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The Facts
- Diabetes is the 7th leading cause of death in the US
- Affects 20.8 million Americans (7% of the population)
- •6.2 million are undiagnosed and have developed complications without being aware of it
- •High risk ethnic population
- African Americans
- Hispanic American
- American Indian
- Asian American
- Asian Pacific Islander
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NEGATIVE FEEDBACK FOR LOW BLOOD GLUCOSE
- LOW BLOOD GLUCOSE
- PANCREAS
- Glucagon released by Alpha cells of Pancreas
- liver released glucose into blood
- ACHIEVE NORMAL BLOOD GLUCOSE LEVEL
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NEGATIVE FEED BACK FOR HIGH BLOOD GLUCOSE
- HIGH BLOOD GLUCOSE
- PANCREAS
- INSULIN RELEASED BY BETA CELLS OF PANCREAS
- FAT CELLS TAKE IN GLUCOSE FROM BLOOD
- ACHIEVE NORMAL BLOOD GLUCOSE LEVEL
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ROLE OF INSULIN
- •Insulin:
- Counters metabolic activity that would increase blood glucose levels
- Enhances transport of glucose into body cells
- Lowers blood glucose levels
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PHYSIOLOGY CONT
INSULIN INJECTION TWO TYPE
- BASAL (CONTINUOUS)
- PRANDIAL (BOLUS)
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HORMONE THAT AFFECT BS
HORMONE DECREASE BG
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HORMONE THAT INCREASE EFFECT ON BG
- GLUCAGON
- EPINEPHRINE
- GLUCOCERTICOIDS
- GROWTH HORMONES
- PROGESTERONE, HPL, CORTISOL
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DIABETES MELLITUS
- •Diabetes Mellitus
- •A disorder of carbohydrate, protein, and fat metabolism resulting from an imbalance between insulin Availability and insulin need. (Porth, 2002)
- End Result : HYPERGLYCEMIA
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CLASSUFICATION OF DM
GASTATIONAL DM
- TYPE 1 IMMUNE MEDIATED
- TYPE 2 INSULIN RESISTANCE
- PRE-DIABETES
- IMPAIRED FASTING GLUCOSE
- IMPAIRED GLUCOSE TOLERANCE
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PHYSIOLOGY GLUCOSE CONTROL
NORMAL PROCESS
- 1 STOMACH CONVERTS FOOD TO GLUCOSE
- 2 GLUCOSE ENTERS BLOODSTREAM
- 3 PANCREAS PRODUCES INSULIN
- 4 GLUCOSE ENTERS BODY EFFECTIVELY
- 5 GLUCOSE LEVELS IN BALANCE
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PATHO DM TYPE I
- 1,STOMACH CONVERTS FOOD TO GLUCOSE
- 2. GLUCOSE ENTERS BLOOD STREAM
- 3. PANCREAS PRODUCES LITTLE OR NO INSULIN
- 4, GLUCOSE UNABLE TO ENTER BODY EFFECTIVELY
- 5 GLUCOSE LEVEL INCREASE
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PATHO CONT; TYPE 2
- 1. STOMACH CONVERTS FOOD TO GLUCOSE
- 2. GLUCOSE ENTERS BLOODSTREAM
- 3. PANCREAS PRODUCES SUFFICIENT INSULIN BUT IT IS RESISTANT TO EFFECTIVE USE
- 4. GLUCOSE UNABLE TO ENTER BODY EFFECTIVELY
- 5.GLUCOSE LEVELS INCREASE
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DM TYPE 1
- No endogenous insulin
- Tx requires insulin injections
- Usually < age 30 yrs. But can occur later
- Ketosis prone
- (DKA)
- Former names: IDDM (Juvenile)
- Diabetes Type 1
- Thin to normal body weight
- Acute metabolic complications
- (DKA)
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DM TYPE 2
- Some endogenous insulin
- Tx diet and exercise 1st, then pills and /or insulin
- Usually over 30yrs. (peaks at 50), but can occur earlier
- no ketosis
- Former names:
- NIDDM (maturity/adult- onset)
- Diabetes Type 2
- Usually Overweight
- Chronic vascular complications
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DIABETES CLINICAL MANIFESTATIONS
