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Discussion: Diabetes and Drug Treatments

NURS 6521 Discussion: Diabetes and Drug Treatments

Discussion: Diabetes and Drug Treatments

According to the Center for Disease Control (CDC) 11.3% or 37.1 million people in the United States have diabetes mellitus.  Major complications of diabetes are neuropathy, heart disease, and hypertension.  Diabetes management should be aimed at preventing short and long-term complications.

Different Types of Diabetes

Type I diabetes, also known as juvenile diabetes, because the onset commonly occurs during childhood or adolescence and is abrupt.  Type I diabetes occurs when pancreatic beta cells are damaged or destroyed.  Pancreatic beta cells produce insulin and when they are damaged or destroyed by autoimmune disease, genetic or environmental factors or viral infections insulin production becomes insufficient.  Type II diabetes commonly occurs in middle age and progresses gradually.  In Type II diabetes a combination of increased tissue resistance to insulin and impaired pancreatic insulin secretion lead to hyperglycemia.  A third type of diabetes is gestational diabetes which occurs during pregnancy and subsides rapidly following delivery.  Gestational diabetes causes high birth weights, and hyperinsulinemia in infants (Rosenthal & Burchum, 2021).

Treatment of Type I Diabetes

The mainstay of treatment for Type I diabetes is insulin.  Insulin dosing is weight-based and recommended ranges are 0.4 to 1.0 units per kilogram per day (u/kg/day) of total insulin.  Higher ends of the dosing range are needed during puberty and if the patient presents with ketoacidosis.  American Diabetes Association (ADA) recommendations for initiation of therapy in a patient who is metabolically stable is 0.5 (u/kg/day) (American Diabetes Association [ADA], 2018).

 Insulin should be administered with a meal and based on blood glucose levels, carbohydrate consumption, and activity level.  While administration of rapid onset insulin should be at meal- time, timing and administration should be individualized (ADA, 2018).

Insulin comes in many forms and prandial dosing insulin should be fast acting to reduce the risk of hypoglycemic episodes.  Humalog (insulin lispro) is a fast-acting insulin that can be administered IV, by subcutaneous injection or by a continuous subcutaneous infusion pump.    Most short acting insulin is available in a pen that is easy for patients to use correctly and conveniently by dialing the dose into the pen and then attaching a small needle and pressing it into subcutaneous tissue on the stomach, back of the arm, or fatty portion of the thigh.  Humalog has a more rapid onset and a shorter duration of action than regular human insulin so when taken with a meal the risk of hypoglycemia is reduced.  Onset is within 5 minutes and peak is usually 30 – 60 minutes after administration (Food and Drug Administration [FDA] & Eli Lilly and Company, 2012).

Short and Long-Term Impacts

Individuals who are diagnosed with Type I diabetes face short-term risks of ketoacidosis if glucose levels are not controlled, and hypoglycemic episodes related to insulin therapy (Rosenthal & Burchum, 2021, Chapter 68).  They face long-term risks of renal failure, peripheral neuropathy, hypertension, and heart disease.  Treatment with ACE inhibitors, angiotensin II receptor blockers, and statin drugs should be considered for long-term disease prevention in adult patients (Gray & Threlkeld, 2019).  Treatment with prandial insulin dosing, and balancing carbohydrate intake with activity are key to maintaining safe blood glucose levels.

Conclusion

Type I diabetes is caused by decreased or lack of insulin production and requires close management that includes insulin dosing to prevent long-term disease complications.  Humalog is a form of insulin that can be used as part of a comprehensive treatment plan to successfully treat Type I diabetes.

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References

American Diabetes Association. (2018). Pharmacologic approaches to glycemic treatment: Standards of medical care in diabetes – 2018. Diabetes Care, 41(1), 573–585. Retrieved March 30, 2022, from https://doi.org/10.2337/dc18-S008

Food and Drug Administration & Eli Lilly and Company. (2012). Humalog (insulin lispro). FDA. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf

Gray, A., & Threlkeld, R. K. (2019). Endotext [Internet]. MD Text, Inc. https://www.ncbi.nlm.nih.gov/books/NBK279012/

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier.

