Diabetes

Diabetic ketoacidosis

Android (abdomina)

• 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.

• 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

• 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

Yearly urine microalbumin, eye check-up, BP and lipid check with HbA1c q 3 months

• Fasting glucose > 126 mg/dL
• HbA1c > 6.5%

• Sulfonylureas, Metformin, TZDs, GLP1 stimulator, DPP4 inhibitor, dopamine receptor agonist, maglinitide & Amylin.
• Insulin if all else fails and pancreas isn't producing insulin.

• 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

Stimulate pancreas at times of food.  Can cause weight gain.  Most likely of these drugs to cause hypoglycemia.

• 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.

• 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

• 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.

Similar t drug used in Parkinson's pts.  Has an effect on brain that can impove insulin resistance.  Expensive.

Don't use with sulfonylureas.  Good for pts who skip meals.

Damps down glucagon & mildly stimulates pancreas.  Almost like GLP1.  Works even if pancreas doesn't make insulin where other drugs won't.

Relax trx. for several weeks.

decrease glucose production in the liver & increase insulin sensitivity in peripheral body tissues

stimulate the pancreatic beta cells to make more 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)

Hyperglycemia leads to insulin resistance.  After initial treatment with insulin, resistance will improve leading to "honeymoon effect."

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)

• 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