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1、DIABETES OVERVIEW AND UPDATE,Barb Bancroft,RN,MSN,PNPBB,Historical highlightsin the old days,Diabetes”to siphon”Mellitus”sweet”Nurse“Taste thy patients urine,for if it be sweet”-Dr.Thomas Willis,When I was in Nursing Schoolit was called“sugar diabetes”the evolution of the name,Juvenile Onset Diabete
2、s Mellitus(JODM)Adult Onset Diabetes Mellitus(AODM)Insulin Dependent Diabetes Mellitus(IDDM)Non-insulin Dependent Diabetes Mellitus(NIDDM)Type I(Roman numeral used)Type II(Roman numeral used)Type 1(Arabic number)Type 2(Arabic number),Definition of Diabetes Mellitus,Chronic disorder of carbohydrate,l
3、ipid,and protein metabolism characterized in its fully expressed clinical form by an absolute deficiency of insulin(Type 1 diabetes)or a relative insulin deficiency(Type 2 diabetes).Huh?Type 1no insulinType 2insulin resistancePLUSits a PROthrombotic,PROinflammatory,and PROatherosclerotic disease!So
4、be PRO-active in DX and RX!Is this a cardiovascular disease?,Type 2 diabetesthe numbers,1.5 million new cases diagnosed per year in the U.S.Over 20 years of age:20.8 million Americans(9.6%);1/3 have no clueOver 60 years of age:10.3 million or 20.9%of all peopleUsual onset after 40;70%increase in inc
5、idence under 40 in last decadeUnder 20 years of age:176,500 or 0.22%of the population;1 in every 400-600 kids with Type 12 million adoloescents(1 in 6 overweight adolescents)aged 12-19 have prediabetes50%of all new cases of Pediatric diabetes are TYPE 2not Type 1,Whos at risk?Whos sitting in YOUR wa
6、iting room?,Genetic risk for Type 1 and for Type 2 diabetesfamily history,sibling or parentHow many genes?,Family history,Family history of early coronary artery diseaseWhat is meant by early?,Hypertension,Greater than 140/90 increases the risk of diabetes50-60%of newly diagnosed patients also have
7、HTN at diagnosisAn interesting note:A family history of hypertension in a child with Type 1 diabetes increases their risk of developing nephropathy,High risk ethnic groups,African AmericanNative AmericanAsian AmericanHispanic AmericanPacific IslanderIndian(from India),Impaired glucose tolerance,Gest
8、ational diabetesBaby weighing greater than 9 lbs.Were YOU,as a baby,exposed to hyperglycemia en utero?,Type 2 diabetes risk factors,Weight gain,What did you weigh as a kid?,The odds that a person who is normal weight at age 18 will develop diabetes later in life are 1-in-5 or 1-in-6.However,if a chi
9、ld is very obese at age 18,they have a 3-in-4 chance of developing diabetes.The lifetime risk of developing diabetes,based on a body mass index at age 18,is as follows:,BMI and risk of Type 2(T2)diabetes,A BMI under 25(normal BMI)risk of T2 diabetes for women is 17%;risk of diabetes for men is 20%A
10、BMI between 25-29risk of T2 diabetes for women is 35%;risk of diabetes for men is 30%A BMI between 30-34risk of T2 diabetes for women is 55%;risk of diabetes for men is 57%A BMI greater than 35risk of T2 diabetes for women is 74%;risk of diabetes for men is 70%(CDCDiabetes Branch,May 2006)(June 2006
11、,ADA),Within a single ethnic group,Diet(high calorie,high fat)Lifestyle(Lack of physical activity and sedentary lifestyle)Both play a major role in obesity and insulin resistance with DM,Abdominal obesity as a risk factor,Abdominal obesity and insulin resistanceVisceral fat is an endocrine organ and
12、 is metabolically activeIt is insulin resistantProduces inflammatory mediators such as TNF-and IL-6,Waist greater than 38 inches in females increases the risk by 6-foldWhat should we look like?,Other conditions that increase the risk of Type 2 diabetesPCOS and documented hypoglycemia,Polycystic ovar
