Glucose Homeostasis

Disorders
By; Julyn Marie Elnas Abad-Gallardo

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Epidemiology Bureau Department of Health, 2018
Key players in DM
Glucose - is sugar and our body needs it to survive
- Glucose enters into the cells so that the cells can work with the help of
the insulin
- Stored in the liver as glycogen

Insulin – is a hormone and it plays a huge role in helping us bring those

sugar levels down, because it regulates the amount of glucose in the body.
- The glucose attached to it and goes inside the cell so that it can be used
- It is secreted by the beta cells in the pancreas (Islet of Langerhan’s cell)
Glucagon – Increase our blood sugar.
- the liver release the glycogen and turn it into glucose

Liver – is very sensitive to insulin levels in the body

- keeps balance in our sugar levels
- High sugar level – absorb that extra glucose and turn it into glycogen
- Low sugar level – release that stored glycogen which will turn into
glucose
Risk Factors

• Family history of DM
• Obesity more than 20% over desired body weight - increase
insulin resistance
• Age >45
• Previously identified impaired testing glucose
• Hyperlipidemia
Diabetes Mellitus (DM)
Pathophysiology

- Is caused by a relative deficit of insulin secretion from the beta cells in the
islet of Langerhans or by lack of response by cells to insulin (insulin
resistance).

Insulin deficit – is used to cover both decreased secretion of the hormone and
insulin resistance.

- An absolute or relative deficiency of insulin results in hyperglycemia.

- Excess glucose spills into the urine (glucosuria) as the level of
glucose in the filtrate exceeds the capacity of the renal tubular
transport limits to reabsorb it.
- glucose in the urine exerts osmotic pressure in the filtrate,
resulting in a large volume of urine to be excreted (polyuria), with
the loss of fluid and electrolytes from the body tissues.
- Fluid loss through the urine and high blood glucose levels draw
water from the cells, resulting in dehydration
- Dehydration causes thirst (polydipsia)
- Lack of nutrients entering the cells stimulates appetite
(polyphagia)
Progressive effects

If the insulin deficit is severe or prolonged, the process continues to

develop, resulting in additional consequences, ultimately, diabetic
ketoacidosis.

This occurs more frequently in persons with type 1 diabetes.

- Lack of glucose in cells results in catabolism of fats and proteins,
leading to excessive amounts of fatty acids and their metabolites
known as ketones or ketoacids in the blood.

Ketones – consist of acetone and two organic acids – beta-hydroxyb

utyric acid and acetoacetic acid.
Because the liver and other cells are limited in the amount of lipids,
fatty acids, or ketones, they can process completely within a given
time, excessive amounts of ketones in the blood cause ketoacidosis.
- Some ketoacids are excreted in the urine (ketunuria). Some
diabetic patients test their urine for ketones.

- As dehydration develops, the glomerular filtration rate in the

kidney is decreased, and excretion of acids becomes more limited,
resulting in decompensated metabolic acidosis (Kussmaul’s
respiration), which has life-threatening potential (DKA or
diabetic coma)
Deficient insulin – results in abnormal carbohydrate, protein, and fat
metabolism because the transport of glucose and amino acids into cells is
impaired as well as the synthesis of protein and glycogen.

In turn, these metabolic abnormalities affect lipid metabolism. Many tissues

and organs in the body are adversely affected by diabetes.
- It can lead to chronic health problems and early death as a result of complications that occur
in the large and small blood vessels in tissues and organs.

Macrovascular
a. coronary artery disease
b. cardiomyopathy
c. hypertension
d. cerebrovascular disease
e. peripheral vascular disease
Microvascular
a. retinopathy
b. nephropathy
c. neuropathy
Infection – is also a concern because of reduced healing ability.
Male erectile dysfunction – can also occur as a result of the disease.
Some types of cells are not affected directly by the deficit of insulin.

