meal. For some patients, insulin doses are tailored to the number of carbohydrates a patient will consume at the meal, with a set number of units insulin given per every 15 g of carbohydrate (or sometimes another number). Teach the patient about the foods that contain carbohydrates, how to read food labels, and appropriate serving sizes. Diabetes exchange lists are another method for meal planning. Instead of counting carbohydrates, the individual is given a meal plan with specific numbers of helpings from a list of exchanges for each meal and snack. The exchanges are starches, fruits, milk, meat, vegetables, fats, and free foods. The patient chooses foods from the various exchanges based on the prescribed meal plan. This method may be easier for some patients than carbohydrate counting. It also encourages a well-balanced meal plan. Another advantage is that this approach helps the patient limit portion sizes and overall food intake, an important component of weight management. Whenever possible, include family members and caregivers in nutrition education and counseling, particularly the person who cooks for the household. However, the responsibility for maintaining a healthy eating plan still belongs to the person with diabetes. Reliance on another person to make health decisions interferes with the patient's ability to develop self-care skills, which is essential in the management of diabetes. Foster independence, even in patients with visual or cognitive impairment. It is also important to discuss traditional foods with the patient. Individualize food choices to take into account the patient's preferences and foods that are culturally appropriate. In an acute health care facility, the nutritional needs of the diabetic patient vary slightly from the normal meal plans. Previously, standardized calorie-level meal patterns were used, but new systems are now being used, such as the consistent carbohydrate diabetes meal plan. Under this system, meal plans are created with consistent carbohydrate content. For example, breakfast contains the same amount of carbohydrates every day. MyPlate for People With Diabetes - MyPlate was developed by the U.S. Department of Agriculture (USDA) to represent national nutrition guidelines for people with or without diabetes. This simple method helps the patient visualize the amount of vegetables, starch, and meat that fills a 9-in plate. The recommendation is that each meal has one half of the plate filled with nonstarchy vegetables, one fourth filled with a starch, and one fourth filled with a protein (www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate). An 8-ounce glass of nonfat milk and a small piece of fresh fruit complete the meal.

Type 1 Diabetes Mellitus

1. Formerly known as juvenile-onset or insulin-dependent diabetes 2. Accounts for about 5% to 10% of all people with diabetes 3. Generally affects people under age 40 - Can occur at any age Type 1 diabetes mellitus, formerly known as juvenile-onset diabetes or insulin-dependent diabetes, accounts for about 5% to 10% of all people with diabetes. Type 1 diabetes generally affects people under 40 years of age, although it can occur at any age. Type 1 Diabetes Mellitus Etiology and Pathophysiology 1. Autoimmune disorder - Body develops antibodies against insulin and/or pancreatic β cells that produce insulin - Results in not enough insulin to survive 2. Genetic link 3. Idiopathic diabetes 4. Latent autoimmune diabetes in adults (LADA) Type 1 diabetes is an autoimmune disorder in which the body develops antibodies against insulin and/or the pancreatic β cells that produce insulin. This eventually results in not enough insulin for a person to survive. Autoantibodies to the islet cells cause a reduction of 80% to 90% of normal function before hyperglycemia and other manifestations occur. A genetic predisposition and exposure to a virus are factors that may contribute to the pathogenesis of immune-related type 1 diabetes. Genetic Link Predisposition to type 1 diabetes is related to human leukocyte antigens (HLAs). Theoretically, when an individual with certain HLA types is exposed to a viral infection, the β cells of the pancreas are destroyed, either directly or through an autoimmune process. The HLA types associated with an increased risk for type 1 diabetes include HLA-DR3 and HLA-DR4. Idiopathic diabetes is a form of type 1 diabetes that is strongly inherited and not related to autoimmunity. It only occurs in a small number of people with type 1 diabetes, most often of Hispanic, African, or Asian ancestry. Latent autoimmune diabetes in adults (LADA), a slowly progressing autoimmune form of type 1 diabetes, occurs in adults and is often mistaken for type 2 diabetes. Type 1 Diabetes Mellitus Onset of Disease - Autoantibodies are present for months to years before symptoms occur - Manifestations develop when pancreas can no longer produce insulin—then rapid onset with ketoacidosis - Necessitates insulin - Patient may have temporary remission after initial treatment In type 1 diabetes, the islet cell autoantibodies responsible for β-cell destruction are present for months to years before the onset of symptoms. Manifestations of type 1 diabetes develop when the person's pancreas can no longer produce sufficient amounts of insulin to maintain normal glucose levels. Once this occurs, the onset of symptoms is usually rapid, and patients often present with impending or actual ketoacidosis. The patient usually has a history of recent and sudden weight loss, as well as the classic symptoms of polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (excessive hunger). The individual with type 1 diabetes requires insulin from an outside source (exogenous insulin) to sustain life. Without insulin, the patient will develop diabetic ketoacidosis (DKA), a life-threatening condition resulting in metabolic acidosis. Patients with newly diagnosed type 1 diabetes may experience a remission, or "honeymoon period," for 3 to 12 months after treatment is initiated. During this time, the patient requires very little injected insulin because β-cell insulin production remains sufficient for healthy blood glucose levels. Eventually, as more β-cells are destroyed and blood glucose levels increase, the honeymoon period ends, and the patient will require insulin on a permanent basis. Clinical Manifestations Type 1 Diabetes Mellitus 1. Classic symptoms - Polyuria (frequent urination) - Polydipsia (excessive thirst) - Polyphagia (excessive hunger) 2. Weight loss 3. Weakness 4. Fatigue Because the onset of type 1 diabetes is rapid, the initial manifestations are usually acute. The classic symptoms are polyuria, polydipsia, and polyphagia. The osmotic effect of glucose produces the manifestations of polydipsia and polyuria. Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose for energy. Weight loss may occur because the body cannot get glucose and turns to other energy sources, such as fat and protein. Weakness and fatigue may result because body cells lack needed energy from glucose.

Diagnostic Studies

1. Hemoglobin A1C level: 6.5% or higher 2. Fasting plasma glucose level: higher than 126 mg/dL 3. Two-hour plasma glucose level during OGTT: 200 mg/dL (with glucose load of 75 g) 4. Classic symptoms of hyperglycemia with random plasma glucose level of 200 mg/dL or higher The diagnosis of diabetes mellitus is made using one of four methods. These methods and their criteria for diagnosis are as follows: 1. Hemoglobin A1C level of 6.5% or higher. 2. Fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher. Fasting is defined as no caloric intake for at least 8 hours. 3. Two-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during an OGTT, with a glucose load of 75 g. 4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher. If a patient presents with a hyperglycemic crisis or clear symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) with a random plasma glucose level of 200 or higher, repeat testing is not warranted. Otherwise, criteria 1 through 3 should be confirmed by repeat testing to rule out laboratory error. It is preferable for the repeat test to be the same test used initially. For example, if a random blood glucose test showed elevated blood glucose levels, the same test should be used again when the person is retested. 1. A1C - Glycosylated hemoglobin: reflects glucose levels over past 2 to 3 months - Used to diagnose, monitor response to therapy, and screen patients with pre diabetes - Goal: < 6.5% to 7% A1C measures the amount of glycosylated hemoglobin as a percentage of total hemoglobin (e.g., hemoglobin A1C of 6.5% means that 6.5% of the total hemoglobin has glucose attached to it). The amount of hemoglobin that is glycosated depends on the blood glucose level. When blood glucose levels are elevated over time, the amount of glucose attached to hemoglobin molecules increases. This glucose remains attached to the red blood cell (RBC) for the life of the cell (approximately 120 days). Therefore, A1C provides a measurement of blood glucose levels over the previous 2 to 3 months, with increases in the A1C reflecting elevated blood glucose levels. The A1C has several advantages over the FPG test, including greater convenience because fasting is not required. Diseases affecting RBCs (e.g., iron deficiency anemia or sickle cell anemia) can influence the A1C level and should be considered in interpreting results. Teach patients with diabetes and prediabetes to have their A1C monitored regularly to determine the success of the current treatment plan and make changes in the plan if glycemic goals are not achieved. The ADA identifies a A1C goal for patients with diabetes of less than 7.0%. The American College of Endocrinology recommends a A1C of less than 6.5%. When the A1C level is maintained at near-normal levels, there is a greatly reduced risk for the development of microvascular and macrovascular complications. For individuals with prediabetes, monitoring the A1C can help detect overt diabetes and provide patients with feedback regarding efforts to prevent diabetes. 2. Fructosamine - Reflects glycemia in previous 1-3 weeks 3. Autoantibodies Fructosamine is another way to assess glucose levels. Fructosamine is formed by a chemical reaction of glucose with plasma protein. It reflects glycemia in the previous 1 to 3 weeks. Fructosamine levels may show a change in blood glucose levels before A1C does. Islet cell autoantibody testing is ordered primarily to help distinguish between autoimmune type 1 diabetes and diabetes due to other causes.

