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According to the ADA and the AHA, new guidelines published in CIRCULATION, the class of drugs called thiazolidinediones (TZDs) which include rosiglitazone (Avandia) and pioglitazone (Actos), must be used with special care in patients with heart failure. Congestive heart failure patients taking these drugs may experience fluid buildup causing greater failure. Those individuals with moderate to severe heart failure should avoid TZDs. Those who do not have symptoms of congestive heart failure, but whose hearts have impaired pumping ability, are able to use the drugs at a lower dosage, but they should be monitored for fluid retention.

According to a study in DIABETES CARE, researchers randomly assigned 60 type 2 diabetics to consume 1, 3 or 6 grams of cinnamon or a placebo daily for 40 days in capsule form. Those taking cinnamon experienced a significant drop in glucose, LDL total cholesterol and triglycerides, despite no changes with the placebo group. Cinnamon appears to enhance the efficiency of insulin and helps fat cells recognize and respond to the hormone. One gram equals slightly less than ¼ tsp. of cinnamon.

Diabetics should aim for these goals:
BP < than 130/80
AlC < than 7.0%
LDL < than 100 mg/dl
HDL > than 45 mg/dl
Triglycerides < than 150 mg/dl

By Annette R. Karnash, R.N., M.N.

Two life threatening acute metabolic complications of diabetes that require immediate medical attention are Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Coma (HHNC). Acute insulin deficits and increased levels of blood glucose precipitate these complications.

Diabetic Ketoacidosis occurs most often in patients with type I diabetes and may be the first evidence of disease. The causes can be: (1) illness, (2) infection – most often viral, mumps, rubella or adenovirus, (3) physical or emotional stress, which can cause prolonged elevation in stress hormone levels of cortisol, glucagon, epinephrine or growth hormone, which in turn raises the blood glucose and increases demands on the pancreas, (4) hormones or drugs that may inhibit the release of insulin and (5) failure to take insulin or with patients on the pump – pump failure or insulin leakage.

Hyperglycemic Hyperosmolar Nonketotic Coma (HHNC) occurs primarily in type 2 diabetics, but also in those undergoing a stressed insulin tolerance, hemo- and peritoneal dialysis, tube feedings, or total parenteral nutrition (TPN).

Because there is inadequate insulin, glucose is unable to enter the fat and muscle cells to be converted into heat and energy. Glucose therefore accumulates in the blood causing the blood sugar to rise. Consequently, the liver, recognizing the cells are starved of energy, converts the stored glycogen to glucose and releases it into the blood, causing the blood glucose to rise to an even higher level. When the blood glucose exceeds the renal threshold, glycosuria results – higher in HHNC than in DKA because blood glucose levels are higher in HHNC.

Because the insulin deprived cells are still unable to utilize the glucose, protein is rapidly metabolized, causing the loss of intracellular potassium and phosphorus and the liberation of an excess amount of amino acids, which are then converted into urea and glucose by the liver. Once again the glucose levels in the blood become profoundly elevated causing high levels of glycosuria and serum osmolarity, leading to osmotic diuresis.

Dehydration, with fluid and electrolyte imbalance results, due to the vast volume of fluid loss from osmotic diuresis. Water loss, far greater than the loss of glucose and electrolytes, contributes to hyperosmolarity, which perpetuates dehydration, thus reducing the rate of glomerular filtration and the amount of glucose excreted in the urine. This leads to a deadly cycle. Diminished glucose excretion further raises the blood glucose, producing hyperosmolarity, dehydration that can continue into shock, coma and even death.

In DKA, to obtain energy, cells convert fats into glycerol and fatty acids because of the insulin deficiency. Fatty cells begin to accumulate in the liver, where they are converted into ketones, because they are unable to be metabolized as fast as they are released. Acidosis, resulting from the buildup of ketones in the blood and urine, leads to the breakdown of tissue, additional ketosis and acidosis and ultimately shock, coma and death.

The same basic principles are used to treat these complications; rehydration, electrolyte replacement, restoration of Insulin/glucose ration, and prevention/treatment of circulatory collapse. In the treatment of DKA, insulin is the key, whereas in HHNC, water is the key. Diagnostic procedures to identify and plan the treatment for these conditions are similar, with differences in the frequency performed.

Hello again. It’s hard to believe spring is already here, especially after winter hit us so hard, so fast. I’m sure we’re all excited about the arrival of spring with sunny, blue skies and warmer weather. I know I am. The Executive Board is working on a number of projects at present:

• Revision of WPADE chapter bylaws: If you have any questions or comments relating to the bylaws, please let me know.
• The Executive Board is striving to fulfill the purpose of WPADE, which according to the bylaws, shall be to:
  • Provide an atmosphere for the sharing of ideas, techniques and materials associated with diabetes education (working to do this through our bi annual continuing education programs and the website).
  • Promote and foster the growth and development of quality diabetes education in the Western Pennsylvania area (again, working to do this through our bi-annual continuing education programs).
  • Assume an active role in providing continuing education programs for the health professionals involved in diabetes education.
  • Strive for continuing excellence in the quality of diabetes education.
  • Serve as a resource to related organizations .
• Spring forum: Linda Fevrier and the program committee are spearheading efforts to provide an informative Continuing Education program on May 14th at the Holiday Inn, Forest Hills. We are all looking forward to learning more about autonomic neuropathies.
• Fall forum: WPADE is planning to partner with UPMC to provide a fall program.
• Continuing to promote the use of the WPADE website as a communication tool and educational resource (www.wpade.org).

Please take the time to review the current legislative issues that we are facing in the Commonwealth of Pennsylvania as well as the nation. What a difference we could make if we all take a few minutes and write to our senators and congressmen and inform them of our concerns.

And finally, I know that I have asked this before, but, if you have an interest in participating in WPADE, please give me a call. We are always looking for volunteers for committees and for the Executive Board. We would love to work with you.

Sincerely, Deb Kulbacki RN, MSN, CDE
Chapter President, WPADE
724-449-7036