13、y syndrome(PCOS)Polycystic ovary syndrome(PCOS)5-10%of women of reproductive age;increasing at the same rate as Type 2 DM and metabolic syndrome in U.S.Anovulation,irregular menses,androgen excess,insulin resistance,increased CV risk and Type 2 DMRx:Metformin and“glitazones”decrease insulin resistan
14、ce:WORD TO THE WISE:These oral drugs also decrease the efficacy of COCs and increase ovulationneed 2 forms of birth control unless pregnancy is the goalHistory of hypoglycemia(documented with OGTT),Undesirable lipid levels,HDL less than 35 mg/dLTriglycerides greater than 150 mg/dLThink diabetes or h
15、ypothyroidism with the above lipid profileDraw a FBS and a TSH,Type 1 diabetes,Type 1 DMprimarily diagnosed in pre-teens or teenagers;onset prior to age 40 in the majority of patients;Caucasians greater than African-AmericansFinland#1 country in world with Type 1 DM1 in 150 kids by the age of 15,Typ
16、e 1 Diabetes,Associated with immune response genes and HLA-DR3 and HLA-DR4Autoimmune attack against specific components of the islet beta cells of the pancreas(anti-glutamic acid decarboxylase antibodiesanti-GAD;anti-islet cell antibodies)Usually present with 3 ps(losspolyuria,polydipsia,polyphagia)
17、,and weight lossClassic presentation is in a Caucasian,blue-eyed,blonde-haired kid,Type 1 diabetes,What triggers the autoimmune response?The most likely culprit is one of the childhood virusesCoxsackie B?Measles?Influenza A or B?,Other conditions associated with Type 1 diabetes,Autoimmune diseases a
18、re more commonCeliac diseaseThyroid diseasePernicious anemia,Secondary diabetes,Exocrine pancreatic diseasecystic fibrosisCushings disease or syndromeDrugscorticosteroids,L-dopa,beta-blockers,atypical anti-psychotics(especially Clozapine/Clozaril and Olanzapine/Zyprexa),sympathomimetics,niacin,gluco
19、samine,thiazide diureticsHospital critical care-stress,Hyperglycemia in the hospital setting,Inpatient hyperglycemia in people with or without diabetes is associated with an increased risk of complications and mortality,a longer hospital stay,a higher admission rate to the ICU,and higher hospitaliza
20、tion costsControl is challengingwhat is the best way to control hyperglycemia in the hospital setting?Basal/bolus therapy is more efficient than sliding scale which is associated with poorer glycemic control and an increase risk of hypoglycemia(Umpierrez GE,Palacio A,Smiley D.Sliding Scale Insulin U
21、se:Myth or Insanity?The Am J of Med 2007(July):120(7).,Laboratory Tests,Prediabetesone-step away HUH?54 million Americans with prediabetes Asymptomatic fasting blood sugars between 100 mg/dL and 125 mg/dLUsed to be called impaired glucose toleranceMay have metabolic syndrome,Central obesity and the
22、metabolic syndrome(insulin resistance syndrome),What is the metabolic syndrome?(Previously known as syndrome X)A clustering of risk factors that,in the aggregate,sharply increase the risk of cardiovascular disease and diabetesBy the time a diagnosis of diabetes is made,70-90%of patients have metabol
23、ic syndrome,irrespective of ethnicity or the definition used1 million adolescents have metabolic syndromeWhat is the definition of metabolic syndrome?,Definition varies by group:NCEP ATP III guidelines:Metabolic syndrome or IRS(insulin resistance syndrome),Central obesitywaist size greater than 40.2
24、 inches in men,34.6 inches in womenHigh TG(150 mg/dL),Low HDL(less than 40 mg/dL in men,less than 50 mg/dL in women)Hypertension(130/85 mm Hg)Fasting glucose 110 mg/dL(or greater than 100 mg/dL)Metabolic syndrome is present when any 3 of these risk factors are presentPCOS(polycystic ovary syndrome i
25、s a form of metabolic syndrome/IRS),Laboratory diagnosis,Fasting plasma glucoseafter 8 hours without caloric intakeA.M.specimens greater than or=to 126 mg/dL(previous was 140 mg/dL),Or,Random glucose of greater than or equal to 200 mg/dLPostprandial glucose excursions with subsequent hypoglycemiapat
