Management of Diabetes Mellitus

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Management of Diabetes Mellitus

Management of Diabetes Mellitus

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  • 1. Prapared by maria carmela l. domocmat, rn, msnMANAGEMENT OF DIABETES
  • 2. Medical Management of DM No cure Goal: Euglycemia and prevention of complications Individualized treatment plans  Appropriate goal setting  Diet  Exercise  Self-monitoring of blood glucose (SMBG)  Regular monitoring for complications  Laboratory assessment  Oral meds/insulin
  • 3. Surgical management of DM pancreas transplant  not usually done Islet cell transplants
  • 4. Dietary management
  • 5. Dietary management of DMFoundation of Diabetic control Goals  Maintain near-normal blood glucose levels  Achieve optimal serum lipid levels  Provide adequate calories for reasonable weight  Prevent & treat acute complications of insulin- treated diabetes  Improve overall health through optimal nutrition
  • 6. Diet Composition Carbohydrates: 60 – 70% of daily diet Protein: 15 – 20% of daily diet Fats: No more than 10% of total calories from saturated fats Fiber: 20 to 35 grams/day; promotes intestinal motility and gives feeling of fullness Sodium: recommended intake 1000 mg per 1000 kcal Sweeteners approved by FDA instead of refined sugars Limited use of alcohol: potential hypoglycemic effect of insulin and oral hypoglycemics
  • 7. The exchange system Six categories  Bread/starch  Meat  Milk  Vegetable  Fruit  Fat
  • 8. General guidelines of DietaryManagement Protein  20% Fat  20% Carbohydrates  60% ADA: American Diabetic Association
  • 9. Diabetic Meal Plan Small frequent meals  CONSISTENCY!  Amount of calories  Amount of carbohydrates  Time  Snacks
  • 10. Diabetic Meal Plan If the pt is obese, the key to treatment is…  Weight los!
  • 11. Sweeteners Nutritive sweeteners  Not calorie free  Cause less h in BS (than regular sugar)  Sorbitol  laxative effect Non-nutritive sweeteners  Minimal or no calories  Do not h BS
  • 12. Meal Plan considerations Food preferences Lifestyle Schedule Ethnic / Cultural background
  • 13. Alcohol and Diabetes Increase risk of…  Hypoglycemia  Affects the liver  Don’t take on empty stomach  Esp. if on insulin or oral hypoglycemic meds  Moderation
  • 14. Exercise
  • 15. Exercise and Diabetes i blood glucose levels  h the uptake of glucose by body muscle  Potentiates action of insulin  i insulin requirement  Effect lasts 24 hours
  • 16. More Benefits of exercise Increases circulation Improve serum lipid levels Improves cardiovascular status Assist with wt control Decreases stress
  • 17. Rules for the exercisingdiabetic Talk to MD first Regular vs. sporadic Correlate exercise and glucose levels Don’t exercise when hypoglycemic Don’t exercise when hyperglycemic >250
  • 18. Rules for the exercisingdiabetic Do not exercise when insulin is peaking Carry a quick source of sugar Best time = 60-90 minutes after a meal
  • 19. Rules for the exercisingdiabetic Proper footwear May need a pre-exercise snack Consistency!
  • 20. Self monitoring of blood glucose(SMBG)
  • 21. Monitoring Glucose SMBG Glucometers Urine testing for glucose  2-4 times a day Continuous glucose monitoring system
  • 22. Monitoring Ketone levels Dipstick method Perform when:  Glucosuria  Unexplained elevated glucose level  Illness  Pregnancy
  • 23. Foot careRegular monitoring for complications
  • 24. Foot care
  • 25. Foot Care Inspect feet daily Wash feet with warm water and mild soap Pat dry – do not rub
  • 26.  Wash daily: wash feet in warm water every day, using a mild soap.  Dry between toes  Lubricate dry feet Inspect  Mirror  Family  Between toes
  • 27.  Do not soak feet. Dry feet well, especially between the toes. If the skin on feet is dry, keep it moist by applying lotion after washing and drying. Apply lotion on feet (not interdigital areas)
  • 28. Foot care  Check toenails once a week.  Trim toenails with a nail clipper straight across.  Do not round off the corners of toenails or cut down on the sides of the nails.  After clipping, smooth the nails with an emery board.
