IM DM

• Type 1        Type 2
• 5-10%        90-95%
• 90% β-cell   ()->FFA->resist
• ins to live     β-cell desens
• HLA assoc    None
• Sxs dys-wks Discov in UA
• Acute DKA   Complications

• Screen: all adults >45 every 3 years; those w/RFs earlier
• Tests: A1c, fasting glu, 2hr OGTT

• Test          tol        DM
• Rand         N/A    >200w/sx
• Fast8h    110-126 >126 x 2
• 2hPP75g 140-200 >200
• HgbA1c   5.7-6.4  >6.5(mo)

Diet & exercise, Oral HGly drugs, Insulin

• X: metformin
• M: inhib hepatic glucose prod <- insulin; targets fasting BG, LDL, TG
• S: wt loss, GI probs, lactic acidosis (rare)
• C: renal dz, hepatic dz, Cr>1.5, contrast/surg

• X: acarbose, miglitol
• M: slows/delays intestinal carb digest/absorb
• S: D, abd pain, flatulence
• C: none - good safety profile

• X: glyburide, glipizide, glimepiiride
• M: stimulates insulin secretion from β-cells
• S: HoGly, wt gain
• C: sulfa allergy, caution hep/renal impair

• X: repaglinide, nateglinide
• M: stimulates acute insulin secretion from β-cells
• S: hypoglycemia
• C: caution hep/renal impair (N), hep impair (R)

• X: pioglitazone
• M: /insulin sens in liver & peripheral tissues
• S: edema, wt gain, CHF, bone fxs
• C: CHF class III/IV, hep dz, EtOH abuse

• X: exenatide, liraglutide
• M: Activate GLP-1 receptors, stim glucose-depend insulin prod, inhib glucagon after meals
• S: N/V, wt loss, ?acute pancreatitis
• C: ESRD, FHx MEN/medul Thy CA, hx pancreatitis

• X: sitagliptan, saxagliptan, linagliptan
• M: Inhib DPP-4 enz, restore incretin to /ins, gluc, & delay gastric emptying
• S: not significant unless used w/sulfonylurea
• C: Dose in renal dz with S&S

• X: pramlintide
• M: Synth amylin, gluc, gastric empty, /satiety
• S: N?V, wr loss, HoGly
• C: HoGly unaware, gastroparesis

• T1DM: always
• T2DM: w/FPG>250, A1c>10%, +urinary ketones
• symptomatic: wt loss, polyuria, polydipsia
• HGly: despite 2 ~DM meds at max eff dose
• /insulin rqmts: illness, infection, glucocorticoids
• CI to meds: renal insuf, CHF, preg, allergy, SEs

• monitor: {3mo} A1c (<7.0);                           {1yr} microalbumin (ACEI/ARB if +), BUN, Cr, eye screen, cholesterol (statin if LDL>100)         {visit} feet (hi-risk->pod), BP (ACEI/ARB if >130/80)
• @home: check glucose AC, 90-120 PC, bedtime; feet for ulcers/neuropathy; daily ASA 30+
• Vaccine: Pneumococcal

• Tp    NPH  Glargine  Detemir
• Br   NovN  Lantus    Levemir
•      HumN
• On   2-4hr   2-4hr    3-8hr
• Pk   4-10hr   none    none
• Dr 10-16hr  /24hr    /24hr
• Ds  am+pm  once     once
• hG   more    less      less
• Wt  more     less      least

• Tp  Regular    Asp/Lisp/Glul
• Br Nov/HumR Nov/Hum/Api
• On  30-45min    5-15 min
• Pk     2- 3hrs    30-90 min
• Dr     4- 8hrs      3- 4 hrs
• Ds  30-45mAC    5-15 mAC
• hG    more            less
• xc     more            less

• Human insulin
• Humulin/Novolin 70/30: NPH, regular             (onset 30 min, duration 10-16 hrs)
• Humulin 50/50: NPH, regular
• Analog insulin
• Humalog 75/25: protamine lispro, lispro
• Humalog 50/50: protamine lispro, lispro
• Novolog 70/30: protamine aspart, aspart

• Regular insulin adjustments on top of intermediate-acting insulin
• Monitor before breakfast and before bed
• Reg: start 2/3 before breakfast, 1/3 before bed
• 150-200: 2 units
• 201-250: 4 units
• 251-300: 6 units
• 301-350: 8 units
• >400: call somebody

• 10 units @ bedtime
• adjust on 3-day avg FBG
• <80 -3u; >110 +3u
• >= 0.5 u/kg, add meal ins
• FBG<120 & A1c high->2hPP