HYPERGLYCEMIA
- POLYDYPSIA
- POLYPHAGIA
- POLYURIA
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•Diabetes Clinical Manifestations
Cont: Signs and Symptoms
Early signs
- •3 Polys
- •Weight loss
- •Fatigue/Always tired
- •VisualBlurring
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LATE SIGN
- Late signs
- •Any of the 3 Polys
- •Frequent Infections
- •Numbness/ tingling offeet or leg pain
- •Slow healing wounds
- •Chronic Complications
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SYMPTOMS OF HYPERGLYCEMIA
- EXTREME THIRST
- FREQUENT URINATION
- DRY SKIN
- BLURRED VISION
- DROWSINESS
- NAUSEA
- HUNGER
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DIABETES: DX TESTS
CHECK MD ORDER ACHS
FASTING BLOOD GLUCOSE
FBC < 100MG/DL
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ORAL GLUCOSE TOLERANCE TEST
OGTT <140MG/DL
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GLYCOSYLATED HEMOGLOBIN
HGBA1C 4-6
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DIABETES: DIAGNOSTIC TEST CONT
GLYCOSYLATED HEMOGLOBIN TEST
- MEASURE THE AMOUNT OF GLYCISYLATED HEMOGLOBIN(HEMOGLOBIN THAT IS CHEMICALLY LINKED TO GLUCOSE ) IN THE BLOOD
- NORMAL 4-6 %
- TARGET RANGE DM PT<7%
- Hba1c check every 3 months
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CRITERIA FOR DIAGNOSIS OF DIABETES MELLITUS
- Normal
- –FPG <100 mg per dL
- –2hr OGTT <140 mg per dL
- Diabetes- positive findings from any two of the following tests on different days:
- –Symptoms of diabetes mellitus* plus casual
- (random) plasma glucose concentration >=200 mg / dL
- or
- –FPG >=126 mg per dL OR
- 2hr OGTT >=200 mg per dL after a 75-g glucose load
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PRE DIABETES
GLUCIDELINES FOR DX OF IFG AND IGT ARE
- –Impaired Fasting Glucose (IFG)
- •FPG> 100 mg/dL but < 126 mg/dL
- –Impaired Glucose Tolerance
- •2 hr PC > 140 mg/dL but < 200 mg/dL
- •Or 2 hr ogtt > 140 mg/dL but < 200 mg/dL
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DIABETES
- DIABETES IS A GROUP OF METABOLIC DISEASE CHARACTERIZED BY
- HYPERGLYCEMIA RESULTING FORM DEFECTS IN INSULIN SECRETION, INSULIN ACTION, OR BOTH
- LONG TERM DAMAGE, DYSFUNCTION, AND ORGAN FAILURE ASSOCIATED WITH CHRONIC HYPERGLYCEMIA ESCPECIALLY
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DM FOR ORGAN
EYE
KIDNEY
NERVES
HEART AND BLOOD VESSELS
- DIABETIC RETINOPATHY
- DIABETIC NEPHROPATHY
- DIABETIC NEUROPATHY
- ATHEROSCLEROSIS, HTN, CARDIO AND CEREBROVASCULAR DISEASE
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LEADING CASES OF DM
- NEW CASES OF BLINDNESS
- END STAGE RENAL DISEASE
- FOOT OR LEG AMPUTATION
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ACUTE COMPLICATION
TYPE 1
- DIABETIC KETOACIDOSIS(DKA)
- BS>300 MG/DL
- CLASSIC SYMPTOMS
- KETOSIS
- CHECK URINE FOR KETONES IF BS>300 MG/DL
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ACUTE COMPLICATION EMERFENCIES
TYPE 2
- HYPERGLYCEMIC HYPEROSMOLAR NON KETOTIC SYNDROME (HHNS)
- BS>600MG/DL
- SIMILAR SYMPTOMS
- NO KETOSIS
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SICK DAY RULES
- CHECK BG MORE FREQUENTLY( Q4H)
- TEST URINE TO KETONES IF BS CONSISTENTLY HIGH >300MG/DL
- CONTINUE WITH INSULIN AND ORAL HYPOGLYCEMICS
- DRINK 8-12 GLASSES OF WATER
- EAT MEALS AT REGULAR TIMES(SUBSTITUTE WITH HIGH CALORIE DRINKS IF EXPERIENCING ANOREXIA)
- GET REST
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ACUTE COMPLICATIONS CONT
HYPOGLYCEMIA TOO MUCH INSULIN OT TOO LITTLE GLUCOSE
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THE MAJOR DIABETIC COMPLICATION
