F U N D A M E N TA L S O F D I S E A S E A N D I N T E RV E N T I O N S

DIABETES MELLITUS

PATHOPHYSIOLOGY OF DIABETES MELLITUS

• Diabetes mellitus (DM) is disorder of endocrine system• Impaired glucose regulation leads to

hyperglycemia• Impairment can be total or partial reduction in

insulin secretion or increased glucose production or decreased glucose utilization• Causative factors can be genetic, lifestyle choices

and exposure to environmental viruses/ bacteria

PATHOPHYSIOLOGY OF DIABETES MELLITUS

Glucose is a nutrient• Basic body fuel for energy• Normal 70-120mg/dL

Insulin is a hormone secreted by pancreatic islets ( Islets of Langerhans)• Supports entry of glucose into the cells• When glucose rises, insulin is secreted and opens

special channels into cells that allow glucose entry.• DM occurs when this process is impaired.

PATHOPHYSIOLOGY OF DIABETES MELLITUS

• DM classified according to reason glucose can not get into cells. Watch YouTube Video• Three types: Type 1, Type 2 and Gestational• Type 1 (juvenile diabetes)- total lack of insulin

production. Thought to be caused by exposure to

virus/bacteria causing an autoimmune responseDx in childhood or adolescenceMust be treated with insulinUntreated leads to diabetic ketoacidosis (DKA),

coma and possible death

PATHOPHYSIOLOGY OF DIABETES MELLITUS

• Type 2 is type in 90% of all patientsOccurs later in lifeRisk factors are family history, obesity, lack of exercise Damages to vascular lining of vesselsUncontrolled HTN, hyperlipidemia or hypercholestremia are

part of metabolic syndrome that greatly increase chances of complications

Can be treated with diet and lifestyle changes, oral medications and, if necessary, insulin.

Complications include blindness, stroke, kidney and heart damage, loss of limb and nerve damage (neuropathy).

PATHOPHYSIOLOGY OF DIABETES MELLITUS

• Gestational diabetes develops during pregnancy

Body becomes resistant to insulinUsually disappears after deliveryBut patient more likely to develop Type 2 in the

future.

SIGNS & SYMPTOMS OF DM

S & S of all types are Frequent urination Weight Loss Excessive thirst Fatigue Hunger Irritability

Additional S&S for Type 2 Frequent infections Non-healing

wounds Blurred vision Numbness/tingling

DIAGNOSIS

• Fasting blood glucose

• Glucose tolerance tests

• Glycosylated hemoglobin (HgA1c)Measures average blood sugar over last three monthsBesides diagnosis also used to monitor progress toward

goals of normalizing blood sugar levelsTarget is less than 7.0

DIAGNOSIS

• Hard for many patients to deal with-denial and resistance to treatment requirements is common• Requires numerous lifestyle changes that include

taking medication, blood sugar monitoring, losing weight, diet modification and increased exercise.• Also must have more preventive exams such as

annual eye exams and monitoring of blood pressure, lipids and kidney function• More frequent office visits

TREATMENT

• Type 1 and gestational diabetics usually treated by specialists rather than primary care provider.• Type 2 treatment is the responsibility of the

primary care team and is best handled with a PCMH approach.Newly diagnosed generally seen by diabetic educator

(PharmD or specially trained RN)Patient self-management skills are key to successful

treatmentTeam approach required

DIET

• Correct balance of carbohydrates, fats, protein and portion size.

Plate plan http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/

Carbohydrate counting 40-60 grams/dayDASH dietWeight Watchers

All encourage use of food diaries, use of complex rather than simple carbohydrates, low fat foods, reduced sodium intake and calorie control.

GLUCOSE MONITORING

• Needed to help prescribing provider set-up the best medication regimen for patient especially those on insulin in addition to oral agents.• Helps give early warning of hypoglycemic or

hyperglycemic situations.• Best practice is before each meal and before bed.

Sometimes, if a patient is having a hard time getting all these in, provider may decrease to once or twice per day.• Should be LOGGED.

FOOT INSPECTIONS

• Teach patients to do daily

• Never go barefoot and buy properly fitting shoes

• If feet have loss of feeling, exercise should be a non-weight bearing activity.

• Don’t ignore open sores or skin redness anywhere on body. These can become serious infections very quickly.

MEDICATIONS-ORAL

• Not all Type II DM patients need medication for diabetic control, but if they do, they are generally started on oral hypoglycemic.

• There are several classes• Patient may need to be on more than one class to

gain control• Choices include medications for the following goals:

helping body produce insulin, slow down the absorption of carbohydrates, or lower blood sugar

• Beyond oral meds there are some injectable drugs as well as insulin that can be prescribed.

