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Diabetes Mellitus Barbara S. Hays Winter, 2006
Blood Glucose ( normal serum level 65 – 105 mg ) <ul><li>Inside CNS </li></ul><ul><ul><li>Brain uses glucose as primary fu...
Blood glucose, cont. <ul><li>Outside CNS, continued </li></ul><ul><ul><li>Endocrine portion of pancreas: Islets of Langerh...
Hyperglycemia <ul><li>When blood glucose becomes high </li></ul><ul><ul><li>INSULIN allows glucose to enter cells </li></u...
Hyperglycemia <ul><li>Drowsy </li></ul><ul><li>Flushed </li></ul><ul><li>Thirsty </li></ul>
Hypoglycemia <ul><li>Glucagon: causes release of glucose from liver </li></ul><ul><ul><li>“ glycogenolysis (breakdown of g...
Hypoglycemia <ul><li>Weak, sweaty </li></ul><ul><li>Confused/irritable/ disoriented </li></ul>
Diabetes Mellitus (problem with glucose metabolism) <ul><li>Major health problem US/worldwide </li></ul><ul><li>Complicati...
Diabetes Mellitus <ul><li>The good news: </li></ul><ul><ul><li>Blood glucose control reduces complications of Diabetes! </...
Diabetes Mellitus <ul><li>Absence (or ineffectiveness of ) insulin </li></ul><ul><li>Cellular resistance </li></ul><ul><li...
Diabetes Mellitus <ul><li>HYPERGLYCEMIA :  fluid/electrolyte imbalance. </li></ul><ul><ul><li>Polyuria </li></ul></ul><ul>...
Diabetes Mellitus <ul><li>Complications of chronic hyperglycemia </li></ul><ul><ul><li>Macrovascular  complications </li><...
Classifying Diabetes Mellitus <ul><li>Type I Diabetes: autoimmune </li></ul><ul><ul><li>Beta cell destruction in genetical...
Classifying Diabetes Mellitus <ul><li>Type II Diabetes </li></ul><ul><ul><li>Reduction in ability of most cells to respond...
Diabetes Mellitus <ul><li>Major risk factors </li></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Obesity </li>...
Diabetes Mellitus <ul><li>Prevention of effects: combination approach </li></ul><ul><ul><li>Increased exercise </li></ul><...
Triad of Treatment <ul><li>Diet </li></ul><ul><li>Medication </li></ul><ul><ul><li>Oral hypoglycemics </li></ul></ul><ul><...
Diabetes treatment <ul><li>Exercise </li></ul><ul><ul><li>Under physician supervision </li></ul></ul><ul><ul><li>Check glu...
Diabetes treatment <ul><li>Diet </li></ul><ul><ul><li>Lower calorie </li></ul></ul><ul><ul><li>Fewer foods of “high glycem...
Diabetes treatment <ul><li>Anti-Diabetic medications </li></ul><ul><ul><li>Oral hypoglycemic agents (“Easy” p 297) </li></...
Sulfonylureas <ul><li>Stimulate pancreas to secrete insulin </li></ul><ul><ul><li>Glyburide (Diabeta) [Prototype Pro p 393...
Biguanides <ul><li>Decreases liver production of glucose </li></ul><ul><li>Decreases intestinal absorption of glucose </li...
Thiazolidinediones <ul><li>Increase cellular sensitivity to insulin </li></ul><ul><ul><li>Pioglitazone (Actos) </li></ul><...
D-Phenylalanine derivatives <ul><li>Nateglinide (Starlix) </li></ul><ul><li>Rapid onset, short half-life </li></ul><ul><ul...
Combinations <ul><li>Glucovance </li></ul><ul><ul><li>Glyburide and Metformin </li></ul></ul><ul><li>Avandamet </li></ul><...
Insulin <ul><li>Made in  beta  cells of the pancreas </li></ul><ul><li>Moves glucose into cells (thus acts like growth hor...
Insulin preparations (“Easy” p 390) given ONLY with syringes marked in “units” <ul><li>Rapid acting  (lispro, asparte) </l...
Your learning <ul><li>Onset of action </li></ul><ul><li>Peak (blood glucose will be lowest then) </li></ul><ul><li>Duratio...
Rapid acting insulin <ul><li>Lispro ( Humolog,  Novolog Aspart) </li></ul><ul><ul><li>Onset of action </li></ul></ul><ul><...
