Diabetes

- Types of diabetes
o Type 1 diabetes mellitus
§ Insulin dependent
o Type 2 diabetes mellitus
§ Non-insulin dependent
o Gestational diabetes
§ Pregnancy
- Gestational diabetes
o Carbohydrates intolerance with onset or first recognition during pregnancy
o Can lead to fetal macrosomia
§ Abnormal large body
o Treatment
§ Glyburide à Daonil
§ Glucophage à Metformin
- Type 1 diabetes
o Most commonly seen in children and adolescents
o Symptoms
§ Polydipsia
§ Polyuria
§ Polyphagia
§ Weight loss
§ Fatigue
§ Blurry vision
- Type 2 diabetes
o More common
o Insulin resistance with insufficient insulin supply
- Treatment
o Insulin
 o Oral agents
§ For type 2 only and gestational
- Insulin
o Two peptides connected by disulfide bonds
o Types
§ Human insulin
§ Insulin analogs
o Side effects include
§ Hypoglycemia à Glucotab
• 4 g glucose, 4 tabs PO
§ Weight gain
§ Lipodystrophy à rotate injection sites
- Short-acting insulin
o Regular insulin
§ Humulin R
§ Actrapid
o Peaks around 50 minutes
o Injected SubQ 30 minutes before meals
o Used IV in emergencies
- Rapid-acting insulin (LAG)
o Insulin lispro à Humalog Lispro
o Aspart à Novorapid
o Glulisine à Apidra
o Peaks around 30 minutes
o Administered 15-20 minutes before meals
- Intermediate-acting insulin
o Neutral protamine hagedron (NPH) à Humulin N and Insulatard
o Peaks around 50 minutes
o Used for basal control in type 1 and 2 diabetes Used twice daily
- Long-acting insulin (GDD)
o Insulin glargine à Lantus and vivaro Toujeo
§ Lower isoelectric point
• Precipitates at the injection site
§ Basal insulin Degludec + Aspart —> Ryzodeg 70/30
o Insulin detemir à Levemir Taken once daily

o Insulin degludec (ultra-long) à Tresiba

§ Slow insulin release
o Injected once daily
- Insulin combinations
o 70% NPH insulin + 30% regular insulin à Mixtard 30
o 70% NPH insulin + 30% rapid insulin à Novomix 30
- Storage
o Discard if there’s particles or color changes
o Unopened vials are stored in refrigerator (2-8 c)
o Do not store in freezer
- Oral agents
o Sulfonylureas
o Glinides
o Biguanides
o Thiazolidinedione
o Alpha-Glucosidase inhibitors
o DPP-inhibitors
o SGLT-2 inhibitors
o Incretin Mimetics (GLP-1)
- Sulfonylureas
o Glyburide à Doanil
o Glipizide à Minidiab
o Glimepiride à Amaryl 1 mg, 2 mg, 3 mg
Glim is alternative 6 mg
 o Dosed once or twice daily
o Side effects include
§ Weight gain
§ Hypoglycemia
- Glinides
o Repaglinide à NovoNorm
§ 0.5 mg, 1 mg, 2 mg
§ Rapid onset with short duration
§ Before or after eating
o Dosed 3 times daily
o Side effects include
§ Weight gain
§ Hypoglycemia
- Biguanides
o Metformin à Glucophage
o First line therapy
o Can cause lactic acidosis so contraindicated in renal insufficiency
o Used in treated polycystic ovary syndrome
o Side effects
§ Decreased B12 absorption
§ Weight loss
- Thiazolidinedione
o Pioglitazone à Actos, glacera
o Used in treating polycystic ovary syndrome
o Side effects include
§ Weight gain
§ Liver toxicity
§ Increased fracture risks
- Alpha-Glucosidase inhibitors
o Acarbose à Glucobay
o Side effects include
§ Flatulence
§ Diarrhea
§ Abdominal cramping
- DPP-4 inhibitors
o Linagliptin à Trajenta
o Saxagliptin à Onglyza
o Vildagliptin à Glavus
o Sitagliptin à Januvia
o Weight neutral
o Food doesn’t affect absorption
o Side effects include
§ Pancreatitis
§ Nasopharyngitis
§ Headache
- SGLT-2 inhibitors
o Canagliflozin à Invokana
§ 100 mg, 300 mg
o Empagliflozin à Jardiance
§ 10 mg, 25 mg
o Dapagliflozin à Froxiga
§ 5 mg, 10 mg
o Once daily in the morning
o Side effects include
§ UTI
§ Female genital mycotic infections
- Incretin mimetics (GLP-1 agonists)
o Exenatide à Byetta
§ 1 hour before breakfast and 1 hour before dinner
o Liraglutide à Victoza
§ Once daily without regards to meals
o Injectable incretin mimetics
o Side effects include
§ N/V/D and constipation
o Dulaglutide à Trulicity Ozempic — semaglutide
Used once weekly
§ 1.5 mg/0.5 mL or 0.75 mg/0.5 ml
§ Once weekly
§ 4 pre-filled pen in one box for one month
§ 1.5 mg once weekly
§ For patients 75 years old or older use 0.75 mg weekly
- Self-monitor blood glucose
o Fasting for 8-12 hours before measuring glucose

Readings Normal Prediabetes Diabetic Goal for

Readings Readings diabetes
Non-fasting ≤140 mg/dL ≤200 mg/dL >200 mg/dL ≤180 mg/dL
glucose
Fasting glucose 70-100 mg/dL 100-126 mg/dL >126 mg/dL ≤140 mg/dL
A1C <5.7% 5.8-6.4% ≥6.5% ≤7%

- Exercise
o Improves insulin resistance
 o 30 minutes/day for 5 days a week for adults
o One hour/day for children
o If glucose is normal or low, avoid exercise and eat 15 g of carbohydrate
§ Glucotab
o Avoid physical activity if glucose is more than 250 mg/dL
- Diabetic foot
o High risks of peripheral arterial diseases and neuropathy
o Prone to frequent and severe infections
§ Can lead to gangrene and amputation
o Symptoms
§ Neuropathic foot
• Warm dry skin
• Reduced sensation
• Callus around ulcer
§ Ischemic foot
• Cool with pink atrophic skin
• Pain
o Complementary treatment
§ Co-Q10 400 mg daily for diabetic foot x12 weeks
§ Alpha lipoic acid à Thiotacid 600-1800 mg (2-4 tabs/day) x 1-2 months
• For neuropathy pain
o Patient education
§ Wash feet daily with warm water
§ Moisturize feet
§ Wear clean and soft socks