Monday , November 20 2017

Diabetes 101

Learning objectives

Upon completion of this chapter, the technician should be able to do the following:

1. Differentiate between Type 1 and Type 2 Diabetes.

2. Explain the Criteria for the diagnosis of Diabetes.

3. Explain Insulin Resistance.

4. Discuss the importance of monitoring blood sugars.

5. Explain the purpose of the HbA1c blood test.

6. Differentiate between the 5 classes of oral medications.

7. Explain the role of insulin treatment in diabetes.

8. Discuss the importance of controlling blood glucose.

What is Diabetes?

Diabetes-the complete name is diabetes mellitus-is one of the oldest diseases known. It was first described by the ancient Greeks as early as 100 AD. The word diabetes originates from the ancient Greek word for “flow through,” since two of the most common symptoms are extreme thirst and a need to urinate frequently.

Scattered throughout the pancreas are cells called islets of Langerhans . About 75% of these cells produce insulin and about 20% of these cells produce glucagon. Insulin decreases blood glucose (sugar) and glucagon increases blood glucose. During normal food metabolism, insulin is released in response to blood glucose, to cause the uptake and storage of glucose ( in the form of glycogen and fat). Without insulin, the body cannot use the glucose. Glucagon (from the pancreas) is released to oppose the actions of insulin

An estimated 16 million people in the United States of America (USA) are known to have diabetes, with 40% not even knowing they have diabetes and about 1 million of these being insulin dependent. Diabetes is a metabolism disorder which will progress over time to more serious problems unless it is managed properly.

In diabetes, the body can’t properly use the energy it gets from food. Normally, many foods we eat are broken down by digestion to glucose, which is a sugar. Glucose travels through the bloodstream to give the body’s cells the energy they need. Glucose needs the help of insulin, a hormone produced by the pancreas, to get inside the cells, where the glucose is burned for energy or stored.

Although there is no cure for diabetes, with proper care and attention it can be kept under control. Monitoring blood sugar, establishing a proper diet and exercise routine, and making other life-style commitments can help keep diabetes under control. Checking blood sugar regularly and recording the readings are the best way to know whether you are keeping your blood sugar levels under control. It is important to keep blood sugar levels within the boundaries set by your doctor throughout the course of the day and over time. This is the best way to avoid the long-term complications of diabetes, which can be serious. They can include heart and kidney problems, blindness, and nerve damage possibly leading to toe or foot amputation.

The DCCT (Diabetes Complications and Trials Study), the largest study every done on diabetics, showed that if you can keep your blood glucose levels as close to normal as possible, you can prevent the long term complications of eye disease by almost 80%, kidney disease by more then 50% and nerve disease by more then 60%.

In diabetes, there is a problem with insulin. In type I diabetes there is no insulin or hardly any insulin present. In type 2 diabetes either there is some, but not enough, insulin, or the body has trouble using the insulin that is present. Without enough insulin the glucose can’t be used by the body, and it accumulates in the blood. This is called hyperglycemia, or too much sugar in the blood. Hyperglycemia is most common after meals, when sugar from digested food reaches the blood stream. When there is too much sugar in the blood for a long period of time, complications such as heart disease can develop.

Symptoms of Diabetes

Most of the symptoms of diabetes are similar for type I and type 2 diabetes. These symptoms include:

•Extreme thirst

•Need to urinate frequently

•Lack of energy

•Weight loss

•Nausea and vomiting

•Irritability

•Blurry vision

•Slow healing of cuts and bruises

•Frequent infections

•Mood changes

Type I Diabetes

Type I diabetes used to be called insulin-dependent diabetes (lDDM) because the pancreas produces very little or no insulin. The cause of type I diabetes in unknown. It is believed to be an autoimmune disease, meaning that something causes the body’s immune system to destroy normal insulin-producing cells. Another older term for type I diabetes is juvenile-onset diabetes, because it is often diagnosed in children and young adults. People with type I diabetes need insulin injections to control their disease.

