Diabetes Mellitus Type 2 - Essay Example

Diabetes Mellitus Type 2 Diabetes Mellitus Type 2 Introduction Diabetes Mellitus is a chronic disorder of carbohydrate metabolism. The condition is characterized by hyperglycaemia and glosure that results in "... resistance to insulin action, inadequate insulin secretion and excessive or inappropriate glucagon secretion" (Daniels & Nicoll, 2011). Type 2 diabetes results from beta-cell dysfunction and is characterized by insulin resistance. Previously, the disorder was known as non-insulin dependent diabetes mellitus (NIDDM) or adult-onset diabetes. However, the name was changed to type 2 diabetes owing to the need for insulin once the disease progresses (Daniels & Nicoll, 2011). The major pathophysiological conditions characteristic of patients with type 2 diabetes include defective beta cell secretion with the premature loss of 1st phase insulin production and insulin resistance in the peripheral tissues such as the muscles and the liver (Daniels & Nicoll, 2011). Another factor identified in type 2 diabetes is the increased production of glucose by the liver as the disease advances. This article aims at information regarding Diabetes Mellitus Type 2, including pathophysiological conditions, diagnosis, treatment and follow-up in the management of the disease. Diabetes Mellitus Type 2 (T2DM) is the most common type of the disorder. In 2014, the global prevalence of the disease was estimated to be 9% among adults that is people above the age of 18 (WHO, 2015). In 2012, approximately 1.5 million deaths were directly caused by diabetes on a global scale. In the U.S. 29.1 million Americans that is, 9.3% of the population had diabetes. The type I form of the disease was prevalent in children in 2012, whereas, 25.9% of the country’s seniors exhibited Type 2 form of the disease (ADA, 2014). In 2012, diabetes was the 7th leading cause of death in the U.S with 69,071 death certificates identifying the disease as the underlying cause of death (ADA, 2014). Approximately 234,051 death certificates listed the disease as the contributing cause of death. The Pathophysiology of the Disease Glucose is the major source of energy and is often derived from food and the liver’s ability to manufacture glucose from its glycogen stores. During the first phase of the disease, insulin secretion is regulated with the balanced production and output of glucose by the liver. The defects of the beta-cell function, results in the loss of inhibitory effects (Daniels & Nicoll, 2011). During a carbohydrate load from a meal, glucose production by the liver is not a requirement, however, owing to the loss of inhibitory effects, the liver continues to produce glucose thus contributing to a state of hyperglycemia in the body (Daniels & Nicoll, 2011). In the pre-diabetes state, the high glucose levels build up over the years and eventually triggers insulin secretion (hyperinsulinemia), for the purposes of regulating blood glucose and to counteract the tissues that are resistant to insulin. During the second phase, the beta-cells continue to secrete high levels of insulin for years to regulate blood glucose levels. Eventually, the beta-cells failure occurs resulting in a decrease in insulin production. These slow and stealthy pathophysiologic changes in type 2 diabetes occur gradually taking up to 20 years to develop (Daniell & Nicoll, 2011). There are a number of identifiable risk factors of diabetes. These factors include obesity, old age, family history of diabetes, and history of gestational diabetes, insulin resistance, impaired glucose metabolism, physical inactivity and less than optimum intrauterine environment (Daniel & Nicoll, 2011). Genetics also play a detrimental role in the development of type 2 diabetes. For example, if a twin is diagnosed with the disease then there is a 70% chance that the counterpart will develop diabetes. When it comes to environmental factors, obesity plays a leading role in the prevalence of the disease. Visceral obesity results in the accumulation of fat, particularly in the abdominal viscera. According to researchers, the adipose tissue accumulation is correlated with insulin resistance (Daniel & Nicoll, 2011). In the U.S, the ethnic groups that are significantly affected with the disease include American Indians, African Americans, Asian Americans and Hispanics (ADA, 2014). Signs & Symptoms Diabetes Mellitus tends to have an insidious onset (Porth, 2011). The disease takes time and can often be identified through routine medical check-ups or when a patient seeks medical care for other health issues. The most commonly identifiable signs and symptoms of the disease are categorised into 3. The first symptom involves excessive urination (polyuria), the second is excessive thirst (polydipsia) whereas, and the third sign is excessive hunger (polyphagia) (Porth, 2011). The three symptoms correlate with hyperglycemia and glycosuria that features in diabetes. The high levels of glucose in the blood exceed the levels that can be reabsorbed by the kidneys and results in significant losses of water that is characteristic in glycosuria. Intracellular dehydration is another early symptom that can easily be overlooked in incidences of type 2 diabetes. Contrarily, polyphagia is not present in patients as people with type 2 diabetes tend to suffer from