Diabetes Mellitus

What needs to be monitored in Pre-Diabetic Patients?

Encourage those with Prediabetes to have their blood glucose and A1C checked regularly Monitor for symptoms of diabetes, such as: --polyuria --polyphagia --polydipsia

Classic Symptoms (Clinical Manifestations) of Type 1 Diabetes

>> Polyuria (frequent urination) --> Body is trying to get glucose out of your blood >> Polydipsia (excessive thirst) --> Because you are trying to excrete so much fluid >> Polyphagia (excessive hunger) --> Because body is not getting enough nutrients in the form of glucose >> Ketones build-up in your system → Keto-Acidosis and Metabolic Acidosis >> Weight loss- from burning fat for energy >> Weakness and Fatigue --> Because body is not getting enough nutrients in the form of glucose

Where is Insulin created?

>> Produced by β-cells (Beta cells) in Pancreatic Islets of Langerhans >> Released continuously into bloodstream in small increments with larger amounts released after food

Other 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 >> Commonly used medications that can induce diabetes in some people include corticosteroids (prednisone), thiazides, phenytoin (Dilantin), and atypical antipsychotics (e.g., clozapine [Clozaril]).

Short-Acting vs. Rapid-Acting Insulin

>> Short-acting insulin is also more likely to cause hypoglycemia because of a longer duration of action. >> Rapid-acting most closely mimic natural insulin secretion in response to a meal >> Rapid-acting is used in insulin pumps >> Rapid-acting is easier to incorporate into lifestyle because it is taken right before a meal (within 15min)

What are some major complications of Diabetes?

Adult blindness End-stage renal disease, renal failure Non-traumatic lower limb amputations Heart disease Stroke *more than half of adults with diabetes have hypertension and high cholesterol levels

Define Insulin Resistance

An impaired response of the body to insulin, resulting in elevated levels of glucose in the blood (a key component of type 2 diabetes and metabolic syndrome).

Insulin Types: Intermediate-Acting

DRUG NAMES: NPH (Humulin N, Novolin N) ONSET: 1.5-4hr PEAK: 4-12hr DURATION: 12-18hr (*2 doses per day; Provides basal insulin) *Not used as frequently anymore **Can mix with Short and Rapid-Acting Insulin ***Greater risk for hypoglycemia as compared to Long-Acting ****NPH is cloudy and must be gently agitated before administration

Insulin Types: Short-Acting

DRUG NAMES: Regular (Humulin R, Novolin R) ONSET: 30min-1hr Bolus injected 30-45min before a meal PEAK: 2-5hr DURATION: 5-8hr

Care of Type 1 vs. Type 2 Diabetes

Diet, exercise, and weight loss may be sufficient for patients with type 2 diabetes All patients with type 1 require insulin (exogenous!!) All patients need education on: Nutrition Exercise Self-monitoring of blood glucose

How can Type I Diabetes be diagnosed later in life?

Possibly, insulin was working earlier in life, but then immune system kicks in and person's insulin then cannot function

What is the function of Insulin?

Promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell **Insulin acts as the key to get glucose into cells for energy

What are the different types of Insulin?

Rapid-Acting Short-Acting Intermediate-Acting Long-Acting Combination Therapy

How to mix Insulin

Rapid-Acting (CLEAR) + Intermediate-Acting (CLOUDY) Short-Acting (CLEAR) + Intermediate-Acting (CLOUDY) Air into NPH (Intermediate) VV Air into Rapid or Short (Regular) Acting vv Draw up Rapid or Short (Regular) Acting vv Draw up NPH (amount of NPH should be larger than Regular)

What types of Insulin can be mixed in the same syringe?

Rapid-Acting + Intermediate-Acting Short-Acting + Intermediate-Acting *These provide mealtime and basal coverage in one injection -> This is appealing to patients, but really the Basal-Bolus Regimen with separate injections works best **DO NOT MIX LONG-ACTING WITH OTHER INSULIN

What is Glycolysis

The breakdown of glucose by enzymes, releasing energy and pyruvic acid.

Define Insulin Peak

when therapeutic levels are at the highest

Define Insulin Onset

when you start to see therapeutic effects of the insulin (decrease in blood sugar)

What is the goal of treatment for Diabetes?

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 > Need to maintain blood glucose levels as near to normal as possible

How does Insulin act as a storage hormone?

The rise in plasma insulin after a meal inhibits gluconeogenesis (protein breakdown), 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.

Risk Factors/Causes for Type 2 Diabetes

overweight obesity poor diet- consuming more sugar than pancreas can handle metabolic syndrome cardiovascular disease advanced age family history hyperlipidemia (high cholesterol) greater prevalence in ethnic groups insulin resistance impaired insulin receptors at skeletal muscle and fat (adipose) tissue Inappropriate glucose production by the liver (glycolysis) that is not matched to body's energy needs

Insulin Injection Tools: Insulin Omnipad

>> OmniPod Insulin Management System. The Pod holds and delivers insulin. >> The Personal Diabetes Manager (PDM) wirelessly programs insulin delivery via the Pod. The PDM has a built-in glucose meter.