  • 29. Foot care Always wear socks or stockings with soft elastic, and that fit feet. Wear socks at night if feet get cold. Always wear closed-toed shoes or slippers. Do not wear sandals and do not walk barefoot, even around the house.
  • 30. Foot care Wear comfortable properly fitted shoes Buy shoes made of canvas or leather and break them in slowly. Extra wide shoes are also available in specialty stores that will allow for more room for the foot for people with foot deformities. Break in new pair of shoes for 1 -2 hours only until it becomes comfortable
  • 31. Foot care Maintain the blood flowing to feet Elevate feet up when sitting Do not wear knee high/ stay up stockings
  • 32. Foot care wiggle toes and move ankles several times a day dont cross legs for long periods of time Avoid activities that icirculation  Smoking  Crossing legs  Tight socks
  • 33.  Good shoes  Prevent injuries  Comfortable  Wear socks  Closed toe  Cotton  No bare feet  Light color  New shoes  No wrinkles  Break in slowly  Check inside of shoe
  • 34.  No temperature  See doctor extremes regularly  Check bath water  Podiatrist  No water bottles  Trim straight across  No heating pads  Do not cut calluses or corns  Range of Motion
  • 35. Foot care see podiatrist q2 to 3 months for check-ups, even if dont have any foot problems. include inspection of skin check for redness or warmth of the skin. check for pulses and temperature of feet Monofilament assessment of foot sensation
  • 36. When to contact Dr? Changes in skin color Changes in skin temperature Swelling in the foot or ankle Pain in the legs Open sores on the feet that are slow to heal or are draining Ingrown toenails or toenails infected with fungus Corns or calluses Dry cracks in the skin, especially around the heel Unusal and/or persistent foot odor
  • 37. Risk for infection Frequent hand washing Early recognition of signs of infection and seeking treatment Meticulous skin care Regular dental examinations and consistent oral hygiene care
  • 38. Sexual dysfunction Effects of high blood sugar on sexual functioning, Resources for treatment of impotence, sexual dysfunction
  • 39. MANAGEMENT DM:PHARMACOLOGIC MGMT
  • 40. Oral Hypoglycemic Agents Oral hypoglycemic meds are NOT Insulin Oral hypoglycemic meds require some production of insulin Oral hypoglycemic agents are used in the treatment of type 2DM Oral hypoglycemic meds are meant to supplement diet and exercise, NOT replace them
  • 41. Oral Hypoglycemic Agents Oral hypoglycemic meds cannot be used during pregnancy Oral hypoglycemic meds may need to be halted temporarily and insulin prescribed if BS levels rise due to infection, trauma, stress, surgery etc. Action vary so effect may be enhanced by use of multiple meds
  • 42. Oral Medication Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists
  • 43. Biguanides Metformin (Glucophage) first choice for oral type 2 diabetes treatment. Action: decreases overproduction of glucose by liver and makes insulin more effective in peripheral tissues
  • 44. Biguanides Major side effects : anorexia/ wt. Loss CI in patients with Renal impairment D/C temp of (+) illness that leads to dehydration or hypoperfusion --lactic acidosis.
  • 45. Sulfonylureas Glyburide (Micronase, DiaBeta, Glynase) Glipizide (Glucotrol, Glucotrol XL) Glimepiride (Amaryl) Cholpropamide (Diabanese)
  • 46. Sulfonylureas Action: Stimulates pancreatic cells to secrete more insulin and increases sensitivity of peripheral tissues to insulin (insulin secretagogues) indicated for use as adjuncts to diet and exercise in adult patients with type 2 DM Used: to treat non-obese Type 2 diabetics
  • 47. Sulfonylureas taken with food  except Glucotrol/Glipizide : taken 30 mins before meals
  • 48. Sulfonylureas (esp. Diabinese) when Side-effects taken with alcohol can  Hypoglycemia cause severe Disulfiram reactions  GI upset Disulfiram (antibus): a compound when used with alcohol produces distressing symptoms Symptoms: Flushed skin, N/V, palpitations, hyperventilation
  • 49. Meglitinides Repaglinide (Prandin) Nateglinide (Starlix) Action: stimulates pancreatic cells to secret more insulin much shorter-acting insulin secretagogues than the sulfonylureas may be used in patients who have allergy to sulfonylurea medications.
