Management of Diabetes Mellitus

MANAGEMENT OF DIABETES

Prapared by maria carmela l. domocmat, rn, msn

Medical Management of DM

No cure Goal: Euglycemia and prevention of

complications Individualized treatment plans

Appropriate goal setting Diet Exercise Self-monitoring of blood glucose (SMBG) Regular monitoring for complications Laboratory assessment Oral meds/insulin

Surgical management of DM

pancreas transplant

not usually done

Islet cell transplants

Dietary management

Dietary management of DM Foundation of Diabetic control

Goals Maintain near-normal blood glucose levels

Achieve optimal serum lipid levels

Provide adequate calories for reasonable weight

Prevent & treat acute complications of insulin-treated diabetes

Improve overall health through optimal nutrition

Diet Composition

Carbohydrates: 60 – 70% of daily diet Protein: 15 – 20% of daily diet Fats: No more than 10% of total calories from

saturated fats Fiber: 20 to 35 grams/day; promotes intestinal

motility and gives feeling of fullness Sodium: recommended intake 1000 mg per 1000

kcal Sweeteners approved by FDA instead of refined

sugars Limited use of alcohol: potential hypoglycemic

effect of insulin and oral hypoglycemics

The exchange system

Six categories

Bread/starch

Meat

Milk

Vegetable

Fruit

Fat

General guidelines of Dietary Management

Protein

20%

Fat

20%

Carbohydrates

60%

ADA: American Diabetic Association

Diabetic Meal Plan

Small frequent meals

CONSISTENCY! Amount of calories

Amount of carbohydrates

Time

Snacks

Diabetic Meal Plan

If the pt is obese, the key to treatment is…

Weight los!

Sweeteners

Nutritive sweeteners

Not calorie free

Cause less h in BS (than regular sugar)

Sorbitol laxative effect

Non-nutritive sweeteners

Minimal or no calories

Do not h BS

Meal Plan considerations

Food preferences

Lifestyle

Schedule

Ethnic / Cultural background

Alcohol and Diabetes

Increase risk of…

Hypoglycemia

Affects the liver

Don’t take on empty stomach

Esp. if on insulin or oral hypoglycemic meds

Moderation

Exercise

Exercise and Diabetes

i blood glucose levels

h the uptake of glucose by body muscle

Potentiates action of insulin

i insulin requirement

Effect lasts 24 hours

More Benefits of exercise

Increases circulation

Improve serum lipid levels

Improves cardiovascular status

Assist with wt control

Decreases stress

Rules for the exercising diabetic

Talk to MD first

Regular vs. sporadic

Correlate exercise and glucose levels

Don’t exercise when hypoglycemic

Don’t exercise when hyperglycemic >250


Do not exercise when insulin is peaking

Carry a quick source of sugar

Best time = 60-90 minutes after a meal


Proper footwear

May need a pre-exercise snack

Consistency!

Self monitoring of blood glucose (SMBG)

Monitoring Glucose

SMBG

Glucometers

Urine testing for glucose 2-4 times a day

Continuous glucose monitoring system

Monitoring Ketone levels

Dipstick method

Perform when:

Glucosuria

Unexplained elevated glucose level

Illness

Pregnancy

Foot care

Regular monitoring for complications

Foot care

Foot Care

Inspect feet daily

Wash feet with warm water and mild soap

Pat dry – do not rub

Wash daily: wash feet in warm water every day, using a mild soap.

Dry between toes

Lubricate dry feet

Inspect

Mirror

Family

Between toes

Do not soak feet. Dry feet well,

especially between the toes.

If the skin on feet is dry, keep it moist by applying lotion after washing and drying.

Apply lotion on feet (not interdigital areas)

Foot care

Check toenails once a week.

Trim toenails with a nail clipper straight across.

Do not round off the corners of toenails or cut down on the sides of the nails.

After clipping, smooth the nails with an emery board.

Foot care

Always wear socks or stockings with soft elastic, and that fit feet.

Wear socks at night if feet get cold.

Always wear closed-toed shoes or slippers.

Do not wear sandals and do not walk barefoot, even around the house.

Foot care

Wear comfortable properly fitted shoes

Buy shoes made of canvas or leather and break them in slowly.

Extra wide shoes are also available in specialty stores that will allow for more room for the foot for people with foot deformities.

