Endocrinology 3

Diabetic coma; DKA

Pronounced hyperglycemia with insulin deficiency

Hyperglycemia > 250 mg/dL or glycosuria 4+ ; Acidosis with blood pH < 7.3; Serum bicarb < 15 mEq/L; Serum positive for ketones

Ocular comps; Nephropathy; Peripheral neuropathy; CVD (Heart dz; PVD)

DKA

Retinopathy; Cataracts; Glaucoma; pts w/ DM need an annual ophthalmologic exam

Small blow-out swellings of blood vessels

Small leaks of fluid from damaged blood vessels

Small bleeds from damaged blood vessels

may become blocked, causing reduced blood & oxygen supply to small sections of the retina; New abnml vessels may grow from damaged vessels (AKA proliferative retinopathy); new vessels are delicate & bleed easily

urine microalbumin

dipstick protein

albumin:creatinine (A:C) ratio

nocturnal systolic blood pressure

renal transplant more promising than dialysis (if patient eligible)

Neuropathy

Distal symmetrical polyneuropathy with loss of motor & sensory function, esp. of long nerves

Painful diabetic neuropathy with hypersensitivity to light touch; Diabetic gastroparesis; Erectile dysfunction

Painless due to peripheral neuropathy; pt unaware unless vigilant with & able to do self exams; Prone to infection & enlargement

10g monofilament test ; Comprehensive foot exam

Funduscopic exam by optometrist or ophthalmologist for retinopathy

No need to screen asymptomatic adults with BP ≤135/80; Should screen adults with HTN (sustained BP >135/80)

sero autoimmune markers of pancreatic islet dysfn and genetic markers

Peripheral insulin resistance in mx & fat; Decreased pancreatic insulin secretion; Increased hepatic glucose output

FH; Age > 45; High-risk ethnic pop; Habitual physical inactivity; Meds (transplant, HIV, anti-psychotics); Obesity

fat cells = endocrine organs

A1C <7.0%; Preprandial capillary plasma glucose 70–130 mg/dL; Peak postprandial cap plasma glu <180 mg/dL; More or less stringent glycemic goals may be appropriate for individual patients.

Dx s/b made if A1c <6.5; s/b confirmed w/ repeat test; not nec for sx pt w/plasma glu ≥200 mg/dL

receive demonstrably effective preventive interventions

Polyuria; Polydipsia; Wt loss; Fatigue; Sometimes blurred vision; Susceptibility to infxn; May be asymptomatic, esp Type 2

serum glu >180 mg/dL (exceeds renal threshold for glu, which leads to increased urinary glu excretion)

osmotic diuresis (ie, polyuria) and hypovolemia

enhanced thirst because of increased serum osmolality from hyperglycemia & hypovolemia

hypovolemia and increased catabolism

Insulin def in DM kids impairs glucose utilization in sk mx & increases fat / mx breakdown; initially, appetite is incd; over time, kids may become anorexic, contributing to wt loss

Type 2 DM

DKA; Nonketotic hyperosmolar syndrome (high blood viscosity; pts w/this syndrome usu have extremely high blood glucose)

DKA ( 4.6-8 episodes per 1000 pts w/ DM); hyperglycemic hyperosmolar syndrome (HHS: < 1% of all primary DM admissions)

DKA tx = 1 in 4 healthcare dollars for direct spend on T1DM pts; 100k hosps / yr for DKA; $13,000 / DKA pt; >1B dollars / yr

Hyperglycemia; Ketonemia; Acidemia

“the worse I ever felt”; N/V; Weak; Lethargy; Fruity Breath; Abd Pain; Hyperventilation

Insulin def: Inc lipase activity increases breakdown of TGs to glycerol & free fatty acids (= precursors to ketone bodies)

continuous insulin drip (monitor) (MOST IMPORTANT); Fluids; Potassium; EKG;

Acanthosis nigricans, skin tags

PCOS (polycystic ovarian syndrome): hirsutism

CVD

occurs in 20–40% of DM pts

Diabetic nephropathy

the duration of diabetes

Diabetic retinopathy

Specific tx for underlying nerve damage: not available; only improved glycemic ctrl (may slow progression but rarely reverses neuronal loss)

16 individual sessions with a registered dietitian (RD)

Minimum of 1 session every other month with RD; additional support as needed

Review food & activity records; Problem-solve difficulties; Praise participant's effort

modest wt loss reduces incidence of new-onset DM in at-risk popn

Aspirin; ACEI; A1C control

Beta-blockade; BP control

Chol mgmt

Diet; do not smoke; decrease DM risk

Exercise

WBC function & facilitates wound healing;

multi dose insulin injxns (3–4 / day of basal & prandial insulin) or CSII tx ; matching prandial insulin to CHO intake, pre-meal blood glu, & anticipated activity; for many pts (esp if hypoglycemia is problem), use of insulin analogs

