THE BASICS OF

DIABETES
Phar 811
Peyton Teets
PharmD Candidate
School of Pharmacy – West Virginia University
 OBJECTIVES
• Differentiate between type 1 and type 2 diabetes
• Analyze normal blood glucose and A1C levels for patients with and
without diabetes
• Identify how to use a glucometer
• Discuss differences between glucometers and the need to use them
• Explain signs, symptoms and treatment for hypoglycemia
• Evaluate insulin injections using a pen device, vials, and syringes
• Identify and discuss Glucagon-Like Peptide-1 (GLP-1) receptor agonists
• Determine the importance of foot exams and how they are performed
 TYPE 1 DIABETES

• Insulin dependent diabetes

• Autoimmune destruction of insulin producing β cells in pancreas
• Over 90% of patients with type-1 diabetes are genetically
predisposed for the disease
• Usually triggered by environmental factor
• “Genetics loads the gun; the environment pulls the trigger”
• Diagnosis most common in early stages of life, but can occur at any
age

Trujillo J, Haines S. Diabetes Mellitus. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill; Accessed January 27,
2021. https://accesspharmacy-mhmedical-com.soleproxy.hsc.wvu.edu/content.aspx?bookid=2577&sectionid=228901946
TYPE 1
DIABETES
PROGRESSION
 TREATMENT
• Patients must use injectable insulin
• Rapid, short, intermediate, long acting
• Trying to mimic pancreas
• Oral diabetes medications will not work
• Possibly effective at the very onset of type 1 diabetes due to
remaining β cells prior to their destruction.
INSULIN
SCHEDULE
 TYPE 2 DIABETES
• Noninsulin-dependent diabetes or adult-onset diabetes
• β-cell dysfunction coupled with some degree of insulin resistance
• Can have progressive lose of β cells due to burnout
• 5-7% per year
• Obesity is a major factor in disease development
• Possibly a poly-genetic disorder leading to insulin insensitivity

Trujillo J, Haines S. Diabetes Mellitus. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill; Accessed January 27,
2021. https://accesspharmacy-mhmedical-com.soleproxy.hsc.wvu.edu/content.aspx?bookid=2577&sectionid=228901946
TYPE-2 DIABETES
PATHOPHYSIOLOGY
 TREATMENT

• Lifestyle modifications
• Diet
• Exercise
• Oral medication
• Increase insulin sensitivity
• Increase insulin production
• Injectable insulin
• Replace insulin that can't be produced from lack of β cells

Trujillo J, Haines S. Diabetes Mellitus. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill; Accessed January 27,
2021. https://accesspharmacy-mhmedical-com.soleproxy.hsc.wvu.edu/content.aspx?bookid=2577&sectionid=228901946
 BLOOD GLUCOSE LEVELS
Adults without diabetes
  Fasting Oral Glucose Tolerance Test (OGTT)
Normal <100 mg/dL <140 mg/dL
Pre-Diabetes 100-125 mg/dL 140-199 mg/dL
Diabetes ≥126 mg/dL ≥200 mg/dL

Adults with diabetes

  ADA ACE and AACE
Pre-Prandial (“Fasting”) 80-130 mg/dL <110 mg/dL

Post-Prandial <180 mg/dL. <140 mg/dL

 A1C
• Another way to analyze blood sugar
• Usually done in labs during checkups or hospital admissions
• Analyzes amount of red blood cells with glucose attached
• Provides rough estimate of average blood glucose over a three-month
period
• No benefit of testing more than every 3 months due to slow A1C
changes

https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html
 A1C INTERPRETATION
A1C Value to Estimated Average
A1C Value Meaning Glucose (eAG)
Normal Below 5.7% A1C % eAG mg/dL
7 154
Prediabetes 5.7% to 6.4%
8 183
Diabetes 6.5% or above
9 212
10 240
 HYPERGLYCEMIA
• Occurs when blood glucose is over >140mg/dl
• Symptoms
• Increased thirst
• Headache
• Decrease concentration
• Blurred vision
• Increased urination

Trujillo J, Haines S. Diabetes Mellitus. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill; Accessed January 27,
2021. https://accesspharmacy-mhmedical-com.soleproxy.hsc.wvu.edu/content.aspx?bookid=2577&sectionid=228901946
 HYPOGLYCEMIA
• Occurs when blood sugar is less than 70mg/dl with symptoms
• Symptoms
• Tachycardia
• Shakiness
• Dizziness
• Difficulty Speaking
• Lightheaded
• Tired/Weak
• Increased hunger
• Sweating
• Pale
• Fainting
 HYPOGLYCEMIA TREATMENT
• Can be deadly if severe and untreated
• Goal is to quickly raise blood sugar
• Glucose tablets (3-4)
• Fruit juice (4oz)
• Non diet soft drink (6oz)
• Skim milk (8oz)
• Honey or sugar (1 tbsp)
• Glucagon (unconscious)
• Rule of 15
• 15g of carbs and wait 15min to retest blood sugar
 SELF-MONITORING BLOOD
GLUCOSE TESTING
• Most commonly done at home by patient
• Requires glucometer
• Multiple different types of glucometer to fit patient needs
• Cost/insurance coverage
• Technology, data management capabilities
• Patient preference (size, color)
• Accuracy
• Test time
• Audio needs
• Amount of blood needed to test
 GLUCOMETER

