Diabetes and Drug Treatments
Diabetes mellitus (DM) is a disorder in the body’s metabolism characterized by altered glucose conversion into energy for cell use, defects in insulin secretion, or increased insulin resistance (Antonioli, Blandizzi, Csoka, Pacher, & Hasko, 2015). DM can occur in children and adults and is diagnosed by measuring glycosylated hemoglobin (HbA1C) levels, fasting plasma blood sugar (FPG) levels, 2-hour plasma blood sugar levels during oral glucose tolerance testing, or random blood sugar level; however HbA1C provides a more accurate and long-term measure of blood sugar control (Huether & McCance, 2017).
Types of Diabetes
Type 1 diabetes mellitus (T1DM), presents during childhood approximately before age 10, with a classic clinical onset of high blood sugar, excessive thirst, excessive urination, and weight loss resulting from an autoimmune dysfunction activating the CD4, CD8 T cell, and macrophages infiltrating the pancreas leading to chronic inflammation, pancreatic B-cell dysfunction, destruction, and death (Antonioli et al., 2015). Genetic susceptibility increases the risk of close relatives to a T1DM patient as a result of gene polymorphisms, whereas environmental exposure can trigger an immune response to genetically susceptible individuals destroying the insulin-producing B-cells in the pancreas (Levitsky & Misra, 2019).
Type 2 diabetes mellitus (T2DM) develops in genetically predisposed individuals as a result of advancing age, inactivity, and obesity resulting in high levels of blood sugar due to the body’s inability to produce insulin, use enough insulin, or use glucose for energy with signs and symptoms of fatigue, weight gain, slow healing wounds, frequent infections, visual changes, and altered sensation (Blair, 2016). Chronic-low grade inflammation, immune system activation, and infiltration in the pancreas results in B-cell dysfunction and progressively increased insulin resistance (Antonioli et al., 2015).
Gestational diabetes mellitus is high blood sugar levels with the onset or first detected during pregnancy; however according to the American Diabetes Association (ADA) (as cited by
Heather & McCance, 2017), women with gestational diabetes may have had undiagnosed pre-existing diabetes, so the ADA recommends that these women should receive a T1DM or T2DM diagnosis instead of gestational diabetes.
Metformin Administration in Type 2 Diabetes
Biguanides such as Metformin is the first line of therapy for T2DM unless contraindicated because it inhibits the liver’s glucose production and increases muscle tissue insulin sensitivity (Blair, 2016). Metformin comes in two oral preparations: a) initial adult dose for the immediate-release tablet is 500 mg orally once or twice daily or 850 mg daily; should be administered with a meal to decrease gastrointestinal (GI) upset; and gradual dosage increases usually every seven days to minimize adverse GI effects; and b) initial adult dose for the extended-release Metformin is 500 mg to 1 gram once daily with the evening meal and gradual dose titration to minimize adverse GI effects (UpToDate, n.d.). Contraindications to Metformin use are hypersensitivity to Metformin or any of its components, patients with eGFR < 30 mL/minute as it can result in lactic acidosis, acute, or chronic metabolic acidosis, and death (UpToDate, n.d.). Short-Term and Long-Term Impact of Type 2 Diabetes and Effects of Drug Treatment Short-term impact of T2DM are : a) hypoglycemia in individuals taking secretagogues such as sulfonylurea agents or exogenous insulin that requires immediate glucose replacement by mouth or intravenously; b) hyperosmolar hyperglycemic nonketotic syndrome (HHNKS), is less common but can result in high mortality rate particularly in the elderly who have comorbidities such as infections, cardiovascular, or renal disease which is characterized by very high blood sugar level resulting in severe dehydration, electrolyte imbalance, and neurologic impairment (Huether & McCance, 2017). The long-term impact of T2DM are categorized into: a) microvascular complications which are damages to small blood vessels leading to renal failure, retinopathy leading to blindness, and neuropathy leading to impotence and foot disorders; and b) macrovascular complications are damage to larger blood vessels leading to cardiovascular diseases (Blair, 2016). Monitoring recommendation for Metformin use are : a) Vitamin B12 levels every two to three years especially in individuals with peripheral neuropathy or anemia because long-term Metformin use can result in Vitamin B12 deficiency; b) initial and yearly hematologic and renal function studies; and c) Bi-annual urine glucose, fasting blood sugar, and hemoglobin A1C in patients with stable glucose control and every four months for individuals not meeting glycemic control (UpToDate, n.d.). References Antonioli, L., Blandizzi, C., Csoka, B., Pacher, P., & Hasko, G. (2015). Adenosine signaling in diabetes mellitus—Pathophysiology and therapeutic considerations. Nature Reviews Endocrinology , 11 (4), 228-. Gale OneFile: Science. Blair, M. (2016). Diabetes mellitus review. Urologic Nursing , 1 , 27. https://doi.org/10.7257/1053-816X.2016.36.1.27 Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby Levitsky, L.L., & Misra, M. (2019, June 27). Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents. In A.G. Hoppin (Ed.), UpToDate. Retrieved March 25, 2020, from https://www.uptodate.com/ Metformin: Drug information—UpToDate . (n.d.). Retrieved March 25, 2020, from https://www.uptodate.com/ Discussion: Diabetes and Drug Treatments Photo Credit: [Mark Hatfield]/[iStock / Getty Images Plus]/Getty Images 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/ 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 “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! NURS_6521_Week5_Discussion_Rubric Grid View List View Excellent Good Fair Poor Main Posting Points Range: 45 (45%) – 50 (50%) Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. Points Range: 40 (40%) – 44 (44%) Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. Points Range: 35 (35%) – 39 (39%) Responds to some of the discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors. Points Range: 0 (0%) – 34 (34%) Does not respond to the discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style. Main Post: Timeliness Points Range: 10 (10%) – 10 (10%) Posts main post by day 3 Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 0 (0%) Does not post by day 3 First Response Points Range: 17 (17%) – 18 (18%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. . Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. Points Range: 15 (15%) – 16 (16%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. . Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. Points Range: 13 (13%) – 14 (14%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. Points Range: 0 (0%) – 12 (12%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited. Second Response Points Range: 16 (16%) – 17 (17%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. . Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English. Points Range: 14 (14%) – 15 (15%) Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English. Points Range: 12 (12%) – 13 (13%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. . Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. Points Range: 0 (0%) – 11 (11%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited. Participation Points Range: 5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days. Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 0 (0%) Points Range: 0 (0%) – 0 (0%) Does not meet requirements for participation by posting on 3 different days Total Points: 100 Type 1 Diabetes Type 1 diabetes generally develops during childhood or adolescence, however type 1 can develop during adulthood (Rosenthal & Burchum, 2018). Previously called insulin dependent or juvenile diabetes, type 1 diabetes is caused by an autoimmune reaction that destroys pancreatic beta cells, which are the cells responsible for insulin synthesis and release into bloodstream. Type 2 Diabetes Type 2 diabetes accounts for 90-95% of diagnosed diabetes cases and approximately 22 million Americans have this disease (Rosenthal & Burchum, 2018). Type 2 diabetes is non-insulin dependent diabetes or also known as adult-onset diabetes mellitus. Insulin is still produced for patients with Type 2, the secretion is no longer tightly coupled to plasma glucose, which makes the release of insulin delayed and peak output is subnormal. A patient will have fasting labs and also check a hemoglobin A1C. Juvenile Diabetes An autoimmune disease where the pancreas stops producing insulin. Also, known as type 1 diabetes or insulin dependent. This is not related to lifestyle or diet. Early signs to watch for, include thirst and urination. If having symptoms, the provider will test blood levels. Gestational Diabetes Diabetes that appears during pregnancy and then subsides after delivery is gestational diabetes (Rosenthal & Burchum, 2018). You want to monitor blood glucose and make sure it is well controlled with diet and insulin if prescribed. Gestational diabetes usually shows up in the middle of pregnancy, and providers test between 24-28 weeks of pregnancy (CDC, n.d.). The medication I chose is Metformin (Glucophage). Metformin