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• Diabetes mellitus


  Chronic multi-system disease related to abnormal insulin production or impaired insulin utilization

  
• Diabetes


  A group of metabolic diseases characterized by hyperglycemia (an elevated-level of glucose in the blood) resulting from defects in insulin secretion, insulin action, or both

  
• Risk factors for diabetes

  • Family history of diabetes
  • Obesity especially abdominal and visceral adiposity
  • BMI > 27%
  • Race/Ethnicity
  • GDM or babies > 9 lbs
  • HTN > 140/90 mm Hg
  • Triglycerides > 200mg/dL
  • Previously impaired glucose tolerance

  
• Causes of diabetes

  • Genetics
  • Autoimmune
  • Viral
  • Environmental

  
• Metabolic processes important in ensuring a supply of glucose for body fuel

  1. Glycolysis - glucose broken down into water and carbon dioxide with release of energy

  2. Glycogenolysis - breakdown of stored glycogen controlled by epinephrine and glucagon

  3. Gluconeogenesis - building of glucose from new sources, stimulated by glucagon, glucocorticoids, and thyroid hormones

  
• Insulin


  Hormone secreted by beta cells in islets of Langerhans, regulates blood glucose levels by controlling glucose production and storage

  
• Insulin


  • Normally released in small increments when food is ingested
  • Consists of 2 polypeptide chains
  • Rise after a meal stimulates storage of glucose as glycogen and fat deposition, fall at night facilitates release of stored glucose, protein and fat

  
• Amylin


  2nd beta cell hormone, suppresses glucagon secretion and slows nutrient transfer to intestine
• Glucagon


  Produced in alpha cells of islets of Langerhans, acts in opposition to insulin to stimulate breakdown of glycogen and fats to glucose and promote gluconeogenesis

  
• Catecholamines (epinephrine and norepinephrine)

  Help maintain glucose levels during stress by inhibiting insulin, promoting glycogenolysis, increasing lipid activity, and conserving glucose

  
• Somatostatin


  Produced by delta cells in islets of Langerhans, inhibits secretion of insulin, glucagon, and growth hormone
• Diabetes classifications


  • Type 1
  • Type 2
  • Gestational
  • Pre-diabetes
  • Secondary

  
• Type 1 diabetes

  • Formerly known as insulin-dependent, results from destruction of pancreatic beta cells
  • Persons do not inherit type 1 itself but have a genetic predisposition

  
• DCCT study showed maintaining blood glucose as close to normal as possible prevents or slows progression of long-term diabetic complications

  
• Type 2 diabetes


  • Most prevalent, results from insulin resistance and impaired insulin secretion, also involves inappropriate glucose production by liver and alterations in hormone/cytokine production by adipose tissue

  
• Gestational diabetes


  • Develops during pregnancy due to insulin resistance caused by placental hormones, increases risk of C-section, perinatal death, neonatal complications, and later development of type 2 diabetes

  
• Secondary diabetes


  • Caused by damage, injury, or interference with the pancreas, can be due to conditions like Cushing's, hyperthyroidism, pancreatitis, or use of certain medications

  
• Clinical manifestations of type 1 diabetes

  • Frequent urination
  • Increased thirst
  • Weight loss
  • Increased hunger
  • Weakness

  
• Clinical manifestations of type 2 diabetes

  • Fatigue
  • Recurrent infections
  • Recurrent vaginal yeast infections
  • Prolonged wound healing
  • Blurred vision
• Diagnostic tests for diabetes

  • Fasting plasma glucose level > 126 mg/dL
  • Random plasma glucose > 200 mg/dL with symptoms
  • 2-hour OGTT level > 200 mg/dL

  
• Assessments for diabetes


  • History of signs/symptoms, hyperglycemia, hypoglycemia
  • Blood glucose monitoring
  • Adherence to treatment regimen
  • Lifestyle, cultural, psychosocial and economic factors
  • Effects of complications

  
• Physical exam for diabetes

  • Blood pressure
  • BMI
  • Dilated eye exam
  • Foot exam
  • Skin exam
  • Neurological exam
  • Oral exam
• Laboratory and diagnostic tests for diabetes

  • HbA1C
  • Fasting lipid profile
  • Microalbuminuria
  • Serum creatinine
  • Urinalysis
  • EKG
  • Referrals to specialists

  
• Goals of diabetes management

  • Be an active participant
  • Experience few or no acute hyper/hypoglycemia emergencies
  • Maintain blood glucose levels as close to normal as possible
  • Prevent, minimize or delay complications
  • Adjust lifestyle to decrease stress

  
• Diabetes Prevention Program showed a modest weight loss of 5-10% of body weight with regular exercise can drop the risk of developing type 2 diabetes by up to 58%
• Metabolic syndrome associated with type 2 diabetes

  • Insulin resistance
  • Elevated insulin levels
  • High triglycerides
  • Decreased HDL
  • Increased LDL
  • Hypertension

  
• Risk factors for metabolic syndrome

  • Central obesity
  • Sedentary lifestyle
  • Westernization
  • Certain ethnic groups
• Components of diabetes management

  • Nutritional management
  • Exercise
  • Monitoring
  • Pharmacologic management
  • Education

  
• Types of insulin


  • Rapid-acting (Humalog, Novolog, Glulisine)
  • Short-acting (Humulin R, Novolin R, ReliOn R)
  • Intermediate-acting (NPH, Novolin N, Humulin N, ReliOn N)
  • Long-acting (Glargine, Detemir)

  
• Insulin storage


  • Can be stored at room temperature for 30 days
  • Refrigerated until expiration date
  • Pre-filled pens good for 30 days refrigerated
• Do's and don'ts of insulin


  • Keep spare insulin
  • Inspect for flocculation before use
  • Avoid extreme temperatures, do not freeze
  • Keep out of direct sunlight or hot cars
• ak 4


  Duration 4 - 14 hrs
• Effects


  Duration 16 - 24 hrs
• Timing


  30 mins before meal
• Long-Acting Insulin


  Glargine (Lantus) - clear, most common

  
• Glargine (Lantus)


  • Onset 1-2 hours
  • Duration 12 - 24 hours
  • No peak
  • Cannot mix with other insulins
  • Cannot Prefill
  • Normally given once a day

  
• Detemir (Levemir)


  • Onset 3-4 hours
  • Peaks in 3-9 hours
  • Duration is 6-23 hours
• Both Glargine and Detemir are for basal glycemic control, doesn't control postprandial levels (levels after you eat)
• Storing Insulin


  • Can be stored at room temp. for 30 days
  • In the refrigerator until expiration date
  • Pre-filled pens 30 days in refrigerator
  • Pre-filled pens with insulin mixture are usually good for 30 days
• Do's and Don'ts of Insulin

  • Keep spare insulin
  • Inspect for flocculation (frosted whitish coating) before use
  • Avoid extreme temperatures, do not freeze (can deactivate it's potency)
  • Keep out of direct sunlight or in a hot car (can deactivate it's potency)