Symptoms of diabetes + casual plasma glucose level less than or equal to 200 mg/dL

OR Fasting plasma glucose higher than or equal to

126 mg/dLOR 2-hour postload glucose level higher than or equal to 200

mg/dL during an oral glucose tolerance test Impaired glucose tolerance (IGT)

◦ FPG <110 mg/dL: normal fasting glucose

◦ FPG ≥110 mg/dL but <126 mg/dL: impaired fasting glucose (IFG)

◦ FPG ≥126 mg/dL: provisional diagnosis of diabetes mellitus

Preprandial-110 mg/dl

Postprandial-180 mg/dl

Of the 16 million Americans – 5 million are probably unaware they

2,000 per day are diagnosed with DM

Causes 200,000 deaths annually

6th leading cause of death

Leading cause of blindness

Causes >50% of nontraumatic lower-limb amputations

Leading cause of end stage renal disease

Two types

◦ Type 1

◦ Type 2

Lack of insulin production OR

Production of defective insulin

Affected patients need exogenous insulin

Complications◦ Diabetic ketoacidosis (DKA)◦ Hyperosmolar nonketotic syndrome

Oral antidiabetic drugs not effective

Symptoms

◦ Polyuria◦ Polydipsia◦ Polyphagia◦ Glycosuria◦ Unexplained weight loss◦ Fatigue◦ Hyperglycemia

Most common type

Caused by insulin deficiency and insulin resistance

Many tissues are resistant to insulin

◦Reduced number insulin receptors

◦Insulin receptors less responsive

Several comorbid conditions• metabolic syndrome OR insulin-resistance

syndrome OR syndrome X

◦ Obesity◦ Coronary artery disease◦ Dyslipidemia◦ Hypertension◦ Microalbuminemia (protein in the urine)◦ Enhanced conditions for embolic events (blood clots)◦ Insulin Resistance

Type 1◦ Exogenous insulin◦ Dietary control

Type 2◦ Lifestyle changes

Dietary control Weight reduction Exercise

◦ May require oral hypoglycemic therapy or exogenous insulin

◦ Insulin when oral hypoglycemic medications can no longer provide glycemic control

◦ Hyperglycemia that develops during pregnancy

◦ Insulin must be given to prevent birth defects

◦ 4% of all pregnancies

◦ Must be reclassified if it persists 6 weeks post-delivery

◦ Usually subsides after delivery

◦ 30% of patients may develop Type 2 DM within 10 to 15 years

hypertensionVascular smoothmuscle cell growth

Release of chemokinesRelease of cytokinesExpression of cellular adhesion molecules

Hyper coagulationPlatelet ActivationDecreased Fibrinolysis

◦ Macrovascular (atherosclerotic plaque) Coronary arteries Cerebral arteries Renal arteries Peripheral vessels

◦ Microvascular (capillary damage) Retinopathy Neuropathy Nephropathy

MI DVT PE Stroke AAA Retinopathy

Increased Glucose Decreased Insulin

Cardiovascular disease, including hypertension Peripheral vascular disease

◦ Delayed healing Visual defects, including blindness Renal disease Infection Neuropathies Impotence

FIGURE 36-1 Complications of diabetes mellitus.

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Insulins

Oral hypoglycemic drugs

Both aim to produce normal blood glucose states

Substitute for & same effects as endogenous insulin

Restores the diabetic patient’s ability to: ◦ Metabolize carbohydrates, fats, and proteins◦ Store glucose in the liver◦ Convert glycogen to fat stores

Some derived from porcine sources

Most now human-derived, using recombinant DNA technologies

Goal: tight glucose control

◦ To reduce the incidence of long-term complications

Rapid-Acting Most rapid onset of action Shorter duration

May be given SC or via continuous SC infusionpump (but not IV)

Insulin Onset (mins)

Peak (hrs) Duration (hrs)

aspart (Novolog) 2-33 1-3 3-5

lispro (Humalog) 2-33 30mins – 2.5 3-6.5

glulisine (Apidra) 2-33 30mins – 1.5 1.-25

Short-Acting◦ regular insulin (Humulin R, Novolin R)

◦ Onset 30 – 60 minutes The only insulin product that can be given

by IV bolus, IV infusion, or even IM

Insulin Onset (mins) Peak (hrs)

Duration (hrs)

Humulin R 30 mins to 4 hrs 2.5-5 5-10

Novolin R 30 2.5-5 8

SC rapid or short-acting doses adjusted according to blood glucose test results

Typically used in hospitalized diabetic patients◦ Or in patients on TPN / enteral tube feedings or receiving

steroids

Subcutaneous insulin is ordered in an amount that increases as the blood glucose increases

