Podcast
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?
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?
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?
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?
Why might Levemir (insulin detemir) be preferred over Lantus (insulin glargine) in some patients when administering long-acting insulin?
A patient with Type 1 diabetes reports morning hyperglycemia at 7 AM. What is the most appropriate initial adjustment to their insulin regimen?
A patient with Type 1 diabetes reports morning hyperglycemia at 7 AM. What is the most appropriate initial adjustment to their insulin regimen?
In the management of Type 1 diabetes, what is the primary purpose of self-monitoring of blood glucose (SMBG)?
In the management of Type 1 diabetes, what is the primary purpose of self-monitoring of blood glucose (SMBG)?
What is the recommended optimal frequency of self-monitoring of blood glucose (SMBG) for patients with Type 1 diabetes?
What is the recommended optimal frequency of self-monitoring of blood glucose (SMBG) for patients with Type 1 diabetes?
A patient with Type 1 diabetes is starting an exercise program. What screening is most important prior to beginning the program?
A patient with Type 1 diabetes is starting an exercise program. What screening is most important prior to beginning the program?
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?
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?
What is the recommended carbohydrate intake as a percentage of total daily calories for individuals with Type 1 Diabetes Mellitus?
What is the recommended carbohydrate intake as a percentage of total daily calories for individuals with Type 1 Diabetes Mellitus?
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?
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?
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?
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?
Which of the following assessment findings is MOST indicative of Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS)?
Which of the following assessment findings is MOST indicative of Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS)?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
Which of the following best describes the underlying cause of hyperglycemia in Type 1 Diabetes Mellitus?
Which of the following best describes the underlying cause of hyperglycemia in Type 1 Diabetes Mellitus?
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?
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?
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?
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?
Which of the following findings would be LEAST likely in a patient experiencing diabetic ketoacidosis (DKA)?
Which of the following findings would be LEAST likely in a patient experiencing diabetic ketoacidosis (DKA)?
Why is C-peptide level measurement useful in the differential diagnosis of diabetes?
Why is C-peptide level measurement useful in the differential diagnosis of diabetes?
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?
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?
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?
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?
Which of the following BEST describes the underlying pathophysiology of Type 2 Diabetes Mellitus?
Which of the following BEST describes the underlying pathophysiology of Type 2 Diabetes Mellitus?
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?
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?
A patient is diagnosed with Impaired Fasting Glucose (IFG). What fasting blood glucose range would confirm this diagnosis?
A patient is diagnosed with Impaired Fasting Glucose (IFG). What fasting blood glucose range would confirm this diagnosis?
Which of the following is NOT typically considered a risk factor for developing Type 2 Diabetes Mellitus?
Which of the following is NOT typically considered a risk factor for developing Type 2 Diabetes Mellitus?
Which of the following is NOT typically associated with Type 1 Diabetes Mellitus at the time of diagnosis?
Which of the following is NOT typically associated with Type 1 Diabetes Mellitus at the time of diagnosis?
Which of the following is the MOST accurate diagnostic criterion for Diabetes Mellitus based on the criteria provided?
Which of the following is the MOST accurate diagnostic criterion for Diabetes Mellitus based on the criteria provided?
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?
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?
Why is it important to screen patients with diabetes for macrovascular and microvascular complications before they begin an exercise program?
Why is it important to screen patients with diabetes for macrovascular and microvascular complications before they begin an exercise program?
A patient with Type 1 Diabetes is planning an exercise routine. What should they do to prevent hypoglycemia?
A patient with Type 1 Diabetes is planning an exercise routine. What should they do to prevent hypoglycemia?
What is the primary immunological mechanism involved in the pathogenesis of Type 1 Diabetes?
What is the primary immunological mechanism involved in the pathogenesis of Type 1 Diabetes?
Which of the following long-term complications is LEAST likely to be directly caused by chronic hyperglycemia in Type 1 Diabetes?
Which of the following long-term complications is LEAST likely to be directly caused by chronic hyperglycemia in Type 1 Diabetes?