Diabetes Exercise

1. Type/amount - Minimum 150 minutes/week aerobic - Resistance training three times/week 2. Benefits - ↓ Insulin resistance and blood glucose - Weight loss - ↓ Triglycerides and LDL , ↑ HDL - Improve BP and circulation Regular, consistent exercise is an essential part of diabetes and prediabetes management. The ADA recommends that people with diabetes engage in at least 150 minutes per week (30 minutes, 5 days per week) of a moderate-intensity aerobic physical activity. The ADA also encourages people with type 2 diabetes to perform resistance training three times a week, in the absence of contraindications. Exercise decreases insulin resistance and can have a direct effect on lowering blood glucose levels. It also contributes to weight loss, which decreases insulin resistance. The therapeutic benefits of regular physical activity may result in a decreased need for diabetes medications in order to reach target blood glucose goals in people with type 2 diabetes. Regular exercise may also help reduce triglyceride and LDL cholesterol levels, increase HDL levels, reduce blood pressure, and improve circulation. - Start slowly after medical clearance - Monitor blood glucose - Glucose-lowering effect up to 48 hours after exercise - Exercise 1 hour after a meal - Snack to prevent hypoglycemia - Do not exercise if blood glucose level > 300 mg/dL and if ketones are present in urine Any new exercise program for patients with diabetes can be started after medical clearance. Patients start slowly with gradual progression toward the desired goal. Patients who use insulin, sulfonylureas, or meglitinides are at increased risk for hypoglycemia when physical activity is increased, especially if the patient exercises at the time of peak drug action or if food intake has not been sufficient to maintain adequate blood glucose levels. This can also occur if a normally sedentary patient with diabetes has an unusually active day. The glucose-lowering effects of exercise can last up to 48 hours after the activity, so it is possible for hypoglycemia to occur for that long after the activity. It is recommended that patients who use medications that can cause hypoglycemia schedule exercise about 1 hour after a meal or that they have a 10- to 15-g carbohydrate snack and check their blood glucose level before exercising. Small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia. Patients using medications that place them at risk for hypoglycemia should always carry a fast-acting source of carbohydrate, such as glucose tablets or hard candies, when exercising. Although exercise is generally beneficial to blood glucose levels, strenuous activity can be perceived by the body as a stress, causing a release of counterregulatory hormones that result in a temporary elevation of blood glucose. In a person with type 1 diabetes who has hyperglycemia and ketones, exercise can worsen these conditions. Teach these patients to delay activity if the blood glucose level is over 250 mg/dL and ketones are present in the urine. If hyperglycemia is present without ketosis, it is not necessary to postpone exercise. Self-Monitoring of Blood Glucose (SMBG) - Enables decisions regarding diet, exercise, and medication - Accurate record of glucose fluctuations - Helps identify hyperglycemia and hypoglycemia - Helps maintain glycemic goals - A must for insulin users - Frequency of testing varies 1. Alternative blood sampling sites 2. Data uploaded to computer 3. Continuous glucose monitoring - Displays glucose values with updating every 1 to 5 minutes - Helps identify trends and track patterns - Alerts to hypoglycemia or hyperglycemia 4. Patient teaching - How to use, calibrate 5. When to test - Before meals - Two hours after meals - When hypoglycemia is suspected - During illness - Before, during, and after exercise Self-monitoring of blood glucose (SMBG) is a critical part of diabetes management. By providing a current blood glucose reading, the primary advantage of SMBG is that it enables the patient to make decisions regarding food intake, activity patterns, and medication dosages. It also produces accurate records of daily glucose fluctuations and trends and alerts the patient to acute episodes of hyperglycemia and hypoglycemia. Furthermore, it provides patients with a tool for achieving and maintaining specific glycemic goals. SMBG is recommended for all patients who use insulin to manage their diabetes. Other patients with diabetes use SMBG to help achieve and maintain glycemic goals, and monitor for acute fluctuations in blood glucose related to medications, food, and exercise. The frequency of monitoring depends on several factors, including the patient's glycemic goals, the type of diabetes that the patient has, the medication regimen, the patient's ability to check blood glucose independently, and the patient's willingness and ability to do so. The recommendation for patients who use multiple insulin injections or insulin pumps is to monitor their blood glucose four or more times each day. Patients using less frequent insulin injections, noninsulin therapy, or medical nutrition management will monitor as often as needed to achieve their glycemic goals. Some systems allow the user to collect blood from alternative sites such as the forearm or palm. Alternate site use is not recommended when blood glucose readings change rapidly, during pregnancy, or when symptoms of low blood glucose levels are present. The data from some glucose monitors can be uploaded to a computer and reviewed by HCPs, allowing for more frequent and efficient adjustment of the plan of care if needed. Continuous glucose monitoring (CGM) systems provide another route for monitoring glucose. Using a sensor inserted subcutaneously under the skin, the systems display glucose values continuously, updating values every 1 to 5 minutes. CGM assesses interstitial glucose, which lags behind blood glucose by up to 20 minutes. The patient inserts the sensor by using an automatic insertion device. Data are sent from the sensor to a transmitter, which displays the glucose value on either an insulin pump or a pagerlike receiver. The continuous glucose monitor can be used with or without an insulin pump. CGMs assist the patient and HCP to identify trends and patterns in glucose levels and are useful for the management of insulin therapy or when continuous blood glucose readings are clinically important. The patient is alerted to episodes of hypoglycemia and hyperglycemia, thus allowing corrective action to be quickly taken. Both systems still require finger-stick measurements and the use of a blood glucose monitor to calibrate the sensor and to make treatment decisions. Because errors in monitoring technique can cause errors in management strategies, comprehensive patient teaching is essential. Initial instruction should be followed up with regular reassessment. Review the instructions that accompany each product for how to use that particular glucose monitor. Teach patients to use and interpret calibration and control solutions. Control solution should be used when a blood glucose meter is first used, when a new bottle of strips are used, or if there is a reason to believe that the readings are not correct. People with type 1 diabetes often test their blood glucose before meals. This is because many patients use insulin pumps or multiple daily injections and base the insulin dose on the carbohydrates in a meal or make adjustments if the premeal value is above or below target. Checking blood glucose 2 hours after the first bite of food helps a person determine if the bolus insulin dose was adequate for that meal. Teach patients to monitor blood glucose whenever hypoglycemia is suspected so that immediate action can be taken. During times of illness, check blood glucose levels at 4-hour intervals to determine the effects of the illness on glucose levels. Teach the patient to monitor blood glucose before and after exercise to determine the effects of exercise on blood glucose levels. This is especially important in a patient with type 1 diabetes. A patient who is visually impaired, cognitively impaired, or limited in manual dexterity needs careful evaluation of the degree to which SMBG can be performed independently. Nurses preparing patients for discharge from the hospital, and those working in home health and outpatient settings may need to identify caregivers who can assume this responsibility. Adaptive devices are available to help patients with certain limitations. These include talking meters and other equipment for the visually impaired. The MiniMed® 530730G with Enlite® (A) delivers insulin through a thin plastic tubing to an infusion set, which has a cannula (B) that sits under the skin. Continuous glucose monitoring occurs through a tiny sensor (C) inserted under the skin. Sensor data are sent continuously to the insulin pump through wireless technology giving a more complete picture of glucose levels, which can lead to better treatment decisions and improved health. Blood Glucose Monitors - Patients who perform SMBG use portable blood glucose monitors. A wide variety of blood glucose monitors are available Disposable lancets are used to obtain a small drop of capillary blood (usually from a finger stick) that is placed in a reagent strip. After a specified time, the monitor displays a digital reading of the blood glucose value. The technology of SMBG is a rapidly changing field; newer and more convenient systems are introduced on an ongoing basis.