Short acting insulins <ul><li>Regular (clear so can be given IV) </li></ul><ul><ul><li>Onset of action </li></ul></ul><ul>...
Intermediate acting insulins <ul><li>NPH , Lente (chemicals added. Cloudy) </li></ul><ul><ul><li>Onset of action </li></ul...
Long acting insulins <ul><li>Ultralente </li></ul><ul><ul><li>Onset of action </li></ul></ul><ul><ul><ul><li>4 – 8 hours <...
Once a day insulin <ul><li>Glargine/Lantus </li></ul><ul><ul><li>Cannot be diluted or mixed in syringe with any other insu...
Combination insulins <ul><li>70/30 (70% NPH and 30% regular) </li></ul><ul><li>Humolog 70/30 (Humolog and regular) </li></...
Miscellaneous <ul><li>Byetta  for type II Diabetics taking sulfonylureas or combination </li></ul><ul><ul><li>Mimics physi...
Some things to know <ul><li>Insulin moves potassium into cells </li></ul><ul><ul><li>Good for emergency situations </li></...
Some things to know… <ul><li>HHNK  ( H yperglycemic  H yperosmolar  N on- K etotic Coma).  Also called </li></ul><ul><ul><...
Some things to know… <ul><li>Dawn Phenomenon vs Somogi’s effect </li></ul><ul><ul><li>Dawn phenomenon </li></ul></ul><ul><...
Some things to know… <ul><li>Diabetic foot care </li></ul><ul><ul><li>Dry, cracked skin + poor circulation could = loss of...
Typical diabetic foot ulcer
 
 
 
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Diabetes Mellitus

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Transcript of "Diabetes Mellitus"

  1. 1. Diabetes Mellitus Barbara S. Hays Winter, 2006
  2. 2. Blood Glucose ( normal serum level 65 – 105 mg ) <ul><li>Inside CNS </li></ul><ul><ul><li>Brain uses glucose as primary fuel </li></ul></ul><ul><ul><li>Brain cannot store/produce glucose </li></ul></ul><ul><li>Outside CNS </li></ul><ul><ul><li>Fatty acids: stored as </li></ul></ul><ul><ul><ul><li>Glycogen (liver/muscles) </li></ul></ul></ul><ul><ul><ul><li>Triglycerides (fat cells) </li></ul></ul></ul>
  3. 3. Blood glucose, cont. <ul><li>Outside CNS, continued </li></ul><ul><ul><li>Endocrine portion of pancreas: Islets of Langerhans </li></ul></ul><ul><ul><ul><li>Alpha cells make glucagon </li></ul></ul></ul><ul><ul><ul><ul><li>“ counterregulatory”, acts opposite of insulin </li></ul></ul></ul></ul><ul><ul><ul><li>Beta cells make insulin </li></ul></ul></ul><ul><ul><ul><ul><li>Allows body cells to store and use carbohydrate, fats, and protein </li></ul></ul></ul></ul>
  4. 4. Hyperglycemia <ul><li>When blood glucose becomes high </li></ul><ul><ul><li>INSULIN allows glucose to enter cells </li></ul></ul><ul><ul><ul><li>Liver </li></ul></ul></ul><ul><ul><ul><ul><li>Production /storage of glycogen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inhibits glycogen breakdown </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increased protein & fat synthesis (VLDL formation) </li></ul></ul></ul></ul><ul><ul><ul><li>Muscles </li></ul></ul></ul><ul><ul><ul><ul><li>Promotes protein and glycogen synthesis </li></ul></ul></ul></ul><ul><ul><ul><li>Fat cells </li></ul></ul></ul><ul><ul><ul><ul><li>Promotes storage of triglycerides </li></ul></ul></ul></ul>
  5. 5. Hyperglycemia <ul><li>Drowsy </li></ul><ul><li>Flushed </li></ul><ul><li>Thirsty </li></ul>
  6. 6. Hypoglycemia <ul><li>Glucagon: causes release of glucose from liver </li></ul><ul><ul><li>“ glycogenolysis (breakdown of glycogen to glucose) </li></ul></ul><ul><ul><li>“ glyconeogenesis of glucose not available </li></ul></ul><ul><ul><ul><li>Lipolysis (breakdown of fat) </li></ul></ul></ul><ul><ul><ul><li>Proteolysis (breakdown of amino acids) </li></ul></ul></ul>
