Assessment and Management of Assessment and Management of Patients with Diabetes MellitusPatients with Diabetes Mellitus

By Linda SelfBy Linda Self

Growing problemGrowing problem

Estimated 7% of US population is Estimated 7% of US population is diabeticdiabetic

Twice that many have prediabetesTwice that many have prediabetes 21% of those over 60 have diabetes21% of those over 60 have diabetes 45% of new diagnoses are being made in 45% of new diagnoses are being made in

children and adolescentschildren and adolescents

DiabetesDiabetes

Type I—beta cells destroyed by Type I—beta cells destroyed by autoimmune processautoimmune process

Type 2—decreased insulin production Type 2—decreased insulin production and decreased sensitivity to insulinand decreased sensitivity to insulin

Type 1 Diabetes MellitusType 1 Diabetes Mellitus

Genetic susceptibilityGenetic susceptibility AutoimmuneAutoimmune GlycosuriaGlycosuria Fat breakdownFat breakdown DKADKA

Type 2 Diabetes MellitusType 2 Diabetes Mellitus

ResistanceResistance Decreased productionDecreased production Generally no fat breakdownGenerally no fat breakdown HHNSHHNS

Type 2 Diabetes MellitusType 2 Diabetes Mellitus

Exercise enhances action of insulinExercise enhances action of insulin Weight loss is cornerstone of treatmentWeight loss is cornerstone of treatment

Gestational DiabetesGestational Diabetes

Glucose intolerance during pregnancyGlucose intolerance during pregnancy Placental hormones contributes to insulin Placental hormones contributes to insulin

resistanceresistance High risk: glycosuria, family history, High risk: glycosuria, family history,

marked obesitymarked obesity Native Americans, African Americans, Native Americans, African Americans,

Hispanics and Pacific IslandersHispanics and Pacific Islanders

Gestational DiabetesGestational Diabetes

Women of average risk tested between Women of average risk tested between 24-28 weeks of gestation24-28 weeks of gestation

Goals for glucose levels during Goals for glucose levels during pregnancy are 105 or less before meals; pregnancy are 105 or less before meals; 130 or less after meals130 or less after meals

Will have greater risk of developing Type Will have greater risk of developing Type 2 DM later in life if weight not controlled2 DM later in life if weight not controlled

Clinical ManifestationsClinical Manifestations

PolyuriaPolyuria PolydipsiaPolydipsia PolyphagiaPolyphagia Fatigue, tingling or numbness in hands, Fatigue, tingling or numbness in hands,

slow healing wounds and recurrent slow healing wounds and recurrent infectionsinfections

Diagnostic findingsDiagnostic findings

Fasting plasma glucose—125 mg/dLFasting plasma glucose—125 mg/dL Random sugar >200mg/dLRandom sugar >200mg/dL According to text, OGTT and IV glucose According to text, OGTT and IV glucose

tolerance test no longer used routinely—tolerance test no longer used routinely—see latest guidelinessee latest guidelines

Gerontologic Gerontologic ConsiderationsConsiderations

Elevated blood glucose levels are also Elevated blood glucose levels are also age relatedage related

Increase with advancing ageIncrease with advancing age Causes may be: increased fat tissue, Causes may be: increased fat tissue,

decreased insulin production, physical decreased insulin production, physical inactivity, decrease in lean body massinactivity, decrease in lean body mass

ManagementManagement

NutritionalNutritional ExerciseExercise MonitoringMonitoring PharmacologicPharmacologic EducationEducation

Dietary ManagementDietary Management

Carbohydrate 45-65% total daily caloriesCarbohydrate 45-65% total daily calories Protein-15-20% total daily caloriesProtein-15-20% total daily calories Fats—less than 30% total calories, saturated Fats—less than 30% total calories, saturated

fats only 10% of total caloriesfats only 10% of total calories Fiber—lowers cholesterol; Fiber—lowers cholesterol; solublesoluble—legumes, —legumes,

oats, fruits oats, fruits Insoluble—Insoluble—whole grain breads, whole grain breads, cereals and some vegetables. Both increase cereals and some vegetables. Both increase satiety. Slowing absorption time seems to satiety. Slowing absorption time seems to lower glycemic index.lower glycemic index.

