Adult Diabetes

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Questions and Answers

A patient with Type 1 Diabetes has a pre-evening meal blood glucose reading consistently above 140 mg/dL. Following the guidelines, what adjustment to their insulin regimen is most appropriate initially?

  • Increase the evening long-acting insulin dose by 5-10 units immediately.
  • Divide the current long-acting insulin dose into four administrations throughout the day.
  • Decrease the morning long-acting insulin dose by 2-5 units.
  • Add 2-5 units of regular insulin to the pre-evening meal dose every 3 days. (correct)

A patient with Type 1 diabetes is experiencing hypoglycemia around 3 AM. What is the most likely physiological explanation for this nocturnal hypoglycemia?

  • Increased insulin sensitivity due to decreased food intake during sleep.
  • Suppressed growth hormone secretion during the early morning hours.
  • The Somogyi effect caused by an overtreatment of insulin.
  • Release of counter-regulatory hormones in response to low blood sugar. (correct)

A patient with Type 1 diabetes consistently has elevated fasting blood glucose levels. According to the guidelines, how should their insulin regimen be adjusted?

  • Divide the long-acting insulin such that 2/3 of the dose is given before breakfast and 1/3 before dinner. (correct)
  • Increase the pre-dinner long-acting insulin dose and decrease the pre-breakfast dose.
  • Switch to a rapid-acting insulin analog administered every 2 hours overnight.
  • Administer the entire long-acting insulin dose at bedtime.

Why might Levemir (insulin detemir) be preferred over Lantus (insulin glargine) in some patients when administering long-acting insulin?

<p>Levemir's shorter duration of action allows for more flexible timing of administration. (C)</p> Signup and view all the answers

A patient with Type 1 diabetes reports morning hyperglycemia at 7 AM. What is the most appropriate initial adjustment to their insulin regimen?

<p>Increase the evening dose of long-acting insulin. (D)</p> Signup and view all the answers

In the management of Type 1 diabetes, what is the primary purpose of self-monitoring of blood glucose (SMBG)?

<p>To evaluate the effectiveness of the insulin regimen, medical nutrition therapy, and exercise. (D)</p> Signup and view all the answers

What is the recommended optimal frequency of self-monitoring of blood glucose (SMBG) for patients with Type 1 diabetes?

<p>3 to 4 times a day—before each meal and before bedtime. (B)</p> Signup and view all the answers

A patient with Type 1 diabetes is starting an exercise program. What screening is most important prior to beginning the program?

<p>Screening for macrovascular and microvascular complications. (C)</p> Signup and view all the answers

Before exercise, a patient with type 1 diabetes has a fasting glucose level of 280 mg/dL and no ketones. What is the most appropriate course of action?

<p>Delay exercise until blood glucose is better controlled because the glucose level is above 250 mg/dL. (B)</p> Signup and view all the answers

What is the recommended carbohydrate intake as a percentage of total daily calories for individuals with Type 1 Diabetes Mellitus?

<p>55-60% (C)</p> Signup and view all the answers

A patient with type 2 diabetes has a fasting glucose level of 275 mg/dL but no signs of ketosis. Which of the following exercise recommendations is MOST appropriate?

<p>Advise the patient to avoid exercise until the glucose level is better controlled. (C)</p> Signup and view all the answers

A patient with a fasting plasma glucose consistently around 190 mg/dL and no severe symptoms of diabetes is being managed. What initial intervention should be prioritized?

<p>Diet and exercise modifications with frequent follow-up. (A)</p> Signup and view all the answers

Which of the following assessment findings is MOST indicative of Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS)?

<p>Blood glucose of 700 mg/dL and serum osmolality of 350 mOsm/L. (B)</p> Signup and view all the answers

An elderly patient is suspected of having Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS). Besides elevated blood glucose, which of the following lab values would be MOST indicative of this condition?

<p>Elevated serum osmolality (B)</p> Signup and view all the answers

During the initial management of Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS), a patient is receiving intravenous fluid replacement. If the patient's serum sodium is 146 mEq/L, which type of fluid should be administered?

<p>0.45% Normal Saline (0.45 NS) (A)</p> Signup and view all the answers

A patient with Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS) is being treated with intravenous insulin. After the first hour of insulin infusion, the plasma glucose level does not fall by 10%. What is the MOST appropriate next step?

<p>Administer a second loading dose of insulin. (A)</p> Signup and view all the answers

A patient with Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS) is being managed with intravenous fluids and insulin. The plasma glucose reaches 200 mg/dL. Which intervention is MOST appropriate at this time?

<p>Decrease the insulin infusion rate and add D5W to the IV fluids. (B)</p> Signup and view all the answers

A patient with type 2 diabetes has been managing their condition with diet and exercise for the past 3 months. However, their fasting plasma glucose levels remain elevated. According to the information, at what level of glucose should pharmacological therapy be considered?

<p>If nutritional therapy and exercise have not achieved and maintained target fasting plasma glucose levels. (C)</p> Signup and view all the answers

A patient being treated for HHS is receiving both IV insulin and fluids. Which electrolyte imbalance is MOST critical to monitor due to the insulin administration, potentially leading to cardiac dysrhythmias?

<p>Potassium (A)</p> Signup and view all the answers

A patient with type 2 diabetes is prescribed an oral medication after 3 months of unsuccessful glucose control through diet and exercise. Which statement BEST describes the role of this medication?

<p>An adjunct therapy to support diet and exercise. (A)</p> Signup and view all the answers

Which of the following best describes the underlying cause of hyperglycemia in Type 1 Diabetes Mellitus?

<p>Autoimmune destruction of pancreatic beta cells leading to insulin deficiency. (B)</p> Signup and view all the answers

For a patient with Type 1 Diabetes Mellitus, what HbA1c level is associated with a significant reduction in the risk of developing complications such as retinopathy, nephropathy, and neuropathy?

<p>Below 7% (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes presents with polyuria, polydipsia, and unexplained weight loss. Which of the following underlying mechanisms is most directly responsible for these symptoms?

<p>Hyperglycemia exceeding the renal threshold for glucose reabsorption, causing osmotic diuresis. (A)</p> Signup and view all the answers

Which of the following findings would be LEAST likely in a patient experiencing diabetic ketoacidosis (DKA)?