Type 2 Diabetes

Type 2 diabetes used to be called non-insulin-dependent diabetes (NIDDM) because it sometimes can be managed without the need for insulin injections. However, some people with type 2 diabetes do have to use insulin. In type 2 diabetes, the pancreas makes some insulin, but it is not enough to manage the body’s glucose. Or, the pancreas may make enough insulin, but the body can’t use it properly to transport glucose into the cells. Another term formerly used for type 2 diabetes is adult-onset diabetes, because it typically affects people who are over 40 years old, have a family history of diabetes, and are overweight.

Type 2 diabetes is much more common than type I diabetes. About 90% of people with diabetes have type 2 diabetes. Also, about 80% of people who have type 2 diabetes are overweight. Being overweight is very strongly linked to the development of type 2 diabetes.

Many people with type 2 diabetes can successfully manage their disease with weight control. Proper diet and exercise can help achieve weight control. Those who cannot manage type 2 diabetes with weight control alone need oral medication or insulin or a combination of both to control their blood glucose.

Gestational Diabetes

Diabetes that develops during pregnancy is called gestational diabetes. During pregnancy, certain hormones may cause glucose levels in the blood to rise. In some cases, the pancreas can’t keep up with the demand for extra insulin, and gestational diabetes develops. The symptoms of gestational diabetes usually disappear after the baby is born. But about one third of women who have gestational diabetes will develop type 2 diabetes later in life. This type of diabetes cannot be treated with oral drugs because of potential harm to the fetus, so only insulin injections can be used if diet and exercise are not sufficient in lowering blood glucose to normal levels.

Insulin Resistance

Sometimes there is enough insulin in the body, but the body isn’t able to use it properly to reduce blood glucose. This is called insulin resistance. Usually insulin resistance is due to problems in the cells that the insulin affects. Rarely, insulin resistance may be due to antibodies that bind to the insulin and prevent it from acting in the normal way. Either way, the result is that blood sugar levels may become too high.

People who are obese often have problems with insulin resistance. No one knows why, but in people who are very overweight the insulin doesn’t work properly. So being overweight may trigger diabetes in people with a family history of it. Insulin resistance is usually treated with diet and, if necessary, oral diabetes medications.

Who Gets Diabetes?

In the United States, nearly 16 million people have been diagnosed with diabetes, which means that about I of every 20 people has this disease. Many people have diabetes but do not know it yet. For example, about half the people with type 2 diabetes have not yet been diagnosed. Diagnosing diabetes early is important so that weight control and, possibly, medication can be begun as soon as possible. This can help avoid serious long-term complications.

Risk Factors

Some reports have linked type I diabetes to viral infections and an impaired immune system. Other reports suggest toxins in the environment may damage the cells and affect insulin production in the pancreas. This can lead to type I diabetes. Family history may play a role in the development of type I diabetes. Other associations between risk factors and the development of type I diabetes are less clear. For example, there does not seem to be a link between race and the development of type I diabetes.

Type 2 diabetes has several well-established risk factors. The chances of developing type 2 diabetes increase with age. There is a very strong link between family history and the development of type 2 diabetes. People in several ethnic groups, including Native Americans, Mexican Americans, African Americans, and inhabitants of Pacific islands like Polynesia and Samoa, have a high risk of type 2 diabetes. But the most important risk factor for type 2 diabetes is being overweight. Researchers have discovered that it is not just the amount of body fat that is important, but where the fat is distributed on the body. Increased body fat at or above the waist is more of a risk for type 2 diabetes than body fat below the waist. Inactivity also adds to diabetes risk. Exercise is important in preventing or delaying the onset of diabetes because it improves the body’s use of glucose.

How is Diabetes Diagnosed?

Often there are few symptoms in the early stage of diabetes. It’s important to have regular check-ups so your doctor can check for diabetes. If diabetes is suspected, a doctor can make the diagnosis based on a complete medical history, physical examination, and blood and urine tests. Once diagnosed, treatment will be based on the type and severity of diabetes. Remember, diabetes can be Controlled.

