Post on 27-Dec-2015
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Role of Insulin
Insulin:– Counters metabolic
activity that would increase blood glucose levels
– Enhances transport of glucose into body cells
– Lowers blood glucose levels
Physiology Cont: InsulinPhysiology Cont: Insulin Basal (continuous)Basal (continuous) Prandial (Bolus)Prandial (Bolus)
*Blood glucose increases within 10 minutes of the beginning of a meal*
Diabetes MellitusDiabetes Mellitus
A disorder of carbohydrate, protein, A disorder of carbohydrate, protein, and fat and fat metabolismmetabolism resulting from an resulting from an imbalance between insulin imbalance between insulin availability and insulin need. (Porth, availability and insulin need. (Porth, 2002)2002)
End Result : End Result : HYPERGLYCEMIAHYPERGLYCEMIA
DM 1&2: The big difference…DM 1&2: The big difference…DM TYPE 1DM TYPE 1 DM TYPE 2DM TYPE 2
No endogenous insulinNo endogenous insulin Some endogenous Some endogenous insulininsulin
Tx requires insulin Tx requires insulin injectionsinjections
Tx diet and exercise 1st, Tx diet and exercise 1st, then pills and /or insulinthen pills and /or insulin
Usually < age 30 yrs.Usually < age 30 yrs. Usually over 30 yrs. (peaks Usually over 30 yrs. (peaks at 50)at 50)
Ketosis prone (DKA)Ketosis prone (DKA) no ketosisno ketosis
Former names: IDDM Former names: IDDM (Juvenile)(Juvenile)
Diabetes Type IDiabetes Type I
NIDDM (maturity/adult- NIDDM (maturity/adult- onset)onset)
Diabetes Type IIDiabetes Type II
ThinThin to normal body to normal body weightweight
Usually OverweightUsually Overweight
Acute metabolic Acute metabolic complicationscomplications
(DKA)(DKA)
Chronic vascular Chronic vascular complicationscomplications
Diabetes Clinical ManifestationsCont: Signs and SymptomsSigns and Symptoms
Early signsEarly signs 3 Polys 3 Polys Weight lossWeight loss Fatigue/Always tiredFatigue/Always tired Visual BlurringVisual Blurring
Late signsLate signs Any of the 3 PolysAny of the 3 Polys Infections Infections Numbness/ tingling of Numbness/ tingling of
feet or leg painfeet or leg pain Slow healing woundsSlow healing wounds Chronic ComplicationsChronic Complications
Diabetes: Dx TestsDiabetes: Dx Tests
Fasting Blood Glucose Fasting Blood Glucose (FBG): <100 mg/dL(FBG): <100 mg/dL– Iggy: 70-110 mg/dLIggy: 70-110 mg/dL
**Random/Casual Blood Random/Casual Blood Glucose*:<200 mg/dLGlucose*:<200 mg/dL
Oral Glucose Tolerance Test Oral Glucose Tolerance Test (OGTT): < 140 mg/dL(OGTT): < 140 mg/dL
Glycosylated Hemoglobin Glycosylated Hemoglobin (HgbA1C): 4-6%(HgbA1C): 4-6%
Check MD orders or agency protocol for frequency of BS MonitoringIn General:AC&HS if pt able to eat;Q4-6 hours if NPO or tube feedings
Diabetes: Diagnostic Tests Cont.Diabetes: Diagnostic Tests Cont. Glycosylated hemoglobin test –
Hemoglobin A1C (HbA1c) – measures the amount of glycosylated
hemoglobin (hemoglobin that is chemically linked to glucose) in blood.
– Normal -4-6%Normal -4-6%– Target range DM patient <7%Target range DM patient <7%
Criteria for the Diagnosis of Diabetes MellitusCriteria for the Diagnosis of Diabetes Mellitus
Normal Normal – FPG <110 mg per dL FPG <110 mg per dL – 2hr OGTT <140 mg per dL 2hr OGTT <140 mg per dL
Diabetes-Diabetes- positive findings from any two of the following positive findings from any two of the following tests on different days: tests on different days:
– Symptoms of diabetes mellitus* plus casual Symptoms of diabetes mellitus* plus casual (random) plasma glucose concentration >=200 (random) plasma glucose concentration >=200 mg / dL mg / dL
oror – FPG >=126 mg per dLFPG >=126 mg per dLoror – 2hr OGTT >=200 mg per dL after a 75-g glucose 2hr OGTT >=200 mg per dL after a 75-g glucose
load load
Diagnostic Tests – Cont.Diagnostic Tests – Cont.Is it Diabetes Yet?Is it Diabetes Yet?
