Diabetes mellitus is a serious medical condition that can lead to long term complications and death.  Diabetes mellitus (DM) is a disorder wherein the body is unable to metabolize carbohydrates appropriately due to either a lack of endogenous insulin, or the body’s inappropriate response to any insulin present (Rosenthal & Burchum, 2018).  The ‘classic symptoms’ of DM include an increase in eating, drinking and urinating, known as polyphagia, polydipsia and polyuria (Rosenthal & Burchum, 2018).  These symptoms are the results of chronic high blood glucose levels, hyperglycemia, that occurs when cells are unable to utilize insulin and/or the body produces too much glucose in response (Rosenthal & Burchum, 2018).  DM is diagnosed by the presence of repeat or chronic hyperglycemia in lab tests; 2 positive hyperglycemic results taken on separate days, or a Hemoglobin A1c level greater than 6.5 are diagnostic (Rosenthal & Burchum, 2018).  There are several different “types” of DM, which will be discussed below, however the focus will be on Type 1 DM and its management.

Type 1 DM/Juvenile DM

Type 1 DM (T1DM) was once also known as Juvenile Onset DM, or insulin dependent DM; however, these terms are no longer commonly used as other forms of DM are now also associated with juvenile onset and insulin use (Rosenthal & Burchum, 2018). T1DM is classified as an autoimmune disorder wherein the body attacks and destroys the insulin producing beta cells in the pancreas’ Islets of Langerhans, leading to a complete absence of endogenous insulin (Rosenthal & Burchum, 2018).  Because of this, T1DM patients require daily insulin replacement; without such treatment T1DM patients will enter a state of diabetic ketoacidosis (DKA), slip into a coma, and die (Rosenthal & Burchum, 2018).

T1DM was previously called Juvenile or Juvenile onset DM because the disease usually abruptly occurs in childhood and early adolescence (Rosenthal & Burchum, 2018).  There is rarely a family history of the disease, patients often exhibit the ‘classic’ symptoms previously mentioned, and may also experience weight loss and the presence of ketones in the urine, known as ketonuria; newly diagnosed patients are often poorly nourished and underweight due to the effects of the untreated disease (Rosenthal & Burchum, 2018).  If T1DM patients do not keep their blood sugars well controlled, they are at risk for several damaging microvascular and macrovascular concerns (Levy, 2011).  Microvascular concerns include blindness through retina damage, kidney disease and failure, and poor wound healing which can lead to amputation of the digits or extremities (Levy, 2011).  Macrovascular concerns include coronary artery disease (CAD), peripheral vascular disease (PVD) and stroke (Levy, 2011).

T1DM was also previously known as insulin dependent DM because, as discussed, there is no production of endogenous insulin and patients are dependent on synthetic insulin replacement.  Insulin replacement is administered subcutaneously, and there are seven man-made insulins available for DM patients; all synthetic insulins are produced utilizing recumbent DNA (Rosenthal & Burchum, 2018).  Of the seven available insulins, “regular insulin”, generically known as Humulin R or Novolin R, is the only insulin that is identical to endogenous insulin; all the other insulins, known as analogs, have been modified to act in the same way as endogenous insulin but have varying time courses (Rosenthal & Burchum, 2018).  A time course is the spectrum of time it takes insulin to take effect, reach its peak efficacy and stop working (Rosenthal & Burchum, 2018).  The short acting insulins, or insulins that have rapid action but only last a few hours, are meant to be taken in conjunction with a patient eating a meal to help control post-prandial blood glucose (Rosenthal & Burchum, 2018).  The long acting insulins, which take longer to start working but last longer, are used for glycemic control throughout the day or night; these insulins are usually given once or twice a day in conjunction with short acting insulins (Rosenthal & Burchum, 2018).  All insulins, except the long acting NPH insulin, are clear and colorless; NPH is cloudy due to the addition of a protein molecule which aides the insulins ability to be slowly absorbed (Rosenthal & Burchum, 2018).  Also, NPH is the only long acting insulin that can be mixed with a short acting insulin within the same syringe (Rosenthal & Burchum, 2018).  Insulins are available in vials, allowing individuals to draw up each dose in syringes, or in prefilled dosing pens; some T1DM patients utilize an insulin pump which is embedded in the abdomen and releases a controlled amount of insulin throughout the day (Rosenthal & Burchum, 2018). Diabetes and Drug Treatments – NURS 6521 Discussion. Recently, surgical transplant of the pancreas or individual Islets has been successful in regulating blood glucose levels through the new formation of endogenous insulin (ADA, 2018). However, as with any organ transplant, patients who undergo this procedure must be on lifelong immunosuppression therapy to prevent rejection; therefore, transplants are only recommended for patients who are already receiving a transplant of a different organ, such as kidneys, or patient for  whom all other forms of management have been unsuccessful (ADA, 2018).

