Discussion: Diabetes and Drug Treatments NURS 6521
Discussion: Diabetes and Drug Treatments NURS 6521
Discussion: Diabetes and Drug Treatments NURS 6521
DIABETES AND DRUG TREATMENTS
Diabetes mellitus (DM) is a significant risk factor for retinopathy, neuropathy, stroke, cardiovascular disease, and renal failure. It affects 1.5 million Americans annually (American Diabetic Association 2019). Furthermore, The International Diabetes Foundation Atlas has predicted a worldwide increase of 642 million people to be affected by 2040 (Ogurtsova et al., 2017). However, drug therapy, diet, and exercise can control and treat it. This discussion will compare the different types of DM, describe the treatment for gestational diabetes using drug therapy, the dietary considerations, and the short- and long-term effects of gestational diabetes.
Different types of diabetes
The types of DM are Type 1, Type 2, gestational, and juvenile diabetes. The underlying pathophysiology of Type 1 DM (T1DM), previously known as insulin-dependent diabetes or juvenile-onset diabetes, is an autoimmune disease resulting from beta-cell destruction due to the body’s immune system attacking the insulin-producing cells of the pancreatic islets, producing little or no insulin. Although the exact cause is unknown, genetic and environmental factors play a significant role (Saberzadeh-Ardestani et al., 2018). It typically presents among adolescence of both sexes, with its peak onset around puberty; however, it can occur at any age.
Type 2 DM (T2DM), previously known as non-insulin dependent diabetes or adult-onset diabetes, is a condition in which the pancreas produces insulin, resulting in elevated glucose levels. Still, the body develops a resistance to the effects of insulin, resulting in a small amount of insulin to meet the body’s needs. As the disease progresses, the insulin-producing ability of the pancreas decreases (Brutsaert et al., 2022).
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Gestational diabetes mellitus (GDM) is a metabolic disorder that affects the mother and fetus during pregnancy, usually occurring in the second and third trimesters. It can develop in overweight insulin-resistant women or relatively thin insulin-deficient women. The contributing risk factors include obesity, uncontrolled weight gain, advanced gestational age, previous diabetic history of parents, and a sedentary lifestyle. It increases perinatal mortality and morbidity (Sharma et al., 2022). Within this disease process, chronic glucose intolerance corresponds to insulin resistance putting women with GDM at increased risk of T2DM in the future.
Treatment for gestational diabetes
A treatment plan is needed to safeguard both the mother and the fetus, with targeted drug delivery to the placenta having minimal side effects. Monitoring blood glucose levels, controlling the level, and managing complications are crucial to treatment (Friel 2022). Insulin is the drug of choice as it does not cross the placenta and provides predictable glucose control. Human insulin is used in some as it minimizes antibody formation. All pregnant women with TIGDM should have glucagon kits, and family members must be instructed on administering glucagon in severe hypoglycemia. For women with T2DM before pregnancy, insulin is most often preferred. If glucose levels remain above target values, treatment with metformin or glyburide can be used. Metformin has recently been introduced as a more user-friendly alternative to insulin. Metformin suppresses hepatic glucose production and is absorbed from the small intestine and excreted by the kidneys with no risk of hypoglycemia (Kattini, Kelly & Hummelen, 2023). The immediate-release dose is 500mg BID with breakfast and dinner, and the extended-release dose is 500mg once daily with dinner.
Along with medical treatment implementing lifestyle changes, nutritional therapy, physical activity, and weight management is vital. Adequate caloric intake is needed to promote fetal/maternal health. Dietary carbohydrates found in glucose, sucrose, and cooked starches found in pasta, potatoes, and white bread get digested quickly and absorbed in the small intestine, rapidly increasing blood glucose. The food should be based on nutrition assessment with guidance from Dietary Reference Intakes such as reduced carbohydrates as it impacts glucose levels, eating three small-sized meals with a snack or two during the day, limiting fats, avoiding trans fats, eating vegetables which also provide carbohydrates to the body and ideally consuming 175 g of carbohydrates, 71 g of proteins, and 28 g of fibers in a diet plan (Mustad et al., 2020).
Short-Term and long-term effects of GDM
With GDM, there is a risk of the fetus having a large gestational age birth weight, the mother having the risk for pre-eclampsia, and potentially a cesarean section delivery method. The fetus could have macrosomia, shoulder dystocia, congenital birth defects, hypoglycemia at birth, and risks of stillbirth (Christian et al., 2018). There is an increased risk of long-term maternal T2DM with a possibility of GDM in future pregnancies, and the offspring will have abnormal glucose metabolism and impaired glucose tolerance in childhood and obesity (Lowe et al., 2019).
Conclusion
DM is a metabolic disorder that constantly rings medical and self-management strategies to restrict complications of the disease process. Early diagnosis of GDM in the first trimester helps with effective long-term management. Further research is needed to develop a strategy to predict, diagnose and treat GDM, safeguarding the mother and the fetus.
References
American Diabetes Association. (2021). Management of diabetes in pregnancy: Standards of medical care in diabetes. Diabetes Care, 44(1).
Brutsaert, E. F. (2022) Diabetes mellitus (DM) Merck Manual. Diabetes Mellitus (DM) – Hormonal and Metabolic Disorders – Merck Manuals Consumer Version
Christian, S. J., Boama, V., Satti, H., Ramawat, J., Elhadd, T. A., Ashawesh, K., Dukhan, K., & Beer, S. (2018). Metformin or insulin: logical treatment in women with gestational diabetes in the Middle East, our experience. BMC Research Notes, 11(1), 1–5. https://doi.org/10.1186/s13104-018-3540-1
Friel, L. A. (2022) Diabetes Mellitus in pregnancy Merk Manual Diabetes Mellitus in Pregnancy – Gynecology and Obstetrics – Merck Manuals Professional Edition
Kattini, R., Kelly, L., & Hummelen, R. (2023). Systematic review of the use of metformin compared to insulin for the management of gestational diabetes: Implications for low-resource settings. Canadian Journal of Rural Medicine : The Official Journal of the Society of Rural Physicians of Canada = Journal Canadien de La Medecine Rurale : Le Journal Officiel de La Societe de Medecine Rurale Du Canada, 28(2), 59–65. https://doi.org/10.4103/cjrm.cjrm_40_22
Lowe, W. L., Jr, Scholtens, D. M., Kuang, A., Linder, B., Lawrence, J. M., Lebenthal, Y., McCance, D., Hamilton, J., Nodzenski, M., Talbot, O., Brickman, W. J., Clayton, P., Ma, R. C., Tam, W. H., Dyer, A. R., Catalano, P. M., Lowe, L. P., & Metzger, B. E. (2019). Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): Maternal Gestational Diabetes Mellitus and Childhood Glucose Metabolism. Diabetes Care, 42(3), 372–380. https://doi.org/10.2337/dc18-1646
Mustad, V. A., Huynh, D. T. T., López-Pedrosa, J. M., Campoy, C., & Rueda, R. (2020). The Role of Dietary Carbohydrates in Gestational Diabetes. Nutrients, 12(2), 385. https://doi.org/10.3390/nu12020385
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.)
