1. #4 Management of Diabetes Mellitus

2. 5 Components of Diabetes Management 5 Components of Diabetes Management Farrell, M. (2005). Textbook of Medical-Surgical Nursing. Lippincott: Philadelphia

3. Multidisciplinary care  Lewis 1187/1363

4. Aims of Treatment  Stabilize BG  Stabilize weight  Stabilize HbA1c <7%  Macro (larger) vascular risk reduction –Lipid control –BP control –Smoking cessation  Self monitoring –Regular eye exams –SMBG monitoring – cornerstone of diabetes management –Autonomic complications –Foot care (orthotics, podiatry, self examination.) –Footwear choice  Dietary and exercise modification  Education of patient and family

5. Type 1 Treatment  Type 1 Diabetes –Exogenous insulin required –Daily dose calculated using weight –Dose usually divided  1/2 pre breakfast  1/4 pre dinner  1/4 pre bedtime –Dose adjusted to keep BG ~ 4.5 - 8.5 –Adjustment slow (3 days) to avoid hypoglycaemic incidences

6. Type 1 Treatment cont…  Diet –Meal planning is based on individuals usual eating habits and life style –Cultural issues considered  Activity –Encourage regular exercise –Maintain hydration –Reduction of insulin or snack to reduce chance of hypoglycemia. Education to prevent complications Education to prevent complications

7. Insulins  Rapid acting (Humalog) –Onset 5 minutes –Peak 1-2 hours –Duration 4-5 hours.  Short acting (actrapid, humulin S) –Onset 30 minutes –Peak 2-3 hours –Durationapprox. 8hrs  Intermediate acting (Humulin I) –Onset 2-4 hours –Peak6-8 hours –Duration12-18 hours

8. Insulin pump http://www.nmh.org/nmh/adam/adamencyclopedia/graphics/images/en/18028.jpg

9. Insulin pens

10. Type 2 Treatment  Diet –Often requires caloric restriction –Within cultural milieu  Activity –Aerobic exercise makes cells less resistant. –Graduated –Older adult evaluate CV risk. Education to prevent complications Education to prevent complications

11. Type 2 Medicati ons Lewis ( 1195/1369)  Sulfonylureas :(glibenclamide, glipizide)  Increase and stimulate insulin secretion  Increases effectiveness of available insulin  monitor for hypoglycaemia  Can cause weght gain  Thiazide diuretics and corticosteroids can decrease action  Alpha-glucosidase inhibitors (acarbose)  Inhibits A-glucosidase enzyme responsible for digesting CHO  Delays carbohydrate absorption and reduces postprandial increase in blood glucose

13. Type 2 Medications  Biguanides (Metformin) glucophage  Increase sensitivity of insulin already present  Reduce insulin resistance  Reduces gluconeogenesis  reduces circulating LDL’s  Use with caution in pts with renal or hepatic disease – risk of lactic acidosis

14. Meglitinides  Repaglinide  Increases insulin production by pancreas  Less chance of hypoglycaemia as rapidly absorbed and eliminated  Before meals  weight gain

15. Type 2 Medications  Thiazolidinediones (TZL,s) (glitazones)  Pioglitazone (Actos) Rosiglitazone  Enhance insulin action and effectiveness at the receptor site without increasing insulin secretion from the beta cells.  Increases glucose uptake into cells  Reduces hepatic glucose output  Slow onset with maximum effect achieved after 1-2 months of treatment.  Regular liver function tests  Fluid retention a problem  Bladder cancer ???  Fractures with chronic use

16. Gut Hormones (Decrease in incretin hormones in type 2 diabetes)

17. GLP–1 Agonists (Incretin Mimetics) GLP–1 Agonists (Incretin Mimetics)  Exanatide (Byetta) – twice daily  Luraglutide (Victosa) – daily  Byrudeon (ER) – weekly (powder form)  Mimics effects of GLP-1 but longer acting  Lowers blood glucose after a meal  Helps preserve and form new beta cells and stimulates insulin secretion  Slows emtying of the stomach  Inhibits production of glucose by the liver by decreasing glucagon release from alpha cells  Supresses appetite and helps with weight loss  Research shows significant decrease in HbA1c and triglyceride concentrations after meals  Administered subcutaneously

18. Exanitide (Byetta) (from lizard to lab)

19. Gila Monster

20. DPP-4 inhibitors (Dipeptidylpeptidase- 4 inhibitors) Sitagliptin (Januvia) OD Sitagliptin (Januvia) OD Vildagliptin (Galvus) BD Vildagliptin (Galvus) BD  Inhibit DPP- 4 which breaks down GLP-1 and GIP  stimulate insulin production from beta cells after a meal  Accelerates the release of insulin for a longer period of time.  Decreases production of glucose by liver by lowering glucagon secretion  Given orally

21. GLP-1 and DPP-4 https://www.youtube.com/watch?v=pwnMphxp5Jc

22. Sites of action for oral medication

23. Potentially new antidiabetic drugs

24. Newer Options (Transplants)  Islet cell transplant: - Still considered experimental. experimental. - Lack of suitable donor pancreases major obstacle - Lack of suitable donor pancreases major obstacle - considered only for pts with severe Type 1 with - considered only for pts with severe Type 1 with complications and who cannot be effectively managed complications and who cannot be effectively managed with insulin. with insulin.  Pancreas transplant: - Potential cure - side effects may be more serious than diabetes - side effects may be more serious than diabetes - uncontrolled with serious complications - uncontrolled with serious complications - may need combined kidney and pancreas - may need combined kidney and pancreas

25. Beta cell transplants