Mary Bruskewitz APN, MS, RN, BC-ADM Clinical Nurse Specialist Diabetes

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1 Mary Bruskewitz APN, MS, RN, BC-ADM Clinical Nurse Specialist Diabetes

2 Objectives Pathophysiology of Diabetes Acute & Chronic Complications Managing acute emergencies Case examples 11/24/2014 UWHealth 2

3 What is Diabetes? Inability of the body to use glucose Disturbances in the metabolism of carbohydrates, proteins and fats. A syndrome of metabolic disease(s) characterized by Hyperglycemia Relative or absolute insulin deficiency Hypoglycemia Complications, cardiovascular, renal, eye, neurological, skin, peripheral vascular 11/24/2014 UWHealth 3

4 Regulation of Glucose Exercise Food Beta cell Insulin Epinephrine Cortisol Glucagon Growth hormone Stress Gut Hormones 11/24/2014 UWHealth 4

5 Terminology Type I IDDM, Type I, Juvenile, Brittle diabetes Type 2 NIDDM, Adult, Type II, Medication Induced, Steroid, 10-20% of solid organ transplants, Insulin resistance from steroids Other Alcoholism,Pancreatitis, Cystic Fibrosis, liver disease, cancer Gestational Pre-Diabetes Impaired Glucose Metabolism (IGT), Syndrome X, Borderline, Metabolic Syndrome 11/24/2014 UWHealth 5

6 Symptoms Polydipsia > T1 Polyuria > T1 Frequent infections >T2, dental, UTI, vaginal, URI Foot ulcers at diagnosis > T2 MI, CVA at diagnosis > T2 Weight loss > T1 dramatic 11/24/2014 UWHealth 6

7 Diagnostic Criteria Normal Fasting mg/dl 2 hr after meal Under 140 mg/dl Random Under 140 mg/dl Diabetes Fasting =/> 126 mg/dl x 2 tests 2 hr after meal Greater than 200 mg/dl x 2 tests Random Greater than 200 mg/dl & symptomatic 11/24/2014 UWHealth 7

8 Pre-Diabetes Fasting BG > 100 < 126 mg/dl 2 hr > 140 < 200 mg/dl Risk factors: family hx, obesity, > 40 age (increasing in children), minorities, obesity, & inactivity, hypertension HTN, hyperlipidemia, waist circumference Will develop into Type 2 Lifestyle changes decreases risk of getting T2 11/24/2014 UWHealth 8

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11 Type 2 a Progressive Disease: Natural History of T2 Plasma Glucose Post meal glucose 126 mg/dl Fasting glucose Relative - Cell Function Insulin resistance Insulin secretion up to 10 yrs Diagnosis Years of Diabetes Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota. 11/24/2014 UWHealth

12 Type 1 Autoimmune Absolute lack of insulin Requires insulin & sensitive Acute onset Profound hyperglycemia Ketosis Possible causes (genetic, viral) 5% all diabetes Hereditary Type 2 Slow onset, with/out symptoms Impaired insulin secretion & resistant Multiple risk factors (age, obesity, inactivity, HTN, cholesterol, gestational, minority) 85 95% & growing epidemic Growing in children Complications at diagnosis 11/24/2014 UWHealth 12

13 Management Type 1 Insulin therapy (intensive = multiple injections or insulin pump) BG Monitoring Healthy eating Activity Type 2 Education Healthy eating & activity (4 wks) Oral medications (3 meds not uncommon) BG Monitoring Insulin (majority will require at some time) 11/24/2014 UWHealth 13

14 Complex Individualized to the person Requires a team approach Follow-up - Surveillance of complications Lifetime of education Monitoring Healthy Eating Exercise Medications 11/24/2014 UWHealth 14

15 PreDiabetes Management Prevention, prevention, prevention Healthy lifestyle Weight loss Exercise Healthy Eating BP control Cholesterol control 11/24/2014 UWHealth 15