Saberzadeh-Ardestani, B., Karamzadeh, R., Basiri, M., Hajizadeh-Saffar, E., Farhadi, A., Shapiro, A. M. J., Tahamtani, Y., & Baharvand, H. (2018). Type 1 Diabetes Mellitus: Cellular and Molecular Pathophysiology at A Glance. Cell Journal (Yakhteh), 20(3), 294–301. https://doi.org/10.22074/cellj.2018.5513
Sharma, A. K., Singh, S., Singh, H., Mahajan, D., Kolli, P., Mandadapu, G., Kumar, B., Kumar, D., Kumar, S., & Jena, M. K. (2022). Deep Insight of the Pathophysiology of Gestational Diabetes Mellitus. Cells (2073-4409), 11(17), 2672. https://doi.org/10.3390/cells11172672
Ogurtsova, K., da Rocha Fernandes, J. D., Huang, Y., Linnenkamp, U., Guariguata, L., Cho, N. H., Cavan, D., Shaw, J. E., & Makaroff, L. E. (2017). IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Research and Clinical Practice, 128, 40–50. https://doi.org/10.1016/j.diabres.2017.03.024
The case study features a 43-year-old white male who complains of pain. When ambulating, he employs a set of clutches. The patient reports that his family doctor referred him for psychiatric evaluation after noticing that he was in psychological distress (Laureate Education, 2016). The pain started seven years ago when I fell and landed on my right hip. Four years ago, it was discovered that the cartilage surrounding the right hip joint was 75% torn. However, no surgeon was willing to perform a total hip replacement because they believed that tissue repair would occur over time (Laureate Education, 2016). He complains of severe cramping in his right limb. He was diagnosed with complex regional pain syndrome by a neurologist (CRPS). He admits to having bad moods but denies being depressed. He had been prescribed Hydrocone, but he used it in low doses due to drowsiness and constipation, and the drug does not effectively manage pain (Laureate Education, 2016). The mental health examination is unremarkable.
Decision Point One: Savella 12.5 mg orally once daily on Day 1, followed by 12.5 mg BD on Day 2 and 3, then 25 mg BD on days 4-7 and then 50 mg BD after that.
Reason: Savella is a serotonin-norepinephrine reuptake inhibitor that has NMDA antagonist activity, which brings analgesia at the nerve endings (Cording et al., 2015). It is indicated for fibromyalgia and thus effective for this client (Cording et al., 2015). I prescribed Savella to help in pain management and improve the overall mood.
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.
Lifestyle changes, such as diet and exercise, are the first-line treatment for Gestational Diabetes (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 are acceptable pharmacotherapy treatments when the patient refuses insulin (“Updated ACOG guidance on gestational diabetes,” 2021). Long-acting insulin, such as NPH, can be administered in the morning, at bedtime, or both, and adjusted as needed based on glucose control. Short-acting insulin, as well as regular insulin, may be required with meals to achieve better control (Venkatesh & Landon, 2021, p. 13). Insulin does not cross the placenta and can result in better perinatal outcomes in terms of the child or mother developing diabetes later in life.
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 https://www.cdc.gov/pregnancy/diabetes-gestational.html
Gestational diabetes. (2020, December). ACOG Gestational Diabetes FAQ’s. Retrieved July 1, 2021, from https://www.acog.org/womens-health/faqs/gestational-diabetes
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 https://www.obgproject.com/2017/06/25/acog-releases-updated-guidance-gestational-diabetes/
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. https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=1&sid=84bba249-070c-48a9-a673-6d38c009d7de%40sessionmgr4007
What is diabetes? (2016, December 1). National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved July 1, 2021, from https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes
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.
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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/
Treatment of Type I Diabetes
The mainstay of treatment for Type I diabetes is insulin. Insulin dosing is weight-based and recommended ranges are 0.4 to 1.0 units per kilogram per day (u/kg/day) of total insulin. Higher ends of the dosing range are needed during puberty and if the patient presents with ketoacidosis. American Diabetes Association (ADA) recommendations for initiation of therapy in a patient who is metabolically stable is 0.5 (u/kg/day) (American Diabetes Association [ADA], 2018).
Insulin should be administered with a meal and based on blood glucose levels, carbohydrate consumption, and activity level. While administration of rapid onset insulin should be at meal- time, timing and administration should be individualized (ADA, 2018).
Insulin comes in many forms and prandial dosing insulin should be fast acting to reduce the risk of hypoglycemic episodes. Humalog (insulin lispro) is a fast-acting insulin that can be administered IV, by subcutaneous injection or by a continuous subcutaneous infusion pump. Most short acting insulin is available in a pen that is easy for patients to use correctly and conveniently by dialing the dose into the pen and then attaching a small needle and pressing it into subcutaneous tissue on the stomach, back of the arm, or fatty portion of the thigh. Humalog has a more rapid onset and a shorter duration of action than regular human insulin so when taken with a meal the risk of hypoglycemia is reduced. Onset is within 5 minutes and peak is usually 30 – 60 minutes after administration (Food and Drug Administration [FDA] & Eli Lilly and Company, 2012).
Short and Long-Term Impacts
Individuals who are diagnosed with Type I diabetes face short-term risks of ketoacidosis if glucose levels are not controlled, and hypoglycemic episodes related to insulin therapy (Rosenthal & Burchum, 2021, Chapter 68). They face long-term risks of renal failure, peripheral neuropathy, hypertension, and heart disease. Treatment with ACE inhibitors, angiotensin II receptor blockers, and statin drugs should be considered for long-term disease prevention in adult patients (Gray & Threlkeld, 2019). Treatment with prandial insulin dosing, and balancing carbohydrate intake with activity are key to maintaining safe blood glucose levels.
Conclusion
Type I diabetes is caused by decreased or lack of insulin production and requires close management that includes insulin dosing to prevent long-term disease complications. Humalog is a form of insulin that can be used as part of a comprehensive treatment plan to successfully treat Type I diabetes.
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.
