The presentation has three parts: UNITE for Diabetes Philippines CPG recommendations on medical nutrition therapy (MNT), improving adherence to MNT and use of SMS.
This presentation deals with the various approaches of medical nutrition therapy in Diabetes, comparison of the ADA, RSSDI and ICMR guidelines. It also talks about the various calorie counting apps as well.
A presentation on the care of diabetes in elderly people. This presentation is chiefly based on ADA guideline 2015 and focuses on the management of diabetes in persons aged >65 years.
SIGNIFICANCE
OVERVIEW
WHAT IS DIABETES?
DEFINITION
MECHANISM
PREVELANCE
EPIDEMIOLOGY
CLASSIFICATION
GESTATIONAL DIABETES
RISK FACTORS
DIAGNOSIS
COMPLICATIONS
MEDICAL TEST
MEDICAL NUTRITIONAL THERAPY
HERBS FOR DIABETES
MYTHS AND FACTS
REFERENCES
Diabetes is a chronic illness that can lead to serious and often fatal complications,including cardiovascular problems, amputations, coma and blindness. Recently,Canadian researchers determined that the life expectancy of diabetics was on average 13 years less than that of non-diabetics.
CME Sohag | internal medicine | Diabetes mellitusEmad Qasem
CME Sohag | internal medicine | Diabetes mellitus training session 22 may 2016 By Dr. Ahmed othman Abodooh, assistant lecturer of internal medicine, Sohag university
The presentation has three parts: UNITE for Diabetes Philippines CPG recommendations on medical nutrition therapy (MNT), improving adherence to MNT and use of SMS.
This presentation deals with the various approaches of medical nutrition therapy in Diabetes, comparison of the ADA, RSSDI and ICMR guidelines. It also talks about the various calorie counting apps as well.
A presentation on the care of diabetes in elderly people. This presentation is chiefly based on ADA guideline 2015 and focuses on the management of diabetes in persons aged >65 years.
SIGNIFICANCE
OVERVIEW
WHAT IS DIABETES?
DEFINITION
MECHANISM
PREVELANCE
EPIDEMIOLOGY
CLASSIFICATION
GESTATIONAL DIABETES
RISK FACTORS
DIAGNOSIS
COMPLICATIONS
MEDICAL TEST
MEDICAL NUTRITIONAL THERAPY
HERBS FOR DIABETES
MYTHS AND FACTS
REFERENCES
Diabetes is a chronic illness that can lead to serious and often fatal complications,including cardiovascular problems, amputations, coma and blindness. Recently,Canadian researchers determined that the life expectancy of diabetics was on average 13 years less than that of non-diabetics.
CME Sohag | internal medicine | Diabetes mellitusEmad Qasem
CME Sohag | internal medicine | Diabetes mellitus training session 22 may 2016 By Dr. Ahmed othman Abodooh, assistant lecturer of internal medicine, Sohag university
Corinne H. Rieder, Executive Director & Treasurer, John A. Hartford Foundation
The National Association of Deans and Directors of Schools of Social Work (NADD)
http://naddssw.org/
This presentation defines ethics and the five approaches to ethical standards. These can then be used to guide the conduct of carers in the course of their duties.