In the management of Diabetes Mellitus Type 2, what is the rationale behind recommending medical nutritional therapy with weight reduction, when indicated?
In the management of Diabetes Mellitus Type 2, what is the rationale behind recommending medical nutritional therapy with weight reduction, when indicated?
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?
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?
What is the significance of HbA1c in managing diabetes mellitus?
What is the significance of HbA1c in managing diabetes mellitus?
Which medication can contribute to iatrogenic hyperglycemia?
Which medication can contribute to iatrogenic hyperglycemia?
Which of the following is considered a life-threatening acute complication primarily associated with Type 1 Diabetes due to severe insulin deficiency?
Which of the following is considered a life-threatening acute complication primarily associated with Type 1 Diabetes due to severe insulin deficiency?
Why is it important to educate a patient with Type 1 Diabetes on sick-day management?
Why is it important to educate a patient with Type 1 Diabetes on sick-day management?
If a patient that has Type 2 diabetes also has hypertension, dyslipidemia and obesity, which of the following conditions describes this combination?
If a patient that has Type 2 diabetes also has hypertension, dyslipidemia and obesity, which of the following conditions describes this combination?
What is the recommended frequency of HbA1c determination for patients with well-controlled diabetes?
What is the recommended frequency of HbA1c determination for patients with well-controlled diabetes?
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?
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?
Why might serum levels of amylin decrease with insulin in individuals with Type 2 Diabetes?
Why might serum levels of amylin decrease with insulin in individuals with Type 2 Diabetes?
Which of the following best explains the dawn phenomenon in patients with Type 1 Diabetes?
Which of the following best explains the dawn phenomenon in patients with Type 1 Diabetes?
A 60 year old patient is diagnosed with T2D. He has a history of CKD (GFR 50) and hypertension. What would be initial treatment?
A 60 year old patient is diagnosed with T2D. He has a history of CKD (GFR 50) and hypertension. What would be initial treatment?
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?
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?
A 62 year old with a T2D history cannot afford any expensive medication. He is currently on Metformin. What is the best option?
A 62 year old with a T2D history cannot afford any expensive medication. He is currently on Metformin. What is the best option?
A 74 year old with T2D has established CAD. What medication should be added to his Metformin therapy?
A 74 year old with T2D has established CAD. What medication should be added to his Metformin therapy?
A 54 year old with T2D has CAD and CHF. What should be added to his Metformin dose?
A 54 year old with T2D has CAD and CHF. What should be added to his Metformin dose?
A 56 year old with T2D is diagnosed with CKD (GFR 25). What should be added to his Metformin therapy?
A 56 year old with T2D is diagnosed with CKD (GFR 25). What should be added to his Metformin therapy?
What two medications should be avoided in patients who experience hypoglycemia?
What two medications should be avoided in patients who experience hypoglycemia?
When initiating insulin therapy for Type 1 Diabetes, which of the following is the MOST appropriate starting dose?
When initiating insulin therapy for Type 1 Diabetes, which of the following is the MOST appropriate starting dose?
If a patient with Type 1 Diabetes experiences hypoglycemia at 3 AM, what is the MOST appropriate initial treatment adjustment to prevent future occurrences?
If a patient with Type 1 Diabetes experiences hypoglycemia at 3 AM, what is the MOST appropriate initial treatment adjustment to prevent future occurrences?
A patient with Type 1 Diabetes has consistently elevated blood glucose levels at 7 AM. Which action is MOST appropriate?
A patient with Type 1 Diabetes has consistently elevated blood glucose levels at 7 AM. Which action is MOST appropriate?
Why might Levemir be preferred over Lantus?
Why might Levemir be preferred over Lantus?
A patient with Type 1 Diabetes is considering starting an exercise program. Besides general fitness, which screening is MOST important before beginning the program?
A patient with Type 1 Diabetes is considering starting an exercise program. Besides general fitness, which screening is MOST important before beginning the program?