obesity. Other key symptoms include blurred vision, fatigue and paresthesias (Porth, 2011). The blurred vision develops as the lens and retina become exposed to hyperosmolar fluids. Also, the lower plasma volumes facilitate the prevalence of fatigue and general body weakness. It is usually at the onset of these symptoms that patients seek medical care. Diagnosing the Disease Diagnosis of the disease involves the use of laboratory tests. The tests include blood tests such as the A1C tests, FPG (Fasting Plasma Glucose), Casual Plasma Glucose, Glucose Tolerance Tests and Glycosylated Hymoglobin (Porth, 2011). The blood tests are ideal in type 2 diabetes as the disease tends to exhibit no physical symptoms during its onset. Lab capillary or finger-stick glucose tests are often used for management of patients with the disease. Previously, A1C tests were used to monitor glucose levels. Currently, the tests have been standardized for the identification of pre-diabetes and Type 2 (Porth, 2011). A limitation to the use of A1C tests is that the occurrence of certain conditions in the patients can interfere with the accuracy of the tests. For example, patients with chronic kidney disease, anaemia of liver disease risk interference with the tests. Moreover, individuals from certain ethnic disparities, for example, African, Mediterranean or South East Asian descent also risk interference (Porth, 2011). People can develop diabetes at any age; however, type 2 diabetes often occurs among the aging populations. Older populations, that is, people above the age of 45 are, therefore, considered for testing (Porth, 2011). Also, younger populations, particularly obese individuals are considered for testing for the disease. Gestational diabetes (GDM) can lead to the development of type 2 diabetes. During pregnancy, insulin levels rise in an attempt to control the levels of glucose in the body. Usually, once the baby is born, GDM tends to go away; however, the prevalence of high glucose levels often leads to the development of type 2 diabetes. Through the lab tests, proper care, diagnosis and management of the disease can be realised. Non-Pharmacological Management of Diabetes Mellitus Type 2 Diabetes is a complex and progressive disease that affects not only the liver but also the pancreas. The disease also affects the skeletal muscles, adipose tissue, brain, kidney and gastrointestinal tract (Cornell, 2015). Consequentially, a variety of approaches to treatment have been adopted so as to promote the well-being of the patient. Non-pharmacological approaches entail lifestyle changes. These changes include the prescription of a healthy diet, regular exercise, management of stress and the avoidance of tobacco (Mennatallah, 2015). The adoption of a healthy diet plays a detrimental role in the management of the disease. The aims of the diet are to maintain an ideal body weight that ensures the achievement of desirable lipid profile and euglycemia (Mennatallah, 2015). Total caloric intake including a percentage intake of the various calories in carbohydrates, proteins and fat are ideal for the control of blood glucose. A healthy diet is beneficial as it reduces the dependency on drugs that is insulin, and other antibiotics. Moreover, a healthy diet reduces the development of complications related to diabetes and provides optimal nutrition during pregnancy, lactation, growth, old age and other associated conditions such as Hypertension and catabolic illnesses (Mennatallah, 2015). Physical exercise facilitates weight reduction thus contributing to the overall management of the disease. By losing weight, the patient improves the general well-being of the body and at the same time, reduces the amount of tissue requiring insulin thereby reducing the need for exogenous drugs (Ciccone , 2015). Exercise is also beneficial as it increases the sensitivity of peripheral tissues to insulin thereby making the medication more effective. Owing to the varying needs of each individual, a physical examination is necessary so as identify the intensity and frequency of exercise that the patient should undertake. Patients who engage in exercise limit the occurrence of other complications such as cardiovascular diseases thus promoting their health and well-being (Ciccone, 2015). The diagnosis of illness often results in stress in the life of an individual. The occurrence of stress in turn affects the general well-being of the individual and can contribute to other complications. Ideally, patients are expected to undergo behavioural modifications that include the adoption of a positive attitude and a healthy lifestyle. Furthermore, the treatment plan should include the adoption of coping skills, family support and a healthy workplace environment (Mennatallah, 2015). Counselling and other emotional support systems should also be included so as enable the patient to manage the disease effectively. Pharmacological Interventions The pharmacological approach is important for the effective treatment of the disease. Currently, there is no single agent that affects all seven organs and tissues involved in the pathogenesis of T2DM. A majority of the drugs target up to four of the physiologic abnormalities such as the reduction of lipids and intensive glycemic control (Cornell, 2015). Based on the ADA (America Diabetes Association) and EASD