Glucose Tolerance Test

The glucose tolerance test is a very sensitive test, meaning it can firmly establish the presence or absence of diabetes. The test is given in the morning. After not eating since the night before, a drink will be given containing glucose. The blood glucose level will be measured at least four or five times over the next two to three hours. The most important measurement is the one at two hours after drinking the glucose.

The table below shows the meaning of the test measurements at two hours measured in milligrams per deciliter (mg/dL).

mq/dL

• 80-140 – normal

•140-200 – glucose intolerance

• Over 200 – diabetes

These values do not apply to patients with gestational diabetes.

Fasting Blood Sugar

The fasting blood sugar (also called fasting blood glucose) is a simple screening test for diabetes. It is not a very sensitive test, but is generally useful in identifying which patients should be followed closely for signs of diabetes. Your must not eat anything beginning the night before the test. Then a blood sample will be drawn in the morning. The table below shows the meaning of the test measurements.

• Below Il0 mg/dl-normal

• Over 126 mg/dl- abnormal (you may have diabetes)

Urine Sugar

When the level of sugar (glucose) in the blood gets too high for the kidneys to handle, some sugar “spills” into the urine. In most people blood sugar levels have to be very high for sugar to get into the urine. So blood sugar levels are now the standard measurements.

Monitoring Your Diabetes

Keeping track of blood sugar levels is the most important step in knowing the patients diabetes is under control. When the blood sugar levels are checked regularly, you get an accurate record of the readings over time. This will help the patient, doctor, and diabetes educator adjust diet, exercise, and medication as needed.

Finger Stick Blood Sugar

You can easily test blood sugar with a simple finger stick device. A tiny blade will prick the finger to get a single drop of blood that you put on a test strip, pad, or sensor. The blood is automatically tested for sugar level. The doctor or pharmacists can help to decide which type of device is best and help the patient know how to use it.

When and how often to test blood sugar depends on many factors. When diabetes is first diagnosed, many people need to check their sugar three to four times each day. This will help find out if diet or medicine needs to be adjusted. But if diabetes is well controlled, less checking of blood sugar levels will be necessary.

Fasting & Postprandial Levels

The doctor and diabetes educator will also set up goals for fasting and postprandial (after eating a meal) blood sugar levels. Many doctors want fasting (more than eight hours after eating) levels of 80 to 120 mg/dL and postprandial (less than two hours after eating) levels of less than 160 mg/dL. These levels show tight control of blood sugar. But these goals can vary for each patient.

Hemoglobin A1c Test

The hemoglobin A1c test is a laboratory blood test the doctor should want to do every three months to help you keep tight control of your diabetes. Keeping tight control is measured by long-term results and is the best way to avoid long-term complications. Hemoglobin is a substance in blood that carries oxygen from the lungs to all parts of the body. A type of hemoglobin called hemoglobin A1c (HbAIc) forms when glucose attaches to hemoglobin. This happens only when blood glucose levels are high. The hemoglobin Alc level can be used to measure a person’s average blood sugar over the past two to three months. Normal HbAIc values for non-diabetics is approximately 4.0-6.2 percent. The American Diabetes Association recommends that it should be below 7 for diabetics to help prevent the complications from diabetes.

How is Diabetes Treated?

How diabetes is treated depends on the type and severity of disease. The cornerstones of diabetes management are diet and exercise. If diet and exercise alone are not enough to control blood glucose levels, one or more oral medications, or perhaps even insulin, will need to be added.

Diet Control

Diet control is the first step in the treatment of diabetes. Proper diet can help control the blood sugar level. In many cases of type 2 diabetes, proper diet, along with exercise, can control the disease without the need for oral medications.

Meal Planning

The most important aspect of the diabetic diet is meal planning. A typical meal plan includes breakfast, lunch, dinner, and a nighttime snack. Some people also need to plan other between-meal snacks. Being consistent in a diet is the most important part of meal planning. It is advisable to eat the same number of calories, the same amounts of food, and the same types of food at the same times each day. It is also important to eat all of the meals on a regular schedule to help avoid sharp ups and downs in blood sugar.