1EYES
2HEART AND CORONARY CIRCULATION
3KIDNEY
4LOWER LIMBS
5BRIAN AND CEREBRAL CIRCULATION
6PERIPHERAL NERVOUS SYSTEM
7DIABETIC FOOT
- 1RETINOPATHY
- 2CORONARY HEART DISEASE
- 3NEPHROPATHY
- 4PERIPHERAL VASCULAR DISEASE
- 5CEREBROVASCULAR DISEASE
- 6NEUROPATHY
- 7ULCERATION AND AMPUTATION
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EFFECT ON BLOOD VESSELS
- HIGH LEVEL OF GLUCOSE
- PLAQUE IN ARTERY WALL
- BLOOD CLOT
- LEFT ANTERIOR DESCENDING ARTERY
- RIGHT CORONARY ARTERY
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CHRONIC COMPLICATION MACROVASCULAR
- CARDIOVASCULAR
- HEARTDISEASE/MI
- CEREBROVASCULAR
- STROKE
- DM PTS HAVE HEART DISEASE AND STROKE ROSKS 2 TO 4X HIGHER THAN NON- DM PTS
- PERIPHERAL VASCULAR DISEASE
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CHRONIC COMPLICATION OF MICROVASCULAR
- DIABETIC RETINOPATHY
- NORMAL RETINA
- MACULA OPTIC DISK
- RATINOPATHY
- HEMORRAGE ANEURYSMS
THE LEADING CAUSE OF NEW CASES OF BLINDNESS IN ADULTS AGES 20-74
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CHRONIC COMPLICATION MICROVASCULAR
- FOR MICROALBUMINURIA
- GLIMERULUS
- SCLEROTIC AFFERENT AND EFFERENT ARTERIOLES
- SCLEROTIC RENAL ARTERY
THE LEADING CAUSE OF ESRD OCCOUR IN ABOUT 20-40% OF PATIENTS WITH DIABETES
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DIABETIC NEUROPATHY MICROVASCULAR
- Diabetic Neuropathy - the poor blood supply will cause the nervous system to malfunction
- NERVES SHRIVEL WHEN BLOOD VESSELS DISAPPEAR
- DUE DISEASE BLOOD VESSELS
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FOR DM PT FOOT
- BLOOD VESSEL DAMAGE IN THE FEET MAY CAUSE TISSUE DAMAGE
- GANGRENE
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MICROVASCULAR FOR SEXUAL PROBLEMS
- SEXUAL PROBLEMS FOR MEN
- EXECTILE DYSFUNCTION
- Sexual problems for women
- decreased vaginal lubrication
- decreased sexual response
- •Urologic problems for men and women
- urinary tract infections neurogenic bladder
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MICROVASCULAR
GASTROPARESIS
NERVE DAMAGE TO THE DIGESTIVE SYSTEM MOST COMMONLY CAUSES CONSTIPATION. DAMAGE CAN ALSO CAUSE THE STOMACH TO EMPTY TOO SLOWLY
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METABOLIC SYNDROME
- Metabolic Syndrome
- Syndrome X
- •Presence of metabolic factors that increase risk of developing DM 2 and CV disease
- –Central obesity – apple shape (45 inches or more in men, 35 inches or more in women)
- –Hyperglycemia
- –HTN (> 130/85 mh/dL)
- –Dyslipidemia
- (Trig > 150 mg/dL; HDL < 40 mg/dL for men or < 50 mg/dL for women)
- –Teach re: ABC (A1c, Blood pressure, cholesterol control)
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MANAGEMENT OF DM
- REGULAR BG MONITORING
- SELF MONITORING BLOOD GLUCOSE(SMBG)
- DRUG THERAPY
- DIET
- EXEERCISE
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GLYCEMIC DIET
- FRUITS, VEG, COOKED OR DRESSED WOTH HEALTHFUL OIL)
- REDUCED FAT DAIRY LEAN PROTEIN NUTS AND LEGUMES
- UNREFINED GRAINS AND PASTA
- REFINED GRAINS POTATO AND SWEETS
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DIET CONT
GETTING THE BALANCE RIGHT
- BIG PORTION FOR VEG AND FRUITS
- PROTEIN
- CANDY
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•Alcohol and DM
- Can affect BG levels
- Alcohol inhibits liver
- glucose production
- Potential for alcohol
- induced hypoglycemia
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MANAGEMENT:EXERCISE
- Helps regulate blood glucose
- Increases insulin effectiveness and
- sensitivity in the body.
