Evidence-Based Pharmacology Paper: Diabetes Mellitus Type 2

Introduction

Diabetes mellitus is a metabolic disorder that is mainly characterized by high blood sugar levels due to impaired secretion of insulin or when its action is not sufficient (sometimes, both conditions can occur). The long-term hyperglycemia often leads to damage of organs in the body, particularly the kidneys, nerves, heart, eyes, and blood vessels. The patient with high blood sugar levels suffers from increased urination, frequent feelings of thirst and hunger, impairment of vision and growth, and susceptibility to other infections. When not controlled, the condition can lead to ketoacidosis or the nonketotic hyperosmolar syndrome, which are both life-threatening issues. In the long term, the condition has complications like retinopathy, which may be accompanied by blindness, renal failure, and peripheral neuropathies that may result in amputations.

Diabetes mellitus type 2, also called noninsulin-dependent diabetes, is the most common form of the disease and accounts for 90-95% of all cases. Its onset usually happens in adulthood. The ill individuals have insulin resistance, and their insulin deficiency is relative. Unlike the type 1 diabetes, these patients do not need insulin to survive. Obesity is thought to cause a certain degree of insulin resistances. In fact, most patients with the condition are obese. Most times, the illness goes undiagnosed for several years because the development of hyperglycemia is gradual. However, the patients are still at risk of developing blood vessel complications. The risk factors for diabetes mellitus type 2 are advanced age, obesity, genetic predisposition, and lack of physical activity. It is also frequent among women with a history of gestational diabetes mellitus (GDM) and individuals with hypertension or lipid abnormalities. This evidence-based pharmacology paper will, therefore, review the diagnosis and treatment approaches for diabetes mellitus type 2.

Diagnosis of Diabetes Mellitus Type 2

The diagnostic criteria for diabetes were introduced in 1997 by the American Diabetic Association (ADA) and later updated in 2010. Three tests to measure blood glucose levels are available for the diagnosis of diabetes. The first one is fasting blood glucose level. The client will fast for eight hours, after which blood sample is taken and the test is done. The patient is positive for diabetes when blood glucose level is 126mg per deciliter (7.0 mmol per l) or greater than that on two separate occasions. The limitation of this test is the duration of fasting required and its lower sensitivity to detect any microvascular complications. The second test is random blood glucose level done at any time. A diagnosis will be made if the patient has symptoms of diabetes: polyuria, polydipsia, weight loss, fatigue and if the patient also has random blood glucose level of 200 mg per dl (11.1 mmol per l) or greater.

The final test is the oral glucose tolerance test. For this test, the patients have to also fast for eight hours. They are then given a 75g load of glucose, and after two hours, their blood samples are taken and tested. If serum blood glucose level is more than 199 mg per dl (11.0 mmol per l), the patient is positive for diabetes. Its limitations are poor reproducibility and patient compliance. The American Diabetic Association has also recently endorsed the use of glycated hemoglobin A1C. A diagnosis is made when A1C level is more than 6.5% on two different occasions. This test has an advantage because it does not require fasting. However, it is limited by racial disparities, interference by anemia, certain drugs, and its low sensitivity. Finally, the tests on beta cells function can be done to determine the etiology of diabetes, thus differentiating between the forms of diabetes mellitus. Markers of immune-mediated beta cell destruction are also indicative of the type of the condition.

Treatment of Diabetes Mellitus Type 2

Diabetes mellitus type 2 is a chronic disease that is not treated; rather, it is managed. The management involves healthy diet, physical activity, medication, and blood sugar monitoring. A healthy diet is composed of consuming food rich in fiber and low in fat such as whole grains, fruits, and vegetables. The glycemic food index is a measure of how the food causes a rise of blood sugar level. Foods that have a low index are those that contain a lot of fiber and are encouraged in the diet of a diabetic patient. As stated earlier, obesity is a major predisposing factor for diabetes mellitus type 2; therefore, physical activity is important in managing the condition. The clients should do some physical activity as part of their daily routine. It must not be major exercises: even the activities like walking, climbing the stairs, and dancing can make a difference.

