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Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Diabetic Ketoacidosis
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Diabetic Ketoacidosis

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    • 1. Diabetic Ketoacidosis April Cope PharmD candidate Presentation at SUNY Downstate
    • 2. Objectives <ul><li>Physiology and pathophysiology overview </li></ul><ul><li>Diagnosis of diabetes </li></ul><ul><li>Types of diabetes </li></ul><ul><li>Treatment options for diabetes </li></ul><ul><li>Complications of diabetes </li></ul><ul><li>Type 1 Diabetes in detail </li></ul><ul><li>Diabetic Ketoacidosis </li></ul><ul><li>Patient Case </li></ul>
    • 3. Physiology Overview
    • 4. Physiology Overview
    • 5. Physiology Overview
    • 6. Diagnosis of Diabetes <ul><li>Any one of the following </li></ul><ul><ul><li>Symptoms plus RBG > 200 mg/dL </li></ul></ul><ul><ul><li>FPG > 126 mg/dL </li></ul></ul><ul><ul><li>Two hour plasma glucose >200 mg/dL during OGT </li></ul></ul><ul><li>Pre-diabetes </li></ul><ul><ul><li>Impaired Fasting Glucose (IFG) </li></ul></ul><ul><ul><li>Impaired Glucose Tolerance (IGT) </li></ul></ul><ul><li>Must be confirmed on a later date </li></ul>
    • 7. Types of Diabetes <ul><li>Type 1 Diabetes </li></ul><ul><li>Type 2 Diabetes </li></ul><ul><li>Other Specific Types </li></ul><ul><li>Gestational Diabetes </li></ul>
    • 8. Type 2 Diabetes <ul><li>Epidemiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Characteristics </li></ul><ul><li>Screening </li></ul>
    • 9. Other Specific Types <ul><li>Genetic Defects </li></ul><ul><ul><li>Beta cell function </li></ul></ul><ul><ul><li>Insulin action </li></ul></ul><ul><li>Diseases </li></ul><ul><li>Drug/Chemical Induced </li></ul><ul><li>Infection Induced </li></ul><ul><li>Immune Mediated </li></ul><ul><li>Genetic Syndromes associated with diabetes </li></ul>
    • 10. Gestational Diabetes <ul><li>High Risk Patients </li></ul><ul><li>Low Risk Patients </li></ul><ul><li>Testing </li></ul><ul><li>Treatment and Goals </li></ul>
    • 11. Treatment Options <ul><li>Non-pharmacological Treatments </li></ul><ul><li>Oral medications </li></ul><ul><li>Exogenous Insulin </li></ul>
    • 12. Non-Pharmacological Treatments <ul><li>Medical Nutrition Therapy </li></ul><ul><li>Exercise </li></ul><ul><li>Proper Monitoring </li></ul><ul><li>Education </li></ul>
    • 13. Oral Medications <ul><li>Sulfonylureas </li></ul><ul><li>Alpha-Glucosidase Inhibitors </li></ul><ul><li>Meglitinides </li></ul><ul><li>Thiazolidinediones </li></ul><ul><li>Biguanides </li></ul>
    • 14. Sulfonylureas <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    • 15. Alpha-Glucosidase Inhibitors <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    • 16. Meglitinides <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    • 17. Thiazolidinediones <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    • 18. Biguanides <ul><li>Mechanism of Action </li></ul><ul><li>Medications Available </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Adverse Effects </li></ul>
    • 19. Exogenous Insulin <ul><li>Rapid Acting </li></ul><ul><li>Short Acting </li></ul><ul><li>Intermediate Acting </li></ul><ul><li>Long Acting </li></ul><ul><li>Mixed Insulins </li></ul><ul><li>Future Possibilities </li></ul>
    • 20. Complications of Diabetes <ul><li>Neuropathy </li></ul><ul><li>Retinopathy </li></ul><ul><li>Nephropathy </li></ul><ul><li>Infection and Impaired healing </li></ul><ul><li>Amputations </li></ul><ul><li>Cardiovascular Event </li></ul>
    • 21. Neuropathy <ul><li>Types of Neuropathy </li></ul><ul><ul><li>Peripheral sensory neuropathy </li></ul></ul><ul><ul><li>Motor neuropathy </li></ul></ul><ul><ul><li>Autonomic neuropathy </li></ul></ul><ul><li>Pathophysiology </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Treatment </li></ul>
    • 22. Retinopathy <ul><li>Microvascular disease </li></ul><ul><li>Types of Retinopathy </li></ul><ul><ul><li>Nonproliferative </li></ul></ul><ul><ul><li>Proliferative </li></ul></ul><ul><li>Treatment </li></ul>
    • 23. Nephropathy <ul><li>Epidemiology </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Nephrotic Syndrome </li></ul><ul><li>Further Complications </li></ul><ul><li>Treatment </li></ul>
    • 24. Infection and Impaired Healing <ul><li>Increased Infections </li></ul><ul><li>Unusual Infections </li></ul><ul><li>Impaired Healing </li></ul><ul><li>Treatments </li></ul>
    • 25. Amputations <ul><li>Epidemiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Goals </li></ul><ul><li>Prognosis </li></ul>
    • 26. Cardiovascular Events <ul><li>Atherosclerosis </li></ul><ul><li>Heart Disease </li></ul><ul><ul><li>Heart Failure </li></ul></ul><ul><ul><li>Myocardial Infarction </li></ul></ul><ul><li>Peripheral Vascular Disease </li></ul><ul><li>Cerebral Vascular Accident </li></ul>
    • 27. Type 1 Diabetes <ul><li>Epidemiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Characteristics </li></ul><ul><li>Screening </li></ul><ul><li>Treatment </li></ul>
    • 28. Diabetic Ketoacidosis <ul><li>Pathophysiology </li></ul><ul><li>Signs and Symptoms </li></ul><ul><li>Diagnosis </li></ul><ul><li>Complications </li></ul><ul><li>Treatment </li></ul>
    • 29.  
