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Chapter 5Chapter 5Drugs for Diabetes Drugs for Diabetes

MellitusMellitus

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Diabetes MellitusDiabetes Mellitus

Diabetes mellitus is a condition in which Diabetes mellitus is a condition in which the body cannot effectively regulate the body cannot effectively regulate blood glucose or “blood sugar.” blood glucose or “blood sugar.” Hyperglycemia – high blood glucoseHyperglycemia – high blood glucose Hypoglycemia – low blood glucoseHypoglycemia – low blood glucose

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Glucose MetabolismGlucose Metabolism

As we consume food, the digestive As we consume food, the digestive system predominately converts those system predominately converts those foods into glucose.foods into glucose. Energy Energy

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Glucose Metabolism Glucose Metabolism ((cont.cont.))

If glucose is not utilized for energy If glucose is not utilized for energy purposes at the time of digestion, it is purposes at the time of digestion, it is stored. stored. Glycogen in the liver and muscles Glycogen in the liver and muscles Adipose Adipose

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Glucose Utilization in the Glucose Utilization in the BodyBody

Requires Insulin Requires Insulin PancreasPancreas

Insulin binds with specific receptors on Insulin binds with specific receptors on the cell membrane. the cell membrane.

Once bound, the receptors signal protein Once bound, the receptors signal protein messengers within the cell.messengers within the cell.

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Glucose Utilization in the Glucose Utilization in the Body (Body (cont.cont.))

Proteins migrate to the cytoplasm of the Proteins migrate to the cytoplasm of the cell membrane, bind with glucose, and cell membrane, bind with glucose, and allow passage into the cell by passive allow passage into the cell by passive transport.transport.

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Glucose Utilization in the Glucose Utilization in the Body (Body (cont.cont.))

Without insulin in the bodyWithout insulin in the body Excess glucose accumulates in the blood, Excess glucose accumulates in the blood,

which goes unusedwhich goes unused Excreted in the urineExcreted in the urine

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ExceptionsExceptions

The brain requires a constant supply of The brain requires a constant supply of glucose. glucose. The brain is freely permeable to glucose at The brain is freely permeable to glucose at

all times. all times.

During exercise, skeletal muscles can During exercise, skeletal muscles can readily uptake glucose into the cells readily uptake glucose into the cells without the presence of insulin. without the presence of insulin.

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Exceptions (Exceptions (cont.cont.))

The liver is also non-insulin dependent The liver is also non-insulin dependent but insulin will enhance the metabolism but insulin will enhance the metabolism of glucose throughout the body.of glucose throughout the body.

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Box 5-2: Diagnostic Box 5-2: Diagnostic Criteria for DiabetesCriteria for Diabetes

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Types of DiabetesTypes of Diabetes

Type 1 DiabetesType 1 Diabetes Formally known as “insulin Dependent Formally known as “insulin Dependent

Diabetes Mellitus” (IDDM) or “Juvenile-onset Diabetes Mellitus” (IDDM) or “Juvenile-onset diabetes” diabetes”

Diagnosed in children, teenagers, and young Diagnosed in children, teenagers, and young adults adults

Can result from an autoimmune destruction Can result from an autoimmune destruction of the pancreatic of the pancreatic -cells -cells

Requires exogenous insulin to sustain life Requires exogenous insulin to sustain life

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Why Type 1 DiabetesWhy Type 1 Diabetes

Auto-immune destruction of the pancreatic Auto-immune destruction of the pancreatic -cells. -cells.

Some will have rapid destruction and others Some will have rapid destruction and others will have slower rate of destruction. will have slower rate of destruction.

Cell destruction can take place over weeks, Cell destruction can take place over weeks, months, or even years. months, or even years.

Virus, toxin, or some environmental Virus, toxin, or some environmental condition is thought to stimulate the condition is thought to stimulate the destruction of the destruction of the -cells.-cells.

The exact destruction process is unclear.The exact destruction process is unclear.

