management of diabetes mellitus
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Management of Diabetes MellitusTRANSCRIPT
MANAGEMENT OF DIABETES
Prapared by maria carmela l. domocmat, rn, msn
Medical Management of DM
No cure Goal: Euglycemia and prevention of
complications Individualized treatment plans
Appropriate goal setting Diet Exercise Self-monitoring of blood glucose (SMBG) Regular monitoring for complications Laboratory assessment Oral meds/insulin
Surgical management of DM
pancreas transplant
not usually done
Islet cell transplants
Dietary management
Dietary management of DM Foundation of Diabetic control
Goals Maintain near-normal blood glucose levels
Achieve optimal serum lipid levels
Provide adequate calories for reasonable weight
Prevent & treat acute complications of insulin-treated diabetes
Improve overall health through optimal nutrition
Diet Composition
Carbohydrates: 60 – 70% of daily diet Protein: 15 – 20% of daily diet Fats: No more than 10% of total calories from
saturated fats Fiber: 20 to 35 grams/day; promotes intestinal
motility and gives feeling of fullness Sodium: recommended intake 1000 mg per 1000
kcal Sweeteners approved by FDA instead of refined
sugars Limited use of alcohol: potential hypoglycemic
effect of insulin and oral hypoglycemics
The exchange system
Six categories
Bread/starch
Meat
Milk
Vegetable
Fruit
Fat
General guidelines of Dietary Management
Protein
20%
Fat
20%
Carbohydrates
60%
ADA: American Diabetic Association
Diabetic Meal Plan
Small frequent meals
CONSISTENCY! Amount of calories
Amount of carbohydrates
Time
Snacks
Diabetic Meal Plan
If the pt is obese, the key to treatment is…
Weight los!
Sweeteners
Nutritive sweeteners
Not calorie free
Cause less h in BS (than regular sugar)
Sorbitol laxative effect
Non-nutritive sweeteners
Minimal or no calories
Do not h BS
Meal Plan considerations
Food preferences
Lifestyle
Schedule
Ethnic / Cultural background
Alcohol and Diabetes
Increase risk of…
Hypoglycemia
Affects the liver
Don’t take on empty stomach
Esp. if on insulin or oral hypoglycemic meds
Moderation
Exercise
Exercise and Diabetes
i blood glucose levels
h the uptake of glucose by body muscle
Potentiates action of insulin
i insulin requirement
Effect lasts 24 hours
More Benefits of exercise
Increases circulation
Improve serum lipid levels
Improves cardiovascular status
Assist with wt control
Decreases stress
Rules for the exercising diabetic
Talk to MD first
Regular vs. sporadic
Correlate exercise and glucose levels
Don’t exercise when hypoglycemic
Don’t exercise when hyperglycemic >250
Rules for the exercising diabetic
Do not exercise when insulin is peaking
Carry a quick source of sugar
Best time = 60-90 minutes after a meal
Rules for the exercising diabetic
Proper footwear
May need a pre-exercise snack
Consistency!
Self monitoring of blood glucose (SMBG)
Monitoring Glucose
SMBG
Glucometers
Urine testing for glucose 2-4 times a day
Continuous glucose monitoring system
Monitoring Ketone levels
Dipstick method
Perform when:
Glucosuria
Unexplained elevated glucose level
Illness
Pregnancy
Foot care
Regular monitoring for complications
Foot care
Foot Care
Inspect feet daily
Wash feet with warm water and mild soap
Pat dry – do not rub
Wash daily: wash feet in warm water every day, using a mild soap.
Dry between toes
Lubricate dry feet
Inspect
Mirror
Family
Between toes
Do not soak feet. Dry feet well,
especially between the toes.
If the skin on feet is dry, keep it moist by applying lotion after washing and drying.
Apply lotion on feet (not interdigital areas)
Foot care
Check toenails once a week.
Trim toenails with a nail clipper straight across.
Do not round off the corners of toenails or cut down on the sides of the nails.
After clipping, smooth the nails with an emery board.
Foot care
Always wear socks or stockings with soft elastic, and that fit feet.
Wear socks at night if feet get cold.
Always wear closed-toed shoes or slippers.
Do not wear sandals and do not walk barefoot, even around the house.