requirements, the pharmacological approach to treatment should be individualised. Furthermore, treatment intensification with a combination of therapy can be utilised if the A1C goals are not attained. Different anti-diabetic agents are put into use in this treatment approach so as to preserve the mass and function of the beta-cells for the purpose of maintaining long-term glycemic control. The pharmacological intervention involves the use of various agents, that is, the hypoglycemic and antihyperglycemic agents. If the beta-cells continue to fail in spite of the use a variety of oral treatments, then the patient is prompted to use insulin-based treatment (Mennatallah, 2015). There are various glucose-lowering drugs in the treatment of T2DM. The Oral Anti-diabetic agents include insulin sensitizers such as Biguanides, including metformin, Thiazolidinediones, rosiglitazone and pioglitazone. Insulin secretagogues include sulfonylureas, gliclazide, glipizide, glimepiride and glibenclamide (Mennatallah, 2015). Other oral treatments include the use of meglitinides including non-sulfonylurea secretagogues such as nateglinide and repaglinide. Alpha-glucosidase inhibitors, for example, acarbose, miglitol and voglibose are also included in the treatment (Mennatallah, 2015). Oral non-insulin parenteral agents are some of the novel treatments used in intervention approach. Treatments such as gliptins including sitagliptin and vitagliptin are commonly used. Furthermore, the treatment uses glucagon-like peptide 1receptor agonist, including exenatide and liraglutide (Mennatallah, 2015). There is also the use of Amylin and amylin analogs including pramlintide, and the use of Rimonabant. Insulin sensitizers work to lower blood glucose by increasing the muscles, fat and liver cells sensitivity to insulin. Thiazolidinediones (TZDs) that is glitazones: rosiglitazone and pioglitazone, are insulin sensitizers and euglycemics. The oral treatment takes time to work but is effective in normalizing blood sugar levels. The TZDs reduce insulin resistance by promoting the differentiation of pre-adipocytes into mature adipocytes (Mennatallah, 2015). This, in turn, facilitates the reduction of circulating, free fatty acids, thereby facilitating glucose utilization and limiting the availability of fatty acids. TZDs also increase the intake of glucose into the adipose tissue and skeletal muscle via the increased availability of GLUT 4 glucose transporters (Mennatallah, 2015). Issues arising in the use of Pharmacological Treatments The side effects characteristic of the various agents used in the treatment is a major issue in the management of the disease. For example, some of the TZD drugs, such as rosiglitazone, Avandia® have been reported to contribute to the occurrence of cardiovascular disease (Kennedy, 2015). Currently, the United States FDA has limited the use of this medication by patients particularly individuals who have failed therapy with other medications, or who fail to take pioglitazone. In some European countries, the use of pioglitazone, Actos® has been limited owing to the increased risk of bladder cancer (Kennedy, 2015). Other side effects involved with TZDs include weight gain and fluid retention particularly with patients taking insulin and insulin secretagogues. Furthermore, the medication has also been linked with the significant rise in congestive heart failure. TZDs increase the amount of certain fat particles, called LDL thereby increasing the risk for complications. When it comes to women, the medication can lead to bone fractures (Kennedy, 2015). The Best Approach to Treatment The best approach to the treatment of the disease involves a combination of various intervention strategies. For example, treatment can involve the use of pharmacological strategies such as the oral intake of drugs coupled with non-pharmacological approaches such as exercise and adopting a healthy diet. Exercise facilitates weight loss, lowers blood pressure and improves the body’s ability to respond to insulin. The rationale for the treatment majorly involves the elimination of symptoms and prevention of further complications. Owing to the progressive and complex nature of the disease physicians are advised to establish individualised glycemic goals and treatment regimens that suit the needs of each patient. Focussing on the reduction of glucose levels is not an ideal strategy and can eventually result in the development of complications. Resultantly, the treatment selected can include the achievement of a variety of goals such as glycemia, blood pressure and lipids reduction. Regular lab assessments and monitoring for complications is advisable so as to detect the occurrence of any side effects or complications promptly. Furthermore, patients should be informed on the appropriate self-monitoring techniques for blood glucose. The treatment of T2DM involves the control of blood glucose to a near normal level. The ideal levels involve pre-prandial levels of 90-130 mg/dL and hemoglobin A1C [HbA1c] levels < 7% (Khadori & Griffin, 2015). Prior to the treatment, physicians are required to conduct a risk stratification so as to incorporate the most appropriate treatment plan for the patient. For example, patients with advanced type 2 diabetes have a high risk for cardiovascular disease. Resultantly, lowering HbA1c to 6% or lower