Chidinma Response Essay

Chidinma Response Essay

 Chidinma Response Essay

Your discussion about diabetes and drug treatments is informative since you have covered the topic extensively. It is good that you have started the discussion by defining what diabetes is and what causes it. According to Kreider (2019), diabetes is a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood. Diabetes is prevalent in the country; hence, developing effective preventive and curative measures is important.

Indeed, type 1 diabetes is not very common since it only accounts for about 5% of all diabetes cases. You should have indicated that type 1 diabetes is caused by an autoimmune reaction whereby the body attacks itself by mistake. On the other hand, type 2 diabetes is the most common form of diabetes. According to Serbis et al. (2021), type 2 diabetes accounts for 90-95% of all diabetes cases in the country. Diabetes 2 occurs when the body fails to produce enough or resists insulin. Insulin therapy is the most common treatment method for type 2 diabetes (Serbis et al., 2021). Therefore, the healthcare sector needs to develop more preventive measures that can help curb these diseases.

            The medication you have given that is used when one is suffering from type 2 diabetes is very effective. It is imperative to start treatment immediately, and Metformin must be given immediately after the diagnosis (Kreider, 2019). The health practitioner should give the right dosage of tablets or oral solution. Proper instructions like taking medication with the morning and evening meals must also be issued, enhancing the medication’s efficiency.

            Just like most lifestyle diseases, diabetes requires one to change their diet so that treatment can be more effective. I like your highlighted points explaining how the diet works with the given treatment. For example, you have indicated that grapefruit leads to negative interactions with some medications. Following this, the patients should be instructed not to consume a lot of grapefruits. You should also have included that engaging in lifestyle practices like walking, jogging, dancing, or swimming is important (Serbis et al., 2021). This keeps the body active; hence the medicine will be absorbed efficiently. I like the dietary guidelines you included in your discussion since they are readily available.

            There are both long-term and short-term effects of type 2 diabetes. Some short-term effects include general body weakness, fainting, seizures, and sweating (Kreider, 2019). Patients should control their blood sugar levels to prevent more serious complications from developing. The most common long-term effect of diabetes 2 is diabetic eye disease, where the patient’s vessels in the eye are damaged, hence poor vision or even blindness.

            It is good that you highlighted the drug treatments’ main effects. Gastrointestinal effects can be mild, transient, and reversible after the dose. Also, some patients suffer from Vitamin B12 deficiency since Metformin reduces the intestinal absorption of Vitamin B12. The healthcare provider needs to discuss these effects with the patients. You should have indicated that some patients suffer from gas, bloating, and diarrhea after taking the Alpha-glucosidase inhibitors (Kreider, 2019). Also, if the effects are extreme, the patient should inform the doctor so that better treatment can be provided with minimal effects. Your discussion is excellent; you have explained all aspects of diabetes, including its treatment.

References

Kreider, K. A. (2019). The Diagnosis and Management of Atypical Types of Diabetes. The Journal of Nurse Practitioners, 15(2), 171-176. DOI:https://doi.org/10.1016/j.nurpra.2018.09.022

Serbis, A., Giapros, V., Kotanidou, E. P., Tsinopoulou, A. G., & Siomou, E. (2021). Diagnosis, Treatment and Prevention of type 2 Diabetes Mellitus in Children and Adolescents. World Journal of Diabetes, 12(4), 344-365. Doi: 10.4239/wjd.v12.i4.344

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Chidinma Okwueze

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Diabetes and Drug Treatments

Diabetes is primarily a disorder of carbohydrate metabolism. There is an often-overlooked point about diabetes: in addition to affecting carbohydrate metabolism, insulin deficiency disrupts the metabolism of proteins and lipids. Symptoms mainly result from a deficiency of insulin or from cellular resistance to insulin’s actions. The principal sign of diabetes is sustained hyperglycemia, which results from impaired glucose uptake by cells and increased glucose production.

In the United States, diabetes is the most common endocrine disorder and the seventh leading cause of death by disease. According to the National Diabetes Statistics Report, compiled by the Centers for Disease Control and Prevention {CDC} (2022a), over 37 million Americans have diabetes, and nearly one-fourth of them have not been diagnosed. An estimated 96 million US adults have prediabetes and are at increased risk for developing diabetes in the future. We need to do a better job of diagnosing diabetes and treating it—and we need to do what we can to reduce the risk of developing the disease in the first place. Unfortunately, the risk of developing diabetes is largely genetic, a factor that can’t be modified. Nonetheless, we can still reduce risk significantly by adopting a healthy lifestyle centered on engaging in physical activity and establishing a healthy diet.

