Respond to Mackenzie and Pearl Provide recommendations for alternative drug treatments and patient education strategies for treatment and management. At least 2 citations and references each.

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Diabetes occurs due to a disruption in carbohydrate metabolism (Rosenthal & Burchum, 2018). Lack of insulin or resistance to insulin causes the main symptom of diabetes, which is sustained hyperglycemia (Rosenthal & Burchum, 2018). Hyperglycemia can cause individuals to experience the hallmark symptoms of diabetes: polyuria, polydipsia, polyphagia, ketonuria, and weight loss (Rosenthal & Burchum, 2018).

Type 1 diabetes can occur in adulthood but is usually diagnosed in childhood or adolescence (Rosenthal & Burchum, 2018). Type 1 diabetes has an abrupt onset and is caused by an autoimmune process (Rosenthal & Burchum, 2018). Type 1 diabetes occurs because the pancreas produces little to no insulin and requires insulin as drug therapy (Rosenthal & Burchum, 2018). Type 1 diabetes was previously referred to as juvenile diabetes or insulin-dependent diabetes mellitus (IDDM) (Rosenthal & Burchum, 2018). Type 2 diabetes is becoming increasingly common in children, and many people with type 2 diabetes require insulin for drug therapy (Rosenthal & Burchum, 2018). The terms juvenile diabetes and IDDM are no longer used clinically to classify diabetes (Rosenthal & Burchum, 2018).

The onset of type 2 diabetes is gradual and typically occurs in adulthood (Rosenthal & Burchum, 2018). Type 2 diabetes is linked to a familial association (Rosenthal & Burchum, 2018). It occurs due to insulin resistance and inappropriate secretion of insulin (Rosenthal & Burchum, 2018). Type 2 diabetes can be treated by oral antidiabetic medications, insulin, or a combination of both (Rosenthal & Burchum, 2018).

Gestational diabetes (GD) can occur during pregnancy due to hormones interfering with insulin (American College of Obstetricians and Gynecologists [ACOG], 2017). Pregnancy hormones can cause insulin to be less effective, resulting in hyperglycemia. Some women can treat GD by monitoring blood sugar levels, eating a healthy diet, and exercising; however, some women require insulin (ACOG, 2017).

Insulin is the main drug therapy for individuals with type 1 diabetes (American Diabetes Association, 2018). Insulin is a high-alert medication (Rosenthal & Burchum, 2018). There are many types of insulin available with various properties. Insulin preparations cannot be used interchangeably because the risk of medical errors is extremely high (Rosenthal & Burchum, 2018). Insulin glargine (Lantus) is a modified human long-acting insulin (Rosenthal & Burchum, 2018). Lantus’ onset is approximately 70 minutes, and it lasts for 18 to 24 hours (Rosenthal & Burchum, 2018). Lantus can achieve relatively steady blood glucose levels because it does not peak (Rosenthal & Burchum, 2018). Lantus is available only with a prescription and is given by subcutaneous injection (Rosenthal & Burchum, 2018). Lantus is given once or twice daily at the same time each day and should not be mixed with other insulins (Rosenthal & Burchum, 2018). It is available in U-100 strength 10 mL vials (100 units/mL) and prefilled SoloStar pens (Rosenthal & Burchum, 2018). Lantus is clear in color (Rosenthal & Burchum, 2018).

Individuals with type 1 diabetes should be eating approximately 35 calories per kilogram of body weight, and half of the consumed calories from all food should be carbohydrates (Norman, 2019). Diabetic patients need to participate in carbohydrate counting, as it helps monitor blood glucose trends (Norman, 2019). Carbohydrate consumptions should be consistent at each meal to help control blood glucose levels when using long-acting insulin (Delahanty, 2019). Individuals can consume meals with low glycemic index and glycemic load to help provide additional glycemic control (Delahanty, 2019). High fiber diets may help control a patient’s hemoglobin A1C, and low sodium diets can help control blood pressure (Delahanty, 2019). Individuals need to remember that consuming more carbohydrates will increase blood glucose levels, which will require more insulin to control (Norman, 2019).