Break in new pair of shoes for 1 -2 hours only until it becomes comfortable

Foot care

Maintain the blood flowing to feet

Elevate feet up when sitting

Do not wear knee high/ stay up stockings

Foot care

wiggle toes and move ankles several times a day

don't cross legs for long periods of time

Avoid activities that icirculation

Smoking

Crossing legs

Tight socks

Good shoes

Comfortable

Closed toe

No bare feet

New shoes Break in slowly

Prevent injuries

Wear socks

Cotton

Light color

No wrinkles

Check inside of shoe

No temperature extremes

Check bath water

No water bottles

No heating pads

See doctor regularly

Podiatrist

Trim straight across

Do not cut calluses or corns

Range of Motion

Foot care

see podiatrist q2 to 3 months for check-ups, even if don't have any foot problems.

include inspection of skin

check for redness or warmth of the skin.

check for pulses and temperature of feet

Monofilament assessment of foot sensation

When to contact Dr?

Changes in skin color Changes in skin temperature Swelling in the foot or ankle Pain in the legs Open sores on the feet that are slow to heal or

are draining Ingrown toenails or toenails infected with fungus Corns or calluses Dry cracks in the skin, especially around the heel Unusal and/or persistent foot odor

Risk for infection

Frequent hand washing Early recognition of signs of infection and

seeking treatment Meticulous skin care Regular dental examinations and consistent oral

hygiene care

Sexual dysfunction

Effects of high blood sugar on sexual functioning,

Resources for treatment of impotence, sexual dysfunction

MANAGEMENT DM: PHARMACOLOGIC MGMT

Oral Hypoglycemic Agents

Oral hypoglycemic meds are NOT Insulin

Oral hypoglycemic meds require some production of insulin

Oral hypoglycemic agents are used in the treatment of type 2DM

Oral hypoglycemic meds are meant to supplement diet and exercise, NOT replace them


Oral hypoglycemic meds cannot be used during pregnancy

Oral hypoglycemic meds may need to be halted temporarily and insulin prescribed if BS levels rise due to infection, trauma, stress, surgery etc.

Action vary so effect may be enhanced by use of multiple meds

Oral Medication

Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists

Biguanides

Metformin (Glucophage)

first choice for oral type 2 diabetes treatment.

Action: decreases overproduction of glucose by liver and makes insulin more effective in peripheral tissues

Biguanides

Major side effects : anorexia/ wt. Loss

CI in patients with Renal impairment

D/C temp of (+) illness that leads to dehydration or hypoperfusion --lactic acidosis.

Sulfonylureas

Glyburide (Micronase, DiaBeta, Glynase)

Glipizide (Glucotrol, Glucotrol XL)

Glimepiride (Amaryl)

Cholpropamide (Diabanese)

Sulfonylureas

Action: Stimulates pancreatic cells to secrete more insulin and increases sensitivity of peripheral tissues to insulin

(insulin secretagogues)

indicated for use as adjuncts to diet and exercise in adult patients with type 2 DM

Used: to treat non-obese Type 2 diabetics

Sulfonylureas

taken with food

except Glucotrol/Glipizide : taken 30 mins before meals

Sulfonylureas

(esp. Diabinese) when taken with alcohol can cause severe Disulfiram reactions

Disulfiram (antibus): a compound when used with alcohol produces distressing symptoms

Symptoms: Flushed skin, N/V, palpitations, hyperventilation

Side-effects

Hypoglycemia

GI upset

Meglitinides

Repaglinide (Prandin)

Nateglinide (Starlix)

Action: stimulates pancreatic cells to secret more insulin

much shorter-acting insulin secretagogues than the sulfonylureas

may be used in patients who have allergy to sulfonylurea medications.

Alpha-glucosidase inhibitors

Acarbose (Precose)

Miglitol (Glyset)

Action: Slow carbohydrate digestion and delay glucose absorption

S/E : diarrhea & flatulence

Take immediately before meals

Thiazolidinediones (TZDs)

Pioglitazone [Actos]

Rosiglitazone [Avandia]

Used for patients with type 2 DM who take insulin injections Acts by increasing insulin action at the receptor site

reduce insulin resistance

act as insulin sensitizers; thus, they require the presence of insulin to work.

must be taken for 12-16 weeks to achieve maximal effect.

Thiazolidinediones (TZDs)

Affects liver function liver function tests

Indications of altered liver function

Yellow skin tone

Nausea

Abdominal pain

Dark urine

Drug Interactions

Directly interact with Sulfonylurea and increase risk of hypoglycemia

Sulfonylurea+ * Med = Hypoglycemia

Sulfonamides

NSAIDS

Drug Interactions

h blood glucose levels

Regardless of what med you might also be taking

Potassium-losing diuretics

Corticosteriods

Estrogen compounds

Phenytoin (Dilantin)

Salicylates (ASA)

Drug interactions

Meds that cause Hypoglycemia

Without drug interaction

Acetaminophen

Alcohol

Monoamine oxidase inhibitors / MAO inhibitors

Drug interactions

Meds that can MASK signs and symptoms of Hypoglycemia

Propranolol (Inderal)


