Diabetes Mellitus Part 2: Pathophysiology and Management

• Diabetes Mellitus is a chronic condition that affects how the body metabolizes glucose.

Acute Complications

• Diabetic Ketoacidosis (DKA)
• Hyperosmolar Hyperglycemic State (HHS)

Microvascular (Chronic) Complications

• Dermopathy
• Nephropathy
• Retinopathy
• Neuropathy

Macrovascular (Chronic) Complications

• Atherosclerosis
• Peripheral Vascular issues
• Cardiovascular problems
• Cerebrovascular issues

Diabetic Ketoacidosis (DKA)

• An acute complication that stems from insulin deficiency
• Commonly seen in type 1 diabetes
• Glucose levels typically exceed 300 mg/dL
• Osmolality is greater than 340 mOsm/L
• Characterized by Kussmaul's respiration
• Presence of confusion
• Develops quickly

Hyperosmolar Hyperglycemic State (HHS)

• Severe hyperglycemia occurs without significant ketoacidosis
• Commonly seen in type II diabetes
• Glucose levels typically exceed 600mg/dL
• Shallow breaths occur
• Lethargy
• Develops slowly

Atherosclerosis Diabetes

• Causes a high incidence of coronary artery disease and vascular insufficiency of the extremities

Dermopathy

• A disease of the skin

Albuminuria

• Albumin in the urine

Neuropathy

• Any disease of the Nerves

Long Term Effects of Diabetes

• Diabetic Neuropathy
• Diabetic Retinopathy
• Stroke
• Cardiovascular Disease
• Diabetic Peripheral Neuropathy

Diabetic Peripheral Neuropathy

• Progressive deterioration of nerve function occurs with the loss of sensory perception.

Diabetic Dermopathy

• Diabetic Skin spots caused by microvascular damage, trauma, or injury.
• Small, round, oval patches of discolored skin

Nephropathy

• Kidney damage occurs, leading to albuminuria.
• Small blood vessels in the kidney are damaged, including the glomeruli.
• Albuminuria (protein) in urine.
• 70% also have HTN (Hypertension)

Diabetic Retinopathy

• Damage to the retina as a complication of uncontrolled diabetes
• Microvascular damage and occlusion of the retina

Glaucoma

• Increased intraocular pressure results in damage to the retina and optic nerve with loss of vision

Cataracts

• Clouding of the lens

Peripheral Neuropathy

• Nerve damage causes numbness and weakness
• Peripheral nerves transmit signals from the CNS to the rest of the body

Sensory Neuropathy

• There is a loss of protective sensation in lower extremities
• Major risk for amputation
• Loss of sensation, numbness, tingling

Motor Neuropathy

• Dysfunction of motor nerves leading to atrophy, weakness, and/or paralysis
• Weakness, cramps

Autonomic Neuropathy

• Damage to nerves supplying internal body structures that regulate functions such as blood pressure, heart rate, bowel and bladder emptying, and digestion

Autonomic Neuropathy Symptoms

• Postural hypotension
• Erectile dysfunction
• Gastroparesis

Gastroparesis

• A condition in which the muscles in the stomach slow down and work poorly or not at all, preventing the stomach from emptying normally

Peripheral Vascular Disease

• Narrowing or blocking of blood vessels in limbs
• Clotting disorders often affect the lower extremities

Peripheral Vascular Disease Risk Factors

• Diabetes
• Cigarette smoking
• HTN
• Hyperlipidemia
• Atherosclerosis
• Obesity
• Sedentary lifestyle
• Infection
• Gangrene
• Amputation

Cardiovascular Disease

• Heart and blood vessel complications.