In addition to insulin treatment, careful diet management and regular exercise are necessary for adequate disease control (Rosenthal & Burchum, 2018).  Patients are often encouraged to be cognizant of the amount of carbohydrates they are eating, as well as the amount of sugar in foods, however there is not a standard diet plan as each individual needs to account for their activity and sensitivity.

Type 2 DM

Type 2 DM (T2DM) differs from T1DM in that T2DM is not autoimmune in origin; although the exact cause of T2DM is unknown, heredity/genetics are suspected in playing a large role, as is the presence of obesity (Rosenthal & Burchum, 2018).  T2DM tends to develop gradually after the age of 40, although recently an increasing trend children and young adults developing the disease is occurring (Rosenthal & Burchum, 2018).  In T2DM, there is still some endogenous insulin production by the pancreas, however that production is usually inadequate, and/or combined with systemic insulin resistance (Rosenthal & Burchum, 2018).  Insulin resistance is due to a reduction of insulin molecules binding to cellular receptor sites, fewer available receptor sites, and less responsiveness of the receptor sites (Rosenthal & Burchum, 2018).  T2DM is treated with a combination of oral antidiabetics, such as metformin, supplemental insulin, and lifestyle adjustments to diet and activity levels (Rosenthal & Burchum, 2018).  T2DM patients tend to have less instances of hypoglycemia and ketosis than T1DM patients as their blood glucose levels are generally more stable; however, T2DM have a high rate of diabetic associate comorbidities such as hypertension and kidney disease (Rosenthal & Burchum, 2018). Diabetes and Drug Treatments – NURS 6521 Discussion.

Gestational DM

Gestational DM is a form of DM that occurs only during pregnancy and resolves after giving birth (Rosenthal & Burchum, 2018).  Gestational DM may occur due to the combination of an increase in cortisol which increases hyperglycemia, and the presence of placental hormones that inhibit insulin production.  Blood glucose levels are controlled through diet and supplemental insulin injections, although T2DM patients who become pregnant may continue to take metformin.

References

American Diabetes Association. (2018). Pharmacologic approaches to glycemic treatment:

Standards of medical care in diabetes—2018. Diabetes Care,

41(Supplement 1), S73–S85. Retrieved from

http://care.diabetesjournals.org/content/41/supplement_1/s73.full-text.pdf

Levy, D. (2011). Type 1 diabetes. [electronic resource]. Oxford University Press. Retrieved

from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=cat06423a&AN=wal.EBC975595&site=eds-live&scope=site

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for

advanced practice providers. St. Louis, MO: Elsevier.

Week 5 Initial Post

Type 1 Diabetes

According to the American Diabetes Association (2019), “1.25 million Americans have been diagnosed with type 1 diabetes and 40, 000 people will be diagnosed this year.”  In type 1 diabetes, the immune system destroys pancreatic beta cells in an autoimmune response (Low Blood, 2019).  The pancreas does not produce insulin (American Diabetes, 2019).  The body is then unable to convert the excess glucose into energy for the body (Low Blood, 2019).  Hyperglycemia and hypoglycemia can be present in type 1 diabetes.  Symptoms of hyperglycemia include:  changes in vision, excessive thirst, increased hunger, a sweet smell in the breath, and extreme exhaustion (Low Blood, 2019).  Hypoglycemia symptoms include:  dizziness, vision changes, erratic behavior, coordination changes, nausea, and sweating (American Diabetes, 2019). Diabetes and Drug Treatments – NURS 6521 Discussion.

