The Types Of Diabetes Discussion Paper

Differences Between Types of Diabetes Type one diabetes mellitus (DM) results from an immune-mediated B-cell destruction. This causes an absolute insulin deficiency leading to hyperglycemia. Type two DM causes hyperglycemia due to either a relative insulin deficiency combined with insulin resistance or a secretory defect with insulin resistance (Petersmann et al., 2019). Gestational diabetes is hyperglycemia that occurs during pregnancy, in patients who have previously not be diagnosed with DM. Typically, during pregnancy, pancreatic B-cell hyperplasia occurs, producing more insulin in response to the pregnancy. At the same time, placental secretion of hormones like growth hormone and corticotropin-releasing hormone cause increased insulin resistance. When the increased B-cell hyperplasia is unable to overcome the insulin resistance, gestational DM occurs (Mack & Tomich, 2017)The Types Of Diabetes Discussion Paper.

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Type one DM was traditionally labeled “juvenile diabetes” however, the term has since fallen out of favor as type one DM can occur at any age with as many as fifty percent starting in adulthood. Furthermore, type two DM has increasingly afflicted the youth related to obesity (DiMegliao, Evans-Molina, & Oram, 2018). One Drug to Treat Type Two Diabetes A drug class commonly used as therapy for type two DM is sulfonylureas. Specifically, second generation sulfonylureas, such as glipizide, are more often utilized as they have a lower incidence of hypoglycemia. Sulfonylureas are secretagogues. These drugs increase the secretion of insulin from the pancreas by binding to the sulfonylurea receptor of adenosine triphosphate sensitive potassium channels on pancreatic B-cells. The side effects are typically related to low blood glucose and include dizziness, sweating, confusion, and nervousness. Patients may also experience weight gain, stomach upset, diarrhea, and dark colored urine (Padhi, Nayak, & Behera, 2020)The Types Of Diabetes Discussion Paper.

Sulfonylureas have been used for decades to treat hyperglycemia with evidence to show an associated reduction in microvascular changes, a decline in cardiovascular events, and a decrease in all-cause mortality (Gloyn & Drucker, 2018). Though not the first line treatment, sulfonylureas can be used as either a monotherapy for patients who have an allergy or intolerance to metformin or in combination with metformin if blood glucose levels are not controlled with metformin alone (Correa, Rodriguez, & Nappe, 2022). When initiated, glipizide is started at 5mg oral daily. Daily dosage may be increased by 2.5mg to 5mg increments daily, though this should be done several days after the previous dose adjustment. Depending on blood glucose response, dosing frequency can be increased from daily to twice daily, however this is associated with decreased compliance. The daily maximum dose is 40mg. Hemoglobin A1c should be monitored every three to six months to both ensure compliance and guide dosing. Glipizide is available in both immediate release and extended released formulations. Immediate release should be taken 30 minutes prior to a meal to gain the maximal reduction in postprandial hyperglycemia. Extended-release tablets are taken just prior to the first meal of the day and patients should be instructed not to crush, chew, or split them. Patients taking beta blockers should be advised to take caution with following blood glucose checks as symptoms of hypoglycemia, such as tachycardia, may not occur (Correa, Rodriguez, & Nappe, 2022)The Types Of Diabetes Discussion Paper.

Dosing adjustments should be considered for the elderly, patients who are malnourished, and those who have liver or renal impairment to prevent hypoglycemia. Extremely rare instances of cholestatic jaundice and syndrome of inappropriate anti-diuretic hormone may occur. Patients taking sulfonylureas should have routine hemoglobin A1c levels checked, along with liver function testing and renal function testing to monitor for potential side effects or dose adjustment needs. Events of hypoglycemia can be managed with intravenous dextrose or oral glucose tablets (Correa, Rodriguez, & Nappe, 2022). Patients with DM should receive nutritional education that includes an individualized eating plan with nutrient-dense foods to replace carbohydrate-rich foods. Guidelines recommend implementing a high- fiber fruit and vegetable diet to replace processed foods, foods high in fats, red or processed meats, and sugary foods. Along with these dietary changes, an exercise plan should be implemented (Cloete, 2021). Short and Long-Term Impacts of Type Two Diabetes on the Patient Type two DM has two acute impacts on the patient: hypoglycemia and hyperglycemia. Less likely of the two is hypoglycemia. Instances of hypoglycemia are typically related to patients taking sulfonylureas. Hyperglycemia is a more common event. Complications related to untreated hyperglycemia include diabetic ketoacidosis and hyperosmolar hyperglycemic state (HHS). Of the two, HHS is more commonly seen in patients with type two DM (Cloete, 2021). Long-term impacts of type two DM are macrovascular and microvascular changes. Macrovascular changes are more common and include cardiovascular disease, stroke, and peripheral vascular disease. Cardiovascular disease is the leading cause of death in patients with type two DM. Diabetes mellitus leads to plaque accumulation in vessels that then rupture, causing coronary artery occlusions. Changes in the cardiac vessels also cause cardiomyopathy which leads to cardiac failure. Atrial fibrillation can result from the vascular changes in the heart as well, increasing the risk for stroke by as high as twenty five percent. Furthermore, those with DM who do have strokes will have higher morbidity and mortality and higher occurrences of dementia after the stroke (Cloete, 2021). Microvascular changes associated with type two DM lead to neuropathy, nephropathy, and retinopathy. These changes occur due to thickening of the vessel membranes, weakening of vessel walls, and reduced vessel compliance. These changes also lead to hypertension, delayed wound healing, and other conditions. Diabetic neuropathy affects almost half of people with DM. It affects every aspect of the patient’s life and can be life threatening due to possible autonomic dysfunction. Autonomic neuropathy can cause postural hypotension, loss of sinus rhythm, tachycardia, myocardial infarctions without pain, and sudden death. Cardiac ischemia that does occur related to DM will present atypically with generalized weakness, fatigue, or congestive heart failure rather than the typical chest pain or angina. Peripheral neuropathy is a symmetrical polyneuropathy that leads to muscle atrophy. Patients with polyneuropathy can also have musculoskeletal changes causing malformations such as Charcot’s foot. Diabetic foot ulcers can occur and are caused by peripheral artery disease and neuropathy. In these, the arterial supply is decreased causing ischemic ulcers, severe pain, and possibly infection. Diabetic foot ulcers are the leading reason for non-traumatic lower extremity amputation. Incidences of retinopathy increase with lack of blood pressure control and glucose control. Cataracts can result before the patient is 30 years-old from microvascular changes brought on by poorly controlled hyperglycemia. Diabetes is the most common cause of renal impairment, resulting from hyperglycemia and hypertension. Gastrointestinal dysfunction is also common in patients with DM, causing gastric emptying delay to gastroparesis. Finally, DM is associated with various other gastrointestinal diseases such as gallstones, inflammatory bowel disease, Clostridium difficile infections, and increased risk of fecal incontinence (Cloete, 2021). Being on sulfonylureas cause short-term impacts, such as hypoglycemia and other previously mentioned side effects. Sulfonylureas can also have long-term consequences. The most commonly seen long-term impact is weight gain. There can also be cardiovascular risk. There has also been some literature to suggest that patients taking sulfonylureas have worse outcomes after myocardial infarction (Sola et al., 2015)The Types Of Diabetes Discussion Paper.