Client must also maintain prescribed diet and exercise program; monitor blood glucose levels

Not used with pregnant or lactating women Specific drug interactions may affect the blood

glucose levels

Insulin

Instituted in 1923

Beef

Pork

1979 – human insulin

Can not be taken by mouth (digested)

Onset – Peak - Duration

Onset

The time period from injection to when it begins to take effect

Peak

When insulin is working its hardest and therefore blood glucose levels are at their lowest

Duration

Length of time the insulin works or lasts

Types

Rapid-acting insulins or Ultra short-acting

Short-Acting Insulins

Intermediate-Acting Insulins

Long-Acting Insulins

Rapid-acting insulins/ or Ultra short-acting

have a short duration of action

appropriate for use before meals or when blood glucose levels exceed target levels and correction doses are needed.

These agents are associated with less hypoglycemia than regular insulin.

Rapid-Acting Insulins/ or Ultra short-acting

Insulin aspart (NovoLog)

Insulin glulisine (Apidra)

Insulin lispro (Humalog)

Rapid-Acting Insulins

Insulin aspart (NovoLog)

Insulin glulisine (Apidra)

Insulin lispro (Humalog)

Insulin pumps

Rapid reduction of glucose level

Appearance Onset Peak Duration

Clear 5-15 minutes

(10 min)

30-90 (1hr) 3-5 hours

(4 hrs)


Regular insulin (Humulin R, Novolin R)

Preparations:

mixture of 70% neutral protamine Hagedorn (NPH) and 30% regular human insulin

(ie, Novolin 70/30, Humulin 70/30)


Humalog R; Novolin R; Iletin II Regular

Administered 20-30 minutes before meals

IV

Usually given 4 x a day

May to taken alone or in combination


Clear ½ - 1 hr

(1 hour)

2-4 hrs

(3 hour)

4-6 hrs

(5 hours)


Insulin NPH (Humulin N, Novolin N)

have a slow onset of action and a longer duration of action.

commonly combined with faster-acting insulins to maximize the benefits of a single injection

onset of action: 3-4 hours.

Peak: 8-14 hours duration of action : 16-24

hrs appears cloudy must be gently mixed

and checked for clumping

if clumping occurs, the insulin should be discarded.


Insulin NPH (Humulin N, Novolin N)

Administer after meals

Usually given 2x a day

Eat at onset!


Cloudy 2-4 hrs

(2 hrs)

6-12 hrs

(12 hrs)

16-20 hrs

(24 hrs)


provide a longer duration of action, and, when combined with rapid- or short-acting insulins, they provide better glucose control

Insulin detemir (Levemir)

Insulin Glargine (Lantus)

Types of Insulin – Long-acting

Ultra Lente (UL)

To control fasting glucose levels

Cannot be mixed!


Cloudy 4-8hour

(6 hrs)

10-30 hrs

(24 hrs)

36+ hours

(36 hrs)


Insulin detemir

for once- or twice-daily dosing

duration of action is up to 24 hours

Insulin glargine

onset of action: 4-8 hours

Duration: 24 hours.

Peak effects; 16-18 hrs

FDA has advised of a possible association of insulin glargine with an increased risk of cancer

Rapid-Acting Insulins


Clear 5-15 minutes

(10 min)

30-90

(1hr)

3-5 hours

(4 hrs)



Clear ½ - 1 hr

(1 hour)

2-4 hrs

(3 hour)

4-6 hrs

(5 hours)

Learning Tip: Even and Odd

Short-acting think odd

(1-3-5)

Intermediate-acting think even

(2-12-24)



Cloudy 2-4 hrs

(2 hrs)

6-12 hrs

(12 hrs)

16-20 hrs

(24 hrs)

Long-acting insulin


Cloudy 4-8hour

(6 hrs)

10-30 hrs

(24 hrs)

36+ hours

(36 hrs)

When should insulin be administered

Short-acting / regular

30 minutes before meals

Do not allow more than 30 minutes to pass by without eating

hypoglycemia

Intermediate acting

After meals

If mixed (regular & intermediate)

30 minutes before meals

What route is insulin administered

Sub-cutaneous

IV

Regular

Pump

Insulin Type Onset Peak Duration

Ultra Short 15 mins 30-90 mins 2- 4 hrs

Short 30 mins 2- 4 hrs 6-8 hrs

Intermediate 1-2 hrs 6-12 hrs 18-24 hrs

Long 4-6 hrs 16-24 hrs 18-36 hrs

Combination

70/30

30-60

mins then

1-2 hrs

2- 4 hrs,

then 6-12

hrs

6-8hrs,then

18-24 hrs

Insulin Type Onset Peak Duration

Insulin

glargine

30-60

minutes

None 24 hours

Diabetes Mellitus

Mixing insulin

Adverse effects of insulin

Local allergic reactions

Insulin lipodystrophy

Insulin resistance

Dawn Phenomenon

Somogyi phenomenon

Insulin waning

Adverse effects of insulin

Insulin lipodystrophy or lipoatrophy

is primary idiopathic atrophy of adipose tissue

can be a lump or small dent in the skin that forms when a person keeps performing injections in the same spot.