All diabetics irrespective of other treatment require some control of their eating and exercise patterns
Dibetics must watch their
- total caloric intake
-types of nutrients and eating schedule
50% of patients may require only diet Another 25% would need to augment their natural insulin with drugs
while the remainder will need insulin
Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre
Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre
Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre Diet recommendations include
- discouraging fats
encouraging complex carbohydrate and fibre
The recommended diabetic diet except in a few respects is now similar to the normal healthy diet that everyone should eat. i.e regular meals, low in fats, low simple sugars, low in sodium and high in complex carbohydrate (starch) and fibre
A brief description of Diabetes with management guidelines
according to different diabetes foundation and their treatment with drugs and their MOA dose and side effects
Approach to case of type 2 DM
lifestyle modificatios
indications to start drug therapy
classification of antidiabetic drugs , mechanism of action , adeverse drug effects , doses , drug interactions , how to add differents class of drugs to give combination therapy . over view insulin therapy
Similar to Diabetes Care in the Elderly in Residential Care - a focus on hypoglycemic medications (Nursing In-Service) (20)
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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Diabetes Care in the Elderly in Residential Care - a focus on hypoglycemic medications (Nursing In-Service)
1. Nursing In-Service:
Diabetes Care in the
Elderly in Residential Care
focus on anti-hyperglycemic medications
Evergreen House, Lion’s Gate Hospital
September 9 & 11, 2013
Joan Ng, B. Sc. Pharm, Pharmacy Resident
1
2. Outline of Presentation
1. Pathophysiology
2. Diagnosis
3. Signs & Symptoms
4. Considerations in Elderly
5. Goals of Therapy & Treatment Targets
6. Treatment: non-drug measures & drug therapy
7. Insulin sliding scale vs. correctional insulin
8. Case Study: BT
9. Management of hypoglycemia
2
3. Pathophysiology of Diabetes
• Diabetes Mellitus
– Metabolic disorder characterized by
hyperglycemia, due to defective insulin secretion,
impaired insulin sensitivity, or both
– T1DM (Insulin dependent)
– T2DM (Non-insulin dependent)
– Gestational Diabetes
– Chronic hyperglycemia complications
3Reference: 1,2
6. Considerations in Elderly
• Most LTC patients are “frail elderly”
– Multiple chronic illnesses with associated
vulnerabilities (e.g. dementia, falls, polypharmacy)
• Increased hypoglycemia risk with treatment
– Diminished hypoglycemia counterregulation
– More neuroglycopenic symptoms
– Associated with poorer outcomes (CV events)
– Leads to impaired cognition and function
• Drug pharmacokinetics are changed
6Reference:
7. Goals of Therapy & Treatment Targets
• Control symptoms
• Glycemic control
• Prevent/minimize
complications
• Reduce all CV risk
factors
• LTC Elderly:
– HbA1c: 8-8.5%
– Random BG: 7-14
mmol/L
7Reference: 1, 2, 6
8. Treatment: non-drug measures
• Exercise:
–Can improve insulin sensitivity
–Encourage in those able to mobilize
• Diet:
–Caution against limiting caloric intake in LTC
• Patients often already have insufficient caloric
intake due to confusion, dysphagia, anorexia
8Reference: 1
9. Treatment: Metformin
• Biguanide; hepatic glucose production,
insulin sensitivity
• 250-500mg qd 1g po bid (max 2550mg/day)
• Elderly: should not be titrated to max dose
• Pros: no hypoglycemia alone, good evidence
• Cons: causes anorexia and weight loss, risk of
lactic acidosis (renal/hepatic dysfunction), risk
of B12 and folate deficiency long-term
9Reference: 2, 4, 5, 7, 10
10. Treatment: Sulfonylureas (Gliclazide,
Glyburide)
• Increases beta-cell insulin release, increases
peripheral glucose utilization
• Gliclazide: 40mg po bid 80mg po bid (regular
release), 30mg MR qd 120mg MR qd
• Pros: very effective, gliclazide less hypoglycemia
than glyburide
• Cons: hypoglycemia, needs consistent food
intake, needs functioning beta-cells, weight gain
10Reference: 2, 4, 10
14. Insulin sliding scale vs. correctional:
What is different?
• Sliding Scale Insulin
– Traditionally: regular/short-acting insulin to treat
hyperglycemia after it has occurred
– (now, almost always give basal insulin too)
– Reactive, not proactive; possible insulin stacking
• Physiological SC insulin protocol
– Basal insulin (NPH or glargine)
– Prandial/meal-time insulin (regular or short-acting)
– Correctional-dose insulin (fine-tuning)
14Reference: 8, 9
16. Case Study: BT
• 55yo female on EGH 3S
• T2DM diagnosed 2005, previous poor control
• alcoholic cirrhosis, history of IDU, BPD
• Current drug therapy:
– Insulin glargine (lantus) 18u q am, 15u q dinner
– Insulin regular sliding scale at 0800, 1100, 1630
– Metformin 750mg bid
16
17. Case Study: BT- CBG control
17
Date Time Before
breakfast
Before
Lunch
Before
Supper
Bedtime Sliding Scale Given
9/1 0750 14.9 none
9/1 1155 23.1 10 units insulin regular
9/1 1600 28.1 14 units insulin given
9/1 2145 12.7 N/A
9/2 0730 21.5 10 units insulin regular
9/2 1130 21.6 none?