Chronic Complications of Diabetes Mellitus

Chronic complications associated with diabetes are primarily those of end-organ disease from damage to blood vessels (angiopathy) secondary to chronic hyperglycemia. Identify chronic complications to be discussed. Chronic Complications Angiopathy - Damage to blood vessels secondary to chronic hyperglycemia - Leading cause of diabetes-related death - Macrovascular and microvascular - Tight glucose levels can prevent or minimize complications Angiopathy is one of the leading causes of diabetes-related deaths; approximately 68% of deaths are due to cardiovascular disease and 16% to strokes in patients aged 65 and older. These chronic blood vessel dysfunctions are divided into two categories: macrovascular complications and microvascular complications. The Diabetes Control and Complications Trial (DCCT), a landmark study in diabetes management, demonstrated that in patients with type 1 diabetes, the risk for microvascular complications could be significantly reduced by keeping blood glucose levels as near to normal as possible for as much of the time as possible (tight glucose control). Subjects who maintained tight glucose levels reduced their risk for the development of retinopathy and nephropathy, some of the most common microvascular complications. On the basis of these findings, the ADA issued recommendations for the management of diabetes that included treatment goals to maintain blood glucose levels as near to normal as possible. Specific targets for individual patients must take into account the risk for severe or undetected hypoglycemia as a side effect of intensive management. The United Kingdom Prospective Diabetes Study (UKPDS) demonstrated that intensive treatment of type 2 diabetes significantly lowered the risk for developing diabetes-related eye, kidney, and neurologic problems. The findings from this study included a 25% reduction of microvascular disease and a 16% reduction in the risk for myocardial infarction in subjects who maintained long-term blood glucose levels. Chronic Complications Macrovascular Angiopathy - Diseases of large and medium-sized blood vessels - Greater frequency and earlier onset in patients with diabetes - Cerebrovascular disease - Cardiovascular disease - Peripheral vascular disease 1. Decrease risk factors (yearly screening) - Obesity - Smoking - Hypertension - High fat intake - Sedentary lifestyle 2. Screen for and treat hyperlipidemia 3. Thickening of vessel membranes in capillaries and arterioles 3. Specific to diabetes and includes - Retinopathy - Nephropathy - Dermopathy 5. Usually appear 10 to 20 years after diagnosis Macrovascular complications are diseases of the large and medium-size blood vessels that occur with greater frequency and with an earlier onset in people with diabetes. Macrovascular diseases include cerebrovascular, cardiovascular, and peripheral vascular disease. Patients with diabetes can decrease several risk factors associated with macrovascular complications, such as obesity, smoking, hypertension, high fat intake, and sedentary lifestyle. Smoking, which is detrimental to health in general, is especially injurious to people with diabetes and significantly increases their risk for blood vessel and cardiovascular disease (CVD), stroke, and lower extremity amputation. The ADA recommends yearly screening for CVD risk factors in people with diabetes. Optimizing BP control in patients with diabetes is significant for the prevention of cardiovascular and renal disease. Treating hypertension in those with diabetes results in a decrease in macrovascular and microvascular complications. Hypertension causes an increase in mortality rate among people with diabetes in comparison with those with hypertension without diabetes. A target BP of less than 140/90 mm Hg is recommended for all patients with diabetes. Patients with diabetes have an increase in lipid abnormalities. This contributes to the increase in cardiovascular disease seen in this population. The American Diabetes Association recommends the LDL cholesterol goal of less than 100 mg/dL (2.6 mmol/L), triglyceride levels of less than 150 mg/dL (1.7 mmol/L), and HDL cholesterol levels greater than 40 mg/dL (1.0 mmol/L) in men and greater than 50 mg/dL (1.3 mmol/L) in women as target values. The ADA advocates lifestyle interventions including nutritional therapy, exercise, and weight loss and smoking cessation to treat hyperlipidemia. In patients over age 40 years, and if clinically indicated, statin treatment is used in addition to lifestyle therapy. In patients under 40 years of age and in those with type 1 diabetes, treatment with a statin is used if the patient has increased CVD risk factors. Microvascular complications result from thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia. They differ from the macrovascular complications in that they are specific to diabetes. Although microangiopathy can be found throughout the body, the areas most noticeably affected are the eyes (retinopathy), the kidneys (nephropathy), and the skin (dermopathy). Microvascular changes are present in some patients with type 2 diabetes at the time of diagnosis. However, clinical manifestations usually do not appear until 10 to 20 years later. Chronic Complications Diabetic Retinopathy - Microvascular damage to retina - Most common cause of new cases of adult blindness - Nonproliferative: more common - Proliferative: more severe 1. Nonproliferative - Partial occlusion of small blood vessels in retina causes micro aneurysms 2. Proliferative - Involves retina and vitreous humor - New blood vessels formed (neovascularization): very fragile and bleed easily - Can cause retinal detachment - Initially no changes in vision - Annual eye examinations with dilation to monitor - Maintain healthy blood glucose levels and manage hypertension Treatment 1. Laser photocoagulation - Most common - Laser destroys ischemic areas of retina 2. Vitrectomy - Aspiration of blood, membrane, and fibers inside the eye 3. Drugs to block action of vascular endothelial growth factor (VEGF) Diabetic retinopathy refers to the process of microvascular damage to the retina as a result of chronic hyperglycemia, presence of nephropathy, and hypertension in patients with diabetes. Diabetic retinopathy is estimated to be the most common cause of new cases of adult blindness. Retinopathy can be classified as nonproliferative or proliferative. In nonproliferative retinopathy, the most common form, partial occlusion of the small blood vessels in the retina causes microaneurysms to develop in the capillary walls. The walls of these microaneurysms are so weak that capillary fluid leaks out, causing retinal edema and eventually hard exudates or intraretinal hemorrhages. This may cause mild to severe vision loss, depending on which parts of the retina are affected. If the center of the retina (macula) is affected, vision loss can be severe. Proliferative retinopathy, the most severe form, involves the retina and the vitreous humor. When retinal capillaries become occluded, the body compensates by forming new blood vessels to supply the retina with blood, a pathologic process known as neovascularization. These new vessels are extremely fragile and hemorrhage easily, producing vitreous contraction. Eventually light is prevented from reaching the retina as the vessels become torn and bleed into the vitreous cavity. The patient sees black or red spots or lines. If these new blood vessels pull the retina while the vitreous contracts, causing a tear, partial or complete, retinal detachment will occur. If the macula is involved, vision is lost. Without treatment, more than half of patients with proliferative diabetic retinopathy will be blind. Persons with diabetes are also prone to other visual problems. Glaucoma occurs as a result of the occlusion of the outflow channels secondary to neovascularization. This type of glaucoma is difficult to treat and often results in blindness. Cataracts develop at an earlier age and progress more rapidly in people with diabetes. The earliest and most treatable stages of diabetic retinopathy often produce no changes in the vision. Therefore, patients with type 2 diabetes should have an eye examination with pupil dilation by an ophthalmologist or a specially trained optometrist at the time of diagnosis and annually thereafter for early detection and treatment. A person with type 1 diabetes should have the eye examined with dilation within 5 years after the onset of diabetes and then repeat this examination annually. The best approach to the management of diabetes-related eye disease is to prevent it by maintaining healthy blood glucose levels and managing hypertension. Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with proliferative retinopathy or macular edema and in some cases of nonproliferative retinopathy. Laser photocoagulation destroys the ischemic areas of the retina that produce growth factors that encourage neovascularization. A patient who develops vitreous hemorrhage and retinal detachment of the macula may need to undergo vitrectomy. Vitrectomy is the aspiration of blood, membrane, and fibers from the inside of the eye through a small incision just behind the cornea. Iluvien (fluocinolone acetonide intravitreal implant) is used to treat retinopathy. It is an injectable micro-insert that provides sustained treatment through continuous delivery of corticosteroid fluocinolone acetonide for 36 months. Iluvien is injected in the back of the patient's eye with an applicator that uses a 25-gauge needle, which allows for a self-sealing wound. Research has identified the importance of vascular endothelial growth factor (VEGF) in the development of diabetic retinopathy. Drugs injected into the eye that block the action of VEGF and reduce inflammation are currently being studied for their effectiveness in treating retinopathy. Chronic Complications Diabetic Nephropathy 1. Damage to small blood vessels that supply the glomeruli of the kidney 2. Leading cause of end-stage renal disease 3. Risk factors - Hypertension - Genetics - Smoking - Chronic hyperglycemia 4. Annual screening 5. If albuminuria present, drugs to delay progression: - ACE inhibitors - Angiotensin II receptor antagonists 6. Control of hypertension and blood glucose levels in a healthy range: imperative Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. It is the leading cause of end-stage kidney disease in the United States and is seen in 20% to 40% of people with diabetes. Risk factors for diabetes-related nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Results of the DCCT and UKPDS research have demonstrated that kidney disease can be significantly reduced when near-normal blood glucose levels are maintained. Patients with diabetes are screened for nephropathy annually for albuminuria and a measurement of the albumin-to-creatinine ratio in a random spot urine collection. Serum creatinine is also measured. Serum creatinine measurements provide an estimation of the glomerular filtration rate and thus the degree of kidney function. Patients with diabetes who have albuminuria receive either angiotensin-converting enzyme (ACE) inhibitor drugs (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (e.g., losartan [Cozaar]). Both classifications of these drugs are used to treat hypertension and have been found to delay the progression of nephropathy in patients with diabetes. Hypertension will significantly accelerate the progression of nephropathy. Therefore, aggressive blood pressure management is indicated for all patients with diabetes. Keeping blood glucose levels in a healthy range is also critical for the prevention and delay of diabetes-related nephropathy. Chronic Complications Diabetic Neuropathy - Nerve damage due to metabolic derangements of diabetes - 60% to 70% of patients with diabetes have some degree of neuropathy - Reduced nerve conduction and demyelinization - Sensory or autonomic 1. Sensory neuropathy - Loss of protective sensation in lower extremities - Major risk for amputation 2. Distal symmetric polyneuropathy - Most common form - Affects hands and/or feet bilaterally - Loss of sensation, abnormal sensations, pain, and paresthesias 3. Autonomic neuropathy - Can affect nearly all body systems - Gastroparesis Delayed gastric emptying - Cardiovascular abnormalities Postural hypotension, resting tachycardia, painless myocardial infarction - Sexual function Erectile dysfunction Decreased libido Vaginal infections - Neurogenic bladder → urinary retention Empty frequently, use Credé's maneuver Medications Self-catheterization Treatment for sensory neuropathy 1. Managing blood glucose levels 2. Drug therapy - Topical creams - Tricyclic antidepressants - Selective serotonin and norepinephrine reuptake inhibitors - Antiseizure medications Diabetic neuropathy is nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus. Approximately 60% to 70% of patients with diabetes have some degree of neuropathy. Screening for neuropathy begins in patients with type 2 diabetes at the time of diagnosis and 5 years after diagnosis in patients with type 1 diabetes. The pathophysiologic processes of diabetic neuropathy are not well understood. Several theories exist, including metabolic, vascular, and autoimmune factors. The prevailing theory is that persistent hyperglycemia leads to an accumulation of sorbitol and fructose in the nerves that causes damage by an unknown mechanism. The result is reduced nerve conduction and demyelinization. Ischemia in blood vessels damaged by chronic hyperglycemia that supply the peripheral nerves is also implicated in the development of diabetes-related neuropathy. Neuropathy can precede, accompany, or follow the diagnosis of diabetes. The two major categories of diabetes-related neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy. Each of these types can take several forms. This can lead to the loss of protective sensation in the lower extremities, and, coupled with other factors, this significantly increases the risk for complications that result in a lower limb amputation. The most common form of sensory neuropathy is distal symmetric polyneuropathy, which affects the hands and/or feet bilaterally. This is sometimes referred to as stocking-glove neuropathy. Characteristics of distal symmetric polyneuropathy include loss of sensation, abnormal sensations, pain, and paresthesias. The pain, which is often described as burning, cramping, crushing, or tearing, is usually worse at night and may occur only at that time. The paresthesias may be associated with tingling, burning, and itching sensations. The patient may report a feeling of walking on pillows or numb feet. At times the skin becomes so sensitive (hyperesthesia) that even light pressure from bed sheets cannot be tolerated. Complete or partial loss of sensitivity to touch and temperature is common. Neuropathy: Neurotrophic Ulceration - Foot injury and ulcerations can occur without the patient's ever having pain. Neuropathy can also cause atrophy of the small muscles of the hands and feet, causing deformity and limiting fine movement. Managing blood glucose is the only treatment for diabetes-related neuropathy. It is effective in many, but not all, cases. Drug therapy may be used to treat neuropathic symptoms, particularly pain. Medications commonly used include topical creams (e.g., capsaicin [Zostrix]), tricyclic antidepressants (e.g., amitriptyline [Elavil]), selective serotonin and norepinephrine reuptake inhibitors (e.g., duloxetine [Cymbalta]), and antiseizure medications (e.g., gabapentin [Neurontin], pregabalin [Lyrica]). Capsaicin is a moderately effective topical cream made from chili peppers. It depletes the accumulation of pain-mediating chemicals in the peripheral sensory neurons. The cream is applied three to four times a day. There is usually an increase in symptoms at the start of therapy, which is followed by relief of pain in 2 to 3 weeks. Tricyclic antidepressants are moderately effective in treating the symptoms of diabetic neuropathy. They work by inhibiting the reuptake of norepinephrine and serotonin, which are neurotransmitters believed to play a role in the transmission of pain through the spinal cord. Duloxetine is thought to relieve pain by increasing the levels of serotonin and norepinephrine, which improves the body's ability to regulate pain. Antiseizure medications decrease the release of neurotransmitters that transmit pain. Autonomic neuropathy can affect nearly all body systems and lead to hypoglycemia unawareness, bowel incontinence and diarrhea, and urinary retention. Gastroparesis (delayed gastric emptying) is a complication of autonomic neuropathy that can produce anorexia, nausea, vomiting, gastroesophageal reflux, and persistent feelings of fullness. Gastroparesis can trigger hypoglycemia by delaying food absorption. Cardiovascular abnormalities associated with autonomic neuropathy are postural hypotension, resting tachycardia, and painless myocardial infarction. Assess patients with diabetes for postural hypotension to determine if they are at risk for falls. Instruct the patient with postural hypotension to change from a lying or sitting position slowly. Diabetes can affect sexual function in men and women. Erectile dysfunction (ED) in men with diabetes is well recognized and common, often being the first manifestation of autonomic neuropathy. ED in diabetes is also associated with other factors, including vascular disease, elevated blood glucose levels, endocrine disorders, psychogenic factors, and medications. Decreased libido is a problem for some women with diabetes. Candidal and nonspecific vaginitis are also common. ED or sexual dysfunction necessitates sensitive therapeutic counseling for both the patient and the patient's partner. A neurogenic bladder may develop as the sensation in the inner bladder wall decreases, causing urinary retention. A patient with retention has infrequent voiding, difficulty in voiding, and a weak stream of urine. Emptying the bladder every 3 hours in a sitting position helps prevent stasis and subsequent infection. Tightening the abdominal muscles during voiding and using Credé's maneuver (mild massage downward over the lower abdomen and bladder) may also help with complete bladder emptying. Cholinergic agonist drugs such as bethanechol (Urecholine) may be used. The patient may also need to learn self-catheterization. Chronic Complications Foot Complications - Microvascular and macrovascular diseases increases risk for injury and infection - Sensory neuropathy and PAD are major risk factors for amputation - Also clotting abnormalities, impaired immune function, autonomic neuropathy - Smoking increases risk 1. Sensory neuropathy → loss of protective sensation → unawareness of injury - Monofilament screening 2. Peripheral artery disease - ↓ Blood flow, ↓ wound healing, ↑ risk for infection 3. Patient teaching to prevent foot ulcers - Proper footwear - Avoidance of foot injury - Skin and nail care - Daily inspection of feet - Prompt treatment of small problems 4. Diligent wound care for foot ulcers 5. Neuropathic arthropathy (Charcot's foot) The development of diabetes-related foot complications can be the result of a combination of microvascular and macrovascular diseases that place the patient at risk for injury and serious infection. Sensory neuropathy and peripheral artery disease (PAD) are risk factors for foot complications. In addition clotting abnormalities, impaired immune function, and autonomic neuropathy also have a role. Smoking is deleterious to the health of lower extremity blood vessels and increases the risk for amputation. Sensory neuropathy is a major risk factor for lower extremity amputation in the person with diabetes. Loss of protective sensation (LOPS) often prevents the patient from being aware that a foot injury has occurred. Improper footwear and injury from stepping barefoot on foreign objects are common causes of undetected foot injury in patients with LOPS. Because the primary risk factor for lower extremity amputation is LOPS, annual screening with a monofilament is important. This is done by applying a thin, flexible filament to several spots on the plantar surface of the foot and asking the patient to report if it is felt. Insensitivity to a monofilament has been shown to greatly increase the risk for foot ulcers that can lead to amputation. PAD increases the risk for amputation by causing a reduction in blood flow to the lower extremities. When blood flow is decreased, oxygen, white blood cells, and vital nutrients are not available to the tissues. Wounds take longer to heal, and the risk for infection increases. Signs of PAD include intermittent claudication, pain at rest, cold feet, loss of hair, delayed capillary filling, and dependent rubor (redness of the skin that occurs when the extremity is in a dependent position). Management includes reduction of risk factors, particularly smoking, cholesterol intake, and hypertension. Bypass or graft surgery is indicated in some patients. If the patient has LOPS or PAD, aggressive measures must be taken to teach the patient how to prevent foot ulcers. These measures include the selection of proper footwear, including prescription shoes. Other measures are to carefully avoid injury to the foot, practice diligent skin and nail care, inspect the foot thoroughly each day, and treat small problems promptly. Proper care of a foot ulcer is critical for wound healing. Several forms of treatment can be used for management of the foot ulcers. Casting can be done to redistribute the weight on the plantar surface of the foot. Wound care for the ulcer can include debridement, dressings, advanced wound healing products (becaplermin [Regranex]), vacuum-assisted closure, ultrasonography, hyperbaric oxygen, and skin grafting. Neuropathic arthropathy, or Charcot's foot, results in ankle and foot changes that ultimately lead to joint dysfunction and footdrop. These changes occur gradually and promote an abnormal distribution of weight over the foot, further increasing the chances of developing a foot ulcer as new pressure points emerge. Foot deformity should be recognized early and proper footwear fitted before ulceration occurs. Chronic Complications Skin Problems 1. Diabetic dermopathy - Most common - Red-brown, round or oval patches 2. Acanthosis nigricans - Manifestation of insulin resistance - Velvety light brown to black skin 3. Necrobiosis lipoidica diabeticorum - Red-yellow lesions Up to two thirds of persons with diabetes develop skin problems. Diabetes-related dermopathy, the most common diabetic skin lesion, is characterized by reddish-brown and round or oval patches. They initially are scaly and then flatten out and become indented. The lesions appear most frequently on the shins but can also be found on the front of the thighs, forearm, side of the foot, scalp, and trunk. Acanthosis nigricans is a manifestation of insulin resistance. It can appear as a velvety light brown to black skin thickening seen predominantly on flexures, axillae, and the neck. Necrobiosis lipoidica diabeticorum usually appears as red-yellow lesions, with atrophic skin that becomes shiny and transparent, revealing tiny blood vessels under the surface. Necrobiosis Lipidoidica Diabeticorum - Necrobiosis lipoidica diabeticorum usually appears as red-yellow lesions, with atrophic skin that becomes shiny and transparent, revealing tiny blood vessels under the surface. This condition is uncommon and occurs more frequently in young women. It may appear before other clinical signs or symptoms of diabetes. Because the thin skin is prone to injury, special care must be taken to protect affected areas from injury and ulceration. Chronic Complications Infection 1. Defect in mobilization of inflammatory cells and impaired phagocytosis 2. Recurring or persistent infections 3. Treat promptly and vigorously 4. Patient teaching for prevention - Hand hygiene - Flu and pneumonia vaccine A person with diabetes is more susceptible to infections. This is due to a defect in the mobilization of inflammatory cells and impaired phagocytosis by neutrophils and monocytes. Recurring or persistent infections such as Candida albicans, as well as boils and furuncles, in patients with undiagnosed diabetes often lead the HCP to suspect diabetes. Loss of sensation (neuropathy) may delay the detection of an infection. Persistent glycosuria may predispose to bladder infections, especially in patients with a neurogenic bladder. Decreased circulation resulting from angiopathy can prevent or delay the immune response. Antibiotic therapy has prevented infection from being a major cause of death among patients with diabetes. The treatment of infections must be prompt and vigorous. Teach patients measures to prevent infection. People with diabetes should practice good hand hygiene and avoid exposure to individuals who have a communicable illness. An annual influenza vaccine is advisable. In addition, a pneumococcal vaccine (Pneumovax) is recommended.