Differences Type I and Type II Diabetes & Pharmacological Management

Type I diabetes is an autoimmune disease specific to the pancreas.  The insulin producing beta cells located in the pancreas are attacked and destroyed by an over active immune system that falsey recognizes beta cells as a threat and continues to destroy them.  This destruction results in little to no insulin production and the onset of type I diabetes can be sudden.  As insulin is a hormone that helps to facilitate the uptake of sugar into the cells to be used for energy as well as signaling the liver to store sugar as glycogen for later use, the sugar remains in the blood stream and continues to increase as we consume more foods.  In type II diabetes, the beta cells are able to produce insulin, but the cells are not able to respond to the insulin (insulin resistance) resulting in little to no uptake of blood glucose also resulting in increased glucose serum levels.  Over time, the beta cells become exhausted in their attempts to lower serum glucose levels that they slow the production of insulin as well as these cells “wear out” over time.  This is especially true in obese patients as the body is unable to keep up with the insulin demand.  Although a hallmark feature of type II diabetes, insulin resistance can also be observed in patients with type I diabetes as well (Butler & Misselbrook, 2020).

Managing diabetes can be very difficult whether treating type I or type II diabetes.  Type I diabetes is most often managed by administering insulin along with careful and consistent blood glucose monitoring.  Medications in the drug class sodium-glucose co-transporter 2 (SGLT-2) inhibitors show promising results.  These medications block reabsorption of glucose in the kidneys by increasing urinary excretion.  They also help to protect the kidneys and beta cells as well as assist in beta cell regeneration.  Weight loss and reduced blood pressure may also be seen with this medication which is beneficial in managing type I diabetes as well.  The con of this medication is that it increases the risk of developing diabetic ketoacidosis if the body does not get enough insulin thus not enough glucose is processed for energy and the body starts to burn fat which is then turned into ketones by the liver.  These ketones in turn reduce the pH of the blood creating an emergent situation.  The peptide anorectic hormone amyline works directly with insulin and is responsible for the secretion of glucagon and insulin.  It is available as an analogue injectable in the synthetic form called pramlintide and helps to control blood sugar levels and appetite by slowing the motility of food (Otto-Buczkowska & Jainta, 2018).

Classes of Drugs used in Type II diabetes Management

Type II diabetes has several treatment options as well based on a non-insulin approach.  The first-line treatment for type II is an oral hypoglycaemic agent (OHL) class of biguanide metformin.  The second class of OHL are the sulfonylureas (SUs).  Thiazolidineiones (TZDs) were introduced in the 1990’s but many were pulled from the market due to the potential to cause liver failure.  Pioglitazone is the TZD most commonly prescribed today.  A class of drugs whose main emphasis is on the gut belongs to a group of anti-hyperglycemic agents called incretin.  The development of dipeptidyl-peptidase inhibitors led to the use of glucagon-like peptide-1 receptor antagonists or GLP-1 (Blaslov et al., 2018).

Treating Type II Diabetes with Biguanides

In treating type II diabetes, antidiabetic biguanides are the first-line drug of choice and are the first medications most often prescribed for type II diabetics.  One such medication metformin belongs to this class of drugs.  This medication is available as a tablet as well as a solution and is taken orally.  The liquid is taken with meals one to two times daily, the regular tablet is taken two to three times daily with meals, and the extended release is taken with a meal once daily and has been noted to cause less gastrointestinal upset such as diarrhea.  Dosing is usually initiated at 500 mg twice daily or 850 mg once daily.  Metformin can build up in the kidneys if there they are not functioning properly therefore careful monitoring is needed in patients with reduced kidney function (Ibrahim et al., 2021).

Biguanides such as metformin, are not metabolized and are excreted in the urine through tubular secretion (kidneys).  Cation transporters distribute the medication to tissues.  The OCT2 gene is responsible for the uptake of metformin from the body’s circulation and then into renal cells.  Metformin suppresses glucose production in the liver through gluconeogenesis while signaling the body to make more insulin and increasing the uptake of glucose into the cells.  It does not cause hypoglycemia as it there is no endogenous insulin secretion stimulation (Zake et al., 2021).

Dietary Considerations & Short-term and Long-term Impacts of Type II Diabetes

Diet is definitely very important in the management of type II diabetes.  Monitoring sugar intake and keeping body fat at a healthy level is vital for controlling this disease.  Excess sugar not only overworks beta cells it also causes narrowing of blood vessels by decreasing the elasticity resulting in reduced blood flow and decreased oxygen levels.  This can lead to neuropathy, heart attacks, stroke, and premature death.  Medications can also cause complications in that many are damaging to the liver and kidneys as the medication is excreted along with sugar.  Managing diet along with routine visits and labs are all crucial in both preventing and controlling diabetes.  Eating foods high in fiber along with unprocessed foods, and exercise are great ways to fight back (Forouhi et al., 2018).