<p>Serum pH &gt; 7.35 (D)</p> Signup and view all the answers

Why is C-peptide level measurement useful in the differential diagnosis of diabetes?

<p>It is co-secreted with insulin from the pancreas and indicates endogenous insulin production. (D)</p> Signup and view all the answers

A patient with Type 1 Diabetes is found unresponsive. Initial blood glucose check shows a level of 50 mg/dL. Which of the following is the most appropriate immediate treatment?

<p>Administering 1 mg of glucagon intramuscularly or subcutaneously. (D)</p> Signup and view all the answers

A patient with DKA is receiving an insulin infusion. After the first hour, the plasma glucose level has not decreased by 10%. What is the MOST appropriate next step in managing this patient's hyperglycemia?

<p>Administer a second loading dose of insulin at 0.1-0.15 units/kg. (B)</p> Signup and view all the answers

Which of the following BEST describes the underlying pathophysiology of Type 2 Diabetes Mellitus?

<p>Insulin resistance combined with impaired insulin secretion. (B)</p> Signup and view all the answers

A patient with Type 1 Diabetes consistently has pre-meal blood glucose levels of 150-180 mg/dL, despite adhering to their insulin regimen. Which of the following adjustments to their treatment plan would be most appropriate, assuming all other factors remain constant?

<p>Increase the dose of their pre-meal bolus insulin. (B)</p> Signup and view all the answers

A patient is diagnosed with Impaired Fasting Glucose (IFG). What fasting blood glucose range would confirm this diagnosis?

<p>Between 100 and 125 mg/dL (B)</p> Signup and view all the answers

Which of the following is NOT typically considered a risk factor for developing Type 2 Diabetes Mellitus?

<p>Low carbohydrate diet (B)</p> Signup and view all the answers

Which of the following is NOT typically associated with Type 1 Diabetes Mellitus at the time of diagnosis?

<p>Insulin resistance (C)</p> Signup and view all the answers

Which of the following is the MOST accurate diagnostic criterion for Diabetes Mellitus based on the criteria provided?

<p>Symptoms of diabetes plus a random plasma glucose concentration ≥200 mg/dL, confirmed on two separate occasions. (B)</p> Signup and view all the answers

A patient with Type 1 Diabetes is planning to participate in a marathon. What adjustment to their insulin regimen is most important to consider to prevent hypoglycemia during the race?

<p>Decreasing the basal insulin dose and increasing carbohydrate intake during the race. (A)</p> Signup and view all the answers

Why is it important to screen patients with diabetes for macrovascular and microvascular complications before they begin an exercise program?

<p>To identify complications that may be exacerbated by exercise. (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes is planning an exercise routine. What should they do to prevent hypoglycemia?

<p>Consume additional carbohydrate if the glucose is less than 100 mg/dL before exercising. (B)</p> Signup and view all the answers

What is the primary immunological mechanism involved in the pathogenesis of Type 1 Diabetes?

<p>T-cell mediated autoimmune destruction of pancreatic beta cells. (A)</p> Signup and view all the answers

Which of the following long-term complications is LEAST likely to be directly caused by chronic hyperglycemia in Type 1 Diabetes?

<p>Osteoarthritis (B)</p> Signup and view all the answers

In the management of Diabetes Mellitus Type 2, what is the rationale behind recommending medical nutritional therapy with weight reduction, when indicated?

<p>To improve glycemic control and reduce the risk of complications. (C)</p> Signup and view all the answers

A patient's lab results reveal a glucose level of 300 mg/dL, pH of 7.2, bicarbonate level of 16 mEq/L and the presence of ketones in the urine. Which condition is MOST likely causing these findings?

<p>Diabetic Ketoacidosis (DKA) (D)</p> Signup and view all the answers

What is the significance of HbA1c in managing diabetes mellitus?

<p>It measures the average blood glucose concentration over the past 2-3 months. (C)</p> Signup and view all the answers

Which medication can contribute to iatrogenic hyperglycemia?

<p>Hormonal therapies (D)</p> Signup and view all the answers

Which of the following is considered a life-threatening acute complication primarily associated with Type 1 Diabetes due to severe insulin deficiency?

<p>Diabetic Ketoacidosis (DKA) (B)</p> Signup and view all the answers

Why is it important to educate a patient with Type 1 Diabetes on sick-day management?

<p>Stress from illness can cause hormonal changes that increase blood glucose levels. (C)</p> Signup and view all the answers

If a patient that has Type 2 diabetes also has hypertension, dyslipidemia and obesity, which of the following conditions describes this combination?

<p>Metabolic Syndrome (B)</p> Signup and view all the answers

What is the recommended frequency of HbA1c determination for patients with well-controlled diabetes?

<p>Twice a year (D)</p> Signup and view all the answers

A patient with Type 1 Diabetes reports frequent episodes of hypoglycemia, particularly after exercise. What should you advise the patient to do immediately after exercise to mitigate this?

<p>Consume a carbohydrate-rich snack or beverage. (B)</p> Signup and view all the answers

Why might serum levels of amylin decrease with insulin in individuals with Type 2 Diabetes?

<p>Because they are co-secreted by pancreatic beta cells (B)</p> Signup and view all the answers

Which of the following best explains the dawn phenomenon in patients with Type 1 Diabetes?

<p>A surge of counter-regulatory hormones in the early morning, leading to increased blood glucose. (C)</p> Signup and view all the answers

A 60 year old patient is diagnosed with T2D. He has a history of CKD (GFR 50) and hypertension. What would be initial treatment?

<p>Metformin 500 mg daily (A)</p> Signup and view all the answers

A 55 year old is diagnosed with T2D. His BMI is 34, and has no heart or kidney disease history. What should be added to Metformin therapy?

<p>GLP1 agonist (B)</p> Signup and view all the answers

A 62 year old with a T2D history cannot afford any expensive medication. He is currently on Metformin. What is the best option?

<p>Sulfonylurea (B)</p> Signup and view all the answers

A 74 year old with T2D has established CAD. What medication should be added to his Metformin therapy?

<p>GLP 1 agonist (A)</p> Signup and view all the answers

A 54 year old with T2D has CAD and CHF. What should be added to his Metformin dose?

<p>SGL2 I (B)</p> Signup and view all the answers

A 56 year old with T2D is diagnosed with CKD (GFR 25). What should be added to his Metformin therapy?

