Gestational Diabetes. In pregnancy, even minor degrees of glucose intolerance Risks of gestational diabetes: frequency of preeclampsia in the mother, and …
DIABETES MELLITUS TYPE 2
Clinical Presentation:
Incidental finding on screening UA or blood sugar measurement
With more significant hyperglycemia:
Polyuria
Polydipsia
Polyphagia with weight loss
Diagnosis:
Impaired Glucose Tolerance
Fasting glucose between 110 mg/dL and 125
Diagnostic Criteria
Presence of any 1 of 3 Glu abnormalities found on 2 separate days:
1 Fasting plasma glucose 126 mg/dL
2 Random plasma glucose 200 mg/dL in a person w/diabetic symptoms, or
3 Two-hour-postprandial plasma glucose level 200 mg/dL after
administration of the equivalent of a 75-g glucose load
Pathogenesis Type 2 disease is characterized by defects in both the
production and peripheral action of insulin: impaired insulin secretion
and decreased muscle glucose uptake
Gestational Diabetes
In pregnancy, even minor degrees of glucose intolerance can be important
Screening is done
Low risk: 25 yo, w/out DM in 1st degree relative, normal prepregnancy
weight, and no prior Hx of poor Ob outcome
High risk: marked obesity, DM in 1st degree relative, previous Hx of
glucose intolerance, or macrosomia in prior pregnancy
Risks of gestational diabetes: frequency of
preeclampsia in the mother,
and increased frequency of macrosomia, and postpartum hypoglycemia in the
fetus
Diet and Exercise
Most pts with DM are obese Initial weight loss of 10-20 lbs can help with
fasting glu/
Acarbose
Alpha glucosidase inhibitors slow breakdown of complex carbos to glucose
delayed absorption of glucose of post-prandial glu levels
Adverse effects: Flatulence Dose related and transient
Metformin
Metformin should not be Rx for pts with serum Creatinine 15 in ?, or
14 in ?
Preparations: Glucophage
Mechanism: Suppresses excessive hepatic glucose production and glucose
uptake in peripheral tissues
Adverse Effects:
GI: mild diarrhea, anorexia, and Abd discomfort Can by slow dose
titration, dosage, and taking metformin with meals
Lactic acidosis: Rare complication, but high mortality rate
Contraindications: Cr 14-15, significant hepatic dz, cardiac
insufficiency, EtOH abuse, hypoxic condition, or Hx of lactic acidosis
Stop Metformin 48 hrs prior to any contrast study Restarting Metformin
should only be done after testing of Cr
Sulfonylureas
Preparations:
1st generation:
2nd generation: glimepiride, Glipizide, and Glyburide
Mechanism: Activate
sulfonylurea receptors on pancreatic beta cells K
influx, depolarization of beta cell membrane, and Ca influx secretion
of insulin hepatic glucose output peripheral glucose disposal
Adverse Effects
Hypoglycemia: 4 with the use of glyburide and 2 to 4 with glipizide
Risk is greatest with potent, long-acting sulfonylureas
Weight gain: enhanced insulin secretion stimulated by oral agent therapy
5 to 10 lbs
Mild GI upset
Lipids: Triglycerides decrease modestly Overall effects on lipids are
minimal
Skin reactions: Rashes, purpura, and pruritis
Efficacy
25: treatment goals are achieved w/sulfonylurea therapy alone
50 to 60: initial response is good, but an additional agent is required
over time to achieve treatment goals
15: fail to exhibit 1 response probably have more advanced dz
Thiazolidinediones:
Preparations: Rosiglitazone
Mechanism of Action: Reduce insulin resistance in skeletal muscle, fat
tissue, and liver
Adverse Effects:
ALT elevation: Test liver enzymes at baseline, every other month for 1st
year, and periodically after that
Weight gain
Anemia
Repaglinide
Closes ATP K channel in pancreatic beta-cells release of insulin in
glucose dependent manner Rapid
rise and fall of insulin secretion when
ingested 30 min prior to a meal
Adverse Effects: Small weight gain Small incidence of hypoglycemia
Cleared by liver, so can be used in pts w/renal impairment
Insulin Therapy:
Subcutaneous Onset Peak Duration
Regular 30 min - 1 hr 2-4 hrs 4-6 hr
Lispro Insulin 15 min - 30 min 1-2 hrs 3-5 hrs
NPH 1-4 hr 8-10 hrs 12-20 hrs
Ultralente 3-5 hrs 10-16 hrs 18-24 hrs
Glargin insulin 2-4 hrs None 24 hrs
IV insulin bolus Immediate 20-30 min 2-3 hrs
Insulin Sliding Scale:
Blood Glucose Regular Insulin SQ
0-70 D50 Amp IV, or OJ Call HO
71-150 No insulin
151-200 2 Units
201-250 4 Units
251-300 6 Units
301-350 8 Units
351-400 10 Units
400 12 Units, Call HO
Basic Mixed/Split Insulin Regimen:
Total insulin in 24 hrs Weight in kg x 05
Divide by 3: 2/3 in AM, 1/3 in PM
Divide by 3: 2/3 NPH, 1/3 Regular
for 60 kg pt 30 U total AM NPH 14 U, Reg 6 U, PM NPH 7U , and Reg 3 U
Complications:
Macrovascular Disease:
Diabetic Nephropathy:
Retinopathy:
Microangiopathic changes
Peripheral neuropathy:
Autonomic neuropathy:
Diabetic mononeuropathy:
