Management of Diabetes Mellitus

1. Prapared by maria carmela l. domocmat, rn, msn
MANAGEMENT OF DIABETES

2. Medical Management of DM
 No cure
 Goal: Euglycemia and prevention of
complications
 Individualized treatment plans
 Appropriate goal setting
 Diet
 Exercise
 Self-monitoring of blood glucose (SMBG)
 Regular monitoring for complications
 Laboratory assessment
 Oral meds/insulin

3. Surgical management of DM
 pancreas transplant
 not usually done
 Islet cell transplants

4. Dietary management

5. Dietary management of DM
Foundation of Diabetic control
 Goals
 Maintain near-normal blood glucose levels
 Achieve optimal serum lipid levels
 Provide adequate calories for reasonable weight
 Prevent & treat acute complications of insulin-
treated diabetes
 Improve overall health through optimal nutrition

8. Diet Composition
 Carbohydrates: 60 – 70% of daily diet
 Protein: 15 – 20% of daily diet
 Fats: No more than 10% of total calories from
saturated fats
 Fiber: 20 to 35 grams/day; promotes intestinal
motility and gives feeling of fullness
 Sodium: recommended intake 1000 mg per 1000
kcal
 Sweeteners approved by FDA instead of refined
sugars
 Limited use of alcohol: potential hypoglycemic
effect of insulin and oral hypoglycemics

9. The exchange system
 Six categories
 Bread/starch
 Meat
 Milk
 Vegetable
 Fruit
 Fat

10. General guidelines of Dietary
Management
 Protein
 20%
 Fat
 20%
 Carbohydrates
 60%
 ADA: American
Diabetic Association

11. Diabetic Meal Plan
 Small frequent meals
 CONSISTENCY!
 Amount of calories
 Amount of carbohydrates
 Time
 Snacks

12. Diabetic Meal Plan
 If the pt is obese, the key to treatment is…
 Weight los!

13. Sweeteners
 Nutritive sweeteners
 Not calorie free
 Cause less h in BS (than
regular sugar)
 Sorbitol  laxative effect
 Non-nutritive sweeteners
 Minimal or no calories
 Do not h BS

14. Meal Plan considerations
 Food preferences
 Lifestyle
 Schedule
 Ethnic / Cultural
background

15. Alcohol and Diabetes
 Increase risk of…
 Hypoglycemia
 Affects the liver
 Don’t take on empty
stomach
 Esp. if on insulin or
oral hypoglycemic
meds
 Moderation

16. Exercise

17. Exercise and Diabetes
 i blood glucose levels
 h the uptake of glucose by body muscle
 Potentiates action of insulin
 i insulin requirement
 Effect lasts 24 hours

19. More Benefits of exercise
 Increases circulation
 Improve serum lipid
levels
 Improves cardiovascular
status
 Assist with wt control
 Decreases stress

20. Rules for the exercising
diabetic
 Talk to MD first
 Regular vs. sporadic
 Correlate exercise and glucose levels
 Don’t exercise when hypoglycemic
 Don’t exercise when hyperglycemic >250

21. Rules for the exercising
diabetic
 Do not exercise when insulin is peaking
 Carry a quick source of sugar
 Best time = 60-90 minutes after a meal

22. Rules for the exercising
diabetic
 Proper footwear
 May need a pre-exercise snack
 Consistency!

23. Self monitoring of blood glucose
(SMBG)

25. Monitoring Glucose
 SMBG
 Glucometers
 Urine testing for glucose
 2-4 times a day
 Continuous glucose monitoring system

26. Monitoring Ketone levels
 Dipstick method
 Perform when:
 Glucosuria
 Unexplained elevated glucose level
 Illness
 Pregnancy

27. Foot care
Regular monitoring for complications

28. Foot care

29. Foot Care
 Inspect feet daily
 Wash feet with warm water and mild soap
 Pat dry – do not rub

30.  Wash daily: wash feet in warm water every
day, using a mild soap.
 Dry between toes
 Lubricate dry feet
 Inspect
 Mirror
 Family
 Between toes

31.  Do not soak feet.
 Dry feet well,
especially between
the toes.
 If the skin on feet is
dry, keep it moist by
applying lotion after
washing and drying.
 Apply lotion on feet
(not interdigital areas)

32. Foot care
 Check toenails once a
week.
 Trim toenails with a nail
clipper straight across.
 Do not round off the
corners of toenails or cut
down on the sides of the
nails.
 After clipping, smooth
the nails with an emery
board.

