The population of patients in my direct care typically have coronary artery disease
Discussion Post
The population of patients in my direct care typically have coronary artery disease. Since diabetes is a risk factor for cardiovascular disease, patients with diabetes benefit from Metformin. Studies have shown that Metformin can improve lipids, decrease oxidated stress, and improves platelet and endothelial function (Zhang et al., 2020). Surprisingly, Metformin could also reduce blood pressure, another risk factor for cardiovascular disease.
The two main forms of diabetes are Type 1 and Type 2. In type 1 diabetes, no insulin is produced by the by the pancreas, and the b-cells are destroyed. This form of diabetes is typically diagnosed during childhood or adolescence. The rationale is still unknown, but environment and genetics are known to play a role. Type 2 diabetes means there is insulin resistance and a gradual insulin deficiency. This type accounts for 90-95% of all cases. Type 2 can occur in all age and a strong familial competent exists. Gestational diabetes occurs during pregnancy and subsides shortly after delivery. Mothers with gestational diabetes are prone to having large babies and elevated blood pressure. Treatment is evaluating and monitor diet, exercise and at time insulin or Metformin is prescribed. Juvenile diabetes is now considered Type 1 diabetes.
Metformin is used to treat Type 2 diabetes showing clear benefits in glucose metabolism. Treatment with Metformin usually begins once diagnosed and may be used alone or in combination with another agent. Metformin works in three different ways. It inhibits glucose production in the liver, sensitizes insulin receptors in fat and skeletal muscle, and reduces glucose absorption in the gut (Rosenthal & Burchum, 2021). One significant difference with Metformin in comparison to sulfonylureas, it does not stimulate insulin release; therefore, the risks of hypoglycemia are low. Metformin is slowly absorbed and does not metabolize in the liver. Instead, it is excreted by the kidneys. Therefore, caution should be taken with patients with renal failure. The most common side effects are gastrointestinal disturbances. Nausea, diarrhea, and poor appetite can occur. Patients are encouraged to take Metformin with food, and if side effects do occur, the dose can be titrated to the point where GI disturbances are minimized.
References
Juvenile diabetes foundation international/the diabetes research foundation. (2018). The Grants Register 2019, 444–445. https://doi.org/10.1007/978-1-349-95810-8_712
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistant (2nd ed.) St. Louis, MO: Elsevier.
Zhang, K., Yang, W., Dai, H., & Deng, Z. (2020). Cardiovascular risk following metformin treatment in patients with type 2 diabetes mellitus: Results from meta-analysis. Diabetes Research and Clinical Practice, 160, 108001. https://doi.org/10.1016/j.diabres.2020.10800
SECOND POST
Type 1 Diabetes Mellitus (T1DM)/Juvenile Diabetes
Type 1 Diabetes Mellitus (TIDM), also known as insulin-dependent diabetes mellitus or juvenile diabetes, arises when there is a cellular-facilitated autoimmune response that destroys pancreatic β cells, resulting in a definite absence endogenous insulin production and availability (Holt, 2017). The pathogenesis of T1DM creates the requirement of a replacing endogenous insulin with pharmacological external insulin to meet body constraints for survival (Otto-Buczkowska & Jainta, 2017). T1DM used to mean an almost certain death soon after its onset; however, after the origination of pharmacological insulin therapy, a remarkable increase in survival followed (Holt, 2017). Patients and their families can have anxiety related to drastic lifestyle changes necessary for glycemic control. Careful teaching regarding signs and symptoms of hyperglycemia and hypoglycemia, techniques for monitoring blood glucose levels and the subsequent dietary and pharmacologic adjustments are necessary to enable patients and their families to manage diabetes successfully.
Long & Short-Term effects of disease
Microvascular and macrovascular chronic diabetes problems begin to effect systems of the body after enduring T1DM for 10 years, and after about 30 years of age cardiovascular complications become increasingly apparent (Holt, 2017). Education should be provided regarding the impact of glucose control on the kidney function, vision, and vascular circulation to help patients comprehend the severity of the disease process and encourage active participation and decrease risk of increased mortality and morbidity
Pharmacological options
Insulin lispro, a rapid acting insulin replacement, can be used by injection prior to and immediately after eating (Otto-Buczkowska & Jainta, 2017). Having a rapid acting medication is preferable when glucose levels fluctuate frequently. Having the capability to provide insulin following a meal is helpful for parents of young children with T1DM, as the quantity of carbohydrates consumed at a meal can be unpredictable (Otto-Buczkowska & Jainta, 2017). Hypoglycemia is the primary concern when administering insulin medication. Patients should keep glucose replacement options available and recognize the signs of hypoglycemia.
Dietary/ Lifestyle Considerations
T1DM requires frequent blood glucose monitoring to ensure that glucose levels remain within a therapeutic range as levels can rapidly fluctuate (Rosenthal & Burchum, 2021). Patients should be educated on the use of complex carbs vs simple carbs in their diet. Patients will have to monitor levels carefully with the addition of exercise as it can increase risk of hypoglycemia (Rosenthal & Burchum, 2021). This can affect participation in athletic programs in the school and impact the safety of the child.
