Week 5: Endocrine System Disorders and the Treatment of Diabetes

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            Essentially, diabetes is a disorder of carbohydrate metabolism (Rosenthal, L. D., & Burchum, J. R., 2018). Symptoms of diabetes are caused by cellular insulin resistance, or a deficiency of insulin and the primary sign of diabetes is sustained hyperglycemia due to increased glucose production and impaired glucose uptake (Rosenthal, L. D., & Burchum, J. R., 2018).

Based on etiology and clinical presentations, diabetes is broadly classified into three types, type 1 diabetes, type 2 diabetes, and gestational diabetes (GDM). Monogenic diabetes and secondary diabetes are other types of diabetes, but are less common (Goyal, R., & Jialal, I., 2021).

Brief explanation of the differences between Types of Diabetes Mellitus

            Type 1 diabetes was previously called juvenile diabetes (because it was thought to develop only in juveniles) or insulin-dependent diabetes (Centers for Disease Control and Prevention., 2021). Type 1 diabetes can develop at any age in life, but it is mostly diagnosed in childhood or adolescence stage of life (Centers for Disease Control and Prevention., 2021). Type 1 diabetes characterized by autoimmune destruction of beta cells in the islets of the pancreas which are responsible for producing insulin (Goyal, R., & Jialal, I., 2021). The result is absolute deficiency of insulin (Goyal, R., & Jialal, I., 2021). The autoimmune activities are thought to be triggered by genetic and environmental factors (Goyal, R., & Jialal, I., 2021).

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes most common with type 1 diabetes, where in the absence of insulin to provide the cells with sugar, the body breaks down fat for energy and the by-product of ketone bodies (Centers for Disease Control and Prevention., 2021).

Type 2 Diabetes Mellitus

            Type 2 diabetes mellitus (T2DM) accounts for 90% to 95% of diagnosed cases of diabetes (Rosenthal, L. D., & Burchum, J. R., 2018). Unlike type 1, T2DM are capable of producing insulin, but just not enough. T2DM is more frequently diagnose in middle age and progresses gradually (Rosenthal, L. D., & Burchum, J. R., 2018). But essentially, the symptoms of T2DM are primarily from combination of insulin resistance and impaired insulin secretion (Rosenthal, L. D., & Burchum, J. R., 2018). Also, unlike type 1 diabetes, T2DM are at risk of Hyperosmolar hyperglycemic syndrome (HHS) a serious and life-threatening complication of type 2 diabetes (Kondamudi, A. A., 2021). long term complications of T2DM are like those of type 1 and they include impairment of organs that creates susceptibility to stroke, retinopathy, heart disease, neuropathy, and nephropathy (Bonikowska, I., et al., 2021).

Gestational Diabetes Mellitus:

            Unlike other types of diabetes, gestational diabetes mellitus (GDM) is hyperglycemia, that first develops during pregnancy, usually in the second and third trimesters. (Goyal, R., & Jialal, I., 2021). Gestational diabetes happens due to the changes and processes in pregnancy which causes the body to require more insulin and impairs the patient’s ability to use insulin effectively, a condition known as insulin resistance (Centers for Disease Control and Prevention., 2021).

Monogenic Diabetes

            Unlike other types of diabetes, monogenic diabetes is caused by a single mutation in an autosomal dominant gene (Goyal, R., & Jialal, I., 2021). In most cases monogenic diabetes presents before 25 years of age, and it is thought to be genetic (Goyal, R., & Jialal, I., 2021). Examples of monogenic diabetes are neonatal diabetes mellitus and maturity-onset diabetes of the young (Goyal, R., & Jialal, I., 2021).

Secondary Diabetes

            Unlike other types of diabetes, secondary diabetes as the name depicts happens because of other diseases affecting the pancreas or could be drug induced (Goyal, R., & Jialal, I., 2021). Factors that cause secondary diabetes are drugs like corticosteroids, or diseases like pancreatitis, or Cushing disease (Goyal, R., & Jialal, I., 2021).