33. Foot care
 Always wear socks or stockings with soft
elastic, and that fit feet.
 Wear socks at night if feet get cold.
 Always wear closed-toed shoes or slippers.
 Do not wear sandals and do not walk
barefoot, even around the house.

34. Foot care
 Wear comfortable properly fitted shoes
 Buy shoes made of canvas or leather and
break them in slowly.
 Extra wide shoes are also available in
specialty stores that will allow for more room
for the foot for people with foot deformities.
 Break in new pair of shoes for 1 -2 hours only
until it becomes comfortable

35. Foot care
 Maintain the blood flowing to feet
 Elevate feet up when sitting
 Do not wear knee high/ stay up stockings

36. Foot care
 wiggle toes and move ankles several times a
day
 don't cross legs for long periods of time
 Avoid activities that icirculation
 Smoking
 Crossing legs
 Tight socks

37.  Good shoes  Prevent injuries
 Comfortable  Wear socks
 Closed toe  Cotton
 No bare feet  Light color
 New shoes  No wrinkles
 Break in slowly
 Check inside of
shoe

38.  No temperature  See doctor
extremes regularly
 Check bath water  Podiatrist
 No water bottles  Trim straight across
 No heating pads  Do not cut calluses
or corns
 Range of Motion

39. Foot care
 see podiatrist q2 to 3 months for check-ups,
even if don't have any foot problems.
 include inspection of skin
 check for redness or warmth of the skin.
 check for pulses and temperature of feet
 Monofilament assessment of foot sensation

40. When to contact Dr?
 Changes in skin color
 Changes in skin temperature
 Swelling in the foot or ankle
 Pain in the legs
 Open sores on the feet that are slow to heal or
are draining
 Ingrown toenails or toenails infected with fungus
 Corns or calluses
 Dry cracks in the skin, especially around the heel
 Unusal and/or persistent foot odor

41. Risk for infection
 Frequent hand washing
 Early recognition of signs of infection and
seeking treatment
 Meticulous skin care
 Regular dental examinations and consistent oral
hygiene care

42. Sexual dysfunction
 Effects of high blood sugar on sexual
functioning,
 Resources for treatment of impotence, sexual
dysfunction

43. MANAGEMENT DM:
PHARMACOLOGIC MGMT

44. Oral Hypoglycemic Agents
 Oral hypoglycemic meds are NOT Insulin
 Oral hypoglycemic meds require some
production of insulin
 Oral hypoglycemic agents are used in the
treatment of type 2DM
 Oral hypoglycemic meds are meant to
supplement diet and exercise, NOT replace them

45. Oral Hypoglycemic Agents
 Oral hypoglycemic meds cannot be used
during pregnancy
 Oral hypoglycemic meds may need to be
halted temporarily and insulin prescribed if
BS levels rise due to infection, trauma, stress,
surgery etc.
 Action vary so effect may be enhanced by use
of multiple meds

46. Oral Medication
 Biguanides
 Sulfonylureas
 Meglitinide derivatives
 Alpha-glucosidase inhibitors
 Thiazolidinediones (TZDs)
 Glucagonlike peptide–1 (GLP-1) agonists
 Dipeptidyl peptidase IV (DPP-4) inhibitors
 Insulins
 Amylinomimetics
 Bile acid sequestrants
 Dopamine agonists

47. Biguanides
 Metformin (Glucophage)
 first choice for oral type 2 diabetes
treatment.
 Action: decreases overproduction of
glucose by liver and makes insulin more
effective in peripheral tissues

48. Biguanides
 Major side effects : anorexia/ wt. Loss
 CI in patients with Renal impairment
 D/C temp of (+) illness that leads to
dehydration or hypoperfusion --lactic
acidosis.

