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Diabetes - type 1 vs type 2
- 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
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Diabetes - testing recommendations
- Screen: all adults >45 every 3 years; those w/RFs earlier
- Tests: A1c, fasting glu, 2hr OGTT
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Diabetes - glucose tests
- 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)
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DM - Tx categories
Diet & exercise, Oral HGly drugs, Insulin
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DM - Oral HGly drugs, biguanides
- 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
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DM - Oral HGly drugs, α-glucosidase inhibitors
- X: acarbose, miglitol
- M: slows/delays intestinal carb digest/absorb
- S: D, abd pain, flatulence
- C: none - good safety profile
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DM - Oral HGly drugs, sulfonylureas
- X: glyburide, glipizide, glimepiiride
- M: stimulates insulin secretion from β-cells
- S: HoGly, wt gain
- C: sulfa allergy, caution hep/renal impair
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DM - Oral HGly drugs, meglitinides
- X: repaglinide, nateglinide
- M: stimulates acute insulin secretion from β-cells
- S: hypoglycemia
- C: caution hep/renal impair (N), hep impair (R)
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DM - Oral HGly drugs, thiazolidinediones
- 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
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DM - Oral HGly drugs, incretin mim/GLP-1 agon
- 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
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DM - Oral HGly drugs, DPP-4 inhib (/incretin)
- 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
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DM - Oral HGly drugs, amylin analog
- X: pramlintide
- M: Synth amylin, gluc, gastric empty, /satiety
- S: N?V, wr loss, HoGly
- C: HoGly unaware, gastroparesis
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Insulin Tx - indications
- 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
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DM - outpatient mgmt
- 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
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Insulin table - basal
- 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
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Insulin table - bolus
- 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
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Insulin table - mixed
- 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
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Insulin tx - sliding scale
- 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
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Basal insulin - dosing
- 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
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Premixed insulin - dosing
- 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
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Basal-bolus insulin - dosing
- 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
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Bolus insulin - dosing
- Carb ratio & correction/ sensitivity factor
- Carb ratio: 1u I:?15g HCO
- Correct fct: 1u I: ?50mg/dL BG >target
- Mon BG b4 meals & PP
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DM - macrovascular complications
- /athero: /stroke, MI, CHF
- CAD: silent MIs
- PVD: .
- CVAs: .
- TX: RFs (BP, statin, xSmoke, exer); ASA; Gly cntl
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DM - microvascular complications
- 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
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DKA - etiology
- 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
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DKA - S/Sx
- N/V, Abd P
- Kussmaul's, fruity breath
- //dehydr, orthostat HoTN
- tachycardia, weakness
- polydipsia,-uria,-phagia
- AMS
- HGly sx hrs-days (<24hrs)
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DKA - Dx
- 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
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DKA - Tx
- IVF!: +5%Glu@250(~HoGly)
- Ins!: prime w/0.1 u/kg reg, infus 0.1 u/kg/hr
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DKA – etiology
- 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
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DKA - S/Sx
- N/V, Abd P
- Kussmaul's, fruity breath
- //dehydr, orthostat HoTN
- tachycardia, weakness
- polydipsia,-uria,-phagia
- AMS
- HGly sx hrs-days (<24hrs)
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DKA - Dx
- 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
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DKA - Tx
- 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
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HHNS - stands for...
Hyperglycemic hyperosmolar nonketotic syndrome
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HHNS - etiology
- 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.
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HHNS - S/Sx
HGly sxs /dys-wks; thirst, polyuria, HoTN, tachyc, CNS & focal neuro (seiz), AMS mod-sev, leth, confus.
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HHNS - Tx
- 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
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DKA vs HHNS
- 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%
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