Dietary ManagementDietary Management

Consistent, well-balanced small meals Consistent, well-balanced small meals several times per dayseveral times per day

Exchange system or counting Exchange system or counting carbohydratescarbohydrates

Exercise and DiabetesExercise and Diabetes

Exercise increases uptake of glucose by Exercise increases uptake of glucose by muscles and improves utilization, alters muscles and improves utilization, alters lipid levels, increases HDL and lipid levels, increases HDL and decreases TG and TCdecreases TG and TC

If on insulin, eat 15g snack before If on insulin, eat 15g snack before beginningbeginning

Check BS before, during and after Check BS before, during and after exercising if the exercise is prolongedexercising if the exercise is prolonged

Exercise and DiabetesExercise and Diabetes

Avoid trauma to the feetAvoid trauma to the feet Avoid pounding activities that could Avoid pounding activities that could

cause vitreous hemorrhagecause vitreous hemorrhage Caution if CADCaution if CAD Baseline stress test may be indicated Baseline stress test may be indicated

(especially in those older than 30 and (especially in those older than 30 and with 2 or more risk factors for CAD)with 2 or more risk factors for CAD)

Glucose monitoringGlucose monitoring

Patients on insulin should check sugars Patients on insulin should check sugars 2-4 times per day2-4 times per day

Not on insulin, two or three times per Not on insulin, two or three times per week (according to text)week (according to text)

Should check before meals and 2 hours Should check before meals and 2 hours after mealsafter meals

Parameters from physician very Parameters from physician very importantimportant

Continuous glucose Continuous glucose monitoringmonitoring

Subcutaneous sensor in abdomenSubcutaneous sensor in abdomen Download data q72hDownload data q72h Evaluates trends and efficacy of Evaluates trends and efficacy of

treatment over 24h periodtreatment over 24h period

HGB A1CHGB A1C

Measures blood levels over 2-3 months Measures blood levels over 2-3 months (per text)(per text)

High levels of glucose will attach to High levels of glucose will attach to hemoglobin hemoglobin

Helps to ensure that the patient’s Helps to ensure that the patient’s glucometer is accurateglucometer is accurate

KetonesKetones

Check in pregnancyCheck in pregnancy During illnessDuring illness If BS >240If BS >240

Insulin therapyInsulin therapy

Rapid acting—lispro (Humalog) and Rapid acting—lispro (Humalog) and insulin aspart (Novolog) onset 15’, peak insulin aspart (Novolog) onset 15’, peak 60-90’ and last from 2-4 hours60-90’ and last from 2-4 hours

Short acting—regular. Onset is 30-60’, Short acting—regular. Onset is 30-60’, peak in 2-3h and last for 4-6 hours. peak in 2-3h and last for 4-6 hours. Regular insulin is only kind for IV use.Regular insulin is only kind for IV use.

Insulin TherapyInsulin Therapy

Intermediate insulins—NPH or Lente. Intermediate insulins—NPH or Lente. Onset 3-4h, peak 4-12 hours and lst 16-Onset 3-4h, peak 4-12 hours and lst 16-20 hours. Names include Humulin N, 20 hours. Names include Humulin N, Novolin N, Humulin L, Novolin LNovolin N, Humulin L, Novolin L

Long acting—Humulin Ultralente. Onset Long acting—Humulin Ultralente. Onset 6-8h, peak 12-16 h and lasts 20-30h.6-8h, peak 12-16 h and lasts 20-30h.