<p>SGL2 I (B)</p> Signup and view all the answers

What two medications should be avoided in patients who experience hypoglycemia?

<p>Insulin and Sulfonylureas (A)</p> Signup and view all the answers

When initiating insulin therapy for Type 1 Diabetes, which of the following is the MOST appropriate starting dose?

<p>0.5 units/kg/day, with 2/3 of the dose in the morning and 1/3 in the evening. (D)</p> Signup and view all the answers

If a patient with Type 1 Diabetes experiences hypoglycemia at 3 AM, what is the MOST appropriate initial treatment adjustment to prevent future occurrences?

<p>Reduce or omit the bedtime dose of insulin. (B)</p> Signup and view all the answers

A patient with Type 1 Diabetes has consistently elevated blood glucose levels at 7 AM. Which action is MOST appropriate?

<p>Split the long-acting insulin dose, giving 2/3 before breakfast and 1/3 before dinner. (A)</p> Signup and view all the answers

Why might Levemir be preferred over Lantus?

<p>It has a shorter duration of action, allowing for greater flexibility in timing the dose. (C)</p> Signup and view all the answers

A patient with Type 1 Diabetes is considering starting an exercise program. Besides general fitness, which screening is MOST important before beginning the program?

<p>Assessment of cardiovascular and peripheral vascular systems. (B)</p> Signup and view all the answers

If a patient with Type 1 Diabetes has a pre-exercise glucose level of 260 mg/dL, what is the MOST appropriate course of action?

<p>Delay exercise until glucose levels are closer to the target range. (D)</p> Signup and view all the answers

What is the general recommendation around carbohydrate intake for individuals with Type 1 Diabetes Mellitus?

<p>Carbohydrate intake should be individualized, but generally constitutes 55-60% of total daily calories. (A)</p> Signup and view all the answers

What is the rationale behind recommending medical nutritional therapy with weight reduction, when indicated, in the management of Type 2 Diabetes Mellitus?

<p>To decrease insulin resistance and improve glycemic control. (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes is diligent about self-monitoring of blood glucose (SMBG). What is the most important reason?

<p>To maintain glucose levels as close to normal as possible. (C)</p> Signup and view all the answers

What is the recommended frequency of self-monitoring of blood glucose (SMBG) for patients with Type 1 diabetes to optimize glycemic control?

<p>Three to four times a day—before each meal and before bedtime. (D)</p> Signup and view all the answers

A patient with Type 2 diabetes has a fasting glucose of 260 mg/dL and no ketones. Which of the following exercise recommendations is most appropriate?

<p>Advise the patient to avoid exercise until glucose is closer to the target range. (B)</p> Signup and view all the answers

A patient with Type 2 diabetes has been following a diet and exercise plan for three months, but their fasting plasma glucose remains at 210 mg/dL. According to the guidelines, what is the next appropriate step in managing this patient's hyperglycemia?

<p>Initiate oral medication as an adjunct to diet and exercise. (C)</p> Signup and view all the answers

Which of the following is the primary reason for the high mortality rate associated with Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS)?

<p>Profound dehydration and hyperosmolality (B)</p> Signup and view all the answers

A patient with HHS presents with disorientation, lethargy, and dehydration. Lab results show severely elevated blood glucose and serum osmolality. Which of the following additional findings would support the diagnosis of HHS over DKA?

<p>Normal pH (C)</p> Signup and view all the answers

During the initial fluid management of a patient with HHS and significant dehydration, what is the MOST appropriate type of intravenous fluid to administer initially?

<p>Isotonic solution (B)</p> Signup and view all the answers

A patient with HHS is being treated with intravenous fluids and insulin. After several hours, the plasma glucose decreases to 200 mg/dL. Which intervention is most appropriate to implement next?

<p>Decrease the insulin infusion rate and add D5W to the IV fluids. (A)</p> Signup and view all the answers

A patient with Type 2 diabetes who also has a history of cardiovascular disease is being considered for pharmacological therapy. Which of the following factors would MOST influence the choice of oral antidiabetic medication?

<p>The medication's potential cardiovascular benefits or risks (C)</p> Signup and view all the answers

Which of the following is the MOST important aspect of pharmacological therapy for Type 2 Diabetes Mellitus?

<p>Adjunct therapy to diet and exercise (C)</p> Signup and view all the answers

A patient with Type 2 diabetes has achieved a fasting plasma glucose close to 120 mg/dL and is without severe presenting symptoms. Which of the following management strategies should be initiated?

<p>Diet and exercise (C)</p> Signup and view all the answers

A patient is admitted with Hyperosmolar Hyperglycemic Non-Ketosis Syndrome (HHS). After initial interventions, which of the following assessment findings would indicate the need for cautious fluid replacement to prevent complications?

<p>History of cardiac failure (D)</p> Signup and view all the answers

What is the MOST appropriate initial step if a DKA patient's plasma glucose does not decrease by 10% within the first hour of a regular insulin IV drip at 0.1 units/kg/hr?

<p>Administer a second loading dose of 0.1-0.15 units/kg regular insulin IV. (A)</p> Signup and view all the answers

In the management of DKA, at what plasma glucose level should the IV insulin infusion rate be decreased to 0.05 units/kg/hr while maintaining D5W & 0.45 NS?

<p>200 mg/dL (B)</p> Signup and view all the answers

A patient with Type 2 Diabetes is starting an exercise program. What screening is most important before beginning the program?

<p>Screening for macrovascular and microvascular complications (D)</p> Signup and view all the answers

What characterizes the pathophysiology of Type 2 Diabetes Mellitus?

<p>Insulin resistance and impaired insulin secretion. (B)</p> Signup and view all the answers

In Type 2 Diabetes, what is the correct interpretation of postprandial hyperglycemia?

<p>Blood sugar levels do not return to normal as quickly after meals as in individuals without Type 2 Diabetes. (A)</p> Signup and view all the answers

What is the recommendation for physical activity for patients with Type 1 Diabetes?

<p>Include 150 minutes/week of moderate to intense aerobic activity (A)</p> Signup and view all the answers

What is the recommendation when should HbA1c be measured for diabetic patients?

