Management of Acute Diabetic Complications

MANAGEMENT OF DIABETIC COMPLICATIONS: FOCUS ON ACUTE COMPLICATIONS KAREN S. FIANO, PHARM.D., BCACP ASSISTANT DEAN, ASSESSMENT AND ACCREDITATION ASSOCIATE PROFESSOR EMAIL: [email protected] LECTURE OBJECTIVES Define acute complications in the management of diabetes mellitus. Identify the signs and symp...

MANAGEMENT OF DIABETIC COMPLICATIONS: FOCUS ON ACUTE COMPLICATIONS KAREN S. FIANO, PHARM.D., BCACP ASSISTANT DEAN, ASSESSMENT AND ACCREDITATION ASSOCIATE PROFESSOR EMAIL: [email protected] LECTURE OBJECTIVES Define acute complications in the management of diabetes mellitus. Identify the signs and symptoms of hypoglycemia. Explain approaches to managing and preventing hypoglycemia. Differentiate between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) Select appropriate treatment recommendations for management of DKA and HHS. GLYCEMIC CONTROL  Achieving good glycemic control is important to reduce the risk of both short- and long-term complications in type 1 and 2 DM  Short-term (acute) complications  Elevated blood sugar – excessive urination, fatigue, weight loss, and DKA or HHS  Low blood sugar – hypoglycemia (can lead to seizure and death)  Long-term (chronic) complications  Vascular and tissue damage  Microvascular (small vessels)  Macrovascular (large vessels) MAJOR COMPLICATIONS OF DIABETES Other complications can include increased risk periodontal disease, erectile dysfunction in males, skin and soft tissue infection RISK OF COMPLICATIONS 2-4 x risk of heart disease Leading cause of blindness Leading cause of nontraumatic limb amputations Leading cause of kidney failure CONTROLLING BLOOD SUGAR REDUCES RISK OF LONG-TERM COMPLICATIONS 1. DCCT; NEJM. 1993; 329:977-86. 2. UKPDS 33; Lancet. 1998; 352:837-53. 3. DCCT-EDIC; NEJM. 2005; 353:2643-53. MANAGEMENT OF COMMON COMORBIDITIES Covered by Dr. Levin Basic Principles: Evaluate ASCVD risk Individuals with DM >40 years of age should minimally be on a moderate intensity statin Higher risk=higher intensity statin Hypertension Lipid Management Glycemic control Covered in IDM-2 Basic Principles: Assess CVD risk using ASCVD calculator BP goal 10 >12 >12 Variable Mental statusb Alert Alert/drowsy Stupor/coma Stupor/coma a = Effective serum osmolality: 2[measured Na+ (mEq/L)] + glucose (mg/dL)/18 b=Anion gap: (Na+) – [(Cl- + HCO3- (mEq/L)]. Diabetes Care 2009 Jul; 32(7): 1335-1343. OTHER CLINICAL SIGNS OF DKA  Usual signs of hyperglycemia (polyuria, polydipsia, polyphagia)  Nausea, vomiting, and abdominal pain present in 40 to 75% of cases  Signs of dehydration (dry mucous membranes, skin)  Changes in mental status  Acetone breath  Kussmaul respirations – labored breathing pattern Diabetes Care 2009 Jul; 32(7): 1335-1343. INITIAL MANAGEMENT Restoration of circulatory volume and tissue perfusion (Fluid) These steps are assessed and managed simultaneously Cessation of ketogenesis (Insulin) Resolution of hyperglycemia Diabetes Care 2009 Jul; 32(7): 1335-1343. Correction of electrolyte imbalances (potassium) GOALS OF THERAPY  Replace fluid deficit  Close anion gap (