Type 2 Diabetes Mellitus

- Formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (NIDDM) - Most prevalent type (90% to 95%) - Many risk factors: overweight, obesity, advanced age, family history - Increasing prevalence in children - Greater prevalence in ethnic groups Type 2 diabetes mellitus was formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (NIDDM). Type 2 diabetes mellitus is the most prevalent type of diabetes, accounting for over approximately 90% to 95% of cases of diabetes. Being overweight, obese, advanced age, and having a family history of type 2 diabetes are some of the many risk factors contributing to the development of the disease. Although the disease is seen less frequently in children, the incidence in children is increasing as a result of the increase in prevalence of childhood obesity. Prevalence of type 2 diabetes is greater in some ethnic populations. African Americans, Asian Americans, Hispanics, Native Hawaiians or other Pacific Islanders, and Native Americans have a higher rate of type 2 diabetes than do white people. Type 2 Diabetes Mellitus Etiology and Pathophysiology 1. Pancreas continues to produce some endogenous insulin but - Not enough insulin is produced OR - Body does not use insulin effectively 2. Major distinction - In type 1 diabetes there is an absence of endogenous insulin 2. Genetic link - Insulin resistance - Decreased insulin production by pancreas - Inappropriate hepatic glucose production - Altered production of hormones and cytokines by adipose tissue (adipokines) - Research continues on role of brain, kidneys, and gut in type 2 diabetes 3. Metabolic syndrome increases risk for type 2 diabetes - Elevated glucose levels - Abdominal obesity - Elevated BP - High levels of triglycerides - Decreased levels of HDLs In type 2 diabetes, the pancreas usually continues to produce some endogenous (self-made) insulin. However, the body either does not produce enough insulin or does not use it effectively, or both. The presence of endogenous insulin is a major distinction between type 1 and type 2 diabetes. (In type 1 diabetes, endogenous insulin is absent.) Metabolic abnormalities have a role in the development of type 2 diabetes. It is likely multiple genes are involved. 1. This is because insulin receptors are unresponsive to the action of insulin and/or insufficient in number. Most insulin receptors are located on skeletal muscle, fat, and liver cells. When insulin is not properly used, the entry of glucose into the cell is impeded, resulting in hyperglycemia. In the early stages of insulin resistance, the pancreas responds to high blood glucose by producing greater amounts of insulin (if β-cell function is normal). This creates a temporary state of hyperinsulinemia that coexists with hyperglycemia. 2. Decrease in the ability of the pancreas to produce insulin, as the β-cells become fatigued from the compensatory overproduction of insulin or when β-cell mass is lost. The underlying reason why the β-cells fail to adapt is unknown. It may be linked to the adverse effects of chronic hyperglycemia or high levels of circulating free fatty acids. In addition, the α cells of the pancreas increase production of glucagon. 3. Inappropriate glucose production by the liver. Instead of properly regulating the release of glucose in response to blood levels, the liver does so in a haphazard way that does not correspond to the body's needs at the time. However, this is not considered a primary factor in the development of type 2 diabetes. 4. Altered production of hormones and cytokines by adipose tissue (adipokines). Adipokines secreted by adipose tissue appear to play a role in glucose and fat metabolism and are likely to contribute to the pathophysiology of type 2 diabetes. Adipokines are thought to cause chronic inflammation, a factor involved in insulin resistance, type 2 diabetes, and cardiovascular disease. The two main adipokines believed to affect insulin sensitivity are adiponectin and leptin. 5. Finally, the brain, kidneys, and gut also have roles in the development of type 2 diabetes, and scientists are continuously learning more about metabolic factors in the development of type 2 diabetes. Individuals with metabolic syndrome are at an increased risk for the development of type 2 diabetes. Five components characterize metabolic syndrome: elevated glucose levels, abdominal obesity, elevated BP, high levels of triglycerides, and decreased levels of high-density lipoproteins (HDLs). An individual with three of the five components is considered to have metabolic syndrome. Overweight individuals with metabolic syndrome can reduce their risk for diabetes through a program of weight loss and regular physical activity. Type 2 Diabetes Mellitus Onset of Disease 1. Gradual onset 2. Hyperglycemia may go many years without being detected 3. Often discovered with routine laboratory testing - At time of diagnosis About 50% to 80% of β cells are no longer secreting insulin Average person has had diabetes for 6.5 years The disease onset in type 2 diabetes is usually gradual. Patients may go for many years with undetected hyperglycemia that might produce few, if any, symptoms. Many people are diagnosed on routine laboratory testing or when patients undergo treatment for other conditions, and elevated glucose or hemoglobin A1C levels are found. The signs and symptoms of hyperglycemia develop when about 50% to 80% of β cells are no longer secreting insulin. At the time of diagnosis, the average person has had type 2 diabetes for 6.5 years. Altered Mechanisms in Type 1 and Type 2 Diabetes Clinical Manifestations Type 2 Diabetes Mellitus 1. Nonspecific symptoms - Classic symptoms of type 1 may manifest 2. Fatigue 3. Recurrent infection 4. Recurrent vaginal yeast or candidal infection 5. Prolonged wound healing 6. Visual changes The clinical manifestations of type 2 diabetes are often nonspecific, although it is possible that an individual with type 2 diabetes will experience some of the classic symptoms associated with type 1 diabetes, including polyuria, polydipsia, and polyphagia. Some of the more common manifestations associated with type 2 diabetes are fatigue, recurrent infections, recurrent vaginal yeast or candidal infections, prolonged wound healing, and visual changes.