Exercising skeletal muscle can utilize glucose without proportionate

amounts of insulin. Conversely, exercise is helpful in controlling
blood glucose levels in the presence of an insulin deficit.
Basic Types of Diabetes

1. Type 1
2. Type 2
3. Gestational
Type 1
Formerly Insulin-dependent DM (IDDM), Type I, or Juvenile diabetes

- Is the more severe form

- It occurs more frequently in children and adolescents, but develop at any age.
- Genetic factor, autoimmune or virus
- It is nearly absolute deficiency of insulin – results from destruction of the
pancreatic beta cells in an autoimmune reaction – requires replacement therapy.
- Demonstrates pancreatic atrophy and specific loss of beta cells
- Macrophages, T and B lymphocytes, and natural killer cells are present
- The amount of insulin required is equivalent to the metabolic needs of the body
based on dietary intake and metabolic activity.
- Hypoglycemia and ketoacidosis – most likely occurs in this group
Type 2
Formerly noninsulin-dependent DM (NIDDM), Type II or mature-onset
diabetes
- Is a relative lack of insulin or resistance to the action of insulin
- Usually, insulin is sufficient to stabilize fat and protein metabolism but not
carbohydrate metabolism
- Milder form of diabetes
- Developing gradually in older adults

This abnormality may involved:

a. Decreased pancreatic beta cell production
b. Increase resistance by body cells to insulin
c. Increased production of glucose by the liver
Gestational Diabetes

- May develop during pregnancy and disappear following delivery of the

child
- In many cases, women who have gestational diabetes develop diabetes
some years later.
• During pregnancy, hormones are made by the placenta to help the baby develop
and grow. These hormones, however, stop the mother’s insulin from working
properly. This is called insulin resistance. As the pregnancy develops and the baby
grows bigger, the mother’s body has to make more insulin to keep her blood
glucose at the optimal level.

• Later in pregnancy the amount of insulin needed to keep blood glucose levels
optimal is two to three times higher than usual. If the mother is unable to
produce enough insulin to meet this demand then her blood glucose levels rise
and gestational diabetes develops.

• The baby’s response to the higher glucose levels is to make more insulin. This can
lead to the baby becoming larger than usual and cause problems during and after
birth.
Diagnostic test

1. Random blood sugar/casual plasma glucose ≥ 200mg/

dl
2. Fasting blood glucose level ≥ 126 mg/dL, Fasting is
defined as no caloric intake for at least 8 hours.
3. 2 hour postprandial/postload blood sugar – after meal
≥ 200mg/dl
3. Glucose tolerance test – used to monitor long-term
control (8 to 12 weeks) of blood glucose level – repeated
every 3 months
4. Glycosylated hemoglobin (HbA1C)
5. Urinalysis – ketones
6. ABG – ketoacidosis
7. Serum electrolytes
Assessment
a. Polyuria
b. Polydipsia
c. Polyphagia Classical sign
d. Weight loss – Type 1
e. Hyperglycemia
f. Blurred vision
g. Slow wound healing
h. Weakness and paresthesia
i. Signs of inadequate circulation to the feet
j. Signs of accelerated atherosclerosis (renal, cerebral, peripheral)
Treatment

1. Diet
2. Exercise
3. Oral medications
4. Insulin injections
Diet
Diabetic diet

1. Weight reduction (Maintaining optimum body weight)

2. Complex carbohydrate (minimal amount of sugar)
3. Adequate protein
4. Maintaining low cholesterol and low lipid levels
5. Increased fiber – reduce surges in blood sugar
associated with food intake
6. Monitor blood glucose before and after, 2 hours after
eating
7. Food intake must match available insulin, metabolic
needs and activity level
8. Meal planning – nutritionist can be consulted
Exercise
! DON’T EXERCISE UNTIL URINE TEST IS NEGATIVE FOR KETONES

- Can increase the uptake of glucose by muscles substantially without an in

crease in insulin utilization.
- It can assist in weight control
- Reduces stress
- Improves cardiovascular fitness

Hypoglycemia – is a risk that may develop with exercise, particularly strenu

ous or prolonged exercise
- If this happens, increase the carbohydrate intake by eating snack to comp
ensate for exercise can decrease the risk.
Oral medications

- It decrease serum glucose levels by stimulating the

pancreas to:
a. produce more insulin
b. increase the sensitivity of peripheral receptors to insuli
n
c. decrease hepatic glucose output
d. Delay intestinal absorption of glucose
Nursing management