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.medgadget.com%2F2019%2F02%2Fglucose-
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inc.html&psig=AOvVaw1qCh7HOQ5XI9mL1y4Y_N9L&ust=1611959680886000&source=images&cd=vfe&ve
d=0CAMQjB1qFwoTCNjUjPTXv-4CFQAAAAAdAAAAABAp
 BLOOD GLUCOSE TESTING CONT.
• Advantages
• Allows patient to test blood sugar at home
• Patient feels involved in their own care
• Quick adjustments in therapy based on results

• Disadvantages
• Painful
• Multiple tests per day could be required
• Patient might not like the sight of blood
 BLOOD GLUCOSE TESTING CONT.
• How to use glucometer
• Select testing site (fingerstick, alternate site testing)
• Wash and dry hands
• Insert test strip into meter (perform any coding if necessary)
• Prick selected site with lancet (clean site if dirty with alcohol but let dry)
• Squeeze finger gently near puncture site, wipe off first drop of blood, and
continue squeezing until large drop of blood forms
• Collect blood sample (sample size varies between products)
• Record results (include date, time, pre-prandial/postprandial, reasons for
abnormal numbers, and if any symptoms occurred)
• Dispose of supplies appropriately
 BLOOD GLUCOSE TESTING CONT.
• Video of glucometer steps
• https://youtu.be/GoV2p1y6flI
• Note: The instructor does not wipe away the first drop of blood.
While not required it does improve accuracy of results.
 FLASH GLUCOSE MONITORING
SYSTEM
• Up and coming method of glucose monitoring
• Requires a sensor that is attached to the skin
• Readings are then sent to a monitor or your phone
• Varies between systems
• Expensive and rarely covered by insurance
• Convenient and less painful due to not having to prick fingers
• Can be uncomfortable to constantly have a sensor attached to your body
• Patient preference to method
 FLASH GLUCOSE
MONITORING SYSTEMS

https://www.google.com/url?sa=i&url=https%3A%2F%2Fhealthwingsindia.wordpress.com%2F2017%2F12%2F26%2Fprick-free-glucose-monitoring-free-style-libre-flash-system
%2F&psig=AOvVaw0DUOic9HXKgmp3qM-UO7nj&ust=1611948827310000&source=images&cd=vfe&ved=0CAMQjB1qFwoTCJCFheGvv-4CFQAAAAAdAAAAABAD

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.childrensdiabetesfoundation.org%2Fflash-glucose-monitoring-future%2F&psig=AOvVaw0DUOic9HXKgmp3qM-UO7nj&ust=1611948827310000&source=images&cd=vfe&ved=0CAMQjB1qFwoTCJCFheGvv-
4CFQAAAAAdAAAAABAJ
 ORAL MEDICATIONS
• There are multiple different classes of oral diabetes medications
• Administration is relatively straight forward
• Further details on oral formulations will be provided later in the
curriculum
 INSULIN
Rapid Acting Onset Peak Duration
Fiasp ® (Aspart) 15-30min 1-2 hours 5-7 hours
Novolog® (Aspart) 15-30min 1-2 hours 5-6 hours
Humalog® (Lispro) 15-30min 1-2 hours 4-6 hours
Apidra® (Glulisine) 15-30min 1-2 hours 5-6 hours
Afrezza® (inhaled insulin) 15-30min ~ 1 hour 2-3 hours
Short Acting      
Humulin/Novolin R (Regular) 30-60min 2-3 hours 6-8 hours
Humulin U-500 30 min 1.5-3.5 hours 13-24 hours
Intermediate Acting      
Humulin/Novolin N (NPH) 2-4 hours 4-8 hours 14-18 hours
Long Acting      
Levemir® (Detemir) 2 hours N/A 24 hours
Lantus® (Glargine) 4-5 hours N/A 24 hours
Toujeo® (Glargine U-300) 6 hours N/A 24 hours
Tresiba® (Degludec U-100 & 200) 1 hour   42 hours
 INSULIN