may increase the risk of cardiovascular events in the patients with advanced type 2 diabetes (Khadori & Griffin, 2015). The Issue of Side Effects and Safety of Treatment A majority of the drugs used in the treatment of T2DM have significant side effects and can contribute to the development of other complications. For example, Metformin is often associated with lactic acidosis, nausea and acute diarrhoea. Also, patients with medical conditions such as kidney failure, heart disease or liver problems together with individuals who consume alcohol are not expected to take Metformin (Mennatallah, 2015). The consumption of Sulfonylureas can lead to the development of hypoglycaemia. Ideally, it is the risk factors associated with the intake of existing drugs that has contributed to a plethora of research to identify new mechanisms to the treatment of the disease. Currently, researchers seek to identify new approaches to the treatment of T2DM. For example, the use of compounds that inhibit sodium-glucose cotransporter 2(SGLT2) is a recent approach that consists of some benefits. This insulin independent treatment facilitates the improvement of glycemic control, lower fasting of glucose concentration and promotes weight loss in patients (Cornell, 2015). Moreover, the treatment is beneficial as it can be utilised together with a combination of therapies so as to optimize treatment. SGLT2 treatment functions by increasing urinary glucose excretion in the setting of hyperglycaemia. A major disadvantage of this treatment approach is that the SGLT2 inhibitors are dependent on the filtration of glucose by the kidney (Cornell, 2015). Resultantly, as glomerular filtration declines, the amount of filtered glucose is reduced which eventually decreases the efficacy of the drugs. Current research, particularly in the fields of Bioinformatics and cheminformatics, seeks to identify the efficacy of drugs on aging populations. According to recent research, Sirtuins have been linked to the process of regulation of aging, transcription, apoptosis and stress resistance (Khadori, 2015). The drug facilitates the regulation of metabolic processes including cellular defence mechanisms. The incorporation of Sitruin treatment provides detrimental effects in the management of the disease particularly amongst the aging populations. Primary-Care Follow-up for Diabetes Mellitus Type 2 T2DM requires continual medical care and patient self-management education so as to ensure wellness and prevent the occurrence of complications. A team of heath care practitioners such as nurses, dieticians, pharmacists including mental health professionals with experience in the treatment of the disease should be involved in the development of a treatment and a follow-up plan that best suits the programme of the patient, for example, their work or school schedule. It is important to incorporate the involvement the support of family members for the patient for the purpose of providing the much-needed support. The follow-up involves a series of lab tests for the purpose of checking for complications and the development of other diseases. Physicians also monitor the patient’s blood pressure, lipids and eye screening so as to facilitate prompt identification for the advancement of the disease. Patient involvement and self-management including the adoption of lifestyle changes greatly facilitates the achievement of the set treatment goals in the management of the disease. Referral for Diabetes Management In some instances, the patient and the physician may fail to achieve the relevant treatment goals. The reasons for failure may include lack of treatment initiation and intensification, patient non-adherence and progressive decline in beta-cell function (Cornell, 2015). In such instances, alternative actions can be adopted such as enhanced diabetes self-management education, co-management with the health care diabetes team and change in pharmacological therapy (Khadori, 2015). Also, self-monitoring strategies for blood glucose level and more frequent contact with the patient are effective approaches for dealing with the issue. References ADA (2014). Statistics about diabetes. Retrieved from http://www.diabetes.org Ciccone, C. D. (2015). Pharmacology in Rehabilitation. F.A. Davis. Cornell, S. (2015). Continual evolution of type 2 diabetes: An update on pathophysiology and emerging treatment options. Therapeutics & Clinical Risk Management, 11621-632. doi:10.2147/TCRM.S67387 Daniels, R., & Nicoll, L. (2011). Contemporary medical-Surgical nursing. Cengage Learning. Kaladhar, D. (2011). Computational studies of sirtuins in the treatment of type 2 diabetes mellitus. Journal of Pharmaceutical Research & Health Care, 3(2), 38-42. Kennedy, M. N. (2015). Insulin sensitizers: Diabetes education online. Retrieved from http://dtc.ucsf.edu Khadori, R., &Griffin, G. T. (2015). Type 2 diabetes mellitus treatment & management. Retrieved from http://emedicine.medscape.com Mennatallah. A., (2015). A new approach in type 2 diabetes mellitus treatment: Evaluation of the beneficial effect of L-cysteine in the treatment of type 2 diabetes mellitus. Anchor Academic Publishing. Porth, C. (2011). Essentials of pathophysiology: Concepts of altered health states. Lippincott Williams & Wilkins. WHO (2015). Diabetes fact sheet. Retrieved from http://www.who.int Read More