Diabetes mellitus is divided into four categories: type 1, type 2, gestational, and other specific kinds. Diabetes type 1 is caused by the loss of pancreatic beta cells and requires daily insulin administration. This is the result of an autoimmune or idiopathic reaction. Type 2 diabetes is the most prevalent kind, accounting for 90-95 percent of all diagnosed cases (Rosenthal & Burchum, 2021). Type 2 diabetes is typically caused by insulin resistance and improper insulin production. At one time, type 1 diabetes was referred to as juvenile-onset since it was believed to only affect young children. It is now recognized that type 1 can develop in adults, and type 2 is becoming increasingly prevalent in youngsters. Type 1 and type 2 diabetes share symptoms, but differ in their etiology, prevalence, treatments, and results (Rosenthal & Burchum, 2021). In gestational diabetes, the need for insulin increases physically throughout pregnancy. Increased maternal caloric intake, maternal weight gain, the presence of placental hormones such as placental growth hormone and placental lactogen, and increased prolactin and growth hormone synthesis all contribute to the rise in insulin requirement (Lende & Rijhsinghani, 2020). As the pregnancy progresses, the pancreatic beta cell mass rises to meet the increased demand for insulin. Failure of beta cell growth accompanied with a relatively insufficient increase in insulin secretion causes gestational diabetes ( McMcance & Heuther, 2019).
Insulin is the treatment of choice for gestational diabetes patients with hyperglycemia. Insulin is a big molecule that cannot pass through the placenta. Consider oral hypoglycemic medications for those who are unable to take insulin. Metformin is chosen over glyburide due to the potential for fetal hypoglycemia when glyburide is administered to the mother.
Typically, oral drugs are administered once or twice daily. Metformin and glyburide have been demonstrated to pass the placenta and enter the fetal circulation. Oral drugs have not been extensively evaluated.
They have not been evaluated for potential long-term implications on neonatal outcomes; consequently, they are not advised as the initial treatment for persistent hyperglycemia in individuals with gestational diabetes (Lende & Rijhsinghani, 2020).
Unawareness of hypoglycemia is a side effect of insulin therapy. When insulin levels exceed insulin requirements, hypoglycemia ensues. The more frequently a patient experiences hypoglycemia, the more gradually their symptoms diminish (Rosenthal & Burchum, 2021). Frequent glucose monitoring reduces the likelihood of this problem. When therapy is effective, both hyperglycemia and hyperinsulinemia are reduced, and the patient actively participates in his or her own therapy. To achieve optimal glucose control, insulin dosage must be closely matched to patient requirements (Rosenthal & Burchum, 2021).
References
Lende, M., & Rijhsinghani, A. (2020). Overview of Gestational Diabetes with an Emphasis on Medical Management. Volume 17 of the International Journal of Environmental Research and Public Health (24). https://doi-org.ezp.waldenulibrary.org/10.3390/ijerph17249573
McCance, K. L., and S. E. Huether (2019). Pathophysiology: The biological underpinning of adult and child disease (8th ed.). The Elsevier Health Sciences journal.
Rosenthal, L., & Burchum, J. (2021). Advanced practice nurses and physician assistants use Lehne’s Pharmacotherapeutics (2nd ed.). The Elsevier Health Sciences journal.
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.
Diabetes and Drug Treatments
Type 1 Diabetes
Type 1 diabetes is an autoimmune illness in which the body’s immune system attacks and destroys the cells in the pancreas that produce insulin. People with type 1 diabetes must take insulin injections or use an insulin pump to manage their blood sugar levels.
Type 2 Diabetes
Type 2 diabetes is when the body does not yield or use insulin suitably. People with type 2 diabetes may need to take oral prescriptions, insulin vaccinations, or monitor their blood sugar levels more closely.
Gestational Diabetes
Gestational diabetes is a type of diabetes that occurs throughout pregnancy. It affects the mother’s blood sugar levels and can root to health complications for the mother and the baby. Women with gestational diabetes need to monitor their blood sugar levels closely and may need to take medications or insulin injections to keep their blood sugar levels under control.
Juvenile Diabetes
Juvenile diabetes is a type of diabetes that affects children and adolescents. It is initiated by the body’s incapability to yield enough insulin to control blood sugar levels. Children with juvenile diabetes must take insulin injections or use an insulin pump to manage their blood sugar levels.
The drug used to treat Type 1 and 2 diabetes, Gestational Diabetes, and Juvenile Diabetes is insulin. Insulin is a hormone made in the pancreas that aids control glucose levels in the body. It is administered through injections or pumps and is available in several forms, including rapid-acting, short-acting, intermediate-acting, and long-acting. Proper preparation and administration of insulin involve selecting the correct type, strength, and dose for the individual patient. The patient should also be counseled on proper injection technique, including how to rotate injection sites. In addition, dietary considerations are essential when treating diabetes with insulin (Omnigraphics, 2018). Patients should be encouraged to eat a balanced diet with carbohydrates, proteins, and fats. They should also be advised to eat meals regularly and avoid large amounts of sugar or carbohydrates.
The short-term and long-term impact of diabetes on patients can vary dependent on the type of diabetes and the severity of the condition. In the short term, diabetes can cause symptoms such as excessive thirst and regular urination, weight loss, fatigue, blurred vision, and numbness or tingling in the extremities. Long-term complications of diabetes can include kidney failure, blindness, nerve damage, and cardiovascular disease. Treating diabetes with insulin can help to reduce the symptoms and prevent long-term complications. Insulin helps to keep glucose levels in check by allowing the body to absorb and use glucose from the bloodstream (Omnigraphics, 2018). Over time, this can help to reduce the symptoms of diabetes and prevent long-term complications. However, it is essential to note that insulin is not a cure for diabetes and must be combined with other treatments, such as diet and exercise, to be effective.
References
Cherney, K. (2018, August 23). A Complete List of Diabetes Medications. Healthline; Healthline Media. https://www.healthline.com/health/diabetes/medications-list
clinic. (2018). Diabetes treatment: Medications for type 2 diabetes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/in-depth/diabetes-treatment/art-20051004
Omnigraphics, I. (2018). Diabetes sourcebook : basic consumer health information about type 1 and type 2 diabetes, gestational diabetes, and other types of diabetes and prediabetes, with details about medical, dietary, and lifestyle disease management issues, including blood glucose monitoring, meal planning, weight control, oral diabetes medications, and insulin ; along with facts about the most common complications of diabetes and their prevention, current research in diabetes care, tips for people following a diabetic diet, a glossary of related terms, and a directory of resources for further help and information. Omnigraphics, Inc.
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!
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 5 Discussion Rubric
Post by Day 3 of Week 5 and Respond by Day 6 of Week 5
To Participate in this Discussion:
Week 5 Discussion
What’s Coming Up in Module 5?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In the next module, you will examine diagnoses for patients with neurologic and musculoskeletal disorders, and you will complete your Midterm Exam.
Looking Ahead: Midterm Exam
Please review the Resources and content in the previous modules in preparation for your Midterm Exam in Module 5.
Next Week
To go to the next week:
Module 5
Module 5: Neurologic and Musculoskeletal Systems
What’s Happening This Module?