Type 2 Diabetes Mellitus (T2DM)
Patients with Type 2 Diabetes Mellitus (T2DM) have insulin insufficiency; they may have the capability to secrete insulin, but the levels are not sufficient to conquer insulin resistance (Holt, 2017). Many patients can make simple lifestyle alterations and use oral antidiabetic medications to sustain glycemic management; however numerous patients become insulin-dependent over the course of the disease process due to chronic overworking of β -cells (Holt, 2017). The connection between genetic predisposition, the promotion of convenience food and inactive lifestyles, as well as the increased aging of the overall population, is a large factor increasing in the incidence of diminished glucose tolerance and T2DM worldwide (Holt, 2017). Encouraging healthy diets to eliminate excess weight is key to reducing the severity of this disease.
Long & Short-Term effects of disease
Patients with diabetes have a four times higher likelihood of developing cardiovascular disease compared to patients without diabetes (Gurnon, 2018). Microvascular and Macrovascular damage are fundamently responsible for the long-term effects of T2DM. Neuropathy is common complaint especially in the lower extremities and can pose an increased risk of complications to feet as patients may not feel pain indicating there is an issue and leave the problem untreated. Renal failure is also a frequent concern and can have effects on other disease processes as the patient may have difficulty eliminating the medications necessary for treatment. Half of all patients who require dialysis have a medical history of diabetes (Gurnon, 2018). Patients with T2DM should have regular vision screening for retinopathy to prevent vision loss. Skin conditions such as fungal or bacterial infections are heightened in patients with T2DM (Gurnon, 2018). Uncontrolled diabetes can also prevent effective wound healing presenting a higher probability of infection and possible amputation.
Pharmacological options
Metformin (Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet), is the primary medication initiated at the onset of T2DM (Rosenthal & Burchum, 2021). The most frequent side effects are gastrointestinal troubles. To reduce the symptoms of nausea, heartburn, diarrhea, and abdominal pain the patient can take the medication with food.
Dietary/Lifestyle Considerations
There is a substantial benefit to incorporating rigorous multifactorial changes to reduce mortality and cardiac complications (Holt, 2017). Simply prescribing Metformin is not as effective as combining metformin with lifestyle changes. Patients who combine weight loss with increased exercise may halt the advancement to chronic diabetes (Holt, 2017). As most patients with T2DM are overweight or obese, the primary focus should be on altering diet and increasing exercise which should dramatically help with glucose control. Patients should also be instructed to routinely check their feet for injury and immediately follow up with their primary physician if injury is noted.
Gestational diabetes (GDM)
Gestational diabetes (GDM) is a condition recognized during pregnancy of glucose intolerance derived from carbohydrate digestion that results in hyperglycemia (Holt, 2017). Pregnant women are usually diagnosed when they go in for a glucose tolerance test during pregnancy and may have never had issues with glycemic control prior to diagnosis. Risk factors for GDM include advanced age at pregnancy, obesity, GDM identified during a preceding pregnancy, history of larger than average infants at birth, and a family history of diabetes (Holt, 2017).
Long & Short-term effects of disease
Hyperglycemia may resolve after the delivery; however, up to 10 percent of patients may continue to experience diabetes and are then classified as T2DM and will require treatment with lifestyle changes and appropriate hypoglycemic agents (Holt, 2017). Women who have unresolved diabetes at birth are subject to the same long-term effects as those with T2DM. Ineffective glycemic control can cause the infant to be larger and weigh heavier at birth imposing risks of complications for mother and child and possible necessity of cesarean birth. Cardiac complications can present as hypertension or preeclampsia.
Pharmacological options
Many patients with GDM prefer to try antidiabetic agents with diet and exercise prior to insulin use as it is less likely to cause hypoglycemia and is less invasive. Glyburide has a comparable success rate in accomplishing targeted glucose levels, positive pregnancy results, and considerably less hypoglycemic incidents than insulin (Alfadhli, 2015). Possible side effects include hypoglycemia, constipation, epigastric fullness, nausea, and heartburn (Rosenthal & Burchum, 2021). Patients can take medication with food if GI upset occurs. Patients should be careful when taking antacids with Glyburide as they can enhance pharmacokinetics of drug leading to an increased risk of hypoglycemia.
Dietary/Lifestyle Considerations
Most patients with GDM can satisfactorily handle their glucose levels with diet modifications and exercise (Alfadhli, 2015). This is wonderful for patients who are hesitant in beginning pharmacological treatment for diabetes and requires compliance on their part to actively participate in glucose management. Patients should carefully monitor their blood glucose regularly to make sure that the glycemic goals set by provider are met with the alterations in diet and exercise and notify provider if blood glucose is uncontrolled so that pharmacological therapy can be started.
References
Alfadhli E. M. (2015). Gestational diabetes mellitus. Saudi medical journal, 36(4), 399–406. https://doi.org/10.15537/smj.2015.4.10307
Gurnon, E. (2018, December 18). What to know about long-term diabetes complications. Next Avenue. Retrieved March 29, 2022, from https://www.nextavenue.org/long-term-complications-diabetes/
Holt, R. I. G. (2017). Textbook of diabetes (Fifth edition.). Wiley Blackwell.
Otto-Buczkowska, E., & Jainta, N. (2017). Pharmacological treatment in diabetes mellitus type 1 – Insulin and what else?. International journal of endocrinology and metabolism, 16(1), e13008. https://doi.org/10.5812/ijem.13008
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
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