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Diabetes Mellitus – derived from the Greek word for fountain and the Latin
word for honey
- primarily a disorder of carbohydrate metabolism
- insulin is the key to unlocking cells to allow carbohydrates in for
energy production
- symptoms result from a deficiency of insulin or from resistance to
insulin’s actions
- principle sign is sustained hyperglycemia (too much sugar) which rapidly
causes polyuria (increased
urine output), polyphagia (increased hunger), polydipsia (increased
thirst), ketonuria, and weight
loss
- hyperglycemia can lead to hypertension, heart disease, renal failure,
blindness, neuropathy,
amputations, impotence and stroke
- most common endocrine disorder: 5th leading cause of death by disease
17 million have the disease, but only 11
million diagnosed
2. TYPE II DIABETES
- most prevalent form of diabetes
- was once called non-insulin dependent diabetes mellitus (NIDDM)
or adult onset diabetes
mellitus
- usually begins in middle age and progresses gradually and obesity
is almost always present
- carries little risk of ketoacidosis
- symptoms result from a combination of insulin resistance and
impaired insulin secretion
- insulin secretion is no longer tightly coupled to plasma glucose
content: release of insulin is
delayed and peak output is subnormal
- target tissues of insulin (liver, muscle, adipose tissue) exhibit
insulin resistance
- resistance results from threes causes: reduced binding of
insulin to receptors
reduced receptor number
reduced receptor for
responsiveness
- hyperglycemia leads to destruction of pancreatic beta cells causing
insulin production and
secretion to eventually decline
1. Macrovascular Disease
- cardiovascular complications are leading cause of death among
diabetic patients
- increased risk of hypertension, heart disease and stroke
- pathology is due to atherosclerosis (develops earlier in diabetics
and progresses at an
accelerated rate)
c. Neuropathy
- nerve degeneration often begins early in the course of
diabetes, but symptoms are
absent for years
- sensory and motor nerves may be affected
- symptoms include tingling sensation in the fingers and toes,
pain, suppression of
reflexes and loss of sensation (especially vibratory
sensation)
- nerve damage is directly related to sustained hyperglycemia
- tight glycemic control can reduce damage
E. DIAGNOSIS OF DIABETES
- patient must be tested on two separate days
- any combination of two tests can be used and both tests must be
positive
3. Oral Glucose Tolerance Test (OGTT) – not used for routine screening
(used when diabetes is
suspected but can’t be confirmed by FPG or casual plasma glucose)
- performed by giving an oral glucose load (equal to 75 gm of
anhydrous glucose) and
measuring plasma glucose levels 2 hours later
- normal individual levels will be below 140 mg/dl
- levels of 200 mg/dl or higher suggest diabetes
- usual testing during pregnancy for gestational diabetes
F. TREATMENT OVERVIEW
1. Type I Diabetes
- goal of therapy is to maintain glucose levels within an acceptable
range in order to prevent
acute complications and reduce or prevent long-term
complications
- glycemic control is accomplished with an integrated program of
diet, self-monitoring of blood
glucose (SMBG), exercise, and insulin replacement – oral
hypoglycemics are not used
- Proper diet, balanced by insulin replacement, is the cornerstone of
treatment
- Type I diabetics are usually thin, the dietary goal is to maintain
weight – not lose it
- total caloric intake should be spread evenly, w/ meals spaced 4 – 5
hrs apart
- ADA recommendations include foods that contain sucrose (table
sugar) – provided there is a
reduction of intake of other carbohydrates
- really important is the total amt of carbohydrates ingested –
not the type or the source
- regular exercise should be part of the management program
- strenuous exercise can produce hypoglycemia
- exercise should be avoided if glycemic control is unstable
- SURVIVAL REQUIRES DAILY ADMINISTRATION OF INSULIN
2. Type II Diabetes
- goal of therapy is to maintain blood glucose levels within an
acceptable range
- core of treatment is diet and exercise; insulin or oral hypoglycemic
agents are employed only
as adjuncts (oral, insulin, or combination of both)
- dietary goal is to promote weight loss and establishment of a
leaner body composition
- patients should be screened for hypertension, nephropathy,
retinopathy, and neuropathy
G. MONITORING TREATMENT
- goal is to determine whether glucose levels are being maintained in a
safe range
Drawbacks:
• more expensive than urine tests