Peakless insulins: determir and glarginePeakless insulins: determir and glargine

Complications of Insulin Complications of Insulin TherapyTherapy

Local allergic reactionsLocal allergic reactions Systemic allergic reactionsSystemic allergic reactions Insulin lipodystrophy (lipoatrophy or Insulin lipodystrophy (lipoatrophy or

lipohypertrophy)lipohypertrophy) Insulin resistanceInsulin resistance Morning hyperglycemia—Dawn phenomenon Morning hyperglycemia—Dawn phenomenon

(nocturnal surges of growth hormone) so give (nocturnal surges of growth hormone) so give dose at HS not before dinnerdose at HS not before dinner

Complications of Insulin Complications of Insulin TherapyTherapy

Somogyi effect—nocturnal hypoglycemia Somogyi effect—nocturnal hypoglycemia followed by rebound hyperglycemia-followed by rebound hyperglycemia-decrease evening dose of insulindecrease evening dose of insulin

To determine cause, test at HS, 3am and To determine cause, test at HS, 3am and upon awakening upon awakening

Methods of Insulin Methods of Insulin DeliveryDelivery

PensPens Jet injectors Jet injectors Insulin pumps—insulin is delivered at .5-Insulin pumps—insulin is delivered at .5-

2 units/hour. Most common risk of insulin 2 units/hour. Most common risk of insulin pump therapy is ketoacidosis.pump therapy is ketoacidosis.

Implantable devicesImplantable devices Transplantation of pancreatic cellsTransplantation of pancreatic cells

Oral antidiabetic agentsOral antidiabetic agents

Sulfonylureas—glipizide, glyburide and Sulfonylureas—glipizide, glyburide and glimepiride. Hypoglycemiaglimepiride. Hypoglycemia

Biguanides—metformin. Lactic acidosis.Biguanides—metformin. Lactic acidosis. Alpha-glucosidase inhibitors—acarbose. Alpha-glucosidase inhibitors—acarbose.

Delay absorption of CHODelay absorption of CHO

Oral AgentsOral Agents

Non-sulfonylurea secretagogues—repaglinide. Non-sulfonylurea secretagogues—repaglinide. Cause secretion of insulin. Cause secretion of insulin.

Thiazolidinediones—pioglitazone and Thiazolidinediones—pioglitazone and rosiglitazone. Sensitize. rosiglitazone. Sensitize. Weight gainWeight gain.Fertility. .Fertility. Liver.Liver.

Pramlintide (Symlin). Analogue of amylin. Used Pramlintide (Symlin). Analogue of amylin. Used with insulin. Injection.with insulin. Injection.

Exanatide (Byetta). Incretin mimetic. Causes Exanatide (Byetta). Incretin mimetic. Causes satiety. Wt loss. satiety. Wt loss.

Januvia.Januvia.

Teaching PlanTeaching Plan

Education is Education is criticalcritical Simple pathophysiologySimple pathophysiology Treatment modalitiesTreatment modalities Recognition, treatment and prevention of Recognition, treatment and prevention of

acute complicationsacute complications When to call the doctorWhen to call the doctor Foot care, eye care, general hygiene, risk Foot care, eye care, general hygiene, risk

factor managementfactor management

Teaching patients to Teaching patients to administer insulinadminister insulin

Storing insulin (may not refrigerate if used Storing insulin (may not refrigerate if used within one month). Prefilled syringes should be within one month). Prefilled syringes should be stored standing up.stored standing up.

SyringesSyringes Concentrations of insulinConcentrations of insulin Mixing insulinsMixing insulins Do not rotate area to area, use same anatomic Do not rotate area to area, use same anatomic

areaarea No need to aspirateNo need to aspirate

Acute Complications of Acute Complications of DiabetesDiabetes

Hypoglycemia—50-60 or lessHypoglycemia—50-60 or less

DKADKA

HHNSHHNS

HypoglycemiaHypoglycemia

Caused by too much insulin or oral Caused by too much insulin or oral agents, too little food or excessive agents, too little food or excessive physical activityphysical activity

Surge in epinephrine and norepinephrine Surge in epinephrine and norepinephrine results in sweating, tremors, tachycardia, results in sweating, tremors, tachycardia, palpitations, nervousness and hungerpalpitations, nervousness and hunger

HypoglycemiaHypoglycemia

CNS effects—inability to concentrate, CNS effects—inability to concentrate, headache, lightheadedness, confusion, headache, lightheadedness, confusion, memory problems, slurred speech, memory problems, slurred speech, incoordination, double vision, seizures incoordination, double vision, seizures and even loss of consciousness. and even loss of consciousness.

