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DIABETES MELLITUS

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DIABETES MELLITUS ISSUES IN THE LONG TERM CARE SETTING AND ALLIED VENUES DIABETES MELLITUS Focus: diabetes in the Medicare population DIABETES MELLITUS Definition: a ... – PowerPoint PPT presentation

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Title: DIABETES MELLITUS


1
DIABETES MELLITUS
  • ISSUES IN THE
  • LONG TERM CARE SETTING AND ALLIED VENUES

2
DIABETES MELLITUS
  • Focus diabetes in the Medicare population

3
DIABETES MELLITUS
  • Definition a metabolic disorder in which
  • there is deficiency of insulin production or
  • resistance of organs to the effect of insulin

4
DIABETES MELLITUS
  • Diabetes is a disorder of metabolism--the way our
    bodies use digested food for growth and energy.
  • Most of the food we eat is broken down into
    glucose, the form of sugar in the blood.
  • Glucose is the main source of fuel for the body.
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

5
DIABETES MELLITUS
  • After digestion, glucose passes into the
    bloodstream, where it is used by cells for growth
    and energy.
  • For glucose to get into cells, insulin must be
    present.
  • Insulin is a hormone produced by the pancreas, a
    large gland behind the stomach.
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

6
DIABETES MELLITUS
  • NORMAL When non-diabetic people eat, the
    pancreas automatically produces the right amount
    of insulin to move glucose from blood into our
    cells.
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

7
DIABETES MELLITUS
  • DIABETES In people with diabetes, when they eat,
    the pancreas either produces little or no
    insulin, or the cells do not respond
    appropriately to the insulin that is produced (or
    both) gt glucose builds up in the blood,
    overflows into the urine, and passes out of the
    body in urine gt body loses its main source of
    fuel even though blood contains large amounts of
    glucose.
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

8
DIABETES MELLITUS (DM)
  • TYPES OF DIABETES
  • Type I
  • Type II
  • MODY (Maturity Onset Diabetes of Youth
  • Gestational

9
DM TYPE I
  • Auto-immune disease
  • Constitutes 5-10 of DM diagnosed in the USA
  • Mostly appears in children and young adults
  • Develops as a result of auto-immune destruction
    of beta-cells in the pancreas
  • Presents with polyuria, thirst, weight loss,
    marked fatigue
  • Can be complicated by coma with ketoacidosis
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

10
DM TYPE II
  • Most common form of diabetes
  • Involves about 90-95 of people with DM
  • Associated with
  • older age
  • obesity
  • family history of DM
  • prior history of gestational diabetes
  • physical inactivity
  • ethnicity
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

11
DM TYPE II
  • Patient with type II DM usually makes enough
    insulin but the body cannot use it effectively gt
    insulin resistance
  • Gradually insulin production decreases over the
    following years
  • Symptoms are similar to type I but develop more
    gradually
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

12
DM TYPE II
  • Symptoms of type II DM include
  • Fatigue
  • Nausea
  • Frequent urination/polyuria
  • Thirst
  • Unusual weight loss
  • Blurred vision
  • Frequent infections
  • Slow healing of wounds or sores
  • Sometimes no specific symptoms
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt

13
GESTATIONAL DIABETES
  • Develops only during pregnancy
  • More common in
  • African Americans
  • American Indians
  • Hispanic Americans
  • women with a family history of diabetes
  • Women with a history of gestational diabetes have
    a 20-50 chance of getting type II DM within 5-10
    years lthttp//diabetes.niddk.nih.gov/dm/pubs/ov
    erview/index.htmwhatgt

14
Diabetes Mellitus Diagnosis
  • Fasting plasma glucose preferred test Positive
    test is glycemia of 126mg/dL or higher after
    fasting at least 8 hours
  • Random plasma glucose of 200mg/dL or higher along
    with symptoms of diabetes
  • Oral glucose tolerance test (OGTT) plasma glucose
    of 200mg/dL or higher done 2 hours after
    ingestion of 75 grams of glucose in water
  • lthttp//diabetes.niddk.nih.gov/dm/pubs/overview/in
    dex.htmwhatgt
  • MKSAP13 Endocrinology and Metabolism. American
    College of Physicians 2004.

15
Diabetes Mellitus
  • Hemoglobin A1c measurement is not recommended
    currently for diagnosis of diabetes.
  • HbA1c is used as a marker to monitor glycemia
    control in patients over time
  • MKSAP13 Endocrinology and Metabolism. American
    College of Physicians 2004.

