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Dr. Escher Dr. Escher Presentation Transcript

  • DIABETES MELLITUS ISSUES IN THE LONG TERM CARE SETTING AND ALLIED VENUES
  • DIABETES MELLITUS
    • Focus: diabetes in the Medicare population
  • DIABETES MELLITUS
    • Definition: a metabolic disorder in which
    • there is deficiency of insulin production or
    • resistance of organs to the effect of insulin
  • DIABETES MELLITUS
    • Diabetes is a disorder of metabolism--the way our bodies use digested food for growth and energy.
    • Most of the food we eat is broken down into glucose, the form of sugar in the blood.
    • Glucose is the main source of fuel for the body.
    • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • DIABETES MELLITUS
    • After digestion, glucose passes into the bloodstream, where it is used by cells for growth and energy.
    • For glucose to get into cells, insulin must be present.
    • Insulin is a hormone produced by the pancreas, a large gland behind the stomach.
    • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • DIABETES MELLITUS
    • NORMAL: When non-diabetic people eat, the pancreas automatically produces the right amount of insulin to move glucose from blood into our cells.
    • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • DIABETES MELLITUS
    • DIABETES: In people with diabetes, when they eat, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced (or both) => glucose builds up in the blood, overflows into the urine, and passes out of the body in urine => body loses its main source of fuel even though blood contains large amounts of glucose.
    • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • DIABETES MELLITUS (DM)
    • TYPES OF DIABETES
          • Type I
          • Type II
          • MODY (Maturity Onset Diabetes of Youth
          • Gestational
  • DM TYPE I
    • Auto-immune disease
    • Constitutes 5-10% of DM diagnosed in the USA
    • Mostly appears in children and young adults
    • Develops as a result of auto-immune destruction of beta-cells in the pancreas
    • Presents with polyuria, thirst, weight loss, marked fatigue
    • Can be complicated by coma with ketoacidosis
            • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • DM TYPE II
    • Most common form of diabetes
    • Involves about 90-95% of people with DM
    • Associated with:
      • older age
      • obesity
      • family history of DM
      • prior history of gestational diabetes
      • physical inactivity
      • ethnicity
            • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • DM TYPE II
    • Patient with type II DM usually makes enough insulin but the body cannot use it effectively => insulin resistance
    • Gradually insulin production decreases over the following years
    • Symptoms are similar to type I but develop more gradually
            • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • DM TYPE II
    • Symptoms of type II DM include:
      • Fatigue
      • Nausea
      • Frequent urination/polyuria
      • Thirst
      • Unusual weight loss
      • Blurred vision
      • Frequent infections
      • Slow healing of wounds or sores
      • Sometimes no specific symptoms
        • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • GESTATIONAL DIABETES
    • Develops only during pregnancy
    • More common in:
      • African Americans
      • American Indians
      • Hispanic Americans
      • women with a family history of diabetes
    • Women with a history of gestational diabetes have a 20-50% chance of getting type II DM within 5-10 years <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
  • Diabetes Mellitus: Diagnosis
    • Fasting plasma glucose = preferred test : Positive test is glycemia of 126mg/dL or higher after fasting at least 8 hours
    • Random plasma glucose of 200mg/dL or higher along with symptoms of diabetes
    • Oral glucose tolerance test (OGTT) plasma glucose of 200mg/dL or higher done 2 hours after ingestion of 75 grams of glucose in water
    • <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
    • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
  • Diabetes Mellitus
    • Hemoglobin A1c measurement is not recommended currently for diagnosis of diabetes.
    • HbA1c is used as a marker to monitor glycemia control in patients over time
    • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
  • Pre-Diabetes
    • Pre-diabetes refers to a state between “normal” and “diabetes” = fasting plasma glucose 100-125mg/dL (higher than normal but not high enough for diagnosis of diabetes) Affects about 41 million people in USA (previously referred to as either impaired fasting glucose or impaired glucose tolerance)
    • http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#types
    • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
  • Type II Diabetes
    • Diagnostic testing - when to do it:
    • People  45 years old => if normal then every 3 years
    • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
  • Type II Diabetes: diagnostic testing
    • Younger than 45 yo or more often than every 3 years if:
    • overweight
    • first degree relative with diabetes
    • member of high risk ethnic group (Afro-American, Hispanic American, Native American, Asian American, Pacific Islander)
    • delivered a baby  9 lbs.