Hypoglycemic Hypoglycemic unawarenessunawareness

Related to autonomic neuropathyRelated to autonomic neuropathy Will not experience the sympathetic Will not experience the sympathetic

surge—with sweating, shakiness, HA, surge—with sweating, shakiness, HA, etc.etc.

Treatment for Treatment for hypoglycemiahypoglycemia

2-3 tsp. of sugar or honey2-3 tsp. of sugar or honey 6-10 hard candies6-10 hard candies 4-6oz. of fruit juice or soda4-6oz. of fruit juice or soda 3-4 commercially prepared glucose tablets3-4 commercially prepared glucose tablets Recheck BS 15 minutes, same s/s, repeat Recheck BS 15 minutes, same s/s, repeat

treatment. After improvement, then cheese and treatment. After improvement, then cheese and crackers or milk.crackers or milk.

Extreme situations, give glucagon. (can cause Extreme situations, give glucagon. (can cause n/v). D50W.n/v). D50W.

Diabetic KetoacidosisDiabetic Ketoacidosis

Clinical features are:Clinical features are:

1.1. HyperglycemiaHyperglycemia

2.2. Dehydration and electrolyte lossDehydration and electrolyte loss

3.3. acidosisacidosis

DKADKA

Three main causes: illness, undiagnosed Three main causes: illness, undiagnosed and untreated and decreased insulinand untreated and decreased insulin

Other causes: patient error, intentional Other causes: patient error, intentional skipping of insulinskipping of insulin

Presentation of DKAPresentation of DKA

3 P’s3 P’s Orthostatic hypotensionOrthostatic hypotension KetosisKetosis GI s/sGI s/s Acetone breathAcetone breath hyperventilationhyperventilation

Diagnostic Findings of Diagnostic Findings of DKADKA

BS between 300-800BS between 300-800 AcidosisAcidosis Electrolyte abnormalitiesElectrolyte abnormalities Elevated BUN, creatinine and hct r/t Elevated BUN, creatinine and hct r/t

dehydrationdehydration

Medical Management of Medical Management of DKADKA

Rehydrate with normal saline, then follow Rehydrate with normal saline, then follow with .45% NaCl then D5.45NS (or other)with .45% NaCl then D5.45NS (or other)

Restore electrolytesRestore electrolytes ECGsECGs Hourly blood sugarsHourly blood sugars IV insulinIV insulin Avoid bicarbonate as can affect serum Avoid bicarbonate as can affect serum

K+K+

Nursing ManagementNursing Management

Administer fluidsAdminister fluids Insulin Insulin Prevent fluid overloadPrevent fluid overload Strict I&OStrict I&O Follow lytesFollow lytes ECG monitoringECG monitoring Vital signsVital signs Monitor patient responses to treatmentsMonitor patient responses to treatments

Hyperglycemic Hyperglycemic Hyperosmolar Nonketotic Hyperosmolar Nonketotic

SyndromeSyndrome Predominated by hyperosmolarity and Predominated by hyperosmolarity and

hyperglycemiahyperglycemia Minimal ketosisMinimal ketosis Osmotic diuresisOsmotic diuresis Glycosuria and increased osmolarityGlycosuria and increased osmolarity Occurs over timeOccurs over time Blood sugar is usually over 600Blood sugar is usually over 600