References

Blaslov, K., Naranđa, F. S., Kruljac, I., & Renar, I. P. (2018). Treatment approach to type 2 diabetes: Past, present and future. World Journal of Diabetes9(12), 209–219. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304295/

Butler, A., & Misselbrook, D. (2020). Distinguishing between type 1 and type 2 diabetes. British Medical Journal, 370. Retrieved from https://www.researchgate.net/publication/343583965_Distinguishing_between_type_1_and_type_2_diabetes

Forouhi, N. G., Misra, A., Mohan, V., Taylor, R., & Yancy, W. (2018). Dietary and nutritional approaches for prevention and management of type2 diabetes. British Medical Journal, 361. Retrieved from https://www.bmj.com/content/361/bmj.k2234

Ibrahim, M., Morley, M. D., Ding, H., & Triggle, C. R. (2021). A critical review of the evidence that metformin is a putative anti-aging drug that enhances healthspan and extends lifespan.  Frontiers in Endocrinology, 12, n. p. Retrieved from https://www.frontiersin.org/articles/10.3389/fendo.2021.718942/full

Otto-Buczkowska, E, & Jainta, N. (2018). Pharmacological treatment in diabetes mellitus type 1- Insulin and what else? International Journal of Endocrinology and Metabolism, 16(1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903388/

Zake, D. M., Kurlovics, J., Zaharenko, L., Komasilovs, V., Klovins, J., & Dtalidzans, E. (2021). Physiologically based metformin pharmacokinetics of  mice and scale-up to humans for the estimation of concentrations in various tissues. Plos One, 16(4), n. p. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249594

The four categories of diabetes mellitus are type 1, type 2, gestational, and other specified types. Type 1 diabetes results from the destruction of pancreatic beta cells and requires daily dosing with insulin. This is caused by an autoimmune or idiopathic response. Type 2 is the most common form of diabetes and accounts for 90-95% of all diagnosed cases (Rosenthal & Burchum, 2021). Type 2 usually results from insulin resistance and inappropriate insulin secretion. At one point type 1 diabetes was termed juvenile- onset as it was thought to occur solely in young children. Type 1 is now known to develop in adulthood as well and type 2 is becoming more common in children. Although both type 1 and type 2 carry signs and symptoms, they differ in etiology, prevalence, treatments, and outcomes (Rosenthal & Burchum, 2021). In gestational diabetes, insulin requirements physiologically increase during pregnancy. The increase in insulin demand is due to increased maternal caloric intake, maternal weight gain, presence of the placental hormones such as placental growth hormone, and placental lactogen, as well as increased prolactin and growth hormone production (Lende & Rijhsinghani, 2020). As pregnancy advances, the pancreatic beta cell mass increases to keep up with the demand for increased insulin. Failure of the beta cell expansion with a relative inadequate rise in insulin secretion leads to gestational diabetes ( McMcance & Heuther, 2019).

Insulin is the preferred treatment for control of hyperglycemia in patients with gestational diabetes. Insulin is a large molecule and does not cross the placenta. In patients unable to take insulin, oral hypoglycemic agents can be considered. Metformin is preferred over glyburide due to the risk of possible fetal hypoglycemia associated with maternal administration of glyburide. Typically, the dose of oral medications is once or twice a day. Metformin and glyburide have been shown to cross the placenta and into the fetus. Oral medications have not been adequately studied for possible long-term effects on neonatal outcomes, and therefore they are not recommended as the first choice in treatment for persistent hyperglycemia in gestational diabetic patients (Lende & Rijhsinghani, 2020).

One complication of insulin treatment is hypoglycemia unawareness. Hypoglycemia occurs when insulin levels exceed insulin needs. The more a patient experiences hypoglycemia, they begin to have diminished symptoms over time (Rosenthal & Burchum, 2021).  Frequent blood glucose monitoring minimizes the risk for this complication. When therapy is successful, both hyperglycemia and hyperglycemia are minimized and the patient is actively involved in their own therapy. To reach optimal glucose control, dosage must be closely matched with insulin needs (Rosenthal & Burchum, 2021).

                                                                References

Lende, M., & Rijhsinghani, A. (2020). Gestational Diabetes: Overview with Emphasis on Medical Management. International Journal of Environmental Research and Public Health17(24). https://doi-org.ezp.waldenulibrary.org/10.3390/ijerph17249573

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier Health Sciences.

Rosenthal, L., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier Health Sciences.