49. Sulfonylureas
 Glyburide (Micronase, DiaBeta, Glynase)
 Glipizide (Glucotrol, Glucotrol XL)
 Glimepiride (Amaryl)
 Cholpropamide (Diabanese)

50. Sulfonylureas
 Action: Stimulates pancreatic cells to
secrete more insulin and increases
sensitivity of peripheral tissues to insulin
 (insulin secretagogues)
 indicated for use as adjuncts to diet and
exercise in adult patients with type 2 DM
 Used: to treat non-obese Type 2 diabetics

51. Sulfonylureas
 taken with food
 except Glucotrol/Glipizide : taken 30 mins before
meals

52. Sulfonylureas
 (esp. Diabinese) when Side-effects
taken with alcohol can  Hypoglycemia
cause severe
Disulfiram reactions  GI upset
 Disulfiram (antibus): a
compound when used
with alcohol produces
distressing symptoms
 Symptoms: Flushed
skin, N/V, palpitations,
hyperventilation

53. Meglitinides
 Repaglinide (Prandin)
 Nateglinide (Starlix)
 Action: stimulates pancreatic cells to
secret more insulin
 much shorter-acting insulin secretagogues
than the sulfonylureas
 may be used in patients who have allergy to
sulfonylurea medications.

54. Alpha-glucosidase inhibitors
 Acarbose (Precose)
 Miglitol (Glyset)
 Action: Slow carbohydrate digestion and
delay glucose absorption
 S/E : diarrhea & flatulence
 Take immediately before meals

55. Thiazolidinediones (TZDs)
 Pioglitazone [Actos]
 Rosiglitazone [Avandia]
 Used for patients with type 2 DM who take
insulin injections
 Acts by increasing insulin action at the receptor site
 reduce insulin resistance
 act as insulin sensitizers; thus, they require the
presence of insulin to work.
 must be taken for 12-16 weeks to achieve
maximal effect.

56. Thiazolidinediones (TZDs)
 Affects liver function  liver function tests
 Indications of altered liver function
 Yellow skin tone
 Nausea
 Abdominal pain
 Dark urine

57. Drug Interactions
Directly interact with Sulfonamides
Sulfonylurea and NSAIDS
increase risk of
hypoglycemia
Sulfonylurea+ * Med =
Hypoglycemia

58. Drug Interactions
h blood glucose levels Potassium-losing diuretics
Regardless of what Corticosteriods
med you might also be Estrogen compounds
taking Phenytoin (Dilantin)
Salicylates (ASA)

59. Drug interactions
Meds that cause Acetaminophen
Hypoglycemia Alcohol
Monoamine oxidase
Without drug inhibitors / MAO inhibitors
interaction

60. Drug interactions
Meds that can Propranolol (Inderal)

MASK signs and
symptoms of
Hypoglycemia

61. Oral Hypoglycemic Agents
 Client must also maintain prescribed diet and
exercise program; monitor blood glucose levels
 Not used with pregnant or lactating women
 Specific drug interactions may affect the blood
glucose levels

62. Insulin

64.  Instituted in 1923
 Beef
 Pork
 1979 – human insulin
 Can not be taken by mouth (digested)

65. Onset – Peak - Duration
 Onset
 The time period from injection to when it begins to
take effect
 Peak
 When insulin is working its hardest and therefore
blood glucose levels are at their lowest
 Duration
 Length of time the insulin works or lasts

66. Types
 Rapid-acting insulins or Ultra short-acting
 Short-Acting Insulins
 Intermediate-Acting Insulins
 Long-Acting Insulins

67. Rapid-acting insulins/
or Ultra short-acting
 have a short duration of action
 appropriate for use before meals or when
blood glucose levels exceed target levels and
correction doses are needed.
 These agents are associated with less
hypoglycemia than regular insulin.