Foot care
Wear comfortable properly fitted shoes
Buy shoes made of canvas or leather and break them in slowly.
Extra wide shoes are also available in specialty stores that will allow for more room for the foot for people with foot deformities.
Break in new pair of shoes for 1 -2 hours only until it becomes comfortable
Foot care
Maintain the blood flowing to feet
Elevate feet up when sitting
Do not wear knee high/ stay up stockings
Foot care
wiggle toes and move ankles several times a day
don't cross legs for long periods of time
Avoid activities that icirculation
Smoking
Crossing legs
Tight socks
Good shoes
Comfortable
Closed toe
No bare feet
New shoes Break in slowly
Prevent injuries
Wear socks
Cotton
Light color
No wrinkles
Check inside of shoe
No temperature extremes
Check bath water
No water bottles
No heating pads
See doctor regularly
Podiatrist
Trim straight across
Do not cut calluses or corns
Range of Motion
Foot care
see podiatrist q2 to 3 months for check-ups, even if don't have any foot problems.
include inspection of skin
check for redness or warmth of the skin.
check for pulses and temperature of feet
Monofilament assessment of foot sensation
When to contact Dr?
Changes in skin color Changes in skin temperature Swelling in the foot or ankle Pain in the legs Open sores on the feet that are slow to heal or
are draining Ingrown toenails or toenails infected with fungus Corns or calluses Dry cracks in the skin, especially around the heel Unusal and/or persistent foot odor
Risk for infection
Frequent hand washing Early recognition of signs of infection and
seeking treatment Meticulous skin care Regular dental examinations and consistent oral
hygiene care
Sexual dysfunction
Effects of high blood sugar on sexual functioning,
Resources for treatment of impotence, sexual dysfunction
MANAGEMENT DM: PHARMACOLOGIC MGMT
Oral Hypoglycemic Agents
Oral hypoglycemic meds are NOT Insulin
Oral hypoglycemic meds require some production of insulin
Oral hypoglycemic agents are used in the treatment of type 2DM
Oral hypoglycemic meds are meant to supplement diet and exercise, NOT replace them
Oral Hypoglycemic Agents
Oral hypoglycemic meds cannot be used during pregnancy
Oral hypoglycemic meds may need to be halted temporarily and insulin prescribed if BS levels rise due to infection, trauma, stress, surgery etc.
Action vary so effect may be enhanced by use of multiple meds
Oral Medication
Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists
Biguanides
Metformin (Glucophage)
first choice for oral type 2 diabetes treatment.
Action: decreases overproduction of glucose by liver and makes insulin more effective in peripheral tissues
Biguanides
Major side effects : anorexia/ wt. Loss
CI in patients with Renal impairment
D/C temp of (+) illness that leads to dehydration or hypoperfusion --lactic acidosis.
Sulfonylureas
Glyburide (Micronase, DiaBeta, Glynase)
Glipizide (Glucotrol, Glucotrol XL)
Glimepiride (Amaryl)
Cholpropamide (Diabanese)
Sulfonylureas
Action: Stimulates pancreatic cells to secrete more insulin and increases sensitivity of peripheral tissues to insulin
(insulin secretagogues)
indicated for use as adjuncts to diet and exercise in adult patients with type 2 DM
Used: to treat non-obese Type 2 diabetics
Sulfonylureas
taken with food
except Glucotrol/Glipizide : taken 30 mins before meals
Sulfonylureas
(esp. Diabinese) when taken with alcohol can cause severe Disulfiram reactions
Disulfiram (antibus): a compound when used with alcohol produces distressing symptoms
Symptoms: Flushed skin, N/V, palpitations, hyperventilation
Side-effects
Hypoglycemia
GI upset
Meglitinides
Repaglinide (Prandin)
Nateglinide (Starlix)
Action: stimulates pancreatic cells to secret more insulin
much shorter-acting insulin secretagogues than the sulfonylureas
may be used in patients who have allergy to sulfonylurea medications.
