Diabetes Mellitus
Ibrahim Sales, Pharm.D.
Assistant Professor of Clinical Pharmacy
King Saud University
isales@ksu.edu.sa
Hyperglycemic Crises in Diabetes
• Diabetes ketoacidosis (DKA) and hyperosmolar
hyperglycemic state (HHS)
• Type 1 and Type 2 diabetes
• Insulin deficiency and increased
counterregulatory hormones leads to free fatty
acids release and hepatic fatty acid oxidation to
ketone bodies in DKA
• Insulin concentrations inadequate for glucose
uptake, but adequate to prevent ketogenesis in
HHS
Precipitating Factors
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The most common is infection
Cerebrovascular accident
Alcohol abuse
Pancreatitis
Myocardial infarction
Trauma
Drugs (corticosteroids, thiazides,
sympathomimetic agents)
Signs and Symptoms
• HHS evolves over several days to weeks
• Symptoms of DKA may be present over several
days; ketoacidosis-related metabolic alterations
usually occur in < 24 hours
• Polyuria, polydipsia, polyphagia, weight loss,
vomiting, abdominal pain (DKA only),
dehydration, weakness, clouding of sensoria
• Poor skin turgor, Kussmaul respirations (DKA),
tachycardia, hypotension, alteration in mental
status, shock, coma (more frequent in HHS)
Diagnosis
Fluid Therapy
• Goals: expansion of intravascular and
extravascular volume and restoration of renal
perfusion
• 0.9% NaCl at the rate of 15-20mL/kg per hour or
1-1.5L during the first hour
• Hypernatremic or eunatremic, 0.45% NaCl
infused at 4-14mL/kg/hour
• Hyponatremic, 0.9% NaCl infused at 414mL/kg/hour
• Replace half of the estimated water deficit over a
period of 12-24 hours
Fluid Therapy
• Patients with DKA and HHS require calories for
proper metabolism of ketone bodies
• DKA: When blood glucose falls below
200mg/dL, change to 5% dextrose with
0.45%NaCl at a rate of 150-250mL/hour
• In HHS, When blood glucose falls between
200-250mg/dL, change to 5% dextrose with
0.45%NaCl at a rate of 150-250mL/hour
Insulin Therapy
• Potassium value should be >3.3mEq/L
• IV bolus of regular insulin (0.1 units/kg body
weight)
• Continuous infusion of regular insulin (0.1
units/kg/hr)
• Optimal rate of glucose reduction between 50-70
mg/hr
• Decrease rate to 0.05 – 0.1 units/kg/hr when
glucose reaches 200mg/dL (DKA); 300mg/dL
(HHS)
Insulin Therapy
Blood should be drawn every 2–4 h for determination of serum electrolytes, glucose,
blood urea nitrogen, creatinine, osmolality, and venous pH (for DKA).
DKA
• Criteria for resolution of
DKA include:
– Glucose 200 mg/dL
– Serum bicarbonate 18 mEq/L
– Venous pH 7.3
• Keep serum glucose
between 150 and 200mg/dL
until resolution
HHS
• Keep serum glucose
between 250 and 300 until
plasma osmolality is ≤315
mOsm/kg and patient is
mentally alert
Insulin Therapy
• When the patient is able to eat, start a
multiple-dose insulin schedule
• Continue IV insulin for 1–2 h after the SQ
insulin
• Continue IV insulin in patients n.p.o.
• Continue previous doses prior to admission in
patients with known DM
• Start a basal and bolus insulin schedule in
insulin naïve patients (0.5-0.8 units/kg/day)
Potassium
• Hyperkalemia on presentation is common
• Initiate K+ after serum levels <5.3mEq/L
• 20–30 mEq K+ in each liter of infusion fluid to
maintain a concentration between 4-5mEq/L
• Hypokalemia: delay insulin until K+ is
>3.3mEq/L
Bicarbonate and Phosphate
Bicarbonate
• Insulin blocks lipolysis and
resolves ketoacidosis
without any added
bicarbonate
• Give 50 mmol of
bicarbonate in 200 ml of
sterile water with 10 mEq
KCL over two hours to
maintain the pH at > 7.0 in
patients with pH between
6.9 and 7.0
Phosphate
• Serum phosphate is often
normal or increased at
presentation
• Phosphate concentration
decreases with insulin
therapy
• When needed, 20 –30
mEq/L potassium
phosphate can be added to
replacement fluids
Prevention of DKA and HHS
• Prevention is the key (better access to medical care, proper
education, effective communication with a health care
provider during illness)
• Sick-day management should include the following
information:
1)
2)
3)
4)
When to contact the health care provider
Blood glucose goals and the use of supplemental short or
rapid-acting insulin during illness
Means to suppress fever and treat infection
Initiation of an easily digestible liquid diet containing
carbohydrates and salt
• Advise all patients to never discontinue insulin and to seek
professional advice early in the course of the illness
Case 4: Neuropathy
AF is a 74 y/o female with Type 2 DM. She has
neuropathy in her feet and was recently started
on Lantus 10 units at bedtime. She is
complaining that the burning in her feet has
gotten worse since she started taking Lantus.
She didn’t take the insulin last night for that
reason. What do you advise?
Circulation Comparison
Molasses vs. Water
Diabetes Mellitus
Ibrahim Sales, Pharm.D.
Assistant Professor of Clinical Pharmacy
King Saud University
isales@ksu.edu.sa