There are several classes of medication used in the management of diabetes. The first one is alpha-glucosidase inhibitors. They act by aiding in the breakdown of starchy food and table sugar through inhibition of alpha-glucosidase, which is an enzyme. Examples of drugs here are acarbose and miglitol. They should be taken during meals. The second category is biguanides. They act by decreasing gluconeosynthesis in the liver and absorbing glucose in the intestines. They further make the body more sensitive to insulin and increase the muscle ability to absorb glucose. An here example is metformin. The third category is dopamine agonist with the primary drug being bromocriptine. Its mode of action implies preventing insulin resistance by affecting the rhythms of the body. The fourth category is DPP-4 inhibitors that reduce sugar in the body without causing hypoglycemia, therefore encouraging the continued production of insulin. An example of the drug is alogliptin. The fifth category is incretin mimetics, also called glucagon-like peptides. They act by promoting the growth of beta cells responsible for secretion of insulin, decreased appetite, and slow gastric emptying. Examples of drugs here are albiglutide, dulaglutide, and exenatide. The sixth category of the medication is meglitinides that encourage the body to release insulin. They are likely to cause hypoglycemia and should be taken with caution. They include nateglinide and repaglinide. The seventh category of drugs is sodium glucose transport inhibitors. They encourage the excretion of glucose in the renal tubules. An example is dapagliflozin. The eighth class is sulfonylureas. These are the oldest diabetes drugs that are still efficacious today. They stimulate the pancreas and promote the function of beta cells. An example here is glimepiride. The final category of drugs is thiazolidinediones. They decrease the glucose content in the liver and encourage the utilization of glucose in the fat cells. An example is rosiglitazone. Anyway, metformin is usually the first-line medication for diabetes mellitus type 2.

The final key component of disease management is blood sugar monitoring. Depending on the stage of the disease, the patient should check blood sugar level from time to time as prescribed by the doctor. It is important in tailoring the dosage and type of medication to be taken. It also helps to monitor for potential complications. Today, rapid testing kits that can be self-administered are available. Therefore, diabetic patients can check their blood glucose levels at the comfort of their homes.

Information in Current Literature

 With the aid of the American Diabetic Association, a lot of research has been done on diabetes. Over the years, this information has been provided to everyone through different media. Several peer-reviewed articles like those used in the current paper provide adequate information on the diagnosis, signs, symptoms, treatment, and complications of diabetes. However, there is still need for more research and literature on different drugs used in treating diabetes and on how to manage its complications.

Approaches to Treatment of DM Type 2

Lifestyle Modification

In the management of type 2 diabetes, interventions targeted towards the patient’s physical activity and food intake are critical. When diagnosed with the disease, the individuals should receive a standardized general diabetes education with the areas of focus being the diet and the need to improve physical activity. Counseling should be done from time to time so as to reinforce the therapeutic lifestyle change. Weight reduction is the key in improving the glycemic control and reducing the risk factors for cardiovascular problems. The client should establish the goal of weight reduction and weight maintenance. Nutritional counselling should be personalized. The individuals are encouraged to eat food that is healthy but consistent with their preferences and cultures. The dietary emphasis is on food rich in fiber and low in fat. The examples are fruits, vegetables, legumes, and low-fat dairy products. High-energy food like sweet snacks and desserts are discouraged.

The patient should take part in as much physical activity as possible. Moderate exercising such as aerobics, resistance, and flexibility training is recommended. Older patients or those with mobility problems may have challenges while adjusting their physical activity. However, they should try to increase their fitness through simple activities like climbing the stairs, walking, and doing house chores. It should be done with caution, particularly for those with cardiovascular problems. With diagnosis, motivated patients with low A1C levels can start their lifestyle modification for 3 to 6 months before they are subjected to medication. On the contrary, those with moderate hyperglycemia or for whom lifestyle intervention is projected to be unproductive start to take medication, usually metformin, immediately. These patients are monitored, and adjustments are made later if their lifestyle changes produce positive results.