<p>HbA1c determination should be performed at least twice a year in patients with good control and quarterly in patients whose therapy has changed or who are not meeting glycemic goals (D)</p> Signup and view all the answers

What is the target HbA1c level to reduce the risk of complications in diabetic patients?

<p>Below 7% (B)</p> Signup and view all the answers

What is the typical glucose level and pH value in DKA?

<p>Glucose &gt; 250 mg/dl; PH &lt; 7.3 (B)</p> Signup and view all the answers

Which finding during a routine physical exam should prompt further screening for diabetes?

<p>Candidiasis infection (A)</p> Signup and view all the answers

A patient undergoing treatment for DKA exhibits improving but still concerning lab values. Which of the following indicates the MOST appropriate progression of care?

<p>Maintain D5W &amp; 0.45 NS to maintain BG around 200 until ketosis is resolved, then transition to subcutaneous insulin. (B)</p> Signup and view all the answers

Which of the following best describes the interplay between obesity and insulin resistance in Type 2 Diabetes?

<p>Obesity contributes to peripheral insulin resistance. (A)</p> Signup and view all the answers

What is the effect of sympathetic tone and cardiac contractility in patients with hyperinsulinemia?

<p>Sympathetic tone and cardiac contractility are increased by hyperinsulinemia (B)</p> Signup and view all the answers

What fasting plasma glucose level is diagnostic during the screening for diabetes?

<p>≥126 mg/dL on 2 occasions (A)</p> Signup and view all the answers

A patient is diagnosed with Type 2 diabetes during a routine physical exam but reports feeling well. The patient's random capillary glucose result was 210 mg/dL. What is the MOST appropriate next step to confirm the diagnosis?

<p>Order screening for blood glucose with whole blood. (B)</p> Signup and view all the answers

A patient with Type 1 Diabetes Mellitus is consistently experiencing hyperglycemia before dinner. Assuming a regimen of basal-bolus insulin, which adjustment would be MOST appropriate?

<p>Increase the pre-dinner dose of rapid-acting insulin. (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes reports frequent episodes of exercise-induced hypoglycemia. Which strategy is MOST appropriate to prevent this?

<p>Reduce the dose of rapid-acting insulin before exercise. (D)</p> Signup and view all the answers

Why is C-peptide level suppressed in individuals with Type 1 Diabetes?

<p>Because of the autoimmune destruction of pancreatic beta cells, which leads to reduced or absent insulin production. (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes is found unresponsive and has a blood glucose level of 40 mg/dL. After administering intravenous glucose, the patient regains consciousness but remains confused. What is the next BEST step?

<p>Provide a longer-acting carbohydrate source orally. (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes is being treated for DKA. The anion gap remains elevated despite a decrease in blood glucose levels towards normal. Which of the following is the MOST likely explanation for this?

<p>Resolution of ketogenesis with persistent ketoacid anions (B)</p> Signup and view all the answers

A patient with Type 1 Diabetes is diagnosed with gastroparesis. How might this condition affect their insulin management?

<p>It may necessitate changes in the timing of insulin injections relative to meals. (C)</p> Signup and view all the answers

What is the primary reason for using multiple daily injections (MDI) of insulin or continuous subcutaneous insulin infusion (CSII) in Type 1 Diabetes management?

<p>To closely mimic the physiological insulin secretion of a healthy pancreas. (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes is prescribed pramlintide. What is the rationale for using pramlintide as an adjunct therapy?

<p>To reduce postprandial glucose excursions by slowing gastric emptying and suppressing glucagon secretion. (D)</p> Signup and view all the answers

A patient with Type 1 Diabetes who uses an insulin pump is planning a strenuous hike. What adjustments should be made to their insulin regimen to prevent hypoglycemia during the activity?

<p>Decrease the basal insulin rate starting 1-2 hours before the hike and continue during the activity. (B)</p> Signup and view all the answers

Which statement BEST describes the role of medical nutrition therapy (MNT) in the management of Type 1 Diabetes?

<p>MNT provides tailored dietary strategies to match insulin regimens, promote stable glucose levels, and support overall health. (A)</p> Signup and view all the answers

A patient with Type 1 Diabetes is found to have elevated levels of microalbuminuria during a routine check-up. What is the significance of this finding?

<p>It suggests early-stage diabetic nephropathy. (D)</p> Signup and view all the answers

A patient with Type 1 Diabetes is experiencing the Somogyi effect. Which adjustment to their insulin regimen is MOST appropriate to address this issue?

<p>Decrease the bedtime dose of intermediate-acting insulin or adjust meal timing. (C)</p> Signup and view all the answers

Which of the following is the MOST appropriate initial step in managing a patient newly diagnosed with Type 1 Diabetes presenting with DKA?

<p>Providing intravenous fluids and regular insulin infusion. (B)</p> Signup and view all the answers

A patient with Type 1 Diabetes is being discharged from the hospital after treatment for DKA. Which educational point is MOST critical to emphasize to the patient and their family?

<p>The technique for administering glucagon and recognizing the signs and symptoms of hypoglycemia. (A)</p> Signup and view all the answers

Flashcards

Insulin Management

Long-acting insulin with regular insulin requires close monitoring of blood glucose levels.

Insulin Starting Dose

Start with 0.5 units/kg/day, divide into 2/3 in the morning and 1/3 in the evening. Adjust based on blood glucose levels.

BG Adjustment Before Dinner

If blood glucose is > 140 mg/dL before the evening meal, add 2-5 units every 3 days.

Elevated Fasting Glucose

Elevated fasting glucose means adjusting the morning dose.

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Nighttime Insulin Resistance

Counter-regulatory hormones and growth hormone spikes can cause decreased insulin sensitivity at night, also it can cause hypoglycemia at 3 am.

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SMBG Purpose

Self-monitoring of blood glucose measures usefulness of the insulin regimen, nutrition, and exercise.

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Type 1 DM Monitoring Frequency

Optimal monitoring for type 1 DM is 3-4 times a day: before meals and bedtime.

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Goals of Nutritional Therapy

Maintain normal blood glucose, prevent hypoglycemia, maintain normal serum lipid levels, attain or maintain reasonable body weight, and promote healthy eating patterns.

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Macronutrient Ratios

Carbohydrates (55-60%), Fiber (25 gm/1000 cal), Fat (25-35%), and Protein (15-20%).