26、ient with early diabetes can present with this picturegive glucometer to take home and measurePostprandial glucose excursions are also associated with an increased risk of CV disease,Laboratory diagnosis,Hemoglobin A1Cgold standard for measuring long-term glycemic controlhow does it work?RBC life sp
27、an50%of glycosylated hemoglobin is from previous month;25%from the month before;25%3-4 months agoNormal range is 4-6%;each percent equals 20-22 mg/dL of plasma glucose(6%is TOO HIGHbut is considered normal range by laboratory)HbA1C of 4%is the equivalent of a FPG of 80-88 mg/dL;10%=200-220 mg/dLWhat
28、 does the ADA recommend for HbA1C for adults?(Less than 7)Clinical endocrinologists for adults?(Less than 6.5),Hemoglobin A1c for kids(ADA guidelines),Guidelines for kidsless than 8.5 but greater than 7.5 for toddlers and preschoolers 0-6 years of ageLess than 8 for kids 6-12Less than 7.5 for adoles
29、cents and young adults(13-19)More liberal numbers for kids and developing brains who are more vulnerable to the effects of hypoglycemia and who may not be able to effectively recognize or speak about the symptoms of hypoglycemiaThe DCCT data certainly showed that tighter blood glucose controls incre
30、ase the risk of serious hypoglycemia BUT also decrease the risk of long-term complications,Hemoglobin A1C for older adults,More complex because of co-morbidities(example aggressive control of BP+BS may increase the risk of falls)How aggressive should we be?LIGHT mnemonic is usefulLlife expectancy:es
31、timate average life expectancy based on age and health statusIimpact of geriatric syndromes and other co-morbiditiesGgoals of care and patient preferencesHhelp the patient prioritize and develop a care planTTime required to benefit from the therapeutic intervention,Six syndromes to consider in older
32、 patients with diabetes,Polypharmacydrug burden and drug-drug and drug-disease interactions are very commonDepressionincreased prevalence and incidence;interferes with self-managementCognitive impairmentscreen yearly and more often in patients having difficulty with disease management and self-care(
33、check TSH and B12);is dementia more common in diabetics?,Six syndromes to consider in older patients with diabetes,Urinary incontinencefrom glucosuria,neurogenic bladder,stool impaction,UTI,vaginal yeast infectionFallsUndertreated painmay not mention or may just blame it on normal aging;may not desc
34、ribe neuropathic pain in the usual terms of tingling,burning,but use terms such as aching,discomfort,Basic physiology/pathophysiology,Insulin is a growth hormonestores fat and sugar and stimulates protein synthesis after the mealToo much?WEIGHT GAIN;hypoglycemiaGlucagon is a catabolic hormone produc
35、ed during the fasting state;breaks down stored glycogenToo much?WEIGHT LOSS;hyperglycemia,The fasting state,The pancreas produces glucagon for glycogenolysis(break down stored sugar in the liver)to maintain a steady state of blood glucoseLipolysisbreaks down fat tissue and forms free fatty acidsGluc
36、oneogenesisturns proteins into sugarType 1 ketoacidosis is a prolonged fasting state;absolute deficiency of insulin;glucagon is working overtime;weight loss;glycogenolysis and lipolysis with hyperglycemia and fatty acid release(ketones);ketones and glycosuria cause a significant osmotic diuresis(sig
37、nificant dehydration),Symptoms of DKA(Diabetic Ketoacidosis),DehydrationAbdominal painAnorexia,weight lossKussmauls respirations(acidosis)TachycardiaWeakness,fatigueFruity breath odorhypotensionN and/or VConfusion,decreased reflexes,coma,Treatment of DKA,Dehydration is your first priorityGIVE FLUIDS