  7. 7. Hypoglycemia <ul><li>Weak, sweaty </li></ul><ul><li>Confused/irritable/ disoriented </li></ul>
  8. 8. Diabetes Mellitus (problem with glucose metabolism) <ul><li>Major health problem US/worldwide </li></ul><ul><li>Complications [lousy blood vessels] </li></ul><ul><ul><li>Blindness </li></ul></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Amputations </li></ul></ul><ul><ul><li>[heart attacks and strokes] </li></ul></ul><ul><ul><li>[OB/neonatal complications] </li></ul></ul>
  9. 9. Diabetes Mellitus <ul><li>The good news: </li></ul><ul><ul><li>Blood glucose control reduces complications of Diabetes! </li></ul></ul>
  10. 10. Diabetes Mellitus <ul><li>Absence (or ineffectiveness of ) insulin </li></ul><ul><li>Cellular resistance </li></ul><ul><li>Cells can’t use glucose for energy </li></ul><ul><ul><li>Starvation mode </li></ul></ul><ul><ul><ul><li>Compensatory breakdown of body fat/protein </li></ul></ul></ul><ul><ul><ul><li>Ketone bodies from faulty fat breakdown </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Metabolic acidosis, compensatory breathing (Kussmal’s breathing) </li></ul></ul></ul></ul></ul>
  11. 11. Diabetes Mellitus <ul><li>HYPERGLYCEMIA : fluid/electrolyte imbalance. </li></ul><ul><ul><li>Polyuria </li></ul></ul><ul><ul><ul><li>Sodium, chloride, potassium excreted </li></ul></ul></ul><ul><ul><li>Polydipsia from dehydration </li></ul></ul><ul><ul><li>Polyphagia : cells are starving, so person feels hungry despite eating huge amounts of food. Starvation state remains until insulin is available. </li></ul></ul>
  12. 12. Diabetes Mellitus <ul><li>Complications of chronic hyperglycemia </li></ul><ul><ul><li>Macrovascular complications </li></ul></ul><ul><ul><ul><li>Cardiovascular disease (heart attack) </li></ul></ul></ul><ul><ul><ul><li>Cerebrovascular disease (strokes) </li></ul></ul></ul><ul><ul><li>Microvascular </li></ul></ul><ul><ul><ul><li>Blindness (retinal proliferation, macular degeneration) </li></ul></ul></ul><ul><ul><ul><li>Amputations </li></ul></ul></ul><ul><ul><ul><li>Diabetic neuropathy (diffuse, generalized, or focal) </li></ul></ul></ul><ul><ul><ul><li>Erectile dysfunction </li></ul></ul></ul>
  13. 13. Classifying Diabetes Mellitus <ul><li>Type I Diabetes: autoimmune </li></ul><ul><ul><li>Beta cell destruction in genetically susceptible person </li></ul></ul><ul><ul><li>Some viral infections </li></ul></ul>
  14. 14. Classifying Diabetes Mellitus <ul><li>Type II Diabetes </li></ul><ul><ul><li>Reduction in ability of most cells to respond to insulin </li></ul></ul><ul><ul><li>Poor control of liver glucose output </li></ul></ul><ul><ul><li>Decreased beta-cell function (eventual failure) </li></ul></ul>
  15. 15. Diabetes Mellitus <ul><li>Major risk factors </li></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Origin (Afro-American, Hispanic, Native American, Asian-American) </li></ul></ul><ul><ul><li>Age (older than 45) </li></ul></ul><ul><ul><li>History of gestational diabetes </li></ul></ul><ul><ul><li>High cholesterol </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul>
  16. 16. Diabetes Mellitus <ul><li>Prevention of effects: combination approach </li></ul><ul><ul><li>Increased exercise </li></ul></ul><ul><ul><ul><li>Decreases need for insulin </li></ul></ul></ul><ul><ul><li>Reduce calorie intake </li></ul></ul><ul><ul><ul><li>Improves insulin sensitivity </li></ul></ul></ul><ul><ul><li>Weight reduction </li></ul></ul><ul><ul><ul><li>Improves insulin action </li></ul></ul></ul>
