Related to the alterations in glucose, lipids and protien metabolism

HYPERGLYCEMIA

polyuria

polydipsia

polyphagia

Blurred vision

poor dental health

Weight loss

1. Microvascular DZ (retinopaht and nephropathy)
2. Macrovascular DZ (atherosclerosis and PVD)
3. Neurologic (neuropathies)
4. Perodontal DZ
5. Altered Immune responses

• Beta cell destruction
• absolute lack of insulin

--Glucose intolerance during pregnancy

--likely to progress to type 2 diabetes later on

Definitions of Diabetes

(ADA)

1. Hemoglobin A-1C
2. Preprandial BG
3. Postprandial BG

1. > 7.0%
2. >126 mg/dL
3. >200 mg/dL

ADA Criteria for DM diagonosis

(three options)

1. Symptoms and casual BG>200mg/dL
2. Fasting BG>126 mg/dL (preferred test)
3. oral glucose tolerance 2hr BG>200 mg/dL

• Improve quality of life
• Reduce mortality and morbidity
• Keep patient assymptomatic
• Reduce risk of microvascular and macrovascular DZ complicaitons
• Aggressive management of cardiovascular risk factors

Target number for DM

1. BP
2. LDL
3. Triglycerides
4. HDL

1. <130/80 mm/Hg
2. <100 mg/dL
3. <150 mg/dL
4. >40 mg/dL

Does the body have a base insulin level?

What happens after meals with the insulin level?

--Yes the body produces a base insulin level

--After a meal the body secrete a large insulin dose.

--Rise in blood glucose levels between 4-8 AM

--Remember that this is based on the sleep wake cycle

--unknown etiology

--Have medication to counteract this

Somogyi Effect

--a rebound hyperglycemia (post-hypoglycemic hyperglycemia)

--Following a significant hypoglycemic even the liver is caused to produce an excessive amount of glucose

--Can reduce the insulin dosing to keep the hypo from occuring

Insulins

1. Background
2. Sources
3. strengths

1. first isolate in 1921
2. recombinant DNA origin
3. typical 100 units/mL

Classes of Insulins

(5)

1. Rapid acting
2. Short Acting
3. Intermediate acting
4. Long acting
5. Combinations products

• lispro (Humalog)
• aspart (Novolog)
• glulisine (Apidra)

• regular insulin (Humulin R, Novolin R)

• NPH (Humulin N, Novolin N)

• glargine (Lantus)
• detemir (Levemir)

• NPH/Regular insulin

Rapid acting

5-15 min onset

.5-1.5 hr peak

4-5 hr duration

IV, IM or sub Q

rapid acting insulin

5-15 min onset

.5-1.5 hr peak

3-5 hr duration

Sub Q only

short acting insulin

30-60 min onset

2-4 hr peak

6-8 hr durations

IV,IM or subQ

Intermediate acting insulin

1-4 hr onset

6-10 hr peak

16-24 hr duration

Suspention

Long acting insulin

1-2 hr onset

no peak

24 hr duration

Long acting insulin

1-2 hr onset

minimal peak

14-24 hr duration

BID dosing

Empiric initial dosing in Type 1 DM

based on actual body weight

--0.3-0.5 units/kg/day

--70kg patient = 20-35 units/day

(with ketosis, illness, or growht: 1-1.5 units/kg/day)

--three or more injections/day to mimic cycle

temporary recovery of endogenous insulin secretion

--markedly decrease insulin needs (cannot totally stop insulin because ATB's can be produced against it and can cause insulin resistance)

-.2-.5 units/kg/day

Typical dosing regimine in type 1 DM

Long acting basal plus short acting bolus

--AM(short/rapid) [R, lispro,aspart]

--NOON(short/rapid) [R, lispro,aspart]

--PM(short/rapid) [R, lispro,aspart]

--HS (long) [glargine]--provide the basal rate

 **most felxible in meeting patients needs**

three injections per day

--AM (short/rapid)[R, lispro, aspart)--breakfast

       (intermediate)[NPH]--lunch and basalday

--PM (short/rapid) [R, lispro,aspart]--dinner

--HS (intermediate)[NPH]basal night

regular human insulin

mg/dL drop in glucose per 1 unit regular insulin=

(patient specific)

1800/total daily insulin =

(rapid insulin)

mg/dL drop in glucos per 1 unit rapid insulin

abdomen>Arm>Hip>thigh

**rotate sites and be consistant**

• Excersize
• Skin temp
• massage
• areas of hypertrophy
• insulin mixutres
• volume of the dose

1. Roll to bring to body temp (NPH needs to be resuspended)--roll slowly
2. watch for air bubbles which can affect dose
3. leave needle in skin for 5 sec
4. proper disposal of each needle

1. glargine--low pH
2. detemir--40% bioavalability lost when mixed

Storage of insulin

• refrigerated can be stabel till experation
• insulin in use does not need to be refrigerated
• discard open vials after 30 days

• continuos sub Q administration
• regular or short acting insulin
• control basal rate
• easily programmed for bolus meal injection

Hypoglycemia

(managment)

possible advers event of DM

--cause: to much insulin, missed meals, low carbs, increase physical activity, increased insulin absorption

treatment: rule of 15, longer acting carbs if not near meal time, glucagon injection

• treatment of hypoglycemia--if concious give 15 grams of Carbs PO
• recheck in 15 min.
• if <70mg/dL give 15 more grams

--if unconcious glucagon injection

>140 mg/dL

treatment: adjustment in the next insulin dose

      bolus of short acting insulin

Sever can lead to DKA

Rapid acting insulin

5-15 min onset

.5-1.5 hr peak

3-5 hr druation

Sub Q only

--Basal shoudl be 50% of total daily insulin

--Meals should be 50% of total daily insulin divided between breakfast/lunch/dinner (20%/15%/15%)

DKA

(management)

• Rapid Hydration of patient (fluids IV)--when glucose falls to 200-300 add 5%dextros
• Insulin IV--bolus and maintenance (remember to flush to prime binding sites)
• Potassium
• Phosphate (if <1mg/dL)
• Sodium bicarb--not unless pH<6.9

Sick Day management

• Continue insulin even if food intake decreases (stress increases insulin requirements)
• Fluids
• Test urine for Ketones
• Blood glucose concentrations every 4hrs
• supplemental insulin doses for individual algorythm based on blood glucose (1-2 units every 30-50mg/dL above target level)
• Call MD glucose >240 md/dL