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?
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?
What is the general recommendation around carbohydrate intake for individuals with Type 1 Diabetes Mellitus?
What is the general recommendation around carbohydrate intake for individuals with Type 1 Diabetes Mellitus?
What is the rationale behind recommending medical nutritional therapy with weight reduction, when indicated, in the management of Type 2 Diabetes Mellitus?
What is the rationale behind recommending medical nutritional therapy with weight reduction, when indicated, in the management of Type 2 Diabetes Mellitus?
A patient with Type 1 Diabetes is diligent about self-monitoring of blood glucose (SMBG). What is the most important reason?
A patient with Type 1 Diabetes is diligent about self-monitoring of blood glucose (SMBG). What is the most important reason?
What is the recommended frequency of self-monitoring of blood glucose (SMBG) for patients with Type 1 diabetes to optimize glycemic control?
What is the recommended frequency of self-monitoring of blood glucose (SMBG) for patients with Type 1 diabetes to optimize glycemic control?
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?
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?
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?
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?
Which of the following is the primary reason for the high mortality rate associated with Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS)?
Which of the following is the primary reason for the high mortality rate associated with Hyperosmolar Hyperglycemic Non-Ketotic Syndrome (HHS)?
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?
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?
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?
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?
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?
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?
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?
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?
Which of the following is the MOST important aspect of pharmacological therapy for Type 2 Diabetes Mellitus?
Which of the following is the MOST important aspect of pharmacological therapy for Type 2 Diabetes Mellitus?
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?
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?
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?
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?
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?
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?
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?
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?
A patient with Type 2 Diabetes is starting an exercise program. What screening is most important before beginning the program?
A patient with Type 2 Diabetes is starting an exercise program. What screening is most important before beginning the program?
What characterizes the pathophysiology of Type 2 Diabetes Mellitus?
What characterizes the pathophysiology of Type 2 Diabetes Mellitus?
In Type 2 Diabetes, what is the correct interpretation of postprandial hyperglycemia?
In Type 2 Diabetes, what is the correct interpretation of postprandial hyperglycemia?
What is the recommendation for physical activity for patients with Type 1 Diabetes?
What is the recommendation for physical activity for patients with Type 1 Diabetes?
What is the recommendation when should HbA1c be measured for diabetic patients?
What is the recommendation when should HbA1c be measured for diabetic patients?
What is the target HbA1c level to reduce the risk of complications in diabetic patients?
What is the target HbA1c level to reduce the risk of complications in diabetic patients?
What is the typical glucose level and pH value in DKA?
What is the typical glucose level and pH value in DKA?
Which finding during a routine physical exam should prompt further screening for diabetes?
Which finding during a routine physical exam should prompt further screening for diabetes?
A patient undergoing treatment for DKA exhibits improving but still concerning lab values. Which of the following indicates the MOST appropriate progression of care?
A patient undergoing treatment for DKA exhibits improving but still concerning lab values. Which of the following indicates the MOST appropriate progression of care?
Which of the following best describes the interplay between obesity and insulin resistance in Type 2 Diabetes?
Which of the following best describes the interplay between obesity and insulin resistance in Type 2 Diabetes?
What is the effect of sympathetic tone and cardiac contractility in patients with hyperinsulinemia?
What is the effect of sympathetic tone and cardiac contractility in patients with hyperinsulinemia?
What fasting plasma glucose level is diagnostic during the screening for diabetes?
What fasting plasma glucose level is diagnostic during the screening for diabetes?
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?
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?
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?
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?
A patient with Type 1 Diabetes reports frequent episodes of exercise-induced hypoglycemia. Which strategy is MOST appropriate to prevent this?
A patient with Type 1 Diabetes reports frequent episodes of exercise-induced hypoglycemia. Which strategy is MOST appropriate to prevent this?
Why is C-peptide level suppressed in individuals with Type 1 Diabetes?
Why is C-peptide level suppressed in individuals with Type 1 Diabetes?