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Exercise Screening

Screen for macrovascular and microvascular complications before starting, such as CAD, retinopathy, nephropathy, and neuropathy.

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Diabetes Mellitus (DM)

Syndrome with hyperglycemia resulting from deficits in insulin secretion/action, and disorder of carbohydrate, fat, and protein metabolism.

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Impaired Glucose IFG/IGT Definition

Fasting glucose between 100 and 125 mg/dL OR 2-hour post-glucose load blood glucose 140 to 199 mg/dL.

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Type 1 DM

Insulin deficiency resulting from beta-cell destruction, which leads to hyperglycemia.

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DKA (Diabetic Ketoacidosis)

Body burns fat for energy, producing ketones leading to acidity.

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Type 1 DM Forms

Autoimmune destruction of beta cells (90% of cases) or unknown cause with no autoimmunity.

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Type 1 DM Symptoms

Polydipsia, polyuria, polyphagia, anorexia and weight loss.

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DM Diagnostic Criteria

Random plasma glucose ≥ 200 mg/dL w/ symptoms, fasting plasma glucose ≥ 125 mg/dL, or 2-hr plasma glucose ≥ 199 mg/dL during OGTT.

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A1C

Average plasma glucose over 2-3 months; used to monitor glycemic control.

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Hypoglycemia Defined

Plasma glucose < 70 mg/dL.

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Hypoglycemia Causes

Excessive insulin, missed meals, exercise, alcohol, or decreased liver/kidney function.

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Hypoglycemia Symptoms

Diaphoresis, tachycardia, hunger, shakiness, altered mentation, seizure & headache

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Hypoglycemia Treatment

Ingest 15g of carbohydrate and recheck blood glucose in 15 minutes.

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Type 1 DM Management

Insulin regimens, self-monitoring of blood glucose (SMBG), medical nutrition therapy (MNT), regular exercise.

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Type 1 DM Goals

Plasma glucose at 80-120 mg/dL before meals, 100-140 mg/dL at bedtime, A1C < 7%.

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Intensive Insulin Regimen

Doses of regular insulin before meals with an evening dose of NPH.

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Low Glucose Action

Consume extra carbs if glucose is under 100 mg/dL to prevent low blood sugar.

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DM Exercise Goal

Aim for 150 minutes per week of moderate to intense aerobic exercise, plus muscle strengthening.

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DM Complications

Damage to eyes, kidneys, and nerves from diabetes.

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HbA1c Test Frequency

Test HbA1c twice yearly if well-controlled, quarterly if therapy changes or goals unmet.

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DKA and Dehydration

High glucose leads to increased blood concentration, causing dehydration.

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DKA Subjective Symptoms

Polyuria, polydipsia, polyphagia, nausea, vomiting, dehydration (sunken eyes, poor skin turgor)

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DKA Lab Values

Glucose >250 mg/dL, pH <7.3, Serum Bicarbonate <15 mEq/L, elevated anion gap, positive ketones.

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DKA Insulin Management

IV regular insulin bolus (0.1-0.15 units/kg), then continuous infusion (0.1 units/kg/hr).

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Type 2 DM Characteristics

Insufficient insulin, insulin resistance, and inadequate insulin secretion.

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Type 2 DM Risk Factors

Family history, ethnicity (African American, Hispanic, Native American, Asian, Pacific Islander), age, gestational DM history.

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Type 2 DM Abnormalities

Insulin resistance and impaired insulin secretion

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Hyperglycemia Progression

Post-meal glucose spikes and eventually high fasting glucose.

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Postprandial Hyperglycemia

High Glucose after eating

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Metabolic Syndrome

Hypertension, dyslipidemia, obesity, disturbed glucose metabolism

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Exercise & Glucose

Avoid exercise if glucose >250 mg/dL with ketosis or >300 mg/dL regardless of ketosis. Consume carbs if glucose <100 mg/dL.

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Initial DM Type 2 Treatment

Diet and exercise are initiated to control hyperglycemia when fasting plasma glucose is less than 200 mg/dL and symptoms are not severe.

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DM Type 2 Management

Begins with diet and exercise; if inadequate after 3 months, oral medications are added.

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HHS Definition

Profound dehydration due to persistent high glucose, mainly in older adults, high mortality.

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HHS Lab findings

BG >600, high osmolarity, elevated BUN & Cr, normal pH and anion gap, present C-peptides.

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HHS Fluid Replacement

Initial fluid: isotonic until stable. Then, hypotonic if Na >145. Monitor for heart failure, cerebral edema, seizures.

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HHS Insulin Management

Loading dose 0.1-0.15 units/kg regular IV, then continuous 0.1 units/kg/hr. Decrease when PG is 200.

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Lifestyle modifications

Dietary modification and exercise.

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Adjunct Therapy

Medication should complement, not replace, diet and exercise.

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When to start drugs?

Considered if 3 months of diet and exercise haven't managed fasting plasma glucose levels.

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Target Fasting Glucose

Blood glucose should ideally be close to 120 mg/dL.

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Mild Hyperglycemia Action

Initiate diet and exercise for hyperglycemia control.

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High Glucose Intervention

Consider oral agent when glucose is very high during trial.

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HHS Cause

Severe dehydration from prolonged hyperglycemia.

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HHS Risk Group

Older adults with infections are at high risk.

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HHS Key Symptoms

Glucose >600 mg/dL, high osmolality, dehydration.

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HHS Neuro Symptoms

Disorientation, lethargy, seizure, coma, dehydration.

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High Serum Osmolarity

310 mOsm/L indicates concentrated blood.

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HHS Initial Fluids

Use isotonic fluids initially, then hypotonic if Na is high.

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HHS Insulin Start

Start with 0.1-0.15 units/kg IV, then continuous drip.

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Venous vs. Capillary Glucose

Plasma glucose measurements are usually within 15% of whole blood capillary test results.

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MNT or Meal Planning

Done with a collaborative team, it often requires substantial lifestyle changes.

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Exercise Effects on Glucose

Exercise can lead to both hyperglycemia and hypoglycemia. Must monitor before, during, and after.