    • 30. DKA Signs and Symptoms <ul><li>Clinical Presentation </li></ul><ul><li>Laboratory Data </li></ul><ul><li>Other </li></ul>
    • 31. DKA Complications <ul><li>Complications of associated illness </li></ul><ul><li>Hypokalemia </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Acute pulmonary edema </li></ul><ul><li>Other complications </li></ul>
    • 32. DKA Treatment <ul><li>Fluid Administration </li></ul><ul><li>Insulin </li></ul><ul><li>Potassium </li></ul><ul><li>Other Electrolytes </li></ul><ul><li>Other Medications </li></ul>
    • 33. Patient Case <ul><li>V.H. is an 18 yo BF presented to the ER on 6/29/05 with: </li></ul><ul><li>CC: “My stomach and back hurt” </li></ul><ul><li>HPI: Abdomen & back pain x 1 day, vomiting since 12 AM </li></ul><ul><li>PMH: Type 1 Diabetes Mellitus, diagnosed 13 years ago </li></ul><ul><li>Family History: Non-Contributory </li></ul><ul><li>Social History: Non-smoker, no alcohol use, no IVDA, lives with mother </li></ul>
    • 34. Patient Case <ul><li>Allergies: NKDA </li></ul><ul><li>Past Medication History: </li></ul><ul><li>Novolin R 12 units AM, 12 units PM </li></ul><ul><li>Novolin 16 units AM, 16 units PM </li></ul><ul><li>Vital Signs </li></ul><ul><li>BP: 155/101 T: 97.7 RR: 20 P: 126 </li></ul><ul><li>Ht: 5’5” Wt: 125 lbs. CrCl: 81.82 </li></ul>
    • 35. Patient Case <ul><li>PE: facial grimace, dry oral mucosa, tachycardic </li></ul><ul><li>HEENT: eyes nml, ENT nml, pharynx nml, dry oral mucosa </li></ul><ul><li>Neck: supple, nml inspection </li></ul><ul><li>Resp: breath sounds nml, no respiratory distress </li></ul><ul><li>CVS: RRR, heart sounds nml, tachycardia </li></ul><ul><li>Abd: soft, no tenderness, nml BS, no distention </li></ul><ul><li>Ext: non-tender, nml ROM, no pedal edema </li></ul><ul><li>Neuro: A&O x 3, mood/affect nml, CNs nml as tested, no motor/sensory deficit </li></ul><ul><li>Pain scale: 5/10, patient describes a dull, constant ache </li></ul>
    • 36. Patient Case <ul><li>Lab Data </li></ul><ul><li>Radiologic Data </li></ul><ul><ul><li>EKG showed sinus tachycardia </li></ul></ul>
    • 37. Patient Problem <ul><li>Diabetic Ketoacidosis due to urosepsis </li></ul><ul><ul><li>Objective data </li></ul></ul><ul><ul><li>arterial pH = 7.324 Cl = 109 CO2= 11 </li></ul></ul><ul><ul><li>anion gap = 25 RBG = 217 K+ = 4.1 </li></ul></ul><ul><ul><li>arterial pCO2 = 23 UA = ketones/protein/glucose </li></ul></ul><ul><ul><li>WBC = 14.8 ANC = 1364 EKG= sinus tachy </li></ul></ul><ul><ul><li>Subjective data </li></ul></ul><ul><ul><li>N/V, abdominal pain, normal temp </li></ul></ul>
    • 38. Pharmacotherapeutic Goal <ul><li>Correct anion gap </li></ul><ul><li>Correct acidosis </li></ul><ul><li>Prevent further production of ketones </li></ul><ul><li>Normalize lab values </li></ul><ul><li>Prevent complications </li></ul><ul><li>Reduce morbidity and mortality </li></ul><ul><li>Increase quality of life </li></ul>
    • 39. Recommendations for Therapy <ul><li>NS 1 Liter IV wide open, then 1 liter at 125cc/hr </li></ul><ul><li>Reglan 10 mg IVPB </li></ul><ul><li>Pepcid 20 mg IVPB </li></ul><ul><li>Regular Insulin 100 units in 100 mL NS, start at 5cc/hr (0.1 units/kg/hr) </li></ul><ul><li>Levofloxacin 500 mg IVPB </li></ul><ul><li>Admit to MICU, continue IVF: D51/2NS at 150 cc/hr, if BG <90, give D50 1 amp, do not stop infusion until anion gap normalizes. </li></ul>