Coronary Heart Disease

• The clogging of the vessels that nourish the heart muscle and is the leading cause of death in many developed countries

Cerebrovascular Disease

• A disorder resulting from a change within one or more blood vessels of the brain

Peripheral Arterial Disease

• Disease of blood vessels supplying arms and legs, also known as a diabetic foot

Diabetic Foot

• A person that has diabetes is at increased risk for slow-healing injuries to distal extremities
• It is caused by decreased vascularization and the risk of an infection that does not heal is higher
• One possible intervention is limb amputation

Diabetes Pharmacotherapy

• Biguanides
• Thiazolidinediones
• Sulfonylureas
• Meglitinides
• a-Glucosidase inhibitors

Biguanides

• Metformin is the preferred initial pharmacological agent.
• Controls hepatic glucose production
• Decreases the rate of hepatic glucose production
• Increases glucose uptake in muscles
• Should not be used in patients with kidney, liver, or heart failure.
• Hold for 48 hours after procedures using contrast dye

Metformin Diabetes

• Biguanides primarily decrease glucose production in the liver and increase the uptake of glucose
• May also decrease intestinal absorption of glucose
• Does not stimulate insulin secretion
• Used for type 2 diabetes in children >10 yrs with type 2
• Good for obesity-related diabetes
• Adverse Effects: experience GI complications
• Assess for lactic acidosis (dizziness, SOB, cardiac irregularities)
• Contraindications: renal disease, acute cardiac events, sepsis - due to risk of lactic acidosis

What is the first line pharmacologic treatment for Type II DM?

• Metformin

Thiazolidinediones

• Pioglitazone (Actos) and Rosiglitazone (Avandia)
• Control hepatic glucose production

Sulfonylureas

• Oldest class of oral hypoglycemics.
• Stimulates the pancreas to make more insulin.
• Take with meals.
• Watch for hypoglycemia
• Includes glyburide (Micronase, Diabeta), glipizide (Glucotrol) and glimepiride (Amaryl)

Glyburide Diabetes

• Sulfonylureas are the first oral agent, that increase the number of insulin receptors, and is an adjunct to diet and exercise
• Only for Type II diabetes only because they need beta cells
• Adverse Effects: hypoglycemia, GI effects (nausea/vomiting/heartburn)
• Do not use if pregnant

α-Glucosidase Inhibitors

• Delay carbohydrate absorption in intestines
• "Starch Blockers"
• Best used for those with normal FBS but elevated Post Prandial Plasma Glucose (PPG)
• Take with the 1st bite of meal
• Monitor liver enzymes

Dipeptidyl Peptidase-4 Inhibitor (DPP-4)

• Includes acarbose (Precose) and miglitol (Glyset)
• Boosts incretin, hormones produced by the gut in response to food intake
• Enhances incretin hormones to regulate glucose
• Includes sitagliptin (Januvia), linagliptin (Tradjenta), alogliptin (Nesina), and saxagliptin (Onglyza)

Incretin Mimetics

• Mimic incretin effects to lower blood sugar
• May combine with oral agents
• Do NOT use with Insulin
• Includes dulaglutide (Trulicity), exenatide (Byetta/Bydureon), liraglutide (Victoza), and semaglutide (Ozempic)

dulaglutide (Trulicity)

• An antidiabetic agent
• Acts as a Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist

Insulin Overview

• Injectable drugs to control:
  • Type 1, dependent
  • Type 2, if not controlled by other means

Banting and Best

• In 1920, they successfully isolated the hormone insulin for the first time.

Rapid Acting / Bolus Insulin

• Inject SQ 5-15 minutes before meals
• Used as prandial insulin and for correction doses (by sliding scale)
• Aspart, Lispro, and Glulisine - all are clear and colorless
• Afreeza - inhaled
• Onset: 10-30 minutes
• Peak: 30 minutes - 1 hr
• Duration: 3 - 5 hours

Short-acting Insulin (bolus/prandial)

• Regular (Humulin R, Novolin R)
• Onset: 30 min - 1 hour
• Peak: 2 - 4 hrs
• Duration: 5 - 8 hrs

Intermediate-acting Insulin

• NPH (Humulin N, Novolin N)
• Onset: 1-2 hrs
• Peak: 4 - 12 hrs
• Duration: 12 - 18 hrs

Long-acting (Basal) Insulin

• glargine (Lantus) and detemir (Levemir)
• Onset: 1 - 2 hours
• Peak: n/a
• Duration: 18 - 24 hrs

Combination Insulin (Premixed)

• Short or rapid-acting insulin is mixed with intermediate acting to provide both mealtime and basal coverage.
• Duration of action is 10-16 hours.