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Fasting Glucose Adjustment

If fasting glucose is elevated, shift more insulin towards the morning; give 2/3 before breakfast & 1/3 before dinner

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Why Night time Increases Glucose levels

Due to counter regulatory hormones and growth hormone spikes, it leads to sugar elevated throughout the night which causes a high level at 7 am

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How can we treat elevated glucose levels at 7 am?

Reduce or omit bedtime dose and give long acting earlier. Levemir is shorter acting than Lantus, thus good to take earlier.

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Why use SMBG?

Evaluate the effectiveness of insulin, nutrition, and exercise.

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Nutritional Therapy GOALS

Maintain normal glucose, prevent lows, manage lipids, achieve healthy weight, promote healthy eating patterns.

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Pre-Exercise Screening

Screen for heart disease, retinopathy, nephropathy, and neuropathy before starting.

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Exercise Risk Levels

Can either exacerbate hyperglycemia or hypoglycemia.

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Impaired Glucose (IFG/IGT)

Fasting glucose between 100-125 mg/dL or 2-hr glucose between 140-199 mg/dL.

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DM Prevalence

Most common endocrine disorder with complications like CVD, renal failure, and retinopathy.

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Pre-Diabetes

Fasting BG of 100-125 mg/dl, 2-hour plasma glucose of 140-199 mg/dl, HbA1c 5.7% – 6.4%.

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Type 1 DM Cause

Autoimmune destruction of beta cells leading to severe insulin deficiency.

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DKA/HHS

Life-threatening complications of hyperglycemia in type 1 DM.

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Type 1 DM Types

Autoimmune destruction of beta cells or unknown cause.

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Type 1 DM Genetic Link

HLA region on chromosome HLA-DR3 & HLA-DR4.

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Type 1 DM Classic Signs

Polydipsia, polyuria, polyphagia, anorexia, and weight loss.

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Objective Indicators of Type 1 DM

Ketones in urine, dehydration, and possible neurological symptoms.

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DM Diagnosis

Random glucose ≥ 200 mg/dL with symptoms; a fasting glucose ≥ 125 mg/dL.

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A1C Purpose

Mean plasma glucose over 2-3 months.

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Hypoglycemia - Common Cause

Excessive insulin, missed meals, exercise, alcohol ingestion.

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Hypoglycemia - Signs

Diaphoresis, tachycardia, altered mentation, seizure, and headache.

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Ideal Glucose Levels - Management

Plasma glucose at 80-120 mg/dL before meals, 100-140 mg/dL at bedtime.

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DM Management: Individualization

Individualize diabetes management based on patient interests, lifestyle, physical condition, and motivation.

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DM Complications & HbA1C

Reduced significantly when HbA1C levels are maintained below 7%.

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HbA1c Testing Frequency

Recommended at least twice a year in well-controlled patients, quarterly if therapy changes or goals aren't met.

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DKA & Dehydration

Elevated glucose leads to increased concentration gradients, causing dehydration.

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DKA in DM Types

DKA can occur in both type 1 and type 2 DM, especially with beta cell function loss.

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DKA - Subjective Clues

Clue include polyuria, polydipsia, polyphagia, nausea, vomiting, sunken eyes, and poor skin turgor.

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Type 2 DM Definition

Characterized by insufficient insulin, resistance to insulin, and inadequate insulin secretion.

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Type 2 DM: Two Main Issues

Insulin resistance and impaired insulin secretion.

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Hyperglycemia Progression in T2DM

Begins as postprandial hyperglycemia, eventually progressing to fasting hyperglycemia.

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Metabolic Syndrome Components

Hypertension, dyslipidemia, obesity, and disturbed glucose metabolism.

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Type 2 DM Presentation

Often diagnosed incidentally during routine exams or treatment for other conditions.

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Initial DM Test Value

Random capillary glucose of 200 mg/dL or more.

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Four DM Diagnostic Criteria

A1C ≥6.5%, random glucose ≥200 mg/dL with symptoms, fasting glucose ≥126 mg/dL, 2-hour post-load glucose ≥200 mg/dL.

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Type 2 DM: Chronic Care

Requires ongoing care and education to prevent complications.

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Study Notes

  • Diabetes Mellitus (DM) refers to a syndrome of carbohydrate, fat, and protein metabolism.
  • DM results from deficits in insulin secretion, insulin action, or a combination of both, leading to hyperglycemia.
  • There exist two distinct types of DM: type 1 and type 2.
    • Type 1 is insulin-dependent, also know as IDDM, and often has a Juvenile onset.
    • Type 2 is non-insulin-dependent, also know as NIDDM, and typically has an adult onset.

DM Epidemiology

  • Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are terms used to describe pre-diabetes.
    • IFG is identified with fasting glucose levels between 100 and 125 mg/dL.
    • IGT is diagnosed with a 2-hour post-glucose load blood glucose between 140 to 199 mg/dL.
  • The most common endocrine disorder is DM.
  • DM affects 25.8 million people in the US.
  • DM can result in Complications like:
    • Cardiovascular and peripheral vascular disease.
    • Decreased immune system functioning.
    • Renal failure.
    • Retinopathy.
  • Diabetic nephropathy is the leading cause of end-stage renal disease.
  • DM is the leading cause of acquired blindness in the United States.

Diagnostic Testing

  • Pre-Diabetes is determined by:
    • Fasting BG of 100-125 mg/dl.
    • 2-hour plasma glucose (75 gm glucose load) of 140-199 mg/dl.
    • HbA1c of 5.7% - 6.4%.

DM Type 1

  • Severe insulin deficiency exists (body cannot make enough insulin).
  • This type results from beta-cell destruction, thus producing hyperglycemia (genetic abnormality).
  • Lack of insulin alters lipid, carbohydrate, and protein metabolism.
  • Complications may include Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS).
  • DM Type 1 can result in life-threatening sequelae of hyperglycemia.

DM Type 1: Epidemiology

  • DM Type 1 occurs in approximately 1 in 800,000 Americans.
  • Type 1 accounts for 10% of all diabetes cases.
  • It's 1.5 to 2 times more common in whites.
  • Sixty percent of patients are under age 18 years.
  • There is a correlation with differential expression of human leukocyte antigen (HLA) haplotypes.
  • Latent autoimmune diabetes of adults (LADA) affects nonpediatric patients.
  • Type 1 has two forms:
    • Immune-mediated DM (90%): autoimmune destruction of the beta cells
    • Idiopathic DM: no known cause and has no evidence of autoimmunity
      • This is inherited and the need for insulin replacement therapy is variable.

