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Intro to Diabetes Mellitus

Intro to Diabetes Mellitus. Angela Venturelli MS II Chelsey Villanueva MS II. Types of DM. Type 1: Autoimmune destruction of pancreatic beta cells (insulin producing cells). Insufficient production of insulin. More common in young people. Types of DM. Type 2

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Intro to Diabetes Mellitus

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  1. Intro to Diabetes Mellitus Angela Venturelli MS II Chelsey Villanueva MS II

  2. Types of DM • Type 1: • Autoimmune destruction of pancreatic beta cells (insulin producing cells). • Insufficient production of insulin. • More common in young people.

  3. Types of DM • Type 2 • Insulin resistance and inability of beta cells in pancreas to produce enough insulin to meet the needs of the body. • No clear reason why it happens, but connected to lifestyle and genetics. • More common in older people, but patients are becoming younger.

  4. Diagnosis of Diabetes 2010 ADA Guidelines (need ONE): http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html • HbA1c reading 6.5% or higher. • Fasting serum glucose is ≥ 126mg/dl. (Fasting= no caloric intake for 8 hrs.) • 2-hour 75 g glucose challenge test yields blood sugar ≥ 200 mg/dl. • Random glucose ≥ 200 and pt. is experiencing symptoms (polydipsia, polyuria, unexplained wt. loss…) * If results from1-3 are unclear then retest.

  5. The History Chief Complaint: • Polyuria • Polydipsia • Polyphagia • Recurrent Blurred Vision • Irritability/Mood Changes • Yeast Infections • Numbness or tingling in hands and or feet • Weight Loss • Dark spots on skin (AcanthosisNigricans)

  6. The History Past Medical History: • Previous DM diagnosis • HTN • Hyperlipidemia • Heart Conditions

  7. The History Past Hospitalizations: • Diabetic Ketoacidosis (DKA): • Happens when body cannot access glucose and starts breaking down fat to ketoacids. Emergency • Hypoglycemic Episode: • shaking, weakness, palpitations, trouble speaking, anxiety, hunger Past Surgeries

  8. The History Family History: • DM • Hypertension • Hyperlipidemia • Kidney Problems • Heart Conditions

  9. The History Social History: • Smoking • Drinking • Drugs • Diet • Exercise

  10. Physical Exam • Vitals: BMI, BP • HEENT: Vision, Fundoscope, Thyroid • Cardio: RRR, Murmurs, Rubs, Gallops, Pedal pulses, peripheral edema • Respiratory: lung auscultation, crackles • Neuro: Sensitivity in hands and feet (filament test), patellar and Achilles reflex. • Skin: Special attention to legs and feet, dark skin in folds and creases

  11. AcanthosisNigricans

  12. Diabetic Retinopathy

  13. Medications Important Questions: • What medications are you taking? • Do you take insulin? • How long have you been on these meds? • Are you taking your meds? • How are you taking them? If different than prescribed, why? • Have you experienced any adverse reactions? • Do you have any drug allergies?

  14. Medications • Insulin • Long Acting: glargine (Lantus), detemir (Levemir) • Dose: 1 time per day • Intermediate Acting: NPH (Novolin N) • Dose: 2-3 times per day • Short Acting: Regular Insulin (Novolin R) • Dose: 30-45 min before a meal (Prandial) • Rapid Acting: lispro (Humalog), aspart (Novolog), glulisine(Apidra) • Dose: 15 min before a meal

  15. Medications • Biguanides • Oral • Inhibit liver glucose production and increase insulin action in muscle and fat • No risk of hypoglycemia • Side Effect: Diarrhea • metformin (Glucophage)

  16. Medications Hypoglycemics (Type II ONLY): • Sulfonylureas: • Oral • Stimulate insulin release • glyburide (DiabetaMicronase), glipizide (Glucotrol), glimeperide (Amaryl) • Meglitinides: • Oral • Stimulate insulin release • repaglinide (Prandin), nateglinide (Starlix) * Yellow medications on formulary.

