Diabetes PDF

DIABETES Diabetes is a chronic health condition that affects how your body processes blood sugar (glucose), which is the main source of energy for your cells Pregnancy: Diabetes management during pregnancy can be challenging due to hormonal changes affecting insulin sensitivity and glucose control...

DIABETES Diabetes is a chronic health condition that affects how your body processes blood sugar (glucose), which is the main source of energy for your cells Pregnancy: Diabetes management during pregnancy can be challenging due to hormonal changes affecting insulin sensitivity and glucose control. For pregnant women with diabetes, it is recommended not to use the abdomen as the site for insulin injections. Instead, the thigh is suggested for safer subcutaneous injections. Types of Diabetes: Type 1 Diabetes: autoimmune condition where the immune system attacks and destroys insulin-producing cells in the pancreas (body makes NO insulin) Managed with insulin injections or pumps. Type 2 Diabetes: The body becomes resistant to insulin or doesn't produce enough most common form, often linked to lifestyle factors Managed with diet, exercise, oral medications, and sometimes insulin. ○ can often be prevented or delayed Symptoms of Diabetes: Increased thirst and hunger Frequent urination Fatigue Unexplained weight loss (more common in Type 1) Slow-healing wounds Numbness or tingling in hands or feet Diagnosis: Blood tests like fasting blood glucose, A1C, and oral glucose tolerance tests. FBG ○ Measures blood sugar levels after an overnight fast (typically 8–12 hours without eating). taken in the morning before eating or drinking anything other than water. ○ Ranges? normal/in target: 4-7 mmol Hypoglycemic: >4 mmol  Hyperglycemic: greater than 7 mmol ○ Significance: High fasting blood glucose indicates impaired insulin regulation. A1C ○ Measures the average blood sugar levels over the past 3 months ○ Blood glucose monitoring is about the here and now ○ A1C and blood glucose meter testing can tell different stories A1C: It reflects overall blood sugar control over a long period, no fasting needed, provides broad overview of long term maintenance, SMBG: provides real-time blood sugar readings, provides immediate feedback, useful for determining insulin effectiveness Glucose tolerance ○ Measures the body’s ability to process glucose ○ Assesses how efficiently the body metabolizes glucose after a sugar load. Fasting blood glucose is measured. Patient drinks a solution containing 75 g of glucose (for adults). Blood sugar levels are measured at intervals (e.g., 1 and 2 hours post-drink). Self Monitoring of Blood Glucose (SMBG) When? ○ Results are being used ○ Helps change lifestyle habits (eating) ○ Adjust meds ○ Prevent issues (hypo, hyperglycemic) Barriers? ○ Pain, cost, inconvenience, diabetes burnout, feeling judged Frequency? ○ Is blood glucose being controlled ○ Changes in diet or meds ○ Someone is sick or significant weight loss ○ Type of med ○ Insulin or not (insulin requires more testing if insulin is more frequent) Hypoglycemic LOW blood sugar levels Most frequent in type 1 diabetes, then type 2 (w insulin), then type 2 (w sulfonylures) Development of autonomic or neuroglycopenic symptoms (fight or flight) ○ Trembling ○ Palpitations ○ Sweating ○ Hunger ○ Anxiety  ○ Nausea Management: ○ Consume fast acting carbohydrates (15g) Dex4 Glucose Tablets (has 4g of carbs per tablet - raises mild episodes of low blood sugar) ○ 15mL (3 tsp) of sugar/honey ○ 6 lifesavers ○ 150mL of juice ○ Wait 15 mins, then retest levels again SEVERE hypoglycemia ○ Emergency, unconsciousness, treatment not given by mouth, use flucagon nasal spray or injection Baqsimi Glucagon Nasal Powder Increases blood sugar by releasing glycogen (stored glucose) from the liver to the blood 3mg of glucagon Replaces glucagon injection Takes less than 24 sec to use Safe for adults and children (4+) Glucagon injection 1mg, S/C or IM Produces great increase within 1 hour Takes up to 2 mins to mix Increase chance of error Hyperglycemic HIGH blood sugar levels When food, activity, med not balanced, sick, under stress Adjustments are made to meals, med and physical activity 20 mmol + , go to ER or consult with HCP 14 mmol + , Type 1 pt should test for presence of ketones in the blood or urine Symptoms ○ Shakiness ○ Sweating ○ Dizziness ○ Hunger ○ Confusion Management What patients should aim for (of the day)  Less than 1% < 3 mmol (more than) Less than 4% < 3.9 mmol 5% > 13.9 mmol 25% < 10 mmol 70% 3.9 - 10 mmol Time in Range The amount of the day that you spend with sugar Sick Day Management If people with diabetes become ill & unable to maintain adequate fluid intake, or have acute decline in renal function (due to GI upset or dehydration), they will be instructed to hold medication which will: Increase risk for decline in kidney function Have reduced clearance and increase risk for adverse effects SADMANS (sick day management) S = suflonylureas (gliclazide) A = ACE inhibitors (ramipril) D = diuretics, direct renin inhibitor (furosemide) M = metformin A = angiotensin receptor blockers (candesartan) N = NSAIDS (naproxen) S = SGLT2 inhibitors (invokana - canagliflozin) Ketones produced when the body doesn't have enough carbohydrates (glucose) to use as its primary energy source. Ketone testing ○ Recommended for all type 1 pt during periods of acute illness + high BG ○ Freestyle is the only meter that does ketone testing + glucose testing Strips for ketone and glucose differ Device will flash “KET” and ask to test your ketones when BG is 13.3 or higher Type 1 diabetes Pt should test when 14 mmol + Target range: < 0.6 mmol 0.6 - 1.5 mmol = recheck BG and ket in 2 hours 1.3 - 3 mmol = risk of ketoacidosis 3 mmol = ER  They can serve as an alternative fuel for the body and brain. Uncontrolled Diabetes (Diabetic Ketoacidosis): When insulin levels are too low, the body burns fat rapidly, leading to an overproduction of ketones. ○ It happens when the body produces high levels of ketones and the blood becomes acidic. ○ life-threatening complication of uncontrolled diabetes ○ (most often type 1 diabetes but sometimes type 2 diabetes) ○ Causes: Not enough insulin Severe infection/illness Severe dehydration ○ Treatment In hospital Insulin and fluids IV Can take several days for blood sugar level to return to target ranges ○ Symptoms of DKA: Fruity-smelling breath (due to acetone) Ketosis vs diabetic ketoacidosis Ketosis: natural metabolic process where ketones are produced in the body form the breakdown of fat for energy ○ Natural DKA: too much ketone accumulates in body ○ Medical emergency Government Coverage and Diabetes (Ontario) Government coverage for diabetes supplies and equipment ends at 18 years old. After age 18, individuals may need private insurance or out-of-pocket payment for some items like insulin pumps and supplies. Getting ready to train patients Gather info on targets Log book (if patient doesn't want to use app) Info on hypo and hyperglycemia Testing patterns or print PDF from diabetes canada Sick day management (SADMANS) - pharmacist counsel Videos and links to online resources, troubleshooting  Scan documents given to patients and training, training of meters can be billed by ontario diabetes medscheck program Follow up Blood Glucose Monitoring (2 types) Traditional finger prick glucometer ○ Ex. contour next, onetouch verio reflect, etc Continuous blood glucose monitoring (CGM) ○ Wearable device ○ Tracks BG every few mins throughout the day and night ○ Real time readings that is read by patient, doctor, caregiver ○ Small disposable sensory worn on stomach or arm (device specific) ○ Reduce time spent in hypoglycemic range & A1C in adults and childs ○ Ex. freestyle, dexcom CGM vs Finger prick CGM: takes sample from interstitial fluid ○ Readings are “older”, lag by 9 mins ○ CGM results don’t always match finger prick readings Finger: sample from blood  INSULIN Introduction Insulin is a hormone that controls blood glucose How many insulin injections per day? ○ 1-4 injections ○ Varies for each individual Carb Counting: the patient enters the carbohydrate amount consumed and their current blood glucose level. This is used to calculate the appropriate insulin dose. Use to be beef and pork insulin (rarely used) Now insulin is manufactured in labs via biogenetic tech using bacteria nd yeast Type 1: insuline routinely used because pancreas doesn’t produce it Type 2: managed with diet, exercise, weight loss, oral antidiabetic meds before insulin is considered ○ Often will need insulin in 10 years as the disease progresses ○ Depends on health status ○ Insulin does not mean patient has failed their healthcare, just the body needs help of insulin Human vs Analogue two types of insulin used to manage diabetes Human insulin ○ Identical to insulin produced by the pancreas ○ Ex. humulin or novolin Analogue insulin ○ Similar to insulin produced by pancreas but structure is modified slightly to give new properties ○ Ex. Lantus, humalog, Levemir Insulin classification According to their action time ○ Onset of action ○ Peak of action ○ Duration of action Insulin Types 1. Rapid acting ○ Covers blood sugar spikes from meals; taken 5-15 minutes before eating. 2. Short acting ○ Covers blood sugar rises from meals; taken 30 minutes before eating. 3. Intermediate acting  ○ Provides background insulin; used between meals and overnight. 4. Long acting ○ Provides steady, basal coverage; minimal or no peak effect. 5. Premixed with rapid and intermediate acting ○ Convenient for those needing both meal and basal coverage but require adherence to fixed schedules due to the mixed action profiles. 