DM Type 1: Pathophysiology

  • DM Type 1 is characterized by a reduction or absence of functioning beta cells which results in insulin absence.
  • An absence of C-peptides exist.
  • A genetic susceptibility begins, and is mapped to the HLA region on chromosome HLA-DR3 & HLA-DR4.
  • A triggering mechanism exists (e.g., viral infection or other environmental factor).
    • This mechanism stimulates an inflammatory response.
  • Autoimmune infiltration of the pancreatic beta cells is initiated.

DM Type 1: Clinical Presentation (subjective)

  • The manifestation of symptoms varies.
  • Classic symptoms of type 1 DM are polydipsia, polyuria, polyphagia, anorexia, and weight loss.
  • Additional symptoms present;
    • Nocturnal enuresis.
    • Visual changes.
    • Weakness.
    • Fatigue.
    • Nausea.
    • Abdominal pain.
  • DM Type 1 may present with repeated infections, decreased wound healing, or infections that are uncommon.

DM Type 1: Clinical Presentation (objective)

  • Objective observations include:
    • Weight loss despite normal or increased appetite (polyphagia)
    • Reduced muscle mass
    • Ketones (byproduct) in urine due to body fat-burning
    • Signs of dehydration: poor skin turgor and dry mucous membranes
    • Neurological: diabetic retinopathy, third cranial nerve palsy, or the sixth (abducens) and fourth (trochlear) cranial nerves affected in cranial neuropathy

DM Diagnostic Testing

  • Initial diagnostic testing is done in-office.
    • A casual (random) plasma glucose measurement is taken.
    • Urine should be tested for ketones.
  • Current recommendations for a diabetes diagnosis:
    • Symptoms of diabetes (e.g., polyuria, polydipsia, weight loss) plus a casual (random) plasma glucose level of 200 mg/dL or higher.
    • OR fasting plasma glucose level of 125 mg/dL or higher.
    • OR a 2-hour plasma glucose of 199 mg/dL or higher during an oral glucose tolerance test (OGTT) with a 75-g glucose load (not for routine use)
    • This criteria should be confirmed by repeat testing on a different day, except in the case of unequivocal hyperglycemia with acute metabolic decompensation.

DM Diagnostic Testing

  • Blood and urine tests must be done as subsequent tests:
  • A1C:
  • This test is characterized by calculating the mean plasma glucose concentration over the preceding to 2 to 3 months.
  • Furthermore, A1C is documenting the degree of glycemic control.
  • The American Diabetic Association (ADA) recommends that the treatment goal should be an A1C below 6.0%, while for the older population it should be 6.0%-7.0%.
  • Other factors that can be tested:
  • Fasting lipid profile urinalysis.
  • Microalbuminuria.
  • Thyroid function tests.
  • Serum creatinine if protein is present.

Hypoglycemia

  • Managing hypoglycemia means maintaining plasma glucose at less than 70 mg/dL, which is diagnostic.
  • Hypoglycemia can manifest due to:
    • Excessive exogenous insulin.
    • Missed meals or inadequate food intake.
    • Exercise abundance.
    • Alcohol ingestion.
    • Drug interactions and a decrease in liver or kidney function.
  • Hypoglycemia signs and symptoms:
    • Diaphoresis.
    • Tachycardia.
    • Hunger.
    • Shakiness.
    • Altered mentation, ranging from inability to concentrate to coma.
    • Slurred speech.
    • Seizure.
    • Headache.

Hypoglycemia - Treatment

  • Treatment Goal: normalize the plasma glucose promptly.
    • This is accomplished by the ingestion of 15 g of carbohydrate.
      • Check blood glucose 15 minutes after treatment.
      • With the blood glucose still less than 60 mg/dL, give additional carbohydrate.
      • In cases of severe hypoglycemia, and/or if the patient is unconscious or unable to swallow, administer 1 mg of glucagon SQ or D5W IVP.

DM Type 1: Management

  • Ongoing health care and education is required to prevent acute and chronic complications.
  • DM Type 1 management is complex and lifelong.
  • The ADA recommends a team approach.
  • A treatment program includes:
  • Insulin regimens.
  • Frequent self-monitoring of blood glucose (SMBG) also know as ACHS sugars.
  • Medical nutrition therapy (MNT).
  • Regular exercise.
  • Continuing education in the prevention and treatment of complications.
  • Periodic assessment of treatment goals.

DM Type 1: Management (cont'd)

  • The initial insulin therapy goal is to normalize blood glucose.
    • Plasma glucose levels at 80 to 120 mg/dL before meals.
    • Plasma glucose levels of 100 to 140 mg/dL at bedtime.
    • Keep A1C below 7%.
  • New-onset type 1 diabetic often presents in crisis and requires hospitalization, covered by endocrinologists.
  • Intensive insulin regimens do increase the chance of hypoglycemic episodes.
    • Doses of regular insulin are taken before meals with an evening dose of neutral protamine Hagedorn (NPH) supplemented with regular insulin.
    • This insulin therapy requires diligent and frequent blood glucose monitoring.

Insulin calculation

  • An insulin calculation starts at 0.5 units/kg/day, with two-thirds in the morning and one-third in the evening.
  • When BG is greater than 140 mg/dl before the evening meal, add 2-5 units every 3 days.
  • If the afternoon BG is <140, then check fasting BG; if elevated, give two-thirds before breakfast and one-third before dinner.
  • After afternoon and fasting BG are regulated, work on the late morning dosage to keep BG <140.
  • Basal long-acting insulin like Lantus or Detemir is is dosed once a day at the same time.
  • Bolus rapid-acting insulin like Lispro, Aspart, or Glulisine are dosed before meals.
  • Type 1 Basal = 1/3 total daily basal.
  • For Type 2 Basal, the dose = 0.2 per kg or 10 units (for naive patients).
    • Typically, with T2D, if no insulin has been used, start with first long-acting dose at 10 units daily which can be eventualy increased until a fasting sugar of 120 is measured.
      • Increase 2-3 units every 2-3 days until a fasting sugar of 120.