Exercise

Exercise is important for the patient with diabetes. Exercise makes insulin work better in the blood and can help lower blood sugar levels. Exercising for just 20 to 30 minutes three times per week can lower the amount of medication needed for people with type I and type 2 diabetes. It can also improve overall health. People with diabetes have to be careful not to let the blood sugar get too low when exercising. The easy way to prevent low blood sugar is to eat within three hours before exercising. The doctor should be consulted before starting an exercise program.

Reducing Stress

There is evidence linking stress with blood sugar levels. Stress has been shown to cause blood sugar to either rise or fall. Many people with diabetes notice that the stresses of daily living can affect their blood sugar levels. In some people, long-term stress can cause the onset of diabetes.

Reducing stress is an important part of diabetes management.

Oral Medications

Oral medications (pills) for diabetes are used when diet and exercise alone are not enough to control diabetes. Most people with type 2 diabetes can be helped by oral medications. Even if oral medications are used, it is still very important to follow a doctor’s advice about diet and exercise.

Many medications are available for the treatment of diabetes. They all work by reducing blood sugar, but they work in different ways. None of these medications contains insulin. The oral medications available now all belong to one of five types:

• Sulfonylureas

• Biguanides

• Alpha-Glucosidase Inhibitors

• Thiazolidinediones

• Meglitinides

Sulfonylureas (Micronase, Glynase, Diabeta, Glyburide-Generic, Amaryl). This was the only class of oral diabetic medicine available from 1950 to 1995. The other 4 classes of medications did not become available until 1995 through 1999.

Sulfonylureas help the body release more insulin from the pancreas. They may also make it easier for the insulin to work. Sulfonylureas are usually taken before meals, although the exact time will vary according to the exact medication used. A sulfonylurea may be used alone, along with another oral medication, or combined with insulin.

All sulfonylureas may cause the blood sugar to go too low (hypoglycemia). Symptoms of hypoglycemia can include nervousness, dizziness, sweating, weakness and a pounding heart. This is more likely to happen if a meal is missed or when used in combination with other diabetic drugs, including insulin. When taking a sulfonylurea, it is important not to skip meals. The most common side effects with most sulfonylureas are gastrointestinal (for example, nausea or heartburn).

Biguanides (Glucophageâ generic name metformin). The biguanides are another class of oral diabetes medication. Sometimes biguanides are prescribed when people have been taking sulfonylureas for a long time and the sulfonylureas no longer lower the blood sugar enough. The biguanides cause the liver to release stored sugar into the blood more slowly, which makes it easier for insulin to work. They are taken several times a day, always with meals. A biguanide may be used alone or in combination with a sulfonylurea.

Biguanides alone usually don’t cause low blood sugar, but it may occur when one is used in combination with a sulfonylurea. The most common side effects of biguanides are gastrointestinal (for example, diarrhea, nausea, vomiting).

Biguanides should not be taken by people with kidney disease. They also should not be taken if a patient is having a certain type of radiologic exam using a radiologic dye. There is a risk of a rare but life-threatening condition called lactic acidosis. The doctor may perform blood tests to monitor kidney and liver function to guard against this rare occurrence.

Aipha-Glucosidase Inhibitors (Precose, Glycet generic name acarbose). The alpha-glucosidase inhibitors are a type of medicine that works in a unique way. They slow down the digestion of carbohydrates after a meal. This means postprandial blood sugar levels don’t rise so sharply. Alpha-glucosidase inhibitors must be taken with the first bite of each meal, three times a day. An alpha-glucosidase inhibitor may be taken alone or in combination with a sulfonylurea.

Alpha-glucosidase inhibitors themselves do not cause hypoglycemia (low blood sugar levels) or hyperinsulinemia (too much insulin in the blood). But it is still possible to develop hypoglycemia if the patient is taking an alpha-glucosidase inhibitor along with a sulfonylurea. If this happens, the patient needs to use a special sugar to bring their blood sugar back up. This sugar is glucose (dextrose), which is different than sucrose (cane sugar) found in table sugar or candy. The patient should not use sucrose to treat hypoglycemia if taking an alpha-glucosidase inhibitor. Glucose is found in honey or bananas but less so in orange juice. Glucose (dextrose) tablets can be found in the pharmacy.