38、what kind?Then what?Regular insulin IVThen what?Check electrolytes and bicarb,Pathophysiology of Type 2 DM,Early in the diseaseinsulin resistance is characterized by a subnormal receptor response to insulin(partially due to abdominal obesity)Abnormal beta cell response with an abnormal release of in
39、sulin to glucosetoo much released resulting in hyperinsulinemia and hypoglycemia in the postprandial stateWhat are the consequences of hyperinsulinemia?,Hyperinsulinemia,Increased TG and decreased HDLsSodium and water retentionHTNStimulate fat storage(CHO to fats)ProthromboticProinflammatoryTriggers
40、 endothelial cell dysfunctionYIKES!,Type 2 diabetes,Metabolic derangements arent usually as severe as Type 1;as insulin resistance continues,serum glucose levels gradually increase;with increasing glucose levels the pancreas responds by increasing insulin output resulting in hyperinsulinemiaFew symp
41、toms initially,2 Ps(no polyphagia),weight gain due to hyperinsulinemiaOther symptomsfatigue,diplopia,nocturiaSkin infections,vaginal infections,poor wound healing,neuropathyCardiovascular complications may be the first presenting symptomsMI,PAD,Stroke“Silent”for a full decade in some individuals,Som
42、e new physiology,You eat a mealand then?The intestine releases incretin hormones known as GLP-1(glucagon-like peptide 1)and GIP(glucose-dependent insulinotropic polypeptide)throughout the day,with an increase right after the meal(postprandial increase)The incretin hormones influence the pancreas to
43、increase the synthesis and release of insulin and decrease the synthesis and release of glucagonDrugs that affect incretinExenatide(Byetta);symlin(Amlin);sitagliptin(Januvia),And then what?,Insulin acts on insulin receptors in the liver,skeletal muscle tissue and adipose tissue to trigger the entry
44、of sugar into the cells(Obesity decreases the number of insulin receptors;exercise increases the receptor sensitivity)HENCE,the strong recommendation to LOSE weight and exercise!The liver stores extra glucose as glycogen and releases it as necessary to keep the blood sugar levels in the normal range
45、 throughout the day and nightThe liver does most of its work at nightClinical implications of giving metformin at night(Metformin blocks the breakdown of glycogen to glucose)the whole dose,How do you treat it?The usual suspects(oral drugs),By decreasing the production of glucose by the liverMetformi
46、n(glucophage)By increasing insulin sensitivity in the tissues(the glitazonesrosi-and pio-)Avandia and Actos;metformin(glucophage)By increasing insulin secretion from the pancreas and increasing insulin receptor sensitivity(the oral sulfonylureas)By giving oral drugs that reduce postprandial excursio
47、ns of glucose(repaglinide/Prandin,nateglinide/Starlix)By inhibiting enzymes in the intestine responsible for breaking down incretins that potentiate insulin release(sitagliptin/Januvia)By mimicking hormones(incretins)that trigger insulin release from the pancreas(exenatide/Byetta),Oral Drugsthe#1 be
48、stseller,Metformin(glucophage)does not have any direct effect on insulin release from the pancreasdoesnt require insulin to workPrimary action:DECREASE hepatic glucose production;also,decreases glucose absorption via the GI tract,and may increase sensitivity of insulin receptorsProblem?GI blues,need
49、 functioning organs-kidneys and heart especially(check serum creatinine before starting metformin)Se Creatinine-Cut-off is 1.4 in females and 1.5 in males Other benefits:lowers BP,increases HDL,lowers LDLB12 deficiencylonger the use and the higher the dose,the greater the risk,Digression:the importa
50、nce of B12,B12 is necessary for the healthy production of RBCs and for the maintenance of the central and peripheral nervous system(cognitive function in the CNS and normal PNS function)B12 deficiency is the one of the top 3 causes of peripheral neuropathy in the U.S.and the#1 cause of nutritional d
