Diabetes Mellitus

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Diabetes Mellitus

• Barbara S. Hays
• Winter, 2006

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Blood Glucose(normal serum level 65 105 mg)

• Inside CNS
• Brain uses glucose as primary fuel
• Brain cannot store/produce glucose
• Outside CNS
• Fatty acids stored as
• Glycogen (liver/muscles)
• Triglycerides (fat cells)

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Blood glucose, cont.

• Outside CNS, continued
• Endocrine portion of pancreas Islets of
  Langerhans
• Alpha cells make glucagon
• counterregulatory, acts opposite of insulin
• Beta cells make insulin
• Allows body cells to store and use carbohydrate,
  fats, and protein

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Hyperglycemia

• When blood glucose becomes high
• INSULIN allows glucose to enter cells
• Liver
• Production /storage of glycogen
• Inhibits glycogen breakdown
• Increased protein fat synthesis (VLDL
  formation)
• Muscles
• Promotes protein and glycogen synthesis
• Fat cells
• Promotes storage of triglycerides

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Hyperglycemia

• Drowsy
• Flushed
• Thirsty

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Hypoglycemia

• Glucagon causes release of glucose from liver
• glycogenolysis (breakdown of glycogen to
  glucose)
• glyconeogenesis of glucose not available
• Lipolysis (breakdown of fat)
• Proteolysis (breakdown of amino acids)

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Hypoglycemia

• Weak, sweaty
• Confused/irritable/ disoriented

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Diabetes Mellitus(problem with glucose
metabolism)

• Major health problem US/worldwide
• Complications lousy blood vessels
• Blindness
• Renal failure
• Amputations
• heart attacks and strokes
• OB/neonatal complications

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Diabetes Mellitus

• The good news
• Blood glucose control reduces complications of
  Diabetes!

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Diabetes Mellitus

• Absence (or ineffectiveness of ) insulin
• Cellular resistance
• Cells cant use glucose for energy
• Starvation mode
• Compensatory breakdown of body fat/protein
• Ketone bodies from faulty fat breakdown
• Metabolic acidosis, compensatory breathing
  (Kussmals breathing)

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Diabetes Mellitus

• HYPERGLYCEMIA fluid/electrolyte imbalance.
• Polyuria
• Sodium, chloride, potassium excreted
• Polydipsia from dehydration
• Polyphagia cells are starving, so person feels
  hungry despite eating huge amounts of food.
  Starvation state remains until insulin is
  available.

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Diabetes Mellitus

• Complications of chronic hyperglycemia
• Macrovascular complications
• Cardiovascular disease (heart attack)
• Cerebrovascular disease (strokes)
• Microvascular
• Blindness (retinal proliferation, macular
  degeneration)
• Amputations
• Diabetic neuropathy (diffuse, generalized, or
  focal)
• Erectile dysfunction

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Classifying Diabetes Mellitus

• Type I Diabetes autoimmune
• Beta cell destruction in genetically susceptible
  person
• Some viral infections

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Classifying Diabetes Mellitus

• Type II Diabetes
• Reduction in ability of most cells to respond to
  insulin
• Poor control of liver glucose output
• Decreased beta-cell function (eventual failure)

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Diabetes Mellitus

• Major risk factors
• Family history
• Obesity
• Origin (Afro-American, Hispanic, Native American,
  Asian-American)
• Age (older than 45)
• History of gestational diabetes
• High cholesterol
• Hypertension

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Diabetes Mellitus

• Prevention of effects combination approach
• Increased exercise
• Decreases need for insulin
• Reduce calorie intake
• Improves insulin sensitivity
• Weight reduction
• Improves insulin action

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Triad of Treatment

• Diet
• Medication
• Oral hypoglycemics
• Insulins
• Exercise

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Diabetes treatment

• Exercise
• Under physician supervision
• Check glucose prior

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Diabetes treatment

• Diet
• Lower calorie
• Fewer foods of high glycemic index
• Spread meals evenly

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Diabetes treatment

• Anti-Diabetic medications
• Oral hypoglycemic agents (Easy p 297)
• Sulfonylureas
• Thiazolidinediones
• Biguanides
• Alpha-glucosidase inhibitors
• D-phenylalinine derivatives
• Combinations
• Insulins (Easy Prototype Pro p 393)