  17. Medications • Incretins: • Injectible • increases insulin secretion, reduce glucagon secretion, slows gastric emptying, reduces appetite and induces weight loss • exenatide (Byetta), sitagliptin (Januvia), saxagliptin (Onglyza) • Amylin: • Injectible • suppress glucagon secretion, delay gastric emptying & suppress appetite • pramlintide (Symlin)

  18. Medication • Thiazolidinediones (Tzds) • Oral • Increases insulin sensitivity in peripheral tissue • pioglitaone (Actos), rosiglitazone (Avandia) • Alpha-Glucosidase Inhibitor • Oral • Reduces intestinal absorption of starch, dextrin and disaccharides • acarbose (Precose), miglitol (Glyset)

  19. Medications Other medications: • ACE Inhibitors- “-pril” • Oral • Start when pt. has microalbuminuria. • Side Effect: Cough • lisinopril, captopril, benazepril, enalapril • ARB- “-sartan” (Not on formulary) • Anti Hypertensives • Statins- “-statin”, Lipitor • Aspirin: • Pts. With cardiac risk. • Men > 50, Women > 60 with 1 major risk factor (famhx, CVD, HTN, smoking, dyslipidemia, albuminuria)

  20. Medications The clinics get most of their medications from the Target or Walmart $4 Formularies and PAPs. • Target: http://sites.target.com/site/en/health/page.jsp?contentId=WCMP04-040590 • Walmart: http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf

  21. Treatment Goals 2010 ADA Recommendations: • HbA1c: < 7.0% • Preprandial capillary plasma glucose: • 70-130 mg/dl • Peak postprandial capillary plasma glucose: • < 180 mg/dl • BP: ≤ 130/80 • Lipids: • LDL < 100mg/dl • HDL >50 mg/dl • Trigs < 150 mg/dl

  22. Labs • HbA1c- Test sugar levels over last 3 months. • Draw= Every 3 months • Urinalysis- Kidney ftn. • 3 specimens in 3-6 month period should be taken to confirm abnormal urine protein results (also true for microalbumin) • MicroalbuminCreatinine Ratio- Kidney ftn. • Type 1: test 5 yrs after dx • Type 2: test immediately • Test annually thereafter.

  23. Labs • CMP- Kidney ftn., Electrolytes, Liver ftn. • Annually, especially Cr. • Fasting Lipid Panel- Cholesterol levels • Fasting lipids annually • Low risk can be done every 2 years • TSH • DM Type I Every 1-2 years

  24. Health Maintenance • Ophthalmology Referral • Every year • Screen for DM retinopathy • BP Control • Important for maintaining kidney ftn. • Cancer Screening • Potentially higher risk of: pancreatic, endometrial, melanoma, breast cancer

  25. Health Maintenance • Routine Vaccinations: • Yearly flu vaccine • Pneumococcal after age 65, if given before 55 (should be given every 10 years) • Tdap • Dental Care • Pregnancy: • Refer to county. Eligible for medical.

  26. Health Maintenance Lifestyle Modification aka: DIET and EXERCISE !!!

  27. Health Maintenance 2010 ADA Recommendations: • Exercise: • 150 min/week of moderate intensity exercise (50-70% of max HR) • In DM 2: Resistance Training 3x week. If not contraindicated. • Diet • Saturated Fats: <7% of total calories • Minimize trans fats • Monitor Carbohydrates with Carb counting: • http://www.diabetes.org/food-and-fitness/food/planning-meals/carb-counting/

  28. Thank You

  29. References • PPTs: • Type 2 Diabetes Mellitus, Dr. Roger K. Long • Type 1 Diabetes Mellitus and Diabetic Ketoacidosis, Dr. Nicole Glaser • Insulin and Oral Hypoglycemic Therapy, Heike Wulff, Ph.D.

  30. Medications Online: • Standards for Medical Care in Diabetes-2010, ADA: • http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html • Uptodate: “Overview of medical care in adults with diabetes mellitus”: • http://www.uptodate.com/online/content/topic.do?topicKey=diabetes/10339&selectedTitle=1%7E150&source=search_result#H22 • Mayo Clinic Website: • www.mayoclinic.com

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