Beta cells- insulin
alpha cells- glucagon
Stimulates uptake
Of glucose, FFA,
Amino acids
Stimulates glycogenolysis,
Lipolysis, GNG
Promotes anabolism Promotes BG, catabolism
& storage of energy,
of stored fuels
BG
In Type 1 DM, destruction of beta cells is viral or
Immune-mediated.
Monitoring:
Factors that affect Blood Glucose Levels
Food
Insulin
Deficiency
Stress
Illness
Infection
Glucagon
et al.
Too much
insulin or
oral agents
Not enough
food
Unusually
high activity
Skipped or
delayed meals
Three Examples:
Type I:
Basal/ Bolus Regimen-- Lispro (Humalog)/NPH
Premeal Humalog x 3
Bedtime NPH to control hyperglycemia at night
(may need some NPH mixed with Humalog
during the day to provide background insulin
throughout the day)
Split/Mixed NPH-Lispro Regimen
NPH/Humalog mixtures at morning and late pm
meals (~6 am & 6 pm)
(provides enough NPH for bkgd coverage during
the night)
Example 3: Type 2 DM
BIDS (Bedtime Insulin-Daytime Oral Agent)
Oral hypoglycemic medication(s)
(e.g., sulfonylureas, etc.) to keep PG
down during day.
Bedtime NPH insulin to keep hepatic glucose
production down during night.
Starting dose= wt (#) / 10
150# / 10 = 15 units NPH at bedtime
Increase 4-5 units/ wk until
FPG < 140 mg/dl
Metabolic Effects of Exercise in Type 1 DM
Adequate
Insulin Trt
Inadequate
Peripheral Glucose Uptake
Hepatic Glucose Output
Glucagon Production
Blood Glucose
Frequency of Monitoring
•
American Diabetes Assn. Clinical Practice
Recommendations (1998):
-
type 1:
frequent SMBG
(at least 3-4 x/ day)
-
type 2:
daily for those trted
with insulin, oral agents,
or both
Only use SMBG if a part of an integrated
treatment program.
Monitoring:
Goals
1.
Achieve and maintain target BG levels.
2.
Prevent and detect hypoglycemia.
3.
Adjust medication (e.g., insulin) with
with lifestyle changes (e.g., food and
physical activity).
4.
Serum Lipids, Blood Pressure, BMI
Monitoring:
1.
2.
3.
4.
Implementation
Establish target BG ranges
Determine frequency of monitoring
Record results
Identify patterns so that
medications
meal plans
physical activity
can be adjusted.
Hypoglycemia and its Management
Sx
Nervous
Headache
Sweating
Weakness
Confusion
Tremors
Lethargy
Mgmt Approaches
Assess BG, if possible
Start with quick-acting CHO sources:
glucose tabs or gel
1/2 c. sugar soft drink or juice
4-7 Lifesavers-type candy
1 c. of milk
Have a snack, unless before a meal
Look for cause of hypoglycemia
If an insulin user, inject glucagon.
Three Polys
Glycosuria
Weight Loss
fatigue
acetone
breath
Labored
breathing
(kussmaul
respirations)
Physical Activity in Type 1 DM
•
Confers great benefits but requires
good planning!
•
If BG <80 or > 300 = Don’t Exercise!!
•
BG varies widely even with small amounts
of exercise. Depends on control level.
•
Check PG before exercise. If moderate
activity, add 10-15 g CHO; if vigorous,
add 20-30 g CHO.
•
Check PG 30 min. before and 1 hour after
exercise.
Metabolic Effects of Exercise in Type 2 DM
Lipolysis
Decreased Plasma
Insulin
Lower Blood Glucose
Increased peripheral glucose uptake
Increased Insulin Sensitivity
When Therapy Changes
Multiple
Dose
Regimen
NPH + Humalog
BID
Add Bedtime NPH
to Orals
Combinations of Oral Agents:
Metformin + Sulfonylureas, etc.
Monotherapy Oral Agents: Sulfonylureas,
Metformin, Troglitazones, etc.
Meal Planning and Physical Activity
Evaluating Outcomes in DM Treatment
Outcomes Can Be:
Clinical
Economic
Quality of Life
Glycemic Control
HbA1c
Blood lipids
Weight/BMI
Blood pressure
Complications
length/stay Participation in
ER visits
care
costs to
- SMBG
health plan - keeps appts.
- Rx refills
Better work
Q of Life survey
attendance
Case Study: 12 y/o with Type 1 DM
Yusef
Pt presented with weight loss, polyuria, polydipsia
Dx: Type 1 DM
ER Visit post-Dx:
N/V/ Thirst, Fever, High BG
(~400)
Confused, Acetone Breath
Urine reveals glycosuria, ketonuria= DKA
Metabolic events leading to these Sx??
Gradual Loss of Pancreatic Beta Cell Function
Body loses major anabolic hormone= cells starve
Cell starvation leads to increase glucagon, attempt
to provide fuel to cell via gluconeogenesis.
None of the fuel reaches the cell-urinary loss
Extra water needed to clear glucose=polydipsia
(thirst)
Fat catabolized faster than used= ketone build-up
Symptoms of Diabetic Ketoacidosis
Nausea
Headache
Dry, itchy skin
Kussmaul Respiration
Positive urinary ketones
BG < 60 mg/ dl
Gradual Onset of Symptoms