16 Targets - Individualized BG - individualize Fasting mg/dl Before meals: 80 mg/dl mg/dl 2 hrs postprandial 100 mg/dl mg/dl Bedtime mg/dl Pregnancy fasting < 90 mg/dl, 2 hr postprandial < 120 mg/dl A1c: < 7% (ACE, under 6.5%), Pregnancy < 6% BP (<130/80) Cholesterol (TC <200, Trig <150, HDL >45 (males) >55 (females), LDL<100 - Multiple CVD risk factors, < 70) Aspirin, debatable 11/24/2014 UWHealth 16

17 Basal Insulin's Lantus (Glargine) Levemir (Detemir) NPH U-500 Regular Insulin (special order by Endocrine only) Pre-mixed Insulin (not used in T1, pregnancy) Novolin 70/30 (70% NPH/30% Regular) NovoNordisk Humulin 70/30 (70%NPH/30% Regular) Lilly Novolog 70/30 (70% NPH and 30% Novolog) Humalog 75/25 (75% NPH and 25% Humalog) 11/24/2014 UWHealth 17

18 Bolus Insulin Short Acting Regular Rapid Acting Lispro Humalog Aspart Novolog Glulisine - Apidra 11/24/2014 UWHealth 18

19 Oral Medications Biganuides Metformin/Riomet (liquid) Extended release Glucophage, Fortamet, Glumetza Decreases amount of glucose produced by the liver Sulfonylureas Glipizide, Glimepiride, Glyburide Increase beta cells release of insulin Thiazolidinedione's (TZD) Use with caution Pioglitazone - Actos Improves sensitivity to the effects of insulin Meglitinides, non-sulfa Nateglinide - Starlix, Rapaglinide - Prandin Increases beta cells release of insulin postprandial Shorter acting compared to sulfonylureas 11/24/2014 UWHealth 19

20 Alpha Glucosidase Inhibitors Acarbose - Precose, Miglitol - Glyset Rarely used (GI side effects) Slows the absorption of carbohydrates postprandial DPP-4 Sitagliptin - Januvia, Saxagliptin - Onglyza, Linagliptin - Tradjenta Decreases glucose uptake by inhibiting DPP-4 via digestion process Improves insulin level postprandial Lowers glucose production by the body (liver) May work in brain to decrease appetite SLGT 2 Inhibitors Canaglifloxin, Invokana Blocks glucose reabsorption in the kidneys Positive glycosuria 11/24/2014 UWHealth 20

21 Combination Oral Medications Actoplus - Pioglitazone & metformin Glucovance - glyburide & metformin Metaglip glipizide & metformin Janumet Sitagliptin & metformin Kombiglyze Saxagliptin & metformin Prandimet Repaglinide & metformin Duetact Pioglitazone & glimepiride 11/24/2014 UWHealth 21

22 Diabetes Oral Medications Metformin Actos Januvia, Onglyza, Tradjenta glipizide, glimepiride Kidney SLGT-2 11/24/2014 UWHealth 22

23 Injectable Incretin mimetics/ GLP-1 analogue Exenatide - Byetta Exenatide extended Bydureon (kit or pen) Liraglutide - Victoza Albiglutide Tanzeum Dulaglutide - Trulicity Insulin Sensitizers Symlin 11/24/2014 UWHealth 23

24 Devices Needles or pens 4 mm (pen only) 5 mm (pen only) 8 mm (5/16 ) 12.7 mm (1/2 ) 1 inch (syringe only) Pumps Sensors 11/24/2014 UWHealth 24

25 Case Study 22 yo university student Symptoms Tired, average 6 hrs sleep Declining grades BG 600 mg/dl Weight gain over 6 months, 15# BMI 33% BP at clinic visit 136/84, usually normal Decreased appetite, erratic meals 1-2/day Decreased exercise, sedentary lifestyle Family hx of T2 11/24/2014 UWHealth 25

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