Type 1 diabetes can be more challenging to treat because blood glucose levels are often inconsistent (Rosenthal & Burchum, 2018). Inconsistent blood glucose levels can cause short-term effects of hypoglycemia and possibly diabetic ketoacidosis, which occurs due to a lack of insulin (Smith-Marsh, 2017). Diabetics must also be cautious of factors that may affect blood sugar levels, such as stress and exercise, and monitor levels accordingly (Delahanty, 2019).

Type 1 diabetes can have several long-term effects on patients. Diabetes can impair one’s quality of life due to its’ never-ending demands. Depression is common with diabetic individuals (American Diabetes Association, n.d.). Type 1 diabetes can cause long-term microvascular complications, resulting in eye, kidney, and nerve disease (Smith-Marsh, 2017). Cataracts, retinopathy or both can occur as a result of sustained hyperglycemia (Smith-Marsh, 2017). If diabetes is untreated, diabetic nephropathy can occur (Smith-Marsh, 2017). Diabetic neuropathy is the most common form of nerve damage and can result from damaged blood cells (Smith-Marsh, 2017). It most often affects the feet, which can be dangerous since sores on feet can easily go undetected, leading to infection (Smith-Marsh, 2017). Infections can spread, and if untreated, may result in surgery for debridement or amputation (Smith-Marsh, 2017). Type 1 diabetes can cause long-term macrovascular complications, resulting in heart disease (Smith-Marsh, 2017). Myocardial infarctions can occur due to plaque buildup; however, controlling diabetes and making heart-healthy choices, such as not smoking, controlling blood pressure, and monitoring cholesterol, can help (Smith-Marsh, 2017).

Insulin can cause complications for type 1 diabetics. Hypoglycemia can occur if insulin doses are too high or if the consumed diet was lower in carbohydrates. Persistent hypoglycemia must be treated promptly as it can cause irreversible brain damage or death (Rosenthal & Burchum, 2018). Insulin causes an enzyme to activate and pump potassium into cells and sodium out of cells (Rosenthal & Burchum, 2018). Hypokalemia can result from this action, which can cause reduced contractility of the heart and fatal dysrhythmias (Rosenthal & Burchum, 2018). Individuals administering insulin must rotate injection sites to prevent complications. Failure to rotate injection sites can result in lipohypertrophy (Rosenthal & Burchum, 2018). The excess subcutaneous fat is eventually shed when the injection site is no longer used; however, rotating injection sites could be prevented or minimized (Rosenthal & Burchum, 2018).

References

American College of Obstetricians and Gynecologists. (2017). Gestational diabetes. https://www.acog.org/patient-resources/faqs/pregnancy/gestational-diabetes

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

American Diabetes Association. (n.d.). Mental health. https://www.diabetes.org/diabetes/mental-health

Delahanty, L. M. (2019). Patient education: Type 1 diabetes and diet (Beyond the basics). In J. E. Mulder & D. M. Nathan (Eds), UptoDate. Available from

https://www.uptodate.com/contents/type-1-diabetes-and-diet-beyond-the-basics#H6

Norman, J. (2019). Treatment of diabetes: The diabetic diet. https://www.endocrineweb.com/conditions/diabetes/treatment-diabetes

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

Smith-Marsh, D. E. (2017). Type 1 diabetes complications.  https://www.endocrineweb.com/conditions/type-1-diabetes/type-1-diabetes-complications

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In the United States, there are approximately 30 million people living with diabetes, a disease that is the seventh leading cause of deaths. Furthermore, the number of adults diagnosed with diabetes has more than doubled over the last 20 years, which means the problem is very quickly becoming a national epidemic (Small et al., 2017).

Types of diabetes

Type1: this is also known as insulin independent diabetes, is a chronic condition where the beta cells in the pancreas are damages and do not produce enough insulin. This can be a result of an autoimmune dysfunction where the system attacks the pancreas causing damages to the beta cells (Huether & McCance, 2017). It can also stem from a genetic predisposition that beta cells are defective and do not produce insulin.

Type2: this is also known as non-insulin dependent diabetes. it is more common than type 1 which 95% of all diabetes varies diagnosis being type 2 diabetes . Type 2 is often associated with insulin resistance, where the beta cells do not secrete enough insulin of the body’s needs, or the body has formed a resistance to its own insulin (Huether & McCance, 2017).