    • gestational diabetes
    • hypertensive (BP  140/90mmHg)
    • High Density Lipoprotein cholesterol 35mg/dl or less
    • TriGlyceride level 250mg/dl or more
    • pre-diabetes
    • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
  • DM type II: Management
    • Basics:
    • healthy eating
    • physical activity
    • blood glucose testing
    • Pharmaceuticals:
    • oral medication(s)
    • insulin(s)
    • both oral medicines and insulin
  • DM: insulin variations
    • Daily insulin requirements are influenced by:
    • diet
    • exercise
    • stress
  • Diabetes Management: Stress
    • Stress influences response to insulin
    • Stress => increased cortisol
    • increased catecholamines
    • increased growth hormone
    • => these hormones all lead to increased insulin resistance (thus, hyperglycemia)
  • Control of Diabetes
    • Control of Diabetes includes:
    • glycemia control (FBS < 126mg/dL; HbA1c <7%)
    • weight management
    • blood pressure control (BP < 130/80mmHg)
    • lipid management
    • reduction in the hypercoagulable state (aspirin or clopidogrel)
  • DM type II: Management
    • Most people with newly discovered type II DM are overweight
    • Basics are diet and exercise:
    • nutrition
    • life style modification
    • increased physical activity
    • Goal = Hemoglobin A1c < 7%
    • If this goal in not reached and maintained => pharmacotherapy (medications)
  • Insulins
    • Type hours to onset time to peak time effective
    • Fast acting:
    • Lispro <0.25 (15min) 0.5-1.5 3-4 (max 4-6)
    • Aspart 0.17-0.33 0.67-0.83 1-3 (max 3-5)
    • Long acting
    • Glargine 2 none 24
    • Ultralente 6-10 10-16 18-20 (max 20-24)
    • Short acting
    • regular 0.5-1.0 2-3 3-6 (max 6-8)
    • Intermediate acting
    • NPH 2-4 6-10 10-16 (max 14-18)
    • Lente 3-4 6-12 12-18 (max 16-20)
    • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
  • Insulin
    • Insulin dependency regimens - examples:
    • 1. insulin glargine q24h and pre-meal insulin
    • 2. NPH and regular before breakfast and supper
    • 3. Rapid or short acting insulin before meals & intermediate acting insulin (NPH or Lente) at bedtime
    • 4. Insulin Glargine at bedtime and rapid or short acting insulin before meals
    • Insulin regimens depend on individual patient requirements
  • Medications for DM type II
    • Sulfonylureas & Meglitinides : promote glucose-stimulated release of insulin from pancreas (they need enough remaining beta-cell function in the pancreas to work) (insulin secretogogues)
    • Metformin : mostly blocks gluconeogenesis in the liver; also interferes with glycogenolysis and improves insulin sensitivity of muscle
    • Thiazolidinediones : bind to nuclear receptors in tissues & activate or suppress expression of specific genes (insulin sensitizers) - risk of fluid retention & weight gain; 4-12 week latency to work; monitor liver enzymes q2mo
    • Acarbose : alpha-glucosidase inhibitor; interferes with intestinal absorption of carbohydrates; causes flatulence & bloating (discontinuation)
    • MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
  • Medications for DM type II
    • Sulfonylureas: insulin secretogogues
    • glyburide
    • glipizide
    • glimeperide
    • chlorpropamide
    • Meglitinides: insulin secretogogues
    • repaglinide
    • nateglinide
    • Biguanide: decreases hepatic gluconeogenesis
    • metformin
    • Thiazolidinediones : insulin sensitizers
    • pioglitazone
    • rosiglitazone
    • Alpha-glucosidase inhibitor : decreases GI absorption of carbohydrate
    • acarbose ;
  • Insulin in Type II DM
    • Usually indicated if HbA1c > 7% despite life style modification and 2 oral medications
    • May be postponed in borderline cases where HbA1c is < 8.5% pending addition of a 3rd oral agent; otherwise =>
