Beta cells- insulin alpha cells- glucagon

Stimulates uptake Stimulates glycogenolysis,Of glucose, FFA, Lipolysis, GNGAmino acids

Promotes anabolism Promotes BG, catabolism& storage of energy, of stored fuels BG

In Type 1 DM, destruction of beta cells is viral orImmune-mediated.

Monitoring: Factors that affect Blood Glucose Levels

Food

Insulin Deficiency

Stress Illness

Infection Glucagon et al.

Too much insulin or oral agentsNot enough foodUnusually high activity

Skipped or delayed meals

Three Examples:

Type I: Basal/ Bolus Regimen-- Lispro (Humalog)/NPH

Premeal Humalog x 3 Bedtime NPH to control hyperglycemia at night (may need some NPH mixed with Humalog

during the day to provide background insulin throughout the day)

Split/Mixed NPH-Lispro Regimen

NPH/Humalog mixtures at morning and late pm meals (~6 am & 6 pm) (provides enough NPH for bkgd coverage during the night)

Example 3: Type 2 DM

BIDS (Bedtime Insulin-Daytime Oral Agent)

Oral hypoglycemic medication(s) (e.g., sulfonylureas, etc.) to keep PGdown during day.

Bedtime NPH insulin to keep hepatic glucoseproduction down during night.

Starting dose= wt (#) / 10

150# / 10 = 15 units NPH at bedtime

Increase 4-5 units/ wk until FPG < 140 mg/dl

Metabolic Effects of Exercise in Type 1 DM

Adequate Insulin Trt Inadequate

Peripheral Glucose Uptake

Hepatic Glucose Output

Glucagon Production

Blood Glucose

Frequency of Monitoring

• American Diabetes Assn. Clinical PracticeRecommendations (1998):

- type 1: frequent SMBG (at least 3-4 x/ day)

- type 2: daily for those trted with insulin, oral agents,or both

Only use SMBG if a part of an integratedtreatment program.

Monitoring: Goals

1. Achieve and maintain target BG levels.

2. Prevent and detect hypoglycemia.

3. Adjust medication (e.g., insulin) withwith lifestyle changes (e.g., food and physical activity).

4. Serum Lipids, Blood Pressure, BMI

Monitoring: Implementation

1. Establish target BG ranges2. Determine frequency of monitoring3. Record results4. Identify patterns so that

medicationsmeal plansphysical activity

can be adjusted.

Hypoglycemia and its Management

Sx Mgmt Approaches

Nervous Assess BG, if possibleHeadache Start with quick-acting CHO sources:Sweating glucose tabs or gelWeakness 1/2 c. sugar soft drink or juiceConfusion 4-7 Lifesavers-type candyTremors 1 c. of milkLethargy Have a snack, unless before a meal

Look for cause of hypoglycemiaIf an insulin user, inject glucagon.

Three Polys fatigue

Glycosuria acetone breath

Weight Loss Labored

breathing

(kussmaul respirations)

Physical Activity in Type 1 DM

• Confers great benefits but requiresgood planning!

• If BG <80 or > 300 = Don’t Exercise!!

• BG varies widely even with small amountsof exercise. Depends on control level.

• Check PG before exercise. If moderateactivity, add 10-15 g CHO; if vigorous,add 20-30 g CHO.

• Check PG 30 min. before and 1 hour afterexercise.

Increased Insulin Sensitivity

Increased peripheral glucose uptake

Lower Blood Glucose

Decreased Plasma Insulin

Lipolysis

Metabolic Effects of Exercise in Type 2 DM

Meal Planning and Physical Activity

Monotherapy Oral Agents: Sulfonylureas,Metformin, Troglitazones, etc.

Combinations of Oral Agents:Metformin + Sulfonylureas, etc.

Add Bedtime NPH to Orals

When Therapy ChangesNPH + Humalog BID

MultipleDoseRegimen

Evaluating Outcomes in DM Treatment

Outcomes Can Be:

Clinical Economic Quality of Life

Glycemic Control length/stay Participation in HbA1c ER visits care Blood lipids costs to - SMBG Weight/BMI health plan - keeps appts. Blood pressure - Rx refills Complications Better work Q of Life survey attendance

Case Study: 12 y/o with Type 1 DM

Pt presented with weight loss, polyuria, polydipsia

Dx: Type 1 DM

ER Visit post-Dx:N/V/ Thirst, Fever, High BG (~400)

Confused, Acetone Breath

Yusef

Urine reveals glycosuria, ketonuria= DKA

Metabolic events leading to these Sx??

Gradual Loss of Pancreatic Beta Cell Function

Body loses major anabolic hormone= cells starve

Cell starvation leads to increase glucagon, attemptto provide fuel to cell via gluconeogenesis.

None of the fuel reaches the cell-urinary loss

Extra water needed to clear glucose=polydipsia (thirst)

Fat catabolized faster than used= ketone build-up

Symptoms of Diabetic Ketoacidosis

Nausea Headache

Dry, itchy skin Kussmaul Respiration

Positive urinary ketones BG < 60 mg/ dl

Gradual Onset of Symptoms