16
Pre-Diabetes
  • Pre-diabetes refers to a state between normal
    and diabetes fasting plasma glucose
    100-125mg/dL (higher than normal but not high
    enough for diagnosis of diabetes) Affects
    about 41 million people in USA (previously
    referred to as either impaired fasting glucose or
    impaired glucose tolerance)
  • http//diabetes.niddk.nih.gov/dm/pubs/overview/ind
    ex.htmtypes
  • MKSAP13 Endocrinology and Metabolism. American
    College of Physicians 2004.

17
Type II Diabetes
  • Diagnostic testing - when to do it
  • People ? 45 years old gt if normal then every 3
    years
  • MKSAP13 Endocrinology and Metabolism. American
    College of Physicians 2004.

18
Type II Diabetes diagnostic testing
  • Younger than 45 yo or more often than every 3
    years if
  • overweight
  • first degree relative with diabetes
  • member of high risk ethnic group (Afro-American,
    Hispanic American, Native American, Asian
    American, Pacific Islander)
  • delivered a baby ? 9 lbs.
  • gestational diabetes
  • hypertensive (BP ? 140/90mmHg)
  • High Density Lipoprotein cholesterol 35mg/dl or
    less
  • TriGlyceride level 250mg/dl or more
  • pre-diabetes
  • MKSAP13 Endocrinology and Metabolism. American
    College of Physicians 2004.

19
DM type II Management
  • Basics
  • healthy eating
  • physical activity
  • blood glucose testing
  • Pharmaceuticals
  • oral medication(s)
  • insulin(s)
  • both oral medicines and insulin

20
DM insulin variations
  • Daily insulin requirements are influenced by
  • diet
  • exercise
  • stress

21
Diabetes Management Stress
  • Stress influences response to insulin
  • Stress gt increased cortisol
  • increased catecholamines
  • increased growth hormone
  • gt these hormones all lead to increased insulin
    resistance (thus, hyperglycemia)

22
Control of Diabetes
  • Control of Diabetes includes
  • glycemia control (FBS lt 126mg/dL HbA1c lt7)
  • weight management
  • blood pressure control (BP lt 130/80mmHg)
  • lipid management
  • reduction in the hypercoagulable state (aspirin
    or clopidogrel)

23
DM type II Management
  • Most people with newly discovered type II DM are
    overweight
  • Basics are diet and exercise
  • nutrition
  • life style modification
  • increased physical activity
  • Goal Hemoglobin A1c lt 7
  • If this goal in not reached and maintained gt
    pharmacotherapy (medications)

24
Insulins
  • Type hours to onset time to peak time effective
  • Fast acting
  • Lispro lt0.25 (15min) 0.5-1.5 3-4 (max 4-6)
  • Aspart 0.17-0.33 0.67-0.83 1-3 (max 3-5)
  • Long acting
  • Glargine 2 none 24
  • Ultralente 6-10 10-16 18-20 (max 20-24)
  • Short acting
  • regular 0.5-1.0 2-3 3-6 (max 6-8)
  • Intermediate acting
  • NPH 2-4 6-10 10-16 (max 14-18)
  • Lente 3-4 6-12 12-18 (max 16-20)
  • MKSAP13 Endocrinology and Metabolism. American
    College of Physicians 2004.

25
Insulin
  • Insulin dependency regimens - examples
  • 1. insulin glargine q24h and pre-meal insulin
  • 2. NPH and regular before breakfast and supper
  • 3. Rapid or short acting insulin before meals
    intermediate acting insulin (NPH or Lente) at
    bedtime
  • 4. Insulin Glargine at bedtime and rapid or
    short acting insulin before meals
  • Insulin regimens depend on individual patient
    requirements

26
Medications for DM type II
  • Sulfonylureas Meglitinides promote
    glucose-stimulated release of insulin from
    pancreas (they need enough remaining beta-cell
    function in the pancreas to work) (insulin
    secretogogues)
  • Metformin mostly blocks gluconeogenesis in the
    liver also interferes with glycogenolysis and
    improves insulin sensitivity of muscle
  • Thiazolidinediones bind to nuclear receptors in
    tissues activate or suppress expression of
    specific genes (insulin sensitizers) - risk of
    fluid retention weight gain 4-12 week latency
    to work monitor liver enzymes q2mo
  • Acarbose alpha-glucosidase inhibitor interferes
    with intestinal absorption of carbohydrates
    causes flatulence bloating (discontinuation)
  • MKSAP13 Endocrinology and Metabolism. American
    College of Physicians 2004.

