NR 601 Final Study Guide Week 5- Glucose Metabolism Disorders/Obesity

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NR 601 Final Study Guide



Week 5- Glucose Metabolism Disorders/Obesity

Dunphy
 Chapter 58: Diabetes Mellitus p.909-938

Kennedy
 Chapter 14: Endocrine, Metabolic, and Nutritional Disorders p.369-376
o Obesity p.392-396

Glucose Metabolism Disorders


Types of diabetes (prediabetes, type 1, and type 2)
Prediabetes: fasting glucose consistently elevated above the normal range but less than 100-125. Impaired
glucose tolerance (IGT) state of hyperglycemia where 2 hr post glucose load glycemic level is 140-199

Type 1: severe insulin deficiency resulting in reduction or absence of functioning beta cells in the pancreatic
islets of Langerhans. This leads to hyperglycemia due to altered metabolism of lipids, carbs, and proteins.
 Initial s/s of hyperglycemia.
 Subjective findings- polyuria, polydipsia, nocturnal enuresis and polyphagia with paradoxical weight
loss, visual changes and fatigue.
 Objective-dehydration (poor skin turgor and dry mucous), wt loss despite normal/increase appetite,
reduction in muscle mass. DKA (fatigue, cramping, abnormal breathing, halitosis (rotten fruit + nail
polish smell)
o Long-stand DM:
 retinopathy (1. dilation of retinal venules and retinal capillary microaneurysms. 2.
Increased vascular permeability. 3. Retinal ischemia due to vascular occlusion. 4.
Angiogenesis – proliferation of new retinal surface blood vessels. 5. Retinal hemorrhage
with fibrovascular proliferation and contraction, which may lead to retinal detachment
 All these findings should be referred to an ophthalmologist.
 Skin complications: chronic pyogenic infections or necrobiosis lipoidica diabeticorum
(plaques with shiny yellow surface on anterior surfaces of legs or dorsal aspects of
ankles)
 Paresthesia to distal extremities (foot ulcers, burns on hands from cooking)
 Gaze deviations in affected eyes from cranial nerve palsies


Type 2: Type 2 DM is characterized by the abnormal secretion of insulin, resistance to the action of insulin in
the target tissues, and/or an inadequate response at the level of the insulin receptor. A patient may,
however, present with pruritus, fatigue, neuropathic complaints such as numbness and tingling, or
blurred vision.

,Risk factors: most common ethnicity
Race/Ethnicity
• African American
• Latino
• Native American
• Asian American
• Pacific Islander


Diabetes Diagnostic Criteria
 Hbg A1C of 6.5% or higher
 Symptoms of diabetes (polyuria, polydipsia, weight loss) + a random plasma glucose of 200 or higher
 Fasting plasma glucose of 126 or higher (fasting for 8 hours)
 Two-hour plasma glucose level of 200 or higher during an oral glucose tolerance test (with a 75 g
glucose load)

*** In the absence of unequivocal hyperglycemia results should be confirmed by repeat testing on a
new blood sample without delay, preferably using the same type of test ***

 *All above-but confirmation of type 2 diabetes mellitus requires: two fasting blood glucoses ≥126
mg/dL or two random blood glucoses ≥200 mg/dL.
 You do not screen for type 1 diabetes but you do screen for type 2 if an individual is overweight or
obese, regardless of age, and for all adults aged 45 years and older. Tests should be repeated at a
minimum of 3 year intervals


Initial treatment recommendations- first line treatment for each type
Type 1 DM:
First line: Insulin
 Goal is to normalize the elevated blood glucose level
 Insulin regimen to achieve plasma glucose levels:
o Before meals: 80-130,
o Peak postprandial (1-2 hours after the beginning of a meal): < 180
o Hgb A1C < 7%
 The 2017 ADA standards: the majority of T1DM should be treated with multiple daily injections of
prandial insulin and daily basal insulin or with a continuous SQ insulin infusion pump

Drugs for Type 1 DM
o Single-Dose Therapy
 Single Injection
 Intermediate or long-acting insulin with or without regular insulin in the morning
 Or
 Intermediate or long acting insulin at bedtime
 Recommended at a minimum SMBG in the morning and at bedtime