Etiology and Pathophysiology

Combination of causative factors - Genetic - Autoimmune - Environmental Absent/insufficient insulin and/or poor utilization of insulin Current theories link the causes of diabetes, singly or in combination, to genetic, autoimmune, and environmental factors (e.g., viruses, obesity). Regardless of its cause, diabetes is primarily a disorder of glucose metabolism related to absent or insufficient insulin supply and/or poor utilization of the insulin that is available. Normal glucose and insulin metabolism - Produced by -cells in islets of Langerhans - Released continuously into bloodstream in small increments with larger amounts released after food - Stabilizes glucose level in range of 70 to 110 mg/dL Insulin is a hormone produced by the β-cells in the islets of Langerhans of the pancreas. Under normal conditions, insulin is continuously released into the bloodstream in small increments, with increased release when food is ingested. Insulin lowers blood glucose and facilitates a stable, normal glucose range of approximately 70 to 110 mg/dL (3.9 to 6.1 mmol/L). The average amount of insulin secreted daily by an adult is approximately 40 to 50 U, or 0.6 U/kg of body weight. {See next slide for figure.} Normal Insulin Secretion - In the first hour or two after meals with normal endogenous insulin secretion, insulin concentrations rise rapidly in blood; they peak at about 1 hour. After meals, insulin concentrations promptly decline toward preprandial values as carbohydrate absorption from the gastrointestinal tract declines. After carbohydrate absorption from the gastrointestinal tract is complete and during the night, insulin concentrations are low and fairly constant, with a slight increase at dawn. The rise in plasma insulin after a meal inhibits gluconeogenesis, enhances fat deposition of adipose tissue, and increases protein synthesis. For this reason, insulin is an anabolic, or storage, hormone. The fall in insulin level during normal overnight fasting facilitates the release of stored glucose from the liver, protein from muscle, and fat from adipose tissue. Insulin 1. Promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell - Cells break down glucose to make energy - Liver and muscle cells store excess glucose as glycogen - Skeletal muscle and adipose tissue are considered insulin-dependent tissues Insulin promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell. Cells break down glucose to make energy, and liver and muscle cells store excess glucose as glycogen. Skeletal muscle and adipose tissue have specific receptors for insulin and are considered insulin-dependent tissues. Insulin is required to "unlock" these receptor sites, allowing the transport of glucose into the cells to be used for energy. Other tissues (e.g., brain, liver, blood cells) do not directly depend on insulin for glucose transport, but require an adequate glucose supply for normal function. Although liver cells are not considered insulin-dependent tissue, insulin receptor sites on the liver facilitate hepatic uptake of glucose and its conversion to glycogen. Normal Glucose and Insulin Metabolism - Normal glucose and insulin metabolism. Insulin binds to receptors along the cell walls of muscle, adipose, and liver cells. Glucose transport proteins (GLUT 4) then attach to the cell wall and allow glucose to enter the cell where it is either stored or used to make energy. Counterregulatory hormones - Glucagon, epinephrine, growth hormone, cortisol - Oppose effects of insulin - Stimulate glucose production and release by the liver - Decrease movement of glucose into cell - Help maintain normal blood glucose levels Glucagon, epinephrine, growth hormone, and cortisol are counterregulatory hormones that work to oppose the effects of insulin. These hormones increase blood glucose levels by (1) stimulating glucose production and release by the liver and (2) decreasing the movement of glucose into the cells. The counterregulatory hormones and insulin usually maintain blood glucose levels within the normal range by regulating the release of glucose for energy during food intake and periods of fasting.

Bariatric Surgery

Bariatric surgery - Patients with type 2 diabetes - When lifestyle and drug therapy management is difficult - BMI >35 kg/m2 Bariatric surgery may be considered for patients with type 2 diabetes who have a body mass index (BMI) greater than 35 kg/m2, especially if the diabetes or associated co-morbidities are difficult to manage with lifestyle and drug therapy. Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and monitoring.

