DIABETIC DRUGS 1

Diabetic Drugs for Baby Ruth

Auburn School of Nursing

Cameron Hill, Emily Waller, Maren Stiles, Riley Hartwell, Sydney Wrighte

NURS-3210/NURS-3230

April 8, 2021
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Diabetic Drugs for Baby Ruth

Baby Ruth is currently being treated for diabetes mellitus (DM). DM is currently the seventh

leading cause of death in the United States (Lin et al., 2020). Alongside adults, there are around 210,000

children who have been diagnosed with DM (Diabetes in children and teenagers, 2020). There are two

types of the disease, type 1 and type 2. Type 1 DM patients’ bodies do not produce insulin and type 2

patients do not respond to insulin correctly. Type 1 is considered juvenile DM because it is an

autoimmune form that is usually diagnosed in infants and young children. Type 2 DM is related to the

genetics and overall lifestyle of the individual. Insulin is a natural substance in the body that helps

regulate blood sugar levels. When insulin is not functioning as it should, too much sugar remains in the

bloodstream which can lead to serious health effects. Clinical manifestations of DM include heart disease,

vision loss, poor wound healing, frequent infections, and increased thirst and hunger (What is diabetes,

2020).

Population Health

According to the National Diabetes Statistics Report in 2020, there were 34.2 million Americans

of all ages who were living with DM, making up 10.5% of the total population (Centers for Disease

Control and Prevention, 2020). DM is one of the more common diseases within the American population

with many more either living with it undiagnosed or in the prediabetic stage. In 2018, there were an

estimated 88 million Americans who were in the prediabetes stage and another 7.2 million who met

laboratory criteria for DM but remained undiagnosed (Centers for Disease Control and Prevention, 2020).

On a state level, approximately 14.6% of the adult population in Alabama (roughly 553,000 people) have

been diagnosed with DM. Along with that, 34.6% of the adult population has prediabetes with higher-

than-normal glucose levels that are not high enough to be formally diagnosed. (The American Diabetes

Association, 2020).

Despite the growing occurrence of DM in the population, there are a multitude of health

disparities that a patient may face. Health disparities can include socioeconomic status, racial or ethnic
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group, gender, age, disability, location, gender identity, and other characteristics linked to discrimination

and or exclusion. These disparities influence the prevalence of DM, the risk of diabetes-related mortality,

and the risk for developing complications. Having insurance is the strongest single predictor of whether

adults with DM are likely to meet individual quality measures of DM care (Hill-Briggs et al., 2021).

Health insurance influences the patient’s ability to have regular doctor appointments and afford

medication. Incidence of DM increases on a gradient from highest to lowest income, and those with an

income below the federal poverty level have a higher risk of DM-related mortality (Hill-Briggs et al.,

2021). Economic status has a direct effect on the management of DM because it determines what foods a

patient can purchase (which influences glucose control) and their ability to obtain health insurance and

comply with a medication regimen. Many patients with DM require a multitude of medications to manage

the disease. Approximately 14% to 20% of adults with DM report reducing or delaying the purchase of

medications due to cost (Hill-Briggs et al., 2021). Unstable housing influences the control of DM as well.

Evidence shows that inequities in living and working conditions and the environments in which people

reside have a direct impact on biological and behavioral outcomes associated with DM prevention and

control. Unstable housing makes it more difficult for a patient to self-manage, afford medications and

supplies, and eat healthy foods (Hill-Briggs et al., 2021). Education also plays an important role in the

prevention and control of DM. The incidence of DM and risk of diabetes-related mortality is associated

with educational level, with lower educational level patients being at a higher risk (Hill-Briggs et al.,

2021). Education influences the patient’s ability to understand necessary lifestyle changes and follow a

medication regimen correctly. Patients with a lower education level may also be embarrassed and less

likely to ask questions or speak up when they do not understand something.

For a patient with DM, there are a lot of considerations and factors that affect patient education

about lifestyle, diet, and medication regimen. Education can also differ based on the socioeconomic status

and age of the patient. Socioeconomic status can affect education because it directly affects the

availability of resources that the patient was informed, that they needed for their care. Age is a significant

consideration because with age comes potential coexisting illnesses, cognitive delays, and the increased
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likelihood that the patient is taking multiple medications (American Association of Diabetes Educators,

2016).

Because of all of these considerations, the health care educator needs to make sure that the

education is realistic and conducive to all aspects of the patient's life. Collaborating with the healthcare

team and the patient is needed when educating about healthy lifestyle modifications. Diet changes and

activity goals should be set with the patient's capability to maintain the plan in mind as finances, physical

health, and resource availability can serve as barriers (American Association of Diabetes Educators,

2016). For example, an older adult with DM living in the hospital on bed rest is at risk for irregular

nutrient absorption, decreased physical activity, and ineffective coping due to possible isolation all of

which can affect DM management. The patient also needs to be able to participate in their health through

preventative care to decrease the risk of complications. Preventative care includes measuring their

glycemic target every day, yearly checkups, and smoking cessation to prevent negative outcomes

(American Association of Diabetes Educators, 2016). Medication compliance is also strongly correlated

with patient education because the more a patient understands why the medication is needed the more

likely medication compliance will occur. The health care educator when discussing the medication with

the patient should make sure that the medication regimen is simplified for the patient’s understanding,

possible expenses have been matched with the patient’s finances, and the patient’s beliefs regarding

medications have been discussed (American Association of Diabetes Educators, 2016).