Conventional (split-dose)

  • Morning insulin is dosed at two-thirds NPH and one-third Regular.
  • Evening insulin is dosed at half NPH and half Regular.
  • Lispro (Humalog) or Aspart (Novolog) at 0.5-1.0 unit/kg
    • Administered 5 min before bfkst & evening meals.
  • Four injections daily is possible with T1D with difficulty controlling levels.
  • Insulin pumps are used for Basal-Bolus dosing and are best for uncontrolled diabetes.
    • Bolus are dosed at 50% total daily needs.
      • Bolus pump administration is good for flexibility, not tied down to any meal times

Somogyi - vs- Dawn Phenomenon

SOMOGYI EFFECT

  • This is characterized by Nocturnal hypoglycemia due to counter-regulatory hormones being released.
    • Hypoglycemia is commonly found at 3 am due to hormones being released.
      • Sugar becomes elevated at 7 am.
      • Treatment:
        • Reduce/omit bedtime dose.
          • Treat with Levemir, a shorter acting insulin than Lantus (benefits to take long acting insulin earlier)
          • Giving long acting insulin earlier is also a possible treatment.

DAWN PHENOMENON

  • Characterized by a decreased sensitivity at night due to a growth hormone spike, which rises BG concentrations.
    • Sugar becomes elevated throughout the night-> resulting in high sugars at 7 am.
    • Treatment would be to increase the evening dose of insulin.

DM Type 1: Management SBGM

  • This involves Self-monitoring of blood glucose (SMBG).
  • Plasma venous glucose measurements are within 15% of the results of whole blood capillary test results.
  • SMBG are used to evaluate the effectiveness of the insulin regimen, medical nutrition therapy, and exercise.
  • It is the most useful mechanism to maintain glucose levels as close to normal as possible.
  • Optimal SBGM for patients with type 1 DM is 3 to 4 times a day-before each meal and before bedtime (ACHS).

DM Type 1: Management (diet)

  • The goal is to provide a meal planning and/or a medical nutritional therapy (MNT) done with a collaborative team.
  • DM Type 1 management requires substantial lifestyle changes.
  • Some goal of nutritional therapy would to maintain normal blood glucose levels and prevent hypoglycemia.
  • Maintaining normal serum lipid levels and attaining or maintaining reasonable body weight by promoting healthy eating patterns is also the goal.

DM Type 1: Management (exercise)

  • It is important to exercise to maintain a healthy life style by following these guidelines:
    • Before beginning an exercise program patients must be screened for the presence of macrovascular and microvascular:
    • This includes knowing the condition of their Coronary artery disease (CAD), peripheral arterial disease, retinopathy, nephropathy, and peripheral or autonomic neuropathy.
    • Patients should have no exercise limitation as long as glycemic control is good and there is no evidence of complications.

DM Type 1: Complications

  • Retinopathy, nephropathy, and neuropathy can occur in patients with hyperglycemia.
  • Complications are significantly reduced when HbA1C levels are maintained below 7%.
  • A1C determination should be performed at least twice a year in patients with good control and quarterly in patients whose therapy has changed or who are not meeting glycemic goals.
  • A comprehensive foot exam and a funduscopic exam are vital to determine patient health.
  • Referral to a specialist for the following complications may be indicated:
    • Retinopathy.
    • Hyperlipidemia.
    • Nephropathy.
    • Hypertension.
    • Macrovascular disease.
    • Neuropathy.

Ketoacidosis: DKA

  • Elevated glucose increases serum osmolality and causes dehydration.
  • 14% of all hospital admissions are due to DKA.
  • DKA can manifest with both Type 1 & Type 2 with 90% Beta cell function loss.
  • DKA is seen with pumps (clogged or malfunctioned), insulin omission, illness.
  • Subjective factors indicate the 3 Ps of polyuria, polydipsia, polyphagia, N&V, Sunken eyes & poor turgor (dehydration), hyperkalemia.

Ketoacidosis - Management

  • Patients must have critical care monitoring with constant blood pressure monitoring and frequent pulse oximetry for monitoring.
  • Patients should use a pulmonary arterial catheter to manage pulmonary hypertension.
  • A solution of 50-100 mEeq/liter of hypotonic saline must be measured and carefully adminstered;
  • Patients must also have parenteral fluid (4-8 L of fluid in first 24 hr).
  • If critically necessary administer Sodium Bicarbonate when the pH is < 7.0 mol/L.
  • Patients must also have parenteral fluid (4-8 L of fluid in first 24 hr).
    • In these cases, the nurse should administer 0.9% NS at 1000 ml/hr for 1-2 hrs then 300-500 ml/hr for 4 hrs & monitor potassium levels.
    • Once dehydration improves - adjust to 250 ml/hr of fluid and electrolytes.

Ketoacidosis - Management

  • Administered 0.1-0.15 units/kg Reg IV and then change administration to continuous IV drip at a rate of 0.1 units/kg/hr until BG levels return to normal.
    • It is important measure plasma glucose levels, if plasma glucose doesn't decrease by 10% w/in 1st hour then, give a second loading dose.
      • If the level of PG tests at a level of 200 -decrease in the IV insulin administration by 0.05 units/kg/hr
    • Patients require continuous monitoring, therefore it is vital to Maintain D5W & 0.45 NS to maintain BG at a reading of 200 until metabolic imbalance levels begin to stabilized.

Diabetes Mellitus Type 2

  • Group of heterogeneous forms characterized by insufficient circulating endogenous insulin, resistance to insulin action, and an inadequate compensatory insulin secretion response.

DM Type 2: Epidemiology and Causes

  • The prevalence of type 2 DM in the US is 6.6%.
  • Often asymptomatic in its early stages.

DM Type 2: Pathophysiology

  • Two physiological abnormalities are a major contributor for T2DM:
    • Insulin resistance can develop, which is characterized as an inherited feature associated with acquired traits of obesity and aging.

DM Type 2: Clinical Presentation

-Objective observations: Patients usually present as obese, and showing signs of comorbid diseases.

  • Patients can be Asymptomatic, and diagnosed during a routine physical examination or during treatment for conditions.

DM Type 2: Diagnostic Testing

  • Initial diagnostic testing is done in an office setting, where a doctor will check:
    • The patient's Random capillary glucose.
      • It is important to consider certain drugs when making a differential diagnosis due to certain drug-induced indications.

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