Alpha-glucosidase inhibitors
Acarbose (Precose)
Miglitol (Glyset)
Action: Slow carbohydrate digestion and delay glucose absorption
S/E : diarrhea & flatulence
Take immediately before meals
Thiazolidinediones (TZDs)
Pioglitazone [Actos]
Rosiglitazone [Avandia]
Used for patients with type 2 DM who take insulin injections Acts by increasing insulin action at the receptor site
reduce insulin resistance
act as insulin sensitizers; thus, they require the presence of insulin to work.
must be taken for 12-16 weeks to achieve maximal effect.
Thiazolidinediones (TZDs)
Affects liver function liver function tests
Indications of altered liver function
Yellow skin tone
Nausea
Abdominal pain
Dark urine
Drug Interactions
Directly interact with Sulfonylurea and increase risk of hypoglycemia
Sulfonylurea+ * Med = Hypoglycemia
Sulfonamides
NSAIDS
Drug Interactions
h blood glucose levels
Regardless of what med you might also be taking
Potassium-losing diuretics
Corticosteriods
Estrogen compounds
Phenytoin (Dilantin)
Salicylates (ASA)
Drug interactions
Meds that cause Hypoglycemia
Without drug interaction
Acetaminophen
Alcohol
Monoamine oxidase inhibitors / MAO inhibitors
Drug interactions
Meds that can MASK signs and symptoms of Hypoglycemia
Propranolol (Inderal)
Oral Hypoglycemic Agents
Client must also maintain prescribed diet and exercise program; monitor blood glucose levels
Not used with pregnant or lactating women Specific drug interactions may affect the blood
glucose levels
Insulin
Instituted in 1923
Beef
Pork
1979 – human insulin
Can not be taken by mouth (digested)
Onset – Peak - Duration
Onset
The time period from injection to when it begins to take effect
Peak
When insulin is working its hardest and therefore blood glucose levels are at their lowest
Duration
Length of time the insulin works or lasts
Types
Rapid-acting insulins or Ultra short-acting
Short-Acting Insulins
Intermediate-Acting Insulins
Long-Acting Insulins
Rapid-acting insulins/ or Ultra short-acting
have a short duration of action
appropriate for use before meals or when blood glucose levels exceed target levels and correction doses are needed.
These agents are associated with less hypoglycemia than regular insulin.
Rapid-Acting Insulins/ or Ultra short-acting
Insulin aspart (NovoLog)
Insulin glulisine (Apidra)
Insulin lispro (Humalog)
Rapid-Acting Insulins
Insulin aspart (NovoLog)
Insulin glulisine (Apidra)
Insulin lispro (Humalog)
Insulin pumps
Rapid reduction of glucose level
Appearance Onset Peak Duration
Clear 5-15 minutes
(10 min)
30-90 (1hr) 3-5 hours
(4 hrs)
Short-Acting Insulins
Regular insulin (Humulin R, Novolin R)
Preparations:
mixture of 70% neutral protamine Hagedorn (NPH) and 30% regular human insulin
(ie, Novolin 70/30, Humulin 70/30)
Short-Acting Insulins
Humalog R; Novolin R; Iletin II Regular
Administered 20-30 minutes before meals
IV
Usually given 4 x a day
May to taken alone or in combination
Appearance Onset Peak Duration
Clear ½ - 1 hr
(1 hour)
2-4 hrs
(3 hour)
4-6 hrs
(5 hours)
Intermediate-Acting Insulins
Insulin NPH (Humulin N, Novolin N)
have a slow onset of action and a longer duration of action.
commonly combined with faster-acting insulins to maximize the benefits of a single injection
onset of action: 3-4 hours.
Peak: 8-14 hours duration of action : 16-24
hrs appears cloudy must be gently mixed
and checked for clumping
if clumping occurs, the insulin should be discarded.
Intermediate-Acting Insulins
Insulin NPH (Humulin N, Novolin N)
Administer after meals
Usually given 2x a day
Eat at onset!
Appearance Onset Peak Duration
Cloudy 2-4 hrs
(2 hrs)
6-12 hrs
(12 hrs)
16-20 hrs
(24 hrs)
Long-Acting Insulins
provide a longer duration of action, and, when combined with rapid- or short-acting insulins, they provide better glucose control
Insulin detemir (Levemir)
Insulin Glargine (Lantus)
Types of Insulin – Long-acting
Ultra Lente (UL)
To control fasting glucose levels
Cannot be mixed!