  17. 17. Triad of Treatment <ul><li>Diet </li></ul><ul><li>Medication </li></ul><ul><ul><li>Oral hypoglycemics </li></ul></ul><ul><ul><li>Insulins </li></ul></ul><ul><li>Exercise </li></ul>
  18. 18. Diabetes treatment <ul><li>Exercise </li></ul><ul><ul><li>Under physician supervision </li></ul></ul><ul><ul><li>Check glucose prior </li></ul></ul>
  19. 19. Diabetes treatment <ul><li>Diet </li></ul><ul><ul><li>Lower calorie </li></ul></ul><ul><ul><li>Fewer foods of “high glycemic index” </li></ul></ul><ul><ul><li>Spread meals evenly </li></ul></ul>
  20. 20. Diabetes treatment <ul><li>Anti-Diabetic medications </li></ul><ul><ul><li>Oral hypoglycemic agents (“Easy” p 297) </li></ul></ul><ul><ul><ul><li>Sulfonylureas </li></ul></ul></ul><ul><ul><ul><li>Thiazolidinediones </li></ul></ul></ul><ul><ul><ul><li>Biguanides </li></ul></ul></ul><ul><ul><ul><li>Alpha-glucosidase inhibitors </li></ul></ul></ul><ul><ul><ul><li>D-phenylalinine derivatives </li></ul></ul></ul><ul><ul><ul><li>Combinations </li></ul></ul></ul><ul><ul><li>Insulins (“Easy” Prototype Pro p 393) </li></ul></ul>
  21. 21. Sulfonylureas <ul><li>Stimulate pancreas to secrete insulin </li></ul><ul><ul><li>Glyburide (Diabeta) [Prototype Pro p 393] </li></ul></ul><ul><ul><ul><li>Glucotrol (Glipizide) </li></ul></ul></ul><ul><ul><ul><li>Diabenese (chlorpropamide) </li></ul></ul></ul><ul><li>Adverse reactions </li></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Water retention/edema </li></ul></ul><ul><ul><li>Photosensitivity </li></ul></ul><ul><li>May need to add insulin in times of stress </li></ul>
  22. 22. Biguanides <ul><li>Decreases liver production of glucose </li></ul><ul><li>Decreases intestinal absorption of glucose </li></ul><ul><li>Improves cell sensitivity to insulin </li></ul><ul><li>Example: Metformin </li></ul><ul><ul><li>GI upset, flatulence </li></ul></ul><ul><ul><li>Cardiac (CHF, MI) </li></ul></ul>
  23. 23. Thiazolidinediones <ul><li>Increase cellular sensitivity to insulin </li></ul><ul><ul><li>Pioglitazone (Actos) </li></ul></ul><ul><ul><li>Rosiglitazone (Avandia) </li></ul></ul><ul><li>Client should have liver enzymes </li></ul><ul><li>checked periodically </li></ul>
  24. 24. D-Phenylalanine derivatives <ul><li>Nateglinide (Starlix) </li></ul><ul><li>Rapid onset, short half-life </li></ul><ul><ul><li>Good for those with rapid post prandial rise in blood glucose </li></ul></ul>
  25. 25. Combinations <ul><li>Glucovance </li></ul><ul><ul><li>Glyburide and Metformin </li></ul></ul><ul><li>Avandamet </li></ul><ul><ul><li>Avandia and Metformin </li></ul></ul><ul><li>[come tell me when you run into this question…] </li></ul>
  26. 26. Insulin <ul><li>Made in beta cells of the pancreas </li></ul><ul><li>Moves glucose into cells (thus acts like growth hormone in a way) </li></ul><ul><li>Moves potassium into cells (can buy time in emergencies) </li></ul>
  27. 27. Insulin preparations (“Easy” p 390) given ONLY with syringes marked in “units” <ul><li>Rapid acting (lispro, asparte) </li></ul><ul><li>Short acting (regular) </li></ul><ul><li>Intermediate acting (NPH) </li></ul><ul><li>Long acting </li></ul><ul><ul><li>Ultralente </li></ul></ul><ul><ul><li>[Glargine/Lantus] </li></ul></ul>
  28. 28. Your learning <ul><li>Onset of action </li></ul><ul><li>Peak (blood glucose will be lowest then) </li></ul><ul><li>Duration </li></ul>
  29. 29. Rapid acting insulin <ul><li>Lispro ( Humolog, Novolog Aspart) </li></ul><ul><ul><li>Onset of action </li></ul></ul><ul><ul><ul><li>“ 15-30” minutes [may come on in 5 minutes…] </li></ul></ul></ul><ul><ul><li>Peak of action </li></ul></ul><ul><ul><ul><li>1 - 2 hours </li></ul></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><ul><li>3 – 4 hours </li></ul></ul></ul>