Insulin

Exogenous insulin - Insulin from an outside source - Required for type 1 diabetes - Prescribed for patients with type 2 diabetes who cannot manage blood glucose levels by other means Exogenous (injected) insulin is needed when insulin is inadequate to meet specific metabolic needs. People with type 1 diabetes require exogenous insulin to survive and may need multiple daily injections of insulin (often four or more) or continuous insulin infusion via an insulin pump to adequately manage blood glucose levels. People with type 2 diabetes may require exogenous insulin during periods of severe stress such as illness or surgery. In addition, because type 2 diabetes is a progressive disease, over time the combination of nutritional therapy, exercise, and OAs may no longer adequately manage blood glucose levels. At that point, exogenous insulin would be added as a part of the management plan. People with type 2 diabetes may also need up to four injections per day to adequately maintain their blood glucose levels. Occasionally insulin pumps are used for patients with type 2 diabetes. Human insulin - Genetically engineered in laboratories Categorized according to onset, peak action, and duration - Rapid-acting - Short-acting - Intermediate-acting - Long-acting Today only genetically engineered human insulin is made in laboratories. The insulin is derived from common bacteria (e.g., Escherichia coli) or yeast cells through recombinant DNA technology. In the past, insulin was extracted from beef and pork pancreas, but these forms of insulin are no longer available. Insulins differ by their onset, peak action, and duration and are categorized as rapid-acting, short-acting, intermediate-acting, and long-acting insulin. The base of all insulin preparations is regular insulin. The onset of activity, peak, and duration times are manipulated by adding zinc, acetate buffers, and protamine. The zinc and protamine added to make intermediate-acting NPH (neutral protamine Hagedorn) can cause an allergic reaction at the injection site in susceptible individuals. [See next slide for description of these four insulin classifications.] Insulin Regimens 1. Basal-bolus regimen - Most closely mimics endogenous insulin production - Rapid- or short-acting (bolus) insulin before meals - Intermediate- or long-acting (basal) background insulin once or twice a day 2. Less intense regimens can also be used The insulin regimen that most closely mimics endogenous insulin production is the basal-bolus regimen: Rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day Intensive or physiologic insulin therapy, consisting of multiple daily insulin injections together with frequent self-monitoring of blood glucose Goal: to achieve a glucose level of 80 to 130 mg/dL before meals Other, less intense regimens can also promote healthy blood glucose levels for some people. Ideally, the patient and the HCP will work together to select a plan. The criteria for selection are based on the desired and feasible blood glucose levels and the patient's lifestyle, food choices, and activity patterns. If a less intense regimen is not giving the patient optimal results, a more intense approach might be encouraged by the HCP. Mealtime Insulin (Bolus) 1. Rapid-acting (bolus) - Lispro, aspart, glulisine - Onset of action 15 minutes - Injected within 15 minutes of mealtime 2. Short-acting (bolus) - Regular with onset of action 30 to 60 minutes - Injected 30 to 45 minutes before meal - Onset of action 30 to 60 minutes To manage postprandial blood glucose levels, the timing of administration of rapid- and short-acting insulin in relation to meals is crucial. Rapid-acting synthetic insulin analogs Include lispro (Humalog), aspart (NovoLog), and glulisine (Apidra) Have an onset of action of approximately 15 minutes Sould be injected within 15 minutes of mealtime Most closely mimic natural insulin secretion in response to a meal Short-acting regular insulin Onset of action is 30 to 60 minutes, and preparation is injected 30 to 45 minutes before a meal to ensure that the onset of action coincides with meal absorption. Because timing an injection 30 to 45 minutes before a meal is difficult for people to incorporate into their lifestyles, the flexibility that rapid-acting insulins offer is preferred by those taking insulin with their meals. Short-acting insulin is also more likely to cause hypoglycemia because of a longer duration of action. (Basal) Background Insulin 1. Used to manage glucose levels in between meals and overnight 2. Long-acting (basal) - Insulin glargine (Lantus) and detemir (Levemir) - Released steadily and continuously with no peak action for many people - Administered once or twice a day - Do not mix with any other insulin or solution 3. Intermediate-acting insulin - NPH - Duration 12 to 18 hours - Peak 4 to 12 hours - Can mix with short- and rapid-acting insulins - Cloudy; must agitate to mix In addition to mealtime insulin, people with type 1 diabetes use a long-acting basal or intermediate-acting (background) insulin to maintain blood glucose levels in between meals and overnight. Without 24-hour background insulin, people with type 1 diabetes are more prone to developing diabetic ketoacidosis. Many people with type 2 diabetes who use mealtime insulin injections or oral medications also require basal insulin to adequately manage blood glucose levels. Insulin glargine (Lantus) and detemir (Levemir) are long-acting insulins that are released steadily and continuously and, for many people, does not have a peak of action. The action time for glargine and determir varies. Although they can be used for once-daily subcutaneous administration, detemir is often given twice daily. Because they lack peak action time, the risk for hypoglycemia from this type of insulin is greatly reduced. Do not mix or dilute glargine or detemir with any other insulin or solution in the same syringe. Intermediate-acting insulin (NPH) is also used as a basal insulin. Its action has a duration of 12 to 18 hours. The disadvantage of NPH is that its peak of action ranges from 4 to 12 hours, which can result in hypoglycemia. NPH can be mixed with short- and rapid-acting insulins. NPH is a cloudy insulin that must be gently agitated (not shaken) before administration. Combination Insulin Therapy - Can mix short- or rapid-acting insulin with intermediate-acting insulin in same syringe - Provides mealtime and basal coverage in one injection - Commercially premixed or self-mix For patients who want to use only one or two injections per day, a short- or rapid-acting insulin is mixed with intermediate-acting insulin in the same syringe. This allows patients to have both mealtime and basal coverage without having to administer two separate injections. Although this may be more appealing to the patient, most patients achieve more optimal blood glucose levels with basal-bolus therapy. Patients may mix the two types of insulin themselves or may use a commercially premixed formula or pen. Premixed formulas offer convenience to patients, who do not have to draw up and mix insulin from two different vials. This is especially helpful to those who lack the visual, manual, or cognitive skills to mix insulin themselves. However, the convenience of these formulas limits the potential for optimal blood glucose levels because there is less opportunity for flexible dosing based on need. Insulin 1. Storage of insulin - Do not heat/freeze - In-use vials may be left at room temperature up to 4 weeks - Extra insulin should be refrigerated - Avoid exposure to direct sunlight, extreme heat or cold - Store prefilled syringes upright for 1 week if 2 insulin types; 30 days for one 2. Administration of insulin - Given by subcutaneous injection - Regular insulin may be given IV - Cannot be taken orally - Absorption is fastest from abdomen, followed by arm, thigh, and buttock - Abdomen is often preferred site - Do not inject in site to be exercised - Rotate injections within and between sites - Usually available as U100 insulin (1 mL contains 100 U of insulin) - Syringes marked for units: various sizes - Only user recaps syringe - No alcohol swab for self-injection; wash with soap and water - Inject at 45- to 90-degree angle 3. Insulin pump - Continuous subcutaneous infusion - Battery-operated device - Connected to a catheter inserted into subcutaneous tissue in abdominal wall - Program basal and bolus doses that can vary throughout the day - Potential for keeping blood glucose levels in a tighter range 4. Problems with insulin therapy - Hypoglycemia - Allergic reaction - Lipodystrophy As a protein, insulin requires special storage considerations. Heat and freezing alter the insulin molecule and can make it less effective. Insulin vials and insulin pens currently in use may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86º F (30º C) or below freezing (less than 32º F [0º C]). Store unopened insulin vials and insulin pens in the refrigerator. Prolonged exposure to direct sunlight should be avoided. A patient who is traveling in hot climates may store insulin in a thermos or cooler to keep it cool (not frozen). Patients who are traveling or caregivers of patients who are sight impaired or who lack the manual dexterity to fill their own syringes may prefill insulin syringes. Prefilled syringes containing two different insulins are stable for up to 1 week when stored in the refrigerator; syringes containing only one type of insulin are stable up to 30 days. Teach patients to store syringes in a vertical position with the needle pointed up to avoid clumping of suspended insulin in the needle. Before injection, gently roll prefilled syringes between the palms 10 to 20 times to warm the insulin and resuspend the particles. Some insulin combinations are not appropriate for prefilling and storage because the mixture can alter the onset, action, and/or peak times of either of the types. Consult a pharmacy reference as needed when mixing and prefilling different types of insulin. Routine doses of insulin are administered by subcutaneous injection. Regular insulin can be given IV when immediate onset of action is desired. Insulin is not taken orally because it is inactivated by gastric juices. Teach patients to avoid injecting insulin intramuscularly because rapid and unpredictable absorption could result in hypoglycemia. The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest subcutaneous absorption is from the abdomen, followed by the arm, thigh, and buttock. Although the abdomen is often the preferred injection site, other sites also work well. Caution the patient about injecting into a site that is to be exercised. For example, injecting into the thigh and then going jogging could increase body heat and circulation, which could increase the rate of insulin absorption and speed it onset of action, thus resulting in hypoglycemia. Teach patients to rotate the injection within and between sites. This allows for better insulin absorption. For example, it may be helpful to think of the abdomen as a checkerboard, with each half-inch square representing an injection site. Injections are rotated systematically across the board, with each injection site at least ½ to 1 inch away from the previous injection site. It can be helpful to inject fast-acting insulin into faster absorbing sites and slow-acting insulin into slower absorbing sites. Subcutaneous Injection Sites - Abdomen is preferred site, but arms, thighs, and back can be used. - Patient can also rotate within each site by using checkerboard pattern, as noted in this figure. Most commercial insulin is available as U100, indicating that 1 mL contains 100 U of insulin. U100 insulin must be used with a U100-marked syringe. Disposable plastic insulin syringes are available in a variety of sizes, including 1.0, 0.5, and 0.3 mL. The 0.5-mL size may be used for doses of 50 U or less, and the 0.3-mL syringe can be used for doses of 30 U or less. The 0.5- and 0.3-mL syringes are in 1-U increments. This provides more accurate delivery when the dose is an odd number. The 1.0-mL syringe is necessary for patients who require more than 50 U of insulin. The 1.0-mL syringe is in 2-U increments. When patients change from a 0.3- or a 0.5-mL to a 1.0-mL syringe, make them aware of the dose increment difference. Only the person using the syringe should do the recapping. Never recap a needle used by a patient. The use of an alcohol swab on the site before self-injection is no longer recommended. Routine hygiene such as washing with soap and rinsing with water is adequate. This applies primarily to patient self-injection technique. When injection occurs in a health care facility, policy may dictate site preparation with alcohol to prevent health care-associated infection (HAI). Insulin injections are typically given at a 90-degree angle. For extremely thin or muscular patients in the hospital, perform injections at a 45- degree angle. At home, patients inject at a 90-degree angle using the shortest needle desired. Pinching up of the skin to avoid intramuscular injection is no longer necessary because of the availability of short needles. Insulin Pen - An insulin pen is a compact portable device loaded with an insulin cartridge that serves the same function as a needle and syringe. Pen needles are available in various lengths and sizes. Insulin pens offer convenience and flexibility. They are portable and compact, their use is more discreet than using a vial and syringe, and they provide consistent and accurate dosing. For patients with poor vision, the pen is a better option as they can hear the clicks of the pen as the dose is selected. Insulin pens come packaged with printed instructions including pictures of the steps to take when using the pen. These instructions are helpful to use in teaching new users and in reviewing technique with current users of a pen. An insulin pump delivers a continuous subcutaneous insulin infusion through a small device worn on the belt, in a pocket, or under clothing. Insulin pumps use rapid-acting insulin, which is loaded into a reservoir or cartridge and connected via plastic tubing to a catheter inserted into the subcutaneous tissue. All insulin pumps are programmed to deliver a continuous infusion of rapid-acting insulin 24 hours a day, known as the "basal rate." Basal insulin can be temporarily increased or decreased on the basis of carbohydrate intake, activity changes, or illness. Some individuals require different basal rates at different times of the day. At mealtime, the user programs the pump to deliver a bolus infusion of insulin appropriate to the amount of carbohydrate ingested and an additional amount, if needed to bring down or correct high preprandial blood glucose. Insulin pump users check their blood glucose level at least four times per day. Monitoring eight times or more per day is common. A major advantage of the insulin pump is the potential for keeping blood glucose levels in a tighter range. This is possible because insulin delivery becomes very similar to the normal physiologic pattern. OmniPad Insulin Management System - A, OmniPod Insulin Management System. The Pod holds and delivers insulin. B, The Personal Diabetes Manager (PDM) wirelessly programs insulin delivery via the Pod. The PDM has a built-in glucose meter. Problems associated with insulin therapy include hypoglycemia, allergic reactions, lipodystrophy, and the Somogyi effect. Hypoglycemia is discussed in detail later. Local inflammatory reactions to insulin may occur, such as itching, erythema, and burning sensation around the injection site. Local reactions may be self-limiting within 1 to 3 months or may improve with a low dose of antihistamine. A true insulin allergy is rare. It is manifested by a systemic response with urticaria and possibly anaphylactic shock. Zinc or protamine, used as preservatives in the insulin, and the latex or rubber stoppers on the vials have been implicated in allergic reactions. Lipodystrophy (atrophy or hypertrophy of subcutaneous tissue) may occur if the same injection sites are used frequently. The use of human insulin has significantly reduced the risk for lipodystrophy. Atrophy is the wasting of subcutaneous tissue and presents as indentations in injection sites. Hypertrophy, a thickening of the subcutaneous tissue, eventually regresses if the patient does not use the site for at least 6 months. The use of hypertrophied sites may result in erratic insulin absorption. Somogyi Effect - Rebound effect in which an overdose of insulin causes hypoglycemia - Release of counterregulatory hormones causes rebound hyperglycemia Hyperglycemia in the morning may be due to the Somogyi effect. A high dose of insulin produces a decline in blood glucose levels during the night. As a result, counterregulatory hormones (e.g., glucagon, epinephrine, growth hormone, cortisol) are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia. The danger of this effect is that when blood glucose levels are measured in the morning, hyperglycemia is apparent and the patient (or the HCP) may increase the insulin dose. If a patient is experiencing morning hyperglycemia, checking blood glucose levels between 2:00 AM and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. The patient may report headaches on awakening and may recall having night sweats or nightmares. A bedtime snack, a reduction in the dose of insulin, or both can help to prevent the Somogyi effect. Dawn Phenomenon 1. Morning hyperglycemia present on awakening 2. May be due to release of counterregulatory hormones in predawn hours - Growth hormone and cortisol The Dawn phenomenon is also characterized by hyperglycemia that is present on awakening. Two counterregulatory hormones (growth hormone and cortisol) which are excreted in increased amounts in the early morning hours may be the cause of this phenomenon. The Dawn phenomenon affects a majority of people with diabetes and tends to be most severe when growth hormone is at its peak in adolescence and young adulthood. Careful assessment is required to document the Somogyi effect or Dawn phenomenon because the treatment for each differs. The treatment for Somogyi effect is less insulin in the evening. The treatment for Dawn phenomenon is an increase in insulin or an adjustment in administration time. Ask the patient to measure and document bedtime, nighttime (between 2:00 and 4:00 AM), and morning fasting blood glucose levels on several occasions. If the predawn levels are less than 60 mg/dL (3.3 mmol/L) and signs and symptoms of hypoglycemia are present, the insulin dosage should be reduced. If the 2:00 to 4:00 AM blood glucose level is high, the insulin dosage should be increased. In addition, counsel the patient on appropriate bedtime snacks. Inhaled Insulin 1. Afrezza - Rapid-acting inhaled insulin - Administered at beginning of each meal or within 20 minutes after starting a meal - Not a substitute for long-acting insulin Afrezza must be used in combination with long-acting insulin in patients with type 1 diabetes. It is not recommended for the treatment of diabetic ketoacidosis or in patients who smoke. The most common adverse reactions are hypoglycemia, cough, and throat pain or irritation. Afrezza should not be used in patients with chronic lung disease, such as asthma or COPD, because bronchospasm can occur. Oral Agents 1. Work on 3 defects of type 2 diabetes - Insulin resistance - Decreased insulin production - Increased hepatic glucose production 2. Can be used in combination OAs and noninsulin injectable agents work to improve the mechanisms by which insulin and glucose are produced and used by the body. These drugs work on three defects of type 2 diabetes: (1) insulin resistance, (2) decreased insulin production, and (3) increased hepatic glucose production. These drugs may be used in combination with agents from other classes or with insulin to achieve blood glucose goals. Mechanisms of Action of Type 2 Diabetes Drugs - Sites and mechanisms of action of type 2 diabetes drugs. DDP-4, Dipeptidyl peptidase; GLP-1, glucagon-like peptide-1. Biguanides 1. Metformin (Glucophage) - Reduces glucose production by liver - Enhances insulin sensitivity Improves glucose transport - May cause weight loss - Used in prevention of type 2 diabetes 2. Withhold if patient is undergoing surgery or radiologic procedure with contrast medium - Day or two before and at least 48 hours after - Monitor serum creatinine 3. Contraindications - Renal, liver, cardiac disease - Excessive alcohol intake The most widely used oral diabetes agent is metformin, the only medication in the biguanide class available in the United States. Metformin is the most effective first line treatment for type 2 diabetes. The primary action of metformin is to reduce glucose production by the liver. It also enhances insulin sensitivity at the tissue level and improves glucose transport into the cells. In addition, it has beneficial effects on plasma lipids. Because it may cause moderate weight loss, metformin may be useful for people with type 2 diabetes and prediabetes who are overweight or obese. It is also used in the prevention of type 2 diabetes in those with prediabetes who are younger than 60 and have risk factors such as hypertension or a history of gestational diabetes Patients who are undergoing surgery or any radiologic procedures that involve the use of a contrast medium are instructed to temporarily discontinue metformin before surgery or the procedure and to not resume taking metformin until 48 hours after the surgery or the procedure and after their serum creatinine has been checked and is normal. Do not use in patients with kidney disease, liver disease, or heart failure. Lactic acidosis is a rare complication of metformin accumulation. Do not use in people who drink excessive amounts of alcohol. Take with food to minimize GI side effects. Sulfonylureas 1. ↑ Insulin production from pancreas 2. Major side effect: hypoglycemia 3. Examples - Glipizide (Glucotrol) - Glyburide (Glynase) - Glimepiride (Amaryl) Sulfonylureas include glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta, Glynase), and glimepiride (Amaryl). The primary action of the sulfonylureas is to increase insulin production from the pancreas. Therefore, hypoglycemia is the major side effect of sulfonylureas. Meglitinides 1. ↑ Insulin production from pancreas 2. Rapid onset: ↓ hypoglycemia 3. Taken 30 minutes to just before each meal 4. Should not be taken if meal skipped 5. Examples - Repaglinide (Prandin) - Nateglinide (Starlix) Like the sulfonylureas, repaglinide (Prandin) and nateglinide (Starlix) increase insulin production from the pancreas. However, because they are more rapidly absorbed and eliminated than sulfonylureas, they are less likely to cause hypoglycemia. When they are taken just before meals, pancreatic insulin production increases during and after the meal, mimicking the normal blood glucose response to eating. Instruct patients to take meglitinides any time from 30 minutes before each meal right up to the time of the meal. These drugs should not be taken if a meal is skipped. α-Glucosidase Inhibitors 1. "Starch blockers" - Slow down absorption of carbohydrate in small intestine 2. Take with first bite of each meal 3. Example - Acarbose (Precose) - Miglitol (Glyset) Also known as starch blockers, these drugs work by slowing down the absorption of carbohydrate in the small intestine. Taken with the first bite of each main meal, they are most effective in lowering postprandial blood glucose. Their effectiveness is measured by checking 2-hour postprandial glucose levels. Acarbose (Precose) and miglitol (Glyset) are the available drugs in this class. Thiazolidinediones 1. Most effective in those with insulin resistance 2. Improve insulin sensitivity, transport, and utilization at target tissues 3. Examples - Pioglitazone (Actos) - Rosiglitazone (Avandia) 4. Rarely used because of adverse effects Sometimes referred to as insulin sensitizers, these agents include pioglitazone (Actos) and rosiglitazone (Avandia). They are most effective for people who have insulin resistance. These agents improve insulin sensitivity, transport, and utilization at target tissues. Because they do not increase insulin production, thiazolidinediones do not cause hypoglycemia when used alone. However, these drugs are rarely used today because of their adverse effects. Rosiglitazone is associated with adverse cardiovascular events (e.g., myocardial infarction) and can be obtained only through restricted-access programs. Pioglitazone can worsen heart failure and is associated with an increased risk of bladder cancer. Dipeptidyl Peptidase-4 (DDP-4) Inhibitor 1. Blocks inactivation of incretin hormones - ↑ Insulin release - ↓ Glucagon secretion - ↓ Hepatic glucose production 2. Examples (gliptins) - Sitagliptin (Januvia) - Saxagliptin (Onglyza) - Linagliptin (Tradjenta) Incretin hormones are released by the intestines throughout the day, but levels increase in response to a meal. When glucose levels are normal or elevated, incretins increase insulin synthesis and release from the pancreas, as well as decrease hepatic glucose production. The incretin hormones are normally inactivated by dipeptidyl peptidase-4 (DPP-4). DPP-4 inhibitors block the action of the DPP-4 enzyme, which is responsible for inactivating incretin hormones (gastric inhibitory peptide [GIP] and glucagonlike peptide [GLP-1]). The result is an increase in insulin release, a decrease in glucagon secretion, and decreased hepatic glucose production. Because the DPP-4 inhibitors are glucose dependent, they lower the potential for hypoglycemia. The main benefit of these drugs over other medications for diabetes with similar effects is the absence of weight gain as a side effect. DPP-4 inhibitors (also known as gliptins) come in pill form and includes sitagliptin (Januvia), saxagliptin (Onglyza), and linagliptin (Tradjenta). Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 1. SGLT2 inhibitors work by - Blocking reabsorption of glucose by kidney - Increasing glucose excretion - Lowering blood glucose levels Canagliflozin (Invokana) Dapagliflozin (Farxiga) Empagliflozin (Jardiance) Drugs in this class include canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance). Dopamine Receptor Agonist - Bromocriptine (Cycloset) - Mechanism of action unknown - Thought that patients with type 2 diabetes have low levels of dopamine - Increases dopamine receptor activity - Alone or in combination Bromocriptine (Cycloset) is a dopamine receptor agonist that improves glycemic control. The mechanism of action is unknown. Patients with type 2 diabetes are thought to have low levels of dopamine activity in the morning. These low levels of dopamine may interfere with the body's ability to control blood glucose. Bromocriptine increases dopamine receptor activity. It can be used alone or as an add-on to another type 2 diabetes treatment. Glucagonlike Peptide-1 Receptor Agonists 1. Simulate glucagonlike peptide-1 (GLP-1) - Increase insulin synthesis and release - Inhibit glucagon secretion - Slow gastric emptying - Increases satiety Exenatide (Byetta), exenatide extended-release (Bydureon), liraglutide (Victoza), albiglutide (Tanzeum), and dulaglutide (Trulicity) simulate glucagonlike peptide-1 (GLP-1) (one of the incretin hormones), which is found to be decreased in people with type 2 diabetes. These drugs increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, slow gastric emptying, and reduce food intake by increasing satiety. These drugs may be used as monotherapy or adjunct therapy for patients with type 2 diabetes who have not achieved optimal glucose levels on OAs. These drugs are administered using a subcutaneous injection in a prefilled pen. In contrast to exenatide, which is given twice a day, and liraglutide, which is given once daily, dulaglutide, albiglutide, and Bydureon are given once every 7 days. The delayed gastric emptying that occurs with these medications may affect the absorption of oral medications. Advise patients to take fast-acting oral medications at least 1 hour before injecting a GLP-1 agonist drug.

