Type 1 diabetes, or juvenile diabetes, involves destroying beta cells, resulting in insulin deficiency
Type 1 diabetes, or juvenile diabetes, involves destroying beta cells, resulting in insulin deficiency
Please provide a feedback and 2 references to each discussion
Discussion 1
Leah Camara Initial Post
Types of Diabetes
Type 1 diabetes, or juvenile diabetes, involves destroying beta cells, resulting in insulin deficiency. The most prevalent type of diabetes is immune-mediated diabetes. Individuals diagnosed with T1D are exposed to ketoacidosis, little insulin secretion, and insulin dependency. These manifest before one reaches the age of 30, even if they are not obese (McCance & Huether, 2019, p. 684). Type 1A is autoimmune, while Type 1B is idiopathic or nonimmune. The causes for the former include genetic and environmental determinants that facilitate the autoimmune destruction of pancreatic beta cells. As for the latter, the causes remain unclear, although there are significant ties with HLA-DQA and HLA-DQB genes (McCance & Huether, 2019, p. 685). There is also Type 3c, which is linked to chronic pancreatitis. Type 2 diabetes, meanwhile, refers to the gradual depletion of beta cell insulin secretion frequency due to insulin resistance. Individuals with T2D are not insulin-dependent but may still need insulin. They are also not susceptible to ketosis but can develop ketones when stressed. Obesity is prominent in the abdominal area. Individuals over 40 are usually diagnosed with T2D, but a noticeable rise exists in younger cases, specifically children. T2D is linked with dyslipidemia and hypertension (McCance & Huether, 2019, p. 684).
For this discussion, I will focus on gestational diabetes mellitus, which is described as glucose intolerance with onset during pregnancy. To be diagnosed with GDM, one must have fasting plasma glucose of >126 mg/dL or random plasma glucose of >200 mg/dL, as well as symptoms of diabetes. In the oral glucose test, one must yield >200 mg/dL for the 2-hour plasma glucose or 6.5% or higher for the hemoglobin A1C (Burchum & Rosenthal, 2021, p. 398). A female patient diagnosed with GDM also has insulin resistance and inadequate insulin secretion due to hyperglycemia. Some of the risk factors of GDM include being over the age of 25, belonging to a certain ethnicity (African American, Asian, Hispanic, Native American), having a family history of diabetes, having a history of GDM, and obesity (McCance & Huether, 2019, p 684). Many women diagnosed with GDM likely have undiagnosed T1D or T2D, and the American Diabetes Association suggests that high-risk women who are found to be diabetic during the prenatal consultation be either diagnosed with T1D or T2D instead of GDM. Women without a history of diabetes are encouraged to undergo screening and an oral glucose tolerance test when they are already at 24 to 28 weeks gestation. To avoid complications, monitoring and managing the glucose level must be done prenatally, during pregnancy, and after delivery. Women whose pregnancies had been affected by GDM but with normal results in the postpartum screening are encouraged to undergo screening 6 to 12 weeks after delivery and then repeat the screening every 1 to 3 years. GDM should not be ignored as this can trigger T2D and impact both the mother and infant’s cardiovascular health and metabolism (McCance & Huether, 2019, p. 692). Women diagnosed with polycystic ovary syndrome are more susceptible to GDM, perinatal mortality, pregnancy-induced hypertension, and preterm birth (McCance & Huether, 2019, p. 765).
