Diabetes mellitus Type II is an endocrine disorder that results from the resistance of tissues to the actions of insulin, inadequate secretion of insulin, and/or the excessive secretion of glucagon. Insufficient insulin discharge and increased hormone tissue resistance lead to poor glucose utilization and consequently hyperglycemia, which refers to high plasma glucose levels beyond the normal limits (70-100 mg/dL).
The condition’s onset is prominent in the older population and usually manifests after the age of 40. Chronic illness or poor management of the condition can lead to microvascular and macrovascular complications. Microvascular complications include retinopathy, nephropathy, and neuropathy while macrovascular complications encompass cerebrovascular disorders, heart conditions, vascular diseases, and organ and tissue damage. Therefore, as the paper reveals, early diagnosis and proper management are essential elements in the prognosis of the condition.
Pathophysiology and Implications of Age Continuum of the Disease
Type II diabetes is caused by a combination of amplified tissue struggle to insulin, scarce insulin emission, or the surplus secretion of glucagon. The results include elevated levels of free fatty acid, decreased glucose utilization by tissues, disproportionate glucose production, and decreased breakdown of fats. In addition, an increase in glucagon production will consequently lead to surplus glucose emission in hepatic cells (gluconeogenesis). According to Barnett (2012), both insulin resistance and unsatisfactory secretion of insulin are determinant factors in the pathophysiology of the condition.
Decreased insulin secretion results from the dysfunction of pancreatic beta cells responsible for producing insulin in reaction to the increased blood glucose levels. Insulin resistance comes about when tissue cells fail to respond to the actions of insulin, including the breakdown of glucose into ATP energy, the transformation of fatty acids and proteins into amino acids. This reduced glucose utilization leads to its accumulation in blood and the resultant deficiency in energy production. The risk of developing the condition increases with age.
Thus, the condition is also referred to as the late onset diabetes mellitus (George, Augustine, & Sebastian, 2016). This age continuum may be due to the combined effects of impaired insulin secretion and increased insulin resistance resulting from amplified abdominal fat, sarcopenia, decreased physical activity, hormonal changes, increased inflammation, and oxidative processes. The prevalence of these processes is high between the third and fourth decades of life, thus explaining the late onset of the condition.
Literature Review on Diagnosis and Management
According to the American Diabetes Association (2015), the criteria for the diagnosis of the condition involves the combined use of the clinical history of signs and symptoms, age factor, the presence of comorbidities, the measurement of BM, and the carrying out of diagnostic tests. Analytical assessments that should be carried out include FPG, OGTT, and hemoglobin AIC tests.
According to Elliot (2012), the advantage of the Fasting Plasma Glucose (FPG) investigation is that it is convenient, fast, easier, and less expensive to carry out. The test requires the patient to fast for a period of at least 12 to 24 hours after which a sample of his or her blood is taken and the glucose level in plasma measured. Normal FPG levels range between 70 to 100 mg/dl. An FPG level below 70 mg/dl symptomizes hypoglycemia where blood glucose capacity is hazardously low. On the other hand, FPG levels that are between 100 mg/dl and 126 mg/dl are an indication of a hyperglycemic state and consequently a risk factor for developing full-blown disease. Levels above 126 mg/dl are diagnostic of diabetes mellitus.
The oral glucose tolerance test (OGTT) should be effected when the fasting glucose test is not sufficient to provide a definitive diagnosis for the condition. The test is performed by giving the patient 75 grams of oral glucose after 8 – 12 hours of fasting and measuring the levels of the substance in plasma following two hours after its administration. In non-diabetic individuals, the levels of plasma glucose will indicate values below 140 mg/dl whereas any amount between 140 and 200 mg/dl or above 200 mg/dl are diagnostic of pre-diabetes and diabetes respectively.
