Intro to diabetes mellitus
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Intro to Diabetes Mellitus. Angela Venturelli MS II Chelsey Villanueva MS II. Types of DM. Type 1: Autoimmune destruction of pancreatic beta cells (insulin producing cells). Insufficient production of insulin. More common in young people. Types of DM. Type 2

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Intro to Diabetes Mellitus

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Intro to diabetes mellitus

Intro to Diabetes Mellitus

Angela Venturelli MS II

Chelsey Villanueva MS II


Types of dm

Types of DM

  • Type 1:

    • Autoimmune destruction of pancreatic beta cells (insulin producing cells).

    • Insufficient production of insulin.

    • More common in young people.


Types of dm1

Types of DM

  • Type 2

    • Insulin resistance and inability of beta cells in pancreas to produce enough insulin to meet the needs of the body.

    • No clear reason why it happens, but connected to lifestyle and genetics.

    • More common in older people, but patients are becoming younger.


Diagnosis of diabetes

Diagnosis of Diabetes

2010 ADA Guidelines (need ONE):

http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html

  • HbA1c reading 6.5% or higher.

  • Fasting serum glucose is ≥ 126mg/dl. (Fasting= no caloric intake for 8 hrs.)

  • 2-hour 75 g glucose challenge test yields blood sugar ≥ 200 mg/dl.

  • Random glucose ≥ 200 and pt. is experiencing symptoms (polydipsia, polyuria, unexplained wt. loss…)

    * If results from1-3 are unclear then retest.


The history

The History

Chief Complaint:

  • Polyuria

  • Polydipsia

  • Polyphagia

  • Recurrent Blurred Vision

  • Irritability/Mood Changes

  • Yeast Infections

  • Numbness or tingling in hands and or feet

  • Weight Loss

  • Dark spots on skin (AcanthosisNigricans)


The history1

The History

Past Medical History:

  • Previous DM diagnosis

  • HTN

  • Hyperlipidemia

  • Heart Conditions


The history2

The History

Past Hospitalizations:

  • Diabetic Ketoacidosis (DKA):

    • Happens when body cannot access glucose and starts breaking down fat to ketoacids. Emergency

  • Hypoglycemic Episode:

    • shaking, weakness, palpitations, trouble speaking, anxiety, hunger

      Past Surgeries


The history3

The History

Family History:

  • DM

  • Hypertension

  • Hyperlipidemia

  • Kidney Problems

  • Heart Conditions


The history4

The History

Social History:

  • Smoking

  • Drinking

  • Drugs

  • Diet

  • Exercise


Physical exam

Physical Exam

  • Vitals: BMI, BP

  • HEENT: Vision, Fundoscope, Thyroid

  • Cardio: RRR, Murmurs, Rubs, Gallops, Pedal pulses, peripheral edema

  • Respiratory: lung auscultation, crackles

  • Neuro: Sensitivity in hands and feet (filament test), patellar and Achilles reflex.

  • Skin: Special attention to legs and feet, dark skin in folds and creases


Acanthosis nigricans

AcanthosisNigricans


Diabetic retinopathy

Diabetic Retinopathy


Medications

Medications

Important Questions:

  • What medications are you taking?

  • Do you take insulin?

  • How long have you been on these meds?

  • Are you taking your meds?

  • How are you taking them? If different than prescribed, why?

  • Have you experienced any adverse reactions?

  • Do you have any drug allergies?


Medications1

Medications

  • Insulin

    • Long Acting: glargine (Lantus), detemir (Levemir)

      • Dose: 1 time per day

    • Intermediate Acting: NPH (Novolin N)

      • Dose: 2-3 times per day

    • Short Acting: Regular Insulin (Novolin R)

      • Dose: 30-45 min before a meal (Prandial)

    • Rapid Acting: lispro (Humalog), aspart (Novolog), glulisine(Apidra)

      • Dose: 15 min before a meal


Medications2

Medications

  • Biguanides

    • Oral

    • Inhibit liver glucose production and increase insulin action in muscle and fat

    • No risk of hypoglycemia

    • Side Effect: Diarrhea

    • metformin (Glucophage)


Medications3

Medications

Hypoglycemics (Type II ONLY):

  • Sulfonylureas:

    • Oral

    • Stimulate insulin release

    • glyburide (DiabetaMicronase), glipizide (Glucotrol), glimeperide (Amaryl)

  • Meglitinides:

    • Oral

    • Stimulate insulin release

    • repaglinide (Prandin), nateglinide (Starlix)

      * Yellow medications on formulary.