Diabetes and Drug Treatments

Each year, 1.5 million Americans are diagnosed with diabetes (American Diabetes Association, 2019). If left untreated, diabetic patients are at risk for several alterations, including heart disease, stroke, kidney failure, neuropathy, and blindness. There are various methods for treating diabetes, many of which include some form of drug therapy. The type of diabetes as well as the patient’s behavior factors will impact treatment recommendations.

For this Discussion, you compare types of diabetes, including drug treatments for type 1, type 2, gestational, and juvenile diabetes.

Reference: American Diabetes Association. (2019). Statistics about diabetes. Retrieved from http://diabetes.org/diabetes-basics/statistics/

Resources

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

To Prepare:

  • Review the Resources for this module and reflect on differences between types of diabetes, including type 1, type 2, gestational, and juvenile diabetes.
  • Select one type of diabetes to focus on for this Discussion.
  • Consider one type of drug used to treat the type of diabetes you selected, including proper preparation and administration of this drug. Then, reflect on dietary considerations related to treatment.
  • Think about the short-term and long-term impact of the diabetes you selected on patients, including effects of drug treatments.

By Day 3 of Week 5

Post a brief explanation of the differences between the types of diabetes, including type 1, type 2, gestational, and juvenile diabetes. Describe one type of drug used to treat the type of diabetes you selected, including proper preparation and administration of this drug. Be sure to include dietary considerations related to treatment. Then, explain the short-term and long-term impact of this type of diabetes on patients. including effects of drug treatments. Be specific and provide examples.

By Day 6 of Week 5

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different type of diabetes than you did. Provide recommendations for alternative drug treatments and patient education strategies for treatment and management.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post

 

The four categories of diabetes mellitus are type 1, type 2, gestational, and other specified types. Type 1 diabetes results from the destruction of pancreatic beta cells and requires daily dosing with insulin. This is caused by an autoimmune or idiopathic response. Type 2 is the most common form of diabetes and accounts for 90-95% of all diagnosed cases (Rosenthal & Burchum, 2021). Type 2 usually results from insulin resistance and inappropriate insulin secretion. At one point type 1 diabetes was termed juvenile- onset as it was thought to occur solely in young children. Type 1 is now known to develop in adulthood as well and type 2 is becoming more common in children. Although both type 1 and type 2 carry signs and symptoms, they differ in etiology, prevalence, treatments, and outcomes (Rosenthal & Burchum, 2021). In gestational diabetes, insulin requirements physiologically increase during pregnancy. The increase in insulin demand is due to increased maternal caloric intake, maternal weight gain, presence of the placental hormones such as placental growth hormone, and placental lactogen, as well as increased prolactin and growth hormone production (Lende & Rijhsinghani, 2020). As pregnancy advances, the pancreatic beta cell mass increases to keep up with the demand for increased insulin. Failure of the beta cell expansion with a relative inadequate rise in insulin secretion leads to gestational diabetes ( McMcance & Heuther, 2019).

Insulin is the preferred treatment for control of hyperglycemia in patients with gestational diabetes. Insulin is a large molecule and does not cross the placenta. In patients unable to take insulin, oral hypoglycemic agents can be considered. Metformin is preferred over glyburide due to the risk of possible fetal hypoglycemia associated with maternal administration of glyburide. Typically, the dose of oral medications is once or twice a day. Metformin and glyburide have been shown to cross the placenta and into the fetus. Oral medications have not been adequately studied for possible long-term effects on neonatal outcomes, and therefore they are not recommended as the first choice in treatment for persistent hyperglycemia in gestational diabetic patients (Lende & Rijhsinghani, 2020).

One complication of insulin treatment is hypoglycemia unawareness. Hypoglycemia occurs when insulin levels exceed insulin needs. The more a patient experiences hypoglycemia, they begin to have diminished symptoms over time (Rosenthal & Burchum, 2021).  Frequent blood glucose monitoring minimizes the risk for this complication. When therapy is successful, both hyperglycemia and hyperglycemia are minimized and the patient is actively involved in their own therapy. To reach optimal glucose control, dosage must be closely matched with insulin needs (Rosenthal & Burchum, 2021).

References

Lende, M., & Rijhsinghani, A. (2020). Gestational Diabetes: Overview with Emphasis on Medical Management. International Journal of Environmental Research and Public Health17(24). https://doi-org.ezp.waldenulibrary.org/10.3390/ijerph17249573

McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier Health Sciences.

Rosenthal, L., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier Health Sciences.