Appearance Onset Peak Duration
Cloudy 4-8hour
(6 hrs)
10-30 hrs
(24 hrs)
36+ hours
(36 hrs)
Long-Acting Insulins
Insulin detemir
for once- or twice-daily dosing
duration of action is up to 24 hours
Insulin glargine
onset of action: 4-8 hours
Duration: 24 hours.
Peak effects; 16-18 hrs
FDA has advised of a possible association of insulin glargine with an increased risk of cancer
Rapid-Acting Insulins
Appearance Onset Peak Duration
Clear 5-15 minutes
(10 min)
30-90
(1hr)
3-5 hours
(4 hrs)
Short-Acting Insulins
Appearance Onset Peak Duration
Clear ½ - 1 hr
(1 hour)
2-4 hrs
(3 hour)
4-6 hrs
(5 hours)
Learning Tip: Even and Odd
Short-acting think odd
(1-3-5)
Intermediate-acting think even
(2-12-24)
Intermediate-Acting Insulins
Appearance Onset Peak Duration
Cloudy 2-4 hrs
(2 hrs)
6-12 hrs
(12 hrs)
16-20 hrs
(24 hrs)
Long-acting insulin
Appearance Onset Peak Duration
Cloudy 4-8hour
(6 hrs)
10-30 hrs
(24 hrs)
36+ hours
(36 hrs)
When should insulin be administered
Short-acting / regular
30 minutes before meals
Do not allow more than 30 minutes to pass by without eating
hypoglycemia
Intermediate acting
After meals
If mixed (regular & intermediate)
30 minutes before meals
What route is insulin administered
Sub-cutaneous
IV
Regular
Pump
Insulin Type Onset Peak Duration
Ultra Short 15 mins 30-90 mins 2- 4 hrs
Short 30 mins 2- 4 hrs 6-8 hrs
Intermediate 1-2 hrs 6-12 hrs 18-24 hrs
Long 4-6 hrs 16-24 hrs 18-36 hrs
Combination
70/30
30-60
mins then
1-2 hrs
2- 4 hrs,
then 6-12
hrs
6-8hrs,then
18-24 hrs
Insulin Type Onset Peak Duration
Insulin
glargine
30-60
minutes
None 24 hours
Diabetes Mellitus
Mixing insulin
Adverse effects of insulin
Local allergic reactions
Insulin lipodystrophy
Insulin resistance
Dawn Phenomenon
Somogyi phenomenon
Insulin waning
Adverse effects of insulin
Insulin lipodystrophy or lipoatrophy
is primary idiopathic atrophy of adipose tissue
can be a lump or small dent in the skin that forms when a person keeps performing injections in the same spot.
Insulin lipodystrophy lipohypertrophy
Rotate site of injection
Nursing Responsibilities
Route : Subcutaneous
Steady absorption
Less painful
IV – in emergency cases ( DKA)
Only regular insulin is given through the IV route
Do not massage the site
Fastest absorption site is the abdomen, then deltoids, thighs then buttocks
Administer at room temperature Cold insulin causes lipodystrophy
Rotate site of injection To prevent lipodystrophy. Inhibits insulin
absorption
Store vial of insulin in current use at room temperature Other vials should be refrigerated
Nursing Responsibilities
Gently roll vial in between the palms to redistribute insulin particles Do not shake. Bubbles make it difficult to
redistribute insulin particles
Nursing Responsibilities
Nursing Responsibilities
Observe for side effects
Localized
Induration or redness
Swelling
Lesions at the site
Lipodystrophy
Edema
Sudden resolution of hyperglycemia causes retention of water
Hypoglycemia
Somogyi Effect Rebound hyperglycemia
Normal or blood glucose levels are present at bedtime
hypoglycemia : occurs at 2-3am
This causes an increase in the production of counterregulatory hormones
Hyperglycemia: by 7 am
Resuts in response to the counterregulatory hormones
Somogyi Effect Treatment
decreasing evening (predinner or bedtime) dose of intermediate acting insulin
or increasing the bedtime snack
Dawn Phenomenon (6 AM – 8 AM) early AM increase in blood
glucose levels associated with release of growth hormone at 12 MN to 3 AM
Dawn Phenomenon:TREATMENT Type 1 diabetes
Intensify insulin therapy Avoid late night snacking, unless appropriate quick-
acting insulin is given.