9/2 1645 17.1 5 units insulin regular
• Suboptimal control
• Nursing labour intensive: 3-4 times daily CBGs
18. Case Study: BT
Recommendation:
• change to regular tid prandial insulin + basal
insulin at bedtime
• Initially: 0.3-0.6 U/kg body weight total daily
dose – ½ basal, ½ regular tid before meals
• Measure BG more regularly in beginning, but
when patient stabilizes, can decrease
monitoring
19. Management of Hypoglycemia
• Hypoglycemia:
CBG <4.0 mmol/L
• If patient is on
acarbose, must
give glucose
• retest BG in 15
mins, re-treat with
another 15 g
carbohydrate if BG
still <4.0 mmol/L
19Reference: 1
21. References
1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association
2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes
2013;37(suppl 1):S1-S212.
2. Chau D, Edelman SV. Clinical Management of Diabetes in the Elderly. Clin Diabetes. 2001 Oct 1;19(4):172–5.
3. e-Therapeutics+ : Therapeutic Choices : Endocrine and Metabolic Disorders: Diabetes Mellitus [Internet]. [cited
2013 Sep 3]. Available from: https://www-e-therapeutics-ca.
4. Treatment of type 2 diabetes mellitus in the elderly patient [Internet]. [cited 2013 Sep 1]. Available from:
https://uptodate.vch.ca/
5. Laubscher T, Regier L, Bareham J. Diabetes in the frail elderly Individualization of glycemic management. Can
Fam Physician. 2012 May 1;58(5):543–6.
6. American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2012 Dec
20;36(Supplement_1):S67–S74.
7. Lee M, Jensen B, Regier L. Oral Anti-Hyperglycemic Agents - Comparison chart. RxFiles drug comparison charts.
7th ed. Saskatoon, SK: Saskatoon Health Region; 2012. p. 25. Available from: www.RxFiles.ca. Accessed 2013
Sep 3.
8. Nau KC, Lorenzetti RC, Cucuzzella M, Devine T, Kline J. Glycemic control in hospitalized patients not in intensive
care: beyond sliding-scale insulin. Am Fam Physician. 2010 May 1;81(9):1130–5.
9. Hirsch IB. SLiding scale insulin—time to stop sliding. JAMA. 2009 Jan 14;301(2):213–4.
10. Acarbose, Metformin, Gliclazide, Repaglinide, Sitagliptin, Exenatide, Liraglutide, Insulin. Lexi-Drugs Online
[Internet]. Hudson (OH) : Lexi-Comp, Inc. 1978-2013 [cited 2013 Sep 5]. Available from: http://online.lexi.com.
21
22. Treatment: Acarbose
• Alpha-glucosidase inhibitor in intestines
– Delays digestion of complex carbs/disaccharides
– Slower rise in postprandial glucose
• 25mg qd 50-100mg tid cc
• Not recommended if CrCl <25mL/min
• Pros: safe, little hypoglycemia
• Cons: less effective than other agents, GI side
effects (flatulence, diarrhea)
22Reference: 2, 4, 10
23. Treatment: Meglitinides
• Short-acting insulin secretagogues, stimulates
beta-cell insulin release at meals
• Repaglinide: 0.5mg tid ac 4mg po tid ac
• Pros: less hypoglycemia than sulfonylureas,
flexible with food intake
• Cons: lack outcome data on
morbidity/mortality
23Reference: 2, 4, 10
24. Treatment: Thiazolidinediones
• Enhances insulin effects by activating PPAR-
alpha receptor in cells
• Pioglitazone: 15mg qd 45mg qd
• Pros: no hypoglycemia
• Cons: limited usefulness in elderly (fluid
retention, CHF, MI, fractures)
24Reference: 2, 4
Brief Pathophysiology: What is Diabetes? Diabetes Mellitus (DM) = Diabetes comes from a Greek word, meaning siphon (describes polyuria), and Mellitus comes from a Latin word, meaning honey (urine is sweet, high in sugars) = metabolic disorder characterized by presence of hyperglycemia, due to defective insulin secretion/action, or both (1) Type 1: Insulin Dependent DM Type 1 diabetes* encompasses diabetes that is primarily a result of pancreatic beta cell destruction and is prone to ketoacidosis. This form includes cases due to an autoimmune process and those for which the etiology of beta cell destruction is unknown. Often presents in young patients, but lean elderly diabetic patients can exhibit autoimmune changes, with islet cell antibodies and insulin deficiency (2) Type 2: Non-insulin dependent DM Type 2 diabetes may range from predominant insulin resistance with relative insulin deficiency to a predominant secretory defect with insulin resistance. Also Gestational diabetes Chronic hyperglycemia microvascular complications: retinopathy, nephropathy, neuropathy, and macrovascular complications (Cardiovascular disease) (1)