is an oral agent that decreases glucose production by the liver and increases tissue response to insulin (Rosenthal & Burchum, 2018). Metformin is started once diagnosis of type 2 diabetes is made unless contraindicated. Metformin is safe and has beneficial effects on A1C, weight management, and cardiovascular mortality (American Diabetes Association, 2018). Metformin can be used as monotherapy, unless A1C is greater than 9%, then consider dual therapy. Keeping a healthy weight is important along with diet and lifestyle changes. Drug Class: Biguanides Pharmacokinetics: Metformin is slowly absorbed from the small intestine and is not metabolized, but excreted unchanged by the kidneys (Rosenthal & Burchum, 2018). Metformin can accumulate to toxic levels. Metformin can be used in patients with mild impairment in kidney function and in some patients with moderate kidney impairment (U.S. Food & Drug, 2017). Before started, obtain patients eGFR. Not recommended in patients with a eGFR <30. Side effects: decreased appetite, nausea, and diarrhea. Severe metabolic acidosis can occur with accumulation of Metformin and patients with significant renal impairment. If a patient had any recent infection or illness they need to be aware to let the provider know and the medication might have to be stopped until feeling better. Patients admitted in the hospital are usually stopped on their Metformin and resumed after discharge. Caution patients if drink alcohol, whether its acute or chronic, because alcohol potentiates the effects of Metformin on lactate metabolism. Metformin can cause low blood sugar if patients do not eat enough, if they drink alcohol or if they take other medications that can lower blood sugar (U.S. Food & Drug, 2017). Monitoring blood glucose levels are very important when educating patients. Sarah 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: https://care.diabetesjournals.org/content/diacare/41/Supplement_1/S73.full.pdf Centers for Disease Control and Prevention. (n.d.). Gestational Diabetes and Pregnancy.Retrieved from: https://www.cdc.gov/pregnancy/diabetes-gestational.html Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier U.S. Food & Drug. (2017). FDA Drug Safety Communication: FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function. Retrieved from: https://www.fda.gov/drugs/drug- safety- and-availability/fda-drug-safety-communication-fda-revises-warnings-regarding-use-diabetes-medicine-metformin-certain response Great job on your discussion regarding Metformin and diabetes management! I did some additional research on Metformin so I could contribute and bring additional information to your chosen topic. I did my discussion post on sulfonylureas which is also an oral agent medication that can be used in the treatment of Type II Diabetes. Biguanides mechanism of action and potential side effects are different from those of sulfonylureas in that they do not usually result in hypoglycemia (when used alone) nor dot hey promote hyperinosemia or weight gain. Biguanides can be used as a first line of treatment in addition to diet and exercise or they can be combined with other oral agents or insulin. It is imperative that providers start patient’s out with a lose dose and gradually increase the dose every 1-2 weeks depending upon therapeutic goals. Metformin should be started at 500mg or 850mg daily or twice daily with a maximum dose of 2550mg. Dosing is most effective when taken before meals in the mornings and evenings (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 792). In review of dietary recommendations and the use of Metformin I was unable to find any solid evidence on whether any dietary intakes affect the use of Metformin. It is noted that while taking the medication one should refrain from high fat diets and those that include a lot of sugar as a diet that consists of high fat and sugar are defeating the purpose of the medication being taken. Metformin taken with cimetidine increases the risk for hypoglycemic events and combination therapy with the use of metformin and glucocorticoids or alcohol can increase the risk of lactic acidosis. Studies have shown that metformin treatment when combined with healthy lifestyles has a long-term effect on the management of diabetes. According to Rojas & Gomes (2013), “Diabetes incidence 10 years since DPP randomization was reduced by 34% and 18% in the lifestyle and metformin group, respectively (Rojas & Gomes, 2013). Arcangelo, V. P. (2017). Pharmacotherapeutics for Advanced Practice. Philadelphia: Wolters Kluwer. Rojas, L. &. (2013). Metformin: an old but still the best treatment for type 2 diabetes. Diabetology & Metabolic Syndrome .