Nursing Management Evaluation

Expected Outcomes - Knowledge - Self-care measures - Balanced diet and activity - Stable, safe, and healthy blood glucose levels - No injuries The expected outcomes are that the patient with diabetes mellitus will do the following: Verbalize key elements of the therapeutic regimen, including knowledge of disease and treatment plan Describe self-care measures that may prevent or slow progression of chronic complications Maintain a balance of nutrition, activity, and insulin availability that results in stable, safe, and healthy blood glucose levels Experience no injury resulting from decreased sensation in feet Implement measures to increase peripheral circulation Additional information on expected outcomes for the patient with diabetes is presented in eNCP 48-1 available on the website for this chapter.

Nursing Assessment

Subjective Data 1. Past health history - Viral infections, trauma, infection, stress, pregnancy, chronic pancreatitis, Cushing syndrome, acromegaly, family history of diabetes 2. Medications - Insulin, OAs, corticosteroids, diuretics, phenytoin 3. Recent surgery - Malaise - Obesity, weight loss or gain - Thirst, hunger, nausea/vomiting - Poor healing - Dietary compliance - Constipation/diarrhea - Frequent urination, bladder infections - Nocturia, urinary incontinence - Muscle weakness, fatigue - Abdominal pain, headache, blurred vision - Numbness/tingling, pruritus - Impotence, frequent vaginal infections - Decreased libido - Depression, irritability, apathy - Commitment to lifestyle changes Obtain the following important health information from the patient: Past health history: mumps, rubella, coxsackievirus or other viral infections; recent trauma, infection, or stress; pregnancy, delivering infant weighing more than 9 lb; chronic pancreatitis; Cushing syndrome; acromegaly; family history of type 1 or type 2 diabetes mellitus Medications: use of and compliance with insulin or OA regimen; use of corticosteroids, diuretics, phenytoin (Dilantin) Surgery or other treatments: any recent surgery Obtain the following important health information related to pertinent functional health patterns: Health perception-health management: positive family history; malaise Nutritional-metabolic: obesity; weight loss (type 1), weight gain (type 2); thirst, hunger; nausea and vomiting; poor healing (especially involving the feet), eating habits in patients with previously diagnosed diabetes Elimination: constipation or diarrhea; frequent urination, frequent bladder infections, nocturia, urinary incontinence Obtain the following important health information related to pertinent functional health patterns: Activity-exercise: muscle weakness, fatigue Cognitive-perceptual: abdominal pain; headache; blurred vision; numbness or tingling of extremities; pruritus Sexuality-reproductive: impotence; frequent vaginal infections; decreased libido Coping-stress tolerance: depression, irritability, apathy Value-belief: commitment to lifestyle changes involving diet, medication, and activity patterns Objective Data - Sunken eyeballs, history of vitreal hemorrhages, cataracts - Dry, warm, inelastic skin - Pigmented skin lesions, ulcers, loss of hair on toes, acanthosis nigricans - Kussmaul respirations - Hypotension - Weak, rapid pulse - Dry mouth - Vomiting - Fruity breath - Altered reflexes, restlessness - Confusion, stupor, coma - Muscle wasting - Serum electrolyte abnormalities - Fasting blood glucose level of 126 mg/dL or higher - Oral glucose tolerance test and/or random glucose level exceeding 200 mg/dL - Leukocytosis - ↑ Blood urea nitrogen, creatinine - ↑ Triglycerides, cholesterol, LDL, VLDL - ↓ HDL - Hemoglobin A1C value > 6.0% - Glycosuria - Ketonuria - Albuminuria - Acidosis Possible focused assessment findings: Soft, sunken eyeballs*; history of vitreal hemorrhages; cataracts Dry, warm, inelastic skin; pigmented lesions (on legs); ulcers (especially on feet); loss of hair on toes; acanthosis nigricans Rapid, deep respirations (Kussmaul respirations)* Hypotension*; weak, rapid pulse* * Indicates manifestations of diabetic ketoacidosis. Possible focused assessment findings: Dry mouth; vomiting*; fruity breath* Altered reflexes; restlessness; confusion; stupor; coma Muscle wasting * Indicates manifestations of diabetic ketoacidosis. Possible diagnostic findings: Serum electrolyte abnormalities; fasting blood glucose level of 126 mg/dL or higher; oral glucose tolerance test result exceeding 200 mg/dL; random glucose test result of 200 mg/dL or higher; leukocytosis; ↑ blood urea nitrogen, creatinine levels.

Pancreas Transplantation

- For type 1 diabetes with kidney transplant - Eliminates need for exogenous insulin, SMBG, dietary restrictions - Can also eliminate acute complications - Long-term complications may persist - Lifelong immunosuppression - Islet cell transplantation experimental Pancreas transplantation can be used as a treatment option for patients with type 1 diabetes. Usually it is done for patients who have end-stage kidney disease and who have had or plan to undergo kidney transplantation. Kidney and pancreas transplantations are often performed together, or a pancreas may be transplanted after kidney transplantation. Pancreas transplantation alone is rare. Successful pancreas transplantation can improve quality of life for people with diabetes, primarily by eliminating the need for exogenous insulin, frequent blood glucose measurements, and the risks involved with hyper- and hypoglycemia. Transplantation can also eliminate the acute complications commonly experienced by patients with type 1 diabetes (e.g., hypoglycemia, hyperglycemia). However, pancreas transplantation is only partially successful in reversing the long-term renal and neurologic complications of diabetes. The patient will also require lifelong immunosuppression to prevent rejection of the graft. Complications can result from immunosuppressive therapy. Pancreatic islet cell transplantation is another potential treatment measure. During this procedure, the islet cells are harvested from the pancreas of a deceased organ donor. Most recipients require the use of two or more pancreases. The islet cells are infused via a catheter through the upper abdomen into the portal vein of the liver. With only the islet cells transplanted, pain and recovery time are diminished in comparison with whole pancreas transplantation. Currently, this procedure is experimental in the United States. Research is continuing to determine the best ways to implant the islet cells and to prevent their rejection.