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Medication

According to Qaseem et al. (2012), pharmacological therapy is an important component in the management of diabetes mellitus type 2. No research has been done on the recommended time of starting the medication for a patient. However, the following factors should be considered: life expectancy, presence of micro or macrovascular complications, the risk for complications related to glucose control, and patient’s preferences. Metformin is the first-line drug used here. It confirms high efficacy in controlling blood sugar level and does not result in weight gain. Instead, it helps to decrease weight and curtails the level of low-density lipoprotein (LDL) cholesterol and triglyceride. It is associated with fewer hypoglycemic events and is cheaper than most diabetic drugs. Nevertheless, it is contraindicated among patients with kidney problems, hemodynamic instability, liver conditions, excessive alcoholic consumption, heart issues, and any other conditions that result in lactic acidosis.

After monotherapy with metformin, a dual-therapy is introduced if hyperglycemia is persistent. Here, an example of medication is the combination of metformin and alogliptin ( i.g. a DPP-4 inhibitor). All dual therapies are more efficacious than monotherapies (Qaseem et al., 2012). Triple therapy combinations are also available and are used when dual therapy is unresponsive. In case hyperglycemia still persists while having pharmacologic therapy and lifestyle modification, the patient may need insulin therapy. Insulin is introduced in small doses unless there is severe hyperglycemia. Basal insulin is used with an initial dose of 0.1-0.2 u/kg body weight. It is given in combination with one or two drugs.

Surgery

Diabetes mellitus type 2 is considered a chronic and progressive disease. Its pathology goes hand in hand with obesity. Bariatric surgery is a procedure done on the stomach and intestines to induce weight loss. Nearly everyone who has had the procedure done shows an improvement in their diabetic state. In some cases, it results in total remission of the disease. Although the mechanism of action is not yet clear, the rearrangement of the gastrointestinal tract after the surgery causes antidiabetic effects exceeding those provided by dietary restrictions and body weight control (Keidar, 2011). According to the American Diabetes Association (2016), bariatric surgeries are recommended for adult patients with BMI (kg/m²) of more than 35 only.

Choice of Treatment Option

Although all three approaches are effective in controlling diabetes, lifestyle changes in combination with medication are the preferred choice of treatment. Both way are affordable and have minimum side effects. The American Diabetic Association (2016) presents approaches to glycemic treatment, which highlight the above as the preferred treatment. The work is based on research and clinical trials. The association is in charge of funding research to promote management of the condition, provide information, and champion the rights of patients diagnosed with diabetes. It has been in operation for 75years now.

Follow-up Plan and Referral

Following diagnosis with diabetes, the healthcare provider counsels the patient on medication, diet, physical activity, and monitoring of blood glucose level. According to the American Association of Diabetes Educators (2016), only 85% of patients take medication as prescribed, 45% of them monitor their blood glucose level as told, and 24-27% follow instructions on exercise and weight loss. It is, therefore, vital to conduct follow-up on patients. In the first year following the diagnosis, the patient should have at least 10 hours of counselling sessions distributed evenly throughout the year. The subsequent years are less demanding; but depending on the client’s abilities and preferences, counselling sessions can be continued. Currently, there are special care providers called diabetes educators, who offer these crucial services. The diabetic educators have knowledge on the disease and dedicate their time to address the patients’ problems. However, the primary care provider must keep contact with both the educator and the client to ensure progress is achieved.

Conclusion

Diabetes mellitus type 2 accounts for a majority of the cases of diabetes and is among the leading causes of death in the United States. It is diagnosed by assessing the blood glucose and glycated hemoglobin levels. The risk factors for developing the disease are advanced age, genetics, and sedentary lifestyle. Currently, the approaches to the treatment of the disease are medication, lifestyle changes, and surgery. The first-line drug for treatment of diabetes is metformin from the biguanides class. The use of dual and triple therapies is recommended when monotherapy fails to work. Lifestyle modification chiefly involves dietary restrictions and exercising. In the recent past, bariatric surgery has been particularly adopted as a way of managing diabetes mellitus type 2. However, it is only used with adults who are extremely obese. Follow-up care is vital in the management of diabetes because the levels of adherence to the instructions are low. In summary, the interventions available for the management of diabetes mellitus type 2 are effective and efficient.