68. Rapid-Acting Insulins/
or Ultra short-acting
 Insulin aspart (NovoLog)
 Insulin glulisine (Apidra)
 Insulin lispro (Humalog)

69. Rapid-Acting Insulins
 Insulin aspart (NovoLog)
 Insulin glulisine (Apidra)
 Insulin lispro (Humalog)
Appearance Onset Peak Duration
Clear 5-15 minutes 30-90 (1hr) 3-5 hours
(10 min) (4 hrs)
 Insulin pumps
 Rapid reduction of glucose level

70. Short-Acting Insulins
 Regular insulin (Humulin R, Novolin R)
 Preparations:
 mixture of 70% neutral protamine Hagedorn
(NPH) and 30% regular human insulin
 (ie, Novolin 70/30, Humulin 70/30)

71. Short-Acting Insulins
 Humalog R; Novolin R; Iletin II Regular
Appearance Onset Peak Duration
Clear ½ - 1 hr 2-4 hrs 4-6 hrs
(1 hour) (3 hour) (5 hours)
 Administered 20-30 minutes before meals
 IV
 Usually given 4 x a day
 May to taken alone or in combination

72. Intermediate-Acting Insulins
 Insulin NPH (Humulin N,  onset of action: 3-4
Novolin N) hours.
 have a slow onset of  Peak: 8-14 hours
action and a longer  duration of action : 16-24
duration of action. hrs
 commonly combined  appears cloudy
with faster-acting
insulins to maximize the  must be gently mixed
benefits of a single and checked for
injection clumping
 if clumping occurs, the
insulin should be
discarded.

73. Intermediate-Acting Insulins
 Insulin NPH (Humulin N, Novolin N)
Appearance Onset Peak Duration
Cloudy 2-4 hrs 6-12 hrs 16-20 hrs
(2 hrs) (12 hrs) (24 hrs)
 Administer after meals
 Usually given 2x a day
 Eat at onset!

74. Long-Acting Insulins
 provide a longer  Insulin detemir
duration of action, and, (Levemir)
when combined with  Insulin Glargine
rapid- or short-acting (Lantus)
insulins, they provide
better glucose control

75. Types of Insulin –
Long-acting
 Ultra Lente (UL)
Appearance Onset Peak Duration
Cloudy 4-8hour 10-30 hrs 36+ hours
(6 hrs) (24 hrs) (36 hrs)
 To control fasting glucose levels
 Cannot be mixed!

76. Long-Acting Insulins
 Insulin detemir  Insulin glargine
 for once- or twice-daily  onset of action: 4-8
dosing hours
 duration of action is up  Duration: 24 hours.
to 24 hours  Peak effects; 16-18 hrs
 FDA has advised of a
possible association of
insulin glargine with an
increased risk of cancer

77. Rapid-Acting Insulins
Appearance Onset Peak Duration
Clear 5-15 minutes 30-90 3-5 hours
(10 min) (1hr) (4 hrs)
Short-Acting Insulins
Appearance Onset Peak Duration
Clear ½ - 1 hr 2-4 hrs 4-6 hrs
(1 hour) (3 hour) (5 hours)

78. Learning Tip: Even and Odd
 Short-acting think
odd
 (1-3-5)
 Intermediate-acting
think even
 (2-12-24)

79. Intermediate-Acting Insulins
Appearance Onset Peak Duration
Cloudy 2-4 hrs 6-12 hrs 16-20 hrs
(2 hrs) (12 hrs) (24 hrs)
Long-acting insulin
Appearance Onset Peak Duration
Cloudy 4-8hour 10-30 hrs 36+ hours
(6 hrs) (24 hrs) (36 hrs)

