1. Potentially fatal side effect of diabetes type 1
    Diabetic ketoacidosis
  2. Body type indicative of metabolic syndrome
    Android (abdomina)
  3. HbA1c
    • Hemoglobin saturation with relative sugar.  This reading tells how diabetes has been controlled over past 3 months.  Strive to keep this number below 8% at worst and 6% at best.  Above 8% they start to have microvascular complications.
    • Aftenoon & evening plasma glucose levels show higher correlations with A1c than morning measurements.
  4. Microvascular complications of diabetes
    • Related to increased glucose at the capillary level which leads to spilling of microalbumin into urine once kidneys are damaged
    • -Leads to retinopathy, neuropathy & nephropathy
  5. Macrovascular complications of diabetes
    • Related to low HDL, high LDL, high BP & hyperlipidemia
    • -Stroke, MI, amputation due to peripheral disease and/or blood clots. 
    • Theses complications occur earlier in people with type 2 diabetes
  6. Standard of care for diabetes pts
    Yearly urine microalbumin, eye check-up, BP and lipid check with HbA1c q 3 months
  7. Diagnosing diabetes
    • Fasting glucose > 126 mg/dL
    • HbA1c > 6.5%
  8. Treatments for Type 2 diabetes
    • Sulfonylureas, Metformin, TZDs, GLP1 stimulator, DPP4 inhibitor, dopamine receptor agonist, maglinitide & Amylin.
    • Insulin if all else fails and pancreas isn't producing insulin.
  9. Metformin (500 mg BID)
    • Improves insulin resistance at liver so pt. doesn't leak glucose.
    • Metabolized in kidneys so pts w/ renal disease can get lactic acidosis.  Withhold for 24 hrs before  CT scan.
    • Contraindications in late HF and liver disease.
    • Take on full stomach - diarrhea & gas otherwise
  10. Sulfonylureas (glyburide, glipizide, glimepiride)
    Stimulate pancreas at times of food.  Can cause weight gain.  Most likely of these drugs to cause hypoglycemia.
  11. TZDs (Pioglitazone - Actos, Avandia not used anymore due to increased risk for heart disease)
    • Improve insulin resistance throughout body & at liver too, but not as much as Metformin.  Actos increases risk of bladder cancer & weight gain w/ fluid retention which can precipitate HF in people with known CHF. 
    • One has been shown to regenerate beta cells in the pancreas at low doses.
    • Require endogenous insulin to work so don't use with type 1 diabetes.
  12. GLP1 stimulator (Byetta) (IM q12h currently, one coming that is injected bi-weekly)
    • GLP1 agonist that leads to more uniformity in gastric emptying with less severe spikes in glucose after meals.  Also decreases glucagon levels and stimulates insulin secretion.
    • Can lead to weight loss.  Can be combined with Metformi & sulfonylureas.
    • Side-effects - PANCREATITIS
  13. DPP4 inhibitor (things that end in -gliptin)
    • GLP1 is broken down by DPP4, by knocking out DPP4, GLP1 isn't metabolized as quickly.
    • Alternative for pts who are opposed to injections in Byetta.
  14. Dopamine receptor agonist (Cyclocet)
    Similar t drug used in Parkinson's pts.  Has an effect on brain that can impove insulin resistance.  Expensive.
  15. Maglinitide (Randin)
    Don't use with sulfonylureas.  Good for pts who skip meals.
  16. Amylin
    Damps down glucagon & mildly stimulates pancreas.  Almost like GLP1.  Works even if pancreas doesn't make insulin where other drugs won't.
  17. After unexplained severe hypoglycemic episode..
    Relax trx. for several weeks.
  18. TZDs & biguanides
    decrease glucose production in the liver & increase insulin sensitivity in peripheral body tissues
  19. Sulfonylureas & meglitinides
    stimulate the pancreatic beta cells to make more insulin
  20. Insulin
    • Regular insulin - lasts 4 hours
    • NPH - lasts 12 hours
    • Long-acting analog - Novalog (Aspart or Lispro)
    • Short-acting bolus - Lantus (Glargin or Detemir)
    • Novolog mix for people who can't tolerate 4 injections per day (70/30)
  21. Glucose toxicity
    Hyperglycemia leads to insulin resistance.  After initial treatment with insulin, resistance will improve leading to "honeymoon effect."
  22. Dawn phenomenon
    During dawn hours (5-8am), the pituitary produced trophic hormones that stimulate target organs to release more cortisol.  This causes increased insulin resistance that may lead to AM hyperglycemia.  A dose of NPH at bedtime may control this.  Presents a problem with Lantus (Glargine)
  23. Sliding scale
    • Glucose 150-200 = 3 units
    • Glucose 201-250 = 5 units
    • Glucose 251-300 = 7 units
    • Glucose 301-350 = 9 units
    • Glucose 351-400 = 11 units
    • Above that, call help
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