Understanding and Managing Type 2 Diabetes

Targeting Insulin Sensitivity and Glucose Production

• Biguanides: The most common example is Metformin (Glucophage). It works by decreasing hepatic glucose production and increasing insulin sensitivity.
• Thiazolidinediones (TZDs): Agents like Pioglitazone (Actos) increase insulin sensitivity in muscle and fat while also decreasing glucose production in the liver.

Stimulating Insulin Secretion

• Sulfonylureas: These agents, such as Glipizide and Glyburide, stimulate the pancreatic beta cells to secrete more insulin.
• Meglitinides: These are short-acting agents like Repaglinide (Prandin) that promote rapid, glucose-dependent insulin secretion, making them useful for managing post-meal spikes.
• DPP-4 Inhibitors: Drugs like Sitagliptin (Januvia) inhibit the DPP-4 enzyme, which in turn increases levels of GLP-1. This increases insulin secretion and decreases glucagon levels.

Managing Absorption and Excretion

• Alpha-glucosidase inhibitors: Acarbose (Precose) reduces the absorption of carbohydrates in the intestines, which helps prevent significant glucose spikes after eating.
• SGLT2 inhibitors: Agents such as Dapagliflozin promote the excretion of glucose through the urine by inhibiting renal glucose reabsorption.

Other Metabolic Agents

Other pharmacological options include Bile Acid Sequestrants (e.g., Colesevelam) to lower LDL cholesterol and modest blood glucose, and Dopamine-2 Agonists (e.g., Bromocriptine) to modulate hypothalamic metabolic regulation. Additionally, appetite suppressants like Ozempic (a GLP-1 analogue) can help regulate insulin secretion and promote weight loss.

Acute Complications: Hypoglycemia vs. Hyperglycemia

Nursing management must prioritize the prevention and recognition of acute glycemic crises.

Hypoglycemia (Low Blood Sugar)

Hypoglycemia is defined as blood glucose $< 4.0$ mmol/L. It is a dangerous condition that can result from too much insulin, insufficient food intake, or inconsistent exercise.

• Symptoms: Shaking, palpitations, sweating, anxiety, hunger, confusion, dizziness, and slurred speech.
• Treatment: For conscious patients, provide 15g of fast-acting carbohydrates (e.g., 4 glucose tablets or 125ml of apple juice). Re-test after 15 minutes. For unconscious patients, administer Glucagon (IM/SC) or IV Dextrose (D50W).

Hyperglycemia (High Blood Sugar)

Hyperglycemia is generally defined as blood glucose $> 7.0$ mmol/L.

• Symptoms: Polyphagia (increased hunger), polydipsia (increased thirst), polyuria (increased urination), blurred vision, and poor wound healing.

Critical Emergencies: DKA and HHS

While both involve severe hyperglycemia, they present differently and require distinct management.

Diabetic Ketoacidosis (DKA)

DKA is more common in Type 1 Diabetes but can occur in Type 2. It is characterized by an absolute insulin deficiency that leads to the breakdown of fat for fuel, producing ketones.

• Clinical Presentation: Nausea, vomiting, abdominal pain, Kussmaul respirations (deep, labored breathing to blow off $CO_2$), and acetone-scented breath.
• Diagnostics: Glucose $> 15$ mmol/L, positive ketones in urine/serum, and metabolic acidosis (pH $< 7.3$).
• Management Priority: The "D, K, A" approach:
  1. Dehydration: Replace fluids with Isotonic saline (0.9% NS).
  2. Potassium (K+): Insulin will drive potassium into cells, risking profound hypokalemia. Crucial Rule: Do not start insulin if $K^+ < 3.3$ mmol/L.
  3. Acidosis/Glucose: Correct glucose gradually. Do not allow glucose to drop faster than 4 mmol/L per hour to prevent cerebral edema.

Hyperosmolar Hyperglycemic State (HHS)

HHS is a life-threatening emergency typically seen in elderly patients with Type 2 Diabetes. Unlike DKA, these patients produce enough insulin to prevent significant ketone production, but not enough to prevent extreme hyperglycemia.

• Clinical Presentation: Extreme dehydration and neurological changes (somnolence, coma, seizures) due to high serum osmolality.
• Diagnostics: Glucose often $> 34$ mmol/L, high serum osmolality, and minimal/absent ketones.
• Management: Requires massive fluid resuscitation (often $> 10$ L) and careful insulin administration.

Exam Tip: The Potassium Rule In DKA management, always check the potassium level before administering insulin. If the patient's potassium is low ($< 3.3$ mmol/L), insulin must be withheld because insulin will cause potassium to shift into the cells, potentially causing fatal cardiac arrhythmias.

Nursing Management and Patient Education

Nursing care focuses on stabilizing blood glucose and preventing injury.

Nursing Priorities

• Unstable Blood Glucose: Monitor glucose levels frequently, especially when the patient is ill (e.g., fever or infection increases insulin needs).
• Injury Prevention: Monitor for hypoglycemia and the resulting risk of falls or seizures.
• Peripheral Neurovascular Function: Patients with long-term diabetes are at high risk for neuropathy and impaired healing.

Essential Patient Education

• Foot Care: Due to the risk of neuropathy and poor circulation, patients must inspect their feet daily for sores or infections.
• Dietary Management: Encourage high-fiber, lean protein, and healthy fats (MUFAs/PUFAs) while limiting saturated and trans fats.
• Self-Management: Patients should be taught to use glucometers, recognize symptoms of hypoglycemia, and carry medical identification for travel.