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Type 2 DiabetesType 2 Diabetes

Formally known as “Non-Insulin Dependent Formally known as “Non-Insulin Dependent Diabetes” (NIDDM)Diabetes” (NIDDM)

Previously known as “Adult-onset diabetes” Previously known as “Adult-onset diabetes” Can occur at any age, including Can occur at any age, including

adolescence, but usually affects older adolescence, but usually affects older individualsindividuals

May stem from insulin deficiency or May stem from insulin deficiency or resistanceresistance

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Why Type 2 DiabetesWhy Type 2 Diabetes

Age Age Lack of exercise Lack of exercise ObesityObesity Hypertension, Hypertension, Dyslipidemia – abnormal amount of lipids Dyslipidemia – abnormal amount of lipids

in the bloodin the blood

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Why Type 2 Diabetes Why Type 2 Diabetes ((cont.cont.))

Certain racial/ethnic groups Certain racial/ethnic groups Women who were diagnosed with Women who were diagnosed with

gestational diabetesgestational diabetes A strong genetic disposition plays a A strong genetic disposition plays a

contributing role in developing type 2 contributing role in developing type 2 diabetes, although the specific genetic diabetes, although the specific genetic link is not clearly knownlink is not clearly known

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Management of Diabetes Management of Diabetes

Glucose MonitoringGlucose Monitoring Blood glucose levels are measured using Blood glucose levels are measured using

Self-Monitored Blood Glucose (SMBG) Self-Monitored Blood Glucose (SMBG) equipment equipment

Blood tests 4 to 6 times per dayBlood tests 4 to 6 times per day

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Blood Glucose LevelsBlood Glucose Levels

Normal fasting plasma glucose (FPG) Normal fasting plasma glucose (FPG) levels = 70 – 120 mg/dLlevels = 70 – 120 mg/dL Fasting test is most appropriate to determine Fasting test is most appropriate to determine

blood glucose levels (diabetes)blood glucose levels (diabetes)

Two hours after a meal, glucose levels Two hours after a meal, glucose levels should be <140 mg/dLshould be <140 mg/dL

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Managing DiabetesManaging Diabetes

Diet Diet Exercise Exercise Insulin AdministrationInsulin Administration

Injection Injection Oral anti-diabetic agentsOral anti-diabetic agents

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DietDiet

Timing of food intakeTiming of food intake Type of foods eaten Type of foods eaten

(carbohydrate, fat, protein)(carbohydrate, fat, protein) Total caloric intakeTotal caloric intake

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ExerciseExercise

Recommended forRecommended for:: Type 1Type 1 Type 2Type 2

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Insulin AdministrationInsulin Administration

Exogenous insulin is required in:Exogenous insulin is required in: Gestational diabetes Gestational diabetes Type 1Type 1 Sometimes Type 2 Sometimes Type 2

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Insulin Injection DevicesInsulin Injection Devices

Syringe/needleSyringe/needle Insulin pump/refillableInsulin pump/refillable Prefilled insulin pens Prefilled insulin pens

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Insulin TypesInsulin Types

Rapid-actingRapid-acting HumalogHumalog

Short-actingShort-acting RegularRegular – slightly longer onset of action – slightly longer onset of action

compared to rapid-actingcompared to rapid-acting Intermediate-acting Intermediate-acting

LenteLente Long-actingLong-acting

UltralenteUltralente Combination ProductsCombination Products

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Rapid-Acting InsulinRapid-Acting Insulin

Humalog Humalog FDA (1996) – first available rapid-acting FDA (1996) – first available rapid-acting

insulininsulin Injected 15 minutes before mealInjected 15 minutes before meal

Onset = < 30 minOnset = < 30 min Peak = 30 min to 1 hour (longer depending on Peak = 30 min to 1 hour (longer depending on

type)type) Duration = 2 to 4 hours (+/Duration = 2 to 4 hours (+/––))

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Short-Acting InsulinShort-Acting Insulin

RegularRegular Longer onset of action compared to rapid-Longer onset of action compared to rapid-

acting acting Onset = ½ Onset = ½ –– 1 hr. 1 hr. Peak = 2 Peak = 2 – – 5 hrs.5 hrs. Duration = 5 Duration = 5 – – 10 hrs. 10 hrs.