Medications4

Medications

  • Incretins:

    • Injectible

    • increases insulin secretion, reduce glucagon secretion, slows gastric emptying, reduces appetite and induces weight loss

    • exenatide (Byetta), sitagliptin (Januvia), saxagliptin (Onglyza)

  • Amylin:

    • Injectible

    • suppress glucagon secretion, delay gastric emptying & suppress appetite

    • pramlintide (Symlin)


Medication

Medication

  • Thiazolidinediones (Tzds)

    • Oral

    • Increases insulin sensitivity in peripheral tissue

    • pioglitaone (Actos), rosiglitazone (Avandia)

  • Alpha-Glucosidase Inhibitor

    • Oral

    • Reduces intestinal absorption of starch, dextrin and disaccharides

    • acarbose (Precose), miglitol (Glyset)


Medications5

Medications

Other medications:

  • ACE Inhibitors- “-pril”

    • Oral

    • Start when pt. has microalbuminuria.

    • Side Effect: Cough

    • lisinopril, captopril, benazepril, enalapril

  • ARB- “-sartan” (Not on formulary)

  • Anti Hypertensives

  • Statins- “-statin”, Lipitor

  • Aspirin:

    • Pts. With cardiac risk.

    • Men > 50, Women > 60 with 1 major risk factor (famhx, CVD, HTN, smoking, dyslipidemia, albuminuria)


Medications6

Medications

The clinics get most of their medications from the Target or Walmart $4 Formularies and PAPs.

  • Target:

    http://sites.target.com/site/en/health/page.jsp?contentId=WCMP04-040590

  • Walmart:

    http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf


Treatment goals

Treatment Goals

2010 ADA Recommendations:

  • HbA1c: < 7.0%

  • Preprandial capillary plasma glucose:

    • 70-130 mg/dl

  • Peak postprandial capillary plasma glucose:

    • < 180 mg/dl

  • BP: ≤ 130/80

  • Lipids:

    • LDL < 100mg/dl

    • HDL >50 mg/dl

    • Trigs < 150 mg/dl


Intro to diabetes mellitus

Labs

  • HbA1c- Test sugar levels over last 3 months.

    • Draw= Every 3 months

  • Urinalysis- Kidney ftn.

    • 3 specimens in 3-6 month period should be taken to confirm abnormal urine protein results (also true for microalbumin)

  • MicroalbuminCreatinine Ratio- Kidney ftn.

    • Type 1: test 5 yrs after dx

    • Type 2: test immediately

    • Test annually thereafter.


Intro to diabetes mellitus

Labs

  • CMP- Kidney ftn., Electrolytes, Liver ftn.

    • Annually, especially Cr.

  • Fasting Lipid Panel- Cholesterol levels

    • Fasting lipids annually

    • Low risk can be done every 2 years

  • TSH

    • DM Type I Every 1-2 years


Health maintenance

Health Maintenance

  • Ophthalmology Referral

    • Every year

    • Screen for DM retinopathy

  • BP Control

    • Important for maintaining kidney ftn.

  • Cancer Screening

    • Potentially higher risk of: pancreatic, endometrial, melanoma, breast cancer


Health maintenance1

Health Maintenance

  • Routine Vaccinations:

    • Yearly flu vaccine

    • Pneumococcal after age 65, if given before 55 (should be given every 10 years)

    • Tdap

  • Dental Care

  • Pregnancy:

    • Refer to county. Eligible for medical.


Health maintenance2

Health Maintenance

Lifestyle Modification aka:

DIET and EXERCISE

!!!


Health maintenance3

Health Maintenance

2010 ADA Recommendations:

  • Exercise:

    • 150 min/week of moderate intensity exercise (50-70% of max HR)

    • In DM 2: Resistance Training 3x week. If not contraindicated.

  • Diet

    • Saturated Fats: <7% of total calories

    • Minimize trans fats

    • Monitor Carbohydrates with Carb counting:

      • http://www.diabetes.org/food-and-fitness/food/planning-meals/carb-counting/


Intro to diabetes mellitus

Thank You


References

References

  • PPTs:

    • Type 2 Diabetes Mellitus, Dr. Roger K. Long

    • Type 1 Diabetes Mellitus and Diabetic Ketoacidosis, Dr. Nicole Glaser

    • Insulin and Oral Hypoglycemic Therapy, Heike Wulff, Ph.D.


Medications7

Medications

Online:

  • Standards for Medical Care in Diabetes-2010, ADA:

    • http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html

  • Uptodate: “Overview of medical care in adults with diabetes mellitus”:

    • http://www.uptodate.com/online/content/topic.do?topicKey=diabetes/10339&selectedTitle=1%7E150&source=search_result#H22

  • Mayo Clinic Website:

    • www.mayoclinic.com


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