  • 50. Alpha-glucosidase inhibitors Acarbose (Precose) Miglitol (Glyset) Action: Slow carbohydrate digestion and delay glucose absorption S/E : diarrhea & flatulence Take immediately before meals
  • 51. Thiazolidinediones (TZDs) Pioglitazone [Actos] Rosiglitazone [Avandia] Used for patients with type 2 DM who take insulin injections  Acts by increasing insulin action at the receptor site  reduce insulin resistance  act as insulin sensitizers; thus, they require the presence of insulin to work. must be taken for 12-16 weeks to achieve maximal effect.
  • 52. Thiazolidinediones (TZDs) Affects liver function  liver function tests Indications of altered liver function  Yellow skin tone  Nausea  Abdominal pain  Dark urine
  • 53. Drug InteractionsDirectly interact with SulfonamidesSulfonylurea and NSAIDSincrease risk ofhypoglycemiaSulfonylurea+ * Med =Hypoglycemia
  • 54. Drug Interactionsh blood glucose levels Potassium-losing diureticsRegardless of what Corticosteriodsmed you might also be Estrogen compoundstaking Phenytoin (Dilantin) Salicylates (ASA)
  • 55. Drug interactionsMeds that cause AcetaminophenHypoglycemia Alcohol Monoamine oxidaseWithout drug inhibitors / MAO inhibitorsinteraction
  • 56. Drug interactionsMeds that can Propranolol (Inderal) MASK signs andsymptoms ofHypoglycemia
  • 57. Oral Hypoglycemic Agents Client must also maintain prescribed diet and exercise program; monitor blood glucose levels Not used with pregnant or lactating women Specific drug interactions may affect the blood glucose levels
  • 58. Insulin
  • 59.  Instituted in 1923  Beef  Pork 1979 – human insulin Can not be taken by mouth (digested)
  • 60. Onset – Peak - Duration Onset  The time period from injection to when it begins to take effect Peak  When insulin is working its hardest and therefore blood glucose levels are at their lowest Duration  Length of time the insulin works or lasts
  • 61. Types Rapid-acting insulins or Ultra short-acting Short-Acting Insulins Intermediate-Acting Insulins Long-Acting Insulins
  • 62. Rapid-acting insulins/or Ultra short-acting have a short duration of action appropriate for use before meals or when blood glucose levels exceed target levels and correction doses are needed. These agents are associated with less hypoglycemia than regular insulin.
  • 63. Rapid-Acting Insulins/or Ultra short-acting Insulin aspart (NovoLog) Insulin glulisine (Apidra) Insulin lispro (Humalog)
  • 64. Rapid-Acting Insulins  Insulin aspart (NovoLog)  Insulin glulisine (Apidra)  Insulin lispro (Humalog)Appearance Onset Peak Duration Clear 5-15 minutes 30-90 (1hr) 3-5 hours (10 min) (4 hrs)  Insulin pumps  Rapid reduction of glucose level
  • 65. Short-Acting Insulins Regular insulin (Humulin R, Novolin R) Preparations:  mixture of 70% neutral protamine Hagedorn (NPH) and 30% regular human insulin  (ie, Novolin 70/30, Humulin 70/30)
  • 66. Short-Acting Insulins Humalog R; Novolin R; Iletin II RegularAppearance Onset Peak Duration Clear ½ - 1 hr 2-4 hrs 4-6 hrs (1 hour) (3 hour) (5 hours) Administered 20-30 minutes before meals IV Usually given 4 x a day May to taken alone or in combination
  • 67. Intermediate-Acting Insulins Insulin NPH (Humulin N,  onset of action: 3-4 Novolin N) hours. have a slow onset of  Peak: 8-14 hours action and a longer  duration of action : 16-24 duration of action. hrs commonly combined  appears cloudy with faster-acting insulins to maximize the  must be gently mixed benefits of a single and checked for injection clumping  if clumping occurs, the insulin should be discarded.
  • 68. Intermediate-Acting Insulins Insulin NPH (Humulin N, Novolin N)Appearance Onset Peak Duration Cloudy 2-4 hrs 6-12 hrs 16-20 hrs (2 hrs) (12 hrs) (24 hrs) Administer after meals Usually given 2x a day Eat at onset!
