NR 601 Final Study Guide
Week 5- Glucose Metabolism Disorders/Obesity
Dunphy
Chapter 58: Diabetes Mellitus p.909-938
Kennedy
Chapter 14:
... [Show More] 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.
NR 601 WEEK 5 FINAL STUDY GUIDE
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
Metformin (Glucophage)
Monotherapy
May be used as an adjunct
to diet in T2DM or with a
sulfonylurea or insulin
therapy
Monitor for hypoglycemia
(especially in older adults.
AE: GI disturbances and
metallic taste.
CI: renal disease; renal
function should be tested
before starting
1
st gen Sulfonylureas (no longer
recommended, given new agents)
Chlorpropamide
(Diabinese)
Tolbutamide (Orinase)
For use as an adjunct to
diet and exercise in T2DM
(largely replaced by 2nd gen
sulfonylureas)
AE:
Hypoglycemia (with high
doses or in fasting
patients)
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
DKA
Worse safety profile than
2
nd gen sulfonylureas, so
no longer recommended
2
nd generation sulfonylureas
Glimepiride (Amaryl;
sometimes considered as
3
rd gen)
Glipizide (Glucotrol)
Glyburide (Diabeta,
Micronase)
For use an adjunct to diet and
exercise in T2DM
AE:
Same for 1st generation,
but with relatively
improved safety profile
than older agents
Increased potency by
weight compared to 1st gen
drugs
Alpha-Glucosidase Inhibitors
Acarbose (Precose)
Miglitol (Glyset)
For use as an adjunct to
diet and exercise in T2DM
Used as monotherapy or
added to insulin,
metformin, or a
sulfonylurea
AE:
Flatulence
Diarrhea
Abdominal pain (advise
patient to take with first
bite of main meal, starting
with a low dose and
gradually increasing)
CI:
DKA
Patients with inflammatory
bowel disease
Colonic ulceration
Intestinal obstruction
Chronic intestinal diseases
impacting digestion
Do not use if serum
creatinine is > 2
Use glucose (tablets, gel),
not fructose (such as fruit
juice) to treat
hypoglycemia as the
metabolism of complex
carbs will be inhibited
Thiazolidinediones
Pioglitazone (Actos)
Rosiglitazone (Avandia)
For use as an adjunct to
diet and exercise in T2DM
Used as monotherapy to
reduce insulin resistance
or added to metformin
Not for use with T1DM or
DKA
AE:
Exacerbation of CHF
Swelling of legs
Fluid retention
Weight gain
Upper URI
Hypersensitivity
Increased risk of bladder
tumors
CI:
Liver disease or if ALT is >
2.5 x upper limit of normal
Monitor transaminases at
baseline, every 2 months
for first 12 months, and
then periodically
D/C if levels increase or
jaundice occurs
CI in NY Heart Association
Class III or IV HF
May cause resumption of
ovulation in an
anovulatory patient (and
thus may result in
unintended pregnancy)
Dipeptidyl Peptidase-4 Inhibitors
Alogliptin (Nesina)
Linagliptin (Tradjenta)
Saxagliptin (Onglyza)
Sitagliptin (Januvia)
Can be used as
monotherapy as incretin
mimetic, but usually used
as an add-on drug for
T2DM
Available in combo with
metformin,
thiazolidinediones, and
sodium-glucose transport2 inhibitors
AE:
Stevens=Johnsons
syndrome
Nasopharyngitis
Diarrhea
Abdominal pain
Pancreatitis
Joint pain
Renal failure
May cause hypoglycemia
when used with
sulfonylureas
Glucagon-like Peptide-1
Analogues
Albiglutide (Tanzeum)
Dulaglutide (Trulicity)
Exenatide
(Byetta/Bydureon)
Liraglutide (Victoza)
Lixisenatide (Adlyxin)
Can be used as
monotherapy, but usually
used as an add-on drug for
T2DM
Available in combo with
insulin
AE:
Severe pancreatitis
Nausea
Dyspepsia
Injection site reactions
Arthralgia
CI:
Gastroparesis
Caution in patients with
renal impairment
Hx of multiple endocrine
neoplasia syndrome type 2
or medullary thyroid
carcinoma, given an
increased risk of thyroid Ccell tumors
Sodium-Glucose Ttansport-2
Inhibitors
Can be used as
monotherapy, but usually
AE:
Acute renal failure
Canaglifozin (Invokana)
Dapaglifozin (Farxiga)
Empaglifozin (Jardiance)
used as an add-on drug [Show Less]