Types of Diabetes

Type 1 diabetes accounts for about 5% of all diabetes cases. In the past, type 1 diabetes was called juvenile-onset diabetes mellitus or insulin-dependent diabetes mellitus (IDDM). However, these terms have fallen out of favor because type 2 diabetes is becoming more common in children, and many people with type 2 diabetes use insulin to manage their diabetes. Generally, type 1 diabetes develops during childhood or adolescence, and symptom onset is relatively abrupt. However, type 1 diabetes can develop during adulthood. The primary defect in type 1 diabetes is the destruction of pancreatic beta cells—the cells responsible for insulin synthesis and release into the bloodstream. Beta cell destruction is the result of an autoimmune process. The trigger for this immune response is unknown, but genetic, environmental, and infectious factors likely play a role.

Type 2 diabetes is the most prevalent form of diabetes, accounting for 90% to 95% of all diagnosed cases. The disease most commonly begins in middle age and progresses gradually. Although the underlying causes of type 2 diabetes are not entirely known, there is a strong familial association, suggesting that genetics play a role. Symptoms of type 2 diabetes usually result from a combination of insulin resistance and impaired insulin secretion. However, although insulin is still produced, its secretion is no longer tightly coupled to plasma glucose content: insulin release is delayed, and peak output is subnormal. More importantly, the target tissues of insulin (liver, muscle, adipose tissue) exhibit insulin resistance. Insulin resistance appears to result from three causes: reduced binding of insulin to its receptors, reduced receptor numbers, and reduced receptor responsiveness. Over time, hyperglycemia leads to diminished pancreatic beta cell function. Hence, insulin production and secretion eventually decline as the beta cells work harder to overcome insulin resistance within the tissues.

Although insulin therapy has greatly improved outcomes, successful management of gestational diabetes remains a challenge. Three factors contribute to the problem. First, the placenta produces hormones that antagonize insulin’s actions. Second, the production of cortisol, a hormone that promotes hyperglycemia, increases threefold during pregnancy. And third, because glucose can pass freely from the maternal to the fetal circulation, hyperglycemia in the mother will stimulate excessive insulin secretion in the fetus. The resultant hyperinsulinism can have multiple adverse effects on the fetus. Gestational diabetes appears during pregnancy and then subsides rapidly after delivery. In most cases, the diabetic state disappears almost immediately after delivery, permitting the discontinuation of insulin. However, if the diabetic state persists beyond parturition, it is no longer considered gestational and should be rediagnosed and treated accordingly.

Type 2 Diabetes

Medication

Metformin (Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet), classified chemically as a biguanide, is the drug of choice for initial therapy in most patients with type 2 diabetes. Typically, metformin is started immediately after the diagnosis of type 2 diabetes. Metformin lowers blood glucose and improves glucose tolerance in three ways. First, it inhibits glucose production in the liver. Second, it slightly reduces glucose absorption in the gut. And third, it sensitizes insulin receptors in target tissues (fat and skeletal muscle), increasing glucose uptake in response to the available insulin.

In contrast to sulfonylureas, metformin does not stimulate insulin release from the pancreas. As a result, metformin does not actively drive blood glucose levels down and hence poses little, if any, added risk for hypoglycemia when used alone. After oral dosing, metformin is absorbed rapidly from the small intestine, with peak plasma concentrations attained in two hours. Of particular interest, metformin is not metabolized. Instead, it is excreted unchanged by the kidneys. The absence of liver metabolism differentiates metformin’s pharmacokinetics from other biguanides, such as phenformin. Metformin undergoes renal excretion and has a mean plasma elimination half-life after oral administration of between 4.0 and 8.7 hours. This elimination is prolonged in renal-impaired patients and correlates with creatinine clearance (Scheen, 2018). Hence, metformin can accumulate to toxic levels in the event of renal impairment.