- Must monitor insulin and food intake to match
- exercise regimen.
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ASSESSMENT TO DM
- Check BG prior to administering any insulins or oral hypoglycemic agents
- Monitorbefore meals and within 2 hours post prandial (PP)
- Correction dose (with rapid or short acting insulins) given to treat blood glucose elevations
- Common BG monitoring and correction dose frequency- (ACHS) but can be done more often
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DRUG THERAPY AND TYPE OF INSULIN
- •Fast-acting insulin
- –Rapid Acting Insulin Analogs
- •Aspart, Lispro, Glulisin
- –Regular Human Insulin
•Intermediate-acting insulin - –NPH Human Insulin•Novolin N/Relion N, Humulin N
- –Pre-Mixed Insulin
- •Humulin 70/30, Humalog 75/25, etc.
- •Long-acting insulin
- Insulin Glargine, Insulin Detemir
- BOLUS USED TO LOWER BLOOD SUGAR AFTER EATING A MEAL
- BASAL USED TO LOWER BLOOD SUGAR THROUGHOUT THE DAY AND NIGHT
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•Drug Therapy Cont.: Insulin
- Onset - how soon it starts to work in the blood
- Peak - when the insulin has the greatest effect on blood sugar levels
- Duration – how long it keeps working
- Each insulin has its strengths and may be appropriate in different pt circumstances
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Drug Therapy-Insulin Cont:Rapid Acting Insulin Analogues “Logs”
- Humalog (insulin lispro)
- Novolog (insulin aspart)
- Apidra (insulin glulisine)
- •Bolus insulin
- •Ideal for meal
- coverage
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Drug Therapy-Insulin Cont:
Short Acting: Regular
Insulin regs
- • Bolus insulin
- Humulin R
- NovolinR/ReliOn R
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Drug Therapy-Insulin
Cont: Rapid Acting
(Humalog/Novolog) VS.
Short Acting (Regular Insulin)
- rapid onset 15 min
- peaks faster limited duration 3-5 h
- short acting
- delayed onset peaks in 2-4 hr
- lasts 5-7 hours
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Drug Therapy-Insulin Cont:
Intermediate acting:NPH Insulin
- Basal insulin: covers blood sugar between
- meals
- Satisfies overnight insulin requirement
- Need snack if NPH given at 5 pm (only)
- Ideal to be given at 9 pm (HS) to address Dawn Phenomenon
- 5 in morning growth hormone release that increase blood sugar
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hypoglycemia s/s
hypoglycemia
- H headache
- I irritable/imparied vision
- W weakness/fatigue
- A anxious
- Sshaking/sweating
- H heartbeat
- dizziness
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•Drug Therapy-Insulin Cont:Hypoglycemia
•BS <60- 70 mg/dL
- An acute complication
- •Causes
- •Tx:
- (15/15 or 20/20 Rule)
- Give 15/20 g simple carb and recheck BG in 15/20 minutes
- 15g check in 15 min
- 4oz oj and couple candy
20g check in 20 min
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•Drug Therapy-Insulin Cont:L ong-Acting: Peakless Insulins!!!
- Lantus (insulin glargine)
- Levimir (insulin detimir)
- •Basal Insulin
- •No risk for hypoglycemia
- •Do not mix with other insulins – becomes inactivated when mixed with other insulins
- Peakless insulins are late
- Lantus(glargine) and levimir(detimir)
- When long acting insulin come out they try to gave at night. And 20-24 hour
- coverage.