Type 2 Diabetes and Short/Long Term Effects

Type 2 diabetes is diagnosed when there is an impairment of pancreatic beta cells, also known as an endocrine involved metabolic disorder (American Diabetes, 2019).  This impairment happens over time.  Insulin is still produced in this type of diabetes, but the body cannot keep up with an adequate amount that is needed (Type Two, 2019).  As with type one, hyperglycemia and hypoglycemia can be present.  Risk factors for type 2 diabetes, creating insulin resistance, include:  obesity, ethnicity, genetics, distribution of fat, and behaviors (Type Two, 2019).  In type 2 diabetes, immediate interventions control short term and long term outcomes.  These interventions include developing a regular exercise regimen, seeking assistance to alter your diet in a way that it will realistically fit into your lifestyle, and weigh the options to determine which medication is appropriate for you (American Diabetes, 2019).  These healthy choices will reduce factors that you are able to control, such as cholesterol, blood pressure, and body mass index.  Controlling these factors can assist in reducing the risk of heart disease, stroke, long term vision problems, kidney damage, short and long term depression, ulcerations in the feet, and heart disease American Diabetes, 2019).

Gestational Diabetes

In gestational diabetes, the hormones of the placenta have an antagonistic effect on the action of insulin in the body of the expectant mother (Rosenthal & Burchum, 2018).  Second, cortisol production is increased, causing hyperglycemia (Rosenthal & Burchum, 2018).  An exact cause is not known for this form of diabetes, but an expectant mother may need up to three times as much insulin as she normally needs to turn glucose into energy (American Diabetes, 2019).  This type of diabetes can be treated by modifying the daily meal-plan, incorporating exercise, and possibly insulin injections (American Diabetes, 2019).

Diabetes Healthy Diet Plan

The basic fundamental approach for learning how to manage diabetes is learning the balance between how many, and what kind of carbohydrates need to be consumed (American Diabetes, 2019).  The key to a balanced diet is to choose an appropriate amount of each:  proteins, carbohydrates, and healthy fats (American Diabetes, 2019).  Education should also occur regarding fiber, starches and sugar (American Diabetes, 2019).

Medication

Tight glucose control during pregnancy is very important for a mother and a fetus.  It is recommended that blood glucose checks occur at least four to five times per day (American Diabetes, 2019).  Diet and exercise are sometimes enough to control an individual with gestational diabetes (American Diabetes, 2019).  If it is not, insulin will then be prescribed.   According to the American Diabetes Association (2019), insulin is the first-choice drug for expectant mothers with gestational diabetes.  This subcutaneous injection is the preferred treatment because it does not cross the placenta like oral medications, and it can be the most effective for fine tuning glucose levels.

American Diabetes Association:  Diabetes overview.  (2019).  Retrieved from https://www.diabetes.org/diabetes

Low Blood Sugar.  (2019).  Retrieved from https://www.jdrf.org/t1d-resources/about/symptoms/low-blood-sugar/

Rosenthal, L. D., & Burchum, J. R.  (2018).  Lehne’s pharmacotherapeutics for advanced practice providers.  St. Louis, MO:  Elsevier

Type 2 diabetes.  (2019, January 09).  Retrieved from https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193

Initial Post

          “Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces” (World Health Organization, 2018, para. 1).  Approximately 8.5% of the global population, age 18 and up, suffers from diabetes and this number has been on the rise since 1980 (WHO, 2018).  In the United States, diabetes is the most prevalent endocrine disorder and is listed as the seventh leading cause of death by disease (Rosenthal & Burchum, 2018).  Over 26 million Americans have been diagnosed while another 76 million are projected to have prediabetes, putting them at increased risk for later developing diabetes (Rosenthal & Burchum, 2018).  As advanced practice nurses, treating patients with diabetes will be common.  Understanding how to manage this disease is critical.

Types

          Diabetes exists in different types.  Type 1 (DM1) generally develops during childhood and is related to the destruction of pancreatic cells responsible for making and releasing insulin, causing insufficient amounts for glucose uptake (Rosenthal & Burchum, 2018).  This type was commonly referred to as “juvenile” diabetes, however, with increasing rates of Type 2 seen in childhood, this term has become less accurate (Rosenthal & Burchum, 2018).  DM1 is not preventable and has no cure (WHO, 2018).

