DIABETES UPDATE (pg2/2)
October 6, 2008
Management of some common complications
Hypoglycemia
<65 - dizziness, confusion, weakness, tremors.
<40 - coma, seizures, irreversible brain damage.
Treat with quickly absorbed glucose - orange juice, soft drinks, glucose tablets (15-20g), cake icing applied to the inside of the mouth.
Hyperglycemia
Blood glucose >130.
Dangerous when symptomatic, but must be identified and treated to avoid complications. Signs and symptoms are as above. If associated with infection, can lead to diabetic ketoacidosis. This results in severe dehydration, acidosis and sepsis. This is a potentially fatal illness; therefore, early recognition and avoidance is important. It is imperative not to skip insulin if the diabetic is unwell and not eating. Maintain adequate hydration. Get urgent medical help if unable to control blood glucose levels or if patient appears unwell.
Hyperosmolar non-ketotic state
In the elderly, Type 2 diabetes is more prevalent. Because there is no absolute lack of insulin, ketoacidosis does not occur. What does occur is a hyperosmolar non-ketotic state which can lead very quickly to coma. Again, prevention is better than cure.
Skin care
Diabetic patients suffer from skin problems for a number of reasons. First, they are more prone to developing infections due to impaired immunity; secondly, they develop peripheral neuropathies which allow easy disturbance of skin integrity; thirdly, they have microvascular disease, which prevents adequate perfusion and immensely compromises the ability to repair. It is imperative to educate patients in thorough cleansing and inspection of extremities. Good podiatry care is very important. Any injuries should be addressed quickly and treated aggressively to avoid chronic ulcers.
Foot ulcers
The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.
There are several key factors in the appropriate treatment of a diabetic foot ulcer:
• Prevention of infection
• Taking the pressure off the area, called “off-loading”
• Removing dead skin and tissue, called “debridement”
• Applying medication or dressings to the ulcer
• Managing blood glucose and other health problems
Not all ulcers are infected; however if the podiatric physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.
There are several important factors involved in keeping an ulcer from becoming infected:
• Keep blood glucose levels under tight control
• Keep the ulcer clean and bandaged
• Cleanse the wound daily, using a wound dressing or bandage
• Do not walk barefoot
For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.” Patients may be asked to wear special footgear, or a brace, or specialized castings, or to use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.
The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.
Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings and skin substitutes, which have been shown to be highly effective in healing foot ulcers.
For a wound to heal there must be adequate circulation to the ulcerated area. The podiatrist can determine circulation levels with noninvasive tests.
Vision and dentation
Diabetics should receive regular follow-up for their vision and dentation. They should also be monitored closely by their primary care physician or diabetology team in order to maintain optimum health and prevent future complications.
Medications commonly used to treat diabetes and their side effects
Sulfonylureas
Sulfonylureas stimulate the beta cells of the pancreas to release more insulin. Sulfonylurea drugs have been in use since the 1950s. Chlorpropamide (brand name Diabinese) is the only first-generation sulfonylurea still in use today. The second-generation sulfonylureas are used in smaller doses than the first-generation drugs. There are three second-generation drugs: glipizide (brand names Glucotrol and Glucotrol XL), glyburide (Micronase, Glynase, and Diabeta), and glimepiride (Amaryl). These drugs are generally taken one to two times a day, before meals. All sulfonylurea drugs have similar effects on blood glucose levels, but they differ in side effects, how often they are taken, and interactions with other drugs.
Meglitinides
Meglitinides are drugs that also stimulate the beta cells to release insulin. Repaglinide (brand name Prandin) and nateglinide (Starlix) are meglitinides. They are taken before each of three meals.
Because sulfonylureas and meglitinides stimulate the release of insulin, it is possible to have hypoglycemia (low blood glucose levels).
It is important to be aware that alcohol and some diabetes pills may not mix. Occasionally, chlorpropamide and other sulfonylureas can interact with alcohol to cause vomiting, flushing, or sickness.
Biguanides
Metformin (brand name Glucophage) is a biguanide. Biguanides lower blood glucose levels, primarily by decreasing the amount of glucose produced by the liver. Metformin also helps to lower blood glucose levels by making muscle tissue more sensitive to insulin so glucose can be absorbed. It is usually taken two times a day. A side effect of metformin may be diarrhea, which can be reduced by taking the drug with food.