Module 5: Neurologic and Musculoskeletal Systems is a 2-week module, Weeks 6 and 7 of the course. In this module, you will analyze drugs prescribed to treat neurological and musculoskeletal disorders and explore patient education strategies for treatment and management of these disorders. You will also evaluate the impact of patient factors on the effects of prescribed drugs and drug therapy plans for neurologic and musculoskeletal disorders. You will also complete your Midterm Exam.
What do I have to do?
When do I have to do it?
Review your Learning Resources
Days 1-7, Weeks 6 and 7
Assignment: Decision Tree for Neurologic and Musculoskeletal Disorders
You are encouraged to begin your Assignment in Week 6 and continue working on it in Week 7. However, this Assignment is not due until Day 7 of Week 8 in Module 6.
Midterm Exam
Complete by Day 7 of Week 7.
Go to the Week’s Content
Week 6
Week 7
Week 6: Neurologic and Musculoskeletal Disorders
Sabrina is a 26 year old female who has just been diagnosed with multiple sclerosis. She has scheduled an appointment for a follow up with her physician but has several questions about her diagnosis and is calling the Nurse Helpline for her hospital network. As she talks with the advanced practice nurse, she learns that her diagnosis also impacts her neurologic and musculoskeletal systems. Although multiple sclerosis is an autoimmune disorder, both the neurologic and musculoskeletal systems will be affected by adverse symptoms that Sabrina needs to be aware of and for which specific drug therapy plans and other treatment options need to be decided on.
As an advanced practice nurse, what types of drugs will best address potential neurologic and musculoskeletal symptoms Sabrina might experience?
This week, you will evaluate patients for the treatment of neurologic and musculoskeletal disorders by focusing on specific patient case studies through a decision tree exercise. You will analyze the decisions you will make in the decision tree exercise and reflect on your experiences in proposing the recommended actions to address the health needs in the patient case study.
Learning Objectives
Students will:
Evaluate patients for treatment of neurologic and musculoskeletal disorders
Analyze decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
Justify decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
Learning Resources
Required Readings (click to expand/reduce)
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Chapter 11, “Basic Principles of Neuropharmacology” (pp. 67–71)
Chapter 12, “Physiology of the Peripheral Nervous System” (pp. 72–81)
Chapter 12, “Muscarinic Agonists and Cholinesterase Inhibitors” (pp. 82–89)
Chapter 14, “Muscarinic Antagonists” (pp. 90-98)
Chapter 15, “Adrenergic Agonists” (pp. 99–107)
Chapter 16, “Adrenergic Antagonists” (pp. 108–119)
Chapter 17, “Indirect-Acting Antiadrenergic Agents” (pp. 120–124)
Chapter 18, “Introduction to Central Nervous System Pharmacology” (pp. 125–126)
Chapter 19, “Drugs for Parkinson Disease” (pp. 127–142)
Chapter 20, “Drugs for Alzheimer Disease” (pp. 159–166)
Chapter 21, “Drugs for Seizure Disorders” (pp. 150–170)
Chapter 22, “Drugs for Muscle Spasm and Spasticity” (pp. 171–178)
Chapter 59, “Drug Therapy of Rheumatoid Arthritis” (pp. 513–527)
Chapter 60, “Drug Therapy of Gout” (pp. 528–536)
Chapter 61, “Drugs Affecting Calcium Levels and Bone Mineralization” (pp. 537–556)
American Academy of Family Physicians. (2019). Dementia. Retrieved from http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=5
This website provides information relating to the diagnosis, treatment, and patient education of dementia. It also presents information on complications and special cases of dementia.
Document: Mid-Term Summary & Study Guide (PDF)
Required Media (click to expand/reduce)
Laureate Education (Producer). (2019b). Alzheimer’s disease [Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat Alzheimer’s disease.
Laureate Education (Producer). (2019e). Complex regional pain disorder [Interactive media file]. Baltimore, MD: Author.
In this interactive media piece, you will engage in a set of decisions for prescribing and recommending pharmacotherapeutics to treat complex regional pain disorders.
Disorders of The Nervous System
Reflect on the comprehensive review of disorders of the nervous system and think about how you might recommend or prescribe pharmacotherapeutics to treat these disorders. (15m)
Week 5: Endocrine System Disorders and the Treatment of Diabetes
The endocrine system includes eight major glands throughout the body which affect such things as growth and development, metabolism, sexual function, and mood (National Institutes of Health). Some of the most commonly diagnosed endocrine disorders include hypothyroidism, diabetes, and Hashimoto’s disease. Not surprisingly, treating any one endocrine disorder may have effects on other body systems or their functions. As an advanced practice nurse, treating patients who may suffer from endocrine disorders requires an acute understanding of the structure and function of the endocrine system. Additionally, a solid understanding of patient factors and behaviors will assist in developing the best drug therapy plans possible to treat your patients. Some of most commonly diagnosed endocrine disorders include
This week, you differentiate the types of diabetes and examine the impact of diabetes drugs on patients. You also evaluate alternative drug treatments and patient education strategies for diabetes management.
Reference: National Institutes of Health. (n. d.). National Institute of Diabetes and Digestive and Kidney Disorders. Endocrine diseases. Retrieved July 3, 2019 from https://www.niddk.nih.gov/health-information/endocrine-diseases
Learning Objectives
Students will:
- Differentiate types of diabetes
- Evaluate the impact of diabetes drugs on patients
- Evaluate alternative drug treatments and patient education strategies for diabetes management
Learning Resources
| Excellent | Good | Fair | Poor | |
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| Main Posting |
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. |
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. |
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. |
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 |
10 (10%) – 10 (10%)
Posts main post by day 3
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0 (0%) – 0 (0%)
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0 (0%) – 0 (0%)
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0 (0%) – 0 (0%)
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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. |
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. |
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. |
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 |
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. |
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. |
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. |
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 |
5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days.
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0 (0%) – 0 (0%)
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0 (0%) – 0 (0%)
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| Total Points: 100 |
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Introduction
Diabetes is primarily a disorder of carbohydrate metabolism that also disrupts protein and lipid metabolism as a result of a defect in insulin secretion, insulin action, or both. It is characterized by sustained hyperglycemia that leads to polyuria, polydipsia, ketonuria, and weight loss (Rosenthal & Burchum, 2021).
Classification of Diabetes
Diabetes is classified into type 1 diabetes mellitus, type 2 diabetes mellitus, gestational diabetes, and juvenile diabetes. Type 1 diabetes is due to autoimmune beta cell destruction, usually leading to absolute insulin deficiency. Gestational diabetes is any degree of glucose intolerance that is first recognized during pregnancy and may persist after pregnancy (American Diabetes Association, 2019). Juvenile diabetes is type 1 diabetes commonly seen in children and adolescents. The incident rate increases from birth and peak between 10-14years (Bimstein, Zangen, Abedrahim, &Katz, 2019).