Oral medications are prescribed for clients with DM Type 2 when diet and
weight control therapy have failed to maintain satisfactory blood glucose
levels.
1. Assess the client’s knowledge of DM and the use of oral hypoglycemic
medication
2. Assess the medications that the client is currently taking (aspirin,
sulfonamides, oral contraceptives and monoamine oxidase, alcohol) –
increases the hypoglycemic effect
3. Assess vital signs ad blood glucose levels
4. Glucocorticoids, thiazide diuretics, and estrogen increase blood glucose
levels
- Teach the client to recognize the signs and symptoms of hyp0- and
hyperglycemia
- Teach the client to avoid over-the-counter medications unless prescribed
by the physician
- Inform the client with Type 2 DM that insulin may be needed during
stress, surgery and infection
5. Teach the client about the importance of compliance with the prescribed
medication
• Sulfonylureas (glipizide, glyburide, gliclazide, glimepiride)
• Meglitinides (repaglinide and nateglinide)
• Biguanides (metformin)
• Thiazolidinediones (rosiglitazone, pioglitazone)
• α-Glucosidase inhibitors (acarbose, miglitol, voglibose)
• DPP-4 inhibitors (sitagliptin, saxagliptin, vildagliptin, linagliptin,
alogliptin)
• SGLT2 inhibitors (dapagliflozin and canagliflozin)
• Cycloset (bromocriptine)
Insulin injections

Insulin is used to treat Type 1 and 2 DM when diet, weight control therapy, and oral
hypoglycemic agents have failed to maintain satisfactory blood glucose level.

Medications that increases the hypoglycemic effect of insulin:

1. Aspirin
2. Oral anticoagulants
3. Oral hypoglycemic medication
4. Β-blockers, tricyclic antidepressant
5. Tetracycline
6. Monoamine oxidase inhibitor
7. Alcohol
Medications that increases the blood glucose level:
1. Glucocorticoids
2. Thiazide diuretics
3. Thyroid agents
4. Oral contraceptives
5. Estrogen
Types of insulin treatments
All types of insulin produce the same effect. They mimic the natural increase
s and decreases of insulin levels in the body during the day. The makeup of
different types of insulin affects how fast and for how long they work.

Rapid-acting insulin: This type of insulin begins working approximately 15

minutes after injection. Its effects can last between three and four hours. It’s
often used before a meal.
Short-acting insulin: You inject this insulin before a meal. It starts working
30 to 60 minutes after you inject it and lasts five to eight hours.
Intermediate-acting insulin: This type of insulin starts working in one to
two hours after injection, and its effects may last 14 to 16 hours.
Long-acting insulin: This insulin may not start working until about two
hours after you inject it. Its effects can last up to 24 hours or longer.
Rapid-acting insulin
Rapid-acting insulin starts working somewhere between 2.5 to 20 minutes after
injection. Its action is at its greatest between one and three hours after injection
and can last up to five hours. This type of insulin acts more quickly after a meal,
similar to the body's natural insulin, reducing the risk of a low blood glucose
(blood glucose below 4 mmol/L). When you use this type of insulin, you must
eat immediately after you inject.

The rapid-acting insulin types currently available are:

• Fiasp and NovoRapid® (insulin aspart)
• Humalog® (insulin lispro)
• Apidra® (insulin glulisine).
• Fiasp – released in Australia June 2019 – is a new, rapid acting insulin with
faster onset of action. It is designed to improve blood glucose levels after a
meal.
Short-acting insulin

Short-acting insulin takes longer to start working than the rapid-

acting insulins.
• Short-acting insulin begins to lower blood glucose levels within
30 minutes, so you need to have your injection 30 minutes before
eating. It has its maximum effect two to five hours after injection
and lasts for six to eight hours.

Short-acting insulins currently available are:

• Actrapid®
• Humulin® R.
Intermediate-acting insulin
• Intermediate-acting and long-acting insulins are often termed backgroun
d or basal insulins.

The intermediate-acting insulins are cloudy in nature and need to be

mixed well.

These insulins begin to work about 60 to 90 minutes after injection, peak

between 4 to 12 hours and last for between 16 to 24 hours.

Intermediate-acting insulins currently available are:

• Humulin® NPH (a human isophane insulin)

• Protaphane® (a human isophane insulin).
Long-acting insulin
The long-acting insulins currently available are:

• Lantus® (glargine insulin) – slow, steady release of insulin with no apparent

peak action. One injection can last up to 24 hours. It is usually injected
once a day but can be taken twice daily.
• Levemir® (detemir insulin) –slow, steady release of insulin with no apparent
peak action and can last up to18 hours. It is usually injected twice daily.

