ST, a 32-year-old patient was diagnosed with type 2 diabetes mellitus after the birth of her first child; her blood sugar was 180 mg/dL. Her serum glucose level has been maintained within the normal range with metformin of 500 mg/day.
1. Complete drug cards for the following medications using the Template provided. Note: These drug cards will not be submitted for a grade. They will be used to help you answer the discussion questions listed below.
a. metformin
b. NPH insulin
2. Use the drug cards you created and your textbook to respond to the following questions:
a. Why is ST taking an oral antidiabetic medication rather than insulin?
b. When should metformin not be taken?
Two years later, ST became pregnant again. Metformin was discontinued, and NPH insulin of 25 units was prescribed. Since the birth of her second child, she has remained on NPH 25 units/day.
a. Why was metformin discontinued and insulin prescribed?
b. What is NPH insulin and how should NPH insulin be administered?
c. What should be included in patient teaching?
As the patient is suffering from type 2 diabetes, oral antidiabetic medication has been prescribed for the patient instead of insulin. Type 2 diabetes is a chronic illness in which the body keeps the body from utilizing insulin (Chatterjee, Khunti & Davies, 2017). In other words, The Patient Suffers From Insulin Resistance. Insulin Is a Type Of Hormone Secreted By The Pancreas That Aids In The Conversion Of Blood Glucose To Energy. Type 2 diabetes patients make insulin, but the cells are unable to use it the way they should manage normal body glucose (McCuistion et al., 2017). Thus, as ST has type 2 diabetes, it means that her body can secrete insulin, but due to insulin resistance, her body is not able to use it (Chatterjee, Khunti & Davies, 2017). Administering insulin directly will thus be of no use as the body won’t be able to use it to break down the glucose for energy. Metformin decreases the glucose amount produced by the liver and helps improving the body's response to the insulin that are being produced.
Metformin passes into breast milk in a small amount and is associated with few side effects in breastfed babies. Thus, it should not be administered while ST is breastfeeding her baby. According to studies, patients who are more than 65 years of age should not take metformin. Also, people who have a history of heart attack, diabetic ketoacidosis, stroke, coma, or liver or heart disease should be cautious (LaMoia & Shulman, 2021). People who are taking dichlorphenamide (Keveyis), acetazolamide (Diamox), methazolamide, zonisamide (Zonegran), or topiramate must not take metformin as taking them together increases the risk of lactic acidosis (LaMoia & Shulman, 2021). Although metformin administration can cause minor side effects such as developing a serious infection, vomiting, severe diarrhea, fever, and so on, these should be reported to your doctor, who may advise you to discontinue metformin until the patient has recovered completely.
Metformin was discontinued because metformin exposure during foetal development may result in birth defects in male offspring like subfertility, less sperm count, and an increased risk of testicular cancer at later stages of life (LaMoia & Shulman, 2021). On the other hand, Insulin is the first-choice drug to control blood sugar levels in pregnancy due to its effectiveness in fine-tuning the level of blood sugar. Moreover, it doesn't cross the placenta, making it safer for the baby. Insulin is injected with an insulin pen, an insulin pump, or a syringe (Guo et al., 2019).
The Neutral Protamine Hagedorn (NPH) insulin, which is also referred as isophane insulin, is an intermediate-acting insulin that is administered to the patient to help reduce the level of blood sugar in diabetic patients. NPH insulin is given once to twice a day through injections under the skin. The onset of effects occurs 90 minutes after the administration and its effects last for 24 hours. It is subcutaneously injected into the stomach (abdomen), upper legs, buttocks, or upper arms. Before the injection, it is important to clean the skin with an alcohol swab. And the site of injection should be dry before injecting the dose (Semlitsch et al., 2020).
Patient education is important for the process of recovery and to maintain the life quality of the patient. Educating the patients about the insulin time–action profile. Irrespective of the insulin type, it is important to promote patients' understanding of the importance of insulin administration and elevate their confidence in self-titration. Next, the patient should be taught about the use of the same brands as well as types of supplies and not to administer expired insulin as this can lead to life-threatening conditions for both the patient and the child in the case of pregnancy (Chatterjee, Khunti & Davies, 2017). Moreover, insulin must be administered at room temperature. The patient should be taught about administering insulin and for that, they need to gather the supplies that are insulin, alcohol wipes, needles, syringes, and a container for used syringes and needles that needs to be disposed of while maintaining precautions (McCuistion et al., 2017). Educating about the adverse side-effects of insulin like Injection site reactions, weight gain, hypoglycaemia, allergic reactions, lipodystrophy, and oedema will aid in identifying the adverse situation, and if the patient experiences any of these, she should seek medical attention and contact their primary care physician. People having type 2 diabetes must check the level of blood sugar daily as taking medication and injections for reducing blood glucose levels can lead to lower blood sugar levels below the threshold level leading to hypoglycaemia. Apart from this, it is important to educate the patient to eat a healthy diet and perform light physical exercises that can help in regulating the level of blood glucose (Chatterjee, Khunti & Davies, 2017).
References
McCuistion, L. E., Yeager, J. J., Winton, M. B., & DiMaggio, K. (2017). Pharmacology-E-Book: A Patient-Centered Nursing Process Approach. Elsevier Health Sciences. https://books.google.com/books?hl=en&lr=&id=N_YoDgAAQBAJ&oi=fnd&pg=PP1&dq=A+Patient-Centered+Nursing+Process+Approach++TENTH+EDITION&ots=AdLIq4xQzO&sig=jJwL5HjX99s-umVut60ty9ItRwM
Chatterjee, S., Khunti, K., & Davies, M. J. (2017). Type 2 diabetes. The lancet, 389(10085), 2239-2251. https://www.sciencedirect.com/science/article/pii/S0140673617300582
Semlitsch, T., Engler, J., Siebenhofer, A., Jeitler, K., Berghold, A., & Horvath, K. (2020). (Ultra‐) long‐acting insulin analogues versus NPH insulin (human isophane insulin) for adults with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews, (11). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005613.pub4/abstract
Guo, L., Ma, J., Tang, J., Hu, D., Zhang, W., & Zhao, X. (2019). Comparative efficacy and safety of metformin, glyburide, and insulin in treating gestational diabetes mellitus: a meta-analysis. Journal of diabetes research, 2019. https://www.hindawi.com/journals/jdr/2019/9804708/
LaMoia, T. E., & Shulman, G. I. (2021). Cellular and molecular mechanisms of metformin action. Endocrine Reviews, 42(1), 77-96. https://academic.oup.com/edrv/article-abstract/42/1/77/5902802
