Med surge week 2: DM

• Diabetes is a chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin use, or both

  
• Diabetes affects an estimated 34.2 million people in the United States
• Diabetes is the 7th leading cause of death

  
• Theories of causes of diabetes

  • Genetic
  • Autoimmune
  • Environmental

  
• Diabetes


  Primarily a disorder of glucose metabolism related to absent/insufficient insulin and/or ineffective use of available insulin

  
• Classes of diabetes recognized by the American Diabetes Association

  • Type 1
  • Type 2
  • Gestational
  • Other

  
• Type 1 diabetes

  • Age of onset: Any age but more common in young people
  • Type of onset: Abrupt but may have been present many years
  • Prevalence: 5%-10%
  • Environmental factors: Virus, toxins
  • Primary defect: Absent of minimal insulin production
  • Islet cell antibodies: Present at onset

  
• Type 2 diabetes

  • Age of onset: Adults
  • Type of onset: Insidious
  • Prevalence: 90%-95%
  • Environmental factors: Obesity, lack of exercise
  • Primary defect: Insulin resistance, decreased production, altered adipokines
  • Islet cell antibodies: Absent

  
• Normal insulin secretion is 40 to 50 units per day in an adult

  
• Normal glucose level range is 74 to 106 mg/dL

  
• Normal glucose and insulin metabolism

  1. Insulin promotes glucose transport into cells

  2. Insulin inhibits gluconeogenesis, enhances fat deposition, and increases protein synthesis

  3. Insulin-dependent tissues: Skeletal muscle and adipose tissue

  4. Non-insulin-dependent tissues: Other tissues still require glucose

  
• Counterregulatory hormones

  • Glucagon
  • Epinephrine
  • Growth hormone
  • Cortisol
• Insulin is synthesized from proinsulin and C-peptide is a useful indicator of beta-cell function and insulin levels

  
• Type 1 diabetes


  Accounts for 5% to 10% of all diabetes, generally affects people under age 40, can occur at any age

  
• Type 1 diabetes etiology

  Autoimmune disorder where body develops antibodies against insulin and/or pancreatic beta cells, genetic link with HLAs and virus exposure

  
• Onset of type 1 diabetes

  1. Islet cell autoantibodies present for months to years before symptoms

  2. Rapid onset with ketoacidosis when pancreas can no longer make enough insulin

  3. Patient may have temporary remission after starting treatment

  
• Type 2 diabetes


  Most prevalent type (90% to 95%), many risk factors including overweight/obesity, advanced age, family history, greater prevalence in ethnic groups

  
• Type 2 diabetes etiology

  Pancreas usually makes some endogenous insulin but not enough is produced and/or body does not use insulin effectively, genetic link with multiple genes and metabolic abnormalities

  
• Onset of type 2 diabetes


  Gradual onset, person may go many years with undetected hyperglycemia, often discovered with routine testing

  
• Prediabetes

  Impaired glucose tolerance (OGTT 140-199 mg/dL) and/or impaired fasting glucose (100-125 mg/dL), intermediate stage between normal and diabetes

  
• Prediabetes is asymptomatic but long-term damage may already be occurring

  
• Gestational diabetes


  Develops during pregnancy, 2% to 10% in US, increases risk for complications, screens high-risk patients first visit and average-risk at 24-28 weeks, up to 63% chance of type 2 within 16 years

  
• Other specific types of diabetes


  Results from injury, interference, or destruction of beta-cell function, resolves when underlying condition is treated or drug is discontinued

  
• Classic symptoms of type 1 diabetes

  • Polyuria
  • Polydipsia
  • Polyphagia
  • Weight loss
  • Weakness
  • Fatigue
  • Ketoacidosis

  
• Nonspecific symptoms of type 2 diabetes

  • Fatigue
  • Recurrent infection
  • Recurrent vaginal yeast or candida infection
  • Prolonged wound healing
  • Visual problems

  
• Diagnostic criteria for diabetes

  A1C ≥6.5%, Fasting plasma glucose ≥126 mg/dL, 2-hour OGTT ≥200 mg/dL, Classic symptoms with random plasma glucose ≥200 mg/dL

  
• A1C


  Glycosylated hemoglobin that reflects glucose levels over past 2-3 months, used to diagnose, monitor, and screen for prediabetes

  
• Other diagnostic tests

  • Fructosamine
  • Islet cell autoantibodies
  • Lipids, BUN, creatinine, electrolytes
  • Albuminuria, urine acetone
  • BP, ECG, eye exam, dental exam, foot exam, neurologic exam, ABI, weight
• Goals of diabetes management

  Reduce symptoms, promote well-being, prevent acute complications, prevent or delay long-term complications

  
• 3 treatment modalities for type 2 diabetes

  • Nutrition therapy
  • Drug therapy (insulin, oral agents, non-insulin injectables)
  • Exercise
• Insulin

  Exogenous (injected) insulin required for type 1 diabetes, prescribed for type 2 as disease progresses

  
• Types of insulin

  • Rapid-acting
  • Short-acting
  • Intermediate-acting
  • Long-acting

  
• Basal-bolus insulin regimen


  Intensive or physiologic insulin therapy that most closely mimics endogenous insulin production, with bolus rapid/short-acting insulin before meals and basal intermediate/long-acting insulin once or twice daily

  
• Human insulin


  Genetically engineered in laboratories from E. coli or yeast cells
• Insulins

  • Rapid-acting
  • Short-acting
  • Intermediate-acting
  • Long-acting

  
• Insulins


  • They differ by onset, peak action, and duration

  
• Basal-bolus regimen


  Intensive or physiologic insulin therapy—most closely mimics endogenous insulin production

  
• Basal-bolus regimen


  1. Administer multiple daily injections (or insulin pump) with frequent self-monitoring of glucose (or continuous glucose monitoring system)

  2. Bolus—rapid- or short-acting insulin before meals

  3. Basal—intermediate- or long-acting (background) insulin once or twice a day

  
• Goal of basal-bolus regimen

  Glucose level as close to normal as possible as much of the time as possible

  
• Choosing insulin plan

  1. Patient and HCP work together

  2. Based on desired and feasible glucose levels

  3. Lifestyle

  4. Food choices

  5. Activity pattern