Pharmacological Management of Gestational Diabetes
Lifestyle modification is the initial treatment for GDM, and patients who do not notice changes from this would have to undergo pharmacological therapy to reduce hyperglycemia and, in turn, prevent perinatal morbidity and improve overall health. Insulin is administered in the treatment of GDM and T1D, and T2D. By ensuring that a diabetic patient’s blood glucose is within an acceptable level, hyperglycemia, hypoglycemia, and other complications can be prevented (Burchum & Rosenthal, 2021, p. 404). Specifically, the types of insulin are insulin lispro (short duration, rapid acting), regular insulin (short duration, short-acting), neutral protamine Hagedorn insulin (intermediate duration), insulin glargine (long duration), and insulin deguldec (ultralong duration). The administration of short-duration insulin is done after the diabetic patient has taken a meal; it regulates the postprandial increase of blood glucose. Insulin lispro (Humalog), a rapid-acting analog of regular insulin, takes effect within 15 to 30 minutes of subcutaneous injection and lasts 3 to 6 hours. Compared to regular insulin, which must be injected 30 to 60 minutes before eating, insulin lispro, which has a rapid onset, can be injected right before or after eating. While insulin lispro’s structure is similar to natural insulin’s, its two amino acids are transposed. The molecules of insulin lispro clump less, thereby making possible the rapid onset. Insulin aspart (NovoLog), an analog of natural insulin, has a rapid onset of 10 to 20 minutes and an effectivity lasting 3 to 5 hours. Insulin glulisine (Apidra), a synthetic analog of natural insulin, has a rapid onset of 10 to 15 minutes and effectivity lasting 3 to 5 hours. This must be injected shortly before or after eating. Short-duration, short-acting insulin-like Regular insulin (Humulin R, Novolin R), an unmodified natural insulin, can be administered through the following routes: subcutaneous injection, subcutaneous infusion, and intramuscular injection, which is rarely done among the three. The routine management of diabetes involves the injection of regular insulin before eating to regulate postprandial hyperglycemia. Insulin is also infused subcutaneously through a pump for basal glycemic regulation. Following the injection, the molecules of the regular insulin develop as small aggregates at the injection site, and absorption is, in turn, slowed down. The insulin takes effect after 30 to 60 minutes, peaks in 1 to 5 hours, and persists for up to 10 hours. The onset of regular insulin is slower than rapid-acting insulin and faster than longer-acting insulin. Long-duration insulin U-100 insulin glargine (Lantus, Basaglar), a modified human insulin, has a longer duration of action (24 hours) and is administered daily through a subcutaneous route. However, certain patients require a twice-a-day administration of U-100 insulin glargine to attain the complete 24 hours of basal coverage. The administration can be done at any time of the day and in a consistent manner. U-100 insulin glargine has four amino acids distinguish it from natural human insulin. After injection, it develops microprecipitates that gradually dissipate and release tiny amounts of insulin glargine over a prolonged period. With insulin glargine, blood levels are commonly steady, unlike other long-acting insulins that make blood levels rise and fall considerably. Insulin detemir (Levemir), a human insulin analog, has a slow onset and a duration of action that depends on the dosage. The effect of insulin detemir lasts around 12 hours at a low dosage (0.2 units/kg), while around 20 to 24 hours can be achieved with a high dosage (0.4 units/kg). Insulin detemir is used in basal glycemic control and is not administered before meals to manage postprandial hyperglycemia.
Effects of Gestational Diabetes and Treatment on Patients
Although insulin is regarded as the gold standard for managing GDM, it is linked with hypoglycemia, increased maternal weight, and the need for training that can be costly to ensure proper administration (Christian et al., 2018). Insulin replacement therapy aims to achieve adequate glucose control every 24 hours while minimizing the required injections, as repeated injections in the same site can result in atrophy or hyperplasia (Olson, 2020, p. 157). The usual side effect of insulin is hypoglycemia, which manifests in several ways: anxiety, dizziness, headache, hunger, mental and visual disturbances, sweating, tachycardia, and tremors (Olson, 2020, p. 158). Meanwhile, hypokalemia, which develops as insulin drives potassium from the serum into the cell, can lead to cardiac arrhythmias and neuromuscular disturbances if untreated (Olson, 2020, p. 159). Hypoglycemia (blood glucose lower than 70 mg/dL) happens when insulin levels exceed insulin needs. This imbalance can be caused by childbirth, diarrhea and vomiting, immoderate alcohol consumption, overdose, reduced food consumption, and unusually intense physical activity (Burchum & Rosenthal, 2021, p. 404). Drug interactions related to hypoglycemic agents are alcohol, glinides, and sulfonylureas, which can aggravate hypoglycemia caused by insulin. Hyperglycemic agents such as glucocorticoids, sympathomimetics, and thiazide diuretics can offset the desired effects of insulin, so to prevent such from happening, it is recommended to increase insulin dosage. Beta-blockers can slow down the awareness of and response to hypoglycemia, as these can conceal signs linked to the stimulation of the sympathetic nervous system. The therapeutic effects of GDM medications include a decrease in fatigue, plasma glucose levels and A1c, and urination, as well as the overall improvement of symptoms. To lessen the risk of adverse effects, it is advised that patients and their families undergo education on the signs and symptoms of hyperglycemia and hypoglycemia (Burchum & Rosenthal, 2021, p. 406).
References
Burchum, J.R., & Rosenthal, L.D. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd Ed.) (pp. 398, 402-404, 406). Elsevier.
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.
