DIABETES Mary Bruskewitz APNP, MS, BC-ADM Clinical Nurse Specialist Diabetes November 2013 mbruskewitz@outlook.com
Objectives Part 1 Overview of Endocrine Physiology Pathophysiology of Diabetes Diabetes Medications Part 2 Acute & Chronic Complications Case examples 11/8/13 UWHealth 2
Endocrine System Glands that produce and secrete hormones, chemical substances produced in the body that regulate the activity of cells or organs. These hormones regulate the body's growth, metabolism (the physical and chemical processes of the body), and sexual development and function. 11/8/13 UWHealth 3
Feedback Regulation The hormones that are regulated by the pituitary gland, a signal is sent from the hypothalamus to the pituitary gland in the form of a "releasing hormone," which stimulates the pituitary to secrete a "stimulating hormone" into the circulation. The stimulating hormone then signals the target gland to secrete its hormone. As the level of this hormone rises in the circulation, the hypothalamus and the pituitary gland shut down secretion of the releasing hormone and the stimulating hormone, which in turn slows the secretion by the target gland. 11/8/13 UWHealth 4
Hypothalamic - Pituitary System Hypothalamic Releasing Hormone Pituitary Stimulating Hormone Hormone TRH (thyroid releasing) TSH (thyroid stimulating) T3 (active) & T4 (thyroxine) CRF (corticotropin releasing) ACTH (adenocorticotropin) Cortisol LHRH (luteinizing releasing) GHRH (gonadatropin releasing) FSH (follicle stimulating) LH (luteinizing) FSH & LH Growth Hormone releasing Growth Hormone IGF- 1 11/8/13 UWHealth 5
Thyroid Parathyroid T3 (active), T4 thyroxine) PTH Metabolism, HR, BP, digestion, muscle tone, reproduction Calcium levels, bone growth Adrenal Cortex Corticosteroids Sodium and water balance, stress response Adrenal Medulla Catecholamines (adrenaline) HR, BP, stress response Pineal Melatonin Regulates sleep wake cycle Reproductive Testes & Ovaries Testes = Testosterone Ovaries = Estrogen, Progesterone Reproduction, growth 11/8/13 UWHealth 6 Pancreas Insulin, glucagon, somatistatin, amylin Glucose Regulation
Hormone Tissue Metabolic Effect Glucose Hormonal Effect on BG Epinephrine Adrenal Medulla 1) Enhances release of glucose from glycogen 2) Enhances release of fatty acids from adipose tissue Raises Cortisol Adrenal Cortex 1) Enhances gluconeogenesis 2) Antagonizes Insulin. ACTH Anterior pituitary 1) Enhances release of cortisol 2) Enhances release of fatty acids from adipose tissue. Raises Raises Growth Hormone Anterior pituitary Antagonizes Insulin Raises Thyroxine Thyroid 1) Enhances release of glucose from glycogen 2) Enhances absorption of sugars from intestine Raises 11/8/13 UWHealth 7
Diabetes Insipidus Caused by problems related to the hormone anti diuretic hormone (ADH) or its receptor. There are two types of diabetes insipidus (rare) Central = lack of ADH production due to damage to the pituitary gland or hypothalamus Nephrogenic = lack of response of the kidney to ADH. May be due to diseases of the kidney (such as polycystic kidney disease), certain drugs (such as lithium), and can also occur an inherited disorder 11/8/13 UWHealth 8
Types of Diabetes Type 1 Type 2 LADA (Latent Onset Diabetes in Adult) Medication Gestational Other 11/8/13 UWHealth 9
Initial Treatment BG under control Type of diabetes is not as important as control, as first step Control survivor steps first 11/8/13 UWHealth 10
Type 1 vs. Type 2 Type 1 Autoimmune & genetic Absolute lack of insulin Requires insulin & sensitive Acute onset Profound hyperglycemia Ketosis Possible causes (genetic, viral) 5% all diabetes Hereditary Type 2 Slow onset, with/out symptoms Impaired insulin secretion & resistant Multiple risk factors (age, obesity, inactivity, HTN, cholesterol, gestational, minority) 85 95% & epidemic (children) Complications at diagnosis (not in children) 11/8/13 UWHealth 11
