1. Assistant Professor of Clinical Pharmacy
Diabetes Mellitus
Ibrahim Sales, Pharm.D.
Assistant Professor of Clinical Pharmacy
King Saud University

2. Hyperglycemic Crises in Diabetes
Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)
Type 1 and Type 2 diabetes
Insulin deficiency and increased counterregulatory hormones leads to free fatty acids release and hepatic fatty acid oxidation to ketone bodies in DKA
Insulin concentrations inadequate for glucose uptake, but adequate to prevent ketogenesis in HHS

3. Precipitating Factors
The most common is infection
Cerebrovascular accident
Alcohol abuse
Pancreatitis
Myocardial infarction
Trauma
Drugs (corticosteroids, thiazides, sympathomimetic agents)

4. Signs and Symptoms HHS evolves over several days to weeks
Symptoms of DKA may be present over several days; ketoacidosis-related metabolic alterations usually occur in < 24 hours
Polyuria, polydipsia, polyphagia, weight loss, vomiting, abdominal pain (DKA only), dehydration, weakness, clouding of sensoria
Poor skin turgor, Kussmaul respirations (DKA), tachycardia, hypotension, alteration in mental status, shock, coma (more frequent in HHS)

5. Diagnosis

6. Fluid Therapy
Goals: expansion of intravascular and extravascular volume and restoration of renal perfusion
0.9% NaCl at the rate of 15-20mL/kg per hour or 1-1.5L during the first hour
Hypernatremic or eunatremic, 0.45% NaCl infused at 4-14mL/kg/hour
Hyponatremic, 0.9% NaCl infused at 4-14mL/kg/hour
Replace half of the estimated water deficit over a period of hours

7. Fluid Therapy
Patients with DKA and HHS require calories for proper metabolism of ketone bodies
DKA: When blood glucose falls below 200mg/dL, change to 5% dextrose with 0.45%NaCl at a rate of mL/hour
In HHS, When blood glucose falls between mg/dL, change to 5% dextrose with 0.45%NaCl at a rate of mL/hour

8. Insulin Therapy Potassium value should be >3.3mEq/L
IV bolus of regular insulin (0.1 units/kg body weight)
Continuous infusion of regular insulin (0.1 units/kg/hr)
Optimal rate of glucose reduction between mg/hr
Decrease rate to 0.05 – 0.1 units/kg/hr when glucose reaches 200mg/dL (DKA); 300mg/dL (HHS)

9. Insulin Therapy DKA HHS Criteria for resolution of DKA include:
Blood should be drawn every 2–4 h for determination of serum electrolytes, glucose,
blood urea nitrogen, creatinine, osmolality, and venous pH (for DKA).
DKA
HHS
Criteria for resolution of DKA include:
Glucose 200 mg/dL
Serum bicarbonate 18 mEq/L
Venous pH 7.3
Keep serum glucose between 150 and 200mg/dL until resolution
Keep serum glucose between 250 and 300 until plasma osmolality is ≤315 mOsm/kg and patient is mentally alert

10. Insulin Therapy
When the patient is able to eat, start a multiple-dose insulin schedule
Continue IV insulin for 1–2 h after the SQ insulin
Continue IV insulin in patients n.p.o.
Continue previous doses prior to admission in patients with known DM
Start a basal and bolus insulin schedule in insulin naïve patients ( units/kg/day)

11. Potassium Hyperkalemia on presentation is common
Initiate K+ after serum levels <5.3mEq/L
20–30 mEq K+ in each liter of infusion fluid to maintain a concentration between 4-5mEq/L
Hypokalemia: delay insulin until K+ is >3.3mEq/L

12. Bicarbonate and Phosphate
Insulin blocks lipolysis and resolves ketoacidosis without any added bicarbonate
Give 50 mmol of bicarbonate in 200 ml of sterile water with 10 mEq KCL over two hours to maintain the pH at > 7.0 in patients with pH between 6.9 and 7.0
Serum phosphate is often normal or increased at presentation
Phosphate concentration decreases with insulin therapy
When needed, 20 –30 mEq/L potassium phosphate can be added to replacement fluids

13. Prevention of DKA and HHS
Prevention is the key (better access to medical care, proper education, effective communication with a health care provider during illness)
Sick-day management should include the following information:
When to contact the health care provider
Blood glucose goals and the use of supplemental short or rapid-acting insulin during illness
Means to suppress fever and treat infection
Initiation of an easily digestible liquid diet containing carbohydrates and salt
Advise all patients to never discontinue insulin and to seek professional advice early in the course of the illness

14. Case 4: Neuropathy
AF is a 74 y/o female with Type 2 DM. She has neuropathy in her feet and was recently started on Lantus 10 units at bedtime. She is complaining that the burning in her feet has gotten worse since she started taking Lantus. She didn’t take the insulin last night for that reason. What do you advise?

15. Circulation Comparison

16. Molasses vs. Water

17. Assistant Professor of Clinical Pharmacy
Diabetes Mellitus
Ibrahim Sales, Pharm.D.
Assistant Professor of Clinical Pharmacy
King Saud University