Differences between Type I and Type 1 Diabetes Mellitus

Age at onset Associated body-Develop ketoacidosis Develop hyperosmolar state ïjpvbI. iiferidogeiifius irtsuiin . ■ feteëonçûp^nce- . HI.A associa! ion

Response to oral hypoglycemics Añühc^iestio ímiííiñ ■Risfc for diabetic cot.»plications : ;: ■Islet .«1! pathology■.

HLA - human tirnkoiyu- aiili'gwi,

4. Diagnosis of nonketotic hyperglycemic hyperosmolar state (type II diabetes mellitus) re quires hyperglycemia and hyperosmolarity without ketonemia.Treatment involves fluids, lluids, fluids, IV insulin, and electrolyte replacement.The mortality rate is about 50%.

Long-term complications of diabetes mellitus include atherosclerosis, coronary artery disease, myocardial infarction, retinopathy, and nephropathy. Use of ACE inhibitors helps to prevent nephropathy; 30% of end-stage renal disease is caused by diabetes mellitus. Diabetes is associated with an increased risk of infections, peripheral, vascular disease (claudication, atrophy), gangrene (the most common cause for nontraumic amputations is diabetes), and neuropathy.

Peripheral neuropathy (autonomic and sensory) causes many problems in diabetics: a Gastroparesis (early satiety, nausea; treat with metoclopromide and cisapride) s Charcot's joints (deformed joints due to lack of sensation; patient puts too much stress on joints)

m Impotence (from autonomic neuropathy as well as peripheral vascular disease) a Cranial nerve palsies (especially 3,4,6-ocular palsies; usually resolve spontaneously within a few months)

0 Orthostatic hypotension (due to lack of effective sympathetic innervation; when patient stands up, heart rate and vascular tone do not increase appropriately to maintain blood pressure)

Note: Diabetics commonly have no chest pain with a myocardial infarction because of neu ropathy ("silent" MI).

Diabetics are also prone to foot infections, ulcers and gangrene because they cannot feel their feet and blood flow is poor so that infection does not heal well. Patients should wear comfortable, properly fitting shoes and regularly inspect their own feet.

When retinopathy becomes proliferative, the treatment is panretinal laser photocoagulation to prevent progression and blindness. All diabetics should be followed once a year by an ophthalmologist to monitor retinal changes.

Know how to use regular and neutral protamine Hagedorn (NPH) insulin. Regular insulin — 45 minutes until onset, peak action at 3-4 hr, and duration of action for 6-8 hr. NPH insulin ~ I -1.5 hr until onset, peak action at 6-8 hr, and duration of about 18-20 hr.

b If patient has high (low) 7 am glucose, increase (decrease) NPH insulin at dinner the night before.

b If patient has high (low) noon glucose, increase (decrease) am regular insulin.

■ If patient has high (low) 5 I'M glucose, increase (decrease) morning NPH.

h If patient has high (low) 9 pm glucose, increase (decrease) dinner time regular insulin.

Somogyi effect vs. dawn phenomenon. The Sornogyi effect is the body's reaction to hypoglycemia. If too much NPH insulin is given at dinner time the night before, the 3 am glucose will be low (hypoglycemia).The body reacts by releasing stress hormones, which cause the.7 am glucose to be high. Treatment is to decrease insulin. The dawn phenomenon is hyperglycemia caused by normal early am growth hormone secretion. 7 am glucose is high, without 4- am hypoglycemia (glucose normal or high at 4 am).Treatment is to increase insulin.

follow compliance with hemoglobin Ale level, which is an accurate measure of overall control for the previous 3 months. Patients are not afraid to fudge their home test number to please their doctors, and this is the way to catch them.

For surgery, patients with diabetes are allowed nothing by month (NPO). Give one-third to one-half of normal insulin dose, then monitor glucose closely through case and postoperatively, using 5% dextrose in water (D5W) and IV regular insulin to maintain glucose control.

Medications in diabetics: Chlorpropamide may cause syndrome of inappropriate secretions of antidiuretic hormone (SIADH), Patients with type I DM are not helped by sulfonylurea medications. Avoid beta blockers, which preven t many of the physical manifestations of hypoglycemia (tachycardia, diaphoresis); therefore, neither you nor the patient will know if the patient is becoming hypoglycemic.

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