hello and welcome to the module for presentation on diabetes mellitus all the exam questions on this content will be derived from the objective objectives listed here on the slide so I want to start by discussing the difference between type 1 and type 2 diabetes type 1 diabetes is an autoimmune disorder which means that the body is attacking itself you may have heard of rheumatoid arthritis as an autoimmune disorder where the body attacks adjoins but in type 1 diabetes the body attacks the pancreas and as a result it can no longer produce insulin not having insulin is immediately life-threatening so patients do not go undiagnosed for very long with type 1 diabetes in general patients with type 1 diabetes are typically diagnosed at a younger age at diagnosis patients with type 1 diabetes are often very thin because the body is burning fat for energy instead of glucose in type 2 diabetes the patient's pancreas still makes insulin but the body is not as sensitive to the insulin so it is possible that patients with type 2 diabetes can be unaware they have the disease patients with type 2 diabetes are typically older than 30 at the time of diagnosis now normally when you eat the body breaks down carbohydrates into glucose the glucose then enters the bloodstream which sends a signal to the pancreas to release insulin insulin is required to get glucose from the blood into the fat and muscle cells where it's used as fuel or energy so until one diabetes when there is no insulin the glucose stays in the blood with an increase in blood glucose there are many complications which we are going to discuss a little bit later now on type 2 diabetes the body isn't as responsive to insulin as it would normally be and blood glucose levels are elevated as well because the body isn't effectively using the glucose high blood glucose causes similar complications regardless of the type of diabetes an individual has so type one diabetes no insulin is present the selves are essentially starving glucose keeps building up in the blood stream and there's no way for the glucose to be used if there's no insulin given patients are often really hungry as well talk about in a couple slides since their cells are getting no energy the body thinks it needs more food although even if they eat more there's still no insulin so the cells still can't get any glucose from the food that they're consuming these patients need to give themselves insulin injections in order to treat their diabetes now type two the body is resistant to the effects of insulin and the body does not make enough insulin to overcome this resistance in some is no insulin no longer works as well to get glucose from the bloodstream into the muscle and fat tissue where it can be used so we can use insulin to treat type 2 diabetes but we also have other medications besides it's insulin to treat type 2 diabetes now the goal of treatment of diabetes is to keep blood glucose under control and as close to normal as we can so the American Diabetes Association or a DA gives goals for treatment for both type 1 and type 2 diabetes the goal is to keep hemoglobin a1c about 7% so a1c is a measure of the average blood glucose over the past three months an a1c of 7% roughly translates to an average blood glucose so fasting and after meals of 150 milligrams per deciliter outside of blood sugar control we also want to control any other conditions such as cholesterol and blood pressure controlling all of these conditions helps lower patient's cardiovascular risk we also want to check patients regularly for diabetes related complications so if these complications are caught early we may be able to intervene for example the ABA recommends regular foot exams eye exams and dental visits to check for foot ulcers diabetic retinopathy and gum disease remember that diabetes also increases the risk for heart disease and kidney failure so keeping blood glucose under control is very important overall we'll talk more about these complications associated aya BT's at the end of this presentation now we do have some oral medications so not injections that we use to treat diabetes but remember this is only used to treat type 2 diabetes these medications can work in one of three main ways they can decrease the amount of glucose made and released by the liver increase the body's sensitivity to insulin or help the pancreas produce more insulin often these medications are used in combination with one another for the best effects metformin is the first oral medication we're going to talk about the main mechanism of action is to decrease glucose production in the liver glucose is necessary for ourselves to work so the liver makes glucose and releases it into our bloodstream to keep a steady level and diabetes there's already too much glucose in the blood so metformin stops the liver from releasing more glucose into circulation it also works to increase glucose uptake by muscle and fat cells by helping the tissues to use more glucose use it more efficiently this decreases blood glucose since more glucose is going into the tissues and coming out of the bloodstream overall metformin is very effective on average at Laura's fasting blood glucose by about 60 to 70 milligrams per deciliter which equates to a 1c reduction of about one and a half to two percent adverse effects usually include nausea vomiting and diarrhea although starting with a smaller dose and then gradually increasing the dose can help minimize those effects since metformin doesn't actually increase insulin levels at all it doesn't cause the blood sugar to go too low so that's a condition that we call hypoglycemia which is really important for patient safety metformin can actually cause some weight loss which is also important for the treatment of type 2 diabetes now one serious concern with metformin is a condition we call lactic acidosis this is a rare but potentially life-threatening side effect it results from a buildup of lactate in the muscles this is the same mechanism that causes muscle cramps after intense exercise however in this case the body cannot get rid of the lactate fast enough