Classic Symptoms (Clinical Manifestations) of Type 2 Diabetes

*Do not have a specific set of symptoms, like Type 1, but may include: >> Fatigue >> Recurrent infection >> Recurrent vaginal yeast or candidal infection >> Prolonged wound healing --> Main reasons DM leads to amputation is when people develop neuropathy >> Visual changes Retinal damage *Possible to also have some of the classic symptoms associated with Type 1 diabetes, including: polyuria, polydipsia, and polyphagia

Insulin Regimen Types: Pump Method

*Used for Type 1 patients >> Filling the pump with just rapid acting insulin and acts likes a pancreas all day >> Can give bolus rapid acting for meals

Insulin Regimen Types: Shot Method

*Used for Type 1 patients >> Receive daily long acting shot (good for 24 hours) >> And short/rapid acting for each meal

Insulin Types: Rapid-Acting

DRUG NAMES: Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) ONSET: 10-30min (*Quickest onset of any Insulin) Bolus injected within 15min of mealtime PEAK: 30min-3hr DURATION: 3-5hr *Most closely mimic natural insulin secretion in response to a meal

Diagnostic Tests for Diabetes Mellitus

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 (polyuria, polydipsia, polyphagia) with random plasma glucose level of 200 mg/dL or higher

What is EXOGENOUS Insulin?

>> Insulin placed into the body from another source (e.g. a subcutaneous insulin injection) >> Required for type 1 diabetes >> Prescribed for patients with type 2 diabetes who cannot manage blood glucose levels by other means, or need insulin intermittently

What is important to know about Exogenous Insulin

>> It is Human insulin that is Genetically engineered in laboratories >> VERY expensive :( >> Comes in different types- differ by their onset, peak action, and duration

What is Metabolic Syndrome?

>> Metabolic syndrome increases risk for Type 2 diabetes and looks like: -- Elevated glucose levels -- Abdominal obesity -- Elevated BP -- High levels of triglycerides -- Decreased levels of HDL cholesterol (good cholesterol)

Define Diabetes Mellitus

>> A chronic multi-system disease characterized by hyperglycemia (high blood sugar) related to abnormal insulin production, impaired insulin utilization, or both >> 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.

What is the Diagnostic Test A1C?

>> A1C test measures what percentage of your hemoglobin — a protein in red blood cells that carries oxygen — is coated with sugar (glycated) --> A1C is also called Glycosylated hemoglobin >> Reflects blood glucose levels over past 2 to 3 months >> Used to diagnose, monitor response to therapy, and screen patients with prediabetes

What is Type 1 Diabetes?

>> An autoimmune disease that attacks B-Cells in the Pancreas or attacks Insulin directly so Insulin is no longer available >> Can effect people of any age, but normally begins in people under age 4o ** These patients may have temporary remission after initial treatment because there are still some B-Cells that are not yet destroyed --> Overtime, insulin will be required on a regular basis

Insulin Injection Tools: 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. >> Insulin pens offer convenience and flexibility. >> Good for lower function, low vision patients

Insulin Injection Tools: Insulin Pump

>> Continuous subcutaneous infusion of Rapid-acting insulin >> DO NOT fill with Long-Acting insulin >> Program basal and bolus doses that can vary throughout the day >> Basal insulin can be temporarily increased or decreased on the basis of carbohydrate intake, activity changes, or illness >> At mealtime, the user programs the pump to deliver a bolus infusion of insulin appropriate to the amount of carbohydrate ingested >> Insulin pump users check their blood glucose level at least four times per day

What is Gestational Diabetes?

>> Develops during pregnancy >> Increases risk of need for cesarean delivery and of perinatal complications >> Usually glucose levels return to normal after birthat 6 weeks post partum --> However, women who had Gestational Diabetes are at greater risk for developing Type II >> Those at high risk include women who are obese, are of advanced maternal age, and have a family history of diabetes.

Storage of Insulin

>> Do not heat/freeze >> In-use vials may be left at room temperature up to 4 weeks >> Extra insulin (that is unopened) should ALWAYS be refrigerated >> Avoid exposure to direct sunlight, extreme heat or cold >> 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

Administration of Insulin

>> Given by subcutaneous injection (45 to 90 degree angle) >> Do not swab injection site with alcohol, use soap and water when at home >> Regular insulin may be given IV >> Cannot be taken orally due to inactivation by gastric juices **Teach patients to avoid injecting insulin intramuscularly because rapid and unpredictable absorption could result in hypoglycemia. >> Absorption is fastest from abdomen, followed by arm, thigh, and buttock >> Do not inject in site that is about to be messed with or used for exercise >> Rotate injection sites as much as possible **Only the person using the syringe should do the recapping. Never recap a needle used by a patient.