          Type 2 (DM2) is the most prevalent form of diabetes and results from the body’s ineffective use of insulin (WHO, 2018).  Unlike type 1, those with DM2 are capable of producing insulin at high levels, known as hyperinsulinemia.  Target tissue is more resistant to taking up and metabolizing glucose related to reduced insulin-receptor binding, decreased receptor binding sites, and less receptor responsiveness (Rosenthal & Burchum, 2018).  Type 2 is largely the result of obesity and physical inactivity (WHO, 2018).

          Gestational diabetes is “diabetes that appears in the pregnant patient during pregnancy and then subsides rapidly after delivery” (Rosenthal & Burchum, 2018, p. 486).  Women with gestational diabetes have higher risks of pregnancy complications (WHO, 2018).  Furthermore, in gestational diabetes, both mother and baby are at increased risk for developing Type 2 in the future (WHO, 2018).  This type is managed in a similar manner as other types of diabetes. Diabetes and Drug Treatments – NURS 6521 Discussion.

Treatment with Metformin

          While all types of diabetes can be managed by monitoring blood glucose levels and injecting insulin subcutaneously, only gestational and type 2 diabetes can use the oral medication metformin as therapy.  Metformin, a biguanide type of oral antidiabetic medication, does not cause an increase in insulin production in order to drive down glucose, but rather it reduces the rise in glucose that occurs after eating (Rosenthal & Burchum, 2018).  Metformin lowers blood glucose and improves glucose tolerance by decreasing glucose production by the liver, reducing glucose absorption in the gut, and increasing target tissue responsiveness to insulin (Rosenthal & Burchum, 2018).  Because metformin does not increase insulin secretion, risk of hypoglycemia is very low.

          Metformin is absorbed by the small intestine and is excreted, unmetabolized, by the kidneys (Rosenthal & Burchum, 2018).  In the presence of renal insufficiency, metformin may become toxic.  Toxicity results in lactic acidosis, a medical emergency with a mortality rate of 50% (Rosenthal & Burchum, 2018).  For this reason, renal patients should not use this medication.  Patients more prone to lactic acidosis, including patients with liver disease, severe infection, excessive alcohol consumption, and patients with shock, should also avoid using metformin (Rosenthal & Burchum, 2018).  This being said, in patients with good renal function and low risk of lactic acidosis, the most common side effect is gastrointestinal upset which usually resides over time.

       Metformin is available in immediate-release (IR) and extended-release (ER) tablets, as well as an oral solution.  IR and elixir preparations are recommended to begin dosing at 500mg twice a day with meals, or 850mg once a day with a meal.  Maintenance dose is generally 850mg two times a day, while maximum dose is 850mg three times a day or 2000mg once a day.  IR may lead to more severe GI symptoms that might be relieved with ER.  ER dosing is once a day and is recommended at night to allow better absorption with slower transit time in the gut.  The initial dose is 500mg, with a maximum daily dose of 2000mg. Diabetes and Drug Treatments – NURS 6521 Discussion.  Short-term effects of metformin may facilitate weight-loss related to nausea, vomiting, diarrhea, and decreased appetite.  However, “decades of clinical use have demonstrated that metformin is generally well-tolerated and safe” (Hostalek, Gwilt, & Hildemann, 2015, p. 1071).  Increasing dosage should be based on symptom tolerance.

          In patients with Type 2 diabetes, lifestyle interventions such as weight loss, exercise, pharmaceutical therapy, and bariatric surgery have been shown to reduce risk of diabetes progression or even reverse it (Hostalek et al., 2015).  This being said, lifestyle modifications have proven difficult to maintain and long-term effects become lost.  The Diabetes Prevention Program (DPP) has studied long-term effects of metformin use in these patients and “its efficacy for delaying or preventing the onset of diabetes has been proven in large, well-designed, randomized trials” (Hostalek et al., 2015, p. 1071).  While metformin is not a substitute for diet and exercise, the combination can reduce risk of Type 2 by 58%, and even more-so in patients over the age of 60 (Rosenthal & Burchum, 2018).

References

Hostalek, U., Gwilt, M., & Hildemann, S. (2015). Therapeutic use of metformin in prediabetes and diabetes prevention. Drugs, 75(10), 1071-1094. http://dx.doi.org/10.1007/s40265-015-0416-8

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier. Diabetes and Drug Treatments – NURS 6521 Discussion.