Metformin is available alone in immediate-release (IR) tablets (500, 850, and 1000 mg) as Glucophage; in extended-release (ER) tablets (500, 750, and 1000 mg) as Glucophage XR, Fortamet, and Glumetza; and in an oral solution (500 mg/5 mL) as Riomet. In addition, the drug is available in several fixed-dose combinations with other drugs for type 2 diabetes mellitus. With the IR tablets and oral solution, the recommended initial dosage is 500 mg twice daily (taken with the morning and evening meals) or 850 mg once daily, taken with a meal. The usual maintenance dosage is 850 mg twice daily. The maximal dosage is 850 mg 3 times a day (for adults) or 2000 mg/day (for children 10–16 years old). With the ER tablets, dosing is done once daily with the evening meal because this timing may enhance absorption owing to slower GI transit time at night.

Dietary Considerations Related to Treatment

Metformin should be taken with meals to reduce gastrointestinal side effects. Excessive alcohol intake (either short-term binge drinking or frequent consumption) should be avoided during treatment. Taking metformin with alcohol may increase the risk of a rare but severe and potentially life-threatening condition known as lactic acidosis, a buildup of lactic acid in the blood that can occasionally occur during treatment with metformin-containing products. Like metformin, alcohol can inhibit lactic acid breakdown, thereby intensifying lactic acidosis caused by metformin (UpToDate, 2023). Lactic acidosis is more likely to occur in patients with kidney or liver disease, acute or unstable congestive heart failure, or dehydration. Metformin is contraindicated in patients who actively abuse alcohol.

There’s limited research available on how having grapefruit while taking metformin affects people with type 2 diabetes. Although grapefruit juice is a good potassium and vitamin C source, it can interact with some medications (US Food & Drug Administration {FDA}, 2022). However, there is limited research evidence on how grapefruit interacts with metformin. A study by Owira & Ojewole (2009) discussed the effects of grapefruit with metformin in nondiabetic rats. Compared to the control group, the study revealed a significant increase in plasma lactic acid levels in the rats exposed to grapefruit juice and metformin. The authors concluded that although grapefruit juice may benefit diabetic patients, it may exacerbate lactic acidosis in diabetic patients taking metformin concurrently.

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Grapefruit does lead to negative interactions with some medications. However, there are no case studies in which consuming grapefruit juice while taking metformin led to adverse effects in humans. Some promising experimental evidence is that including grapefruit in diet can help promote weight loss and lower fasting glucose levels. According to Park (2021), eating whole fruits with a lower glycemic load may help glycemic control in people with type 2 diabetes. Consuming up to 133 g of fresh fruit daily may lower the risk of complications and mortality in people with diabetes. The study’s author pointed out that eating whole fruit may be protective against developing type 2 diabetes and may also replace an energy-dense snack. This is supported by Den Hartogh & Tsiani (2019) in their study that suggests that naringenin, a flavonoid found in high levels in grapefruit, has been shown to have antidiabetic properties, in addition to other health benefits. This flavonoid is associated with weight loss and improved insulin resistance. It has been found to improve hyperglycemia and high cholesterol.

General dietary guidelines for people with diabetes include consuming carbohydrates from vegetables, fruits, and whole grains. Also, avoid foods high in saturated and trans fats. Instead, consume fats from fish, nuts, and olive oil. Eating up to 35 grams of fiber from whole grains, fresh fruits, and vegetables daily may help control blood glucose levels (Reynolds, Akerman & Mann, 2020). The American Diabetes Association (2019) recommends that people with type 2 diabetes follow the US dietary guidelines for sodium intake and try to consume less than 2300 milligrams of sodium daily.

Impact of Type 2 Diabetes

Short term impact

Short-term complications can present immediate danger and must be treated quickly to avoid emergencies. The most common short-term complication of diabetes is hypoglycemia. This is defined as having a blood glucose level of below 4.0 mmol/l. Symptoms include weakness, confusion, sweating or feeling clammy, drowsiness, dizziness or lightheadedness, headaches, tingling, or numbness in hands or feet. Extremely low blood sugar can even cause fainting or seizures. it is crucial to treat hypoglycemia immediately to prevent blood glucose levels from going dangerously low when taking blood glucose-lowering medication such as insulin, sulfonylureas, and postprandial glucose regulators. Also, binge or chronic, heavy drinking while on metformin can cause extremely low blood sugars.

The hyperosmolar hyperglycemic state is a metabolic complication of diabetes characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. It most often occurs in type 2 diabetes, often in the setting of physiologic stress. Hyperosmolar hyperglycemia is diagnosed by severe hyperglycemia, hyperosmolarity, and absence of significant ketosis. Complications include coma, seizures, and death. Treatment consists of IV saline, correction of hypokalemia, and IV insulin (Karslioglu French, Donihi, & Korytkowski, 2019).