The hemoglobin AIC test measures a person’s ability to control the levels of blood glucose over a prolonged period, usually 2 to 3 months. The test is based on research findings from Elliot’s (2012) work concerning glucose attachment to hemoglobin in red blood cells. Elliot (2012) reveals that higher levels of glucose in plasma indicate its availability for binding to hemoglobin. Besides, once glucose binds to hemoglobin, it will remain attached throughout the life cycle of the red blood cell, which is usually 120 days or 4 months. Medical scientists have developed the AIC test based on this knowledge. The test measures the amount of glucose that is bound to hemoglobin. The test results are expressed as a percentage of the amount of glucose that has been attached to hemoglobin. For normal persons, the levels are 4 to 4.5 percent. Levels that range between 6 and 6.5 are indicative of a pre-diabetic state while levels above 6.5 after two separate tests are diagnostic of the condition.
Regarding the management of the disease, Guglielmo, Alldredge, Ernst, and Jacobson (2012) highlight specific goals of therapy for persons diagnosed with diabetes Type II. The goals include the elimination of symptoms caused by hyperglycemia, avoiding hypoglycemic state, reducing risks associated with the cardiovascular system, and averting or slowing the progression of macrovascular and microvascular complications. The American Diabetic Association (2015) obtained significant evidence from a study carried out by UKPDS on Type II diabetes patients.
The report demonstrated that improved glucose control in diabetic patients reduced the risk of developing complications. Preliminary data obtained from ACCORD trial, as highlighted by Gerstein, Miller, Ismail-Beigi, Largay, and McDonald (2014), indicated that a thorough assessment of patients with Type II diabetes mellitus should be carried out before defining a treatment plan. For instance, in elderly patients and patients with cerebrovascular disorders, less aggressive HbAIC goals should be contemplated.
The initial therapy of Type II diabetic patients should be aimed at changing their lifestyle habits that may have been attributed to their high insulin resistance. The therapy includes dietary changes, the avoidance of alcohol, reduction in carbohydrate and fat intake, an increase in physical activity, and smoking cessation for smokers. Moreover, the physician should manage the patient for comorbidities such as hypertension and dyslipidemias. The rationale for this non-pharmacological approach, as Guglielmo et al. (2012) explain, is that conditions such as obesity are associated with an increased resistance of tissues to insulin.
Initial pharmacological therapy involves prescribing metformin. The American Diabetics Association (2015) suggests an algorithmic plan whereby metformin is initiated together with lifestyle control because of the observed cases of failure to control hyperglycemia in monotherapy. Metformin lowers blood glucose by directly reducing the hepatic glucose output and indirectly reducing the resistance to insulin. In the case of failed glycemic control with metformin, other anti-diabetic drugs should be considered as monotherapy and/or combined psychoanalysis with metformin. The medication includes sulfonylureas, thiazolidinediones, dipeptidyl peptidase 4 inhibitors, sodium glucose co-transporter 2 inhibitors, and glucagon, for instance, peptide 1 antagonists and insulin regimens.
Assumptions in the Diagnosis and Management of Type II Diabetes Mellitus
Physicians have used HbAIC as a diagnostic and monitoring tool for diabetes Type II. However, questions have been raised regarding the verifiable assumptions in its applicability. Research carried out by Kapadia (2013) questions the use of HbAIC as a criterion for the diagnosis of pre-diabetics and Type II diabetics. The criterion is based on the existing evidence indicating various differences between the results obtained for HbAIC and the fasting plasma glucose test. Such gap necessitates the establishment of a cause to improve the accuracy and reliability of the test. Similarly, a separate study carried out by Kapadia (2013) asserted the lack of a definitive applicability of the HbAIC criterion for the diagnosis of Type II diabetes in persons below the age of 40, particularly young adults.