World Health Organization (WHO). (2018). Diabetes. Retrieved from https://www.who.int/news-room/fact-sheets/detail/diabetes

NURS 6521: Advanced Pharmacology

Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) starts when the body is not able to make and use all the insulin it needs for pregnancy. Hormones naturally provided from the placenta, help baby develop and survive. These same hormones also block the action of the mother’s insulin in her body, causing insulin resistance as in Type 2. Having gestational diabetes doesn’t mean that you had diabetes before you conceived, or that you will have diabetes after giving birth, ADA, (2019).

Initially, effective treatment consists of lifestyle intervention, comprising dietary modification, exercise, and weight management, is an essential component of GDM management. A carbohydrate restricted diet management in conjunction with insulin treatment can be associated with improved placental vascular circulation of fetal origin in women with GDM. If blood glucose targets are not achieved with lifestyle intervention, adding glucose-lowering therapy is needed, consisting of insulin and oral anti-diabetic medications.  Kintiraki, E., & Goulis, D. G. (2018) explain insulin is the gold standard pharmacological agent for Gestational diabetes mellitus (GDM) treatment. Metformin and glyburide are two oral anti-diabetic agents that could serve as alternative, although not equal in terms of effectiveness and safety, treatment for GDM, Kintiraki, E., & Goulis, D. G. (2018). Metformin is meant to be used as short-term treatment during pregnancy. Johns, E. C., Denison, F. C., Norman, J. E., & Reynolds, R. M. (2018) explain Metformin crosses the placenta readily and similar plasma concentrations have been observed in the fetal and maternal circulation.  Insulin is recommended as the first-line pharmacological therapy for GDM in the US and Canada, Johns, E. C., Denison, F. C., Norman, J. E., & Reynolds, R. M. (2018). Based on a study by Barda, G., Bar, J., Mashavi, M., Schreiber, L., & Shargorodsky, M. (2019), “findings favored insulin treatment in terms of placental vascular circulation, and support recently published guidelines indicating insulin as the preferred medication in gestational diabetes treatment.”. Diabetes and Drug Treatments – NURS 6521 Discussion.

Blood glucose is checked before a meal (preprandial), 1 hour after meal (postprandial), and 2 hours after meal (postprandial). Insulins used are rapid-acting mealtime insulins lispro (Humalog) and aspart (Novolog), and long-acting basal insulin glargine (Lantus). Mealtime insulins are used to control post-meal blood glucose. Blum (2016) reports insulin is weight-based dosing, weight plus gestational age-based dosing, and a one-dose-for-all have been used. National guidelines lack an algorithm for adjusting doses in pregnancy and because of lack of time and risk of rapid fetal harm development quick control is imperative, Blum (2016). CDAPP (2002) recommends changes by 2-4 units in short and intermediate-acting insulins every 2-3 days.

Summary

Gestational diabetes mellitus (GDM) treatment would be the inclusion of insulin, diet, and lifestyle change. ADA (2019) explains there is a link between having GDM and type 2 diabetes since both involve insulin, however basic lifestyle changes may help prevent diabetes after GDM. Diabetes and Drug Treatments – NURS 6521 Discussion.

References

American Diabetes Association. (2019). Gestational diabetes: Treatment and prospective. Retrieved from https://www.diabetes.org/diabetes/gestational-diabetes/how-to-treat-gestational-diabetes

American Diabetes Association. (2019). Gestational Diabetes. Retrieved from https://www.diabetes.org/diabetes-basics/gestational/

Blum, A. (2016). Insulin use in pregnancy: An update. Diabetes Spectrum; 29(2). 92-97

California Diabetes & Pregnancy Program (2002). Insulin for gestational and pregestational diabetes. Retrieved from https://www.Perinatology.com

Center for Disease Control. (2019). Diabetes: Type 2. Retrieved from https://www.cdc.gov/diabetes/basics/type2.html

Barda, G., Bar, J., Mashavi, M., Schreiber, L., & Shargorodsky, M. (2019). Insulin treatment is associated with improved fetal placental vascular circulation in obese and non-obese women with gestational diabetes mellitus. Frontiers in Endocrinology. https://doi-org.ezp.waldenulibrary.org/10.3389/fendo.2019.00084