Diet Interventions and in Gestational Diabetes Mellitus

            In addition to glucose monitoring, nutritional interventions in diet are an important part of treatment and management of gestational diabetes (Dolatkhah, N., et al., 2018). Treatment guidelines for patients with GDM have advised that patients with GDM should be referred to a nutritionist for specialized medical nutrition therapy (MNT) to plan the patients’ meals with controlled carbohydrate levels to adequately fulfill nutritional needs and prevents Ketosis (Neda Dolatkhah, et al., 2018).

Metformin Administration in Gestational Diabetes Mellitus

            Metformin does not actively reduce blood glucose levels and does not stimulate insulin release from the pancreas (Rosenthal, L. D., & Burchum, J. R., 2018). It lowers blood sugar by inhibiting glucose production in the liver, reducing absorption of glucose in the gut and increases glucose uptake by sensitizes insulin receptors in target tissues. Therefore, there is low risk of hypoglycemia with metformin (Rosenthal, L. D., & Burchum, J. R., 2018). Using metformin in GDM has similar effective outcomes with patients who used insulin to manage their GDM (Rosenthal, L. D., & Burchum, J. R., 2018).

            Metformin is available in immediate release (IR) as Glucophage in 500, 850, and

1000 mg; extended release (ER) Glucophage XR, Fortamet, and Glumetza in 500, 750, and 1000 mg, and in an oral solution as Riomet in 500 mg/5 mL (Rosenthal, L. D., & Burchum, J. R., 2018). Metformin is also available in fixed-dose combinations with other diabetes medication. For 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 (Rosenthal, L. D., & Burchum, J. R., 2018). Recommended maintenance dose is 850 mg twice daily (Rosenthal, L. D., & Burchum, J. R., 2018). Recommended highest dosage is 850 mg 3 times a day (for adults) or 2000 mg/day (for children 10–16 years old) (Rosenthal, L. D., & Burchum, J. R., 2018). Recommended dose for ER tablets is initial dose of 500 mg daily or 1000mg daily for Fortamet (Rosenthal, L. D., & Burchum, J. R., 2018). Recommended highest dose for ER is 2000 mg (or 2500 mg for Fortamet and ER should be taken with evening meals to enhance absorption (Rosenthal, L. D., & Burchum, J. R., 2018).

Short-Term and Long-Term Impact of Gestational Diabetes and Effects of Metformin Treatment

            Possible short-term outcomes for GDM patient are hypertension, preeclampsia, hydramnios, macrosomia which may lead to early childbirth and cesarean section (Goyal, R., & Jialal, I., 2021).

Possible fetal short-term outcomes in GDM includes respiratory distress syndrome, hypoglycemia following birth, risk of shoulder dystocia, congenital anomalies and neonatal admission following birth (Goyal, R., & Jialal, I., 2021).

Long-term outcomes of GDM for the patient includes increased chances of obesity, hypertension, diabetes type II and subsequent gestational diabetes (Goyal, R., & Jialal, I., 2021). Long-term fetal outcomes of GDM are increased chances of respiratory distress syndrome, congenital anomalies, cardiometabolic problems, obesity, and diabetes type II (Murray, SR, Reynolds, RM., 2020).

            Short-term effects of metformin include gastrointestinal (GI) side effects, possible drug interactions with alcohol, cimetidine, and iodinated radio contrast media, or possible risk of lactic acidosis (Rosenthal, L. D., & Burchum, J. R., 2018). Also, because metformin is capable crossing the placenta it has similar concentrations in fetal as with maternal circulations (Murray, SR, Reynolds, RM., 2020).

Long-term effects of metformin include, possible renal complications, also metformin has Blackbox warning of severe metabolic acidosis when metformin accumulates in the body (Rosenthal, L. D., & Burchum, J. R., 2018). Metformin has drug interactions with alcohol, cimetidine, and iodinated radio contrast media (Rosenthal, L. D., & Burchum, J. R., 2018).

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