MEDICATIONS-INSULIN

• Insulin may be necessary when diet, weight loss, exercise and oral medications fail.• BIG challenge/failure for some patients.• Good coaching from PCMH team needed to

support both the learning needs and the emotional aspect of this treatment regimen.• This YouTube video can be a resource for patients

needing teaching on this new skill or needing a refresher (see PCMH server for education module).

MEDICATIONS-INSULIN

• Insulin is classified by the duration of action:INSULIN TYPES AND ACTIONS

Brand Name Generic Name Onset Peak DurationRAPID ACTING

Apidra Insulin Glulisine <15 minutes 1-2 hours 3-4 hoursHumalog Insulin Lispro <15 minutes 1-2 hours 3-4 hoursNovolog Insulin Aspart <15 minutes 1-2 hours 3-4 hours

REGULARHumulin R Regular 1/2 - 1 hour 2-3 hours 3-6 hoursNovolin R Regular 1/2 - 1 hour 2-3 hours 3-6 hours

INTERMEDIATE ACTINGHumulin N NPH 2-4 hours 4-10 hours 10-16 hoursNovolin N NPH 2-4 hours 4-10 hours 10-16 hours

LONG ACTINGLevemir Insulin Detemir 3/4 - 2 hours minimal peak

actionup to 24 hours

Lantus Insulin Glargine 2-4 hours no peak 20-24 hours

Insulin Types and Actions

MEDICATION ASSISTANCE

• Diabetes can be an expensive chronic disease due to increased medical office visits, medication cost, and supplies.• Know your patient’s financial situation!! Don’t

assume they know the most economical way to get medication and supplies.• Be prepared to refer to MUSC’s Pharmacy

Assistance Program located in Rutledge Tower on the 1st floor.• Also remember our social worker and home

health can be valuable resources in challenging cases.

SHORT-TERM COMPLICATIONS

• Hypoglycemia is defined as BS <70 mg/dL.• Patients on insulin and their families must understand

how to recognize and what to do as untreated can lead to coma and death

• S&S are shaking, fast heart rate, sweating, dizziness, anxiety, hunger, impaired vision, fatigue, HA and irritability.

• Should have necessary supplies with them at all times.• Ingest food that will deliver quick glucose to blood

such as juice, cola 3-4 hard candies or several saltines.

• Recheck BS in 30 minutes and repeat as necessary• Record episode in diary.

SHORT-TERM COMPLICATIONS

• Hyperglycemia is any blood sugar reading over 120mg/dL.

• Will not feel S&S till reach much higher level (i.e. > 200mg/dL).

• Initially will feel increased thirst and frequent urination.

• Progress to N/V, SOB, very dry mouth and fruity breath leading to diabetic ketoacidosis (DKA), coma and death.

• Causes are inadequate medication doses, increased food consumption, decreased exercise from normal pattern, stress R/T illness or life challenges.

• Record all in diary and go to ER if approaching DKA.

LONG-TERM COMPLICATIONS

• Long-term complications due to changes in large vessels (macrovascular) and small vessels (microvascular) because of damage to the lining of the vessels• Common complications are:

BlindnessKidney and heart damageStrokeLoss of limbs R/T poor circulationNeuropathy (nerve pain) due to nerve damage

WHEN TO CALL THE PCMH TEAM

• The following guidelines should be periodically reviewed with patient:

Call 911 if the patient becomes confused, very sleepy or unconscious (likely hypoglycemia) or has rapid breathing with fruity breath along with confusion and sleepiness.

Call UIM right away if blood glucose readings are over 300 (or another figure set by the PCP)

Call UIM if sick and having trouble controlling blood glucose or if nausea and vomiting or diarrhea is present greater than 6 hours. Also call for any skin breakdown that is not healing properly.

Tell your PCP or PCMH team member if having frequent problems with high or low readings, are asymptomatic during hypoglycemic episodes or have any other questions. 

SELF-MANAGEMENT

Old paradigm in health care was medical team told patient what to do, patient did it and that was that! BUTAs we all know from experience patients do not necessarily follow “doctor’s orders”.

Our roles are changing away from directors of care to partners of care as the patient is the true team leader.

SELF-MANAGEMENT

• One of the core tenets of PCMH with patient centered care is successful promotion of self-management for chronic diseases such as diabetes.• Self-management is how the patient manages

all aspects of their chronic disease care. Some do well and some don’t.• The PCMH team includes the patient and goals

should be jointly developed to the degree the patient is capable of achieving.• Key-element is trust.