Diabetes Mellitus: Types, Medications, Complications, Nursing Diagnosis and intervention

 Diabetes Mellitus

Diabetes mellitus is also called as diabetes, is a metabolic disease associated with hyperglycemia and results from inadequate insulin production, secretion or utilization

Secretion and function of insulin

• Insulin is hormone secreted by the beta cells of the islet of Langerhans in the pancreas.
• Limited amounts of insulin are delivered into the blood in response to maintain  glucose levels.
• Maintain secretion or a bolus of insulin, released after a food, helps keep normal glucose level.
• Insulin is necessary for the usage of glucose for cellular metabolism also for the normal metabolism of fat and protein.
• Carbohydrate- insulin affects the modification of glucose into glycogen for storage in the liver and skeletal muscles and allows for the fast release and utilization of glucose by the cells.
• Protein- amino acid conversion develop in the presence of insulin to replace muscle tissue or to provide needed glucose 
• Fat-collection of fat in adipose tissue and conversion of fatty acids from excess glucose occurs only in the presence of insulin.

Different types of diabetes

Type 1 Diabetes mellitus:  previously referred to as insulin-dependent diabetic mellitus. It is an autoimmune disease condition. It happen when your immune system attack and destroy the pancreatic cells with antibodies. The pancreas is damaged and doesn't make adequate insulin

• Little or no endogenous insulin, requiring injections of insulin to prevent diabetes and ketoacidosis.
• 5 to 10% of all diabetic patient have type 1 
• Etiology: genetic components, immunologic, or environmental factors (e.g, virus). Often have islet cell antibodies
• Symptoms of  polydipsia, polyphagia, recent weight loss and polyuria
• Onset any age, but commonly seen under age 30 years

Type 2 Diabetes mellitus: previously known as non-insulin-dependent diabetes mellitus or adult-onset diabetes mellitus.  Type 2 occurs when your body resistant to insulin 

• Caused by a combination of insulin resistance and relative insulin deficiency- someone has insulin resistance, whereas others have deficient insulin secretion, with little insulin resistance.
• 90 to 95% of diabetic patient have type 2.
• Causes include obesity, heredity, or environmental factors
• Symptoms of weight gain, fatigue, poor wound healing and recurrent infection.
• Onset any age, usually, over 30 years, maybe seen in younger adults who are overweight

Prediabetes

• Prediabetes is an abnormality irregularity in glucose level intermediate between normal and overt diabetes.

Altered Fasting Glucose Level

• Fasting blood glucose more than or equal to 100 but less than 126 mg/dL

Impaired Fasting Glucose Tolerance

• Glucose measurement on a glucose tolerance test more than or equal to 140 mg/dL but below 200 in the 2-hr sample.
• It can progress to type 2 diabetes or may remain unchanged
• It can be a risk component for the development of coronary artery disease, hypertension and hyperlipidemias.

Gestational diabetes mellitus 

•  Usually in the second or third trimester Due to hormones secreted by the placenta, which inhibit the action of insulin.
• Gestational diabetes described as carbohydrates intolerance occurring during period of pregnancy
• Occurs in almost 7% of pregnancy and generally disappears after delivery.
• Women with gestational diabetes mellitus are at more risk for type 2 diabetes at a later.
• It increased risk of fetal morbidity.
•  Recommended that all pregnant women get tested starting around 24–28 weeks gestation.

Laboratory Test

Fasting Blood Glucose: 

•  Fasting is defined as no caloric intake for at least 8 hours. FBS level is 99 mgdL OR lower is normal range. FBS level is 100 to 125 mg/dL indicates you are prediabetes and 126 mg/dL or more indicates you are diabetes.

Glucose  Tolerance Test 

• It measures insulin response to glucose loading. FBS required before the glucose loading. In case of non-pregnant adults 75 gm glucose load and blood sample drawn at 30 minutes, 1 hour and 2 hours. For pregnant adults 100 gm glucose load and blood sample drawn 30 minutes, 1,2 and 3 hours. At 2 hours, a blood sugar level of 140 mg/dL or below level considered normal, 140 to 199 mg/dL indicates prediabetes, and 200 mg/dL or more indicates diabetes.

Glycated Hemoglobin ( HbA1c)

• Measures glycemic control of past 2 or 3 months duration by calculating the irreversible reaction of glucose to hemoglobin through freely permeable erythrocytes period of their 120 days life circle. An HbA1c is below 5.7 % is normal, between 5.7 and 6.4% means prediabetes, and 6.5% higher means you are diabetes.

Random Blood Sugar Test

• Random blood sugar test can take at any time and no need for fasting and other special instructions. More than 200 mg/dL or above considered as diabetes.

Management of Diabetes Mellitus

Diet

• Diet control with caloric restriction of carbohydrates and saturated fats to build ideal body weight.
• Weight control is an initial treatment for type 2 diabetes.

Meal Planning Instruction

• Meal should consist of fats, protein and carbohydrates.
• Maintain in timing of meals and amounts of food eaten on a day to day basis helps balance blood glucose level.
• Boost the intake of soluble and insoluble fiber
• Decreased salt intake as possible
• Prepare meals to contain minerals and vitamins and low fats.
• Include snacks in the diet plan depending on insulin and medication regimens, lifestyle and physical activity.
• Alcohol use only in moderation.

Exercise

• Regularly scheduled, balanced exercise performed 1 hour most days of the week improve the utilization of carbohydrates, weight control, enhances the action of insulin and maintain cardiovascular fitness.