Intermediate-Acting

◦ isophane insulin suspension (also called NPH) (Humulin N, Novolin N)

◦ isophane insulin suspension & insulin injection(Humulin 50/50 , Humulin 70/30, Novolin 70-30)

◦ Lispro protamine suspension (Humalog 75/25, Novolog Mix 70/30)

◦ insulin zinc suspension (Lente, Novolin L)

Cloudy appearance Slower in onset and more prolonged duration than endogenous insulin

Insulin Onset (hrs)

Peak (hrs) Duration (hrs)

Isophane (NPH):

Humulin N 1-4 4-12 16-28

Novolin N 1-5 4-12 24

Isophane & Insulin:

Humulin 50/50 0.5 4-8 24

Humulin 70/30 0.5 4-12 24

Novolin70/30 0.5 2-12 24

Insulin Onset (hrs)

Peak (hrs) Duration (hrs)

lispro protamine & lispro:

Humalog Mix 75/25 0.25-0.5 0.5-1.5 12-24

Novolog Mix 70/30 0.2-0.33 2.4 24

Insulin Zinc Suspension:

Lente Iletin II 1-1.5 8-12 24

Novolin L 1-4 7-15 20-28

Combination Insulin Products

◦ NPH 70% and regular insulin 30% (Humulin 70/30, Novolin 70/30)

◦ NPH 50% and regular insulin 50% (Humulin 50/50)

◦ insulin lispro protamine suspension 75% and insulin lispro 25% (Humalog Mix 75/25)

Insulin Onset Peak Duration

glargine (Lantus 1 No peak activity

24 (when administered at hs)

detemir (Levemir) 1 6-8 6-28

It is a test that allows healthcare providers to see how diabetics have managed their blood glucose level over the last 2-3 months….

Storage:

◦ Neither be allowed to freeze or heated above 98oF

◦ Store in refrigerator until opened

◦ Once opened, store at room temp: 68o to 75oF

◦ Once opened, discard after 30 days

◦ Avoid excess agitation – gently roll in the palms of hands (not shaken) to warm and resuspend insulin

Atrophy or hypertrophy◦ Dermatologic conditions

◦ Hypertrophy more common

Fat pads become anesthetized

Results in prolonged & erratic insulin absorption Loss of diabetic control

Used for type 2 diabetes

Treatment for type 2 diabetes includes lifestyle modifications◦ Diet, exercise, smoking cessation, weight loss

Oral antidiabetic drugs may not be effective unless the patient also makes behavioral or lifestyle changes

HbA1c ◦ Good indicator of the average blood glucose levels.

◦ Shows the average blood glucose level during the previous 120 days

◦ Used to assess long term glycemic control

◦ Performed at diagnosis and at specific intervals to evaluate the treatment plan

◦ Altered by pregnancy, increased triglycerides & bilirubin

◦ Twice annually for patients with good control◦ ◦ Quarterly for patients whose therapy has

changed

◦ First generation:

chlorpropamide (Diabinese), tolazamide (Tolinase) tolbutamide (Orinase)

◦ Second generation:

glimepiride (Amaryl) glipizide (Glucotrol) glyburide (DiaBeta, Micronase)

Sulfonylureas

Stimulate insulin secretion from the beta cells of the pancreas, thus increasing insulin levels

Beta cell function must be present

Improve sensitivity to insulin in tissues

Result: lower blood glucose levels

First-generation drugs not used as frequently now

Sulfonylureas

◦ Hypoglycemia◦ hematologic effects◦ nausea◦ epigastric fullness◦ heartburn◦ many others

Sulfonylureas◦ Hypoglycemic effect increases when taken with alcohol, anabolic steroids,

many other drugs

◦ Adrenergics (beta blockers) may mask many of the symptoms of hypoglycemia

◦ Hyperglycemia: corticosteroids, phenothiazines, diuretics, oral contraceptives, thyroid replacement hormones, phenytoin, diazoxide and lithium.