Discussion 2
Latrice
Gestational Diabetes
Gestational diabetes is a diagnosed health condition in which blood glucose is elevated during pregnancy and then subsides to it natural state rapidly after delivery. Complications of gestational diabetes for the fetus and infant include spontaneous abortion, fetal anomalies, fetal demise, preeclampsia, macrosomia, cesarean delivery, neonatal hypoglycemia, and neonatal hyperbilirubinemia (Dugan & Ma-Crawford, 2019). In addition, it may increase the risk of postpartum maternal development of type 2 diabetes. The testing of gestational diabetes (GM) is done by an oral glucose tolerance test (OGTT) and is usually done between 24-28 week of pregnancy. The American Diabetes Associate offer two diagnostic strategies: “One-step” fasting 75-g oral glucose tolerance test at 1 hour and 2 hours or “two-step” with a nonfasting 50-g glucose load test screen measured at 1 hour, followed by a fasting 100-g oral glucose tolerance test measured at 1, 2, and 3 hours for patients who screened positive with the glucose load test. For the one-step test, a fasting glucose level of 92mg/dl or greater is diagnostic for gestational diabetes, as is a level of 180 or greater after 1 hour or 153 or greater than 2 hours (Dugan & Ma-Crawford, 2019). In the two-step test, 130mg/dl or greater, or 135 or 140 for the 1-hour 50-g glucose load test (Dugan & Ma-Crawford, 2019).
Insulin for gestational diabetes
Lifestyle modification is the first resource in managing a patient with gestational diabetes by maintaining healthy diet, keeping active, and not gaining more weight than recommended. If the patient is not able to reach their glycemic goal or target, medication may need to be added in their treatment plan. Insulin is the first-line pharmacologic therapy for gestational diabetes (Dugan & Ma-Crawford, 2019). According to American Diabetes Association (ADA) it is the most effective for maintaining blood sugar and it does not cross the placenta, therefore, it is safe for the baby. In order to maintain healthy pregnancy and safe delivery, it is imperative, the patients understand how to self-monitor their blood sugar level and to take the insulin as prescribed to reach the desire blood glucose level recommended by the physician. To determine which types of insulin the patient will need and how much is determined by the type of diabetes the patient has, glucose level and how much the blood sugar fluctuates throughout the day and, their lifestyle. Some types of insulin that are ideal for preventing blood sugar spikes after eating are Lispro (Humalog), regular ( Humulin R, Novolin R), aspart (Novolog), these are all rapid or short-acting insulin or intermediate-acting such as NPH ( Humulin N, Novolin N ) these insulin helps the body use this glucose and keeps glucose levels from rising too high. The insulin can be administered by shots, pens, or an insulin pump. Diabetic education will need to provide thorough education to ensure the patient understands how to monitor blood sugar, properly prepared and self-administered insulin based upon the glycemic goal as well as understanding the signs and symptoms of hypoglycemia and hyperglycemia.
Short- term versus long -term impact of Gestational diabetes
If gestational diabetes is diagnosed during the pregnancy, the blood sugar level returns to it usual level soon after delivery. However, during the pregnancy, lifestyle changes will need to occur, eating healthy meals and food, being active, and taking medication as prescribed will help the patient to control the blood sugar level to have a healthy baby and safe deliver. The main insulin side effect during pregnancy can occur is hypoglycemia by missing a meal or taking more than needed. On the other hand, having gestational diabetes does increase the risk of developing type 2 diabetes, especially if the patient is non-compliant to lifestyle changes, good eating habits , monitoring blood sugar levels and taking medications as instructed. Or having other risk factors such as obesity, family history of diabetes, not being physical active, having prediabetes, or have had gestational diabetes with previous pregnancy will increase their chances of having type 2. Since the diabetic state disappears after delivery, insulin is discontinued (Rosenthal et al., 2021). Nevertheless, if the diabetic state persists beyond parturition, it is no longer gestational and should be rediagnosed and treated accordingly (Rosenthal et al., 2021). Recent evidence suggests GDM increases long-term maternal cardiovascular disease, chronic kidney disease, and cancer risks (Shou et al., 2019). Maternal hyperglycemia is associated with offspring obesity, overweight, insulin resistance, and neurocognitive (Shou et al., 2019).
References
Dugan, J. A., & Ma-Crawford, J. (2019). Managing gestational diabetes. Journal of the American Academy of Physician Assistants, 32(9), 21–25. https://doi.org/10.1097/01.jaa.0000578760.60265.e0
Prenatal care. Prenatal Care | ADA. (n.d.). Retrieved March 28, 2023, from https://diabetes.org/diabetes/gestational-diabetes…
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