Type 2 diabetes accounts for 90-95% of all diabetes. It is as a result of relative insulin deficiency and insulin resistance. Patients with type 2 diabetes are capable of insulin synthesis but the liver, muscles and adipose tissue exhibits insulin resistance because the cells are less able to take up and metabolize the glucose available to them. The risk of developing type 2 diabetes increases with age, obesity, and lack of physical activity. Type 2 diabetes is associated with a strong genetic predisposition. It occurs more in certain racial and ethnic subgroups such as African American, American India, Hispanic/Latino, and Asian American (American Diabetes Association, 2018).
Drug Used for Type 2 Diabetes
Metformin classified as biguanide is the drug of choice for initial treatment of type 2 diabetes in combination with a reduced-calorie diet and exercise. Metformin increases glucose uptake by inhibiting glucose production in the liver, reduces glucose absorption in the gut, and sensitizes insulin receptors in target tissues. Metformin is effective, safe, inexpensive, and may reduce the risk of cardiovascular events and death. It can be used alone or in combination with other drugs. Common side effects are decreased appetite, nausea, and diarrhea. The dose is titrated to minimize the severity of gastrointestinal side effects (American Diabetes Association, 2018).
Metformin is available as immediately released tablets, extended-release tablets, and an oral solution. The recommended initial dose for immediate-release tablets and oral solution is 500mg twice or 850mg once daily taken with meals. The extended-release tablets are taken once daily with the evening meal to enhance absorption due to gastrointestinal transit time at night (Rosenthal & Burchum, 2021).
Impact of Type 2 Diabetes and Drug Therapy on Patients
Acute life-threatening consequences of type 2 diabetes are hypoglycemia and nonketotic hyperosmolar syndrome. Long term complications include retinopathy with a potential loss of vision, nephropathy leading to renal failure, peripheral neuropathy with risk of foot ulcers and amputation, impotence, heart disease, and stroke (American Diabetes Association, 2019).
Metformin leads to vitamin B12 and folic acid deficiencies. Vitamin B12 deficiency can contribute to peripheral neuropathy. Also, severe lactic acidosis can occur in patients with significant renal impairment due to the accumulation of metformin (Rosenthal & Burchum, 2021)
References
American Diabetes Association. (2018). Pharmacologic approaches to glycemic treatment:
Standards of medical care in diabetes-2018. Diabetes care,41(Suppl.1, S73-S85. doi:10.2337/dc18.S008. Retrieved from https://care.diabetesjournals.org/content/diacare/41/supplement_1/S73.full.pdf.
American Diabetes Association. (2019). Classification and diagnosis of diabetes: Standards of
medical care in diabetes-2019. Diabetes Care, 42(Suppl.1), S13-S28. doi:10.2337/dc19.S002. Retrieved from https://care.diabetesjournals.org/content/42/Supplement_1/S13
Bimstein, E., Zangen, D., Abedrahim, W., & Katz, J. (2019). Type 1 diabetes mellitus (juvenile
diabetes): A review of pediatric oral health provider. The journal of clinical pediatric Dentistry, 43(6),417-423. doi:10.17796/1053-4625-43.6.10. Retrieved from https://www.proquest-com.ezp.waldenulibrary.org/docview/2330603107?accountid=14872
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.). St. Louis, MO: Elsevier.
That was a great introduction to the use of metformin for type 2 diabetes mellitus. As the course of diabetes progresses, there can be damage to the kidneys from elevated levels of glucose damaging the glomerulus in both type 1 and type 2 diabetes and is the common cause of chronic kidney disease and end-stage renal failure (McCance, & Huether, 2019). Being mindful of this possibility, adding an ACE inhibitor may be beneficial to a patient with type 2 diabetes mellitus. In a meta-analysis study of five random control trials, including 2,975 patients, the result showed that patients taking an ACE inhibitor versus a placebo, had an 18% decrease in microalbuminemia and macroalbuminemia that can contribute to diabetic kidney disease. (Trietley, Wilson, Chaudri, Payette, Higbea, and Nashelsky, 2017). ACE inhibitors can also decrease renal injury by decreasing glomerular filtration pressure (Rosenthal, & Burchum, 2021). The ACE inhibitor, Lisinopril is administered as a once a day tablet starting at 2.5mg a day and progressing up to a maintenance dose of 20-40mg/day as tolerated by monitoring blood pressure and urinalysis (Rosenthal, & Burchum, 2021). Patients taking this drug must be educated on signs and symptoms of hypotension.
References
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). St. Louis, MO: Elsevier
Trietley, G. S., Wilson, S. A., Chaudri, P., Payette, N., Higbea, A., & Nashelsky, J. (2017). Do ACE inhibitors or ARBS help prevent kidney disease in patients with diabetes and normal BP? Journal of Family Practice, 66(4), 257,263. Retrieved from https://cdn.mdedge.com/files/s3fs/JFP06604257.PDF
RE: First response
I enjoyed reading your post. I also choose the topic of treating Type 2 Diabetes (T2DM) because most patients in the hospital setting are T2DM. From experience, Metformin is a popular oral antidiabetic medication, and many patients in their admission data stated that Metformin is the med they take at home. However, when they are in the hospital, nurses have to explain to the patient why a physician has changed their med to insulin on a sliding scale to manage diabetes. The downside is that many patients did not like getting fingerstick three times or more a day. In my opinion, Metformin will be used less and less with adult T2DM patients in the future. Metformin causes deficiencies of both B12 and folic acid because it hampers absorption, just as you also mentioned, there is some consideration to using Metformin. Also, for patients on Metformin, there can be procedural delays because of contrast-induced renal failure. Furthermore, for the patient who has renal insufficiency, high levels of Metformin can be toxic (Rosenthal & Burchum, p.409). Another reason the patient might consider changing from Metformin to another medication is that many people need B12; lack of B12 causes patient fatigue, slows daily activities, causes depression, memory loss, and anemia (Harvard Health Publishing, 2020).
Many patients must meet the challenge of managing diabetes; some forget to check glucose levels or are tired of fingerstick. Fortunately, Medicare now covers the cost of a device called Freestyle Libre CGM. This system continuously monitors glucose without fingerstick (Levine et al.). However, there is no perfect medication for T2DM. A patient needs to understand the critical of a balanced glucose level with adequate dietary intake and a healthy lifestyle.
References
Levine, B., Brown, A., Close, K. (2018). Medicare Now covers Abbott’s Freestyle Libre CGM. Retrieved from: https://diatribe.org/medicare-now-covers-abbotts-freestyle-libre-cgm
Harvard Health Publishing. (2020). Vitamin B12 deficiency can be sneaky, harmful. Retrieved from: https://www.health.harvard.edu/blog/vitamin-b12-deficiency-can-be-sneaky-harmful-201301105780
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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Great discussion of the risk factors associated with diabetes. You did a great job outlining the risk factors of the disease. Some of these risk factors are modifiable. Risk factors such as weight, a sedentary lifestyle, and diet are modifiable. However, other factors that you addressed, such as ethnicity, are not modifiable. Providers should discuss individual risk factors with their patients and address specific ways to help prevent the disorder.