Thiazolidinediones
Rosiglitazone (Avandia), troglitazone (Rezulin), and pioglitazone (ACTOS) form a group of drugs called thiazolidinediones. These drugs help insulin work better in the muscle and fat and also reduce glucose production in the liver. Thiazolidinediones are taken once or twice a day with food. Although effective in lowering blood glucose levels, thiazolidinediones can have a rare but serious effect on the liver. For this reason, the physician should perform blood tests regularly to monitor the health of the liver.
Alpha-glucosidase inhibitors
Acarbose (brand name Precose) and meglitol (Glyset) are alpha-glucosidase inhibitors. These drugs help the body to lower blood glucose levels by blocking the breakdown of starches, such as bread, potatoes, and pasta in the intestine. They also slow the breakdown of some sugars, such as table sugar. Their action slows the rise in blood glucose levels after a meal. They should be taken with the first bite of a meal. These drugs may have side effects, including gas and diarrhea.
Oral combination therapy
Because the drugs listed above act in different ways to lower blood glucose levels, they may be used together. For example, a biguanide and a sulfonylurea may be used together. Many combinations can be used. Though taking more than one drug can be more costly and can increase the risk of side effects, combining oral medications can improve blood glucose control when taking only a single pill does not have the desired effect. Switching from one single pill to another is not as effective as adding another type of diabetes medicine.
Insulin therapy
Most insulin in use today is synthetically produced from laboratory cultures. However, a small percentage of people with Type 1 diabetes still use animal-based insulins that are distilled and purified from the pancreases of cows (bovine insulin) and pigs (porcine insulin).
There are six types of synthetic insulin available-rapid-acting, regular, NPH (N), lente (L), ultralente, and long-acting basal. Each has its own unique therapeutic effect. An insulin’s onset of action is how long it takes the hormone to start working at lowering blood glucose levels. The peak is the point at which the dose is at the height of its therapeutic effectiveness, and the duration is how long the insulin’s blood glucose lowering effect lasts from injection to end.
Summary
Diabetes is a multi-systemic disease with grave implications for future health. A multi-disciplinary approach to the care of these patients is important and has proven to improve morbidity and mortality from the disease. Monitoring and maintaining good blood sugar levels is the most important intervention in the care of the diabetic. This involves patient education and a teamwork approach. Long-term complications from diabetes can be delayed and their extent controlled with good evaluation, treatment and management.
DIABETES UPDATE (References)
October 6, 2008
RESOURCES & REFERENCES
Barnett, Anthony H., Diabetes - Best Practice & Research Compendium. Saunders 2006. ISBN: 0080446868.
Harmel, Anne Peters and Ruchi Mathur, Davidson’s Diabetes Mellitus , 5th ed. Saunders, 2004. ISBN: 0721695965.
Marso, Steven P. and David M. Stern, Diabetes and Cardiovascular Disease . Lippincott Williams & Wilkins, 2003. ISBN-10: 0-7817-4053-3.
Springhouse , Diabetes Mellitus: A Nurse’s Guide to Patient Care. Lippincott Williams & Wilkins, 2006. ISBN-10: ISBN-10: 1-58255-732-2.
www.cdc.gov/diabetes/statistics/maps/index.htm
www.diabetes.niddk.nih.gov/complications/index.htm
www.diabetes.org/type-2-diabetes/complications.jsp
www.fda.gov/diabetes/related.html
www.ndep.nih.gov/diabetes/WhatIs/WhatIs.htm
DIABETES UPDATE (Outline)
October 6, 2008
OUTLINE:
I. What is diabetes?
II. Definition of diabetes
III. Signs/symptoms
IV. Prevalence of diabetes
V. Complications of diabetes
A. Heart and blood vessel disease
B. High blood pressure
C. Blindness
D. Kidney disease
E. Foot ulcers
F. Nervous system disease
G. Amputations
H. Dental disease
I. Complications of pregnancy
J. Impotence
K. Other complications
VI. Management of some common complications
A. Hypoglycemia
B. Hyperglycemia
C. Hyperosmolar non-ketotic state
D. Skin care
E. Foot ulcers
F. Vision and dentation
VII. Medications commonly used to treat diabetes and their side effects
A. Sulfonylureas
B. Meglitinides
C. Biguanides
D. Thiazolidinediones
E. Alpha-glucosidase inhibitors
F. Oral combination therapy
G. Insulin therapy
VIII. Summary
DIABETES UPDATE (purpose)
October 6, 2008
PURPOSE:
To update health care professionals on the risks, complications and management of diabetes.
