DIABETES MELLITUS

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DIABETES MELLITUS

• ISSUES IN THE
• LONG TERM CARE SETTING AND ALLIED VENUES

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DIABETES MELLITUS

• Focus diabetes in the Medicare population

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DIABETES MELLITUS

• Definition a metabolic disorder in which
• there is deficiency of insulin production or
• resistance of organs to the effect of insulin

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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.
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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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.
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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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.
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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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) gt glucose builds up in the blood,
  overflows into the urine, and passes out of the
  body in urine gt body loses its main source of
  fuel even though blood contains large amounts of
  glucose.
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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DIABETES MELLITUS (DM)

• TYPES OF DIABETES
• Type I
• Type II
• MODY (Maturity Onset Diabetes of Youth
• Gestational

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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
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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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
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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DM TYPE II

• Patient with type II DM usually makes enough
  insulin but the body cannot use it effectively gt
  insulin resistance
• Gradually insulin production decreases over the
  following years
• Symptoms are similar to type I but develop more
  gradually
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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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
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt

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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 lthttp//diabetes.niddk.nih.gov/dm/pubs/ov
  erview/index.htmwhatgt

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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
• lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
  dex.htmwhatgt
• MKSAP13 Endocrinology and Metabolism. American
  College of Physicians 2004.

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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.

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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/ind
  ex.htmtypes
• MKSAP13 Endocrinology and Metabolism. American
  College of Physicians 2004.

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Type II Diabetes

• Diagnostic testing - when to do it
• People ? 45 years old gt if normal then every 3
  years
• MKSAP13 Endocrinology and Metabolism. American
  College of Physicians 2004.

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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.

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DM type II Management

• Basics
• healthy eating
• physical activity
• blood glucose testing
• Pharmaceuticals
• oral medication(s)
• insulin(s)
• both oral medicines and insulin

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DM insulin variations

• Daily insulin requirements are influenced by
• diet
• exercise
• stress

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Diabetes Management Stress

• Stress influences response to insulin
• Stress gt increased cortisol
• increased catecholamines
• increased growth hormone
• gt these hormones all lead to increased insulin
  resistance (thus, hyperglycemia)

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Control of Diabetes

• Control of Diabetes includes
• glycemia control (FBS lt 126mg/dL HbA1c lt7)
• weight management
• blood pressure control (BP lt 130/80mmHg)
• lipid management
• reduction in the hypercoagulable state (aspirin
  or clopidogrel)

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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 lt 7
• If this goal in not reached and maintained gt
  pharmacotherapy (medications)

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Insulins

• Type hours to onset time to peak time effective
• Fast acting
• Lispro lt0.25 (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.

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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

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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.

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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

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Insulin in Type II DM

• Usually indicated if HbA1c gt 7 despite life
  style modification and 2 oral medications
• May be postponed in borderline cases where HbA1c
  is lt 8.5 pending addition of a 3rd oral agent
  otherwise gt
• Addition of bedtime dose of basal insulin therapy
  (glargine) to sulfonylureas /- metformin (not
  thiazolidinediones because of risk of CHF from
  fluid retention)

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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?ident
  ifier4756

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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

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Acute Complications of type II DM

• Hyperglycemic hyperosmolar state
• serum osmolarity gt 320 mosm/L
• plasma glucose gt 600mg/dL
• dehydration
• no ketoacidosis
• underlying disorder(s)

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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)

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Hypoglycemia

• Hypoglycemia plasma glycemia lt 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

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Complications of DM

• Chronic complications of diabetes mellitus
  include
• Macrovascular
• Microvascular
• Neuropathic

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Complications of DM

• Macrovascular
• atherosclerosis/cardiovascular disease
• peripheral vascular disease

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Complications of DM

• Microvasculardiabetic retinopathy due to
  ischemia of retna provokes neovascularization
  with vessels more fragile gt leaking gt 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-Is and
  ARBs too

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Complications of DM

• Diabetic Neuropathy
• peripheral sensory neuropathy
• cardiovascular autonomic neuropathy
• gastrointestinal autonomic neuropathy
• erectile dysfunction
• mononeuropathy
• diabetic foot

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Complications of DM

• Peripheral sensory neuropathy
• variable presentation
• dysesthesia
• tingling
• pain
• loss of pain sensation (risk of injury)

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Complications of DM

• Cardiovascular Autonomic Neuropathy
• orthostatic hypotension
• lack of normal variation in heart rate with
  breathing, tachycardia

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Complications of DM

• Gastrointestinal Autonomic Neuropathy
• gastroparesis nausea, bloating, vomiting (tx
  metoclopramide)
• diarrhea often nocturnal

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Complications of DM

• Erectile dysfunction
• autonomic neuropathy
• absent nocturnal and morning erections
• more common than diagnosed

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Complications of DM

• Mononeuropathy
• acute local pain
• distribution of a nerve
• may recede if treated early with improved
  glucose control (glucotoxicity)

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Complications of DM

• Diabetic Foot
• sensory deficit (skin, bone, ligament)
• fungal infection
• wounds
• pulses (PVD)
• slow healing
• ulcers

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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

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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

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