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I enjoyed reading your post. Type 2 diabetes is the most prevalent form of diabetes and accounts for ninety to nine-five percent of diagnosed cases (Rosenthal and Burchum, 2021). The onset of Type 2 diabetes occurs mostly in adulthood, but the number of children being diagnosed is on the rise. This is due to the number of children suffering from obesity. According to the CDC (2017), people who are overweight and have excess belly fat are more likely to have insulin resistance, which is a major risk factor for type 2 diabetes. Diet and exercise are the key ways to prevent the development of type 2 diabetes. Metformin is a medication that is FDA approved to lower glucose in children. It can be used in combination with diet and exercise for children, also, to assist with glycemic control.
References:
Mayo Clinic. (2017). Type 2 diabetes in children. www.mayoclinic.org.
Rosenthal, L.D. and Burchum, J.R. (2021). Lehne’s pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.). St. Louis, MO: Elsevier.
RE: WK5 Initial Discussion
Main Post-Gestational Diabetes Mellitus
Diabetes
Diabetes mellitus is an autoimmune disease that results in elevated blood glucose levels. There are generally three categories of diabetes mellitus: Type 1/Juvenile, Type 2, and Gestational Diabetes Mellitus. Type 1, used to be referred to as juvenile diabetes and presents itself before age of thirty, has destruction of pancreatic beta cells so no insulin is produced and this person would be insulin dependent (McCance, & Heuther, 2019). Type 2 presents in patints that are generally older than fourty, has b-cell insulin secretion decrease and insulin resistance and may require some insulin administration (McCance, & Heuther, 2019). Gestaitonal diabetes mellitus presents itself in pregnancy due to an increase insulin resistance and decreased insulin secretion (McCance, & Heuther, 2019).
Gestational Diabetes Mellitus
In patients that have not been previous diagnosed with diabetes, gestational diabetes mellitus (GDM) presents itself during the second or third trimester of pregnancy and starts to resolve up to twelve weeks after the delivery of the placenta (Chiefari, Arcidiacono, Foti, & Brunetti, 2017). As a woman’s metabolic needs increase over time of a pregnancy the pancreas does not secrete enough insulin to keep up with the demands at the same time insulin resistance develops (Alfadhli, 2015). The first line treatment for GDM is dietary changes, and physical activity (Chiefari, Archidiacono, Foti, & Brunetti, 2017). If the lifestyle changes are not effective enough then the first line drug of choice is regular insulin because it does not cross the placenta (Kelley, Carroll, & Meyer, 2015).
Regular Insulin for GDM
The utilization of subcutaneous, rapid action insulin is needed to treat GDM. The starting point for the dosing of insulin is based on body weight and gestational age. First trimester 0.7u/kg/day, the second trimester 0.8u/kg/day, and the third trimester 0.9-1u/kg/day divided up into 50% of the dose to be administer nightly and the other 50% to be divided up to pre-meal doses and with the adjustments of dosage made on self-monitoring glucose testing (Alfadhli, 2015). Patient instruction for administering the injection, monitoring of their glucose levels and the importance of glucose controls, storage of insulin and being aware of signs and symptoms of hypoglycemia and treatment are very important (Rosenthal, & Burchum, 2021). Monitoring for the end of insulin requirements after delivery is part of the treatment plan.
Dietary Considerations
Consistent glucose control is the goal for GDM management. Patients are encouraged to have a diet that is high in complex carbohydrates and fiber and to decrease glycemic index carbohydrates and decrease saturated fats (Chiefari, Arcidiacono, Foti, & Brunetti, 2017).
Short-Term and Long-Term Affects
Allowing for ongoing hyperglycemia during pregnancy can lead to complications for mother and baby due to an increased growth rate of fetus resulting in potential for birth traumas like shoulder dystonia, maternal morbidity for the need of a c-section delivery (Alfadhli, 2015). Long term complications for the mother are the development of Type 2 diabetes mellitus and cardiovascular disease and for the infants, obesity and diabetes (Alfadhli, 2015).
Conclusion
The management of GDM focuses of diet, exercise and potential need for the use of fast acting subcutaneous insulin during the pregnancy and briefly after delivery. Preventing short-term and long-term complications is the goal of treatment for the health of both the mother and the infant.
References
Alfadhli, E. M. (2015). Gestational diabetes mellitus. Saudi Medical Journal, 34(4), 399-406.https://doi.org/10.15537/smj.2015.4.10307
Chiefari, E., Arcidiacono, B., Foti, D., & Brunnetti, A. (2017). Gestational diabetes mellitus: An updated overview. Journal of Endocrinology Investigation, 2017(40), 899-909. https://doi.10.1007/s40618-016-0607-5
Kelley, K. W., Carroll, D. G., & Meyer, A. (2015). A review of current treatment strategies for gestational diabetes mellitus. Drugs in Context, 4, 212282. https://doi.org/10.7573/dic.212282
McCance, K. L,, & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). St. Louis, MO: Elsevier.
RE: Main Post-Gestational Diabetes Mellitus
Excellent post, Penny! In recent years, gestational diabetes has become prevalent in expectant mothers. It can have devastating effects on the mother, fetus, and neonate. The complications for mothers include preeclampsia, increased risk of being induced and/or having a cesarean section, delayed milk production, and an increased risk of developing cardiovascular disease, type two diabetes later in life, and during subsequent pregnancies (Ansarzadeh et al., 2020). For fetus/neonate, the complications include large for gestational age, stillbirth, hypoglycemia, asphyxia, and polycythemia (Ansarzadeh et al., 2020). Also, both mother and infant are at an increased risk of mortality.
Due to the high risk of complications, gestational diabetics need to receive prompt and appropriate treatment to reduce these dangers. Treatment includes both diet control, exercise, and insulin. The patient must be instructed to check her blood sugars “six to seven times a day” (Rosenthal & Burchum, 2021, p. 398). The amount of insulin and food intake that she needs will depend on blood sugar reading.
According to Martis et al., 2018, the preferred type of insulin for gestational diabetics is either rapid-acting (lispro, aspart) or intermediate-acting (neutral protamine Hagedorn (NPH)). The rapid-acting and intermediate-acting insulins are designed to mimic the body’s natural secretion of insulin from the pancreas. To provide the best glycemic control, insulin should be injected as a basal-bolus regime (before each meal). Due to limited data regarding effects on pregnancy, long-acting insulin is not preferred.