Diabetes mellitus may present in a variety of settings:(3) asymptomatic; incidental discovery through routine laboratory screening nonspecific signs and symptoms such as fatigue, lassitude, weight changes presence of diabetic complications such as macrovascular or microvascular changes, neuropathy, kidney disease, erectile dysfunction acute metabolic symptoms such as polyuria, polydipsia, weight loss diabetic ketoacidosis Elderly: (2) age-related changes – affect clinical presentation of diabetes(2) renal threshold for glucose increases: glucosuria not seen at usual levels(2) tolerate relatively higher blood glucose levels before manifest osmotic diuresis (lower GFRs, lower glucose load delivered to tubules for reabsrption) (4) polydipsia absent because of decreased thirst with increased age dehydration common confusion, incontinence, and complications (e.g. neuropathy/retinopathy) are presenting symptoms complications: neuropathy, nephropathy, retinopathy, erectile dysfunction, foot ulcers, plus diabetic neuropathic cachexia, amyotrophy, malignant otitis externa, pappilary necrosis, osteoporosis Diabetic Ketoacidosis Diabetic ketoacidosis ( DKA ) is a potentially life-threatening complication in patients with diabetes mellitus . It happens predominantly in those with type 1 diabetes , but it can occur in those with type 2 diabetes under certain circumstances. DKA results from a shortage of insulin ; in response the body switches to burning fatty acids and producing acidic ketone bodies that cause most of the symptoms and complications. [1] DKA may be the first symptom of previously undiagnosed diabetes, but it may also occur in people known to have diabetes as a result of a variety of causes, such as intercurrent illness or poor compliance with insulin therapy . Vomiting , dehydration , deep gasping breathing , confusion and occasionally coma are typical symptoms. DKA is diagnosed with blood and urine tests ; it is distinguished from other, rarer forms of ketoacidosis by the presence of high blood sugar levels. Treatment involves intravenous fluids to correct dehydration, insulin to suppress the production of ketone bodies, treatment for any underlying causes such as infections, and close observation to prevent and identify complications. [1] [2] DKA is a medical emergency , and without treatment it can lead to death. DKA was first described in 1886; until the introduction of insulin therapy in the 1920s it was almost universally fatal. [3] It now carries a mortality of less than 1% with adequate and timely treatment. [4]
Frail elderly (Definition): pts with accumulation of multiple chronic illnesses with associated vulnerabilities (dementia, functional decline, geriatric syndrome including falls, impaired mobility, and polypharmacy)(5) Increased hypoglycemia risk: (2) elderly patients glucose counterregulation (glucagon, epinephrine, growth hormone) to hypoglycemia is diminished reduced autonomic warning symptoms(2) autonomic neuropathy and decreased beta-receptor response also result in absense of typical hypoglycemic symptoms (5) more neuroglycopenic manifestations (dizziness, weakness, delirium, confusion) than adrenergic (tremors, sweating)(4) also delayed psychomotor responses to intervene in the correction of hypoglycemia associated with poorer outcomes – traumatic falls, exacerbation of comorbid conditions (4) lead to impaired cognition and function(4) **insulin secretagogues (sulfonylureas and meglitinides) and insulin should be used with caution in frail elderly (2) Can be severe, and precipitate cardiovascular events (5) Changes to PK of insulin and oral medications: (2) affect individual drug choices and dosing decisions
Goals of Therapy (TC) Control symptoms Establish and maintain glycemic control, while avoiding hypoglycemia Prevent or minimize the risk of complications Achieve optimal control of associated risk factors such as hypertension, obesity and dyslipidemia Base on evaluation of functional status, life expectancy, social and financial support, own desires for treatment. (2) Reduce all CVD risk factors, smoking cessation, improvement in exercise, elimination of obesity, optimal control of hypertension. (2) HbA1c below 8-8.5% is reasonable, random BG between 7-14 mmol/L reasonable. (6) ACCORD, ADVANCE, VADT: confirmed the benefit of intensive glycemic control on microvascular outcomes (1) None of the above studies independently confirmed a significant benefit of tight glycemic control on macrovascular outcomes meta-analysis: those treated with more intensive therapy, compared to less intensive glycemic control, were found to have a 10% to 15% reduction in the risk of major CV events, primarily because of a 15% reduced risk of MI, but with no effect on stroke, CV death or all cause mortality Intensive glycemic control, associated with more than a 2-fold increase in the risk of severe hypoglycemia Increased mortality/lack of macro benefits: suggested factors: patient age, duration of diabetes, presence of CVD, history of severe hypoglycemic events, weight gain and the rapid decrease in A1C values