    • Addition of bedtime dose of basal insulin therapy (glargine) to sulfonylureas +/- metformin (not thiazolidinediones because of risk of CHF from fluid retention)
  • The Metabolic Syndrome
    • Hypertension
    • Visceral (central) obesity
    • Hypertriglyceridemia
    • Low HDL cholesterol
    • Insulin resistance or glucose intolerance
    • Prothrombotic state (high fibrinogen or plasminogen activator inhibitor [-1] in blood)
    • Proinflammatory state (high C-reactive protein in blood)
    • http://www.americanheart.org/presenter.jhtml?identifier=4756
  • Acute Complications of type II DM
    • Hyperglycemic hyperosmolar state:
    • common in elderly
    • triggered by underlying disorder(s)
    • risk increased in elderly due to decreased thirst reflex
    • often complicated by delirium
  • Acute Complications of type II DM
    • Hyperglycemic hyperosmolar state:
    • serum osmolarity > 320 mosm/L
    • plasma glucose > 600mg/dL
    • dehydration
    • no ketoacidosis
    • underlying disorder(s)
  • Hyperosmolar State
    • Therapy:
    • rehydration with hypotonic solution
    • insulin infusion (initially)
    • watch for signs of fluid overload/CHF
    • monitor potassium
    • treat underlying cause (eg UTI, cellulitis)
  • Hypoglycemia
    • Hypoglycemia = plasma glycemia < 50mg/dL with or without symptoms
    • More common in type I DM and patients with significant renal or liver disease
    • Another reason for glucose monitoring
    • Treated with po sugar (e.g. fruit juice or glucose tablets)
    • or IV dextrose 50% in water or IV glucagon or both
  • Complications of DM
    • Chronic complications of diabetes mellitus include:
    • Macrovascular
    • Microvascular
    • Neuropathic
  • Complications of DM
    • Macrovascular
    • atherosclerosis/cardiovascular disease
    • peripheral vascular disease
  • Complications of DM
    • Microvascular diabetic retinopathy : due to ischemia of retna; provokes neovascularization with vessels more fragile => leaking => scarring & fibrosis
    • diabetic nephropathy : common cause of ESRD;
    • prevention via control of blood pressure and glycemia; earliest signs urine albumin 30mg/day or 20  g/min; appears to benefit from ACE-I’s and ARB’s too
  • Complications of DM
    • Diabetic Neuropathy
    • peripheral sensory neuropathy
    • cardiovascular autonomic neuropathy
    • gastrointestinal autonomic neuropathy
    • erectile dysfunction
    • mononeuropathy
    • diabetic foot
  • Complications of DM
    • Peripheral sensory neuropathy
    • variable presentation
    • dysesthesia
    • tingling
    • pain
    • loss of pain sensation (risk of injury)
  • Complications of DM
    • Cardiovascular Autonomic Neuropathy
    • orthostatic hypotension
    • lack of normal variation in heart rate with breathing, tachycardia
  • Complications of DM
    • Gastrointestinal Autonomic Neuropathy
    • gastroparesis: nausea, bloating, vomiting (tx metoclopramide)
    • diarrhea: often nocturnal
  • Complications of DM
    • Erectile dysfunction:
    • autonomic neuropathy
    • absent nocturnal and morning erections
    • more common than diagnosed
  • Complications of DM
    • Mononeuropathy
    • acute local pain
    • distribution of a nerve
    • may recede if treated early with improved glucose control (glucotoxicity)
  • Complications of DM
    • Diabetic Foot
    • sensory deficit (skin, bone, ligament)
    • fungal infection
    • wounds
    • pulses (PVD)
    • slow healing
    • ulcers
  • Type II DM: Goals
    • Prevention of pre-diabetes
    • Prevention of change from pre-diabetes to diabetes
    • Diagnosis through screening
    • Early management/therapy
    • Prevention of complications
  • Type II DM: Goals
    • Screening via fasting glycemia and history
    • Life-style history and modification
    • Physical activity
    • Diet
    • Treatment of glycemia, lipids, hypercoagulable state, blood pressure
    • Management of complications
  •