The insulin that you discussed was rapid-acting insulin. In this post, NPH, an intermediate-acting insulin will be described. NPH is injected subcutaneously (SubQ) two to three times per day to provide good glycemic control throughout the day or night. It starts working in 60-120 minutes, peaks in six to 14 hours, and lasts 16-24 hours (Rosenthal & Burchum, 2021). NPH can be mixed with short-acting insulins to save the patient from an extra SubQ injection.
There are different treatment options for women with gestational diabetics. The type of treatment plan that each woman is given will depend on current treatment guidelines and shared decision making between the patient and the provider. With any treatment plan, the patient should be given extensive educated regarding proper diet, exercise, and anti-diabetic medications.
References
Ansarzadeh, S., Salehi, L., Mahmoodi, Z., & Mohammadbeigi, A. (2020). Factors affecting the quality of life in women with gestational diabetes mellitus: A path analysis model. Health and Quality of Life Outcomes, 18(1), 31. https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=2&sid=e01b9b51-0ff2-405c-8909-e2ae6729e803%40sessionmgr4007
Martis, R., Crowther, C. A., Shepherd, E., Alsweiler, J., Downie, M. R., Brown, J., & Brown, J. (2018). Treatments for women with gestational diabetes mellitus: An overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews, 8, 1-111.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). St. Louis, MO: Elsevier.
RE: Main Post-Gestational Diabetes Mellitus
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Thanks for adding onto additional treatment for gestational diabetes mellitus. Also for reinforcing the importance of educating patients on exercise, diet and medications.
RE: Main Post-Gestational Diabetes Mellitus
If clinicians do not work in the woman’s clinic, they will be less experienced with gestational diabetes patients (GDM). During my time working at the hospital, I have rarely encountered a GDM patient. So, I find that reading your post is educational, and I believe nurse practitioners must have knowledge about gestation diabetes (GDM). According to Rosenthal and Burchum, GDM patients should monitored blood glucose six to seven times a day to keep glucose at its therapeutic level. Many patients who have GDM should change the oral drug to insulin (p.398).
Further information from the CDC indicates the critical goal of treating gestational diabetes is to keep glucose levels the same as those of women who do not have gestation diabetes. However, all pregnant women are insulin resistant during late pregnancy (CDC, 2019). Also, it is vital to educate women who have GDM the importance of exercise and maintaining a healthy food diet during pregnancy. Clinicians need to let the patient know GDM also presents a risk of high blood pressure, the woman may have a large baby, causing a difficult delivery, and many women may develop T2DM within five to ten years after delivery(Mayo Clinic, 2019).
Gestational diabetes has many adverse effects on women’s bodies. Clinicians should educate and help women maintain a healthy weight during pregnancy, eating healthy good food, low in fat and calories, more fruits, vegetables, and whole-grain intake than fast food. Keep active to prevent having an early birth or C-section and hypoglycemia after birth.
There are many illnesses related to diabetes; as a clinician, we should take any chance to educate the public about healthy diets, staying active, and following up with the six month and annual health assessment.
References
Centers for Disease Control and Prevention. (2019). Diabetes. Gestational Diabetes. Retrieved from: https://www.cdc.gov/diabetes/basics/gestational.html
Mayo Clinic. (2019). Gestational Diabetes. Retrieved from: https://diabetes.diabetesjournals.org/content/55/3/792#:~:text=Risk%20estimates%20of%20type%202,to%20be%20increasing%20(5).
appetite by slowing the motility of food (Otto-Buczkowska & Jainta, 2018).
Classes of Drugs used in Type II diabetes Management
Type II diabetes has several treatment options as well based on a non-insulin approach. The first-line treatment for type II is an oral hypoglycaemic agent (OHL) class of biguanide metformin. The second class of OHL are the sulfonylureas (SUs). Thiazolidineiones (TZDs) were introduced in the 1990’s but many were pulled from the market due to the potential to cause liver failure. Pioglitazone is the TZD most commonly prescribed today. A class of drugs whose main emphasis is on the gut belongs to a group of anti-hyperglycemic agents called incretin. The development of dipeptidyl-peptidase inhibitors led to the use of glucagon-like peptide-1 receptor antagonists or GLP-1 (Blaslov et al., 2018).
Treating Type II Diabetes with Biguanides
In treating type II diabetes, antidiabetic biguanides are the first-line drug of choice and are the first medications most often prescribed for type II diabetics. One such medication metformin belongs to this class of drugs. This medication is available as a tablet as well as a solution and is taken orally. The liquid is taken with meals one to two times daily, the regular tablet is taken two to three times daily with meals, and the extended release is taken with a meal once daily and has been noted to cause less gastrointestinal upset such as diarrhea. Dosing is usually initiated at 500 mg twice daily or 850 mg once daily. Metformin can build up in the kidneys if there they are not functioning properly therefore careful monitoring is needed in patients with reduced kidney function (Ibrahim et al., 2021).
Biguanides such as metformin, are not metabolized and are excreted in the urine through tubular secretion (kidneys). Cation transporters distribute the medication to tissues. The OCT2 gene is responsible for the uptake of metformin from the body’s circulation and then into renal cells. Metformin suppresses glucose production in the liver through gluconeogenesis while signaling the body to make more insulin and increasing the uptake of glucose into the cells. It does not cause hypoglycemia as it there is no endogenous insulin secretion stimulation (Zake et al., 2021).
Dietary Considerations & Short-term and Long-term Impacts of Type II Diabetes
Diet is definitely very important in the management of type II diabetes. Monitoring sugar intake and keeping body fat at a healthy level is vital for controlling this disease. Excess sugar not only overworks beta cells it also causes narrowing of blood vessels by decreasing the elasticity resulting in reduced blood flow and decreased oxygen levels. This can lead to neuropathy, heart attacks, stroke, and premature death. Medications can also cause complications in that many are damaging to the liver and kidneys as the medication is excreted along with sugar. Managing diet along with routine visits and labs are all crucial in both preventing and controlling diabetes. Eating foods high in fiber along with unprocessed foods, and exercise are great ways to fight back (Forouhi et al., 2018).
