Top 200: Diabetes

•Blood glucose levels higher than desired

•Affects >23.6 million Americans

•1/4 is undiagnosed

•Type 1

•Type 2

•Gestational

•Pre-diabetes (impaired) 100-125 mg/dl

•Fasting levels >126 mg/dl

•Metabolism disorder

•Food : glucose : energy/fuel

•Glucose use requires the presence of insulin

•Pancreas (beta cells) produces insulin

• •When insulin is not present, too much glucose
• builds up in blood, and overflows into urine

•Finding balance

The pancreas and the liver.

Type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency)

Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance)

Other specific types of diabetes due to other causes, e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced (such as in the treatment of HIV/AIDS or after organ transplantation)

Gestational diabetes mellitus (GDM) (diabetes diagnosed during pregnancy that is not clearly overt diabetes)

•Glucometers

–Requires blood sample

–Prick finger several times a day

–desired glucose levels are 70-110 mg/dl

•Hemoglobin A1c

–Measures glycosylated hemoglobin

–Glucose binds to hemoglobin A (for the life of the cell ~120 days)

–Evaluates the average amount of glucose in the blood over the last 2 to 3 months

–Goal <6.5%

A1C ≥6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*

or

FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.

or

• 2-h plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using
• a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

or

In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dl (11.1 mmol/l). Essentially, this test means that if you take a random blood glucose test and your blood sugars are greater than or equal to 200 mg/dl, you could be diagnosed with diabetes on the spot.

• When blood glucose levels are elevated

• Symptoms include:

–Increased thirst

–Headaches

–Difficulty concentrating

–Blurred vision

–Frequent urination

–Fatigue

–Weight loss

• Blood glucose levels fall to low levels

• Stimulates stress in the body

• Symptoms:

–Hot

–Sweaty

–Shaky

–Dizzy

–Headache

–Pale skin

•Treatment:

–Get glucose on board (glucose tablets, candy)

–In an emergency use a glucagon kit which contains:

• 1 mg of freeze dried glucagon (vial)
• 1 mL of of reconstitution (syringe)

Combine glucagon and water immediately before use and discard any unused portion after injection.

Store at room temperature. Monitor for expiration date.

• •Alcohol should be avoided in patients with
• diabetes

–Increases risks of low blood sugar

–Alcohol is a toxin

–The liver reacts to alcohol like a poison. It will clear it from the blood quickly. The liver won't produce any glucose again until it has taken care of the alcohol.

• •Results from the body's failure to produce
• insulin (from the pancreas)

•5-10% of Americans

•Diagnosed in children or young adults (<20 yo)

•Presentation:

–Thin

–Polyuria: excessive urination

–Polyphagia: excessive hunger

–Polydipsia: excessive thirst

–Fruity breath (ketoacidosis)

•Type 1 diabetes develops in someone older

–Must be >20 years old

•Presentation:

–Thin—typically loss of weight over time

–Fatigue

–Polyuria

–Polyphagia

–Polydipsia

–Fruity breath

•Most common form

•Often occurs later in life (~40+ years old)

•Some patients fail to make enough insulin

•Others make enough or too much insulin

–Insulin resistance

–Cells won’t take up the insulin for use

•Presentation:

–Obese

–May be asymptomatic

–Polydipsia

–Polyphagia

–Polyuria

•Diabetes while pregnant

•Affects 4% of all pregnant women

•Often goes away after the baby is born

•Small % continue to have diabetes after giving birth

Type 1.5 Diabetes

J.P. is over 20 years old and therefore would not fit into the Diabetes Type 1 category. Yet, he also doesn't qualify for Diabetes Type 2 because of his thin profile.