A major issue identified in the management of Type II diabetes has been the advocacy for the initial use of monotherapy in early stages of the disease with the subsequent gradual addition of more drugs in the case of treatment failure or inadequate response. However, Phung, Sobieraj, Engel, and Rajpathak (2014) argue that early combination therapy may improve the health outcomes and/or reduce incidences of treatment failure. In a separate study, Freeman (2013) set to establish the advantages of initial combined therapy of metformin and linagliptin in the management outcomes of diabetes Type II compared to monotherapy with either metformin or linagliptin. According to Freeman (2013), combined therapy should include drugs from different classes with diverse mechanisms for actions to achieve optimal therapeutic outcomes. Moreover, the drugs used should target the fundamental pathophysiological mechanisms that lead to the development of the condition.
Approaches that Address the Diagnostic and Management Assumptions
According to the results obtained from a study carried out by Cosson et al. (2013), gaps in hemoglobin glycosylation could explain the discrepancies between HbA1C tests and blood glucose tests such as FPG and OGTT. Zafon, Ciudin, Valladares, Mesa, and Simo (2013) also carried out a separate study on 508 Type II diabetes mellitus patients to determine the variables responsible for glycosylation gaps. The study results indicated that patients with high serum levels of creatinine, high mean corpuscular hemoglobin, and metformin treatment were more likely to have glycosylation gaps. Due to such factors that affect the accuracy and sensitivity of HbAIC test, Olokoba (2012) recommends the use of more than one test to confirm the diagnosis and treatment response of a patient. Ideally, the physician should incorporate the use at least two other methods of diagnosis, for instance, FPG and OGTT, to improve the screening outcomes.
The management of Type II diabetes can be quite complex, with fewer than anticipated patients achieving and maintaining the recommended target levels of HbA1C and blood glucose. A study carried out by Freeman (2013) established that adequate glycemic control is seen in patients who receive a combination therapy of linagliptin and metformin compared to erratic glycemic control in patients on monotherapy with either linagliptin or metformin. This finding holds because of the synergistic pharmacological action stemming from the different but complementary mechanisms of the action of the two drugs.
Citing Freeman’s (2013) study as an example, metformin acts by increasing the insulin sensitivity of the hepatic cells, thus allowing them to increase their utilization of glucose. The process helps to reduce the blood glucose levels. Contextually, linagliptin, which is a dipeptidyl peptidase 4 inhibitor, acts by inhibiting the degradation of GLP1 and GIP with the resultant increase in the endogenous incretins. In turn, the increase in hormones stimulates the postprandial glucose-dependent insulin secretion, thus increasing its utilization. Therefore, both drugs complement each other by enhancing glucose utilization.
Two Major Approaches to the Treatment of the Condition
According to Bagchi and Sreejayan (2012), a holistic approach entails addressing all aspects of managing the condition in a complementary fashion through the incorporation of treatment of short-term complications while preventing long-term problems. This approach includes the management of comorbidities such as cardiovascular conditions, hypertension, dyslipidemias, and cerebrovascular complications. Most of the comorbidities in Type II diabetes are associated with lifestyle habits, for instance, bad dietary habits, cigarette smoking, alcoholism, and sedentary lifestyle. Lifestyle can also explain the reason for obesity as a symptom in most patients with Type II diabetes. Therefore, physicians should encourage patients to adopt healthier lifestyles that can improve their treatment outcomes. Additionally, Guglielmo et al. (2012) assert that most of the comorbidities, particularly dyslipidemias and hypertension, play a significant role in increasing tissue resistance to the actions of endogenous insulin. Therefore, the management of other associated conditions is also essential in improving the body’s response to medication.
The American Diabetes Association (2015) suggests a stepwise approach to the management of Type II diabetes mellitus. This conventional approach involves the stepwise selection of medications based on the glycemic control. The addition of drugs should be done whenever HbA1C levels record above the recommended limits of 6 and 6.5 percent. The increment should be done as soon as treatment failure is established since this move will prevent disease progression. A challenge to this approach would be delayed the addition of drugs possibly due to potential side effects posed by some of the second line drugs and/or due to drug-drug interactions.