80. When should insulin be
administered
 Short-acting / regular
 30 minutes before meals
 Do not allow more than 30 minutes to pass by without
eating
  hypoglycemia
 Intermediate acting
 After meals
 If mixed (regular & intermediate)
 30 minutes before meals

81. What route is insulin
administered
 Sub-cutaneous
 IV
 Regular
 Pump

82. Insulin Type Onset Peak Duration
Ultra Short 15 mins 30-90 mins 2- 4 hrs
Short 30 mins 2- 4 hrs 6-8 hrs
Intermediate 1-2 hrs 6-12 hrs 18-24 hrs
Long 4-6 hrs 16-24 hrs 18-36 hrs
Combination 30-60 2- 4 hrs, 6-8hrs,then
70/30 mins then then 6-12 18-24 hrs
1-2 hrs hrs

83. Insulin Type Onset Peak Duration
Insulin 30-60 None 24 hours
glargine minutes

84. Diabetes Mellitus
 Mixing insulin

86. Adverse effects of insulin

87. Adverse effects of insulin
 Local allergic reactions
 Insulin lipodystrophy
 Insulin resistance
 Dawn Phenomenon
 Somogyi phenomenon
 Insulin waning

88. Insulin lipodystrophy
 or lipoatrophy
 is primary idiopathic atrophy of adipose
tissue
 can be a lump or small dent in the skin that
forms when a person keeps performing
injections in the same spot.

89. Insulin lipodystrophy lipohypertrophy

90. Rotate site of injection

91. Nursing Responsibilities
 Route : Subcutaneous
 Steady absorption
 Less painful
 IV – in emergency cases ( DKA)
 Only regular insulin is given through the IV
route
 Do not massage the site
 Fastest absorption site is the abdomen, then
deltoids, thighs then buttocks

92. Nursing Responsibilities
 Administer at room temperature
 Cold insulin causes lipodystrophy
 Rotate site of injection
 To prevent lipodystrophy. Inhibits insulin
absorption
 Store vial of insulin in current use at room
temperature
 Other vials should be refrigerated

93. Nursing Responsibilities
 Gently roll vial in between the palms to
redistribute insulin particles
 Do not shake. Bubbles make it difficult to
redistribute insulin particles

94. Nursing Responsibilities
 Observe for side effects
 Localized
 Induration or redness
 Swelling
 Lesions at the site
 Lipodystrophy
 Edema
 Sudden resolution of hyperglycemia causes
retention of water
 Hypoglycemia

95. Somogyi Effect
 Rebound hyperglycemia
 Normal or blood glucose levels are present
at bedtime
 hypoglycemia : occurs at 2-3am
 This causes an increase in the production of
counterregulatory hormones
 Hyperglycemia: by 7 am
 Resuts in response to the counterregulatory
hormones

96. Somogyi Effect
 Treatment
 decreasing evening (predinner or bedtime) dose of
intermediate acting insulin
 or increasing the bedtime snack

97. Dawn Phenomenon
 (6 AM – 8 AM) early AM increase in blood
glucose levels associated with release of
growth hormone at 12 MN to 3 AM

98. Dawn Phenomenon:TREATMENT
 Type 1 diabetes
 Intensify insulin therapy
 Avoid late night snacking, unless appropriate quick-
acting insulin is given.
 Type 2 diabetes
 Adjust diet content (decrease carbohydrates) and
timing of the evening meal so that the glucose level at
bedtime is 70-110 mg/dl
 If dietary modification is not enough, consider an
intermediate or long-acting sulfonylurea at evening
meal.
 Basal insulin is indicated if the dawn phenomenon
continues.

99. Insulin Waning
 Progressive rise in the blood glucose levels
from bedtime to morning
 Treatment:
 Increase dose of evening intermediate acting or
long acting insulin

100. Difference between dawn phen
and insulin waning
10 PM 2 AM 4 AM 8 AM
Dawn
100 110 135 250
Phenomenon
Waning of
100 160 220 270
insulin
Dawn phenomenon shows an abrupt increase between
4 a.m. and 8 a.m., whereas waning of exogenous
insulin effect shows gradual rise between 2 a.m. and 8
a.m.