HHNSHHNS

Occurs more often in older peopleOccurs more often in older people Type 2 diabetes mellitusType 2 diabetes mellitus No ketosisNo ketosis Do not usually have the concomitant n/vDo not usually have the concomitant n/v Hyperglycemia, dehydration and Hyperglycemia, dehydration and

hyperosmolarity may be more severe hyperosmolarity may be more severe than in DKAthan in DKA

Medical ManagementMedical Management

Similar treatment as seen in DKASimilar treatment as seen in DKA Watch fluid resuscitation if history of Watch fluid resuscitation if history of

heart failureheart failure ECGECG Lytes monitoringLytes monitoring Fluids with potassium replacementFluids with potassium replacement

Nursing Management of Nursing Management of HHNSHHNS

Monitor neurologicallyMonitor neurologically Monitor ECGMonitor ECG Monitor vital signsMonitor vital signs LabsLabs Hourly blood glucose monitoringHourly blood glucose monitoring Insulin IVInsulin IV Cautious correction of hyperglycemia to Cautious correction of hyperglycemia to

avoid cerebral edemaavoid cerebral edema

Long term complications Long term complications of Diabetesof Diabetes

Increasing numbers of deaths from Increasing numbers of deaths from cardiovascular and renal complicationscardiovascular and renal complications

Renal (microvascular) disease is more Renal (microvascular) disease is more common in type 1 diabeticscommon in type 1 diabetics

Cardiovascular disease (macrovascular) Cardiovascular disease (macrovascular) complications are more common in type complications are more common in type 2 diabetics2 diabetics

Diabetic Vascular Diabetic Vascular DiseasesDiseases

Chronic hyperglycemia causes Chronic hyperglycemia causes irreversible structural changes in the irreversible structural changes in the basement membranes of vessels. Result basement membranes of vessels. Result is thickening and organ damage.is thickening and organ damage.

Glucose toxicity affects cellular integrityGlucose toxicity affects cellular integrity Chronic ischemia in microcirculatory Chronic ischemia in microcirculatory

brances>>cause connective tissue brances>>cause connective tissue hypoxia and microischemiahypoxia and microischemia

Diabetic Vascular Diabetic Vascular DiseasesDiseases

Up to 21% of diabetics have retinopathy Up to 21% of diabetics have retinopathy at time of diagnosisat time of diagnosis

Macrovascular Macrovascular ComplicationsComplications

Coronary artery diseaseCoronary artery disease Cerebrovascular diseaseCerebrovascular disease Peripheral arterial diseasePeripheral arterial disease

Management of Management of Macrovascular DiseasesMacrovascular Diseases Modify/reduce risk factorsModify/reduce risk factors Meds for hypertension and Meds for hypertension and

hyperlipidemiahyperlipidemia Smoking cessation Smoking cessation Control of blood sugars which will help Control of blood sugars which will help

reduce TGreduce TG

Microvascular Microvascular Complications--RetinopathyComplications--Retinopathy Diabetic retinopathy-leading cause of blindness Diabetic retinopathy-leading cause of blindness

in those 20-74in those 20-74 Blood vessel changes—worst case scenario, Blood vessel changes—worst case scenario,

proliferative retinopathy. Also an increased proliferative retinopathy. Also an increased incidence of cataracts and glaucoma in incidence of cataracts and glaucoma in diabetics.diabetics.

Need regular eye examsNeed regular eye exams Control BP, control BS and cessation of Control BP, control BS and cessation of

smoking can helpsmoking can help

Microvascular Microvascular complications-Nephropathycomplications-Nephropathy

Accounts for 50% of patients with ESRDAccounts for 50% of patients with ESRD Earliest clinical sign of nephropathy is Earliest clinical sign of nephropathy is

microalbuminuria.microalbuminuria. Warrants frequent periodic monitoring for Warrants frequent periodic monitoring for

microalbuminuria—if exceeds 30mg/24h microalbuminuria—if exceeds 30mg/24h on two consecutive random urines, need on two consecutive random urines, need 24h urine sample24h urine sample

