Diabetes and drug treatments peer answers

Peer #1

Nicholette Thomas

Types of diabetes:

          Type 1 diabetes only accounts for 5% of diabetes cases and is usually diagnosed in childhood or adolescent ages (Rosenthal & Burchum, 2017). In type 1, the body destroys its own pancreatic beta cells through an autoimmune process. For this reason, no insulin can be produced innately, hence why it is known as insulin-dependent diabetes (Rosenthal & Burchum, 2017). Juvenile diabetes used to be used interchangeably with the term Type 1 diabetes, although the incidence of children developing type 2 diabetes is on the rise as well as the correlated rates of childhood obesity (Valaiyapathi et al., 2020).  

           Type 2 diabetes, which will be the main focus of this discussion, is usually diagnosed after the age of 40, and while there is a large hereditary component, it is often brought on largely by modifiable risk factors such as obesity, poor diet and sedentary lifestyle (Rosenthal & Burchum, 2017). It is characterized by the development of insulin resistance within target tissues such as the liver and adipose tissue, as well as an impaired or delayed secretion of insulin (Rosenthal & Burchum, 2017). Diagnosis of diabetes can include a combination of different tests including a fasting plasma glucose (FPG) of greater than 126 mg/dL, a random glucose of greater than 200, an oral glucose tolerance test (OGTT) of greater than 11, and an A1c of greater than 6.5% (Quattrocchi et al., 2020). It is important to note that other conditions can affect the hgb A1c as well, such as sickle cell, anemia, blood transfusions, dialysis and pregnancy (Quattrocchi et al., 2020). Therefore, multiple tests should be performed and possibly repeated before making a definitive diagnosis.

          Gestational diabetes is brought on by pregnancy and subsides rapidly after the birth of the child (Rosenthal & Burchum, 2017). It can be difficult to control due to elevated cortisol levels during pregnancy, other placental hormones that can antagonize the actions of insulin, and also due to the ability of glucose to freely get into the blood of the fetus (Rosenthal & Burchum, 2017). For this reason, blood glucose levels often need to be checked six to seven times per day and be correlated properly with meals / amount of carbohydrates to avoid harm to the fetus. Diet and insulin are utilized primarily to treat this type of diabetes (Rosenthal & Burchum, 2017).  

Drug Therapy: Metformin

          There are many different types of oral medications and different types of insulin that can be used to manage diabetes. Each class of oral medications works differently in the body to help lower blood sugar. A stepwise approach for managing diabetes, especially alongside different comorbidities such as heart disease and CKD should be implemented, as noted by the recommendations by the ADA, which I will link the updated 2023 articles for standards of care for pharm management under the references listed below. For the purpose of this discussion, we will focus on Metformin. This drug belongs to a class called 
biguanides. This oral medication is used in type 2 diabetes and is typically more helpful and safer than other types of oral medications used for diabetes, as it does not directly increase insulin secretion in b-cells of pancreas like other oral meds such as sulfonylureas do (Rosenthal & Burchum, 2017). In other words, it somewhat coincides with how much you eat, and has a lower risk of hypoglycemic episodes. However, patients with renal impairment cannot take Metformin, as it is wholly extracted through the kidneys and can rapidly accumulate to toxic levels (Rosenthal & Burchum, 2017). This is unfortunate, as there are many patients out there who have both diabetes and renal impairment or diabetic nephropathy. In fact, almost half of those who are diagnosed with chronic kidney disease come from those also diagnosed with diabetes (Trikkalinou et al., 2017). Elderly patients also have a high incidence and risk of renal impairment, therefore this medication should be used with caution in the elderly and routine BUN/creatinine levels should be monitored with its use (Rosenthal & Burchum, 2017).  