Alpha-glucosidase inhibitors should not be taken by patients with diabetic ketoacidosis, cirrhosis, or chronic intestinal disorders. The most common side effects are gastrointestinal (for example, gas, diarrhea, and abdominal pain).

Thiazolidinediones (Avandia – rosiglitazone and Actos – pioglitazone). The thiazolidinediones are another type of oral diabetes medication. They are useful for patients already taking insulin and Type 2’s who are obese and insulin resistant because they work by making the body’s cells more responsive to insulin. Thiazolidinediones are taken only once per day, usually with breakfast, in the middle of the meal. They can also be used alone, or by patients taking another oral medication. These medications are also referred to as insulin sensitizers.

Hypoglycemia (low blood sugar) may occur when a thiazolidinedione is used in combination with insulin or another medication. It has not occurred when used alone.

The most common side effects reported include infection, headache, and pain. In rare cases, a serious liver malfunction has been associated one of the thiazolidinediones (Rezulinâ) that has been removed from the market. The doctor must do blood tests every 2 months to check on liver function.

Meglitinides ( Prandin – repaglinide). The meglitinides are another type of oral medicine that helps your body release more insulin from the pancreas. The medicine responds to your body’s blood sugar level by signaling the pancreas to put out more insulin when the blood glucose level is high. Meglitinides may be used alone or with metformin. Meglitinides are taken before meals, usually three times a day and only work if food is present.

Meglitinides can cause the blood sugar to go too low (hypoglycemia), but the risk of this is less than with the sulfonylureas.

People with diabetic ketoacidosis should not take meglitinides. Higher doses of meglitinides should be used carefully in patients with liver or kidney problems. The most common side effects reported include infection, headache, and gastrointestinal symptoms (for example, diarrhea or vomiting).

Insulin. Initially all patients with type I diabetes and a few with type 2 diabetes need insulin. Many people with type 2 diabetes may eventually need insulin. So far, insulin is only available as an injection.

Types of Insulin

There are several different types of insulin. These are:

• Ultra-short acting insulin (an example is Lysine-proline analog insulin, also called Lisproâ or Humalogâ insulin) This Insulin is only available on a prescription, where most of the other insulins are available without a prescription,

• Short acting insulin (an example is Regular insulin or Humalinâ R)

• Intermediate acting insulin (examples are NPH and Lenteâ or Humalin âN insulin)

• Long acting insulin (an example is Ultralenteâ insulin or Humalinâ U)

• Mixed insulins (mixtures of NPH and Regular insulin; examples are 70/30 and 50/50)

New Mixture- Humalog 75/25 – N/Humalog

• Buffered insulin (which is used in insulin pumps)

These types of insulin are not alike in terms of when and how long they act in the body. Onset is how long the insulin takes to begin working. Peak is the time after taking the insulin when it is working the most. Duration is how long the insulin keeps working. Onset, peak, and duration for each type of insulin are shown in the following table.

Activity of Different Types of Insulin
Ultra-Short- Short- Intermediate- Long-Acting

Ex. Humalog, Humalin R, Humalin N, Humalin U

Onset 5 min. ½ hour 2-4 hours 4-8 hours

Peak 1 hour 2-4 hours 6-12 hours 12-18 hours

Duration 2-4 hours 6-8 hours 18-24 hours 24-36 hours

The doctor will prescribe the type of insulin that is best for the patient based on how difficult it is to control the blood sugars as well as on other factors. It should be noted that ultra-short acting insulin is not approved for use during pregnancy.

How Is Insulin Given?