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Intermediate-Acting Intermediate-Acting InsulinInsulin

Lente Lente Onset = 1 – 3 hrs.Onset = 1 – 3 hrs. Peak = 6 – 14 hrs.Peak = 6 – 14 hrs. Duration = 18 – 24 hrs. (+/Duration = 18 – 24 hrs. (+/––))

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Long-Acting InsulinLong-Acting Insulin

UltralenteUltralente Onset = 4 Onset = 4 –– 6 hrs. 6 hrs. Peak = 16 Peak = 16 –– 24 hrs. 24 hrs. Duration = 24 Duration = 24 –– 28 hrs. (+/ 28 hrs. (+/––))

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Table 5-4: Insulin Types Table 5-4: Insulin Types and Actions*and Actions*

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Injections/DayInjections/Day

Two Two One in the morningOne in the morning One in the late afternoonOne in the late afternoon

Mix of short and intermediateMix of short and intermediate

Three to FourThree to Four Mainly used for more control of the diabetesMainly used for more control of the diabetes

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Figure 5-8: Onset and Figure 5-8: Onset and Duration of ActionDuration of Action

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Adverse Effects of Adverse Effects of Injections Injections

Insulin shock – HypoglycemiaInsulin shock – Hypoglycemia Excess levels of insulin in the bodyExcess levels of insulin in the body Weak, drowsy, confused, hungry, or dizzy Weak, drowsy, confused, hungry, or dizzy Loss of consciousness and possibly coma Loss of consciousness and possibly coma

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Diabetic ConcernsDiabetic Concerns

Diabetic ketoacidosis Diabetic ketoacidosis More common in Type 1More common in Type 1 Insulin deficiency results in use of fatty acids Insulin deficiency results in use of fatty acids

for energyfor energy Ketones are released as a by-product of fat Ketones are released as a by-product of fat

metabolism = high blood levels of ketonesmetabolism = high blood levels of ketones Hyperglycemia, thirst, excess urination, Hyperglycemia, thirst, excess urination,

fatigue, blurred vision, fruity breath, nausea, fatigue, blurred vision, fruity breath, nausea, muscular stiffness, and difficulty breathing muscular stiffness, and difficulty breathing

Ketoacidosis can lead to coma and Ketoacidosis can lead to coma and potentially deathpotentially death

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Oral Antidiabetic AgentsOral Antidiabetic Agents

Combination of oral antidiabetic Combination of oral antidiabetic medications plus a regimen of diet and medications plus a regimen of diet and exercise allows diabetics to better exercise allows diabetics to better manage hyperglycemia manage hyperglycemia

Variety or oral antidiabetic agentsVariety or oral antidiabetic agents

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Table 5-5: Oral Antidiabetic Table 5-5: Oral Antidiabetic Agents: Types & ActionsAgents: Types & Actions

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Table 5-5: Oral Antidiabetic Table 5-5: Oral Antidiabetic Agents: Types & Actions Agents: Types & Actions

((cont.cont.))

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Box 5-1: Complications Box 5-1: Complications of Diabetesof Diabetes

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The Athletic Trainer’s The Athletic Trainer’s ResponsibilityResponsibility

Monitor blood glucose levels – before Monitor blood glucose levels – before and after exerciseand after exercise

Record food and insulin intakes for all Record food and insulin intakes for all types of activitytypes of activity

Monitor athlete/person for hypoglycemiaMonitor athlete/person for hypoglycemia Make appropriate decisions regarding Make appropriate decisions regarding

activity and blood glucose levelsactivity and blood glucose levels