Case Study of Diabetes Mellitus

A Case Study Presented to the

CSV Maternity & Lying-In Clinic

In Partial Fulfillment of the Requirements for the course:

Medical-Surgical RLE

Deypalan, Judiel
Dimapilis, Aaron Miguel
Dio, Yanneka
Domingo, Lucky Leu
Enriquez, Hillary

Ms. Angel Velasquez, RM

Clinical Instructor
November 5, 2022
 DIABETES MELLITUS

I. DEFINITION

Diabetes Mellitus (DM) is a group of diseases characterized by a consistently elevated

blood sugar level. Diabetes is derived from the Greek word siphon, whereas Mellitus is derived
from honey or sweet. Having elevated blood sugar levels for an extended period of time results in
sugar leakage in the urine and more urination, thus the name and reference (Souaid, 2020).

Diabetes mellitus is a condition of carbohydrate metabolism characterized by an impaired

ability of the body to produce or respond to insulin and maintain normal blood sugar levels
(glucose). Diabetes is a leading source of morbidity and mortality; however, these consequences
are not attributable to the disorder's direct impact. They are instead associated with the illnesses
caused by persistent diabetes mellitus. These include diseases of big blood vessels (including
coronary heart disease and peripheral artery disease) and small blood vessels (including retinal and
renal vascular disease), as well as nerve diseases (Britannica, 2022).

a. Four (4) Main Types of Diabetes Mellitus

Fig. 1: Four (4) Main Types of Diabetes Mellitus

 II. TREATMENT AND MANAGEMENT

1. Diet and Exercise

Diabetes Mellitus is a chronic disease in which a proper and healthy lifestyle is necessary
to achieve health promotion and maintenance.
● Patients with DM are encouraged to attain and maintain a normal body weight by
putting them on diet and exercise regularly.
● Diet and exercise enhances the movement of glucose into muscle cells and blunts
the rise in blood glucose that follows carbohydrate ingestion.
● Patients are encouraged to follow a diet that is relatively low in fat and contains
adequate amounts of protein.
● In practice, about 30% of calories should come from fat, 20% from protein, and the
remainder from carbohydrates, preferably from complex carbohydrates rather than
simple sugars.
● In addition, weight loss, preferably combined with exercise, can lead to improved
insulin sensitivity and even restoration of normal glucose metabolism.

2. Insulin Therapies
Diabetics who are unable to produce insulin in their bodies require insulin therapy.
● Traditional insulin therapy entails regular injections of the hormone, which are
often customized according to individual and variable requirements.
● Beef or pork insulin, made from the pancreatic extracts of cattle or pigs, can be
used to treat humans with diabetes.
● However, in the United States, beef and pork forms of insulin are no longer
manufactured, having been discontinued in favor of human insulin production.
● Modern human insulin treatments are based on recombinant DNA technology.
● Human insulin may be given as a form that is identical to the natural form found in
the body, which acts quickly but transiently (short-acting insulin), or as a form that
has been biochemically modified so as to prolong its action for up to 24 hours (long-
acting insulin).
● Patients also have the option of using an insulin pump, which allows them to control
variations in the rate of insulin administration.
● Patients taking insulin also may need to vary food intake from meal to meal,
according to their level of activity; as exercise frequency and intensity increase,
less insulin and more food intake may be necessary.

3. Drugs used to control blood glucose levels

There are several classes of oral drugs used to control blood glucose levels, including
sulfonylureas, biguanides, and thiazolidinediones.
 ● Sulfonylureas, such as glipizide and glimepiride, are considered hypoglycemic
agents because they stimulate the release of insulin from beta cells in the pancreas,
thus reducing blood glucose levels. The most common side effect associated with
sulfonylureas is hypoglycemia (abnormally low blood glucose levels), which
occurs most often in elderly patients who have impaired liver or kidney function.
● Biguanides, such as metformin, is considered an antihyperglycemic agent because
it works by decreasing the production of glucose in the liver and by increasing the
action of insulin on muscle and adipose tissues. A potentially fatal side effect of
metformin is the accumulation of lactic acid in blood and tissues, often causing
vague symptoms such as nausea and weakness.
● Thiazolidinediones, such as rosiglitazone and pioglitazone, act by reducing insulin
resistance of muscle and adipose cells and by increasing glucose transport into these
tissues. These agents can cause edema (fluid accumulation in tissues), liver toxicity,
and adverse cardiovascular events in certain patients. Furthermore, oral
hypoglycemic agents lower mean blood glucose concentrations by only about 50–
80 mg per 100 ml (2.8–4.4 mmol per liter), and sensitivity to these drugs tends to
decrease with time.

4. Glucometer monitoring
● All patients with diabetes mellitus, particularly those taking insulin, should measure
blood glucose concentrations periodically at home, especially when they have
symptoms of hypoglycemia. This is done by pricking a finger, obtaining a drop of
blood, and using an instrument called a glucometer to measure the blood glucose
concentration. Using this technology, many patients become skilled at evaluating
their diabetes and making appropriate adjustments in therapy on their own
initiative.

5. Glucose-Responsive Insulin Patch/Smart Insulin Patch

● Glucose responsive insulin (GRI) is a form of insulin that only works when the
body's blood- glucose levels start to rise. When blood sugar levels are in the proper
range, the insulin is inactive. GRI would profoundly and positively change the lives
of people with T1D.
● An insulin patch is a transdermal patch that works by being placed on the skin and
agents within the patch help insulin to pass through the skin and then into the
bloodstream. An insulin patch contains a set dose of insulin that is absorbed over a
number of hours.
● Different types of insulin patches have been developed to release insulin more
quickly to counteract rises in blood sugar following meals (bolus insulin patches)
and other insulin patches have been developed to counteract the gradual release of
glucose through the day by the liver (basal insulin patches).
 III. PATHOPHYSIOLOGY

A. TYPE 1

Fig. 2: Pathogenesis of Type 1 Diabetes Mellitus

Type 1 Diabetes Mellitus is an autoimmune disease characterized by progressive destruction of

islet beta cells, leading to absolute insulin deficiency. Both autoreactive T cells and auto antibodies
are involved.

