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Diabetes

• Insulin
  • Produced in the pancreas by specialized cells called islet cells. They make up 1–2% of the mass of the pancreas but yes 10–15%of the blood supply to it. Islet means small island
  • Increases cellular uptake of glucose
  • A MAJOR anabolic hormone

DM Type 1

• When the pancreas produces little or no insulin
  • 5–10% of diabetes is type 1
  • Greater than 95% diabetes type 1 is secondary to autoimmune disease affecting the islet beta cells of the pancreas.
  • Average age of diagnosis is 14 (previously known as juvenile diabetes)
  • Normal or low body weight
  • DM is the leading cause of blindness in the United States
  • DM accounts for approximately 30% of end stage renal disease in the U.S.
  • DM patients are at increased risk for atherosclerosis

Clinical Findings

• Early Disease Symptoms
  • DM may present with mild signs of hypoglycemia
    • Urinary frequency, polyuria, and polydipsia
    • Orthostatic hypotension and dehydration.
    • Weakness
    • Fatigue
    • Nausea and vomiting
    • Weight loss
    • Blurred vision
    • Poor wound healing
    • Bacterial and fungal infections
  • Patients may present in ketoacidosis
    • Very ill appearance
    • Nausea/vomiting
    • Polyuria & polydipsia secondary to hyperosmolar state
    • Abdominal pain
    • Change in mental state all the way two stupor
    • Fruity breath
• Late Disease Symptoms
  • Eyes
    • Diabetic Retinopathy
      • After 20 year so DM 80% of patients will have retinopathy
      • Leaky weakened blood vessels. New weak blood vessels form and create scaring.
      • Symptoms
        • Increasing number of floaters
        • Blurry vision,
        • Vision that changes sometimes from blurry to clear,
        • Blank or dark areas in your field of vision,
        • Poor night vision
        • Colors appear faded or washed out
      • Fundal exam
        • Cotton-wool spots
        • Flame hemorrhages, dot/blot hemorrhage
  • Orthostatic hypotension due to to autonomic neuropathy and low plasma volume
  • Acanthosis nigricans
  • Neuropathy
    • Loss of sensation in limbs in a stocking glove distribution.
    • 50–80% of non traumatic lower extremity amputations are secondary to DM.
  • Atonic bladder
  • Erectile dysfunction
  • Delayed gastric emptying

Labs

• Fasting blood glucose levels of >126 mg/dL on more than one occasion is diagnostic
• Nonfasting blood glucose of >200 mg/dL
• If above tests are negative but symptoms persist an oral glucose tolerance can be diagnostic. Fasting patient consumes 75 g oral glucose. Two hours later glucose level > 200 mg/dL is diagnostic
• Hemoglobin A1c – indicates sugar levels over previous 3 months and is used for monitoring glucose control. 3.8–5.7% is normal. 5.7–6.3% is considered at risk. Over 6.3% is diagnostic.
• Patients may have glucosuria and ketonuria

Treatment

• All type 1 diabetics require insulin replacement therapy
• Insulin is administered subcutaneously
• Insulin is categorized by the rate it is metabolized
  • Rapid acting insulin
    • Lispro (Humalog), aspart (Novolog)
    • Onset: 5–15 minutes
    • Peak: 1–1.5 hours
    • Effective duration: 3–4 hours
  • Short acting insulin
    • Regular (Human R), (Novolin R)
    • Onset: 30–60 minutes
    • Peak: 2 hours
    • Effective duration: 6–8 hours
    • Used before meals
  • Intermediate acting insulin
    • NPH (Neutral protamine hagedorn), insulin zinc (Lente)
    • Onset: 2–4 hours
    • Peak: Flat
    • Effective duration: about 24 hours
    • Typically two doses daily and used in conjunction with a short acting insulin – Long acting insulin
    • Extended insulin zinc (Ultralente), Insulin glargine (Lantus)
    • Onset: 30–180 minutes
    • Peak: Lantus no peak, Ultralente 10–20hrs
    • Effective duration: 20–36 hrs
• Diet & Education
  • Management of diet is extremely important
  • Increase fiber and complex carbohydrates – Monitor carbohydrate intake
  • Patient glucose monitor
• Patients have increased risk for cardiovascular events
  • Treat HTN aggressively
  • Manage hyperlipidemia
• Regular visits to podiatrist for foot care secondary to neuropathy
• Regular diabetic eye exams