OBJECTIVES:
Upon completion of this program the learner will be able to:
• Explain the difference between Type 1 and Type 2 diabetes
• Name 5 complications of diabetes.
• Identify the most important intervention in the care of the diabetic.
• List four medications commonly used in the treatment of diabetes.
DIABETES UPDATE (pg1/2)
October 6, 2008
| Purpose and Objectives |
Outline | References | Test |
What is diabetes?
Diabetes mellitus is a chronic health condition in which the body is unable to produce adequate insulin to properly break down sugar (glucose) in the blood. Symptoms include hunger, thirst, excessive urination, dehydration and weight loss. Over time, diabetes can lead to heart and blood vessel disease, blindness, kidney failure, and foot ulcers, among other conditions.
Diabetes is a disease of the endocrine system, specifically, the pancreas, and of glucose metabolism. Insulin is normally produced in the pancreas in response to high blood glucose levels; for example, after a meal. The Islets of Langerhan are small areas of tissue within the pancreas that contain beta cells, which produce insulin. In Type 1 diabetes, the beta cells are destroyed, leading to an absolute lack of insulin. In Type 2 diabetes, there is resistance peripherally to the inherent insulin. This leads to a relative lack of insulin and therefore hyperglycemia.
Type 1 diabetes occurs at a very early age, caused, as mentioned above, by a destruction of beta cells in the pancreas. People with Type 1 diabetes have little or no ability to produce insulin and are entirely dependent on injections of insulin for survival.
The cause of Type 1 diabetes is unknown, although childhood infections and a genetic tendency are two possibilities. The pancreas undergoes a change, and cells that normally produce insulin are destroyed. This may be a result of the body’s own immune system believing the pancreas to be a foreign organ. Patients with Type 1 diabetes tend to be very slim people.
Type 2 diabetes tends to be of adult onset, although more and more young people are now being diagnosed with this insulin-resistance syndrome.
In Type 2 diabetes , the pancreas retains its ability to produce insulin , but either the quantity is inadequate for the body’s needs, or insulin cannot be used to its full extent by the tissues. Most people who have this condition suffer from being overweight, and require a strict weight-reducing diet and exercise program, as well as possible treatment with drugs, sometimes including insulin.
Definition of diabetes
• Random plasma glucose of >200mg/dL
• Fasting plasma glucose =126mg/dL on 2 separate occasions
• Fasting plasma glucose 110-125mg/dL is considered Impaired Glucose Tolerance
• Fasting plasma glucose <110mg/dL is considered normal
• HbA1c <6.5% indicates good glucose control
Signs/symptoms
At onset, the two types of diabetes present with distinction:
Type 1 - weight loss, polyuria, polydypsia
Type 2 - polyuria, polydypsia, recurrent infections
Prevalence of diabetes
It is estimated that 20.8 million people in the United States –7 percent of the population-have diabetes, including 6.2 million who are undiagnosed. Ninety-five percent of people with diabetes have Type 2. Diabetes was the sixth leading cause of death listed on U.S. death certificates in 2002. Diabetes is also likely to be underreported as a cause of death. Overall, the risk of death among people with diabetes is about twice that of people without diabetes of similar age.
Complications of diabetes
Diabetes is a systemic disease which can have devastating effects on the body as a whole. Diabetes has numerous serious complications.
Heart and blood vessel disease
Heart disease is the leading cause of death for people with diabetes. Heart disease and stroke account for about 65 percent of deaths in people with diabetes.
People with diabetes are 2-4 times more likely to have heart disease than persons without diabetes. Even people with Type 2 diabetes who do not have heart disease have an increased risk of having a heart attack. People with diabetes also tend to have other risk factors for heart disease, including obesity, high blood pressure, and hardening of the arteries (atherosclerosis).