  • 69. Long-Acting Insulins provide a longer  Insulin detemir duration of action, and, (Levemir) when combined with  Insulin Glargine rapid- or short-acting (Lantus) insulins, they provide better glucose control
  • 70. Types of Insulin –Long-acting Ultra Lente (UL) Appearance Onset Peak Duration Cloudy 4-8hour 10-30 hrs 36+ hours (6 hrs) (24 hrs) (36 hrs) To control fasting glucose levels Cannot be mixed!
  • 71. Long-Acting Insulins Insulin detemir  Insulin glargine  for once- or twice-daily  onset of action: 4-8 dosing hours  duration of action is up  Duration: 24 hours. to 24 hours  Peak effects; 16-18 hrs  FDA has advised of a possible association of insulin glargine with an increased risk of cancer
  • 72. Rapid-Acting InsulinsAppearance Onset Peak Duration Clear 5-15 minutes 30-90 3-5 hours (10 min) (1hr) (4 hrs) Short-Acting Insulins Appearance Onset Peak Duration Clear ½ - 1 hr 2-4 hrs 4-6 hrs (1 hour) (3 hour) (5 hours)
  • 73. Learning Tip: Even and Odd Short-acting think odd  (1-3-5) Intermediate-acting think even  (2-12-24)
  • 74. Intermediate-Acting InsulinsAppearance Onset Peak Duration Cloudy 2-4 hrs 6-12 hrs 16-20 hrs (2 hrs) (12 hrs) (24 hrs)Long-acting insulinAppearance Onset Peak Duration Cloudy 4-8hour 10-30 hrs 36+ hours (6 hrs) (24 hrs) (36 hrs)
  • 75. When should insulin beadministered Short-acting / regular  30 minutes before meals  Do not allow more than 30 minutes to pass by without eating   hypoglycemia Intermediate acting  After meals If mixed (regular & intermediate)  30 minutes before meals
  • 76. What route is insulinadministered Sub-cutaneous IV  Regular Pump
  • 77. Insulin Type Onset Peak DurationUltra Short 15 mins 30-90 mins 2- 4 hrs Short 30 mins 2- 4 hrs 6-8 hrsIntermediate 1-2 hrs 6-12 hrs 18-24 hrs Long 4-6 hrs 16-24 hrs 18-36 hrsCombination 30-60 2- 4 hrs, 6-8hrs,then70/30 mins then then 6-12 18-24 hrs 1-2 hrs hrs
  • 78. Insulin Type Onset Peak Duration Insulin 30-60 None 24 hours glargine minutes
  • 79. Diabetes Mellitus Mixing insulin
  • 80. Adverse effects of insulin
  • 81. Adverse effects of insulin  Local allergic reactions  Insulin lipodystrophy  Insulin resistance  Dawn Phenomenon  Somogyi phenomenon  Insulin waning
  • 82. Insulin lipodystrophy or lipoatrophy is primary idiopathic atrophy of adipose tissue can be a lump or small dent in the skin that forms when a person keeps performing injections in the same spot.
  • 83. Insulin lipodystrophy lipohypertrophy
  • 84. Rotate site of injection
  • 85. Nursing Responsibilities Route : Subcutaneous Steady absorption Less painful IV – in emergency cases ( DKA) Only regular insulin is given through the IV route Do not massage the site Fastest absorption site is the abdomen, then deltoids, thighs then buttocks
  • 86. Nursing Responsibilities Administer at room temperature  Cold insulin causes lipodystrophy Rotate site of injection  To prevent lipodystrophy. Inhibits insulin absorption Store vial of insulin in current use at room temperature  Other vials should be refrigerated
  • 87. Nursing Responsibilities Gently roll vial in between the palms to redistribute insulin particles  Do not shake. Bubbles make it difficult to redistribute insulin particles
  • 88. Nursing Responsibilities Observe for side effects  Localized  Induration or redness  Swelling  Lesions at the site  Lipodystrophy  Edema  Sudden resolution of hyperglycemia causes retention of water  Hypoglycemia
  • 89. Somogyi Effect Rebound hyperglycemia Normal or blood glucose levels are present at bedtime hypoglycemia : occurs at 2-3am  This causes an increase in the production of counterregulatory hormones Hyperglycemia: by 7 am  Resuts in response to the counterregulatory hormones
  • 90. Somogyi Effect Treatment  decreasing evening (predinner or bedtime) dose of intermediate acting insulin  or increasing the bedtime snack
  • 91. Dawn Phenomenon (6 AM – 8 AM) early AM increase in blood glucose levels associated with release of growth hormone at 12 MN to 3 AM
  • 92. Dawn Phenomenon:TREATMENT Type 1 diabetes  Intensify insulin therapy  Avoid late night snacking, unless appropriate quick- acting insulin is given. Type 2 diabetes  Adjust diet content (decrease carbohydrates) and timing of the evening meal so that the glucose level at bedtime is 70-110 mg/dl  If dietary modification is not enough, consider an intermediate or long-acting sulfonylurea at evening meal.  Basal insulin is indicated if the dawn phenomenon continues.