(when used in adequate doses) decrease any level of elevated A1C to, or close to, the therapeutic goal

Unlike other blood glucose–lowering medx, there is no max dose of insulin beyond which a tx effect will not occur

Relatively lg doses of insulin (1 unit/kg), cf w/ those required to tx T1DM, may be necessary to overcome the insulin resistance of T2DM and lower A1C to the target level

Lispro; Aspart; Glulisine

Regular

NPH

Glargine (Lantus); Detemir (Levemir)

70/30 regular; 70/30 aspart; 75/25 lispro; 50/50

Onset of Action 5-15 min; Peak 30-90 min; Duration of Action 4-6 h

Onset of Action 5-15 min; Peak 30-90 min; Duration of Action 6-8 h

Onset of Action 30-60 min; Peak 2-4 h; Duration of Action 6-10 h

Onset of Action 1-2 h; Peak 4-8 h; Duration of Action 10-20 h

Onset of Action 1-2 h; Peak: None; Duration of Action 24 h

Onset of Action 1-2 h; Peak 6-8 h; Duration of Action 12-24 h

Strenuous use of injected limb within one hour

Do not rub site vigorously

Heat increases, cold decreases

Abdomen>arms>thigh (R & N only)

Delays absorption

Delay onset and duration

Severity of illness; Meds (g’corticoids, pressors); Diet: different, unpredictable; Type of diabetes; Previous glycemic ctrl; Setting: ICU vs ward

Increase absorption rate

Lente causes loss of rapid acting insulin action

Delay onset and duration

Proper resuspension needed

decrease glucose absorption in intestines

Decrease hepatic glucose output; increase glucose uptake

Mx & adipose tissue: decrease insulin resistance; increase glucose uptake

Pancreas: increase insulin secretion

L-cells of the jejunum & ileum

stimulates glucose-dependent insulin secretion; suppresses glucagon secretion; slows gastric emptying; leads to reduction in food intake; increases insulin sensitivity

increase in beta cell mass; improved beta fn

Worsened hepatic fn; advanced CHF

stop metformin

hold metformin

should NOT be used as monotherapy

target <7.0; <6.0 if poss w/o inducing hypoglycemia

<130/80 (ACEI / ARB)

LDL <100 (<70 optimal); HDL >40 M, >50 F; TG <150; statin for CV hx or >40 yo to lower LDL 30-40%

>40 yo or other risk factors; all w/ CV hx

> 55 yo w/ other CV risk factor

Acute illness; Erratic food intake; Poor coordination of insulin dosing with meals

IV Dextrose (D50) Admin = most rapid method of alleviating hypoglycemia; appropriate for pts who are unconscious, severely symptomatic, or NPO

be given 15 gm CHO in a rapidly available form (ie, ½ cup of fruit juice, 4 oz nondiet soda, or 3 glucose tablets)

to over-treat hypoglycemia with an excess of carbohydrate (this, plus counter-reg hormone response to hypoglycemia, facilitates subsequent hyperglycemia)

N/V (consider checking BG before meal & rapid insulin just after, if N/V consistent prob); sepsis? Renal/Liver prob? Too much insulin? Other endocrine prob (hypothyroid/ adrenal)

First find underlying cause (insufficient insulin dosing OR other)

Infxn; Dehydration; Cardiac; hormones (ie epinephrine); Stress / Surgery; Rebound from a prior episode of HYPOglycemia ; Medications (ie, steroids)

3 of 5: Waist circum >40 (M) / >35 (F); TG ≥150; HDL <40 (M) / <50 (F); BP ≥ 130/85; FPG ≥110

acanthosis nigricans, estd T2DM, central obesity

hypercoagulability , PCOS, vascular endothelial dysfunction, CAD, microalbuminuria

Cytomel

Thyrolar

Synthroid, Unithroid, Levoxyl, Levothroid

Tapazole

Hypothyroid Agent

Hypothyroid Agent

Hypothyroid Agent

Hyperthyroid Agent

Hyperthyroid Agent

Humalog

NovoLog

Apidra

Lantus

Levemir

Diabeta

Glucotrol

Amaryl

Prandin

Starlix

Glucophage

Avandia

Actos

Precose

Glyset

Januvia

Onglyza

Byetta

Victoza

Symlin

Rapid acting insulin

Rapid acting insulin

Rapid acting insulin

Long acting insulin

Long acting insulin

Sulfonylurea

Sulfonylurea

Sulfonylurea

Meglitinide

Meglitinide

Biguanide

Thiazolidinedione

Thiazolidinedione

Alpha-glucosidase Inhibitor

Alpha-glucosidase Inhibitor

DPP-4 inhibitor

DPP-4 inhibitor

Incretin mimetic GLP-1 agonist

Incretin mimetic GLP-1 agonist

Amylin analog