Johns, E. C., Denison, F. C., Norman, J. E., & Reynolds, R. M. (2018). Gestational diabetes mellitus: Mechanisms, treatment, and complications. Trends in Endocrinology & Metabolism, 29(11), 743–754. https://doi-org.ezp.waldenulibrary.org/10.1016/j.tem.2018.09.004 Diabetes and Drug Treatments – NURS 6521 Discussion

Kintiraki, E., & Goulis, D. G. (2018). Gestational diabetes mellitus: Multi-disciplinary treatment approaches. Metabolism, 86, 91–101. https://doi-org.ezp.waldenulibrary.org/10.1016/j.metabol.2018.03.025

Management of Diabetes Mellitus

 Diabetes mellitus (DM) is a class of metabolic disorders that are characterized by elevated blood sugar levels or hyperglycemia due to insulin resistance or a deficiency in insulin secretion (Huether & McCance, 2017).  The most common forms or “types” of DM are type 1 DM (T1DM), accounting for approximately 5 percent of cases of DM, and type 2 DM (T2DM), which accounts for between 90 and 95 percent of cases of DM (Rosenthal & Burchum, 2018).  Less common, but important to mention is gestational diabetes (GDM), which is a form of DM that presents during pregnancy and typically disappears immediately after birth. Diabetes and Drug Treatments – NURS 6521 Discussion.

Pathophysiology of Diabetes Mellitus

 T1DM previously referred to as “juvenile-onset diabetes” is the most common chronic disease affecting children in the United States (Huether & McCance, 2017).  Autoimmune in nature (idiopathic is heard of, but extremely rare), T1DM has strong genetic and environmental components that result in the destruction of and apoptosis of beta cells on the pancreas. As a result, patients with T1DM have a severe insulin deficiency or are completely incapable of insulin secretion (Huether & McCance, 2017).  The resultant hypoinsulinemia leads to an increase of glucagon secretion by the liver in an attempt to increase insulin production, but due to destruction of the beta cells, this only proliferates patients’ hyperglycemia. 

 T2DM. previously referred to as “adult-onset diabetes” or “insulin resistant diabetes,” also carries a strong genetic-environmental component (McCulloch & Robertson, 2019).  The incidence of T2DM has increased significantly in the last decade in the United States, which can be directly attributed to the increased incidence of obesity and sedentary lifestyles.  An array of genetic abnormalities results in beta-cell dysfunction (but not destruction) which negatively impacts insulin secretion, as well as decreased sensitivity to insulin by insulin-sensitive organs (Huether & McCance, 2017).  

 GDM is defined as “any degree of glucose intolerance with onset or first recognition during pregnancy” (Huether & McCance, 2017, p. 476). GDM can be classified by controlling mechanism; GMD controlled with diet is A1GDM and GDM controlled pharmacologically is A2GDM (Quintanilla-Rodriguez & Mahdy, 2019).  GDM prevalence is variable in the United States, with between 2 and 10 percent of all pregnant women affected.  While the clinical risk factors for the development of GDM mirror that of T2DM (obesity, sedentary lifestyle, genetics, race, other comorbidities), the etiology of GDM is usually related to the secretion of human placental lactogen (Quintanilla-Rodriguez & Mahdy, 2019).  Various hormones secreted by the placenta during pregnancy results in an increased insulin resistance and subsequent hyperglycemia. Therefore, the majority of patients with GDM tend to no longer be insulin resistant after delivery of child and placenta. Diabetes and Drug Treatments – NURS 6521 Discussion. That being said, patients with GDM that carry the risk factors for T2DM are at an increased risk for the develop of T2DM over the course of their lifetime. 

Pharmacological and Non-Pharmacological Management of T1DM

 As previously discussed, T1DM is the most common chronic disease in children, is (typically) autoimmune in nature and results in inability to secrete insulin due to beta cell destruction.  Management of any childhood disease is complicated and has its challenges, but successful management of T1DM in children involves strict glycemic control through dietary modification and insulin replacement, as well as extensive education and developing a personalized, realistic, and practical management plan.  Unlike T2DM, patients with T1DM tend to be underweight and have varying degrees of control, thus creating a blanket “diet plan,” or a “low carb diet” may not be ideal (Rosenthal & Burchum, 2018).  Multidisciplinary involvement is key in managing T1DM, therefore a referral to a registered dietician with experience in pediatric nutrition and T1DM is imperative (Levitsky & Misra, 2019).  Consistency of diet, especially that of carbohydrate intake, is more important than limitation of carbohydrates in T1DM.  Diabetes and Drug Treatments – NURS 6521 Discussion.