causing symptoms of weakness and muscle pain at first followed by trouble breathing patients with the following conditions should be cautious when using that form and due to their increased risk of lactic acidosis so first patients with kidney problems and liver problems because these conditions can decrease the ability of the body to get rid of metformin and the excess lactate patients also getting radioactive contrast dye during some CT or MRI scans should stop metformin for a few days before and after the scan because the dye can cause temporary kidney issues as well now the next trick we're going to talk about is glue control or glipizide this medication actually causes the pancreas to release more insulin particularly in response to meals glipizide is also fairly effective decreasing the a1c by one to two percent also since this medication actually increases the amount of insulin in the body it can cause hypoglycemia remember that metformin does not cause the same side effect other adverse effects of globocide include diarrhea and gas patients may also feel jittery or nervous which is likely due to low blood sugar so patients are kept aside should check their blood sugar regularly to be sure it is not too low now we will switch gears from our oral medications and move on to our injectables starting with insulin so insulin is given subcutaneously meaning it's given under the skin but above the muscle it's actually injected into the fatty tissue layer in between those two layers so this allows the needles on insulin syringes to be very tiny and relatively painless insulin can't be given orally and this is because the stomach and intestines would actually break it down before it could reach the bloodstream remember that insulin is absolutely necessary in type 1 diabetes and optional on the treatment of type 2 diabetes so in type 1 we give insulin in a manner that most closely mimics the body's natural insulin release so this is what we refer to as the basal bolus method so baseline insulin is given once a day and it releases slowly over the day this mimics the body's natural baseline level of insulin in a healthy individual bolus insulin on the other hand is given throughout the day so it's given with typically given with each meal this gives the patient a peak of insulin right when the body needs it when the blood sugar is at its highest insulin can be ejected into the abdomen thighs and upper arms it is usually injected in the abdomen as the absorption is best and tends to be the easiest for patients to do wherever patients inject insulin they should stick to that area only as there are differences in absorption between the different sites so we talked a little bit about hypoglycemia or low blood sugar as a side effect of glipizide and it can also occur with insulin as well so this can be a life-threatening condition if your body does not have enough glucose you can lose consciousness and have seizures if your blood sugar gets too low your heart cannot get enough energy to beat and you go into cardiac arrest additionally because insulin works to move more glucose into the cells it is also likely to cause weight gain and then finally those who use insulin may also experience mild injection site reactions where they are injecting the medication so this is a diagram of normal insulin secretion in a patient without diabetes you can see that the basal insulin is always present to supply energy to the cells all day then when the person eats a meal the insulin concentration increases this allows the cells to take in more energy from the food that's being consumed extra glucose that is not needed is converted to storage in the form of glycogen or fat so there are three basal insulin products in the market lantus loving me rent receive f they are essentially interchangeable and work in the same way they mimic the basal insulin that the body secretes normally so when injected these medications for micro crystals that slowly release insulin at a steady rate over 24 hours so these medications are typically only injected once a day we also have three different bolus insulins on the market novalog Humalog and a Pietra like the basal insulin these products are also interchangeable they work quickly after the injection and also wear off fairly quickly they closely mimic the after meal insulin response deciding which insulins to use is generally determined by a patient's insurance coverage remember that unfortunately there is no cure for diabetes all patients with diabetes will have some form of lifelong treatment and take one diabetes that treatment is lifelong insulin therapy and type 2 patients may be managed with diet alone oral medications insulin or a combination of all three so there are two main types of complications from diabetes these are both micro vascular and macro vascular micro vascular complications affect the small blood vessels these complications affect the eyes kidneys and the nerves once these effects have started they cannot be reversed their progression however can be slowed by having better or tighter glucose control macro vascular complications affect the large vessels and include heart attack stroke and peripheral vascular disease so peripheral vascular disease is the complication that can lead to amputation of the limbs since the extremities are not getting enough sufficient blood flow they are more prone to infection and less likely to heal essentially the tissue in the extremities begins to die once the tissue dies it must be removed in order to avoid serious systemic infections usually the toes are the first extremities to be removed to summarize this presentation remember that there are two different types of diabetes and they are treated somewhat differently so in type 1 patients must receive insulin in order to survive in type 2 insulin is often used but it is optional first-line therapy for type 2 islets diet and the oral medications we discussed here metformin and globocide also remember that untreated or poorly controlled diabetes can lead to severe medical problems regardless of the type of type 2 diabetes someone has