Questions, questions, questions

[mmc51264, BSN, MSN, RN]

I have questions as a nursing student and as a T2.

My son is Type 1 and his management is fairly straightforward: carbs in, insulin in. Check for highs/lows as needed (he wears a pump with Novalog). Other Type 1 can do Lantus (or other long-acting) and a rapid-acting.

My first question is: If T2 have problems using insulin and, for example, Metformin, helps the body use the insulin, why do they take people admitted OFF the Metformin and put them on sliding scales??? They have insulin, their body just can't use it. I understand about being NPO, the affects of steroids, etc., but it doesn't make sense to me.

Next: I see some T2 with Lantus as a basal and then a 70/30 for sliding scale. I see others with a 70/30 for a basal AND a sliding scale.

I haven't even explored the other oral D meds. Is this something I will learn as I go? I feel extremely underprepared to answer questions about T2 and I AM T2!!!! All of my instructors, but one (the one who s the bomb in Patho) lump T1 and T2 together and I know from experience that they are 2 different animals.

Can someone send me to some resources so I can understand more? I am interested in becoming a CDE down the road, but I REALLY need to know more.

TIA

[Always_Learning, BSN, RN]

"People can get diabetes at any age. Type 1, type 2, and gestational diabetes are the three main kinds. Type 1 diabetes, formerly called juvenile diabetes or insulin-dependent diabetes, is usually first diagnosed in children, teenagers, or young adults. With this form of diabetes, the beta cells of the pancreas no longer make insulin because the body's immune system has attacked and destroyed them. Treatment for type 1 diabetes includes taking insulin and possibly another injectable medicine, making wise food choices, being physically active, taking aspirin daily-for some-and controlling blood pressure and cholesterol.

Type 2 diabetes, formerly called adult-onset diabetes or noninsulin-dependent diabetes, is the most common form of diabetes. People can develop type 2 diabetes at any age-even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which fat, muscle, and liver cells do not use insulin properly. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, it loses the ability to secrete enough insulin in response to meals. Being overweight and inactive increases the chances of developing type 2 diabetes. Treatment includes using diabetes medicines, making wise food choices, being physically active, taking aspirin daily-for some-and controlling blood pressure and cholesterol."

Quote from: Your Guide to Diabetes: Type 1 and Type 2 - National Diabetes Information Clearinghouse

Sooooo...I think of Type 1 as "DOA" - the poor little pancreatic cells are dead on arrival. Kaput. Nada. They never had a chance to make insulin, poor souls. Never have made insulin, never will. This is why Type 1 folks need continuous insulin (some people call this "insulin dependent"), or they will die. Oral diabetes meds won't do the trick for these folks because none of them will produce insulin magically.

I think of Type 2 as Scotty from Star Trek ("I'm givin' her all she's got, Captain!!") In Type 2, the body can and does produce insulin. It's just that it doesn't do the job, because the cells aren't utilizing it properly (sometimes people say the cells are "insulin-resistant"). Initially, the body will try to keep up by producing more insulin ("I need more dilithium crystals!") but that won't last forever. Now, these people may or may not need insulin (some people call this type "non-insulin dependent"). Some Type 2 folks are diet controlled; some controlled with oral meds; some require insulin. Oral meds all work differently; some inhibit absorption of carbs; some stimulate the pancreas to make more insulin, some improve the body's response to insulin. It's a matter of finding what works for the patient.

You mentioned the sliding scale and Lantus. For Type 2 folks, again, this is a matter of what works for the patient. Just one scenario: when a Type 2 patient is not controlled with diet/oral meds alone, a doctor may start a patient on Lantus at night. This is long-acting and sloooooooooow, so it works overnight to maintain blood sugars, and you don't have to worry so much about bottoming a patient out. If the patient still has outrageous blood sugars, or varies greatly with meals, they may order "coverage." This is a bump of short acting insulin to "cover" the extra glucose ingested at mealtime. This might be something like Novolog, which is rapid-acting. (70/30 insulin is a mix of shorter acting and longer acting...again, it's all about what controls the blood sugar best for the patient with a minimum of highs and lows.)

Hope this helps :)

[Always_Learning, BSN, RN]

Oh, sorry....about your second question. Lots of Type 2 folks that DON'T normally use insulin at home may be placed on insulin in the hospital. As you mentioned, this is because there are lots more variables in the hospital (use of steroids, presence of infection, surgical wounds, stress, etc.) which all wreak havoc on blood sugar. Sliding scales allow tighter control while this is all happening to the body.

Now, without seeing the patient and his/her chart, I couldn't specify why they would take someone OFF Metformin and put them on insulin - there are many reasons. Being NPO is one. Another is that Metformin has some pretty nasty side effects (Google Metformin and "lactic acidosis"), and these can be compounded if the patient is dehydrated, in kidney failure, in liver failure, or hypoxic. Also, you can't give Metformin within 48 hrs. of a test requiring contrast/dye, or you get....*drumroll*....lactic acidosis. (And docs love CT scans, am I right? Another reason to stop Metformin).

Learning the different classes of oral diabetes meds will help a lot...it will come in time. :)

[merlee]

I am a type 2, insulin dependent at this time. I have been diabetic 10 years, on insulin about 5 years. Have been thru a variety of regimens. Now I take 70/30 BID, and extra R for coverage. Was on Levimir, but couldn't afford it out of pocket.

Metformin gave me the worst diarrhea. Some of the others did nothing.

Everyone is different.

[Spidey's mom, ADN, BSN, RN]

Always learning - awesome explanations! I may use them at my inservice today on diabetes!

If that's ok.

[Always_Learning, BSN, RN]

Go for it! (Can you tell hubby and I like Star Trek? LOL)

Oh, and I saw your post on the blue side...let me know how it goes. I'm sure you'll do great!

[classicdame, MSN, EdD]

look at diabetes.org to better understand both types. In ACUTE care situations, the ADA and AACE do not recommend any oral meds as many interact with contrast, other drugs and and too slow acting. Having insulin (T2) is not the same as having enough.

[GitanoRN, BSN, MSN, RN]

always_learning i couldn't have said it better myself...kudos!!! 2/u

[Esme12, ASN, BSN, RN]

Always learning....I agree I couldn't have said it better myself!!!!

[Always_Learning, BSN, RN]

Thanks! It was a good review for me getting all this info together. :)

[ChrissyRN74]

Great review. Loved the Star Trek reference!