Define Impaired glucose tolerance (IGT)

A diagnosis of IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL

Normal and Diabetic Blood Glucose Ranges

A fasting blood sugar level less than 100-110 mg/dL is normal A fasting blood sugar level from 100 to 125 mg/dL is considered prediabetes If it's 126 mg/dL or higher on two separate tests, you have diabetes *Goal for Diabetic patients: to achieve a glucose level of 80 to 130 mg/dL before meals

What is Diabetic Ketoacidosis?

A life-threatening condition whereby a person does not have Insulin to utilize glucose, and therefore will breakdown protein for energy

What is the prevalence of Type 1 Diabetes?

Accounts for about 5% to 10% of all people with diabetes

What is a goal percentage for an A1C Test?

Below 6.5% to 7% *4-5% is good for people without DM **The ADA identifies a A1C goal for patients with diabetes of less than 7.0%.

Why does the body need Glucose?

Cells break down glucose to make energy Liver and muscle cells store excess glucose as glycogen

Insulin Types: Long-Acting

DRUG NAMES: Glargine (Lantus) Detemir (Levemir) Degludec (Tresiba) ONSET: 0.8-4hr PEAK: No Peak (*Provides basal insulin; less risk for hypoglycemia) DURATION: 16-24hr (*Insulin your body needs for the whole day) **DO NOT MIX WITH OTHER INSULIN

What did Type 2 Diabetes used to be called?

Formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (NIDDM)

What did Type 1 Diabetes used to be called?

Formerly known as juvenile-onset or insulin-dependent diabetes

Causes of Diabetes

Genetic Autoimmune (Type I) Environmental- obesity, diet, lifestyle factors

Hormones that Counteract Insulin

Glucagon, epinephrine, growth hormone, cortisol: >> Oppose effects of insulin by putting glucose back into the blood stream >> Stimulate glucose production and release by way of hormones released from the liver >> Decrease movement of glucose into cell >> Help maintain normal blood glucose levels by raising blood sugar when blood sugar gets too low

What is Gluconeogenesis?

Gluconeogenesis is the generation of glucose from non-carbohydrate precursors (like odd chain fatty acids and proteins).

Define Impaired fasting glucose (IFG)

IFG is diagnosed when fasting blood glucose levels are 100 to 125 mg/dL

What is the main difference between Type 1 and Type 2 Diabetes?

In Type 2 Diabetes, there is still insulin being produced; while there is NO insulin in Type 1 In Type 1 diabetes, endogenous insulin is absent. Type 2 Diabetes has a slow onset and may go years without detecting hyperglycemia, while Type 1 is obvious, fast, and always critical

Process of Glucose moving into the cell using Insulin

In normal glucose and insulin metabolism... Insulin binds to receptors along the cell walls of muscle, adipose, and liver cells vv Glucose transport proteins (GLUT 4) then attach to the cell wall and allow glucose to enter the cell vv Glucose is then either stored inside the cell or used to make energy

Normal Peaks and Troughs of Plasma Insulin

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 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.

What is Pre-Diabetes?

Individuals diagnosed with Prediabetes are at increased risk for the development of Type 2 diabetes, but may be asymptomatic *Prediabetes is defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both.

What is ENDOGENOUS Insulin?

Insulin made by the body's own B-Cells of the Pancreas

Insulin Regimen Types: Basal-Bolus Regimen

Intermediate- or long-acting (basal) background insulin once or twice a day Rapid- or short-acting (bolus) insulin before meals Most closely mimics endogenous insulin production

How Glucose is returned to the Bloodstream

Liver stores Glucagon, which is released during exercise vv Glucagon activates Glycogen to raise blood sugar vv Glycogensis (release of glucose from storage) vv Increased blood sugar

What is the prevalence of Type 2 Diabetes?

Most prevalent type with 90% to 95% of all people with diabetes

Define Insulin Non-Dependent Tissue

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.

What is Type 2 Diabetes?

Pancreas B-Cells continues to produce some endogenous insulin but: A) Not enough insulin is produced OR B) Body does not use insulin effectively

What are the 2 Insulin-Dependent Tissues?

Skeletal muscle and adipose tissue (fat) are considered insulin-dependent tissues

Define Insulin Dependent Tissue

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.

What is a Oral Glucose Tolerance Test?

Test to see how well your insulin can use a high level of blood glucose

4 recognized types of Diabetes

Type 1 Type 2 Gestational Other specific types *Prediabetes- person at risk for Type II DM

Which type of Diabetes is more prevalent?

Type II

Insulin Dosing

Usually available as U100 insulin (1 mL contains 100 U of insulin)

Ways to reduce risk for Type 2 Diabetes

Weight loss Exercise Healthy Diet

When is Insulin released into the bloodstream?

When rises in Blood Glucose are detected

What will happen if the body does not have enough Insulin?

Without insulin, blood sugar would spike uncontrollably and cells are not getting energy/nutrition → Body is starving for glucose → Body will compensate when it goes not get enough glucose without insulin → Body will start breaking down fat for energy (Ketoacidosis) → Person can get very thin

Define Insulin Duration

amount of time drug stays in the therapeutic range