◦ Allergic cross-sensitivity may occur with loop diuretics and sulfonamide antibiotics

◦ May interact with alcohol/OTC medication containing alcohol) - causing a disulfiram (Antabuse) -type reaction (facial flushing, pounding headache, feeling of breathlessness, and nausea)

Meglitinides◦ repaglinide (Prandin)◦ nateglinide (Starlix)

Meglitinides◦ Action similar to sulfonylureas◦ Increase insulin secretion from the pancreas

Meglitinides

◦ Headache◦ hypoglycemic effects◦ Dizziness◦ weight gain◦ joint pain◦ upper respiratory infection or flu-like

symptoms

Biguanides◦ metformin (Glucophage)

Biguanides◦ Decrease production of glucose

◦ Increase uptake of glucose by tissues

◦ Does not increase insulin secretion from the pancreas (does not cause hypoglycemia)

Metformin

◦ Primarily affects GI tract: abdominal bloating, nausea, cramping, diarrhea, feeling of fullness

◦ May also cause metallic taste, reduced vitamin B12 levels

◦ Lactic acidosis is rare but lethal if it occurs

◦ Does not cause hypoglycemia

Thiazolidinediones◦ pioglitazone (Actos),◦ rosiglitazone (Avandia)◦ Also known as “glitazones”

Thiazolidinediones◦ Decrease insulin resistance ◦ “Insulin sensitizing drugs”◦ Increase glucose uptake and use in skeletal

muscle◦ Inhibit glucose and triglyceride production in the

liver

Thiazolidinediones

◦ Moderate weight gain◦ Edema ◦ Mild anemia ◦ Hepatic toxicity—monitor liver function tests

Alpha-glucosidase inhibitors◦ acarbose (Precose)◦ miglitol (Glyset)

Alpha-glucosidase inhibitors◦ Reversibly inhibit the enzyme alpha-glucosidase in the

small intestine◦ Result: delayed absorption of glucose◦ Must be taken with meals to prevent excessive

postprandial blood glucose elevations (with the “first bite” of a meal)

α-glucosidase inhibitors

◦ Flatulence◦ diarrhea◦ abdominal pain

◦ Do not cause hypoglycemia, hyperinsulinemia, or weight gain

Used alone or in combination with other drugs and/or diet and lifestyle changes to lower the blood glucose levels in patients with type 2 diabetes

Amylin Mimetic: pramlintide (Symlin)◦ Mimics the natural hormone amylin

◦ Slows gastric emptying

◦ Suppressed glucagon secretion, reducing hepatic glucose output

◦ Centrally modulates appetite and satiety

◦ Used when other drugs have not achieved adequate glucose control

Incretin Mimetic: exenatide (Byetta)

◦ Mimics the incretin hormones

◦ Enhances glucose-driven insulin secretion from β cells of the pancreas

◦ Only used for Type 2 diabetes

◦ Injection pen device

Inhaled Insulin: Exubera

FIGURE 36-2 Mechanisms of action of antidiabetic agents.

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Early◦ Confusion, irritability, tremor, sweating

Later◦ Hypothermia, seizures◦ Coma and death will occur if not treated

Abnormally low blood glucose level (<50 mg/dL)

Mild cases can be treated with diet—higher intake of protein and lower intake of carbs—to prevent a rebound postprandial hypoglycemia

Rapid decrease in blood sugar – during the night

Stimulates the release of hormones that elevate blood glucose◦ Epinephrine, cortisol, and glucagon

Results in elevated early morning blood glucose

Insulin administration may cause a rapid rebound hypoglycemia

Oral forms of concentrated glucose◦ Buccal tablets, semisolid gel

50% dextrose in water (D50W)

Glucagon

diazoxide

State of hyperglycemia with ketosis Usually results from infection, environment, or

emotional stressor◦ As a result of Lack of Insulin, Breakdown:

Fat – free fatty acids in liver – ketone bodies – ketones in urine

Protein – to form new glucose / increased BUN Glycogen to glucose (decrease use of glucose because of

decreased insulin) Osmotic diuresis Dehydration / Electrolyte Imbalance Hyperosmolality Hemoconcentration Acidosis Death

Sudden onset Factors: infection, stressors, inadequate insulin Kussmaul respiration / fruity odor to breath, nausea,

abdominal pain Dehydration, electrolyte imbalance, polyuria,

polydipsia, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, coma

Glucose >300 mg/dL pH <7.35 / Bicarbonate < 15 mEq/L Na – low / K+ </> / Cr >1.5 mg/dL Blood & Urine Ketones - Positive

Treatment Insulin Bolus (0.1U/kg IV) & Infusion (0.1 U/kg/hr)

◦ Regular Insulin only insulin that can be given by intravenous

infusion Restore fluid volume Potassium Runs

◦ K+ depleted severely with insulin therapy Insure urine output >30mL/hr

Correct acidosis◦ Bicarbonate is used rarely

arterial pH < 7.0 or bicarbonate level < 5 mEq/L

State of hyperglycemia without ketosis Little breakdown of fat (little or no ketone

bodies) Breakdown

◦ Glycogen– formation of new glucose – hyperglycemia Very high levels of glucose >800mg dL