Impaired Fasting Glucose
Impaired Glucose Tolerance
<6
100-125140-200
<100<140
>126>200>6
Acute ComplicationsAcute Complications Diabetic Diabetic
Ketoacidosis (DKA)Ketoacidosis (DKA) BS > 300 mg/dLBS > 300 mg/dL Classic symptomsClassic symptoms KetosisKetosis
Hyperglycemic-Hyperglycemic-Hyperosmolar Hyperosmolar Nonketotic Syndrome Nonketotic Syndrome (HHNS)(HHNS)
BS > 800 mg/dLBS > 800 mg/dL Similar symptomsSimilar symptoms No KetosisNo Ketosis
Check urine for ketones
Chronic Complications - MacrovascularChronic Complications - Macrovascular CardiovascularCardiovascular
– heart heart diseasedisease CerebrovascularCerebrovascular
– StrokeStroke
Peripheral vascularPeripheral vascular
diseasedisease
DM pts have heart disease and stroke risks 2 to 4 X higher than non-DM pts
Chronic Complications-Chronic Complications-Microvascular :Microvascular :
Diabetic RetinopathyDiabetic Retinopathy
The leading cause of new cases of blindness in adults ages 20 - 74
Chronic Complications-Chronic Complications-MicrovascularMicrovascular
NephropathyNephropathy
The leading cause of end-stage renal disease (ESRD), occurs in about 20 - 40% of patients with diabetes
Chronic Complications-MicrovascularChronic Complications-Microvascular
Diabetic Neuropathy - Diabetic Neuropathy - the poor blood supply will cause the nervous system to malfunction
Chronic Complications-Chronic Complications-MicrovascularMicrovascular
Sexual problems for men erectile dysfunctionretrograde ejaculation
Sexual problems for women
decreased vaginal lubrication decreased sexual response
Urologic problems for men and women
urinary tract infectionsneurogenic bladder
Chronic Complications-Chronic Complications-MicrovascularMicrovascular
Gastroparesis
Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly
Management: ExerciseManagement: Exercise Helps regulate Helps regulate
blood glucoseblood glucose Increases insulin Increases insulin effectiveness and effectiveness and sensitivity in the sensitivity in the body.body.
Must monitor Must monitor insulin and food insulin and food intake to match intake to match exercise regimen. exercise regimen.
Drug Therapy: Insulin Types Fast-acting insulin
– Rapid Acting Insulin Analogs Aspart, Lispro, Glulisine
– Regular Human Insulin
Intermediate-acting insulin – NPH Human Insulin– Pre-Mixed Insulin
Humulin 70/30, Humalog 75/25 Long-acting insulin
– Insulin Glargine, Insulin Detemir
BASALBASALUsed to lower Used to lower blood sugar blood sugar throughout the throughout the day and nightday and night
BOLUSBOLUSUsed to lower Used to lower blood sugar blood sugar after eating a after eating a mealmeal
Drug Therapy Cont.: InsulinDrug Therapy Cont.: InsulinOnset - Onset - how soon it starts to work in the bloodhow soon it starts to work in the blood Peak - Peak - when the insulin has the greatest effect on when the insulin has the greatest effect on
blood sugar levelsblood sugar levels Duration – Duration – how long it keeps workinghow long it keeps working
Drug Therapy Cont:Drug Therapy Cont:
Goal of Insulin TherapyGoal of Insulin Therapy
Basal and Bolus Insulin Coverage
Drug Therapy Cont:Drug Therapy Cont:
SampleSample Insulin Regimen Insulin Regimen (NPH & Regular insulin)(NPH & Regular insulin)
Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:
Rapid ActingRapid Acting “ “LogsLogs””HumaHumaloglog (insulin lispro) (insulin lispro)NovoNovologlog (insulin aspart) (insulin aspart)
Bolus insulinBolus insulin Onset 15 min; peaks 1-2 hrs; lasts 4-6 Onset 15 min; peaks 1-2 hrs; lasts 4-6
hourshours Ideal for meal coverageIdeal for meal coverage
““Give the shot while Give the shot while the plate is the plate is hothot!”!”
Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:
Short Acting: Regular Insulin Short Acting: Regular Insulin RegsRegs
Bolus insulin Onset ½-1 hr; peaks
2-4 hrs; lasts 6-8 hrs
Give 30 minutes to 1 hour before a meal
Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:
Short Acting: Regular InsulinShort Acting: Regular Insulin♪ ♪ It’s time give you yourIt’s time give you your regular insulinregular insulin ♪♪
♪♪ It’s time to give itIt’s time to give it 30 minutes before your 30 minutes before your plate is inplate is in ♪♪
♪♪ Come back to check you Come back to check you in 2 (hours)in 2 (hours) ♪♪
♪♪ Watch out for Watch out for shakesshakes and and sweatssweats too too ♪♪
♪♪ If your lucky you’ll have no clue!!!!If your lucky you’ll have no clue!!!! ♪♪
Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:Rapid Acting (Humalog/Novolog) VS. Short Acting (Regular
Insulin)
Rapid onset1-2 hour peakLimited duration
Delayed onsetPeaks in 2-4 hrLasts 6-8 hours
Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:
Intermediate acting: NPH InsulinIntermediate acting: NPH Insulin
Basal insulin: covers blood sugar between meals
Satisfies overnight insulin requirement
Onset 1-2 hrs, peaks 6-10 hrs, lasts 12+ hrs
Need snack if NPH given at 5 pm (only)
Ideal to be given at 9 pm (HS) to address Dawn Phenomenon
Drug Therapy-Insulin Cont:Drug Therapy-Insulin Cont:
LL ong-Acting: ong-Acting: Peakless InsulinsPeakless Insulins!!!!!!
LLantusantus (insulin glargine) (insulin glargine)
LLevimirevimir (insulin detimir) (insulin detimir)
Basal InsulinBasal Insulin Onset 1.5 hrs; no peak (max effect in 5 Onset 1.5 hrs; no peak (max effect in 5
hrs); lasts 24 hourshrs); lasts 24 hours No risk for hypoglycemiaNo risk for hypoglycemia Do not mix with other insulins – Do not mix with other insulins – becomes becomes
inactivated when mixed with other insulinsinactivated when mixed with other insulins
Drug Therapy-Drug Therapy-Insulin Cont:Insulin Cont:HypoglycemiaHypoglycemia
BS < 60-70 mg/dLBS < 60-70 mg/dL
An acute An acute
complication complication
of insulin administrationof insulin administration
Tx: (15/15 or Tx: (15/15 or
20/20 Rule)20/20 Rule)
– Give 15/20 g simple Give 15/20 g simple
carb and recheck carb and recheck
BG in 15/20 minutesBG in 15/20 minutes
Synthetic injectables
Byetta: Synthetic incretin mimetic hormone– Indicated for patients with type 2
diabetes who don’t use insulin
Symlin: Synthetic analogue of human amylin– Approved for use with insulin in adults
with type 1 and type 2 diabetes
Drug Therapy Cont:Drug Therapy Cont:Other Methods of AdministrationOther Methods of Administration
For Uncontrolled DM 1 0r 2
Rapid-acting insulin
Continuous IV insulin infusion Used to maintain glycemic control
in hospitalized patients with high blood glucose levels; in DKA and HHNS
Regular insulin may be used IV
May also be given preoperatively or postoperatively
More frequent BS monitoring ( q1-2 hours per agency protocol)
Drug Therapy Cont:Drug Therapy Cont:
Oral Antidiabetic agents Oral Antidiabetic agents
(see handout)(see handout)
New Oral Med
Januvia (Sitagliptin)
– An oral drug that reduces blood sugar levels in patients with type 2 diabetes.
– Sitagliptin is the first approved member of a class of drugs that inhibit the enzyme, dipeptidyl peptidase-4 (DPP-4).
Acute ComplicationAcute Complicationof Insulin and (some) Oral Meds of Insulin and (some) Oral Meds
HypoglycemiaHypoglycemia
Diabetic TeachingDiabetic TeachingNeedsNeeds
Disease processDisease processS/S of hyperglycemia and hypoglycemiaS/S of hyperglycemia and hypoglycemiaBlood sugar monitoringBlood sugar monitoringDiet Diet ExerciseExerciseDrug therapyDrug therapySick Day RulesSick Day RulesComplications (acute and chronic)Complications (acute and chronic)Prevention: Foot care, eye exam etc.Prevention: Foot care, eye exam etc.