• Notice different peak times

 INSULIN ADMINISTRATION
• All insulin is administered subcutaneously
• Patients can choose between these possible injection sites
 INSULIN STORAGE
• Insulin Storage
• Store unopened insulin in refrigerator
• Store opened insulin at room temperature for 28 days (except
Novolin R is 30 days, Levemir® is 42 days, and Tresiba ® is 56 days)
 INSULIN ADMINISTRATION
• Two different delivery methods to discuss today
• Vial/syringe and insulin pens
• Vial/syringe steps
• Wash hands and lay out supplies (vial, syringe, rubbing alcohol, Sharps container)
• Inspect insulin vial for lumps, crystals, or discoloration
• If insulin is suspended (NPH and mixed insulins) roll vial gently between hands
• Wipe top of insulin vial with alcohol swab
• Inject appropriate volume of air into vial
• Turn vial and syringe upside down and remove appropriate amount of insulin
• Clean injection site, allow to dry
• Pinch skin and inject at a 90o angle (unless very thin inject at a 45o)
• Count to 10 then remove needle
• Dispose of all supplies appropriately
INSULIN
ADMINISTRATION
• Vial/Syringe Video
• https://youtu.be/C0coWZbO-_E

https://images.app.goo.gl/zc5Pc44jDbJSipEu8
 INSULIN ADMINISTRATION
• Very common and patient friendly
• Insulin Pen Steps
• Wash hands and lay out supplies (Pen, pen needle, rubbing alcohol, Sharps container)
• Inspect insulin in pen for lumps, crystals, or discoloration
• If insulin is suspended (NPH and mixed insulins) roll pen gently between hands
• Clean tip of pen with alcohol swab
• Attach pen needle
• Prime pen
• Dial appropriate dose
• Inject subcutaneously at a 90o angle (unless very thin inject at a 45o angle)
• Count to 10 then remove needle
• Dispose of all supplies appropriately
INSULIN PEN
ADMINISTRATION
• Insulin pen video
• https://youtu.be/RcUspg3jb8Q
 GLUCAGON-LIKE PEPTIDE-1 RECEPTOR
AGONISTS
(GLP-1 RECEPTOR AGONISTS)

• Demonstrated equal or superior efficacy compared to basal insulin as initial

treatment
• Can lead to weight loss instead of weight gain
• Low risk of hypoglycemia
• Increase insulin secretion and inhibit glucagon release, which helps the body
lower blood sugar
• Not effective in type 1 diabetes
• Pens look similar to insulin pens and can lead to confusion to patients on both

Trujillo J, Haines S. Diabetes Mellitus. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill; Accessed January 27,
2021. https://accesspharmacy-mhmedical-com.soleproxy.hsc.wvu.edu/content.aspx?bookid=2577&sectionid=228901946
 GLP-1 RA ADMINISTRATION
• GLP-1 RA steps same as insulin pens however dosing is different
• Can be dosed QD, BID, or QWK depending on product
• Types of GLP-1 RA
GLP-1 Agonist (generic name) Brand Name Dosing Frequency

Exenatide Byetta® /Bydureon® Byetta®: Twice Daily

Bydureon®: Once weekly
Liraglutide Victoza® Once daily
Lixisenatide Adlyxin® Once daily
Albiglutide Tanzeum® Once weekly
Dulaglutide Trulicity® Once weekly
Semaglutide Ozempic® Once weekly
 GLP-1 RA

• Notice similarity to
insulin pens

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.newswire.ca%2Fnews-releases%2Fozempic-r-is-now-listed-on-the-alberta-provincial-formulary-for-adults-living-with-type-2-diabetes-840597791.html&psig=AOvVaw2ZWHTZfEUWHdNyT-
6GtKSX&ust=1611944954909000&source=images&cd=vfe&ved=0CAMQjB1qFwoTCIjysIuhv-4CFQAAAAAdAAAAABAD
 SHARPS DISPOSAL
• All of these techniques utilize needles
• This includes lancets
• Proper disposal is necessary for others safety
• Two proper methods of disposal
• Commercially available sharps container
• Hard plastic container like a laundry
detergent bottle
• When full throw away in trash
 FOOT EXAMS
• Prolonged and extreme expose to Increased glucose can cause nerve
damage (peripheral neuropathy) and poor blood flow
• Patients are prone to ulcers and infection especially in their feet
• Foot exams measure sensation and look for any wounds
• Can be a good indicator of disease progression and wound care
intervention

https://care.diabetesjournals.org/content/31/8/1679
 POTENTIAL
AREAS OF
CONCERN

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.ausmed.com%2Fcpd%2Farticles%2Fdiabetic-foot-explained&psig=AOvVaw1P8t8NqS2zOwiC28-
hjYes&ust=1611944273829000&source=images&cd=vfe&ved=0CAMQjB1qFwoTCJis7Miev-4CFQAAAAAdAAAAABAD
 FOOT EXAMS
• Foot exam steps
• Take a good patient history focusing on foot problems
• Inspect the feet (don’t be afraid to touch the feet; use gloves); assess for deformities,
foreign bodies, hair loss, skin temperature and infection (Remember to look between the
toes)
• Check for the absence or presence of pedal pulses
• Check for vibratory sensation using a tuning fork
• Test multi-point sensory perception using a 10-gram monofilament
• Check for proprioception (use a tuning fork)
• Video demonstration: Diabetic foot examination – OSCE guide (New Version)
• https://www.youtube.com/watch?v=vwIyulPnXcg
PEDAL PULSE