● Type 1 DM is characterized by an absolute deficiency of insulin secretion caused by

pancreatic beta cell destruction, usually resulting from an autoimmune attack. Accounts
for approximately 10% of all cases.
- Insulin is a hormone that helps regulate the amount of glucose in the blood (because
too much glucose is very toxic to the body). It is a hormone made in the pancreas
by special beta cells. When an autoimmune attack beta cell, it produces little or no
insulin.
● Type 1 diabetes is an autoimmune disease in which islet destruction is caused primarily by
immune effector cells reacting against endogenous beta cell antigens.
- The beta cells in the islet do not work because it has been destroyed therefore, the
body does not release any more insulin. For treatment, the patient MUST USE
INSULIN. Without ample insulin, glucose pushes up in the bloodstream instead of
going into the cells. This leads to the symptoms of type 1 diabetes.
 ● The manifestations of the disease occur late in its course, after more than 90% of the beta
cells have been destroyed.
- After a large amount of the beta cells have been destroyed, there are manifestations
that may occur. To further explain this, what would patients look like clinically?
Patients will have weight loss (systemic), abdominal pain, nausea & vomiting (GS).
They will also be lethargic and may present unconsciousness (CNS), and
hyperventilation (RS). Additionally, ketones will be present in the urine.
● The fundamental immune abnormality in type 1 diabetes is a failure of self-tolerance in T
cells.
- The immune system's failure to "tolerate" self-tissues can result in pathological
autoimmune conditions leading to illness and sometimes death.
- Loss of T-cells leads to an abnormal attack of insulin-producing beta-cells,
breaking down the immune system's self-tolerance.
● Environmental factors, especially infections, may be involved too.
- External factors such as diet, viruses (including rubella and mumps), drugs, toxins,
and conditions that elicit stress (such as persistent illness, surgery, and even
puberty) are all examples of environmental variables that cause Type 1 Diabetes
Mellitus.

B. TYPE 2

Fig. 3: Pathogenesis of Type 2 Diabetes Mellitus

Type 2 Diabetes Mellitus is caused by insulin resistance and beta cell dysfunction, resulting in
relative insulin deficiency. Therefore, autoimmunity is not involved.
● It is a prototypical complex multifactorial disease that basically includes both genetic and
environmental factors, such as sedentary lifestyle and dietary habits.
○ Because of these factors, either the body does not produce enough insulin or the
cells ignore the insulin.
● There is actually a combination of peripheral resistance to insulin action and an inadequate
compensatory response of insulin secretion by the pancreatic beta cells (so in other words,
it is relative to insulin deficiency).
● Due to aging, which is also considered as one of the contributing factors of this disease,
beta cell mass declines as a person ages, so those predisposed to insulin resistance may
develop TYPE 2 DM.
● Therefore, the 2 defects that characterize type 2 diabetes are :
1. Decreased ability of peripheral tissues to respond to insulin (INSULIN
RESISTANCE )
2. Beta cells dysfunction that is manifested as inadequate insulin secretion in the face
of insulin resistance and hyperglycemia. (INSULIN DEFICIENCY).
● Clinical manifestations are;
○ CNS
■ Polydipsia - the feeling of extreme thirstiness
■ Polyphagia - eats excessive amounts of food.
○ EYE
■ Blurred Vision
○ Urinary
■ Polyuria - the frequent passage of large volumes of urine (more than 3 liters
a day compared to the normal daily urine output in adults of about 1 to 2
liters).
■ Glycosuria - a condition in which too much of the simple sugar glucose is
removed through the urine.
 IV. PATIENT INTERVENTION COMPARISON OUTCOME (PICO)

DIABETES MELLITUS

Patient Intervention Comparison Outcome

Patients with type 2 Administration of Administration of Reduced risk of major

diabetes mellitus insulin and metformin insulin only. adverse cardiac
effects and death.
Furthermore, this can
also reduce HbA1c,
weight gain, and
insulin dose.

Critical review with summary of literature:

In a study conducted by Holden et al. (2016), patients who are taking a combination therapy
of insulin and metformin have a reduced risk of major adverse cardiac effects (MACE) and death
compared to those patients who are only taking insulin. Furthermore, the results of the study
conducted by Holden et al. (2016) is coherent with the results of Currie et al. (2013), because it
was found that patients with Type 2 Diabetes Mellitus, who are receiving exogenous insulin
therapy alone is associated with an increased risk of diabetes-related complications, cancer, and
death compared to patients who are receiving oral medications and combination therapies such as
insulin plus metformin.

The combination of metformin and insulin is able to reduce 0.5% of Hemoglobin A1C
(HbA1c) in the body (Hemmingsen et al., 2012). The normal level of HbA1c in the body ranges
from 4% to 5.6%, whereas people who have more than 5.6% but less than 6.5% are said to be
prediabetic, but once it reaches more than 6.5% it would mean that a person is already diabetic
(WebMD, 2020). Furthermore, their study revealed that this combination reduces weight gain by
1 kg and insulin dose of 5 U/day compared to insulin alone (Hemmingsen et al., 2012).
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