Type 2 diabetes Adjust diet content (decrease carbohydrates) and
timing of the evening meal so that the glucose level at bedtime is 70-110 mg/dl
If dietary modification is not enough, consider an intermediate or long-acting sulfonylurea at evening meal.
Basal insulin is indicated if the dawn phenomenon continues.
Insulin Waning Progressive rise in the blood glucose levels
from bedtime to morning
Treatment:
Increase dose of evening intermediate acting or long acting insulin
Difference between dawn phen and insulin waning
10 PM 2 AM 4 AM 8 AM
Dawn Phenomenon
100 110 135 250
Waning of insulin
100 160 220 270
Dawn phenomenon shows an abrupt increase between 4 a.m. and 8 a.m., whereas waning of exogenous insulin effect shows gradual rise between 2 a.m. and 8 a.m.
Other meds
Glucagonlike peptide–1 (GLP-1 ) agonists
Exenatide injectable solution (Byetta)
Exenatide injectable suspension (Bydureon)
mimic the endogenous incretin GLP-1
it enhances glucose-dependent insulin secretion by pancreatic beta cells, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying.
Glucagonlike peptide–1 (GLP-1 ) agonists
Liraglutide (Victoza)
a once-daily injectable
stimulates G-protein in pancreatic beta cells.
Dipeptidyl peptidase IV (DPP-4) inhibitors
prolong action of incretin hormones
Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Linagliptin (Tradjenta)
Amylinomimetics
Pramlintide acetate (Symlin)
amylin analog that mimics the effects of endogenous amylin, which is secreted by pancreatic beta cells.
delays gastric emptying, decreases postprandial glucagon release, and modulates appetite.
Bile acid sequestrants
bile acid sequestrant colesevelam
lipid-lowering agents for the treatment of hypercholesterolemia but were subsequently found to have a glucose-lowering effect.
Antiparkinson Agents, Dopamine Agonists Bromocriptine (Cycloset)
Quick-release bromocriptine acts on circadian neuronal activities within the hypothalamus to reset the abnormally elevated hypothalamic drive for increased plasma glucose, triglyceride, and free fatty acid levels in fasting and postprandial states in patients with insulin resistance.
indicated as an adjunct to diet and exercise to improve glycemic control.
Non-Insulin Injectables
New drugs are available for people with type 2 diabetes.
Pramlintide (Symlin), exenatide (Byetta), and liraglutide (Victoza) are non-insulin injectable drugs.
insulin pulls glucose into the cells
these medications cause the body to release insulin to control blood sugar levels.
Other meds
Glucagonlike peptide–1 (GLP-1 ) agonists
Exenatide injectable solution (Byetta)
Exenatide injectable suspension (Bydureon)
mimic the endogenous incretin GLP-1
it enhances glucose-dependent insulin secretion by pancreatic beta cells, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying.
Glucagonlike peptide–1 (GLP-1 ) agonists
Liraglutide (Victoza)
a once-daily injectable
stimulates G-protein in pancreatic beta cells.
Dipeptidyl peptidase IV (DPP-4) inhibitors
prolong action of incretin hormones
Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Linagliptin (Tradjenta)
Amylinomimetics
Pramlintide acetate (Symlin)
amylin analog that mimics the effects of endogenous amylin, which is secreted by pancreatic beta cells.
delays gastric emptying, decreases postprandial glucagon release, and modulates appetite.
Bile acid sequestrants
bile acid sequestrant colesevelam
lipid-lowering agents for the treatment of hypercholesterolemia but were subsequently found to have a glucose-lowering effect.
Antiparkinson Agents, Dopamine Agonists Bromocriptine (Cycloset)
Quick-release bromocriptine acts on circadian neuronal activities within the hypothalamus to reset the abnormally elevated hypothalamic drive for increased plasma glucose, triglyceride, and free fatty acid levels in fasting and postprandial states in patients with insulin resistance.
indicated as an adjunct to diet and exercise to improve glycemic control.