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LADA vs T1 Onset Initial treatment GAD 11/8/13 UWHealth 14
Type 2 a Progressive Disease: Natural History of Type 2 Diabetes Post meal glucose β - - 11/8/13 UWHealth 15
Other Medication Induced, Steroid Alcoholism Illicit Drugs Pancreatitis Cystic Fibrosis Liver Disease Cancer and treatment HIV 11/8/13 UWHealth 16
PreDiabetes Borderline Touch of sugar Impaired glucose metabolism (IGT) Impaired postprandial glucose (IPPG) Impaired FBG Syndrome X Metabolic Syndrome 11/8/13 UWHealth 17
Diagnostic Criteria Non-Diabetes Fasting 70-100 mg/dl 2 hr after meal Diabetes Fasting =/> 126 mg/dl x 2 tests 2 hr after meal Under 140 mg/dl Random Under 140 mg/d A1c under 5.6% Greater than 200 mg/dl x 2 tests Random Greater than 200 mg/dl & symptomatic 11/8/13 UWHealth 18 A1c > 6.5%
Impaired Fasting Glucose (Pre-Diabetes) If undiagnosed, will develop T2 DM Risk is higher with risk factors Will start treatment A1C 5.7 to 6.4% Fasting BG > 100 < 126 mg/dl 2 hr > 140 < 200 mg/dl 11/8/13 UWHealth 19
Targets BG Fasting 70-100 mg/dl (ideal) Before meals: 80 mg/dl - 120 mg/dl 2 hrs after: 100 mg/dl - 140 mg/dl (ideal) Bedtime 120-130 mg/dl A1c: Individualized (normal, under 5.6%) 7% ADA 6.5% (ACCE) 11/8/13 UWHealth 20
Other Monitoring BP (<130/80) Cholesterol TC <200 Trig <150 HDL >40-45 (males) > 50-55 (females) LDL<100. Multiple CVD risk factors, < 70 Aspirin, debatable 11/8/13 UWHealth 21
Insulin Basal (covers non-eating states) Lantus (Glargine) Levemir (Detemir) NPH U-500 Regular Insulin (special order by endocrine only) Insulin pumps (Humalog, Novolog, Apidra, Regular, U500 Regular 11/8/13 UWHealth 22
Insulin Bolus (covers food) Short Acting Insulin Regular Insulin Rapid Acting Insulin Humalog (Lispro) Novolog (Aspart) Apidra (Glulisine) 11/8/13 UWHealth 23
Devices Needles or pens 4 mm (pen only) 5 mm (pen only) 8 mm (5/16 ) 12.7 mm (1/2 ) 1 (syringe only) Pumps 11/8/13 UWHealth 24
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Biganuides Metformin Oral Medications decreases amount of glucose produced by the liver Sulfonyureas Glipizide, Glimiperide, Glyburide Pancreas releases more insulin Thiazolidinediones (TZD) Use with caution Actos, Avandia Helps muscles and cells use insulin better Meglitinides Starlix, Prandin Beta cells release more insulin Alpha Glucosidase Inhibitors Rarely used (GI side effects) Acarbose, Miglitol Blocks the breakdown of starches DPP-4 Januvia, Onglyza, Tradjenta Decreases glucose by inhibiting DPP-4 via digestion process Injectables Synthetic hormone (Incretin mimetics/ GLP-1 analogue) Byetta Victoza Bydureon Insulin Sensitizers Symlin 11/8/13 UWHealth 26
Oral Diabetes Medications Sulfonylureas Increase pancreatic insulin secretions Improves A1c 1-1.5% SE: hypoglycemia (may be severe), weight gain Glyburide, Glipizide, Glimiperide Not recommended as 1 st line Inexpensive 11/8/13 UWHealth 27
Biguanides Decreases hepatic glucose production, especially early morning A1c 1-1.5% decrease SE: GI intolerance (self-limitiing), lactic acidosis Metformin 1 st drug of choice PreDiabetes Inexpensive 11/8/13 UWHealth 28
DPP-4 Increase GLP-1 (gut hormone) and GIP (glucose-like peptide) in response to food present Inhibit glucagon Increase insulin Decrease BG Decrease gastric emptying A1c 0.7% SE: nausea (self-limiting), pancreatitis Sitagliptin (Janivia) Sexagliptin (Onglyza) Linagliptin (Trajenta) Alogliptin 11/8/13 UWHealth 29
GLP-1 or Incretin Mimetics Increases insulin secretion in the presence of food Decreases glucagon secretion Delays gastric emptying Impact on satiety (Byetta effecton brain appetite center) A1C 1-2% SE: nausea (usually limited), pancreatitis Injected Exenatide (Byetta, Bydureon), Liraglutide (Victoza) 11/8/13 UWHealth 30
Diabetes Management Type 1 (LADA) Insulin Amylin, try PreDiabetes Metformin Type 2 Metformin DPP-4 GLP-1 Amylin 11/8/13 UWHealth 31