NephropathyNephropathy

Diabetes causes hypertension in renal Diabetes causes hypertension in renal vessels which cause leaking glomeruli, vessels which cause leaking glomeruli, deposits in narrow vessels, scarring and deposits in narrow vessels, scarring and vascular damagevascular damage

Microvascular disease-Microvascular disease-NephropathyNephropathy

Medical management: control BP (ACE Medical management: control BP (ACE or ARB)or ARB)

Tx of UTIsTx of UTIs Avoid nephrotoxic agents, contrast dyesAvoid nephrotoxic agents, contrast dyes Low sodium diet Low sodium diet Low protein dietLow protein diet Tight glycemic controlTight glycemic control

NephropathyNephropathy

May require dialysisMay require dialysis May have co-existent retinopathyMay have co-existent retinopathy Kidney transplantation—success now 75-Kidney transplantation—success now 75-

80% for 5 years80% for 5 years Pancreas transplantation may also be Pancreas transplantation may also be

performed at time of kidney performed at time of kidney transplantationtransplantation

NeuropathiesNeuropathies

Group of diseases that affect all types of Group of diseases that affect all types of nerves.nerves.

Includes peripheral, autonomic and Includes peripheral, autonomic and spinal nerves. spinal nerves.

Prevalence increases with duration of the Prevalence increases with duration of the disease and degree of glycemic controldisease and degree of glycemic control

NeuropathiesNeuropathies

Capillary basement membrane thickening Capillary basement membrane thickening and capillary closure may be present.and capillary closure may be present.

May be demyelination of the nerves, May be demyelination of the nerves, nerve conduction is disrupted. nerve conduction is disrupted.

Two most common types of neuropathy Two most common types of neuropathy are: sensorimotor polyneuropathy and are: sensorimotor polyneuropathy and autonomic neuropathy. autonomic neuropathy.

Peripheral neuropathyPeripheral neuropathy

Manifestations:paresthesias, burning Manifestations:paresthesias, burning sensations, numbness, decrease in sensations, numbness, decrease in proprioception. proprioception.

Charcot foot can result from abnormal Charcot foot can result from abnormal weight distribution on joints secondary to weight distribution on joints secondary to lack of proprioceptionlack of proprioception

Management of Management of Peripheral NeuropathiesPeripheral Neuropathies Pain management in the form of TCAs, Pain management in the form of TCAs,

Dilantin, Tegretol, Neurontin, mexilitene, Dilantin, Tegretol, Neurontin, mexilitene, and TENS. Cymbalta has been and TENS. Cymbalta has been recommended. Also, the drug Lyrica recommended. Also, the drug Lyrica (pregabalin)(pregabalin)

Autonomic NeuropathiesAutonomic Neuropathies

Cardiac, gastrointestinal and renal systemsCardiac, gastrointestinal and renal systems Cardiac—myocardial ischemia may be painlessCardiac—myocardial ischemia may be painless GI—delayed gastric emptying with early GI—delayed gastric emptying with early

satiety, nausea, bloating, diarrhea or satiety, nausea, bloating, diarrhea or constipationconstipation

Urinary retention—decreased sensation of Urinary retention—decreased sensation of bladder, neurogenic bladderbladder, neurogenic bladder

Autonomic neuropathy—Autonomic neuropathy—hypoglycemia unawarenesshypoglycemia unawareness

No longer feel shakiness, sweating, No longer feel shakiness, sweating, nervousness and palpitations associated nervousness and palpitations associated with hypoglycemiawith hypoglycemia

The inability to detect warning signs of The inability to detect warning signs of hypoglycemia can place the patient at hypoglycemia can place the patient at very high riskvery high risk

Autonomic neuropathy-Autonomic neuropathy-sudomotor neuropathysudomotor neuropathy Patient will have a decrease or absence Patient will have a decrease or absence

of sweating of the extremities with of sweating of the extremities with compensatory increase in upper body compensatory increase in upper body sweating.sweating.