Gestational: This is a condition that occurs in approximately 2 to 10% of pregnancies each year. It is a condition where a pregnant woman’s placenta secrets human placental lactogen (HPL) which causes glucose to build up in the bloodstream making the body more resistant to insulin (Huether & McCance, 2017) .

Juvenile: Juvenile diabetes is another name for type one diabetes. this mostly occurs before one gets to age 20.

Types of drug used

Insulin glargine or Lantus is a long acting insulin used to treat adults with type 2 diabetes and pediatric patients mostly children six years and older with type1 diabetes for the control of high blood sugar. It works by allowing a slow steady release of insulin over a long period of time, allowing for sustained serum glucose over a period of 18 to 26 hours (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Lantus is disposed as a liquid vial or an injectable pen device. It is a clear liquid that should be drawn up in a special unit-based syringe and given subcutaneously in an area that has adipose tissue that has been sanitized with alcohol example back of arm and lower abdomen. Needles should never be used more than once and if using the injectable pen, a new needle needs to be attached prior to each injection. Lantus is best given between meals and before bedtime, patients should monitor their blood sugar throughout the day to manage their risk of hypo/hyperglycemia (Arcangelo et al., 2017) . Before bedtime, patients taking Lantus should have a small snack to consisting of at least 4 grams of carbs to prevent hypoglycemia while they are sleeping. Lantus dosing starts at 0.2 units/kilogram once daily and increased as needed based on the patient’s blood sugar levels and A1C (Arcangelo et al., 2017).

Short term and long-term impact

Diabetes in any of its form is a serious disease complication. Short term impact of the disease can be variant levels of serum blood glucose leading to hypo and hyperglycemia. Acute hypoglycemia  under 70mg/dl can lead to low energy levels, altered levels of consciousness, and if not corrected can lead to death (Small et al., 2017). Hyperglycemia can lead to diabetic ketoacidosis (DKA), in which the body breaks down fat and produces a high number of ketones, sending the body into a dangerous state of acidosis which can be fatal (Small et al., 2017). Short term drug treatments aimed at correcting the acute blood sugar or ketone imbalances that have occurred. Glucose tablets and dextrose 50% is given in response to acute hypoglycemia. Most hospitals have a DKA protocol in order to counteract the DKA process. This usually consist of fluid resuscitation, intravenous insulin drip and electrolyte replenishment. Side effects of this treatments include serious electrolyte imbalances, for example intravenous insulin can causes serious and fatal decrease in potassium levels leading to fatal cardiac arrhythmias (Arcangelo et al., 2017).

Long term impact of diabetes stem from uncontrolled blood glucose levels over a long period of time period. High levels of glucose can start to attack the macro and microvasculature of the organs (Huether & McCance, 2017). Major effect such as blindness, neuropathy, and kidney damage all can occur due to damage to the vessels and decreased blood flow as a result of sustained high serum glucose levels. To prevent these effects from developing, the consistent levels of blood glucose within therapeutic levels needs to be maintained. Medications such as sulfonylureas, Glucophage medication and synthetic insulins are used to keep blood glucose levels maintained. Side effects from these medications can include stomach upset, lactic acidosis, and hypoglycemia.

                                                           Conclusion

Diabetes in all its types is a serious and life-threatening disease. Differences between the different types stem from how the beta cells are affected and the body’s response to insulin. Treatment of diabetes seeks to control and maintain serum blood glucose levels. Long acting insulin, such as Lantus, is used to maintain blood glucose levels over a long period of time by slowly secreting insulin over time. An important factor in treatment of diabetes is the prevention of short term and long-term impacts of the disease such as DKA and neuropathy from developing or worsening. Side effects of both short- and long-term medication treatment should be considered and monitored while the patient is being treated.

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics

For advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams

& Wilkins.

Huether, S. E., &McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis,

MO: Mosby.

Small, C., Egan, A. M., Elhadi, E. M., O’Reilly, M. W., Cunningham, A., & Finucane, F. M.

(2017). Diabetic Ketoacidosis: a challenging diabetes phenotype. Endocrinology, Diabetes

& Metabolism Case Reports. Doi: 10.1530/EDM-16-0109.

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