 The use of insulin pump therapy, more specifically portable insulin pumps that provide continuous subcutaneous insulin infusions and intermittent boluses, has become increasing prevalent in children and adolescents with T1DM (Levitsky & Misra, 2019).  Recent trials have shown that T1DM is better controlled with insulin pump therapy over multiple daily insulin injections and should be considered regardless of time of diagnosis (but not age) (Levitsky & Misra, 2019).  Insulin pumps are small devices that delivers continuous insulin (in small doses, every few minutes over the course of each our) and intermittent boluses via a subcutaneous catheter through the abdomen (Rosenthal & Burchum, 2018). Diabetes and Drug Treatments – NURS 6521 Discussion. The basal rate is programmed specifically for each patient, based on their metabolic demands and mealtime boluses are based on carbohydrate intake instead of a set rate.  Another reason why consistency regarding carbohydrate intake and extensive education in carbohydrate counting is important.  Insulin pumps are typically used with rapid acting insulin, making education important, as hypoinsulinemia will occur relatively quickly if the pump is off or disconnected for a longer period of time (Levitsky & Misra, 2019).

References

Huether, S., & McCance, K. (2017). Understanding pathophysiology. St. Louis, MO: Mosby.

Levitsky, L., & Misra, M. (2019). Management of type 1 diabetes mellitus in children and adolescents. UpToDate. In A. Hoppin (Ed.) Retrieved from: https://www.uptodate.com/contents/management-of-type-1-diabetes-mellitus-in-children-and-adolescents?search=t1dm&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H26

McCulloch, D., & Robertson, R. (2019). Pathogenesis of type 2 diabetes mellitus. UpToDate. In J. Mulder (Ed). Retrieved from: https://www.uptodate.com/contents/pathogenesis-of-type-2-diabetes-mellitus?search=type%202%20dm&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3

Quintanilla-Rodriguez, B., & Mahdy, H. (2019). Gestational diabetes. In StatPearls [Internet]. Treasure Island, Fl: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545196/

Rosenthal, L., & Burchum, J. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

Diabetes Mellitus

Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both (Huether & McCance, 2017).  Type I DM is beta-cell destruction and leads to absolute insulin deficiency (Huether & McCance, 2017).  Type I DM is an auto-immune T-cell mediated disease that destroys beta cells of the pancreas (Huether & McCance, 2017).  Insulin synthesis declines and hyperglycemia develops over time (Huether & McCance, 2017).  Type I diabetes used to be called juvenile diabetes.

Type 2 is insulin resistance with insulin deficiency or insulin secretory defect with insulin resistance (Huether & McCance, 2017). Type II DM is associated with obesity which causes insulin resistance.  Insulin resistance is a response of insulin-sensitive tissues such as the liver, muscle, and adipose tissue (Huether & McCance, 2017).  Adipokines are hormones produced by adipose tissue and obesity increases serum levels of leptin and decreases levels of adiponectin (Huether & McCance, 2017).  These changes decrease insulin sensitivity (Huether & McCance, 2017). Diabetes and Drug Treatments – NURS 6521 Discussion.

Gestational diabetes develops during pregnancy and affects how your cells use sugar (Mayo Clinic, n.d.).  In gestational diabetes, blood sugar usually returns to normal after delivery (Mayo Clinic, n.d.).  Women that have a history of gestational diabetes are at risk for developing type 2 diabetes.