Autonomic neuropathy—Autonomic neuropathy—sexual dysfunctionsexual dysfunction

Decreased libido in womenDecreased libido in women AnorgasmiaAnorgasmia ED in men ED in men UTI and vaginitisUTI and vaginitis Retrograde ejaculationsRetrograde ejaculations

Management of Management of neuropathiesneuropathies

Early detection, periodic f/u on patient’s Early detection, periodic f/u on patient’s with cardiac diseasewith cardiac disease

Monitor BP frequently for s/s orthostatic Monitor BP frequently for s/s orthostatic hypotensionhypotension

Low fat diet, frequent small meals, close Low fat diet, frequent small meals, close BS monitoring and use of prokinetic BS monitoring and use of prokinetic medicationsmedications

Meticulous skin careMeticulous skin care

Foot and Leg ProblemsFoot and Leg Problems

Sensory lossSensory loss Sudomotor neuropathy leads to dry, Sudomotor neuropathy leads to dry,

cracking feetcracking feet PAD—so poor wound healing/gangrenePAD—so poor wound healing/gangrene Lowered resistance to infectionLowered resistance to infection

Management of Foot and Management of Foot and Leg ProblemsLeg Problems

Teaching patient foot care-inspect feet and Teaching patient foot care-inspect feet and shoes dailyshoes daily

Examine feet every time goes to doctorExamine feet every time goes to doctor See podiatrist at least annuallySee podiatrist at least annually Closed toe shoesClosed toe shoes Trimming toenailsTrimming toenails Good foot hygieneGood foot hygiene Glycemic control is the key to preventing Glycemic control is the key to preventing

complicationscomplications

Special issuesSpecial issues

Hyperglycemia in the hospital—increased food, Hyperglycemia in the hospital—increased food, decreased insulin, steroids, IV dextrose,overly decreased insulin, steroids, IV dextrose,overly vigorous treatment of hypoglycemia, vigorous treatment of hypoglycemia, inappropriate holding of insulininappropriate holding of insulin

Hypoglycemia in the hospital—overuse of Hypoglycemia in the hospital—overuse of sliding scale, lack of insulin change when sliding scale, lack of insulin change when dietary intake withheld, overzealous treatment dietary intake withheld, overzealous treatment of hyperglycemia, delayed meals after insulin of hyperglycemia, delayed meals after insulin givengiven

Alterations in diet—enteral, TPN and clear Alterations in diet—enteral, TPN and clear liquid dietsliquid diets

Latest guidelines in diabetes Latest guidelines in diabetes management according to management according to Clinical Clinical

AdvisorAdvisor

Risk factors for Diabetes Risk factors for Diabetes MellitusMellitus

Family historyFamily history Cardiovascular diseaseCardiovascular disease ObesityObesity Sedentary lifestyleSedentary lifestyle History of impaired fasting glucose or impaired History of impaired fasting glucose or impaired

glucose toleranceglucose tolerance HypertensionHypertension PCOSPCOS Gestational diabetesGestational diabetes

Risk Factors continuedRisk Factors continued

Ethnic groups at high risk—Asian Ethnic groups at high risk—Asian Americans, Native Americans, Latinos, Americans, Native Americans, Latinos, Blacks, Pacific IslandersBlacks, Pacific Islanders

Recommended ScreeningRecommended Screening

Fasting glucose levelsFasting glucose levels Oral glucose tolerance testing using 75g Oral glucose tolerance testing using 75g

of Glucolaof Glucola Fasting glucose of Fasting glucose of

100-125mg/dL=100-125mg/dL=prediabetesprediabetes Fasting level >126 is diagnosticFasting level >126 is diagnostic OGTT>200 is diagnosticOGTT>200 is diagnostic

Reducing RiskReducing Risk

Weight reductionWeight reduction Exercise of 150 minutes per weekExercise of 150 minutes per week Comprehensive dietComprehensive diet educationeducation