Insulin shots can be administered by several techniques. The first is the traditional syringe, or needle. The second is a special insulin pen in which a cartritage of insulin is put into a pen like syringe and used multiple times. There are also pens with a single dose of insulin that you throw away after use. The third is a pump the size of a beeper that injects the right amount of insulin automatically into the bloodstream. The pump is used by people with more brittle diabetes or those who want very tight control of their diabetes and more control over their lifes.

Important Considerations When Using Insulin

Using insulin is not difficult to learn. Usually, a doctor, pharmacist, nurse, or diabetes educator can provide this training. Insulin comes in different strengths. Most manufacturers recommend that insulin be stored in the refrigerator (not the freezer!) when not in use. Insulin should not be used after the expiration date shown on the package. It is also important to learn to recognize the normal appearance of insulin. Regular insulin should be clear. NPHâ, Lenteâ, and Ultralenteâinsulin should be cloudy. But no type of insulin should have any little specks (called precipitates) floating in it. If the insulin doesn’t look right, it should not be used.

Most important of all is that the patient uses the insulin exactly as directed by the doctor. Insulin has a very strong effect on blood sugar. Taking the wrong type of insulin or the wrong dose of insulin can have serious results. Insulin should not be mixed unless the patient has been instructed to do so.

Short-Term Complications of Diabetes

Short-term complications of diabetes (also called acute complications) occur because the blood sugar gets too high or too low and causes immediate symptoms. It is important to keep short-term complications under control so they don’t lead to long-term problems. Short-term complications include:

Low blood sugar (also called hypoglycemia or insulin shock). In hypoglycemia, the blood sugar becomes too low. This might happen if a person with diabetes misses a meal and still takes the normal dose of insulin. It might also happen during exercise if a person with diabetes has not eaten extra carbohydrates before exercising. Or it might happen if a person with diabetes takes too much of some oral medications. (Alpha-glucosidase inhibitors and thiazolidinediones alone don’t cause hypoglycemia because of the way in which they work. But some sulfonylureas are long acting and can cause prolonged hypoglycemia.) Symptoms of hypoglycemia include nervousness, dizziness, sweating, weakness, and a pounding heart. Or there may be no symptoms at all.

Moderate hypoglycemia can usually be treated by taking some milk and crackers. If the blood sugar is extremely low, eating candy or drinking orange juice can help. If your blood sugar drops too low when you are taking an alpha-glucosidase inhibitor, you need to use a special sugar to bring it back up. This sugar is glucose (dextrose), which is different than sucrose (cane sugar) found in table sugar or candy. If the symptoms don’t improve after about 15 minutes, emergency help should be called for, since uncontrolled hypoglycemia is very dangerous. If low blood sugar continues to the point where the patient passes out and you cannot give them something orally, then the alternative is to give them an injection of Glucagonâ which is available by prescription.

High blood sugar (hyperglycemia). It can occur if you have not taken your oral medication or insulin, if you have eaten too much food, or if you haven’t exercised enough. Many times there won’t be symptoms during hyperglycemia. Other times, there may be thirst, frequent urination or tiredness. The best way to control hyperglycemia is to talk to a doctor about changing the diet or an adjust in oral medications or insulin.

Ketoacidosis. Ketoacidosis (also called diabetic ketoacidosis or DKA) happens when there is no insulin in the blood and glucose can’t be used by the body’s cells. This occurs more commonly in people with type I diabetes. The body starts using stored fat for energy, and ketone bodies increase in the blood. Ketoacidosis starts slowly and builds up. The symptoms of ketoacidosis include extreme thirst, loss of appetite, abdominal pain, nausea, vomiting, flushed skin, fever, frequent urination, drowsiness, alcohol breath and rapid breathing. It can cause dehydration, and if the person is not given fluids and insulin right away, ketoacidosis can lead to coma and even death.

Long-Term Complications of Diabetes

The long-term complications (also called chronic complications) of diabetes are those that typically occur after years of elevated blood sugar. Perhaps the most important reason for good blood sugar control in people with diabetes is that the longer the blood sugar remains elevated, the greater the chances of developing one or more of the complications of diabetes. Keeping blood sugar under control can actually reduce the chances of developing complications! If short-term complications can be controlled, then long-term complications are less likely to occur.

