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#4 Management of Diabetes Mellitus 5 Components of Diabetes Management Farrell, M. (2005). Textbook of Medical-Surgical Nursing. Lippincott: Philadelphia Multidisciplinary care Lewis 1187/1363 Aims of Treatment Stabilize BG Stabilize weight Stabilize HbA1c <7% Macro (larger) vascular risk reduction – Lipid control – BP control – Smoking cessation Self monitoring – – – – – 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 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… Diet – Meal planning is based on individuals usual eating habits and life style – Cultural issues considered Activity – Encourage regular exercise – Maintain hydration – Reduction of insulin or snack to reduce chance of hypoglycemia. Education to prevent complications Insulins Rapid acting (Humalog) – Onset – Peak – Duration 5 minutes 1-2 hours 4-5 hours. Short acting (actrapid, humulin S) – Onset 30 minutes – Peak 2-3 hours – Duration approx. 8hrs Intermediate acting (Humulin I) – Onset 2-4 hours – Peak 6-8 hours – Duration 12-18 hours Insulin pump http://www.nmh.org/nmh/adam/adamencyclopedia/graphics/images/en/18028.jpg Insulin pens Type 2 Treatment Diet – Often requires caloric restriction – Within cultural milieu Activity – Aerobic exercise makes cells less resistant. – Graduated – Older adult evaluate CV risk. Education to prevent complications Type 2 Medications Lewis ( 1195/1369) 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 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 Biguanides (Metformin) glucophage Increase sensitivity of insulin already present Reduce insulin resistance Reduces gluconeogenesis reduces circulating LDL’s Use with caution in pts with renal or hepatic disease – risk of lactic acidosis Meglitinides Repaglinide Increases insulin production by pancreas Less chance of hypoglycaemia as rapidly absorbed and eliminated Before meals weight gain Type 2 Medications 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) 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) 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) 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. 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