References
Blaslov, K., Naranđa, F. S., Kruljac, I., & Renar, I. P. (2018). Treatment approach to type 2 diabetes: Past, present and future. World Journal of Diabetes, 9(12), 209–219. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304295/
Butler, A., & Misselbrook, D. (2020). Distinguishing between type 1 and type 2 diabetes. British Medical Journal, 370. Retrieved from https://www.researchgate.net/publication/343583965_Distinguishing_between_type_1_and_type_2_diabetes
Forouhi, N. G., Misra, A., Mohan, V., Taylor, R., & Yancy, W. (2018). Dietary and nutritional approaches for prevention and management of type2 diabetes. British Medical Journal, 361. Retrieved from https://www.bmj.com/content/361/bmj.k2234
Ibrahim, M., Morley, M. D., Ding, H., & Triggle, C. R. (2021). A critical review of the evidence that metformin is a putative anti-aging drug that enhances healthspan and extends lifespan. Frontiers in Endocrinology, 12, n. p. Retrieved from https://www.frontiersin.org/articles/10.3389/fendo.2021.718942/full
Otto-Buczkowska, E, & Jainta, N. (2018). Pharmacological treatment in diabetes mellitus type 1- Insulin and what else? International Journal of Endocrinology and Metabolism, 16(1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903388/
Zake, D. M., Kurlovics, J., Zaharenko, L., Komasilovs, V., Klovins, J., & Dtalidzans, E. (2021). Physiologically based metformin pharmacokinetics of mice and scale-up to humans for the estimation of concentrations in various tissues. Plos One, 16(4), n. p. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249594
People with diabetes have elevated blood glucose levels. Type I, Type II, gestational, and juvenile diabetes are the four types of diabetes. The etiology and timing of onset are the main differences between the two types of diabetes. For instance, diabetes type one is primarily an autoimmune condition brought on by the body’s immune system attacking the pancreas, impairing its ability to produce enough insulin and causing an elevated level of glucose in the blood (Redondo et al., 2020). It usually starts during childhood and has a higher hereditary component than the others.Contrarily, type 2 diabetes can be brought on by either a decline in the body’s sensitivity to insulin or a decline in its capacity to produce insulin. T2DM typically appears later in life and is primarily triggered by food. Juvenile diabetes, like type 1 DM, advances in adolescents and young adults, whereas gestational diabetes is frequently characterized by uncontrollable sugar levels during the 2nd or 3rd trimester of pregnancy.
Type 1 Diabetes Treatment
The majority of clinical practice guidelines recommend starting Type 1 diabetes treatment with insulin (TID). Patients with type 1 diabetes should start their treatment with aggressive insulin therapy. Once or twice a day, 100 units of short-acting standard insulin are diluted in 1 ml of the liquid solution and administered intravenously (Tornese et al., 2020). Subcutaneous or insulin pump administration is an option for other insulin formulations. The dose is typically adjusted following the patient’s blood sugar levels.
Dietary Considerations
To attain and retain acceptable blood sugar levels, T1D patients are frequently advised to eat foods with a lower glycemic index. Proteins and complex carbohydrates like brown rice are also appropriate for T1D patients. The timing of meals must be ideal to prevent hypoglycemia (Yuan et al., 2022).
The Short-Term and Long-Term Impacts
Patients with T1D frequently experience numerous side effects linked to higher risks of hypoglycemia during the first few months after diagnosis, including palpitations, anxiety, headaches, and disorientation (DiMeglio et al., 2018). Long-term, however, this condition can lead to significant organ failure, with kidney damage, nerve damage, heart disease, and ocular impairment being the most common. On the contrary, insulin administration for a brief period may result in weakened metabolic control. In addition to other issues, long-term insulin use can increase the likelihood of cardiovascular and psychiatric issues.
References
DiMeglio, L. A., Evans-Molina, C., & Oram, R. A. (2018). Type 1 diabetes. The Lancet, 391(10138), 2449–2462. https://doi.org/10.1016/s0140-6736(18)31320-5
Redondo, M. J., Hagopian, W. A., Oram, R., Steck, A. K., Vehik, K., Weedon, M., Balasubramanyam, A., & Dabelea, D. (2020). The clinical consequences of heterogeneity within and between different diabetes types. Diabetologia, 63(10), 2040–2048. https://doi.org/10.1007/s00125-020-05211-7
Tornese, G., Ceconi, V., Monasta, L., Carletti, C., Faleschini, E., & Barbi, E. (2020). Glycemic Control in Type 1 Diabetes Mellitus During COVID-19 Quarantine and the Role of In-Home Physical Activity. Diabetes Technology & Therapeutics, 22(6), 462–467. https://doi.org/10.1089/dia.2020.0169
Yuan, X., Wang, J., Chen, X., Yan, W., Niu, Q., Tang, N., Zhang, M. Z., Gu, W., & Wang, X. (2022). Effects of the timing of the initiation of dietary intake on pediatric type 1 diabetes for diabetic ketoacidosis. BMC Pediatrics, 22(1). https://doi.org/10.1186/s12887-022-03243-z
Thank you for your informative post. As a twin-carrying third-trimester individual, I deeply appreciate gestational diabetes. During the course of pregnancy, often a glucose tolerance test is performed twice, once before 20 weeks (usually around 18 weeks) and then again at around week 28. Studies have concluded that immediate treatment of gestational diabetes before 20 weeks gestation led to a significantly lower incidence of adverse neonatal outcomes than no immediate treatment (Simmons, et. al., 2023). Treatment aims to keep blood glucose levels equal to the blood sugar of a pregnant woman without gestational diabetes. Treatment typically includes specific meal plans and scheduled activities. Treatment may also include daily blood glucose testing and insulin injections. The American Diabetes Association (n.d.) suggests specific blood glucose level targets, and for some individuals, these values may be stricter. Before a meal, the individual’s blood glucose should be 95mg/dl or less. One hour after a meal, the individual’s blood glucose should be 140mg/dl or less; in two hours, this number should be 120mg/dl or less. As you mentioned, many individuals who have gestational diabetes do go on to develop type 2 DM later in life as there appears to be a link between the two as both types involve insulin resistance. However, lifestyle changes that are relatively basic may aid in preventing DM after the patient has gestational diabetes.
Metformin and glyburide are being used more often with women who are experiencing gestational diabetes, although there is a lack of FDA approval for this. Glyburide can start at a dose of 2.5mg up to a maximum dose of 20mg. Metformin dosing should start at 500mg with a maximum dose of 2500mg. You mentioned insulin as the drug of choice for the individual who has gestational diabetes due to the insulin not crossing the placenta and being highly effective. Basal insulin dosing can be determined by the patient’s weight (0.2units/kg/day). If a patient’s glucose level becomes elevated after a meal, a rapid-acting insulin or regular insulin can be prescribed to take prior to the meal, with dosing starting at 2 to 4 units. Total daily insulin requirements change from trimester to trimester. In the first trimester, the requirement is 0.7units/kg/day. The second-trimester requirement is 0.8units/kg/day, while the insulin requirement is 0.9 to 1.0 units/kg/day for an individual in the third trimester. Educating the patient and appropriately prescribing insulin to help manage their blood sugar is important. The individual should divide the total dose of daily insulin into two halves. One half should be given in the evening prior to bed as basal insulin. The other half should be divided between three meals, and as mentioned prior, this insulin should be rapid-acting or regular insulin (Quintanilla Rodriguiz, et. al., 2022).
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