Controlling blood sugarControlling blood sugar

Hemoglobin A1C less than or equal to Hemoglobin A1C less than or equal to 6.5%6.5%

Fasting plasma glucose <110Fasting plasma glucose <110 Two hour postprandial sugar <140Two hour postprandial sugar <140 Comprehensive educationComprehensive education

Treating Type I DiabetesTreating Type I Diabetes

Basal bolus insulin and mealtime rapid-Basal bolus insulin and mealtime rapid-acting insulin analog (lispro, aspart, or acting insulin analog (lispro, aspart, or glulisine)glulisine)

Basal insulin should include determir or Basal insulin should include determir or glargineglargine

Continuous subcu insulin infusion or Continuous subcu insulin infusion or pump very effectivepump very effective

Treating Type I diabetesTreating Type I diabetes

Pump is ideal for those with very “brittle Pump is ideal for those with very “brittle diabetes” or hypoglycemic unawarenessdiabetes” or hypoglycemic unawareness

Pump also very useful in pregnant Pump also very useful in pregnant womenwomen

Symlin (pramlintide) should be Symlin (pramlintide) should be considered to enhance glycemic control considered to enhance glycemic control and control weightand control weight

Treating Type I diabetesTreating Type I diabetes

If poor control—check 2h postprandial If poor control—check 2h postprandial and at 2AMand at 2AM

Check urine ketones if BS>250Check urine ketones if BS>250

Type 2 diabetesType 2 diabetes

Diagnosed 9-12 years after they develop Diagnosed 9-12 years after they develop the conditionthe condition

HgbA1C 6-7% needs monotherapyHgbA1C 6-7% needs monotherapy Choices are: thiazolidinedione, Choices are: thiazolidinedione,

metformin, insulin secretagogue metformin, insulin secretagogue (sulfonylureas, Prandin), alpha (sulfonylureas, Prandin), alpha glucosidase inhibitor or a dipeptidyl-glucosidase inhibitor or a dipeptidyl-peptidase-4 inhibitor (Januvia)peptidase-4 inhibitor (Januvia)

Using insulin in Type 2 Using insulin in Type 2 DMDM

Usually will meet patient resistance Usually will meet patient resistance May benefit from a 70/30 combinationMay benefit from a 70/30 combination Requires frequent blood glucose Requires frequent blood glucose

monitoringmonitoring

Cardiac risk factorsCardiac risk factors

50% of those with Type 2 Diabetes 50% of those with Type 2 Diabetes Mellitus have hypertension, 25% in type Mellitus have hypertension, 25% in type 11

Need ARB or ACE inhibitorNeed ARB or ACE inhibitor Dyslipidemia needs to be addressed—Dyslipidemia needs to be addressed—

goal of LDL <100 (<70 if DM and CAD); goal of LDL <100 (<70 if DM and CAD); HDL >40 in men and >50 in women, TG HDL >40 in men and >50 in women, TG <150<150

Cardiac risk factorsCardiac risk factors

Treat with statins, Zetia (ezetimibe) or Treat with statins, Zetia (ezetimibe) or fibrates if TG >400***fibrates if TG >400***

NutritionNutrition

CHO 45-65% of total caloriesCHO 45-65% of total calories Protein 15-20%Protein 15-20% Fiber intake 25-50g/day---blunts the Fiber intake 25-50g/day---blunts the

glycemic responseglycemic response Dietary fat <30% w/saturated fat <10% Dietary fat <30% w/saturated fat <10%

and cholesterol <300mg/dayand cholesterol <300mg/day

Type 2 diabetesType 2 diabetes

Evaluate treatment response within 3 Evaluate treatment response within 3 monthsmonths

HgbA1C >8% in patient who has been HgbA1C >8% in patient who has been educated about DM should begin insulin educated about DM should begin insulin therapytherapy

Questions--DiscussionQuestions--Discussion