Insulin lipodystrophy lipohypertrophy

Rotate site of injection

Nursing Responsibilities

Route : Subcutaneous

Steady absorption

Less painful

IV – in emergency cases ( DKA)

Only regular insulin is given through the IV route

Do not massage the site

Fastest absorption site is the abdomen, then deltoids, thighs then buttocks

Administer at room temperature Cold insulin causes lipodystrophy

Rotate site of injection To prevent lipodystrophy. Inhibits insulin

absorption

Store vial of insulin in current use at room temperature Other vials should be refrigerated


Gently roll vial in between the palms to redistribute insulin particles Do not shake. Bubbles make it difficult to

redistribute insulin particles



Observe for side effects

Localized

Induration or redness

Swelling

Lesions at the site

Lipodystrophy

Edema

Sudden resolution of hyperglycemia causes retention of water

Hypoglycemia

Somogyi Effect Rebound hyperglycemia

Normal or blood glucose levels are present at bedtime

hypoglycemia : occurs at 2-3am

This causes an increase in the production of counterregulatory hormones

Hyperglycemia: by 7 am

Resuts in response to the counterregulatory hormones

Somogyi Effect Treatment

decreasing evening (predinner or bedtime) dose of intermediate acting insulin

or increasing the bedtime snack

Dawn Phenomenon (6 AM – 8 AM) early AM increase in blood

glucose levels associated with release of growth hormone at 12 MN to 3 AM

Dawn Phenomenon:TREATMENT Type 1 diabetes

Intensify insulin therapy Avoid late night snacking, unless appropriate quick-

acting insulin is given.

Type 2 diabetes Adjust diet content (decrease carbohydrates) and

timing of the evening meal so that the glucose level at bedtime is 70-110 mg/dl

If dietary modification is not enough, consider an intermediate or long-acting sulfonylurea at evening meal.

Basal insulin is indicated if the dawn phenomenon continues.

Insulin Waning Progressive rise in the blood glucose levels

from bedtime to morning

Treatment:

Increase dose of evening intermediate acting or long acting insulin

Difference between dawn phen and insulin waning

10 PM 2 AM 4 AM 8 AM

Dawn Phenomenon

100 110 135 250

Waning of insulin

100 160 220 270

Dawn phenomenon shows an abrupt increase between 4 a.m. and 8 a.m., whereas waning of exogenous insulin effect shows gradual rise between 2 a.m. and 8 a.m.

Other meds

Glucagonlike peptide–1 (GLP-1 ) agonists

Exenatide injectable solution (Byetta)

Exenatide injectable suspension (Bydureon)

mimic the endogenous incretin GLP-1

it enhances glucose-dependent insulin secretion by pancreatic beta cells, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying.


Liraglutide (Victoza)

a once-daily injectable

stimulates G-protein in pancreatic beta cells.

Dipeptidyl peptidase IV (DPP-4) inhibitors

prolong action of incretin hormones

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin (Tradjenta)

Amylinomimetics

Pramlintide acetate (Symlin)

amylin analog that mimics the effects of endogenous amylin, which is secreted by pancreatic beta cells.

delays gastric emptying, decreases postprandial glucagon release, and modulates appetite.

Bile acid sequestrants

bile acid sequestrant colesevelam

lipid-lowering agents for the treatment of hypercholesterolemia but were subsequently found to have a glucose-lowering effect.

Antiparkinson Agents, Dopamine Agonists Bromocriptine (Cycloset)

Quick-release bromocriptine acts on circadian neuronal activities within the hypothalamus to reset the abnormally elevated hypothalamic drive for increased plasma glucose, triglyceride, and free fatty acid levels in fasting and postprandial states in patients with insulin resistance.

indicated as an adjunct to diet and exercise to improve glycemic control.

Non-Insulin Injectables

New drugs are available for people with type 2 diabetes.

Pramlintide (Symlin), exenatide (Byetta), and liraglutide (Victoza) are non-insulin injectable drugs.

insulin pulls glucose into the cells

these medications cause the body to release insulin to control blood sugar levels.