27
Medications for DM type II
  • Sulfonylureas insulin secretogogues
  • glyburide
  • glipizide
  • glimeperide
  • chlorpropamide
  • Meglitinides insulin secretogogues
  • repaglinide
  • nateglinide
  • Biguanide decreases hepatic gluconeogenesis
  • metformin
  • Thiazolidinediones insulin sensitizers
  • pioglitazone
  • rosiglitazone
  • Alpha-glucosidase inhibitor decreases GI
    absorption of carbohydrate
  • acarbose

28
Insulin in Type II DM
  • Usually indicated if HbA1c gt 7 despite life
    style modification and 2 oral medications
  • May be postponed in borderline cases where HbA1c
    is lt 8.5 pending addition of a 3rd oral agent
    otherwise gt
  • Addition of bedtime dose of basal insulin therapy
    (glargine) to sulfonylureas /- metformin (not
    thiazolidinediones because of risk of CHF from
    fluid retention)

29
The Metabolic Syndrome
  • Hypertension
  • Visceral (central) obesity
  • Hypertriglyceridemia
  • Low HDL cholesterol
  • Insulin resistance or glucose intolerance
  • Prothrombotic state (high fibrinogen or
    plasminogen activator inhibitor -1 in blood)
  • Proinflammatory state (high C-reactive protein in
    blood)
  • http//www.americanheart.org/presenter.jhtml?ident
    ifier4756

30
Acute Complications of type II DM
  • Hyperglycemic hyperosmolar state
  • common in elderly
  • triggered by underlying disorder(s)
  • risk increased in elderly due to decreased
    thirst reflex
  • often complicated by delirium

31
Acute Complications of type II DM
  • Hyperglycemic hyperosmolar state
  • serum osmolarity gt 320 mosm/L
  • plasma glucose gt 600mg/dL
  • dehydration
  • no ketoacidosis
  • underlying disorder(s)

32
Hyperosmolar State
  • Therapy
  • rehydration with hypotonic solution
  • insulin infusion (initially)
  • watch for signs of fluid overload/CHF
  • monitor potassium
  • treat underlying cause (eg UTI, cellulitis)

33
Hypoglycemia
  • Hypoglycemia plasma glycemia lt 50mg/dL with or
    without symptoms
  • More common in type I DM and patients with
    significant renal or liver disease
  • Another reason for glucose monitoring
  • Treated with po sugar (e.g. fruit juice or
    glucose tablets)
  • or IV dextrose 50 in water or IV glucagon or
    both

34
Complications of DM
  • Chronic complications of diabetes mellitus
    include
  • Macrovascular
  • Microvascular
  • Neuropathic

35
Complications of DM
  • Macrovascular
  • atherosclerosis/cardiovascular disease
  • peripheral vascular disease

36
Complications of DM
  • Microvasculardiabetic retinopathy due to
    ischemia of retna provokes neovascularization
    with vessels more fragile gt leaking gt scarring
    fibrosis
  • diabetic nephropathy common cause of ESRD
  • prevention via control of blood pressure and
    glycemia earliest signs urine albumin 30mg/day
    or 20?g/min appears to benefit from ACE-Is and
    ARBs too

37
Complications of DM
  • Diabetic Neuropathy
  • peripheral sensory neuropathy
  • cardiovascular autonomic neuropathy
  • gastrointestinal autonomic neuropathy
  • erectile dysfunction
  • mononeuropathy
  • diabetic foot

38
Complications of DM
  • Peripheral sensory neuropathy
  • variable presentation
  • dysesthesia
  • tingling
  • pain
  • loss of pain sensation (risk of injury)

39
Complications of DM
  • Cardiovascular Autonomic Neuropathy
  • orthostatic hypotension
  • lack of normal variation in heart rate with
    breathing, tachycardia

40
Complications of DM
  • Gastrointestinal Autonomic Neuropathy
  • gastroparesis nausea, bloating, vomiting (tx
    metoclopramide)
  • diarrhea often nocturnal

41
Complications of DM
  • Erectile dysfunction
  • autonomic neuropathy
  • absent nocturnal and morning erections
  • more common than diagnosed

42
Complications of DM
  • Mononeuropathy
  • acute local pain
  • distribution of a nerve
  • may recede if treated early with improved
    glucose control (glucotoxicity)

43
Complications of DM
  • Diabetic Foot
  • sensory deficit (skin, bone, ligament)
  • fungal infection
  • wounds
  • pulses (PVD)
  • slow healing
  • ulcers

44
Type II DM Goals
  • Prevention of pre-diabetes
  • Prevention of change from pre-diabetes to
    diabetes
  • Diagnosis through screening
  • Early management/therapy
  • Prevention of complications

45
Type II DM Goals
  • Screening via fasting glycemia and history
  • Life-style history and modification
  • Physical activity
  • Diet
  • Treatment of glycemia, lipids, hypercoagulable
    state, blood pressure
  • Management of complications

46
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