Blurry vision. This can occur if the blood sugar level is too high. Vision usually returns to normal when the blood sugar level returns to normal.

Retinopathy. Long-term diabetes can affect the retina of the eye, causing vision problems and, eventually, blindness. It is very important for people with diabetes to have regular eye examinations. Retinopathy from diabetes is the leading cause of blindness.

Nephropathy (kidney damage). A major job of the kidneys is to filter all of the waste products of the body out of the blood into the urine. When the small blood vessels in the kidneys become damaged, the kidneys cannot do this work as well. If this happens, your doctor can prescribe a blood pressure medication to help your kidneys work better. Your doctor may also advise you to change the amount of protein and potassium in your diet. Sometimes patients with diabetic nephropathy require dialysis, in which a machine does the filtering for them. Nephropathy from is the leading cause of kidney failure.

Neuropathy (nerve damage). Neuropathy can occur after years of poor blood sugar control because the small blood vessels feeding the nerves become blocked. Peripheral neuropathy is the most common type of diabetic neuropathy. Typically, patients with peripheral neuropathy feel numbness, tingling, or pain in the feet, legs, hands, and arms due to poor circulation from diabetes. This may even lead to foot amputation. In some cases, medications can be prescribed by your doctor to ease the symptoms of neuropathy.

Macrovascular Complications. Macrovascular complications are those affecting the large blood vessels (arteries and arterioles) of the body. Macrovascular complications include:

Heart and blood-vessel disease. Such disease can develop because of poor circulation, caused by damage to the blood vessels. This can increase the chances of a heart attack or stroke. To help prevent heart disease and circulation problems, people with diabetes should eat a low-fat diet and exercise regularly.

High blood pressure. High blood pressure can cause a strain on the kidneys, which may make it more likely for nephropathy to develop. High blood pressure can be controlled with changes in the diet and with medications.

Living with Diabetes

The key to controlling diabetes is by educating and empowering the patient to manage their own diabetes. With modern advancements in diabetes treatments and the availability of widespread support from doctors, pharmacists, nurses, diabetes educators, and organizations like the American Diabetes Association, American Association of Diabetes Educators and the American Dietetic Association, it is possible now-more than ever-to successfully manage diabetes. Diabetes must be controlled by self-management and in order to do that, they need to become educated on their diabetes.

Criteria for the diagnosis of diabetes:

1. Symptoms of diabetes plus casual plasma glucose concentration > 200mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.

OR

2. FPG (Fasting Plasma Glucose) > 126mg/dl (7 mmol/l). Fasting is defined as no caloric intake for at least 8 hours.

OR

3. 2 hour PPG (Post-Prandial meaning after meals) > 200mg/dl (11.1 mmol/l). during an OGTT (Oral Glucose Tolerance Test). The test should be performed using a glucose load containing the equivalent of 75 grams anhydrous glucose dissolved in water

In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day. The third measure (OGTT) is not recommended for routine clinical use. American Diabetes Association

DIABETES ORAL MEDICATIONS

This Chart is only a brief overview, for more information, review the information from your print out or drug insert.

Name of Class
Examples
Mechanism of Action
Unique factors
Major Side effect
Primary Site of Action

Sulfonylurea

Micronaseâ

Glynaseâ

Diabetaâ

Glyburide

Amarylâ
Increases the release of Insulin from the Pancreas
Can be used in combination
Hypoglycemia.