Diabetes type 2 (DM) causes polyuria, polydipsia, fatigue, blurry vision, slow healing, tingling or numbness in the hands, and patches of dark skin (Rosenthal & Burchum, 2018).  Type 2 DM may include other factors such as obesity, dyslipidemia, and hypertension (Huether & McCance, 2017).  Also, the practitioner needs to examine the renal, nervous system, cardiac, peripheral, vascular, retinal, and boney tissue for damage due to DM (Huether & McCance, 2017).  To diagnosis DM a medical history and physical exam are required.  Criteria for diagnosing diabetes 2 includes, HbA1c greater than 6.5%, fasting glucose greater than 126 mg/dl, or a two-hour plasma glucose greater than 200mg/dl (Rosenthal & Burchum, 2018).  In a patient with symptoms of hyperglycemia, a random plasma glucose of greater than 200mg/dl is utilized to diagnose diabetes type 2 (Rosenthal & Burchum, 2018).

Treatment for Diabetes Type 2

Current treatment is to achieve optimal glucose levels without causing episodes of hyperglycemia (Huether & McCance, 2017).  A combination of medications, meal planning, and exercise regimen are important (Huether & McCance, 2017) Diabetes and Drug Treatments – NURS 6521 Discussion.  Patients with diabetes type 2 should be educated on proper nutrition.  Weight loss of 7% of body weight is recommended for all patients that are overweight or obese (Rosenthal & Burchum, 2018).  Low carbohydrate, low fat, and a calorie restricted diet is necessary (Rosenthal & Burchum, 2018).  Saturated fats should be less than 7% of total calories.  Physical activity should increase to at least 150 minutes per week and resistance training of large muscle groups should be two times a week (Rosenthal & Burchum, 2018).  Smoking cessation counseling is necessary if patient smokes.

Initial drug of choice for diabetes type 2 is metformin and the starting dosage is 500 mg orally twice a day for a non-elderly patient (Rosenthal & Burchum, 2018).  Metformin is an effective glucose-lowering agent and reduces HbA1c by 1.5% (Marshall, 2017).  Metformin does not bind to plasma proteins and is eliminated by renal tubular secretion and glomular filtration (Rosenthal & Burchum, 2018).  The half-life is six hours, but red blood cells are a second way to deliver metformin with a half-life of 17 hours (Rosenthal & Burchum, 2018).  Metformin should be taken with morning and evening meals to reduce stomach and bowel side effects (Mayo Clinic, n.d.).  Swallow the tablet with a full glass of water and do not crush, break, or chew (Mayo Clinic, n.d).  A patient may notice an improvement of blood glucose control in 1 to 2 weeks, but may take up to 2 to 3 months (Mayo Clinic, n.d).  Metformin is contraindicated for GFR less than 30 and should not be started in eGFR is between 30-45 (Rosenthal & Burchum, 2018).

Short-Term and Long-Term Impact

Symptoms of diabetes type 2 if left uncontrolled can even progress to CAD, nerve damage, kidney damage, retinopathy, wounds that are slow to heal, and cerebrovascular disease (Huether & McCance, 2017).  The short-term side effects are gastrointestinal side effects such as diarrhea and nausea which can be minimized by titrating the dose up slowly, taking medication with food, and if necessary switch to an extended release preparation (Marshall, 2017). Metformin can also cause hypoglycemia if combined with alcohol use (Marshall, 2017). Long term use of metformin might cause lactic acidosis.  Metformin is contraindicated in chronic kidney disease stage 3 and beyond (Marshall, 2017).  Long-term use of metformin can cause vitamin B-12 deficiency and may need a vitamin B12 supplement (American Diabetes Association, 2018). Diabetes and Drug Treatments – NURS 6521 Discussion.

References

American Diabetes Association. (2018).  Pharmalogic approaches to glycemic treatment: Standards of medical care in diabetes.  Diabetes Care, 41(Supplement 1), S73-S85.  Retrieved from http://care.diabetesjournal.org/content/41/supplement_1/s73.full.text.pdf

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology. (6^thed.). St. Louis, MO: Mosby.

Marshall, S. M. (2017).  60 years of metformin use: a glance at the past and a look to the future.  Diabetetologia, 60(9), 1561-1565. Retrieved from https://link.springer.com/article/10.1007/s00125-017-4343-y

Mayo Clinic (n. d.).   Retrieved from https://www.mayoclinic.org/diseases-conditions/gestational-diabetes/symptoms-causes/syc-20355339

Rosenthal, L. D., & Burchum, J. R. (2018).  Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier. Diabetes and Drug Treatments – NURS 6521 Discussion.