Other Specific Types of Diabetes

- Results from injury to, interference with, or destruction of β-cell function in the pancreas - From medical conditions and/or medications - Resolves when underlying condition is treated or medication is discontinued Diabetes occurs in some people because of another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels. Conditions that may cause diabetes can result from injury to, interference with, or destruction of the β-cell function in the pancreas. These include Cushing syndrome, hyperthyroidism, recurrent pancreatitis, cystic fibrosis, hemochromatosis, and the use of parenteral nutrition. Commonly used medications that can induce diabetes in some people include corticosteroids (prednisone), thiazides, phenytoin (Dilantin), and atypical antipsychotics (e.g., clozapine [Clozaril]). Diabetes caused by medical conditions or medications can resolve when the underlying condition is treated or the medication is discontinued.

Classes of Diabetes

- Type 1 - Type 2 - Gestational - Other specific types - Prediabetes The American Diabetes Association (ADA) recognizes four different classes of diabetes. The two most common are type 1 and type 2 diabetes mellitus. The two other classes are gestational diabetes and other specific types of diabetes due to various causes. Finally, there is a category of disorder called "prediabetes" - individuals with prediabetes are at an increased risk for the development of type 2 diabetes.

Culturally Competent Care

1. Culture can have a strong influence on dietary preferences and meal preparation 2. High incidence of diabetes - Hispanics - Native Americans - African Americans - Asians and Pacific Islanders Because culture can have a strong influence on dietary preferences and meal preparation practices, culturally competent care has special relevance for the patient with diabetes. For example, certain ethnic and cultural groups, such as Hispanics, Native Americans, African Americans, and Asians and Pacific Islanders have a high incidence of diabetes. The increased prevalence can be attributed to genetic predisposition, environmental factors, and dietary choices. Explore the influences of culture on food choices and meal planning with the patient as part of the health history. When giving diet instructions, consider the patient's cultural food preferences. Nutrition resources specifically designed for members of different cultural groups are available from the ADA.

Interprofessional Care

1. Goals of diabetes management - Decrease symptoms - Promote well-being - Prevent acute complications - Delay onset and progression of long-term complications 2. Need to maintain blood glucose levels as near to normal as possible 3. Patient teaching - Nutritional therapy - Drug therapy - Exercise - Self-monitoring of blood glucose 4. Diet, exercise, and weight loss may be sufficient for patients with type 2 diabetes 5. All patients with type 1 require insulin The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications related to hyper- and hypoglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient is able to maintain blood glucose levels as near to normal as possible. Diabetes is a chronic disease that requires daily decisions about food intake, blood glucose monitoring, medication, and exercise. Patient teaching, which enables the patient to become the most active participant in his or her own care, is essential for a successful treatment plan. Nutritional therapy, drug therapy, exercise, and self-monitoring of blood glucose are the tools used in the management of diabetes. For some people with type 2 diabetes, a healthy eating plan, regular physical activity, and maintenance of healthy body weight are sufficient to attain an optimal level of blood glucose levels. However, for the majority, drug therapy is necessary because diabetes is a progressive disease. The major types of glucose-lowering agents (GLAs) used in the treatment of diabetes are insulin, oral agents (OAs), and nonisulin injectable agents. All individuals with type 1 diabetes require insulin.

Psychologic Considerations

1. High rates of - Depression - Anxiety - Eating disorders 2. Open communication is critical for early identification Patients with diabetes have high rates of depression, anxiety, and eating disorders. Depression contributes to diminished diabetes self-care, feelings of helplessness related to chronic illness, and poor outcomes. Assess patients for manifestations of depression and/or diabetes distress. Disordered eating behaviors (DEB) can occur in people with both type 1 and type 2 diabetes. DEBs include anorexia, bulimia, binge eating, excessive restriction of calories, and intense exercise. The greatest incidence of eating disorders is seen in females. Adolescent girls with diabetes are more than twice as likely to develop DEB than those who do not have diabetes. Patients may intentionally decrease their dose of insulin or omit the dose. This is called "diabulimia" and leads to weight loss, hyperglycemia, and glycosuria because the food ingested cannot be used for energy without adequate insulin. Insulin omission and DEBs can have serious consequences, including retinopathy, neuropathy, lipid abnormalities, DKA, and death. Open communication is critical to identify these behaviors early. Patients with eating disorders need to be seen by a mental health professional with expertise in eating disorders and an understanding of diabetes management.

Gerontologic Considerations

1. Increased prevalence and mortality 2. Glycemic control challenging - Increased hypoglycemic unawareness - Functional limitations - Renal insufficiency 3. Meal planning and exercise 4. Patient teaching must be adapted to needs Diabetes is present in more than 25% of persons older than 65 years, and this age group is the fastest growing segment of the population developing diabetes. The prevalence of diabetes increases with age. A major reason for this is that the process of aging is associated with a reduction in β-cell function, decreased insulin sensitivity, and altered carbohydrate metabolism. Older people with diabetes have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension and stroke than do those without diabetes. One reason is that hypoglycemic unawareness is more common in older adults, and so these patients are more likely to suffer adverse consequences from blood glucose-lowering therapy. They may have delayed psychomotor function that could interfere with the ability to treat hypoglycemia. Other factors to consider in establishing glycemic goals for an older patient include the patient's own desire for treatment and other coexisting medical problems such as cognitive impairment. Compounding the challenge, diabetes increases the rate of decline of cognitive function. Although it is generally agreed that a level of treatment is indicated to prevent complications intensive diabetes management may be difficult and dangerous to achieve, especially in older adults. Meal planning and exercise are recommended as therapy for older adult patients with diabetes. This therapy should take into account functional limitations that may interfere with physical activity and the ability to prepare meals. Because of the physiologic changes that occur with aging, the therapeutic outcome for the older adult with diabetes who receives OAs may be altered. Assess renal function and creatinine clearance in patients older than 80 years who are taking metformin. Monitor those taking sulfonylurea drugs (e.g., glipizide) for hypoglycemia and for renal and liver dysfunction. Insulin therapy may be instituted if OAs are not effective. However, it is important to recognize that older adults are more likely to have limitations in the manual dexterity and visual acuity necessary for accurate insulin administration. Insulin pens may be a safer alternative for older adults. Patient education issues for the older patient include those related to altered vision, mobility, cognitive status, and functional ability. Plan patient teaching based on the individual's needs; for patients with cognitive and functional limitations, use a slower pace with simple printed or audio materials. It is important to include the family or caregiver in the teaching. Consider the patient's financial and social situation, as well as the effect of multiple medications, eating habits, and quality-of-life issues.

Drug Therapy

Amylin Analog - Pramlintide (Symlin) - Slows gastric emptying, reduces postprandial glucagon secretion, increases satiety - Used concurrently with insulin - Subcutaneously in thigh or abdomen before meals - Watch for hypoglycemia Pramlintide (Symlin) is the only available amylin analog. Amylin, a hormone secreted by the β-cells of the pancreas in response to food intake, slows gastric emptying, reduces glucagon secretion, and increases satiety. Pramlintide is used in addition to mealtime insulin in patients with type 1 or type 2 diabetes who have elevated blood glucose levels on ideal insulin therapy. It is used only concurrently with insulin and is not a replacement for insulin. Pramlintide is administered before major meals subcutaneously into the thigh or abdomen. It cannot be injected into the arm because absorption from this site is too variable. The drug cannot be mixed in the same syringe with insulin. The concurrent use of pramlintide and insulin increases the risk of severe hypoglycemia during the 3 hours after injection. Severe hypoglycemia is possible, especially in patients with type 1 diabetes. Patients should be instructed to eat a meal with at least 250 calories and keep a form of fast-acting glucose on hand in the event that hypoglycemia develops. When pramlintide is used, the bolus dose of insulin should be reduced. Combination oral therapy - Blend two different classes of medications to treat diabetes - Improves adherence because patient takes fewer pills Other drugs affecting blood glucose levels - Drug interactions can potentiate hypoglycemia and hyperglycemia effects Many combination drugs are currently available. These drugs combine two different classes of medications to treat diabetes. (Examples of these agents are listed in Table 48-7.) One advantage of combination therapy is that the patient takes fewer pills, thus improving adherence to taking medications. Both the patient and the HCP must be aware of drug interactions that can potentiate hypoglycemia and hyperglycemia effects. For example, β-adrenergic blockers can mask symptoms of hypoglycemia and prolong the hypoglycemic effects of insulin. Thiazide and loop diuretics can potentiate hyperglycemia by inducing potassium loss, although low-dose therapy with a thiazide is usually considered safe.

Planning

Overall Goals - Active patient participation - Few or no hyperglycemia or hypoglycemia emergencies - Maintain normal blood glucose levels - Prevent or minimize chronic complications - Adjust lifestyle to accommodate diabetes plan with a minimum of stress The overall goals are for the patient with diabetes mellitus to (1) engage in self-care behaviors to actively manage his or her diabetes, (2) experience few or no hyperglycemia or hypoglycemia emergencies, (3) maintain blood glucose levels at normal or near-normal levels, (4) prevent or minimize chronic complications related to diabetes, and (5) adjust lifestyle to accommodate the diabetes plan with a minimum of stress. The patient with diabetes needs to safely and effectively fit diabetes into life, rather than living life around diabetes.

Prediabetes

↑ Risk for developing type 2 diabetes 1. Impaired glucose tolerance (IGT) - OGTT - 140-199 mg/dL 2. Impaired fasting glucose (IFG) - Fasting glucose of 100-125 mg/dL Intermediate stage between normal glucose homeostasis and diabetes Individuals diagnosed with prediabetes are at increased risk for the development of type 2 diabetes. Prediabetes is defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both. It is an intermediate stage between normal glucose homeostasis and diabetes where the blood glucose levels are elevated, but not high enough to meet the diagnostic criteria for diabetes. A diagnosis of IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL (7.8 to 11.0 mmol/L). IFG is diagnosed when fasting blood glucose levels are 100 to 125 mg/dL (5.56 to 6.9 mmol/L). Asymptomatic but long-term damage already occurring Patient teaching important - Undergo screening - Manage risk factors - Monitor for symptoms of diabetes - Maintain healthy weight, exercise, make healthy food choices Persons with prediabetes usually do not have symptoms. However, long-term damage to the body, especially the heart and blood vessels, may already be occurring. It is important for patients to undergo screening and to understand risk factors for diabetes. Patients with prediabetes can take action to prevent or delay the development of type 2 diabetes. Encourage those with prediabetes to have their blood glucose and A1C checked regularly and monitor for symptoms of diabetes, such as polyuria, polyphagia, and polydipsia. Maintaining a healthy weight, exercising regularly, and making healthy food choices have all been found to reduce the risk of developing overt diabetes in people with prediabetes.