•Sulfonylureas

•Biguanides

•Thiazolidinediones (Glitazones)

•Alpha-glucosidase inhibitors

•Dipeptidyl peptidase IV (DPP-IV) inhibitors

•Meglitinides

•Incretin mimetics

•Combination Therapy

-Thiazolidinediones (TZD)

-Biguanides

-Sulfonylureas

-Meglitinides

-DPP-IV Inhibitors

-Incretin mimetics

-Alpha-glucosidase Inhibitors

-DPP-IV Inhibitors

-Thiazolidinediones (TZD)

-Biguanides

-Sulfonylureas (rate)

•Sulfonylureas increase endogenous insulin secretion

•Reduces rate of hepatic glucose production

•Generally the least expensive class of medication

•Adverse Effects:

–Hypoglycemia

–Weight gain

•Medications in this Class:

–glyburide (Micronase, Glynase, and DiaBeta)

–glimepiride (Amaryl)

–glipizide (Glucotrol, Glucotrol XL)

• •Decrease insulin resistance by making muscle
• and adipose cells more sensitive to insulin.

•Suppress hepatic glucose production.

•6 weeks for maximum effect

•Improves HDL cholesterol and plasma triglycerides; usually LDL neutral

•Adverse Effects:

–Weight gain, edema

–Hypoglycemia (if taken with insulin or agents that stimulate insulin release)

–Contraindicated in patients with abnormal liver function or CHF

•Medications in this class:

•pioglitazone (Actos)

•rosiglitazone (Avandia)

Why?

•Decrease hepatic glucose production

•Increase insulin-mediated peripheral glucose uptake.

•Adverse Effects:

–Diarrhea and abdominal discomfort

–Lactic acidosis if improperly prescribed

•Medications in this class:

•Metformin (Glucophage, Glucophage XR)

• •Stimulate insulin secretion (rapidly and for
• a short duration) in the presence of glucose.

•Other Effects:

–Hypoglycemia (although may be less than with sulfonylureas if patient has a variable eating schedule)

–Weight gain

•Medications in this class:

•Repaglinide (Prandin)

•Block the enzymes that digests glucose in the small intestine (delays glucose uptake)

•Take with food!!

•Adverse Effects:

–Flatulence or abdominal discomfort

•Medications in this class:

•acarbose (Precose)

•miglitol (Glyset)

•Stimulates the beta cell to release insulin.

•Decreases hepatic glucose production.

•Efficacy:

–Decrease fasting blood glucose 10-15 mg/dl

–Decrease A1C 0.5-0.6%

–Decrease post-prandial glucose 50 mg/dl

•Adverse Effects:

–GI side effects

•Medications in this class:

•Januvia (Sitagliptin)

•Incretin: hormone in the gut which act on the pancreas to increase insulin production

•Stimulates pancreas to make more insulin

•Increases B-cell growth/replication

•Treats type 2 diabetes

•Administered SQ

•Medications in this class:

•Byetta

•Glimepiride

•Glipizide

•Glyburide

•Glyburide with Metformin

•Metformin

•Pioglitazone

•Rosiglitazone

•Sitagliptin

•Exenatide

•Is a hormone and a protein

•Secreted by the islet cells of the pancreas

•Is a necessary hormone

•Binds to cells to allow glucose from the body to be absorbed

•Excess insulin stimulates your fat cells to store more fat—causes weight gain

History:

•Since the 1920s

• •Past:
• made from pork or beef

•Now recombinant DNA

–Biosynthetic

–Semisynthetic

Types of Insulin:

•Rapid acting

•Short acting

•Intermediate acting

•Long acting

•Combination products

Administration:

•Given SQ

•Proper injection is KEY

•Can be given IV (only Regular insulin)

Storage:

•Stored in fridge or at room temp

–Unopened vials kept in fridge until expiration date

–Opened vials good at room temp for 30 days

-Via SQ injection

-Insulin pump

Type 1 Diabetes

•Requires Insulin Administration

•Body does not make enough insulin

•Many types of insulin on the market

•Insulin Aspart.

•Insulin Glargine

•Insulin Lispro

•Insulin

www.diabetes.org

www.joslin.org/info/oral_diabetes_medications_summary_chart.html

www.diabetes.about.com/od/equipmentandbreakthroughs/a/med_ref_chart.htm