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AMYLIN
- –A naturally occuring hormone secreted with insulin by
- the beta cells
- –action similar to insulin, responds to blood glucose elevation
- –Amylin levels found to be decreased in DM type 1 pts
- ANALIGUES
- •Symlin: Synthetic analogue of human amylin
- –Approved for use with insulin in adults with type 1 and type 2 diabetes
- –Delays gastric emptying, reduces after meal BG levels, triggers sateity
–Do not mix with insulin in one syringe
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INCRETIN HORMONE GLP-1
- •Incretin hormone GLP-1
- –Secreted once food is in the stomach
- –Increases insulin secretion
- –Inhibits glucagon secretion
- –Slows the rate of gastric emptying
- –Prevents hyperglycemia after meals
- –Pts with DM2 found to have reduced incretin effect
- •Byetta:Synthetic incretin(GLP-1) mimetic hormone
- –Indicated for patients with type 2 diabetes who don’t use insulin
- –Delays gastric emptying, slows nutrient absorption, reduces food intake (decreasing BG)
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•Insulin Administration
- •Rotate injection site- prevents lipodystrophy
- (hypertrophy and atrophy)
- •Rotate within one anatomic site (rather than
- from one site to another)
- •Abdomen site- most rapid absorption
- Atrphy loss of tone
- Hypertrophy too much
- Abdomen is most rapid site absorption
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DRUG THERAPY CONT: OTHER METHOD OF ADMINSITRATION
- Insulin pump are used to controlled,
- Disadvange
- infection and site they have to change every
- 2-3 day, but do body follow that
- Pt use waterproof cover if they want to swimming
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•Drug Therapy Cont:Other Methods of Administration-Insulin pens
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•Small lightweight prefilled insulin cartridges
- Dial insulin
- Most accurate but expensive
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•Continuous IV insulin infusion
- •Used to maintain glycemiccontrol in hospitalized patients with high blood glucose levels; in DKA and
- HHNS
- •Regular insulin may be used IV
- •May also be given preoperatively or postoperatively
- •More frequent BS monitoring ( q1-2 hours per agency protocol)
Acute stage insulin gave as insulin drip for icu/ccu
Continous drip
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•Oral Antidiabetic agents
- •Oral Agents
- –Modify insulin secretion
- –Modify insulin sensitivity
- –Modify glucose
- absorption/secretion
•
•
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Sulfonylureas
meglitinides
- Sulfonylureas stimulate the pancreas to produce more insulin thesedrugs assist insulin in moving glucose into cell.
- Drugs
- acetphexamide
Chlorpropamide (diabinese) glimepiride(amarly) glipizide(glucotrol) glyburide(micronase, diabeta)
meglitinides
No risk for hypoglycemina by metformin
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new oral med
- januvia(sitagliptin) DPP INHINITOR
- An oral drug that reduces blood sugar levels in patients with type 2 diabetes.
- –DPP-4 increasesBG- its inhibition leads to
- decreased BG
- – Sitagliptin is the first approved member of
- a class of drugs that inhibit the enzyme, dipeptidyl
- peptidase-4 (DPP-4)
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DRUG THERAPY
•BS <60- 70 mg/dL
- •An acute complication
- •Causes
- •Tx:
- (15/15 or 20/20 Rule)
–Give 15/20 g simple and recheck BG in 15/20 minutes
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•Dawn phenomenon
•Somogyieffect
•Neuroglycopenic symptoms
- Dawnphenomenon:high fasting blood sugar
- level in the morning due unrecognized hypoglycaemic episode during the night in a person with diabetes due
- to hormone
- Somogyi effect Somogyieffect or chronicSomogyi rebound is a rebounding
- high blood sugar that is a response to low blood sugar.[1] In context of
- managing the blood glucose level manually with insulin injections, this effect
- is counter-intuitive to insulin users who experience high blood sugar in the
- morning as a result of an overabundance of insulin at night
- Neuroglycopenic symptomsis a medical term that
- refers to a shortage of glucose (glycopenia) in the brain, usually due to hypoglycemia. Glycopenia affects the functionof neurons, and alters brain function and behavior. Prolonged neuroglycopenia can result in
- permanent damage to the brain
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Diabetic TeachingNeeds
- Disease process
- S/S of hyperglycemia and hypoglycemia
- Blood sugar monitoring
- Diet
- Exercise
- Drug therapy
- Sick Day Rules
- Complications (acute and chronic)
- Prevention: Foot care, eye exam etc.
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Preventionof Complications…
Tight BS control
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