  30. 30. Short acting insulins <ul><li>Regular (clear so can be given IV) </li></ul><ul><ul><li>Onset of action </li></ul></ul><ul><ul><ul><li>0.5 to 1 hour </li></ul></ul></ul><ul><ul><li>Peak of action </li></ul></ul><ul><ul><ul><li>2 – 4 hours </li></ul></ul></ul><ul><ul><li>Duration of action </li></ul></ul><ul><ul><ul><li>6 – 8 hours </li></ul></ul></ul>
  31. 31. Intermediate acting insulins <ul><li>NPH , Lente (chemicals added. Cloudy) </li></ul><ul><ul><li>Onset of action </li></ul></ul><ul><ul><ul><li>1 – 4 hours </li></ul></ul></ul><ul><ul><li>Peak of action </li></ul></ul><ul><ul><ul><li>4 – 12 hours </li></ul></ul></ul><ul><ul><li>Duration of action </li></ul></ul><ul><ul><ul><li>18 – 24 hours </li></ul></ul></ul>
  32. 32. Long acting insulins <ul><li>Ultralente </li></ul><ul><ul><li>Onset of action </li></ul></ul><ul><ul><ul><li>4 – 8 hours </li></ul></ul></ul><ul><ul><li>Peak of action </li></ul></ul><ul><ul><ul><li>18 hours </li></ul></ul></ul><ul><ul><li>Duration of action </li></ul></ul><ul><ul><ul><li>24 – 36 hours </li></ul></ul></ul>
  33. 33. Once a day insulin <ul><li>Glargine/Lantus </li></ul><ul><ul><li>Cannot be diluted or mixed in syringe with any other insulin </li></ul></ul><ul><ul><li>Slow, steady release </li></ul></ul><ul><ul><li>Daily dosing [usually at bedtime] </li></ul></ul><ul><ul><li>Refrigerated or tosses every 14 days </li></ul></ul>
  34. 34. Combination insulins <ul><li>70/30 (70% NPH and 30% regular) </li></ul><ul><li>Humolog 70/30 (Humolog and regular) </li></ul><ul><li>Fewer injections </li></ul><ul><li>Rotate sites to decrease lipodystrophy </li></ul>
  35. 35. Miscellaneous <ul><li>Byetta for type II Diabetics taking sulfonylureas or combination </li></ul><ul><ul><li>Mimics physiologic glucose control </li></ul></ul><ul><ul><ul><li>Inhances insulin secretion only in presence of hyperglycemia </li></ul></ul></ul><ul><ul><ul><li>Insulin secretion decreases as blood glucose approaches normal </li></ul></ul></ul><ul><li>Neutontin for Diabetic nerve pain </li></ul>
  36. 36. Some things to know <ul><li>Insulin moves potassium into cells </li></ul><ul><ul><li>Good for emergency situations </li></ul></ul><ul><ul><li>Dangerous if potassium level already low </li></ul></ul>
  37. 37. Some things to know… <ul><li>HHNK ( H yperglycemic H yperosmolar N on- K etotic Coma). Also called </li></ul><ul><ul><li>HHNK </li></ul></ul><ul><ul><li>HNKS [syndrome] </li></ul></ul><ul><ul><ul><li>Like dibetic ketoacidosis, without the ketones </li></ul></ul></ul><ul><ul><ul><li>Type II diabetic, makes enough insulin to avoid ketones, but sugar guilds up to dangerous levels -> cellular dehydration </li></ul></ul></ul>
  38. 38. Some things to know… <ul><li>Dawn Phenomenon vs Somogi’s effect </li></ul><ul><ul><li>Dawn phenomenon </li></ul></ul><ul><ul><ul><li>Blood sugar rises in early morning </li></ul></ul></ul><ul><ul><li>Somogi’s (rebound) effect </li></ul></ul><ul><ul><ul><li>Blood sugar rise in morning as reaction to hypoglycemic time during the night </li></ul></ul></ul>
  39. 39. Some things to know… <ul><li>Diabetic foot care </li></ul><ul><ul><li>Dry, cracked skin + poor circulation could = loss of a limb </li></ul></ul><ul><ul><li>For the most part nurses don’t trim nails of diabetic clients. Refer to Podiatrist. </li></ul></ul>
  40. 40. Typical diabetic foot ulcer
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