• 5u pre-bkfst, 5u pre-supper
• Adj pre-supper on 3 FBG
• Adj pre-bkfst on 3 pre-sup
•       <80: -2u
•  80-110: nc
• 111-140: +2u
• 141-180: +4u
•      >180: +6u

• 50/50 (10-20% per meal)
• Adding bolus, basal 10%
• Start bolus 10% //basal
• Adj to 3-day 2hPP
•      <100: -2u
• 100-140:  nc
• 141-179: +1u
•      >180: +2u

• Carb ratio & correction/ sensitivity factor
• Carb ratio: 1u I:?15g HCO
• Correct fct:                      1u I: ?50mg/dL BG >target
• Mon BG b4 meals & PP

• /athero: /stroke, MI, CHF
• CAD: silent MIs
• PVD: .
• CVAs: .
• TX: RFs (BP, statin, xSmoke, exer); ASA; Gly cntl

• Diabetic nephrop: -> ESRD (scrn microalb, tx ACEI/ARB)
• Diabetic retinop: scrn/yr, ?photocoag tx
• Diabetic neurop: periph neurop, CN complic, mononeurop, autonomic neurop (NSAIDs, TCAs, gabapentin); gastroparesis (metaclopramide)
• Diabetic foot: best tx prevention

• acute,life-threat med emerg
• T1DM >> T2DM
• 2/2 ins & /glucagon -> /sev HGly & /ketogenesis
• sev HGly->osmotic diuresis -> dehydr & vol
• precip Fs: infect, trauma, MI, stroke, surg, sepsis, GIB, inadeq ins admin

• N/V, Abd P
• Kussmaul's, fruity breath
• //dehydr, orthostat HoTN
• tachycardia, weakness
• polydipsia,-uria,-phagia
• AMS
• HGly sx hrs-days (<24hrs)

• HGly: 450<Glu<850
• Metabolic acidosis
• - pH<7.3, bicarb<15-18
• - /AG
• - ketonemia/-uria (//acetoacetate, acetone, B-hydroxybutyrate)
• - ketonemia & acidosis req!
• - HOsm,HoNa,HoP,HoMg,HK

• IVF!: +5%Glu@250(~HoGly)
• Ins!: prime w/0.1 u/kg reg, infus 0.1 u/kg/hr

• acute,life-threat med emerg
• T1DM >> T2DM
• 2/2 ins & /glucagon -> /sev HGly &
• /ketogenesis
• sev HGly->osmotic diuresis -> dehydr &
• \vol
• precip Fs: infect,
• trauma, MI, stroke, surg, sepsis, GIB, inadeq ins admin

• N/V, Abd P
• Kussmaul's, fruity breath
• //dehydr, orthostat HoTN
• tachycardia, weakness
• polydipsia,-uria,-phagia
• AMS
• HGly sx hrs-days (<24hrs)

• HGly: 450<Glu<850
• Metabolic acidosis
• - pH<7.3, bicarb<15-18
• - /AG
• - ketonemia/-uria (//acetoacetate, acetone, B-hydroxybutyrate)
• - ketonemia & acidosis req!
• - HOsm,HoNa,HoP,HoMg,HK

• IVF!: +5%Glu@250(~HoGly)
• Ins!: prime w/0.1u/kg reg, infus 0.1u/kg/hr
• until: AG closes, metab acid corrected, urine ketones resolve
• then: ins, Xition to SC when eating
• HoK!: in 1-2hrs prophyl IV if urine
• Misc: balance lytes; bicarb controversial

Hyperglycemic hyperosmolar nonketotic syndrome

• Def: State of severe HGly, HOsm, dehydr'n
• MC: Elderly T2DM
• Path: vIns->sev HGly -> Osm diuresis -> dehydr. Resid Ins glucagon -> ketogen & acidosis. Pt can't drink enough.

HGly sxs /dys-wks; thirst, polyuria, HoTN, tachyc, CNS & focal neuro (seiz), AMS mod-sev, leth, confus.

• IVF: 1L ns 1st hr, 1L next 2 hrs, stable .5ns; cont Ins, Glu=250, add 5% Glu
• Ins: IV bolus 5-10u, cont infus 2-4u/hr
• Lyte: Tx disturb, esp K

• DvsH       DKA                     HHNS
• Path  I->ket,pH,deh  Ins->HOsm,diur,deh
• Lab G>450,pH<7.3,Kt G>900,O>320,pH>7.3
• Tx        Ins, IVF, K         /IVF, low dose Ins
• Mort        5-10%                   10-20%