,o Conventional Split-Dose Therapy
 Two Injections
 Mixture of NPH and regular insulin in the morning and evening
 Recommended at a minimum SMBG before each dosing and at bedtime
o Intensive Insulin Therapy
 Three Injections
 NPH + regular insulin in the morning; regular insulin at dinner; NPH insulin at bedtime
 Monitor for increased risk of hypoglycemic episodes
 Four injections
 Regular or lispro insulin before meals and long-acting insulin to maintain basal insulin levels
 Monitor for increased risk of hypoglycemic episodes


TYPES OF INSULIN
Class Type Onset Peak Duration
Insulin Glulisine Apidra < 5 min 1-2 hours 2-3 hours
Insulin Aspart Novolog < 10 min 1-3 hours 3-5 hours
Insulin Lispro Humalog < 15 min 1-2 hours 3-4 hours
Regular Insulin Humulin R 30-60 min 2-6 hours 6-8 hours
Iletin II Regular 30-60 min 2-6 hours 6-8 hours
Novolin R 30-60 min 2-6 hours 6-8 hours
Purified Pork Regular 30-60 min 2-6 hours 6-8 hours
Velosulin 30-60 min 2-4 hours 6-8 hours
Insulin (NPH) Humulin N 1-1.5 hours 4-12 hours 18-24 hours
Iletin II NPH 1-1.5 hours 4-12 hours 18-24 hours
Novolin N 1-1.5 hours 4-12 hours 18-24 hours
Purified Pork NPH 1-1.5 hours 4-12 hours 18-24 hours
NPH/Regular Humulin 70/30 30-60 min 2-12 hours 24 hours
Humulin 50/50 30-60 min 3-5 hours 24 hours
Novolin 70/30 30-60 min 2-12 hours 24 hours
Insulin Glargine Lantus Gradual onset Peakless Up to 24 hours
Insulin Detemir Levemir Gradual onset 6-10 hours Up to 24 hours


Type 2 DM Treatment
First line: Lifestyle Management
 Nutrition therapy
 Activity prescriptions for exercise
 Decreased prolonged sitting
 Older adults: training in balance and flexibility
 Mental health
 Proper sleep
 Smoking cessation
 Obesity management
 Diabetes self-management education and diabetes self-management support at the time of diagnosis
 Treatment directed at both risk reduction and glycemic control

Pharmacological therapy

,  When lifestyle management does not result in adequate blood glucose control
 Metformin if no contraindications (renal disease or abnormal creatinine clearance, acute MI, or
septicemia)-
o Not for patients with an eGFR < 45
 If Hgb A1C is > 7.5% at the time of diagnosis or after 3 months of monotherapy
o Add second agent

How to adjust diabetes meds
 At diagnosis of T2DM, begin lifestyle therapy with medically assisted obesity treatment
 After 3 months, if glycemic goals are not met, begin a single-agent or dual therapy with antidiabetic
agents, depending on whether A1C is < or > 7.5%
 If glycemic controls are not met in 3 months, initiate triple therapy
 If after 3 additional months (or at the time of diagnosis) A1C is 9.0% or higher and the patient is
symptomatic, add insulin therapy

Glycemic control qualifications
 A1C over 2-3 months and is helpful in documenting control and continuing care
 A1C < 7% indicates strong control
 6.5% or less decreases occurrence of complications achieved w/o hypoglycemia or other adverse
effects

Noninsulin Agents for T2DM
Drug Class & Examples Indication Adverse Reactions and Prescribing
Considerations
Biguanides  Monotherapy  Monitor for hypoglycemia
 Metformin (Glucophage)  May be used as an adjunct (especially in older adults.
to diet in T2DM or with a AE: GI disturbances and
sulfonylurea or insulin metallic taste.
therapy  CI: renal disease; renal
function should be tested
before starting
1st gen Sulfonylureas (no longer  For use as an adjunct to AE:
recommended, given new agents) diet and exercise in T2DM  Hypoglycemia (with high
 Chlorpropamide (largely replaced by 2nd gen doses or in fasting
(Diabinese) sulfonylureas) patients)
 Tolbutamide (Orinase)  Weight gain
 Headache
 GI upset
 Skin rashes
 Severe anemia
 Hypersensitivity
 Increased risk of
cardiovascular mortality

CI:
 Impaired liver or kidney
function
 Not for use in T1DM or