Top 200: Diabetes

  1. What is Diabetes?
    •Blood glucose levels higher than desired

    •Affects >23.6 million Americans

    •1/4 is undiagnosed

    Type 1

    Type 2


    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
  2. Which organs are responsible for ensuring that blood glucose levels are kept stable?
    The pancreas and the liver.

    Image Upload 1
  3. 2011 Standards of Care Classifications
    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)
  4. Measuring Glucose Levels

    –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%

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  5. 2011 Criteria for the Diagnosing of Diabetes
    A1C ≥6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*


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


    • 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.


    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.
  6. Hyperglycemia
    • When blood glucose levels are elevated

    • Symptoms include:

    Increased thirst


    Difficulty concentrating

    Blurred vision

    Frequent urination


    Weight loss
  7. Hypoglycemia
    • Blood glucose levels fall to low levels

    • Stimulates stress in the body

    • Symptoms:






    Pale skin


    –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.

    Image Upload 3
  8. Alcohol and Diabetes
    • •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.
  9. Type 1 Diabetes
    • •Results from the body's failure to produce
    • insulin (from the pancreas)

    •5-10% of Americans

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



    Polyuria: excessive urination

    Polyphagia: excessive hunger

    Polydipsia: excessive thirst

    Fruity breath (ketoacidosis)
  10. Type 1.5 Diabetes
    •Type 1 diabetes develops in someone older

    –Must be >20 years old


    Thin—typically loss of weight over time





    Fruity breath
  11. Type 2 Diabetes
    •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



    –May be asymptomatic



  12. Gestational Diabetes
    •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
  13. Case Example:

    •J.P. comes into your community pharmacy to purchase a glucometer. He tells you he was just diagnosed with diabetes.

    –Fasting Glucose level: 469

    –Age: 25 years of age

    –Presentation: Thin with recent weight loss, excessively thirsty, increased urination, increased hungry
    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.
  14. Medications for Type 2 Diabetes


    •Thiazolidinediones (Glitazones)

    •Alpha-glucosidase inhibitors

    •Dipeptidyl peptidase IV (DPP-IV) inhibitors


    •Incretin mimetics

    •Combination Therapy
  15. Major Classes of Medications: Drugs that sensitize the body to insulin and/or control hepatic glucose production?
    -Thiazolidinediones (TZD)

  16. Major Classes of Medications: Drugs that stimulate the pancreas to make more insulin?


    -DPP-IV Inhibitors

    -Incretin mimetics
  17. Major Classes of Medications: Drugs that slow the absorption of glucose from the gut?
    -Alpha-glucosidase Inhibitors
  18. Major Classes of Medications: Reduces glucose production?
    -DPP-IV Inhibitors

    -Thiazolidinediones (TZD)


    -Sulfonylureas (rate)
  19. Sulfonylureas
    •Sulfonylureas increase endogenous insulin secretion

    •Reduces rate of hepatic glucose production

    •Generally the least expensive class of medication

    Adverse Effects:


    –Weight gain

    Medications in this Class:

    –glyburide (Micronase, Glynase, and DiaBeta)

    –glimepiride (Amaryl)

    –glipizide (Glucotrol, Glucotrol XL)
  20. Thiazolidinediones
    • •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)
  21. AVANDIA®
    (rosiglitazone maleate) Tablets Initial U.S.
    Approval: 1999
  22. Biguanides
    •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)
  23. Meglitinides
    • •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)
  24. Alpha-glucosidase Inhibitors
    •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)
  25. Dipeptidyl-Peptidase 4 (DPP4) Inihibitor
    •Stimulates the beta cell to release insulin.

    •Decreases hepatic glucose production.


    –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)
  26. Incretin Mimetics
    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:

  27. Oral Diabetes Medications



    •Glyburide with Metformin





  28. Insulin
    •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


    •Since the 1920s

    • •Past:
    • made from pork or beef

    •Now recombinant DNA



    Types of Insulin:

    •Rapid acting

    •Short acting

    •Intermediate acting

    •Long acting

    •Combination products


    •Given SQ

    •Proper injection is KEY

    •Can be given IV (only Regular insulin)


    •Stored in fridge or at room temp

    –Unopened vials kept in fridge until expiration date

    –Opened vials good at room temp for 30 days
  29. What is the duration of time for each type of insulin?
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  30. How can Insulin be administered?
    -Via SQ injection

    -Insulin pump
  31. Where should insulin be administered?
    Image Upload 5
  32. Which type of Diabetes requires insulin?
    Type 1 Diabetes

    •Requires Insulin Administration

    •Body does not make enough insulin

    •Many types of insulin on the market
  33. Insulin Drug List
    •Insulin Aspart.

    •Insulin Glargine

    •Insulin Lispro

  34. Useful Website Links for Diabetes

Card Set
Top 200: Diabetes
1/18/2011: Diabetes