NR-601 Primary Care of the Maturing & Aged

Family Practicum

Final Exam Study Guide

Glucose metabolism disorders

Types of DM

1. Type 1- insulin deficiency. (CHARACTERISTICS OF TYPE 1) LAB to differentiate between type 1 and

type 2. How often do you do a1c if stable? How often do you do microalbumin? How long should

diet and exercise be tried before labs rechecked? Diabetes can or commonly causes.. I put kidney

disease. Subjective findings- polyuria, polydipsia, and polyphagia.

2. Objective-dehydration.

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3. Type 2- Type 2 DM is characterized by the abnormal secretion of insulin, resistance to the action

of insulin in the target tissues, and/or an inadequate response at the level of the insulin receptor.

A patient may, however, present with pruritus, fatigue, neuropathic complaints such as

numbness and tingling, or blurred vision.

● Diagnostic criteria- AIC of 6.5 or higher, symptoms of diabetes plus random glucose of 200

mg/dL or higher, fasting glucose of 126 or higher, and 2 hour plasma glucose level of 200 mg/dL.

A1C, fasting, and plasma should be repeated. Diagnosis of type 2 diabetes mellitus: two fasting

blood glucose ≥126 mg/dL or two random blood glucose ≥200 mg/dL.

● Initial Treatment- The initial goal of treatment for type 1 DM is to normalize the elevated blood

glucose level. This is best accomplished by intensive insulin regimens to achieve the following

goals: plasma glucose levels of 80 to 130 mg/dL before meals, peak postprandial (1–2 hours after

the beginning of a meal) glucose levels of less than 180 mg/dL, and an A1C below 7% for adults

with type 1 DM.

Type 2-Pharmacological therapy for type 2 DM is required when lifestyle management does not result in

adequate blood glucose control. Drug therapy should always be considered an adjunctive

therapy to lifestyle management, as the latter is typically initiated first. The ADA and AACE

recommend metformin if there are no contraindications, such as renal disease or abnormal

creatinine clearance, acute myocardial infarction, orsepticemia. The AACE recommends adding a

second agent to lifestyle treatment and metformin if the A1C is more than 7.5% at the time of

diagnosis or after 3 months of monotherapy without achievement of the patient’s blood glucose

goals. Metformin can be used as a monotherapy unless the patient has contraindications or

intolerance. Although metformin is the first-line medication recommended by the ADA and the

AACE for DM type 2, it should be used only in patients with adequate renal function and should

not be used in patients with an eGFR below 45 mL/min/1.73 m2

. Metformin also has a boxed

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warning in its FDA-approved prescribing information for lactic acidosis, although this side effect

is very rare. Metformin should be discontinued 24 to 48 hours before diagnostic and surgical

procedures due to the risk of decreased kidney function, and its administration should not be

resumed for at least 6 hours after these procedures or until the patient is adequately hydrated.

Initial dosing is 500 mg once a day with breakfast or dinner for 1 week, then twice daily with

Single Injection

• Intermediate or long-acting insulin with or without regular insulin in the

morning or Intermediate or long-acting insulin at bedtime

• Recommend at a minimum SMBG in the morning

and at bedtime

SINGLE-DOSE THERAPY

Two Injections

• Mixture of NPH and regular insulin in the morning and evening

• Recommend at a minimum SMBG before each dosing and at bedtime

CONVENTIONAL SPLIT-DOSE THERAPY

Three Injections

• NPH and regular insulin in the morning; regular insulin at dinner; NPH insulin at bedtime

• Monitor for increased risk of hypoglycemic episodes

Four Injections

• Regular or lispro insulin before meals and long-acting insulin to maintain basal insulin levels

• Monitor for increased risk of hypoglycemic episodes

INTENSIVE INSULIN THERAPY

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breakfast and dinner. Several weeks of therapy may be needed to achieve maximum effects of

the given dose. Common adverse reactions include diarrhea, nausea, anorexia, and abdominal

discomfort, which usually resolve with a gradual increase of dosage. Metformin has been shown

to cause decreased vitamin B12 absorption, and patients on long-term metformin therapy should

undergo periodic testing for B12 deficiency, especially if the patient complains of peripheral

neuropathy. At the maximum dose, the monthly cost of metformin in the United States is

approximately $4 on many generic formularies. Metformin is currently found in 20 combination

formulations with other medications.

• Immediately upon diagnosis of type 2 DM, begin lifestyle therapy with medically assisted

obesity treatment.

• If glycemic goals are still not met 3 months later, begin single-agent or dual therapy with oral

antidiabetic agents, depending on whether A1C is less than or greater than 7.5%.

• If glycemic goals are not met in 3 months, initiate triple therapy.

• If after 3 additional months (or at the time of diagnosis) A1C is 9.0% or higher and the patient

is symptomatic, add insulin therapy.

● Treatment goalsfor older adults(Kennedy table 14-2).

Healthy (few chronic illnesses) A1C <7.5, Fasting glucose 90-130, Bedtime 90-150, BP < 140/90,

statins

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