Diabetes Mellitus Today

DIABETES MELLITUS TODAY DIANA W. GUTHRIE RN, PhD 2006

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DEFINITION & THE PROBLEM •

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CRITERIA FOR DIAGNOSIS DEFINITION PATHOPHYSIOLOGY PREVALENCE OBESITY METABOLIC SYNDROME

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Glucose To Tolerance Ca Cate ories 2-hr PG on

FP mg/d

mg/d Diabetes

100 and <126

<100

Prediabet Glucos Norm

Diabetes 140 and

<

Prediabet Toleranc Norm

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Etiologic Classification of  Type 1 -cell destruction with lack of  insulin Type Ty pe 2 In Insu sulilin n res resis ista tanc nce e wit with h insulin deficiency

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Diabetes T Trends* rends* Among Amo ng Adults Adult s in the U.S., 19

19

20

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Prevalence of Diabetes in

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Obesity Trends* Among U.S. Adults BRFSS, 1991-2002 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4”

1

1

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DNPA DNPA Graphics: Graphics:

Diabetes T Trends* rends* Among Amon g Adults Adult s in the U.S.,

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Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI(*BMI ≥30,30, oror~ 30lbs lbs overweight 5’ 4” ~ 30 overweight for 5’4”for person)

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GLOBAL PROJECT PROJECTIONS PROJECTIIONS ONS FOR THE

World

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Diabetes Today: An Epidemic •

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20.8 million Americans have diabetes 1.5 million new cases in 2005 more than 3500 each day

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Total Cost of Diabetes in the US, 2002

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The Problem

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Modern Life Has Both

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METABOLIC SYNDROME

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ACANTHOSIS NIGRICANS

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IN-HOSPITAL MANAGEMENT •

•

•

•

•

PREVALENCE SURGERY MI INFECTION ICU

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Consensus: •

Intensive care unit  –

•

110 mg/dL (6.1 mmol/L)

Medical/surgical floors  –

 –

110 mg/dL (6.1 mmol/L) preprandial 140 mg/dL (7.78 mmo/L) maximal glucose

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Diabetes in Hospitalized •

• •

Fourth most common co-morbid condition among hospitalized patients 10–12% of all hospital discharges 29% of all cardiac surgery patients 1–3 days longer hospital stay

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Hyperglycemia in Patients •

Hyperglycemia occurred in 38% of patients admitted to the hospital  –  –

•

26% had known history of diabetes 12% had no history of diabetes

Newly discovered hyperglycemia was associated with:  –

Higher in-hospital mortality rate (16%) compared with

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Higher Costs: • • • •

Higher rate of hospitalization Longer stays More procedures, meds. Chronic complications

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Hyperglycemia Is an Independent Marker of  P < 0.01 P < 0.01

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Hospital Mortality Rate and

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Intensive Insulin Therapy in 100 96

Intensive treatment

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Intensive Insulin Therapy in Critically •

Intensive therapy to achieve blood glucose levels of 80– 110 mg/dL reduced mortality (-34%), sepsis (-46%), dialysis (-41%), blood transfusion (-50%), and

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Hyperglycemia and Risk of  •

Glucose > 220 mg/dL on postoperative day 1 is

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Portland Diabetic Project:

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Insulin Glargine AGl Gl Il y e

Va Gl Gi Cy Cy Th Se r  r  l u n s s

Il Cy Se Le Ty Gi Le Gl As Ty Cy e s r  u r  n u u n r  s

As n

21

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Mechanism of Action Clear solution pH pH

Injection acidic solution (pH

Microprecipitati Dissolutio

Microprecipitation of  Microprecipitation o f  glargine in SC (pH Slow dissolution stabilized

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INSULIN TACTICS

Glargine vs NPH Insulin in Type 6   e 5    t   a    R   n 4   o    i    t   h   a   /   z    i    k    l    / 3    i    t    U  m   e   s 2   o   c   u    l    G 1

P

Glargin

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Insulin detemir  LysB29(N -tetradecanoyl)des(B30)human -tetradecanoyl)des(B30)human insulin C 1 4  4 f   a t t  t y    a  c i   d  c  h a i   n  Thr

T r

Ph

Ph

Gl

Ar

Gl

Pro Thr L s

Cys

L s

Val B2

A2

Asn

C T r

A

Gl

Glu

Asn

Leu T r

Ile

Glu

Leu

Val

Leu

Ala

Gln

Glu

Glu Gln

T r

Val

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INSULIN IN DIABETES •

INSULIN REQUIREMENTS  –

 –

1-2 UNITS/KG/DAY FOR CHILDREN-1/21UNITS/KG/DAY 1UNITS/KG/DA Y FOR ADULTS DEPENDING ON DEGREE OF KETOSIS &/OR GROWTH RATE DISTRIBUTION FOR INJECTABLE INSULIN •

BREAKFAST 20% OF TOTAL AS FAST ACTING LUNCH 13% OF TOTAL AS FAST ACTING

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EXAMPLE – 24 Units/day

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CASE K.M.

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EXUBERA INHALABLE INSULIN

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