High blood pressure
About 73 percent of adults with diabetes have blood pressure greater than or equal to 130/80 mm Hg or use prescription medications for hypertension.
Blindness
Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years. Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.
Adults with diabetes should have yearly eye exams to ensure the health of their eyes and to protect their vision.
Over time, high blood sugar levels can damage the blood vessels that feed the retina of the eye. In nonproliferative diabetic retinopathy (NPDR), an early stage of diabetic eye disease, the blood vessels may leak fluid. This may cause the retina to swell and vision to blur, a condition called diabetic macular edema. In advanced or proliferative diabetic retinopathy (PDR), abnormal new blood vessels grow on the surface of the retina. The abnormal blood vessels don’t supply the retina with normal blood flow. In addition, they may eventually pull on the retina and cause it to detach.
Some cases of diabetic retinopathy can be treated with laser surgery. In this procedure, doctors aim a strong beam of light onto the patient’s retina to shrink or seal leaking or abnormal vessels. Laser surgery can’t restore vision already lost, so early detection is important. In some advanced cases of PDR, a surgeon may remove the vitreous portion of the eye and replace it with a clear solution (called a vitrectomy).
Kidney disease
Over time, high blood sugar levels can damage the kidneys. Even when drugs and diet are able to control diabetes, the disease can lead to kidney disease (diabetic nephropathy) and kidney failure.
Healthy kidneys act like filters to clean the blood of waste products and extra fluid. Damaged kidneys do not clean the blood well. Instead, waste products and fluid build up in the blood.
Diabetes is the leading cause of kidney failure. People with kidney failure must either have dialysis treatment (to substitute for some of the filtering functions of the kidneys) or receive a kidney transplant.
Foot ulcers
Adults with diabetes need to take special care of their feet. People with diabetes are at risk for foot injuries due to numbness caused by nerve damage (diabetic neuropathy) and low blood flow to the legs and feet. The most serious injury is a foot ulcer. Diabetic foot ulcers are at very high risk of becoming infected, and sometimes they cannot be healed. Non-healing foot ulcers are a frequent cause of amputation in people with diabetes. Patients with foot ulcers may use wound dressings, skin substitutes, or other treatments to protect and heal their skin.
Wound dressings are medical devices that are used to protect ulcerated skin and assist in its healing. They can range from simple bandages that can be bought in the drug store to complex materials that contain antibacterial and antiviral substances.
Skin substitutes are products that help in closing the wounds of slow healing ulcers in patients with diabetes. They are made from human cells known as fibroblasts that are placed on a dissolvable mesh material. When the mesh material is placed on the ulcer, it is gradually absorbed and the human cells grow and replace the damaged tissue in the ulcer.
Nervous system disease
About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, and other nerve problems.
Almost 30 percent of people with diabetes aged 40 years or older have impaired sensation in the feet. Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations.
Amputations
More than 60 percent of nontraumatic lower-limb amputations occur among people with diabetes.
Dental disease
Periodontal (gum) disease is more common in people with diabetes. Among young adults, those with diabetes have about twice the risk of those without diabetes. Almost one-third of people with diabetes have severe periodontal diseases with loss of attachment of the gums to the teeth measuring 5 millimeters or more.
Complications of pregnancy
Poorly controlled diabetes before conception and during the first trimester of pregnancy can cause major birth defects in 5 to 10 percent of pregnancies and spontaneous abortions in 15 to 20 percent of pregnancies.
Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to both mother and child.
Impotence
Impotence is a common problem for men and is more common in men with diabetes. The relationship between diabetes and impotence is not clear and the reasons why men with diabetes are more prone to problems with impotence are not fully understood. Some people with diabetes suffer from hardened arteries, which may contribute to impotence by restricting the flow of blood to the penis. Nerve damage, another problem for people with diabetes, may also contribute to impotence. If blood glucose levels are kept in the normal range, it will help reduce the chance of these problems occurring.
Other complications
Uncontrolled diabetes often leads to biochemical imbalances that can cause acute life-threatening events, such as diabetic ketoacidosis and hyperosmolar (nonketotic) coma. People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes.
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