Long-term impact

Diabetic eye disease is a group of eye problems that can affect people with diabetes. These conditions include diabetic retinopathy, diabetic macular edema, cataracts, and glaucoma. Over time, diabetes can cause damage to the tiny vessels in the eyes, leading to poor vision or even blindness. Diabetes can cause damage to the kidney through many different and complicated pathways. Most of this damage is directed toward the blood vessels that filter the blood to make urine resulting in a buildup of waste in the body. If untreated, diabetic nephropathy leads to impaired kidney function, dialysis, or kidney transplant.

Over time, high blood glucose levels and high levels of fats, such as triglycerides, in the blood from diabetes can damage th nerves resulting in diabetic neuropathy. Different types of nerve damage cause different symptoms. Symptoms can range from pain and numbness in the feet to problems with the functions of your internal organs, such as your heart, bladder, and genitals. Type 2 diabetes can damage your body’s large blood vessels, causing plaque to eventually build up and potentially leading to a heart attack, stroke, or vessel blockage in the legs (peripheral vascular disease). People with diabetes are also more likely to have certain risk factors, such as high blood pressure or high cholesterol, that increase their chances of heart disease or stroke (CDC, 2022b).

Effects of Drug Treatments

Gastrointestinal

The most common side effects of metformin are gastrointestinal, including a metallic taste in the mouth, mild anorexia, nausea, abdominal discomfort, and soft bowel movements or diarrhea. These symptoms are usually mild, transient, and reversible after dose reduction or discontinuation of the drug. They are minimized by taking the medication with food. In clinical trials, approximately 5 to 8% of study subjects discontinue metformin because of gastrointestinal side effects (GRADE Study Research Group et al., 2022). Although metformin is generally well tolerated, patients taking metformin may develop gastrointestinal side effects even after many years of use. If gastrointestinal symptoms develop while taking metformin, a metformin holiday is initiated, which may lead to the resolution of symptoms. After a period of non-use, metformin may be successfully resumed at the same or a lower dose with a slow titration of the immediate-release or extended-release formulation.

Vitamin B12 deficiency

Metformin reduces intestinal absorption of vitamin B12 in about 30% of patients and lowers serum vitamin B12 concentrations in 5 to 10% of patients, but it only rarely causes megaloblastic anemia (possibly due to folic acid supplementation of the United States food supply) (Aroda et al., 2018; Dejager et al., 2018). In some patients, vitamin B12 deficiency may present as peripheral neuropathy (Bell, 2018). The dose and duration of use of metformin correlate with the risk of vitamin B12 deficiency. Owing to data that suggest vitamin B12 deficiency is often asymptomatic and anemia is not a sensitive indicator, as well as a prevalence of vitamin B12 deficiency (or borderline low levels) in metformin-treated patients that may approach 20% over five years, routine B12 monitoring or administration is reasonable in patients with poor dietary intake, absorption, or long-term (>5 years) metformin use.

Lactic acidosis

The incidence of lactic acidosis in metformin users appears to be very low (Lazarus et al., 2018). Despite its rarity, lactic acidosis related to metformin remains a concern because of the high case-fatality rate. Severe lactic acid accumulation occurs in patients with conditions that predispose them to hypo perfusion and hypoxemia (acute or progressive renal impairment, acute or progressive heart failure, acute pulmonary decompensation, sepsis, dehydration) (Zanza et al., 2022). This finding has resulted in the development of standard contraindications to metformin, including significantly impaired renal function, heart failure, liver disease, and excessive alcohol intake.

Conclusion

Diabetes mellitus is a chronic, lifelong condition that occurs due to several conditions and factors— the destruction of pancreatic beta cells, insulin resistance, impaired insulin secretion, hormonal changes, and metabolic demands of pregnancy. In the absence of contraindications, metformin is considered the initial medication of choice for hyperglycemia in type 2 diabetes. Metformin comes in two oral preparations— immediate-release (IR) tablets (500, 850, and 1000 mg) and extended-release (ER) tablets (500, 750, and 1000 mg). Metformin should be taken with meals to reduce gastrointestinal side effects, and alcohol should be avoided during treatment to reduce the risk of lactic acidosis. Short-term complications of diabetes can present immediate danger and therefore need to be treated quickly to prevent emergencies. Over time, diabetes can damage the body’s organs resulting in long-term health problems.

