-
Diabetes Characteristics
- Hyperglycemia
- Impaired metabolism of carbohydrates, fat, and protein
- Impaired insulin secretion, insulin resistance, or both
-
Complications of Diabetes
- Nephropathy
- Retinopathy
- Amputation
- Neuropathy
- Cardiovascular disease
- Decreased life expectancy
-
Type I
- Onset < 30 years
- Weak genetic link
- Absolute deficiency of Insulin Production
-
Type II
- Onset > 30 years
- Strong genetic link
- Insulin resistance, defective insulin release
-
NPH Insulin
- Absorbed slower after injection
- Longer duration than regular
- Shorter than glargine or detemirs
-
Cloudy Insulin
NPH Insulin Appearance
-
Basal Insulin
- Half total daily insulin dose
- May use any long acting Insulin
-
Meal-time Insulin
- Other 50% of TDD
- Divided between meals
- Short-intermediate acting insulin
-
Non-Mixing Insulins
Lantus and Levemir cannot be mixed
-
Mixing order
Clear before cloudy
-
Pros of Non-intensive Therapy
Fewer Injections
-
Cons of Non-intensive Therapy
- Less control of sugars
- More difficult to change to intenstive later
-
Pros of Intensive Insulin Therapy
- Tight glucose control
- Allows flexibility in meal times and sizes
-
Cons of Intensive Insulin Therapy
- More daily injections
- 3x risk for severe hypoglycemia
- weight gain
-
Candidate for Intensive Insulin Therapy
- Type 1 > 7 years old
- Willing to test/inject > 4x/day
- Able to interpret readings/adjust doses
- Understand importance of non-insulin components of therapy
-
Lantus
- Long duration
- Peakless unlike NPH
-
HbA1c
- Glycemic control over 2-3 months
- measured q3months not well controlled, q6months well controlled
-
Pre-prandial glucose goals
< 110-130 mg/dL
-
2-hour post-prandial glucose goals
< 140-180 mg/dL
-
-
Disorder of insulin secretion
Disorder of insulin resistance
Disorder of excess glucose production
Type II Diabetes
-
Biguanides
- Metformin
- IR, ER, Combination
-
Metformin MOA
- Reduces hepatic glucose production
- Reduces intestinal glucose absorption
- Increase insulin sensitivity - improves peripheral glucose uptake and utilization
-
Promotes modest weight loss or weight stabilization
Less likely to cause hypoglycemia
Metformin
-
Adverse reactions of Metformin
GI: Nause/vomiting, diarrhea, flatulence
-
Precautions with Metformin
- Renal or hepatic dysfunction
- lactic acidosis
-
MOA of Sulfonylureas
- Stimulate release of insulin from pancreas
- Requires presence of insulin
-
Oldest and most popular class of oral hypoglycemic agents
Sulfonylureas
-
Adverse reaction of Sulfonylureas
hypoglycemia
-
Absent or diminished S&S of hypoglycemia with Beta-Blockers
- Palpitations
- tachycardia
- sweating
-
Adrenergic Manifestations S&S of hypoglycemia
- Shakiness, nervous, anxiety
- Palpitations, tachycardia, sweating
-
Neuroglycopenic manifestations of hypoglycemia
impaired judgement, mentationFatigue, lethargy, ataxiastupor, coma, seizures
-
Glucagon manifestations of hypoglycemia
hunger, n/v, headache
-
Mild hypoglycemia (Glucose < 50 mg/dL) tx
3 glucose tablets or 1/2 cup of fruit juice
-
Severe hypoglycemia (glucose < 40 mg/dL) tx
Glucagon injection
-
Thiazolidinediones
- First line as monotherapy
- Synergistic when combined
-
MOA of Thiazolidinediones
- Increases insulin senesitivity in liver, fat and skeletal muscle by increasing glucose utilization and decreasing glucose production
- Requires presence of insulin
-
Adverse effects of Avandia
- weight gain
- Increased total cholesterol, LDL, and HDL
- Edema
- Hepatic metabolism
-
Drug with increased risk of MI
Avandia
-
-
Favorable effect of Actos
- Decreased TG
- Increased HDL
-
Thiazolidinediones precautions/contraindications
-
Alpha Glycosidase Inhibitors
- Precose
- Glyset
- Used in type I and II Diabetes
-
MOA of Alpha Glycosidase Inhibitors
- inhibits GI tract that convert carbohydrates to glucose
- Slows intestinal absorption of glucose - slowe rrise in post-prandial glucose
-
MOA of Rapid Acting Secretagogues
- Stimulates insulin release fromt eh pancreas
- Similar to sulfonylureas yet shorter half-life
-
Adverse effects of Rapid Acting Secretagogues
- Hypoglycemia - short-acting for skipping dose if skipping meal
- High cost.