6. Premixed with short and intermediate acting Insulin TYPES Basal (background) ○ long-acting or intermediate-acting insulins that maintain consistent blood glucose levels between meals and overnight. Long acting: lantus, levimer, toujeo, basaglar, tresiba Intermediate (cloudy): Humulin N, Novolin ge NPH Bolus (meal) ○ taken before meals to control post-meal blood sugar spikes. ○ Rapid analogue: humalog, fiasp, novorapid, apidra ○ Short acting: humulin R, novolin Pre-mixed ○ combine basal and bolus insulin in one product, simplifying the regimen for some patients. ○ Ex. humulin 30/70, novolin 30/70, 50/50, 40/60 Starting Type 2 Diabetes Patients on insulin Often start with basal (background) at bedtime Slowly titrate upwards every few days Avoid hypoglycemia Add meal time next Adjusting insulin via pattern Blood glucose testing Look for patterns Always address hypoglycemia first (more dangerous than hyperglycemia) Check BG at 3:00AM ○ To rule out morning hypoglycemia caused by rebound Insulin SUPPLIES Comes in ○ vials (mainly used by insulin pump patients) ○ Preloaded prefilled pen Cartridge is permanent and the whole unit is disposed once used up Comes in a box of 5 pens ○ Cartridges Reusable pen must be used with this NO syringes with this Tresiba 200U/mL Prefilled pen Ex. patient uses 40 units daily, how long will the box of pens last? ○ 3 pens per box ○ Each pen contains 3mL ○ 200U/mL X xU/3mL = 200 x 3 = 600 units per pen ○ 600 units x 3 (pens) = 1800U per box ○ 1800U/40U = 45 days HumaPen Luxura HD Reusable Pen LILLY 1-30 units in half doses/increments Use with humalog 3mL insulin cartridges HumaPen Luxura Reusable Pen LILLY 1-60 in 1 unit increments Use with 3mL insulin cartridge NovoPen 4 Reusable Pen - NovoNordisk 1-60 in 1 unit increments Use with 3mL cartridge Levemir, Novolin, Fiasp, NovoRapid, NovoMix NovoPen Echo Reusable Pen NovoNordisk 0.5 - 30 units in half increments ClikSTAR Reusable Pen Sanofi 1- 80 units in 1 unit increments Uses with lantus, Apidra Insulin KwikPen Must prime everytime ○ How? Dial up to 2-3 units and look for a droplet of insulin to come out of the needle tip ○ A small bead of insulin should come out; if it doesn’t, replace the needle.  Use new needle for each injection (keep outer cap and throw away inner green cap) ○ Green cap is disposed in garbage, put clear cap back on and twist off, place the needle into sharp container Always dial to dose with window facing person who is administering the injection Pen tips (needles) Pen needles: 4mm most recommended ○ BD nano pro: new and approved 4mm ○ Into fat (S/C) not muscle ○ 62% less thumb force required to use pen ○ Higher insulin flow rate ○ 8mm no longer recommended Proper use ○ Only use once, they are thin and can bend or break if reused ○ Reusing can make the injection more painful ○ Leaving pen tips on cartridge can cause leakage or allow air which may affect concentration of the insulin Coverage: ○ Not covered by ODB or the Ontario Assistive Devices Program (ADP). ○ Private Insurance: May cover the cost of pen needles. Needle Disposal: After use, place the needle in a sharps container (dispose of the green cap in regular trash, but place the clear cap back on before disposal). Insulin SYRINGES Not used much anymore ○ Pens become available Comes in different units 30-100 Some patients have vials and syringes as backup to an insulin pumps Insulin INJECTIONS Injected into fat layer under the skin (subcutaneous) Caution with tattoos AVOID muscular (causes erratic blood glucose control) ○ as it gets absorbed much faster, inject subcutaneously allows the insulin to sit longer and release slowly Device: ○ Syringe, pen, insulin pumps Rotate sites to avoid fatty lumps (Lipohypertrophy) ○ Common complication ○ Causes erratic insulin levels at this site  ○ Train patients to look for lumps and bumps before picking a site Avoid a 2 inch area around the belly button & scar tissue Choosing a site: ○ Abdomen (tummy) Most common, easy to reach, insulin absorbs fast & consistently Stay 2 inches (5cm) away from your belly button ○ Buttock & thigh Slower absorption than arm & stomach ○ Outer arm 2nd fastest absorption Area hard to reach when injecting yourself, so not often recommended Injection TECHNIQUE No need to pinch the skin (the needle is small enough to pierce deep into the subcutaneous fat). Hold the needle in place for 5-10 seconds to ensure full insulin delivery. Avoid injecting in the abdomen during pregnancy. Instead, use the thigh as the injection site. A1C worsens with injection technique errors ○ Number of errors = higher A1C value Skin thickness remains consistent regardless of BMI Recommend Self administration = abdomen buttocks Arms administration usually reserved for parents, health care workers Insulin CARE and STORAGE Insulin pens should stay in the fridge until they are used. Once a pen is taken out for use, it can be kept at room temperature Unopened insulin should be stored in the fridge (2 - 8C) Open insulin = at room temp (25-28 days) ○ Always check package for various storage requirement Levemir and toujeo safe at room temp (42 days) Away from direct heat and light Discard insulin that has been: ○ Frozen ○ Greater 30 C ○ Expired Check drug monograph FIT - Forum for Injection Techniques a global initiative aimed at providing evidence-based training and guidance on best practices for injection techniques in various healthcare settings improving patient education and clinician knowledge regarding the safe, effective, and proper methods for self-administered injection