101. Other meds

102. Glucagonlike peptide–1 (GLP-1 )
agonists
 Exenatide injectable solution (Byetta)
 Exenatide injectable suspension (Bydureon)
 mimic the endogenous incretin GLP-1
 it enhances glucose-dependent insulin
secretion by pancreatic beta cells, suppresses
inappropriately elevated glucagon secretion,
and slows gastric emptying.

104. Glucagonlike peptide–1 (GLP-1 )
agonists
 Liraglutide (Victoza)
 a once-daily injectable
 stimulates G-protein in pancreatic beta cells.

105. Dipeptidyl peptidase IV (DPP-4)
inhibitors
 prolong action of
incretin hormones
 Sitagliptin (Januvia)
 Saxagliptin (Onglyza)
 Linagliptin (Tradjenta)

106. Amylinomimetics
 Pramlintide acetate
(Symlin)
 amylin analog that
mimics the effects of
endogenous amylin,
which is secreted by
pancreatic beta cells.
 delays gastric emptying,
decreases postprandial
glucagon release, and
modulates appetite.

107. Bile acid sequestrants
 bile acid sequestrant
colesevelam
 lipid-lowering agents
for the treatment of
hypercholesterolemia
but were subsequently
found to have a
glucose-lowering
effect.

108. Antiparkinson Agents, Dopamine
Agonists
 Bromocriptine (Cycloset)  indicated as an adjunct to
 Quick-release diet and exercise to
bromocriptine acts on improve glycemic control.
circadian neuronal
activities within the
hypothalamus to reset the
abnormally elevated
hypothalamic drive for
increased plasma glucose,
triglyceride, and free fatty
acid levels in fasting and
postprandial states in
patients with insulin
resistance.

109. Non-Insulin Injectables
 New drugs are available for people with type
2 diabetes.
 Pramlintide (Symlin), exenatide (Byetta), and
liraglutide (Victoza) are non-insulin injectable
drugs.
 insulin pulls glucose into the cells
 these medications cause the body to release
insulin to control blood sugar levels.

110. Other meds

111. Glucagonlike peptide–1 (GLP-1 )
agonists
 Exenatide injectable solution (Byetta)
 Exenatide injectable suspension (Bydureon)
 mimic the endogenous incretin GLP-1
 it enhances glucose-dependent insulin
secretion by pancreatic beta cells, suppresses
inappropriately elevated glucagon secretion,
and slows gastric emptying.

113. Glucagonlike peptide–1 (GLP-1 )
agonists
 Liraglutide (Victoza)
 a once-daily injectable
 stimulates G-protein in pancreatic beta cells.

114. Dipeptidyl peptidase IV (DPP-4)
inhibitors
 prolong action of
incretin hormones
 Sitagliptin (Januvia)
 Saxagliptin (Onglyza)
 Linagliptin (Tradjenta)

115. Amylinomimetics
 Pramlintide acetate
(Symlin)
 amylin analog that
mimics the effects of
endogenous amylin,
which is secreted by
pancreatic beta cells.
 delays gastric emptying,
decreases postprandial
glucagon release, and
modulates appetite.

116. Bile acid sequestrants
 bile acid sequestrant
colesevelam
 lipid-lowering agents
for the treatment of
hypercholesterolemia
but were subsequently
found to have a
glucose-lowering
effect.

117. Antiparkinson Agents, Dopamine
Agonists
 Bromocriptine (Cycloset)  indicated as an adjunct to
 Quick-release diet and exercise to
bromocriptine acts on improve glycemic control.
circadian neuronal
activities within the
hypothalamus to reset the
abnormally elevated
hypothalamic drive for
increased plasma glucose,
triglyceride, and free fatty
acid levels in fasting and
postprandial states in
patients with insulin
resistance.