Supportive Evidence for Suggested Approaches
Patient education and patient-centered care are the cornerstones of the holistic management of Type II diabetes mellitus. However, such care and education should be in addition to effective lifestyle strategies and medication therapy with individualized goals in glycemic control. Pharmacotherapy in holistic treatment involves the use of both antidiabetics, as well as medications that treat comorbidities. Based on the findings of a study carried out by Ofori and Unachukwu (2014), treatment should involve the whole family. This recommendation implies that during the initial consultation with the patient, his or her family members should attend. The strategy encourages the adoption of a healthy lifestyle by both the patient and his or her family.
The suggested lifestyle changes that the patient and family members should be encouraged to adopt include cessation of cigarette smoking, the avoidance of alcohol, increase in regular exercise, healthy nutritional plan with reduced intake of carbohydrates and fatty food, and the avoidance of sugary drinks. The changes should also include the education of patient and family on the prescribed medication and probable complications, self-monitoring of blood glucose, and dealing with psychosocial issues. The study found out that this type of approach reduced the HbA1C levels by about 0.8 percent during the period of the study. Additionally, active participation of the individual in pharmacotherapy and lifestyle modification was found to be essential in achieving treatment objectives.
According to the guidelines for stepwise treatment approach, metformin is the first line drug for a newly diagnosed patient. Raz (2013) suggests that the rationale could be due to the drug’s large safety margin with the reduced number of side effects compared to other classes of drugs. The drug works by reducing hepatic glucose production, decreasing peripheral glucose resistance and increasing the levels of GLP 1 in response to food. Additionally, the drug has also been suggested to be cardioprotective in obese patients.
In the case where poor glycemic control with metformin is established, other classes of drugs can be added. The suggested agents include second-generation sulfonylureas, thiazolidinediones, DPP-4 inhibitors, GLP agonists, and insulin preparations. If targeted HbA1C is still not achieved in approximately 3 months, the American Diabetic Association (2015) recommends the addition of a third agent to the existing two-drug regimen. If the response is not significant in 3 months, the guidelines recommend moving to more complex multidose insulin regimens. This process should be done while avoiding the use sulfonylureas and meglitinides in this group of patients. The study carried out by Raz (2013) justifies this approach asserting that the model allows the evaluation of the efficacy of the medication, as well as patient tolerance to side effects.
Follow-up and Referral Plan for the Suggested Approaches
The American Diabetes Association (2015) suggests that both holistic and stepwise approaches should involve all members of the healthcare management team. The team includes physicians, nursing practitioners, nurses, dieticians, exercise specialists, dentists, pharmacists, and psychiatrists. Additionally, individuals with the condition must also assume the active roles of self-follow-up and self-care. The holistic approach also suggests that the patient, the physician and the rest of the members of the healthcare team should help to formulate the management plan while participating in the assessment of the patients’ progress. Regarding stepwise approach, the patient should consult his or her physician in case he or she suspects there is no or little improvement in treatment.
Conclusion
Diabetes is an endocrine disorder resulting from a combination of increased insulin resistance and inadequate insulin secretion. Consequently, the events lead to a reduction in glucose utilization and ultimately hyperglycemia. The condition has a higher prevalence in the older population usually manifesting from the age of 40. The diagnosis of the condition involves taking comprehensive patient history, analyzing symptoms, and carrying out diagnostic tests. Diagnostic tests that can be used include HbAIC, FPG, and OGTT. Treatment involves both non-pharmacological and pharmacological methods. A challenge that exists in the use of HbAIC as a diagnostic criterion is the difference in values between HbAIC and OGTT.
This issue can be avoided by performing at least three tests to improve screening outcomes. Regarding management, combined therapy in early disease stages has shown to have better outcome compared to the recommended monotherapy. Additionally, two approaches are used in the treatment of the condition. The approaches include a holistic plan that involves the elimination of short-term complications while reducing the risk of long-term ones. Regarding the stepwise approach, a drug is added in a systematic manner to an existing regimen in the case of poor response. In both cases, patient and family involvement is encouraged.
References
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