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?
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?
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?
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?
A patient with Type 1 Diabetes is diagnosed with gastroparesis. How might this condition affect their insulin management?
A patient with Type 1 Diabetes is diagnosed with gastroparesis. How might this condition affect their insulin management?
What is the primary reason for using multiple daily injections (MDI) of insulin or continuous subcutaneous insulin infusion (CSII) in Type 1 Diabetes management?
What is the primary reason for using multiple daily injections (MDI) of insulin or continuous subcutaneous insulin infusion (CSII) in Type 1 Diabetes management?
A patient with Type 1 Diabetes is prescribed pramlintide. What is the rationale for using pramlintide as an adjunct therapy?
A patient with Type 1 Diabetes is prescribed pramlintide. What is the rationale for using pramlintide as an adjunct therapy?
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?
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?
Which statement BEST describes the role of medical nutrition therapy (MNT) in the management of Type 1 Diabetes?
Which statement BEST describes the role of medical nutrition therapy (MNT) in the management of Type 1 Diabetes?
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?
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?
A patient with Type 1 Diabetes is experiencing the Somogyi effect. Which adjustment to their insulin regimen is MOST appropriate to address this issue?
A patient with Type 1 Diabetes is experiencing the Somogyi effect. Which adjustment to their insulin regimen is MOST appropriate to address this issue?
Which of the following is the MOST appropriate initial step in managing a patient newly diagnosed with Type 1 Diabetes presenting with DKA?
Which of the following is the MOST appropriate initial step in managing a patient newly diagnosed with Type 1 Diabetes presenting with DKA?
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?
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?
Flashcards
Insulin Management
Insulin Management
Long-acting insulin with regular insulin requires close monitoring of blood glucose levels.
Insulin Starting Dose
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
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
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Nighttime Insulin Resistance
Nighttime Insulin Resistance
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SMBG Purpose
SMBG Purpose
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Type 1 DM Monitoring Frequency
Type 1 DM Monitoring Frequency
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Goals of Nutritional Therapy
Goals of Nutritional Therapy
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Macronutrient Ratios
Macronutrient Ratios
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Exercise Screening
Exercise Screening
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Diabetes Mellitus (DM)
Diabetes Mellitus (DM)
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Impaired Glucose IFG/IGT Definition
Impaired Glucose IFG/IGT Definition
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Type 1 DM
Type 1 DM
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DKA (Diabetic Ketoacidosis)
DKA (Diabetic Ketoacidosis)
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Type 1 DM Forms
Type 1 DM Forms
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Type 1 DM Symptoms
Type 1 DM Symptoms
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DM Diagnostic Criteria
DM Diagnostic Criteria
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A1C
A1C
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Hypoglycemia Defined
Hypoglycemia Defined
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Hypoglycemia Causes
Hypoglycemia Causes
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Hypoglycemia Symptoms
Hypoglycemia Symptoms
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Hypoglycemia Treatment
Hypoglycemia Treatment
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Type 1 DM Management
Type 1 DM Management
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Type 1 DM Goals
Type 1 DM Goals
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Intensive Insulin Regimen
Intensive Insulin Regimen
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Low Glucose Action
Low Glucose Action
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DM Exercise Goal
DM Exercise Goal
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DM Complications
DM Complications
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HbA1c Test Frequency
HbA1c Test Frequency
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DKA and Dehydration
DKA and Dehydration
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DKA Subjective Symptoms
DKA Subjective Symptoms
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DKA Lab Values
DKA Lab Values
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DKA Insulin Management
DKA Insulin Management
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Type 2 DM Characteristics
Type 2 DM Characteristics
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Type 2 DM Risk Factors
Type 2 DM Risk Factors
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Type 2 DM Abnormalities
Type 2 DM Abnormalities
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Hyperglycemia Progression
Hyperglycemia Progression
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Postprandial Hyperglycemia
Postprandial Hyperglycemia
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Metabolic Syndrome
Metabolic Syndrome
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Exercise & Glucose
Exercise & Glucose
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Initial DM Type 2 Treatment
Initial DM Type 2 Treatment
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DM Type 2 Management
DM Type 2 Management
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HHS Definition
HHS Definition
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HHS Lab findings
HHS Lab findings
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HHS Fluid Replacement
HHS Fluid Replacement
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HHS Insulin Management
HHS Insulin Management
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Lifestyle modifications
Lifestyle modifications
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Adjunct Therapy
Adjunct Therapy
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When to start drugs?