    • 40. Recommendations for Therapy <ul><li>6/30/05: anion gap normalized, d/c insulin infusion, begin subcutaneous injections: NPH/regular 70/30 28 units AM and 20 units PM </li></ul><ul><li>6/30/05: K+ = 2.5/2.8. Begin: </li></ul><ul><ul><li>KCl 20 mEq in 100 cc NS IVPB x 2 doses at 2 hours apart </li></ul></ul><ul><ul><li>KCl 40 mEq p.o. x 2 doses at 1 hour apart </li></ul></ul>
    • 41. Specific Desired Endpoint <ul><li>No anion gap </li></ul><ul><li>No ketonemia or ketonuria </li></ul><ul><li>No proteinuria </li></ul><ul><li>No metabolic acidosis or respiratory alkalosis </li></ul><ul><li>Resolution of infection </li></ul><ul><li>K+ = 3.5 – 5.0 </li></ul><ul><li>Cl = 98 – 107 </li></ul><ul><li>CO2 = 22 – 31 </li></ul><ul><li>FPG < 126 </li></ul><ul><li>WBC = 4.8 – 10.8 </li></ul>
    • 42. Specific Desired Endpoint <ul><li>Adherence with medications </li></ul><ul><li>Regular self-glucose monitoring </li></ul><ul><li>No complications </li></ul><ul><li>No ADRs </li></ul><ul><li>Increased quality of life </li></ul>
    • 43. Monitoring Parameters & Frequency <ul><li>Parameters </li></ul><ul><ul><li>Blood Glucose </li></ul></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><ul><li>CBC w/ diff </li></ul></ul><ul><ul><li>Blood Gases </li></ul></ul><ul><ul><li>UA </li></ul></ul><ul><ul><li>Signs & Symptoms </li></ul></ul><ul><li>Frequency </li></ul><ul><ul><li>Every hour until controlled, then three times daily </li></ul></ul><ul><ul><li>Twice daily until normal, then once daily </li></ul></ul><ul><ul><li>Once daily </li></ul></ul><ul><ul><li>Twice daily until normal, then once daily </li></ul></ul><ul><ul><li>Once daily </li></ul></ul><ul><ul><li>Continuously </li></ul></ul>
    • 44. Patient Counseling <ul><li>Importance of medication adherence </li></ul><ul><li>Proper injection technique </li></ul><ul><li>Re-teach self-glucose monitoring </li></ul><ul><li>Educate patient and family about complications </li></ul><ul><li>Importance of regular MD appointments </li></ul><ul><li>Ways to prevent UTIs </li></ul><ul><li>Q&A with patient and family </li></ul>
    • 45. References <ul><li>Julie C. Oki, William L. Isley “Diabetes Mellitus” Pharmacotherapy A Pathophysiologic Approach. Ed. Joseph T. Dipiro, New York, McGraw Hill. Fifth Edition: 1335-1358 </li></ul><ul><li>Stephen N. Davis, Daryl K. Granner “Insulin, Oral Hypoglycemic Agents, and the Pharmacology of the Endocrine Pancreas” The Pharmacological Basis of Therapeutics . Ed. Alfred Goodman Gilman, New York, McGraw Hill. Tenth Edition: 1679-1714 </li></ul><ul><li>www.harrisonsonline.com . July 2005. Accessed July 6-10, 2005 </li></ul>
    • 46. References <ul><li>www.crlonline.com . July 2005. Accessed July 6-10, 2005 </li></ul><ul><li>www.guidelines.gov . July 2005. Accessed July 9, 2005 </li></ul><ul><li>www.efactsonline.com . July 2005. Accessed July 6-9, 2005 </li></ul><ul><li>www.cdc.gov . July 2005. Accessed July 9, 2005 </li></ul><ul><li>“ Management of Diabetes Mellitus” by Dr. Elaena Quattrocchi (Supplemental Lecture to Pharmacotherapeutics IV, Fall 2004) </li></ul>

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