Mary Bruskewitz APN, MS, RN, BC-ADM Clinical Nurse Specialist Diabetes

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Mary Bruskewitz APN, MS, RN, BC-ADM

Clinical Nurse Specialist – Diabetes

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Objectives

 Pathophysiology of Diabetes

 Acute & Chronic Complications

 Managing acute emergencies

 Case examples

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What is Diabetes?

Inability of the body to use glucose

Disturbances in the metabolism of carbohydrates, proteins and fats.

A syndrome of metabolic disease(s) characterized by

Hyperglycemia

Relative or absolute insulin deficiency

Hypoglycemia

Complications, cardiovascular, renal, eye, neurological, skin, peripheral vascular

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Regulation of Glucose

Exercise

Food

Beta cell Insulin

Epinephrine

Cortisol

Glucagon

Growth hormone

Stress

Gut Hormones

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Terminology

Type I

IDDM, Type I, Juvenile, Brittle diabetes

Type 2

NIDDM, Adult, Type II, Medication Induced,

Steroid, 10-20% of solid organ transplants , Insulin resistance from steroids

Other

Alcoholism ,Pancreatitis, Cystic Fibrosis, liver disease, cancer

Gestational

Pre-Diabetes

Impaired Glucose Metabolism (IGT), Syndrome X, Borderline, Metabolic Syndrome

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Symptoms

Polydipsia

> T1

Polyuria

> T1

Frequent infections

>T2, dental, UTI, vaginal, URI

Foot ulcers at diagnosis

> T2

MI, CVA at diagnosis

> T2

Weight loss

> T1 – dramatic

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Diagnostic Criteria

Normal

Fasting

70-100 mg/dl

2 hr after meal

Under 140 mg/dl

Random

Under 140 mg/dl

Diabetes

Fasting =/> 126 mg/dl x 2 tests

2 hr after meal

Greater than 200 mg/dl x 2 tests

Random

Greater than 200 mg/dl &

symptomatic

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Pre-Diabetes

Fasting BG > 100 < 126 mg/dl

2 hr > 140 < 200 mg/dl

Risk factors:

family hx, obesity, > 40 age (increasing in children), minorities, obesity, & inactivity, hypertension

HTN, hyperlipidemia, waist circumference

Will develop into Type 2

Lifestyle changes decreases risk of getting T2

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Type 2 a Progressive Disease: Natural History of T2

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20 10 0 10 20 30

Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota.

Years of Diabetes Relative -

Cell Function Plasma

Glucose

Insulin resistance Insulin secretion

126 mg/dL Fasting

glucose

6-6

Diagnosis up to 10 yrs

Post meal glucose

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Type 1

Autoimmune

Absolute lack of insulin

Requires insulin & sensitive

Acute onset

Profound hyperglycemia

Ketosis

Possible causes (genetic, viral)

5% all diabetes

Type 2

Hereditary

Slow onset, with/out symptoms

Impaired insulin secretion & resistant

Multiple risk factors (age, obesity, inactivity, HTN, cholesterol, gestational, minority)

85 – 95% & growing – epidemic

Growing in children

Complications at diagnosis

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Management

Type 1

Insulin therapy (intensive = multiple injections or

insulin pump)

BG Monitoring

Healthy eating

Activity

Type 2

Education

Healthy eating & activity

(4 wks)

Oral medications (3 meds not uncommon)

BG Monitoring

Insulin (majority will require at some time

)

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Complex

Individualized to the person

Requires a team approach

Follow-up - Surveillance of complications

Lifetime of education

Monitoring

Healthy Eating

Exercise

Medications

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PreDiabetes Management

Prevention, prevention, prevention

Healthy lifestyle

Weight loss

Exercise

Healthy Eating

BP control

Cholesterol control

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Targets - Individualized

BG - individualize

Fasting 70-100 mg/dl

Before meals: 80 mg/dL - 120 mg/dL

2 hrs postprandial 100 mg/dL - 140 mg/dl

Bedtime 120-130 mg/dl

Pregnancy fasting < 90 mg/dL, 2 hr postprandial < 120 mg/dL

A1c: < 7% (ACE, under 6.5%), Pregnancy < 6%

BP (<130/80)

Cholesterol (TC <200, Trig <150, HDL >45 (males) >55 (females), LDL<100 - Multiple CVD risk factors, < 70)

Aspirin, debatable

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Basal Insulin's

Lantus (Glargine)

Levemir (Detemir)

NPH

U-500 Regular Insulin (special order by Endocrine only)

Pre-mixed Insulin (not used in T1, pregnancy)

Novolin 70/30 (70% NPH/30% Regular) NovoNordisk

Humulin 70/30 (70%NPH/30% Regular) Lilly

Novolog 70/30 (70% NPH and 30% Novolog)

Humalog 75/25 (75% NPH and 25% Humalog)

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Bolus Insulin

Short Acting – Regular

Rapid Acting

Lispro – Humalog

Aspart – Novolog

Glulisine - Apidra

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Oral Medications

Biganuides

Metformin/Riomet (liquid)

Extended release – Glucophage, Fortamet, Glumetza

Decreases amount of glucose produced by the liver

Sulfonylureas

Glipizide, Glimepiride, Glyburide

Increase beta cells release of insulin

Thiazolidinedione's (TZD) Use with caution

Pioglitazone - Actos

Improves sensitivity to the effects of insulin

Meglitinides, non-sulfa

Nateglinide - Starlix, Rapaglinide - Prandin

Increases beta cells release of insulin postprandial

Shorter acting compared to sulfonylureas

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Alpha Glucosidase Inhibitors

Acarbose - Precose, Miglitol - Glyset Rarely used (GI side effects)

Slows the absorption of carbohydrates postprandial

DPP-4

Sitagliptin - Januvia, Saxagliptin - Onglyza, Linagliptin - Tradjenta

Decreases glucose uptake by inhibiting DPP-4 via digestion process

Improves insulin level postprandial

Lowers glucose production by the body (liver)

May work in brain to decrease appetite

SLGT – 2 Inhibitors

Canaglifloxin, Invokana

Blocks glucose reabsorption in the kidneys

Positive glycosuria

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Combination Oral Medications

Actoplus - Pioglitazone & metformin

Glucovance - glyburide & metformin

Metaglip – glipizide & metformin

Janumet – Sitagliptin & metformin

Kombiglyze – Saxagliptin & metformin

Prandimet – Repaglinide & metformin

Duetact – Pioglitazone & glimepiride

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Diabetes Oral Medications

Metformin

Actos

glipizide, glimepiride Januvia, Onglyza, Tradjenta

Kidney

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Injectable

Incretin mimetics/ GLP-1 analogue

Exenatide - Byetta

Exenatide extended – Bydureon (kit or pen)

Liraglutide - Victoza

Albiglutide – Tanzeum

Dulaglutide - Trulicity

Insulin Sensitizers

Symlin

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Devices

Needles or pens

4 mm (pen only)

5 mm (pen only)

8 mm (5/16 “)

12.7 mm (1/2 “)

1 inch (syringe only)

Pumps

Sensors

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Case Study

22 yo university student

Symptoms

Tired, average 6 hrs sleep

Declining grades

BG 600 mg/dL

Weight gain over 6 months, 15#

BMI 33%

BP at clinic visit 136/84, usually normal

Decreased appetite, erratic meals 1-2/day

Decreased exercise, sedentary lifestyle

Family hx of T2

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Figure

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References

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