Nursing Pharmacology Chapter 29:  Diabetes

• Type II diabetes represents a group of milder forms of diabetes that occurs mainly in adults.

  • Endogenous insulin is sufficient to prevent ketoacidosis; however, abnormal insulin secretion and resistance to insuling action at tissues occur.

  • Obesity: common risk factor

• Type II diabetic patients exhibit a deficiency in pancreatic B cell response to glucose.

  • The impaired response is worsened by hyperglycemia.

• Pathophysiological Phases:

  1. Plasma glucose may be normal withelevated insulin levels.

  2. Elevated insulin levels are associated with postprandial hypoglycemia.

  3. Reduced insulin secretion causes fasting hyperglycemia.

• Clinical Presentations

  • Type II diabetes often presents in middle age or later and most typically in overweight patients.

  • Onset of symptoms is typically gradual.

    • Presenting symptoms

      1. Extreme hyperglycemia

      2. Hyperosmolality

      3. Volume depletion

      4. CNS symptoms (ranging from clouded sensorium to coma)

         1. Seizure activity (Jacksonian)

         2. Transient hemiplegia

      5.  Infections: pneumonia and gram-negative sepsis (common, associated with very negative prognosis)

  • Patients with Type II disease do not develop ketoacidosis

  • Patients with Type II disease may develop hyperosmolar, nonketotic coma

    • Syndrome properties

      • Results from sustained hyperglycemia diuresis if patient cannot drink enough water to keep up with urinary fluid loss

      • Complete manifestation occurs when volume depletion decreases urine output

    • Hyperosmolar coma can occur in insulin-dependent diabetics if the insulin given is sufficient to prevent ketosis but not enough to control hyperglycemia.

  • Hyperosmolar coma can also be caused by:

    • Peritoneal/hemodialysis

    • Tube feeding of high-protein formulas

    • High-carbohydrate in fusion loads

    • Osmotic agents (mannitol and urea)

  •   Prognosis

    • Mortality rate and hyperosmolar coma: > 50%

  • Treatment of hyperosmolar coma states

    • Large amounts of intravenous fluids (average fluid deficit: 10-11 liters.

    • Insulin: more rapid control hyperglycemia

    • Potassium salts (counteract intracellular shifted plasma K⁺)

    • Sodium bicarbonate (if lactic acidosis present)

    • Antibiotics

• Type II diabetes treatment: Overview

  1. Diet

  2. Weight reduction

  3. Drugs other than insulin, if diet in weight reduction are inadequate.

  4. Insulin may be required.

Karam, J. H., Pancreatic Hormones and Antidiabetic Drugs, in Basic and Clinical Pharmacology, (Katzung, B. G., ed) Appleton-Lange, 1998, pp 684-703

Foster, D. W., Diabetes Mellitus, In Harrison's Principles of Internal Medicine 14th edition, (Isselbacher, K.J., Braunwald, E., Wilson, J.D., Martin, J.B., Fauci, A.S. and Kasper, D.L., eds) McGraw-Hill, Inc (Health Professions Division), 1998, pp 2060-2080