Discussion: Diabetes and Drug Treatments NURS 6521

            Diabetes is a widespread disease in the United States, affecting over thirty million people while affecting more people over sixty-five (“What is diabetes?,” 2016). Diabetes often can be managed by lifestyle and diet modifications, but medications may necessary to assist in managing blood glucose levels. Diabetes is an endocrine disorder that affects carbohydrate metabolism (Rosenthal & Burchum, 2021, p. 397).

Type one diabetes or juvenile diabetes and type two diabetes are the primary two diabetes diseases. Other forms are gestational diabetes, monogenic diabetes, and cystic fibrosis related diabetes (“What is diabetes?,” 2016). Type one diabetes also termed juvenile diabetes because it is diagnosed in early childhood or adolescence. The body has an autoimmune response and destroys the pancreatic B cells responsible for insulin production. Type two diabetes is the most common form and progresses gradually, where type one diabetes is abrupt. Insulin is still produced and used by the body with Type two diabetes but falls over time. Genetics, diet, lifestyle, and obesity play a significant role in the cause of type two diabetes. Gestational diabetes occurs only in pregnancy and can causes problems for the mother and the fetus.

The first-line treatment for Gestational Diabetes is lifestyle modifications with diet and exercise (Venkatesh & Landon, 2021, p. 9). The American College of Obstetricians and Gynecologists (ACOG) recommends insulin therapy as the first-line treatment for gestational diabetes control; however, metformin or glyburide is an appropriate pharmacotherapy treatment when the patient declines to take insulin (“Updated ACOG guidance on gestational diabetes,” 2021). Long-acting insulin, as NPH, can be started in the morning, at bedtime, or both and adjusted as needed depending on glucose control. Sometimes short-acting insulin, as regular, may be needed with meals to achieve better control (Venkatesh & Landon, 2021, p. 13). Insulin does not cross the placenta barrier and can lead to better perinatal outcomes related to the child or mother developing diabetes later in life (Venkatesh & Landon, 2021, p. 14). Patient education is critical because the patient needs to learn to give themselves injections, correctly check and monitor glucose levels, and store insulin in the refrigerator. Using insulin versus metformin in pregnancy remains controversial because the long-term effects of developing diabetes are not thoroughly studied  (Venkatesh & Landon, 2021, p. 12). Insulin is given subcutaneously anywhere that fatty tissue can be located on the body, like the abdomen or upper outer arm. Forms of insulin cannot be used interchangeably because some are long-acting, short-acting, and intermediate (Rosenthal & Burchum, 2021, p. 402).

Gestational diabetes requires commitment on both sides of the patient and provider. Frequent provider visits are required with insulin to obtain optimum control and prevent the patient from becoming hypo or hyperglycemic. Gestational diabetes can cause fetal macrosomia, stillbirth, high blood pressure, preeclampsia, and a higher risk for a cesarean section (“Gestational diabetes and pregnancy,” 2020). Women with gestational diabetes should have testing for diabetes four to twelve weeks postpartum (“Gestational diabetes,” 2020). One in three women with gestational diabetes will develop type two diabetes postpartum (Venkatesh & Landon, 2021, p. 15). Prepregnancy risk factors include obesity, inactivity, previous diagnosis of gestational diabetes, heart disease, and high blood pressure (“Gestational diabetes,” 2020). There can never be enough patient education which is neverending.

References

Gestational diabetes and pregnancy. (2020, July 14). Centers for Disease Control and Prevention. Retrieved July 1, 2021, from 

Gestational diabetes. (2020, December). ACOG Gestational Diabetes FAQ’s. Retrieved July 1, 2021, from 

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Nurse Practitioners and Physician Assistants (2nd ed.). Elsevier, Inc.

Updated ACOG guidance on gestational diabetes. (2021, January 4). The ObG Project. Retrieved July 1, 2021, from 

Venkatesh, K. K., & Landon, M. B. (2021). Diagnosis and Management of Gestational Diabetes: What every OB/GYN needs to know to manage this complication. Contemporary OB/GYN, 66(5), 9-15. 

