NR601 FINAL EXAM STUDY GUIDE
Week 5: Glucose metabolism disorders
Types of DM
1. Type 1- severe insulin deficiency resulting in reduction or absence
of functioning beta cells in the pancreatic islets of Langerhans.
This leads to hyperglycemia due to altered metabolism of lipids,
carbs, and proteins. Initial s/s of hyperglycemia. Subjective
findings- polyuria, polydipsia, nocturnal enuresis and polyphagia
with paradoxical weight loss, visual changes and fatigue.
Objective-dehydration(poor skin turgor and dry mucous), wt loss
despite normal/increase appetite, reduction in muscle mass. DKA-
fatigue, cramping, abnormal breathing
2. Type 2- Type 2 DM is characterized by the abnormal secretion of
insulin, resistance to the action of insulin in the target tissues,
and/or an inadequate response at the level of the insulin
receptor. A patient may, however, present with pruritus, fatigue,
neuropathic complaints such as numbness and tingling, or blurred
vision.
3. Prediabetic- fasting glucose consistently elevated above the
normal range but less than 100-125. Impaired glucose tolerance
(IGT) state of hyperglycemia where 2 hr post glucose load
glycemic level is 140-199
Diagnostic criteria- there are 4 lab-based criteria to confirm DM: A1C,
random plasma glucose, fasting plasma glucose, and 2-hr post load
plasma glucose
AIC of 6.5 or higher=diabetes
1
, Random plasma glucose level of 200 WITH classic symptoms of
hyperglycemia or a hyperglycemic crisis
Fasting plasma glucose level of 126 or higher on TWO
occasions(fasting is defined as no caloric intake for at least 8 hrs
2-hour post load plasma glucose level of 200 or higher during an
OGTT, following consumption of a glucose load containing the
equivalent of 75g of anhydrous glucose dissolved in water (OGTT
is also used to screen for diabetes during pregnancy)
*** In the absence of unequivocal hyperglycemia results should be
confirmed by repeat testing on a new blood sample without delay,
preferably using the same type of test.***
*All above-but confirmation of type 2 diabetes mellitus requires:
two fasting blood glucoses ≥126 mg/dL or two random blood
glucoses ≥200 mg/dL.
You do not screen for type 1 diabetes but you do screen for type 2
if an individual is overweight or obese, regardless of age, and for
all adults aged 45 years and older. Tests should be repeated at a
minimum of 3 year intervals
Initial Treatment-
Type 1- FIRST LINE: INSULIN. The initial goal of treatment for type
1 DM is to normalize the elevated blood glucose level. This is best
accomplished by intensive insulin regimens to achieve the
following goals: plasma glucose levels of 80 to 130 mg/dL before
meals, peak postprandial (1–2 hours after the beginning of a
meal) glucose levels of less than 180 mg/dL, and an A1C below 7%
for adults with type 1 DM. A comprehensive treatment plan
requires exogenous insulin, frequent self-monitoring of blood
glucose (SMBG), medical nutrition therapy, regular exercise,
continuing education in prevention and treatment of diabetic
2
, complications, and the periodic reassessment of treatment goals.
(Type 1A: insulin dependent, Type 1B: variably insulin
dependent). The ADA Standards of medical care in diabetes states
that the majority of patients with type 1 DM, should be treated
with multiple daily injections of prandial insulin and daily basal
insulin or with a continuous subcutaneous insulin infusion pump.
INITIATION OF INSULIN THERAPY IN NEWLY DIAGNOSED TYPE 1
DM, SHOULD BE MANAGED BY OR IN CLOSE COLLABORATION
WITH AN ENDOCRINOLOGIST.
Type 2-FIRST LINE: LIFESTYLE MANAGEMENT. Interventions
should include treatments directed at both risk reduction and
glycemic control. Lifestyle management is an important part of
treatment and comprises nutrition therapy, activity prescriptions
for exercise, decreased prolonged sitting, and in older adults,
training in balance and flexibility. Lifestyle management should
focus on mental health, sleep, and smoking cessation. Obesity
management has become a high-level target in the treatment of
pts with type 2 DM. ADA states that every patient should receive
diabetes self-management education and diabetes self-
management support at the time of diagnosis.
Pharmacological therapy for type 2 DM is required when lifestyle
management does not result in adequate blood glucose control.
Drug therapy should always be considered an adjunctive therapy
to lifestyle management, as the latter is typically initiated first.
The ADA and AACE recommend metformin if there are no
contraindications, such as renal disease or abnormal creatinine
clearance, acute myocardial infarction, or septicemia.
The AACE recommends adding a second agent to lifestyle
treatment and metformin if the A1C is more than 7.5% at the time
3
, of diagnosis or after 3 months of monotherapy without
achievement of the patient’s blood glucose goals. Metformin can
be used as a monotherapy unless the patient has
contraindications or intolerance. Although metformin is the first-
line medication recommended by the ADA and the AACE for DM
type 2, it should be used only in patients with adequate renal
function and should not be used in patients with an eGFR below
45 mL/min/1.73 m2.
• Immediately upon diagnosis of type 2 DM, begin lifestyle therapy with
medically assisted obesity treatment.
• If glycemic goals are still not met 3 months later, begin single-agent or
dual therapy with oral antidiabetic agents, depending on whether A1C
is less than or greater than 7.5%.
• If glycemic goals are not met in 3 months, initiate triple therapy.
• If after 3 additional months (or at the time of diagnosis) A1C is 9.0%
or higher and the patient is symptomatic, add insulin therapy.
A1c-Gyycemic level over 2-3months and is helpful is documenting
control and continuing care.
A1c less than 7% indicate strong control
6.5%or less decrease occurrence of complications achieved w/o
hypoglycemia or other adverse effect.
Medication Side Effects
-Type 1:
Hypoglycemia is a common occurrence in patients with type 1 DM and
occurs for a variety of reasons: excessive exogenous insulin, missed
meals or inadequate food intake, excessive exercise, alcohol ingestion,
drug interactions, or decreases in liver or kidney function. Signs and
symptoms: diaphoresis, tachycardia, hunger, shakiness, altered
mentation (ranging from an inability to concentrate to frank coma),
slurred speech, and seizures. The ADA classifies hypoglycemia as a
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