When to start drugs?
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Target Fasting Glucose
Target Fasting Glucose
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Mild Hyperglycemia Action
Mild Hyperglycemia Action
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High Glucose Intervention
High Glucose Intervention
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HHS Cause
HHS Cause
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HHS Risk Group
HHS Risk Group
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HHS Key Symptoms
HHS Key Symptoms
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HHS Neuro Symptoms
HHS Neuro Symptoms
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High Serum Osmolarity
High Serum Osmolarity
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HHS Initial Fluids
HHS Initial Fluids
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HHS Insulin Start
HHS Insulin Start
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Venous vs. Capillary Glucose
Venous vs. Capillary Glucose
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MNT or Meal Planning
MNT or Meal Planning
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Exercise Effects on Glucose
Exercise Effects on Glucose
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Fasting Glucose Adjustment
Fasting Glucose Adjustment
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Why Night time Increases Glucose levels
Why Night time Increases Glucose levels
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How can we treat elevated glucose levels at 7 am?
How can we treat elevated glucose levels at 7 am?
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Why use SMBG?
Why use SMBG?
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Nutritional Therapy GOALS
Nutritional Therapy GOALS
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Pre-Exercise Screening
Pre-Exercise Screening
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Exercise Risk Levels
Exercise Risk Levels
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Impaired Glucose (IFG/IGT)
Impaired Glucose (IFG/IGT)
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DM Prevalence
DM Prevalence
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Pre-Diabetes
Pre-Diabetes
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Type 1 DM Cause
Type 1 DM Cause
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DKA/HHS
DKA/HHS
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Type 1 DM Types
Type 1 DM Types
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Type 1 DM Genetic Link
Type 1 DM Genetic Link
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Type 1 DM Classic Signs
Type 1 DM Classic Signs
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Objective Indicators of Type 1 DM
Objective Indicators of Type 1 DM
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DM Diagnosis
DM Diagnosis
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A1C Purpose
A1C Purpose
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Hypoglycemia - Common Cause
Hypoglycemia - Common Cause
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Hypoglycemia - Signs
Hypoglycemia - Signs
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Ideal Glucose Levels - Management
Ideal Glucose Levels - Management
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DM Management: Individualization
DM Management: Individualization
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DM Complications & HbA1C
DM Complications & HbA1C
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HbA1c Testing Frequency
HbA1c Testing Frequency
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DKA & Dehydration
DKA & Dehydration
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DKA in DM Types
DKA in DM Types
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DKA - Subjective Clues
DKA - Subjective Clues
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Type 2 DM Definition
Type 2 DM Definition
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Type 2 DM: Two Main Issues
Type 2 DM: Two Main Issues
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Hyperglycemia Progression in T2DM
Hyperglycemia Progression in T2DM
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Metabolic Syndrome Components
Metabolic Syndrome Components
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Type 2 DM Presentation
Type 2 DM Presentation
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Initial DM Test Value
Initial DM Test Value
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Four DM Diagnostic Criteria
Four DM Diagnostic Criteria
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Type 2 DM: Chronic Care
Type 2 DM: Chronic Care
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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.
- This is accomplished by the ingestion of 15 g of carbohydrate.
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.
- 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.
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
- Bolus are dosed at 50% total daily needs.
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.
- Reduce/omit bedtime dose.
- Hypoglycemia is commonly found at 3 am due to hormones being released.
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.
- 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.
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.
- The patient's Random capillary glucose.
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