Although these insulins are long-acting, they are clear and do not need mixing
before injecting.
Administration and dosage

It can’t taken by mouth. It must be injected with a syringe, insulin

pen, or insulin pump. The type of insulin injection that will be use
will be based on the patient’s personal preference, and health needs.
Inject the insulin SQ under the skin in many different parts of the
body, such as:
• thighs
• buttocks
• upper arms
• abdomen
Common injection sites

• The abdomen, but at least 5 cm (2 in.) from the belly button. The
abdomen is the best place to inject insulin, because your
abdomen area can absorb insulin most consistently.
• The top outer area of the thighs. Insulin usually is absorbed more
slowly from this site, unless you exercise soon after injecting
insulin into your legs.
• The upper outer area of the arms.
• The buttocks.
Lipodystrophy insulin

Don’t inject insulin within two inches from the umbilicus because
the body won’t absorb it as well.

You should vary the location of injections to prevent the thickening

of your skin from constant insulin exposure.
• Insulin should not be withheld during illness, infection, or stress -increase
the blood glucose level and the need for insulin or Hyperglycemia and
even ketoacidosis can result

• Instruct the client to recognize the signs and symptoms of hypo- and
hyperglycemia

• The peak action time of insulin is important to explain to the client

because of the possibility of hypoglycemic reactions occurring during this
time.
Storing Insulin

1. Avoid exposing insulin to extremes in temperature.

- Insulin should not be frozen or keep in direct sunlight or a hot
car
2. Before injection, insulin should be at room temperature
3. If a vial of insulin will be used up in 1 month, it may be kept at
room temperature; otherwise, the vial should be refrigerated.
Hormones
Exenatide (Byetta)

- A synthetic hormone classified as an incretin mimetic that is administered SQ.

- Used for clients with Type 2 DM (not recommended for clients taking insulin nor s
hould clients be taken off of insulin and given exenatide)

Action:
- Restores first-phase insulin response (first 10 minutes after food ingestion)
- lowers the production of glucagon after meals
- slows gastric emptying (which limits the rise in the blood glucose level after meal)
- Reduces fasting and postpradial blood glucose level
- Reduces caloric intake, resulting in weight loss
- Packaged in premeasured dose (pen) that require refrigeration (cannot be
frozen)
- Administered as a SQ injection in the:
a. Thigh
b. Abdomen
c. Upper arm

- Given with in 60 minutes before morning and evening meals

- Not taken after meals
- If a dose is missed – the treatment regimen is resumed as prescribed
with the next scheduled dose
- Can cause mild to moderate nausea
Pramlintide (Symlin)

- Synthetic form of amylin, a naturally occurring hormone secreted by the

pancreas
- Used for clients with Type 1 and 2 DM who use insulin
- Given before meal – to lower blood glucose level after meals, leading to
less fluctuation during the day and better long-term glucose control
- Associated with an increased risk of insulin-induced severe hypoglycemia,
particularly in clients with type 1 DM
- Gastrointestinal side effects including nausea can occur
- Unopened vials are refrigerated; opened vials can be refrigerated or kept
at room temperature for up to 28 days
Glucagon

- Hormone secreted by the alpha cells of the islet of Langerhans in the

pancreas
- Increases blood glucose level by stimulating glycogenolysis in the liver
- Can be administered SQ, IM, or IV
- Used to treat insulin-induced hypoglycemia when the client is
semiconscious or unconscious and is unable to ingest liquids
- The blood glucose levels begin to increase within 5 to 20 minutes after
administration
- Instruct the family in the procedure for administration
Patient education

1. Pathophysiology
a. Basic definition of diabetes
b. Normal blood glucose ranges and target blood glucose levels
c. Effects of insulin and exercise (decrease glucose)
d. Effects of food and stress including illness and infections
(increased glucose)
e. Basic treatment approaches
2. Treatment modalities

a. Administration of insulin and oral antidiabetes medications

b. Meal planning (food groups, timing of meal)
c. Monitoring of blood glucose and urine ketones
3. Recognition, treatment, and prevention of acute complications

a. Hypoglycemia
b. Hyperglycemia
4. Pragmatic information

a. Where to buy and store insulin, syringes, and glucose monitoring

supplies
b. When and how to contact the primary provider
Factors that may influence the treatment and education

1. Low literacy level

2. Limited financial resources
3. Presence or absence of family support
4. Typical daily schedule (meal time, work, exercise schedule, plan
for travel)
5. Neurologic deficits (stroke – assessed for the ability to follow
simple commands)