1. Beta cells- insulinalpha cells- glucagon Stimulates uptake Stimulates glycogenolysis, Of glucose, FFA, Lipolysis, GNG Amino acids Promotes anabolism Promotes BG, catabolism & storage of energy, of stored fuels BG In Type 1 DM, destruction of beta cells is viral or Immune-mediated.

2. Monitoring:Factors that affect Blood Glucose Levels Food Insulin Deficiency Stress Illness Infection Glucagon et al. Too much insulin or oral agents Not enough food Unusually high activity Skipped or delayed meals

3. Three Examples: Type I: Basal/ Bolus Regimen-- Lispro (Humalog)/NPH Premeal Humalog x 3 Bedtime NPH to control hyperglycemia at night (may need some NPH mixed with Humalog during the day to provide background insulin throughout the day) Split/Mixed NPH-Lispro Regimen NPH/Humalog mixtures at morning and late pm meals (~6 am & 6 pm) (provides enough NPH for bkgd coverage during the night)

4. Example 3:Type 2 DM BIDS (Bedtime Insulin-Daytime Oral Agent) Oral hypoglycemic medication(s) (e.g., sulfonylureas, etc.) to keep PG down during day. Bedtime NPH insulin to keep hepatic glucose production down during night. Starting dose= wt (#) / 10 150# / 10 = 15 units NPH at bedtime Increase 4-5 units/ wk until FPG < 140 mg/dl

5. Metabolic Effects of Exercise in Type 1 DM Adequate Insulin Trt Inadequate Peripheral Glucose Uptake Hepatic Glucose Output Glucagon Production Blood Glucose

6. Frequency of Monitoring American Diabetes Assn. Clinical Practice Recommendations (1998): -type 1:frequent SMBG (at least 3-4 x/ day) -type 2:daily for those trted with insulin, oral agents, or both Only use SMBG if a part of an integrated treatment program.

7. Monitoring:Goals 1.Achieve and maintain target BG levels. 2.Prevent and detect hypoglycemia. 3.Adjust medication (e.g., insulin) with with lifestyle changes (e.g., food and physical activity). 4.Serum Lipids, Blood Pressure, BMI

8. Monitoring:Implementation 1.Establish target BG ranges 2.Determine frequency of monitoring 3.Record results 4.Identify patterns so that medications meal plans physical activity can be adjusted.

9. Hypoglycemia and its Management SxMgmt Approaches NervousAssess BG, if possible HeadacheStart with quick-acting CHO sources: Sweatingglucose tabs or gel Weakness1/2 c. sugar soft drink or juice Confusion4-7 Lifesavers-type candy Tremors1 c. of milk LethargyHave a snack, unless before a meal Look for cause of hypoglycemia If an insulin user, inject glucagon.

10. Three Polys fatigue Glycosuria acetone breath Weight Loss Labored breathing (kussmaul respirations)

11. Physical Activity in Type 1 DM Confers great benefits but requires good planning! If BG 300 = Don’t Exercise!! BG varies widely even with small amounts of exercise. Depends on control level. Check PG before exercise. If moderate activity, add 10-15 g CHO; if vigorous, add 20-30 g CHO. Check PG 30 min. before and 1 hour after exercise.

12. Increased Insulin Sensitivity Increased peripheral glucose uptake Lower Blood Glucose Decreased Plasma Insulin Lipolysis Metabolic Effects of Exercise in Type 2 DM

13. Meal Planning and Physical Activity Monotherapy Oral Agents: Sulfonylureas, Metformin, Troglitazones, etc. Combinations of Oral Agents: Metformin + Sulfonylureas, etc. Add Bedtime NPH to Orals When Therapy Changes NPH + Humalog BID Multiple Dose Regimen

14. Evaluating Outcomes in DM Treatment Outcomes Can Be: Clinical Economic Quality of Life Glycemic Control length/stay Participation in HbA1c ER visits care Blood lipids costs to - SMBG Weight/BMI health plan - keeps appts. Blood pressure - Rx refills Complications Better work Q of Life survey attendance

15. Case Study: 12 y/o with Type 1 DM Pt presented with weight loss, polyuria, polydipsia Dx:Type 1 DM ER Visit post-Dx:N/V/ Thirst, Fever, High BG (~400) Confused, Acetone Breath Yusef Urine reveals glycosuria, ketonuria= DKA

16. Metabolic events leading to these Sx?? Gradual Loss of Pancreatic Beta Cell Function Body loses major anabolic hormone= cells starve Cell starvation leads to increase glucagon, attempt to provide fuel to cell via gluconeogenesis. None of the fuel reaches the cell-urinary loss Extra water needed to clear glucose=polydipsia (thirst) Fat catabolized faster than used= ketone build-up

17. Symptoms of Diabetic Ketoacidosis NauseaHeadache Dry, itchy skinKussmaul Respiration Positive urinary ketonesBG < 60 mg/ dl Gradual Onset of Symptoms