What is diabetes? (2016, December 1). National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved July 1, 2021, from 

            Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia. Diabetes Mellitus is classified into different categories; Type 1 (Juvenile DM), Type 2, and gestational diabetes (Huether, McCance, Brashers, & Rote, 2017). Common clinical manifestations of DM are polydipsia, polyphagia, and polyuria

In Type 1 DM, the destruction of beta cells is related to genetic susceptibility and environmental factors. Autoimmune destruction of beta cells leads to decreased insulin secretion. The peak onset of Type 1 DM is from age 11-15 years and could be younger in girls (Huether et al., 2017). With Type 2 DM, genetic-environmental interactions lead to insulin resistance. The most common genetic-environmental contribution of Type 2 DM is obesity. Type 2 DM is commonly non-insulin-dependent. Gestational DM is glucose intolerance during pregnancy, common in women with previously undiagnosed Type 1 or Type 2 DM (Huether et al., 2017). Women with Gestational DM are at an increased risk of developing diabetes in the future.

Type 2 Diabetes Mellitus and Metformin (Glucophage)

Metformin (Glucophage) is used in the treatment and prevention of Type 2 DM. Metformin (Glucophage) is a well understood oral hyperglycemic agent with minimal side effects and low-cost efficiency (Salber, Wang, Lynch, Pasquale, Rajan, Stevens, Grady, & Kenny, 2017). Metformin (Glucophage) increases insulin sensitivity and decreases intestinal glucose absorption. The kidney eliminates Metformin (Glucophage); thus, caution should be used when prescribing to patients with renal disease due to lactic acid build-up (Vallerand, Sanoski, Deglin, & Rodenberger, 2015). Metformin (Glucophage) is also contraindicated in dehydration, sepsis, hypoxemia, and hepatic impairment. Side effects of Metformin (Glucophage) are abdominal bloating, diarrhea, nausea, vomiting, and decreased Vitamin B12 levels in the long term. The starting daily dose of Metformin (Glucophage) is 500 mg and can be increased based on clinical needs and renal function (Chung, H., Oh, Yoon, Yu, Cho, & Chung, J., 2018).

In Type 2 DM, patient teaching should include diet control, exercise, and carbohydrate monitoring. Carbohydrates are broken down to glucose, which can cause hyperglycemia in patients with DM.

Short-term and Long-term Impact of Diabetes Mellitus

The Short-term impact of Type 2 DM and Metformin (Glucophage) is hypoglycemia and hyperglycemia. Thus, medication teaching, diet control, and exercise should be included in the treatment plan. Macrovascular complications due to damaged blood vessels in the eyes, kidneys, and nerves is a long-term effect of Type 2 DM. Insulin therapy should be considered in patients who do not respond to Metformin (Glucophage) and a combination of oral Sulfonylureas after three months (Vallerand et al., 2015).

Conclusion

Type 2 DM is an endocrine disorder characterized by insulin resistance. Obesity is the most common risk factor in the development of Type 2 DM. Diet, exercise, and oral hyperglycemic agents such as Metformin (Glucophage) are used to manage Type 2 DM. Renal function should be closely monitored when patients are on Metformin (Glucophage) because of lactic acidosis. Patient education should also include signs and symptoms of hypoglycemia and hyperglycemia. Metformin (Glucophage) can be used with other antidiabetic agents based on the patient’s clinical needs.

References

Chung, H., Oh, J., Yoon, S. H., Yu, K.-S., Cho, J.-Y., & Chung, J.-Y. (2018). A non-linear pharmacokinetic-pharmacodynamic relationship of metformin in healthy volunteers: An open-label, parallel group, randomized clinical study. PLoS ONE, 13(1), 1–11. https://doi-org.ezp.waldenulibrary.org/10.1371/journal.pone.0191258

Huether, S. E., McCance, K. L., Brashers, V. L., & Rote, N. S. (2017). Understanding pathophysiology. St. Louis, Missouri: Elsevier.

Salber, G. J., Wang, Y. B., Lynch, J. T., Pasquale, K. M., Rajan, T. V., Stevens, R. G., Grady, J. J., & Kenny, A. M. (2017). Metformin Use in Practice: Compliance with Guidelines for Patients with Diabetes and Preserved Renal Function. Clinical diabetes: a publication of the American Diabetes Association, 35(3), 154–161. 

Vallerand, A. H., Sanoski, C. A., Deglin, J. H., & Rodenberger, J. (2015). Davis’s drug guide for nurses (Fourteenth edition.). F. A. Davis Company.