Short and Long Term Effects of Type 2 Diabetes:

          Type 2 diabetes has many effects on the body, some of which can be lethal if not managed properly. There are very poor outcomes associated with having too low or too high of blood sugar. Hypoglycemia can lead to seizures, coma, irreversible brain damage, and death (Rosenthal & Burchum, 2017). Hyperglycemia can lead to DKA (more common in type 1) or hyperosmolar hyperglycemic syndrome or HHS (more common in Type 2). Having a blood glucose level of greater than 600 for an extended period of time puts one at a very high risk of developing HHS (Trikkalinou et al., 2017). It is important to educate patients and families on the signs and symptoms of these occurrences, such as excessive thirst, confusion, lethargy, and excessive urination (Trikkalinou et al., 2017). Some potential long-term effects of type 2 diabetes include diabetic retinopathy, nephropathy, and neuropathy (Rosenthal & Burchum, 2017). These conditions and comorbidities can be managed and prevented with the help of proper blood sugar control, patient education, monitoring and follow-ups. There are many different drug therapies to consider but what is most important is assessing the patient’s ability and willingness to comply with the treatment regimen. For example, insulin pumps and CGM devices can be very helpful but also very expensive, and elderly patients may be unable to understand the technology associated with it. Furthermore, certain insulin injection options like Tresiba and Toujeo have an ultralong duration of greater than 24 hours and can minimize the number of injections needed per day, however these pens are very expensive, and one may not be able to afford them, much less be able to comply with the consistent-carb diet needed to maintain blood sugar levels without risking hypoglycemia.

 

References:

 

Rosenthal, L., & Burchum, J. (2017). 
Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.

 

Quattrocchi, E., Goldberg, T., & Marzella, N. (2020). Management of type 2 diabetes: consensus of diabetes organizations. 
Drugs in context, 
9, 212607. 

https://doi.org/10.7573/dic.212607Links to an external site.

 

Trikkalinou, A., Papazafiropoulou, A. K., & Melidonis, A. (2017). Type 2 diabetes and quality of life. 
World journal of diabetes, 
8(4), 120–129. 

https://doi.org/10.4239/wjd.v8.i4.120Links to an external site.

   

Valaiyapathi, B., Gower, B., & Ashraf, A. P. (2020). Pathophysiology of Type 2 Diabetes in Children and Adolescents. 
Current diabetes reviews, 
16(3), 220–229. 

https://doi.org/10.2174/1573399814666180608074510

Peer #2

Sonia Lizet Molina

Diabetes mellitus (DM) is a widely examined disorder characterized by increased insulin resistance, secretion defects, and altered glucose conversion into energy for cell use. The US has over 30 million DM cases, doubling over the past two decades, meaning DM is a critical concern emerging as a national epidemic (American Diabetes Association, 2019). DM affects adults and children, with a diagnosis involving glycosylated hemoglobin (HbA1C) and fasting plasma blood sugar (FPG) measurement. Nevertheless, measuring HbA1C is the most effective diagnostic approach, providing accurate and long-term blood sugar control measurements.

Type 1 and 2 DM are the primary DM types (Rosenthal & Burchum, 2021). T1DM mainly emerges during childhood and comprises five percent of DM cases. T1DM’s main component encompasses pancreatic beta cells being destroyed; these cells carry out insulin production, meaning T1DM patients have significantly reduced insulin levels, which can reduce to zero in some cases. Comparatively, T2DM encompasses the most prevalent DM type globally; it usually occurs in adulthood. Juvenile diabetes encompasses T2DM in childhood; it is increasingly becoming a critical global health concern. Additionally, Gestational DM emerges during pregnancy; academic literature shows that women with gestational DM have preexisting but undiagnosed DM. Thus, patients should receive a T1DM or T2DM diagnosis.

In treating T2DM, academic and practitioner literature recommend biguanides as the first line of pharmacological intervention. In this context, Metformin is recommended, with oral preparation encompassing an immediate-release tablet (850mg daily) (Rosenthal & Burchum, 2021). Contraindication encompasses liver glucose production inhibition and muscle tissue hypersensitivity. T2DM’s long term impact encompasses macro- and microvascular complications, including damage to small and large blood vessels (Chatterjee et al., 2017).

References

American Diabetes Association. (2019). 9. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes—2019. Diabetes care, 42(Supplement_1), S90-S102.

Chatterjee, S., Khunti, K., & Davies, M. J. (2017). Type 2 diabetes. The Lancet, 389(10085), 2239-2251.

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