  • 93. Insulin Waning Progressive rise in the blood glucose levels from bedtime to morning Treatment:  Increase dose of evening intermediate acting or long acting insulin
  • 94. Difference between dawn phen and insulin waning 10 PM 2 AM 4 AM 8 AM Dawn 100 110 135 250 Phenomenon Waning of 100 160 220 270 insulinDawn phenomenon shows an abrupt increase between4 a.m. and 8 a.m., whereas waning of exogenousinsulin effect shows gradual rise between 2 a.m. and 8a.m.
  • 95. Other meds
  • 96. Glucagonlike peptide–1 (GLP-1 )agonists Exenatide injectable solution (Byetta) Exenatide injectable suspension (Bydureon) mimic the endogenous incretin GLP-1 it enhances glucose-dependent insulin secretion by pancreatic beta cells, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying.
  • 97. Glucagonlike peptide–1 (GLP-1 )agonists Liraglutide (Victoza)  a once-daily injectable  stimulates G-protein in pancreatic beta cells.
  • 98. Dipeptidyl peptidase IV (DPP-4)inhibitors prolong action of incretin hormones Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta)
  • 99. Amylinomimetics Pramlintide acetate (Symlin) amylin analog that mimics the effects of endogenous amylin, which is secreted by pancreatic beta cells. delays gastric emptying, decreases postprandial glucagon release, and modulates appetite.
  • 100. Bile acid sequestrants bile acid sequestrant colesevelam lipid-lowering agents for the treatment of hypercholesterolemia but were subsequently found to have a glucose-lowering effect.
  • 101. Antiparkinson Agents, DopamineAgonists Bromocriptine (Cycloset)  indicated as an adjunct to Quick-release diet and exercise to bromocriptine acts on improve glycemic control. circadian neuronal activities within the hypothalamus to reset the abnormally elevated hypothalamic drive for increased plasma glucose, triglyceride, and free fatty acid levels in fasting and postprandial states in patients with insulin resistance.
  • 102. Non-Insulin Injectables New drugs are available for people with type 2 diabetes. Pramlintide (Symlin), exenatide (Byetta), and liraglutide (Victoza) are non-insulin injectable drugs. insulin pulls glucose into the cells these medications cause the body to release insulin to control blood sugar levels.
  • 103. Other meds
  • 104. Glucagonlike peptide–1 (GLP-1 )agonists Exenatide injectable solution (Byetta) Exenatide injectable suspension (Bydureon) mimic the endogenous incretin GLP-1 it enhances glucose-dependent insulin secretion by pancreatic beta cells, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying.
  • 105. Glucagonlike peptide–1 (GLP-1 )agonists Liraglutide (Victoza)  a once-daily injectable  stimulates G-protein in pancreatic beta cells.
  • 106. Dipeptidyl peptidase IV (DPP-4)inhibitors prolong action of incretin hormones Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta)
  • 107. Amylinomimetics Pramlintide acetate (Symlin) amylin analog that mimics the effects of endogenous amylin, which is secreted by pancreatic beta cells. delays gastric emptying, decreases postprandial glucagon release, and modulates appetite.
  • 108. Bile acid sequestrants bile acid sequestrant colesevelam lipid-lowering agents for the treatment of hypercholesterolemia but were subsequently found to have a glucose-lowering effect.
  • 109. Antiparkinson Agents, DopamineAgonists Bromocriptine (Cycloset)  indicated as an adjunct to Quick-release diet and exercise to bromocriptine acts on improve glycemic control. circadian neuronal activities within the hypothalamus to reset the abnormally elevated hypothalamic drive for increased plasma glucose, triglyceride, and free fatty acid levels in fasting and postprandial states in patients with insulin resistance.