• more difficult to perform than urine tests
• machines require periodic calibration
• patients require education on how to apply test results
• not practical for patients with limited economic resources
• not practical for patients who are unable or unwilling to learn
how to use the device and apply the results
Advantages:
• superior to measuring glucose in urine
• hyperglycemia can be detected long before blood glucose
levels are high enough to cause spilling of glucose into urine
• can detect hypoglycemia, something that urinary
measurements simply can’t do
II. INSULIN
- available in several forms which differ with respect to time course of
action, route of administration,
and source
4. Mixing Insulins
- with the use of two different insulin preparations, it is usually
desirable to mix the preparations
rather than inject them separately, so as to eliminate the need
for additional shots
- mixing offers convenience, but can alter the time course of
the response
- only insulins that are compatible with each other should be
combined
5. Storage
- unopened vials should be stored under refrigeration (not frozen)
until needed and can be used
up to the expiration date on the vial
- in current use vials can be kept at room temperature for up to 1
month without significant loss
of activity
- direct sunlight and extreme heat must be avoided
- partially filled vials should be discarded after several weeks if
left unused
- room temperature causes less pain than cold insulin
- insulin mixture vials are stable for 1 month at room temperature
and 3 months under
refrigeration
- prefilled insulin mixture syringes (plastic or glass) should be stored
under refrigeration where
they are stable for at least 1 week, perhaps 2
- syringes should be stored vertically with the needle pointing
up to avoid clogging
- prior to administration, the syringe should be agitated gently
to resuspend insulin
b. Pen Injectors – look like a fountain pen but have a disposable needle
(where the writing tip
would be)
- disposable insulin-filled cartridge inside
- administration is accomplished by sticking the needle under
the skin and injecting the
insulin manually
A. SULFONYLUREAS
- work by promoting insulin release from the pancreas
- may also increase cellular sensitivity to insulin
- major adverse effect is hypoglycemia
Groups:
• first generation agents
• second generation agents
- reduce glucose levels to the same extent
- principal difference is 2nd generation agents are more potent (produce
their effects at much lower
doses than do the 1st generation agents)
- more important than potency are differences in duration of action,
since agents with longer
durations can be given once daily
B. MEGLITINIDES
- work by promoting pancreatic insulin release
D. THIAZOLIDINEDIONES (“GLITZAONES”)
- also known as “glitazones”
- reduce glucose levels by decreasing insulin resistance
- can expand blood volume and cause edema, thereby posing a risk for
patients with heart failure
E. ALPHA-GLUCOSIDASE INHIBITORS
- act in the intestine to delay absorption of carbohydrates
1. Acarbose – (trade name: Precose)
- delays absorption of dietary carbohydrates, reducing the rise in
blood glucose that occurs after
meals
- acarbose inhibits this enzyme, slowing digestion of carbohydrates,
hence reducing the
postprandial rise in blood glucose
- MUST be taken with every meal
F. COMBINATION PRODUCTS
1. Glyburide / Metformin – (trade name: Glucovance)
- combination of a sulfonamide (glyburide) and a biguanide
(metformin)
- glyburide acts primarily by increasing insulin secretion
- metformin acts primarily by decreasing hepatic glucose production,
partly by increasing
glucose uptake and utilization by muscle
- only advantage of combination is convenience
TREATMENT
• Insulin Replacement – levels are restored with an initial IV bolus of regular
insulin followed by
continuous infusion
- when infusion is preferred to SC, insulin levels cannot be lowered
quickly in response to
excessive dosing; hence, avoiding hypoglycemia may be
difficult
• Water & Sodium Replacement – dehydration and sodium loss are both
corrected with IV saline
- adults usually require between 8 and 10 L of fluid during the first
12 hours of treatment
- central venous pressure should be monitored in elderly and
patients with heart disease
• Potassium Replacement – as a rule the serious problem of potassium loss
is corrected by IV
administration
- electrocardiographic monitoring is essential
V. GLUCAGON
- “glucose is gone to the cell”
- used if there is an insulin overdose
- promotes breakdown of glycogen
- glucose level in blood stream increases
- administered parenterally – IV, IM, SC