Weight gain,

Beta Cell Depletion
Pancreas

Biguanide
Metformin (Glucophageâ)
Reduces the production of Glucose by the Liver
Can be used in combination
Abdominal Distress
Liver

Alpha-Glucosidase Inhibitor

(Dose needs to be titrated gradually)
Acarbose (Precoseâ)

Glycetâ
Delays the adsorption of carbohydrates in the Intestinal tract
Abdominal distress Can be used in combination
Abdominal Distress, flatulence
Intestines

Meglitinides

Repaglinide

(Prandinâ)
Similar to Sulfonylurea, except it is shorter acting and only works when glucose is present.
Taken with food. Not to be taken without food

Can be

used in combination
Short Duration – A meal time drug
Pancreas

Thiazolidinediones
Avandiaâ (Rosiglitazone)

Actosâ

(Pioglitazone)

Insulin sensitizer, allows for the more effective use of insulin
Can be used in combination. Liver Enzyme test must be performed at onset and every 2 months for 1 year
Decreases the amount of Insulin required, including bodies own insulin and injectable insulin
Skeletal Muscle

Steve Freed, R.Ph., Diabetes Educator

www.partnersincontrol.com

June 8, 2000

Self assessment questions

1. Explain the difference between Type 1 and Type 2 diabetes____________________

2. What is the criteria for the diagnosis of Diabetes?____________________________

3. List the 5 classes of oral diabetes medication

_________________________ __________________________

_________________________ __________________________

_________________________

4. If a patient has a hypoglycemic reaction while on Precose, what would be the most effective product to take?

a. Orange Juice

b. Snickers Candy Bar

c. Should not take anything

d. Glucose Tablets

e. Sucrose

5. What are times for the different insulin’s to begin working (onset)?

a. Humalog____________hr

b. Humalin R __________hr

c. Humalin N __________hr

d. Humalin U__________hr

6. Which of the following is not a long term complication from diabetes?

a. Retinopathy

b. Neuropathy

c. Ketoacidosis

d. Macrovascular

7. The Hemaglobin A1c or HbA1c test

a. Is a 3 month average of a persons blood sugar

b. Has a normal range of 6-8%

c. Is recommended once a year

d. Can be done by the patient on a blood glucose monitor

e. Is a urine test for protein

8. What are the possible symptoms for Hypoglycema (Low Blood Sugar)?

a. _________________ d. _________________

b. _________________ e. _________________

c. _________________

9. Which Oral Diabetes medication causes the liver to release stored sugar into the blood more slowly?

a. Glucotrolâ d. Micronaseâ

b. Prandinâ e. Precoseâ

c. Glucophageâ

10. Which oral diabetes medication requires that a Liver Enzyme test must be performed at onset and every 2 months for 1 year?

a. Glucophageâ d. Rezulinâ

b. Glysetâ e. Avandiaâ

c. Precoseâ

11. Once a diabetic you are always a diabetic?

a. True

b. False

12. Which of the following drugs is used for primarily for insulin resistance?

a. Glucophageâ d. Avandia & Actosl

b. Glycetâ e. Micronase & Amarylâ

c. Coumadinâ

Answers to Self assessment questions

1. Type 1 diabetes is a severe from of diabetes where the pancreas cannot produce insulin and blood glucose is elevated. Persons with Type 1 diabetes require insulin injections to maintain their blood glucose in an acceptable range. Type 2 diabetes is a form of diabetes where insulin is produced in the pancreas but, may not be sufficient to control blood sugars in the normal range and the body is insensitive to the insulin’s effect. Type 2 diabetes can usually be treated with diet, exercise or, if needed, oral hypoglycemic drugs or in combination with insulin.

2. Symptoms of diabetes plus casual plasma glucose concentration over 200mgm/dl, or

FPG (Fasting Plasma Glucose) greater or equal to 126mg/dl or a 2 hour PPG (after meal)of 200mg/dl from a meal or during an Oral Glucose Tolerance Test.

3. a. Sulfonylureas

b. Biguanides

c. Alpa-Glucosidase Inhibitors

d. Meglitinides

e. Thiazolidinediones

4. d

5. Humalog 5 minutes

Humalin R ½ hour

Humalin N 2-4 hours

Humalin U 4-8 hours

6. c

7. a

8. nervousness, dizziness, sweating, weakness, and a pounding heart.

9. c

10. e

11. a

12. d.

Author information

Stephen Freed, R.Ph., Diabetes Educator

Partners In Control, Inc. CEO

The Gladstone Group, Inc

Clinical Director

Email: steverx@home.com