Drawing Up Two Different Insulins

1. Draw air into syringe.
2. Inject air into NPH insulin.
3. Inject air into Short-Acting Insulin.
4. Draw Short-Acting Insulin
5. Draw NPH Insulin

Insulin Pump

• A device delivering continuous insulin infusion
• Delivers Insulin via an infusion set
• The infusion set goes through a thin tube that goes under the skin and mimics a healthy pancreas
• Basal dose
• Bolus dose

Phases of Insulin Action

• Onset, peak, and duration of insulin effects.

Insulin Onset

• When the effect of Insulin first begins

Insulin Peak

• When the Insulin is working at its "optimal" level

Insulin Duration

• How long the Insulin persists in the system

Non Pharmacologic Therapies for Diabetes

• Exercise
• Diet
• Medications
• Blood Pressure & Cholesterol Management
• Using Risk Reduction Approach

Dietary Recommendations in Diabetes

• Non-starchy Veggies, such as spinach, carrots, and broccoli
• Protein, such as chicken, salmon, and eggs
• Carbohydrates, such as whole grain foods, pasta, and potatoes
• Water is the best beverage choice
• Add: serving of fruit & dairy choosing healthy fats

Role of Fiber in DM

• Improves blood sugar control.
• Digestive health
• Weight management
• Heart health

Physical Activities Recommendations

Aerobic Exercise Anaerobic Exercise Mixed Exercise

Aerobic Exercise Diabetes

• Lower intensity; longer duration
• Expect a drop in blood glucose

Anaerobic Exercise Diabetes

• Higher intensity and shorter duration
• Expect spikes in glucose levels

Mixed Exercise Diabetes

• Combination of aerobic and anaerobic activity
• Expect glucose level to fluctuate and can spike or drop

Sick Days Management

• Special considerations for illness in diabetes.

Foot Care

• Essential practices to prevent diabetic foot complications include:
• Wash Daily
• Dry well especially between toes
• Feel for bumps or temp changes
• Look between toes and check each toenail
• File toenails straight across
• Check for dry, cracked skin
• Examine bottom of feet
• Track your findings

Tips for Healthy Feet

• Check your feet every day
• NEVER go barefoot
• Wear well-fitting shoes
• Trim your toenails straight across
• Do NOT try to remove corns or calluses by your self
• Get your feet checked at EVERY healthcare visit

Vision Care

• Complete a dilated eye exam every year
• Contact doctor immediately with complications

Vision Complications to CONTACT PROVIDER IMMEDIATELY

• Blurred or double vision
• Narrowed field of vision
• Seeing dark spots
• Feeling pressure in the eyes
• Unusual difficulty seeing in dim light

Skin Care Diabetes

• Bathe daily with mild soap and lukewarm water
• Avoid scratches or bruises
• Gardener gloves
• Sunscreen
• Avoid long exposure to very cold weather
• Treat skin injuries quickly

Diabetic Sick Days (S.I.C.K)

• Sugar
• Insulin
• Carbs
• Ketones

Patient Education (T.R.A.C.K)

• Take your meds as prescribed
• Reach and maintain a healthy weight
• Add more physical activity to daily routine
• Control your ABC's; A1C, BP, and Cholesterol
• Kick the smoking habit

Generate Solutions: Patient/Caregiver will:

Demonstrates blood glucose test on self. Verbalize proper foot care. Verbalizes exercise guidelines. Verbalize when to contact a physician. Verbalizes importance of outpatient DM education after discharge. Verbalizes target glucose ranges and A1C levels. Demonstrate SQ injection. States appropriate time schedule for insulin. States drug/drug and drug/nutrient interactions. States symptoms and treatment of hypoglycemia. States symptoms and treatment of hyperglycemia. Verbalizes sick day guidelines. States one day meal plan.