Diabetes - Clinical Presentation.ppt

Diabetes – Clinical Presentation Kenric B. Ware, PharmD, MBA, AAHIVP Clinical Associate Professor Mercer University College of Pharmacy [email protected] Objectives  Evaluate clinical assessment tools available to recognize and manage diabetes mellitus  Differentiate between diabetic ketoaci...

Diabetes – Clinical Presentation Kenric B. Ware, PharmD, MBA, AAHIVP Clinical Associate Professor Mercer University College of Pharmacy [email protected] Objectives  Evaluate clinical assessment tools available to recognize and manage diabetes mellitus  Differentiate between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic states (HHS) as diabetes mellitus complications  Examine the body’s compensatory mechanisms in the presence of hyperglycemia 2 Glucose     Regulation by homeostatic mechanisms  Insulin and Glucagon Measurement of blood concentrations  Fasting or post – prandial state Therapeutic agents that increase values  Corticosteroids, Niacin Elevations can predispose to infections 133 Blood Glucose Distribution 4 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ Comparison of Type 1 and Type 2 Diabetes Mellitus Type 2 Diabetes Mellitus Type 1 Diabetes Mellitus  Autoimmune condition      Body attacks its on beta-cells in the pancreas Often develops in childhood Insulin dependency Genetic predisposition No currently approved method of prevention   Lifestyle factors Typically seen in adulthood    Increasing childhood T2DM cases Insulin independency Lifestyle modifications, exercise and healthy diets, are methods of prevention 5 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ 6 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ Criteria for Screening 7 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ Criteria for Screening (continued) American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ 8 Diagnostic Criteria 9 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ Diagnostic Criteria Signs/Symptoms • Polyuria, Polyphagia, Polydipsia Pre diabetes Diabetes* Fasting Plasma glucose (FPG) 100-25 mg/dL > 126 mg/dL 2 hr Plasma glucose (75 g oral glucose tolerance test) 140-199 mg/dL > 200 mg/dL A1C 5.7-6.4 % > 6.5 % *Diabetes can also be diagnosed with symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose > 200 mg/dL American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ 10 Glycemic Targets • Primary assessment techniques • • • Optimizing SMBG routines • • Self-monitoring of blood glucose (SMBG) A1c testing Prior to meals, snacks and possibly bedtime A1c measurements • Average blood glucose over past 2-3 months American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ 11 Knowledge Check #1  Which hormone when in deficient amounts or when it is not working properly could lead to polyuria? a) b) c) d) Anti-diuretic hormone Calcitonin Glucagon Parathyroid hormone 12 Knowledge Check #1 – discussed 13 Relationship between blood glucose levels and A1c values 14 https://www.medicalnewstoday.com/articles/a1c-chart-diabetes-numbers#how-it-works. Accessed November 3, 2023 Childhood screening for T2DM 15 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ Approaches to Gestational Diabetes Gestational diabetes: Diabetes diagnosed during the 2nd or 3rd trimester of pregnancy that was not identified as diabetes prior to pregnancy. 16 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ What are ketones and why do they mostly form in T1DM individuals? Examples of ketone bodies: acetoacetate, beta-hydroxybutyrate, and acetone 17 Acute Complications of Diabetes Mellitus Hyperosmotic hyperglycemic state (HHS) Diabetic Ketoacidosis (DKA)   Metabolic acidosis commonly observed Serum glucose levels  Generally below 800 mg/dL   Mostly 350 – 500 mg/dL Neurological complications uncommon   Little or no ketoacid build-up Serum glucose levels   Usually greater than 1000 mg/dL Neurological complications frequently present  Coma results in one-fourth to one-half of patients with HHS 18 American Diabetes Association. (January 2023). Standard of Care in Diabetes – 2023. Retrieved from https://www2.diabetes.org/ Comprehensive management of DKA Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006; 29:2739. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32:1335. 19 Comprehensive management of HHS Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32:1335. 20 Fluid replacement options Solution concentrations may vary based upon the body’s overall fluid needs Other examples: 3% NaCl, D50W 21 Knowledge Check #2  A physician consults you for assistance with prescribing an antidepressant medication to a patient with uncontrolled T2DM. The physician would like to treat the depression without negatively impacting other complications of the uncontrolled T2DM. Which antidepressant should likely be recommended? a) Amitriptyline Citalopram Duloxetine Fluoxetine b) c) d) Disclaimer: Proper selection of an antidepressant would require more information than what is presented here. 22 Knowledge Check #2 – Discussed 23 Key points from Comprehensive management of DKA schematic  Insulin infusion consists of regular (short-acting) insulin   Additive effects on K+ levels by NaHCO3 and insulin   Subcutaneous formulation (rapid-acting) insulin NaHCO3 and insulin shifts K+ from extracellular to intracellular space If K+ drops too low, hold insulin and replete with KCl  Why does the recommendation not include holding NaHCO3? 24 Key points from Comprehensive management of DKA schematic  Serum sodium correction in hyperglycemia   Monitor medications that can lead to hyperglycemia Bacterial cultures may be needed (infection risk)   Increased amounts of glucose allow bacteria to grow, replicate, and cause infections Infection risk reduces with better glucose control 25 Hypovolemia secondary to DKA 26 Knowledge Check #3  Which electrolyte abnormality is usually associated with uncontrolled hyperglycemia? Hypernatremia or Hyponatremia?? 27 Knowledge Check #3 – discussed 28 Changes in sodium levels in hyperglycemic conditions 29