Medication

Antidiabetic Medication Chart

Insulin Secreting Agents

Second Generation Sulfonylureas

• Glyburide: Dosage- 1.25-20 mg PO in  once or separate doses with meals
• Glipizide: Dosage- 2.5-40 mg PO in once or separate dose.
• Glyburide, Micronized: Dosage- 0.75-12 mg PO in once or separate dose
• Glipizide, long-acting: Dosage- 2.5-20 mg PO in one dose, usually before breakfast.
• Glimepiride: Dosage- 1-8 mg PO in a once dose with first main meal.

Meglitinide Analogue

• Repaglinide: Dosage- 0.5-16 mg PO in 2-4 separate doses, 1-30 minutes before meals. Do not take if meal is skipped.

Amino Acid Derivative

• Nateglinide: Dosage- 120-360 mg PO in 3 separate doses, 1-30 minutes before meals. Do not take if meal is skipped.

Insulin Sensitizing Agents

Biguanides

• Metformin: Dosage- 500-2550 mg PO in 2-3 separate doses
• Metformin, long-acting: Dosage- 500-2000 mg PO in single or two separate doses.

Thiazolidinediones 

• Pioglitazone: Dosage- 15-45 mg PO once daily 
• Rasiglitazone: Dosage- 4-8 mg PO in once or two dividend doses

Glucose Absorption-Delaying Agents

Alpha-glucosidase inhibitors

• Acarbose: Dosage- 50-300 mg PO in 3 separate doses before meals.
• Miglitol:  Dosage- 50-300 mg PO in 3 separate doses before meals.

Glucagon-Suppressing Agents

Dipeptidyl peptidase-4 (DD-4) inhibitors

• Sitagliptin: Dosage-25-100 mg PO once daily

Incretin Mimetics 

• Exenatide: Dosage- 5-10 mcg subcutaneously, BD daily 1-60 minutes before

Amylin analogue

• Pramlintide: Dosage- Type 1: 15-60 mcg subcutaneously every main meal. Type 2: 60-120 mcg subcutaneously with every main meal.

Combination Agents

• Metaglip ( glipizide + metformin): Dosage -Maximum 20 mg/2000 mg PO in once or separate dose.
• Glucovance:(glyburide + metformin) Dosage-Maximum 20 mg/2000 mg PO in once or separate dose.
• Avandamet ( metformin + rosiglitazone): Dosage- Maximum 8/2000 mg PO in separate dose.
• Actoplusment ( pioglitazone+metformin): Dosage-Maximum 45 mg/2550 mg PO separate dose.
• Duetact ( glimepiride+pioglitazone): Dosage- Maximum 30 mg /4 mg PO single dose daily.
• Janumet (sitagliptin+metformin): Dosage- Maximum 100 mg /2000 mg PO in separate dose.
• Avandaryl ( rasiglitazone+glimepiride): Dosage - Maximum 8 mg/4 mg PO in once or separate dose.

Insulin Therapy: Insulin Onset, Peak, and Duration

Fast or short-acting

• Humulin Regular (R) and Novolin Regular (R) 
• Onset: 30-60 minutes 
• Peak: 2-3 hours
• Duration: 5-8 hours

Rapid Acting

• Novolog (aspart)
• Apidra ( glulisine)
• Humalog (lispro)
• Onset: 5-15 minutes 
• Peak: 30-90 minutes
• Duration: Less than 5 hours

Intermediate Acting

• Insulin Isophane
• Suspension
• Humulin N
• Novolin N
• Onset: 2-4 hours
• Peak: 4-10 hours 
• Duration: 10-16 hours.

Long-Acting

• Levemir (detemir): Onset: 3-8 hours, Peak: None, Duration: 13-15 hours
• Lantus (glargine): Onset: 2-4 hours, Peak: None, Duration: 20-24 hours

Pre Mixed Insulin

Non-NPH Suspension

• Novolog Mix 70/30
• Humalog Mix 75/25
• Humalog Mix 50/50
• Onset: ≤ 15 minutes
• Peak: Half-4 hours
• Duration: 16-24 hours

NPH and Regular Suspension

• Novolin 70/30
• Humulin 70/30
• Humulin 50/50
• Onset: 30 minutes
• Peak: 2-12 hours
• Duration: 18-24 hours

Chronic Complications of Diabetes Mellitus 

• Cerebrovascular disease
• Coronary artery disease
• Peripheral vascular disease
• Retinopathy
• Nephropathy
• Peripheral neuropathy
• Gastroparesis
• Diarrhea
• Impotence and sexual dysfunction
• Orthostatic hypotension
• Hypoglycemia

Nursing Diagnoses

• Imbalanced nutritional status more than body requirements related to intake in excess of activity expenditures.
• Anxiety-related to insulin injection
• Risk for hypoglycemia-related to effects of insulin 
• Deficient knowledge related to using of  hypoglycemic agents
• Risk for impaired skin integrity related to decreased circulation to lower extremities.

Nursing Intervention

•  Nutritional status
• Check timing and content of  diet
• Advise patient on the importance of an individualized diet plan and weight loss goals.
•  Low intake of carbohydrates may help some patients.
• Teaching about insulin therapy
• Assist patient to reduce fear about insulin injection
• Explain the procedure for insulin self-injection practice.

• Prevention of hypoglycemia
• Closely monitor blood glucose level.
• Explain importance of accuracy in insulin dosage and diet timing to avoid hypoglycemia
• Monitor the patient for the signs and symptoms of hypoglycemia. e.g sweating, tremor, tachycardia
• Assess skin integrity 
• Observe legs and feet for skin sensation, temperature, injuries etc.
• Maintain proper skin integrity 
• Instruct patient about foot care.