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Sulfonylureas

• Stimulate pancreas to secrete insulin
• Glyburide (Diabeta) Prototype Pro p 393
• Glucotrol (Glipizide)
• Diabenese (chlorpropamide)
• Adverse reactions
• Hypoglycemia
• Water retention/edema
• Photosensitivity
• May need to add insulin in times of stress

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Biguanides

• Decreases liver production of glucose
• Decreases intestinal absorption of glucose
• Improves cell sensitivity to insulin
• Example Metformin
• GI upset, flatulence
• Cardiac (CHF, MI)

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Thiazolidinediones

• Increase cellular sensitivity to insulin
• Pioglitazone (Actos)
• Rosiglitazone (Avandia)
• Client should have liver enzymes
• checked periodically

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D-Phenylalanine derivatives

• Nateglinide (Starlix)
• Rapid onset, short half-life
• Good for those with rapid post prandial rise in
  blood glucose

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Combinations

• Glucovance
• Glyburide and Metformin
• Avandamet
• Avandia and Metformin
• come tell me when you run into this question

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Insulin

• Made in beta cells of the pancreas
• Moves glucose into cells (thus acts like growth
  hormone in a way)
• Moves potassium into cells (can buy time in
  emergencies)

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Insulin preparations (Easy p 390)given ONLY
with syringes marked in units

• Rapid acting (lispro, asparte)
• Short acting (regular)
• Intermediate acting (NPH)
• Long acting
• Ultralente
• Glargine/Lantus

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Your learning

• Onset of action
• Peak (blood glucose will be lowest then)
• Duration

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Rapid acting insulin

• Lispro (Humolog, Novolog Aspart)
• Onset of action
• 15-30 minutes may come on in 5 minutes
• Peak of action
• 1 - 2 hours
• Duration
• 3 4 hours

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Short acting insulins

• Regular (clear so can be given IV)
• Onset of action
• 0.5 to 1 hour
• Peak of action
• 2 4 hours
• Duration of action
• 6 8 hours

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Intermediate acting insulins

• NPH, Lente (chemicals added. Cloudy)
• Onset of action
• 1 4 hours
• Peak of action
• 4 12 hours
• Duration of action
• 18 24 hours

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Long acting insulins

• Ultralente
• Onset of action
• 4 8 hours
• Peak of action
• 18 hours
• Duration of action
• 24 36 hours

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Once a day insulin

• Glargine/Lantus
• Cannot be diluted or mixed in syringe with any
  other insulin
• Slow, steady release
• Daily dosing usually at bedtime
• Refrigerated or tosses every 14 days

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Combination insulins

• 70/30 (70 NPH and 30 regular)
• Humolog 70/30 (Humolog and regular)
• Fewer injections
• Rotate sites to decrease lipodystrophy

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Miscellaneous

• Byetta for type II Diabetics taking sulfonylureas
  or combination
• Mimics physiologic glucose control
• Inhances insulin secretion only in presence of
  hyperglycemia
• Insulin secretion decreases as blood glucose
  approaches normal
• Neutontin for Diabetic nerve pain

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Some things to know

• Insulin moves potassium into cells
• Good for emergency situations
• Dangerous if potassium level already low

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Some things to know

• HHNK (Hyperglycemic Hyperosmolar Non-Ketotic
  Coma). Also called
• HHNK
• HNKS syndrome
• Like dibetic ketoacidosis, without the ketones
• Type II diabetic, makes enough insulin to avoid
  ketones, but sugar guilds up to dangerous levels
  -gt cellular dehydration

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Some things to know

• Dawn Phenomenon vs Somogis effect
• Dawn phenomenon
• Blood sugar rises in early morning
• Somogis (rebound) effect
• Blood sugar rise in morning as reaction to
  hypoglycemic time during the night

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Some things to know

• Diabetic foot care
• Dry, cracked skin poor circulation could loss
  of a limb
• For the most part nurses dont trim nails of
  diabetic clients. Refer to Podiatrist.

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Typical diabetic foot ulcer
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