Rxfiles: if CrCl <60, dose should be =< 850-1700mg/d Decreases morbidity and mortality Lactic acidosis is a physiological condition characterized by low pH in body tissues and blood ( acidosis ) accompanied by the buildup of lactate, especially D-lactate, and is considered a distinct form of metabolic acidosis. [1] The condition typically occurs when cells receive too little oxygen (hypoxia), for example, during vigorous exercise. In this situation, impaired cellular respiration leads to lower pH levels. Simultaneously, cells are forced to metabolize glucose anaerobically, which leads to lactate formation. Therefore, elevated lactate is indicative of tissue hypoxia, hypoperfusion, and possible damage. Lactic acidosis is characterized by lactate levels >5 mmol/L and serum pH <7.35 [U.S. Boxed Warning]: Lactic acidosis is a rare, but potentially severe consequence of therapy with metformin that requires urgent care and hospitalization. The risk is increased in patients with acute congestive heart failure, dehydration, excessive alcohol intake, hepatic or renal impairment, or sepsis. Symptoms may be nonspecific (eg, abdominal distress, malaise, myalgia, respiratory distress, somnolence); low pH, increased anion gap and elevated blood lactate may be observed. Discontinue immediately if acidosis is suspected. Lactic acidosis should be suspected in any patient with diabetes receiving metformin with evidence of acidosis but without evidence of ketoacidosis. Discontinue metformin in patients with conditions associated with dehydration, sepsis, or hypoxemia. The risk of accumulation and lactic acidosis increases with the degree of impairment of renal function.
Discussing all the different types of regimens is beyond the scope of this presentation (insulin therapy itself can be its on presentation!) but briefly…
Prospective observational studies have documented superior glycemic control with this three-pronged physiologic approach. Randomized Study of Basal Bolus Insulin Therapy in the Inpatient Management of Patients with Type 2 Diabetes Compared traditional SSI to new basal-bolus glargine + glulisine (and correctional) – basal-bolus better control (8) 3 components of insulin in physiologic subcutaneous insulin protocols: Basal insulin (usually NPH or glargine, inhibits hepatic glucose production overnight and between meals)(9) RCT of Lantus…bariatric surgery…superior glycemic control compared to SSI Prandial insulin (regular release or short-acting analogues, bolus or meal-time) (9) Correction-dose insulin (usually given in addition to the usual dose of mealtime insulin as a specific algorithm based on total daily dose of insulin or patient weight) Resembles SSI, but is actually only small fine-tuning therapy Initial dose: 0.3-0.6 U/kg body weight, ½ basal, ½ divided daily over 3 meals (8), plus correctional to provide final insulin adjustment based on preprandial glucose value Sliding Scale: different. Traditionally includes regular insulin or rapid-acting analogue to treat hyperglycemia after it had already occurred – often no insulin is given if premeal glucose levels are within target range (9) Reactive, not proactive(9) Does not take into account basal insulin needs, diet, personal characteristics, or insulin history (8) --now, basal insulin is often included in regimen Physicians only notified of extremes of hypoglycemia or hyperglycemia (8) Possibility of insulin stacking (PK of regular insulin given every 6 hours) (8) (Medscape: 8 hr duration) No way to anticipate nutritional status or illness-related changes in glucose levels roller coaster fluctuations in blood glucose (8) Not very effective: MEDLINE search of 52 trials from 1966-2003 – no report of benefit (9) Has been used for ~50 years because it is convenient and straightforward to administer(9)