DM
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Transcript of DM
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Diabetes melitus
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Glucose metabolismInsulin release -cells, Islets of Langerhans in pancreasStimulated by rising blood glucoseInhibited by low blood glucoseInsulin actionsIncreases metabolism of glucoseLowers blood concentration of glucoseEnhances carbohydrate metabolism (energy)Spares fat and protein metabolism
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Blood glucose regulationGlucagon-cells, Islets of LangerhansPrevents hypoglycemiaStimulates the release of glucose from the liver into the bloodstream
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InsulinMust be used in type 1 diabetesMay be used in type 2 diabetes when oral agents are not effective enoughInsulin use does not mean insulin dependence
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Insulin onset & peak of action
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Types of insulinClassified byDuration of actionSpecies of origin
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Insulin characteristicsNovolin insulin profilesHumulin insulin profiles
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Insulin dosage regimensHighly individualizedInsulin needsDiet & exercisePatient motivation & ability to complyOnce a dayTwice a dayIntermediate or long-acting with regular & sliding scale
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Insulin dosage regimensIntensive insulin therapyMultiple daily measurements and injectionsGoal: near normalization of blood glucose without hypoglycemia50-75% reduction in complications (retinopathy, nephropathy, neuropathy)Insulin pump administration
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Monitoring of insulin regimen effectivenessShort term: Fingerstick Blood glucose measurementQID & prn with changes & intensive therapy Log results & insulin usageGoal: 80-120 (tight control)Long term: Hemoglobin A1C Glycosylated hemoglobinGoal: < 7.0 (normal 4-6 in nondiabetics)Frequency of Hypoglycemia episodesOften occurs in middle of night
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Adverse reactionsHypoglycemiaCauses:Too much insulinNot enough foodExcessive physical activityMost likely to occur with insulin peakMost common with tight glucose control
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Adverse reactionsAllergic reactionsSoreness, erythema, induration at injection siteSystemic rash & itchingAllergic reactions are most common with animal insulin, especially beef
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Adverse reactionsLipodystrophiesLipoatrophySaucer-like depressions in skin surfaceFat seems to have melted awayLipohypertrophySpongy (fatty) area at injection siteInsulin stimulates fat synthesisSite rotation used to prevent problems
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Special SituationsSick daysHospitalizationMay need insulin drip & frequent checksDiet restrictions (NPO, etc)
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Drugs for Type 2 diabetes
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Sites of action for oral hypoglycemic drugs
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SulfonylureasGlipizide (Glucotrol, Glucotrol XL)Glyburide (Diabeta)Glimepiride (Amaryl)Used in type 2 onlyActionStimulates pancreatic -cell release of insulin
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Sulfonylureas: adverse reactionsHypoglycemia:More common with long-acting agents, in elderly & in renal failureLong-acting Glipizide is less likely to cause hypoglycemia
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Sulfonylureas: administrationShort-acting sulfonylureas are often given 30 minutes before meal to promote normalization of blood glucoseLong-acting sulfonylureas may be given with meals
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BiguanidesMetformin (Glucophage)Action: decreases hepatic production of glucose, decreases intestinal glucose absorption, increases insulin sensitivityMay be used in combination with sulfonylureas
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Biguanides: MetforminAdverse effectsCommon: Nausea, vomiting, diarrhea, bloating (resolve with therapy)Serious: Lactic acidosis Contraindicated in renal, hepatic & cardiac dysfunctionMust be stopped 24-48 hrs prior to procedure with IV contrast (i.e. angiogram)
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Thiazolidinediones: glitazonestroglitazone (Rezulin)rosiglitazone (Avandia) newpioglitazone hydrochloride (Actos) new
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Thiazolidinediones: glitazonesAction:Improves target cell response to insulinDecreases hepatic glucose outputDoes Not stimulate insulin secretionAction on pre-existing presence of insulinUsed as adjunct to diet and exercise in type 2May be added to sulfonylurea
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Thiazolidinediones: glitazonesDoes not cause hypoglycemia May increase fertility in womenPatient counseling about contraception Should not be used in type 1May cause liver damage 1/57,000 transplant or deathMonitor liver function
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Alpha-glucosidase Inhibitors(Starch blockers)acarbose (Precose)miglitol (Glyset)
ActionsSlows carbohydrate digestion & glucose absorptionAdministrationTid, before each meal
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Alpha-glucosidase Inhibitors
Adverse effects: think GIAbdominal discomfort, diarrhea, flatulenceWeight lossBeneficial in obese patientsIncreased liver function tests
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Meglitinidesrepaglinide(Prandin)Action: stumulates pancreatic insulin secretionUsed either alone or with metforminRapid onset, duration 4 hoursTake prior to each mealPrevents insulin peak after mealsAllows for irregular meal patternAdverse reaction: hypoglycemia
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Treatment of hypoglycemic episodes15 grams of fast-acting carbohydrate4-6 oz fruit juice1/2 cup regular pop2-3 graham cracker squaresGlucagon IV or SCOnset: 5-20 minutes, peak 30 minutesDextrose 50% IV
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Nursing ImplicationsPatient educationBlood glucose monitoringDietSkin care