-
Januvia
- Dipeptidyl peptidase-4 inhibitor
- Once daily oral tablet
-
SE of Januvia
- minimal hypoglycemia
- weight neutral
-
MOA of Byetta
Incretin mimetic - inhibits release of glucagon, slows rate of gastric emptying, increases satiety
-
Byetta Usage
- Twice daily SubQ Injection
- Requires Refigeration
-
SE of Byetta
Nausea and Vomiting
-
Symlin
Decreases post-prandial glucose levels - prolongs gastric emptying time, reduces caloric intake through appetite suppression
-
Etiology of DKA
- reduced insulin levels
- decreased glucose utilization
- Increased gluconeogenesis
- Precipitated by omittion of tx, infection or EtOH abuse
-
DKA Presentation
- Poly's
- Weakness
- Kussmaul Respiration
- "fruity breath"
- N/V
- Abdominal Pain
-
DKA Treatment
- Fluids
- Insulin
- Potassium
- Bicarbonate
- Phosphate
- Magnesium
- Sodium
-
Most common primary hypothyroidism
Hashimoto's thyroiditis
-
Thyroid gland enlargement
lymphocytic involvement
gradual loss of thyroid function
Autoimmune disorder
Hashimoto's thyroditis
-
Environmental triggers of Hashimoto's Thyroiditis
- Infection
- Stress
- Sex steroids
- Pregnancy
- Ionizing radiation
-
Presentation of Hypothyroidism
- Enlarged thyroid (goiter)
- dry/scaly skin
- coarse hair, brittle nails
- periorbital puffiness
- Weakness, fatigue, slow speech
- Weight gain
-
Increased TSH
Normal Free/Total T4
Subclinical hypothyroidism
-
Increased TSH
Decreased Free/Total T4
Hypothyroidism
-
Decreased TSH
Increased Free/Total T4
Hyperthyroidism
-
Normal TSH
Decreased Free/Total T4
Pituitary Problem
-
Drug of choice for Hypothyroidism
Levothyroxine
-
Dosing for Hypothyroidism
-
Causes of Hyperthyroidism
- Graves' Disease
- Autonomous thyroid nodule
- Multinodular goiters
- Subacute thyroiditis
- Exogenous hormone ingestion
- Tumor
-
Presentation of Hyperthyroidism
- Nervousness/anxiety/palpitations
- Emotional lability
- heat intolerance
- onycholysis
- finger tremor
- weight loss with increased appetite
-
Cardinal sign of Hyperthyroidism
Loss of weight concurrent with an increased appetite
-
Physical symptoms of Hyperthyroidism
- Retraction of the eyelids/lagging of hte upper lid
- Warm, smooth, moist skin
- Unusually fine hair
-
Most common cause of hyperthyroidism
Graves' Disease
-
Triad of Graves' Disease
- Hyperhtyroidism
- Opthalmopathy
- Dermopathy
-
Tx of Hyperthyroidism
- Antithyroid medications
- Radioactive iodine
- Surgical removal of the thyroid gland
-
First line hyperthyroid treatment for children, adolescents and pregnancy
Antithyroid medications usage
-
PTU MOA
Pervents peripheral conversion of T4 to T3
-
SE of Antithyroid Medications
- Agranulocytosis
- Aplastic anemia
- Thrmobocytopenia
- Lupus-like
- Minor: rash, urticaria, fever, transient, leukopenia, GI discomfort
|
|