References

American Diabetes Association (2019). 5. lifestyle management: Standards of medical care in diabetes-2019. Diabetes Care, 42(1), 46–60

Aroda, V. R., Edelstein, S. L., Goldberg, R. B., Knowler, W. C., Marcovina, S. M., Orchard, T. J., Bray, G. A., Schade, D. S., Temprosa, M. G., White, N. H., Crandall, J. P., & Diabetes Prevention Program Research Group (2018). Long-term metformin use and vitamin B12 deficiency in the diabetes prevention program outcomes study. The Journal of Clinical Endocrinology and Metabolism, 101(4), 1754–1761

Bell D. S. (2018). Metformin-induced vitamin B12 deficiency presenting as a peripheral neuropathy. Southern Medical Journal, 103(3), 265–267.

Centers for Disease Control and Prevention {CDC} (2022a). National diabetes statistic report. Retrieved from https://www.cdc.gov/diabetes/data/statisticsreport/index.html#:~:text=Total%3A%2037.3%20million%20people%20have%20diabetes%20%2811.3%25%20of,8.5%20million%20people%20%2823.0%25%20of%20adults%20are%20undiagnosed%29Links to an external site.

Centers for Disease Control and Prevention {CDC} (2022b). Diabetes and your heart. Retrieved from https://www.cdc.gov/diabetes/library/features/diabetes-and-heart.htm

Den Hartogh, D. J., & Tsiani, E. (2019). Antidiabetic properties of naringenin: A citrus fruit polyphenol. Biomolecules, 9(3), 99

Dejager, J., Kooy, A., Lehert, P., Wulffelé, M. G., van der Kolk, J., Bets, D., Verburg, J., Donker, A. J., & Stehouwer, C. D. (2018). Long-term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: Randomised placebo controlled trial. British Medical Journal, 340(12), 2181-2190

GRADE Study Research Group, Nathan, D. M., Lachin, J. M., Balasubramanyam, A., Burch, H. B., Buse, J. B., Butera, N. M., Cohen, R. M., Crandall, J. P., Kahn, S. E., Krause-Steinrauf, H., Larkin, M. E., Rasouli, N., Tiktin, M., Wexler, D. J., & Younes, N. (2022). Glycemia reduction in type 2 diabetes – Glycemic outcomes. The New England Journal of Medicine, 387(12), 1063–1074

Karslioglu French, E., Donihi, A. C., & Korytkowski, M. T. (2019). Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: Review of acute decompensated diabetes in adult patients. British Medical Journal, 365(11), 1-26

Lazarus, B., Wu, A., Shin, J. I., Sang, Y., Alexander, G. C., Secora, A., Inker, L. A., Coresh, J., Chang, A. R., & Grams, M. E. (2018). Association of metformin use with risk of lactic acidosis across the range of kidney function: A community-based cohort study. JAMA Internal Medicine, 178(7), 903–910

Owira, P. M., & Ojewole, J. A. (2009). Grapefruit juice improves glycemic control but exacerbates metformin-induced lactic acidosis in nondiabetic rats. Methods and Findings in Experimental and Clinical Pharmacology, 31(9), 563–570

Park H. A. (2021). Fruit intake to prevent and control hypertension and diabetes. Korean Journal of Family Medicine, 42(1), 9–16

Reynolds, A. N., Akerman, A. P., & Mann, J. (2020). Dietary fiber and whole grains in diabetes management: Systematic review and meta-analyses. PLoS Medicine, 17(3), e1003053.

Scheen A. J. (2018). Clinical pharmacokinetics of metformin. Clinical pharmacokinetics, 30(5), 359–371

UpToDate (2023). Metformin in the treatment of adults with type 2 diabetes mellitus. Retrieved from https://www.uptodate.com/contents/metformin-in-the-treatment-of-adults-with-type-2-diabetes-mellitus#H3889588303

US Food & Drug Administration {FDA} (2022). Grapefruit juice and some drugs don’t mix. Retrieved from https://www.fda.gov/consumers/consumer-updates/grapefruit-juice-and-some-drugs-dont-mixLinks to an external site.

Zanza, C., Facelli, V., Romenskaya, T., Bottinelli, M., Caputo, G., Piccioni, A., Franceschi, F., Saviano, A., Ojetti, V., Savioli, G. & Longhitano, Y. (2022). Lactic acidosis related to pharmacotherapy and human diseases. Pharmaceuticals, 149(12), 1-15.