diabetes mellitus
DESCRIPTION
DIABETES MELLITUS. ISSUES IN THE LONG TERM CARE SETTING AND ALLIED VENUES. DIABETES MELLITUS. Focus: diabetes in the Medicare population. DIABETES MELLITUS. Definition: a metabolic disorder in which there is deficiency of insulin production or - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/1.jpg)
DIABETES MELLITUS
ISSUES IN THE
LONG TERM CARE SETTING AND ALLIED VENUES
![Page 2: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/2.jpg)
DIABETES MELLITUS
Focus: diabetes in the Medicare population
![Page 3: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/3.jpg)
DIABETES MELLITUS
Definition: a metabolic disorder in which
there is deficiency of insulin production or
resistance of organs to the effect of insulin
![Page 4: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/4.jpg)
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.
• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 5: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/5.jpg)
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.
• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 6: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/6.jpg)
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.
• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 7: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/7.jpg)
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) => glucose builds up in the blood, overflows into the urine, and passes out of the body in urine => body loses its main source of fuel even though blood contains large amounts of glucose.
• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 8: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/8.jpg)
DIABETES MELLITUS (DM)
• TYPES OF DIABETES– Type I– Type II– MODY (Maturity Onset Diabetes of
Youth– Gestational
![Page 9: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/9.jpg)
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» <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 10: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/10.jpg)
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
» <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 11: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/11.jpg)
DM TYPE II
• Patient with type II DM usually makes enough insulin but the body cannot use it effectively => insulin resistance
• Gradually insulin production decreases over the following years
• Symptoms are similar to type I but develop more gradually
» <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 12: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/12.jpg)
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
• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 13: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/13.jpg)
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 <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>
![Page 14: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/14.jpg)
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
• <http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what>• MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
![Page 15: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/15.jpg)
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.
![Page 16: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/16.jpg)
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/index.htm#types
• MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
![Page 17: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/17.jpg)
Type II Diabetes
Diagnostic testing - when to do it:
People 45 years old => if normal then every 3 years
MKSAP13 Endocrinology and Metabolism. American College of Physicians 2004.
![Page 18: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/18.jpg)
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.
![Page 19: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/19.jpg)
DM type II: ManagementBasics:
healthy eating
physical activity
blood glucose testing
Pharmaceuticals:
oral medication(s)
insulin(s)
both oral medicines and insulin
![Page 20: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/20.jpg)
DM: insulin variations
Daily insulin requirements are influenced by:
diet
exercise
stress
![Page 21: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/21.jpg)
Diabetes Management: Stress
Stress influences response to insulin
Stress => increased cortisol
increased catecholamines
increased growth hormone
=> these hormones all lead to increased insulin resistance (thus, hyperglycemia)
![Page 22: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/22.jpg)
Control of Diabetes
Control of Diabetes includes:
glycemia control (FBS < 126mg/dL; HbA1c <7%)
weight management
blood pressure control (BP < 130/80mmHg)
lipid management
reduction in the hypercoagulable state (aspirin or clopidogrel)
![Page 23: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/23.jpg)
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 < 7%
If this goal in not reached and maintained => pharmacotherapy (medications)
![Page 24: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/24.jpg)
Insulins
Type hours to onset time to peak time effective
Fast acting:
Lispro <0.25 (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.
![Page 25: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/25.jpg)
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
![Page 26: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/26.jpg)
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.
![Page 27: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/27.jpg)
Medications for DM type IISulfonylureas: 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;
![Page 28: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/28.jpg)
Insulin in Type II DM
Usually indicated if HbA1c > 7% despite life style modification and 2 oral medications
May be postponed in borderline cases where HbA1c is < 8.5% pending addition of a 3rd oral agent; otherwise =>
Addition of bedtime dose of basal insulin therapy (glargine)
to sulfonylureas +/- metformin (not thiazolidinediones because of risk of CHF
from fluid retention)
![Page 29: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/29.jpg)
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?identifier=4756
![Page 30: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/30.jpg)
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
![Page 31: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/31.jpg)
Acute Complications of type II DM
Hyperglycemic hyperosmolar state:
serum osmolarity > 320 mosm/L
plasma glucose > 600mg/dL
dehydration
no ketoacidosis
underlying disorder(s)
![Page 32: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/32.jpg)
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)
![Page 33: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/33.jpg)
Hypoglycemia
Hypoglycemia = plasma glycemia < 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
![Page 34: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/34.jpg)
Complications of DM
Chronic complications of diabetes mellitus include:
Macrovascular
Microvascular
Neuropathic
![Page 35: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/35.jpg)
Complications of DM
Macrovascular
atherosclerosis/cardiovascular disease
peripheral vascular disease
![Page 36: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/36.jpg)
Complications of DM
Microvasculardiabetic retinopathy: due to ischemia of retna; provokes neovascularization with vessels more fragile => leaking => scarring & fibrosis
diabetic nephropathy: common cause of ESRD;
prevention via control of blood pressure and glycemia; earliest signs urine albumin 30mg/day or 20g/min; appears to benefit from ACE-I’s and ARB’s too
![Page 37: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/37.jpg)
Complications of DM
Diabetic Neuropathy
peripheral sensory neuropathy
cardiovascular autonomic neuropathy
gastrointestinal autonomic neuropathy
erectile dysfunction
mononeuropathy
diabetic foot
![Page 38: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/38.jpg)
Complications of DM
Peripheral sensory neuropathy
variable presentation
dysesthesia
tingling
pain
loss of pain sensation (risk of injury)
![Page 39: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/39.jpg)
Complications of DM
Cardiovascular Autonomic Neuropathy
orthostatic hypotension
lack of normal variation in heart rate with breathing, tachycardia
![Page 40: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/40.jpg)
Complications of DM
Gastrointestinal Autonomic Neuropathy
gastroparesis: nausea, bloating, vomiting (tx metoclopramide)
diarrhea: often nocturnal
![Page 41: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/41.jpg)
Complications of DM
Erectile dysfunction:
autonomic neuropathy
absent nocturnal and morning erections
more common than diagnosed
![Page 42: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/42.jpg)
Complications of DM
Mononeuropathy
acute local pain
distribution of a nerve
may recede if treated early with improved glucose control (glucotoxicity)
![Page 43: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/43.jpg)
Complications of DM
Diabetic Foot
sensory deficit (skin, bone, ligament)
fungal infection
wounds
pulses (PVD)
slow healing
ulcers
![Page 44: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/44.jpg)
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
![Page 45: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/45.jpg)
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
![Page 46: DIABETES MELLITUS](https://reader035.vdocuments.us/reader035/viewer/2022062719/5681324e550346895d98c6b1/html5/thumbnails/46.jpg)