Download 4 DIABETES GDE BN 2015

#4 Management of Diabetes
Mellitus
5 Components of Diabetes
Management
Farrell, M. (2005). Textbook of Medical-Surgical Nursing. Lippincott: Philadelphia
Multidisciplinary care
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Lewis 1187/1363
Aims of Treatment
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Stabilize BG
Stabilize weight
Stabilize HbA1c <7%
Macro (larger) vascular risk reduction
– Lipid control
– BP control
– Smoking cessation
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Self monitoring
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Regular eye exams
SMBG monitoring – cornerstone of diabetes management
Autonomic complications
Foot care (orthotics, podiatry, self examination.)
Footwear choice
Dietary and exercise modification
Education of patient and family
Type 1 Treatment
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Type 1 Diabetes
– Exogenous insulin required
– Daily dose calculated using weight
– Dose usually divided
 1/2
pre breakfast
 1/4 pre dinner
 1/4 pre bedtime
– Dose adjusted to keep BG ~ 4.5 - 8.5
– Adjustment slow (3 days) to avoid
hypoglycaemic incidences
Type 1 Treatment cont…
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Diet
– Meal planning is based on individuals usual
eating habits and life style
– Cultural issues considered
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Activity
– Encourage regular exercise
– Maintain hydration
– Reduction of insulin or snack to reduce
chance of hypoglycemia.
Education to prevent complications
Insulins
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Rapid acting (Humalog)
– Onset
– Peak
– Duration
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5 minutes
1-2 hours
4-5 hours.
Short acting (actrapid, humulin S)
– Onset
30 minutes
– Peak
2-3 hours
– Duration approx. 8hrs
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Intermediate acting (Humulin I)
– Onset
2-4 hours
– Peak
6-8 hours
– Duration 12-18 hours
Insulin pump
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Insulin pens
Type 2 Treatment
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Diet
– Often requires caloric restriction
– Within cultural milieu
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Activity
– Aerobic exercise makes cells less resistant.
– Graduated
– Older adult evaluate CV risk.
Education to prevent complications
Type 2 Medications Lewis ( 1195/1369)
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Sulfonylureas :(glibenclamide, glipizide)
 Increase and stimulate insulin secretion
 Increases effectiveness of available insulin
 monitor for hypoglycaemia
 Can cause weght gain
 Thiazide diuretics and corticosteroids can
decrease action
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Alpha-glucosidase inhibitors (acarbose)
 Inhibits A-glucosidase enzyme responsible for
digesting CHO
 Delays carbohydrate absorption and reduces
postprandial increase in blood glucose
Type 2 Medications
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Biguanides (Metformin) glucophage
 Increase sensitivity of insulin already present
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Reduce insulin resistance
Reduces gluconeogenesis
reduces circulating LDL’s
Use with caution in pts with renal or hepatic disease
– risk of lactic acidosis
Meglitinides
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Repaglinide
Increases insulin production by pancreas
Less chance of hypoglycaemia as rapidly
absorbed and eliminated
Before meals
weight gain
Type 2 Medications
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Thiazolidinediones (TZL,s) (glitazones)
Pioglitazone (Actos) Rosiglitazone
Enhance insulin action and effectiveness at the
receptor site without increasing insulin secretion
from the beta cells.
Increases glucose uptake into cells
Reduces hepatic glucose output
Slow onset with maximum effect achieved after 1-2
months of treatment.
Regular liver function tests
Fluid retention a problem
Bladder cancer ???
Fractures with chronic use
Gut Hormones
(Decrease in incretin hormones in type 2 diabetes)
GLP–1 Agonists (Incretin Mimetics)
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Exanatide (Byetta) – twice daily
Luraglutide (Victosa) – daily
Byrudeon (ER) – weekly (powder form)
Mimics effects of GLP-1 but longer acting
Lowers blood glucose after a meal
Helps preserve and form new beta cells and stimulates insulin
secretion
Slows emtying of the stomach
Inhibits production of glucose by the liver by decreasing
glucagon release from alpha cells
Supresses appetite and helps with weight loss
Research shows significant decrease in HbA1c and triglyceride
concentrations after meals
Administered subcutaneously
Exanitide (Byetta)
(from lizard to lab)
Gila Monster
DPP-4 inhibitors
(Dipeptidylpeptidase- 4 inhibitors)
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Sitagliptin (Januvia) OD
Vildagliptin (Galvus) BD
Inhibit DPP- 4 which breaks
down GLP-1 and GIP
stimulate insulin production
from beta cells after a meal
Accelerates the release of
insulin for a longer period of
time.
Decreases production of
glucose by liver by lowering
glucagon secretion
Given orally
GLP-1 and DPP-4
https://www.youtube.com/watch?v=pwnMphxp5Jc
Sites of action for oral
medication
Potentially new antidiabetic drugs
Newer Options (Transplants)
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Islet cell transplant:
- Still considered
experimental.
- Lack of suitable donor pancreases major obstacle
- considered only for pts with severe Type 1 with
complications and who cannot be effectively managed
with insulin.
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Pancreas transplant: -
Potential cure
- side effects may be more serious than diabetes
- uncontrolled with serious complications
- may need combined kidney and pancreas
Beta cell transplants