◦ Osmotic diuresis – extracellular dehydration◦ Renal insufficiency – hyperosmolality – intracellular

dehydration◦ Hypokalemia – shock – tissue hypoxia - Coma

Gradual onset Factors: infection, other stressors, poor fluid

intake Altered CNS function – neurologic symptoms Dehydration / electrolyte loss Glucose > 800 mg/dL pH >7.4 / Bicarbonate >20 mEq/L Na & K+ normal or low Bun & Cr – elevated Blood & Urine Ketones - negative

Treatment Rehydrate with NS (if severe) or ½ NS

◦ Use CVP or PCWP / UO / blood pressure monitoring

IV insulin 10U/hr◦ Reduce hyperglycemia by 10% /hr

Replace Potassium (will not be as severe as DKA)

Before giving any drugs that alter glucose levels, obtain and document:

◦ A thorough history◦ Vital signs◦ Blood glucose level, HbA1c level◦ Potential complications and drug interactions

Before giving any drugs that alter glucose levels:

◦ Assess the patient’s ability to consume food

◦ Assess blood glucose level

◦ Assess for nausea or vomiting

◦ Hypoglycemia may be a problem if antidiabetic drugs are given and the patient does not eat

◦ If a patient is NPO for a test or procedure, consult physician to clarify orders for antidiabetic drug therapy

Keep in mind that overall concerns for any diabetic patient increase when the patient:

◦ Is under stress

◦ Has an infection

◦ Has an illness or trauma

◦ Is pregnant or lactating

Thorough patient education is essential regarding:◦ Disease process◦ Other Risk Factors:

Smoking HTN CAD

◦ Self-Care: Medication Psychological adjustment Nutrition Activity and Exercise Blood-glucose testing Self-administration of insulin or oral drugs

◦ Potential complications How to recognize and treat hypoglycemia and hyperglycemia

FIGURE 36-3 Diabetes health care plan.

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

When insulin is ordered, ensure:◦ Correct route◦ Correct type of insulin◦ Timing of the dose◦ Correct dosage

Insulin order and prepared dosages are second-checked with another nurse◦ Check blood glucose level before giving insulin◦ Roll vials between hands them to mix suspensions – no shaking!◦ Ensure correct storage of insulin vials◦ ONLY insulin syringes, calibrated in units, to administer insulin◦ Ensure correct timing of insulin dose with meals

Insulin

◦ When drawing up two types of insulin in one syringe: Always withdraw the regular or rapid-acting insulin

first

◦ Provide thorough patient education regarding self-administration of insulin injections, including timing of doses, monitoring blood glucoses, and injection site rotations

Always check blood glucose levels before giving

Usually given 30 minutes before meals◦ Administer the medication at exact time – with

meal or when food is in sight*

Alpha-glucosidase inhibitors are given with the first bite of each main meal

Metformin is taken with meals to reduce GI effects

Assess for signs of hypoglycemia

If hypoglycemia occurs:

◦ Give glucagon or◦ Have the patient eat glucose tablets or gel, corn

syrup, honey, fruit juice, or nondiet soft drink or◦ Have the patient eat a small snack such as

crackers or half a sandwich

◦ Monitor blood glucose levels

Monitor for therapeutic response

◦ Decrease in blood glucose levels to the level prescribed by physician

◦ Measure hemoglobin A1c to monitor long-term compliance to diet and drug therapy

◦ Watch for hypoglycemia and hyperglycemia

Neuropathies are:

1. low blood sugar.

2. degenerations in the central nervous system.

3. degeneration of peripheral nerves.

4. a numbness and tingling of the extremities

A dose of long acting insulin has been ordered for bedtime for a diabetic patient. The nurse expects to give which type of insulin?◦ A: Regular◦ B: Lente◦ C: NPH◦ D: Glargine (Lantus)

Diabetic ketoacidosis is:

1. an abnormality in the metabolism of fats.

2. an accumulation of ketones associated with poor control of diabetes mellitus.

3. an abnormal increase in hydrogen ion concentration.

4. abnormal deposits of fat caused by repeated injection of insulin at the same site.

The biguanide oral antidiabetic metformin(Glucophage) has the expected side effect of:

1. hepatotoxicity.

2. blood dyscrasias.

3. hypotension.

4. abdominal cramping and flatulence.

A dose of long acting insulin has been ordered for bedtime for a diabetic patient. The nurse expects to give which type of insulin?◦ A: Regular◦ B: Lente◦ C: NPH◦ D: Glargine (Lantus)

The order reads 10 units of U-100 Regular insulin. U-100 means there is/are:

1. 10 units of insulin in 1 mL of solution.

2. 1 mL solution/unit of insulin.

3. 100 units of Regular insulin in 1 mL of solution

4. 10 units of insulin in each bottle.