Community Resources

Within the Auburn, Alabama community, there are various resources available for people of all

ages living with either Type 1 or Type 2 DM. Among those community resources are East Alabama

Medical Center DM support groups, Doggone Diabetes, and East Alabama Diabeaters. EAMC has

various services for those in the community to help educate on different DM medicines, glucose

monitoring, using insulin pumps, healthy dieting, and healthy exercises (EAMC, 2021). The patients meet

with various nurses, DM educators, and even registered dieticians to help maintain healthy lifestyles.

These are done to help patients understand more about their disease, while also having a support group
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and medical professionals there to help at any time. EAMC’s main plan of focus is maintaining ABC’s.

The goal of this focus is to help patients understand the importance of A1C, blood pressure, and

cholesterol (EAMC, 2021). EAMC also has similar programs for pediatric patients such as education for

the children and their parents, meetings with dieticians, insulin pump instructions, and how to make

healthy life choices. The hospital not only offers services to help pediatric patients living with DM but

also has programs to prevent DM in young people. Educators from Diabetes and Nutrition Center of EAMC

help children and teens make diet and exercise plans to better support their health in the future (EAMC,

2021). The Diabetes Focus Support Group meets quarterly (EAMC, 2021).

Doggone Diabetes is a research program hosted by Auburn University School of Nursing to

combat the prevalence of metabolic disease. The goal of this program is to increase the physical activity

of those with DM by walking therapy dogs (Bhavani, 2020). The program helps the community reach the

CDC recommendation of 150 minutes of exercise per week. The program is for those that are 19 years of

age and older with pre-diabetes or DM from the Auburn-Opelika community. Throughout the program,

there is an evaluation of A1C, weight, BMI, waist circumference, blood pressure, and heart rate (Bhavani,

2020).

East Alabama Diabeaters is a non-profit community group affiliated with Camp Seale Harris in

Auburn, Alabama. This program is focused on families of children with DM and offering them fun events

every other month to help educate them on DM. These events include guest speakers, movie days, skating

rink days, tours around the Auburn football field, ziplining, swimming, and many more in the community

to have fun while learning (East Alabama Diabeaters, 2017). Those that are involved in Diabeaters are

encouraged to join the overnight camp at Camp Seale Harris to get feedback from volunteer physicians,

nurses, diabetes educators, nutritionists, pharmacists, and counselors while having a community of people

going through the same process to manage DM (East Alabama Diabeaters, 2017).

Pharmacology

Pioglitazone (Actos)
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Indicated for Type 2 DM along with a good diet and exercise. The capsule PO decreases the patient’s

insulin resistance which allows for glycemic control. It does this by acting as an agonist on insulin

receptor sites. However, the drug is contraindicated in patients who have: (a) hypersensitivity, (b) Type 1

DM, (c) Diabetic Ketoacidosis, (d) Liver Disease, or (e) active bladder cancer. Also, nursing mothers

should talk to their doctor about continuing or discontinuing use, as insulin should be used when

lactating. While taking, patients should be aware of signs and symptoms of hypoglycemic reactions. As

well, be aware of signs and symptoms of heart failure, especially since the risk is increased when first

taking the drug and when the dosage is increased. If the patient misses a dose, they are directed to not

double the dose the next day. (Vallerand et al., 2017)

Metformin (Glucophage)

Metformin is a first-line oral blood glucose-lowering medication for the management of Type 2

DM (Bailey, 2017). The drug manages blood glucose by (a) decreasing hepatic glucose production; (b)

decreasing intestinal glucose absorption; and (c) increasing sensitivity to insulin. However, metformin is

contraindicated in patients with: (a) hypersensitivity; (b) metabolic acidosis; (c) diabetic ketoacidosis; (d)

renal impairment; (e) hepatic disease; (f) kidney impairment or disease; and (g) history of heart failure.

Patients should be instructed to take the medication at the same time every day, and if a dose is missed, to

take it as soon as possible, unless the next dose is already due. As well, patients should be taught that the

drug may cause a metallic taste, that will resolve spontaneously. Patients should be made aware that the

medication is not a cure for DM, however, it helps control hyperglycemia and is usually a long-term

regimen. Since, metformin in general decreases blood glucose, patients should be taught signs and

symptoms of hypoglycemia, and what to do in case of a hypoglycemic episode. (Vallerand et al., 2017)

Insulin aspart (Novolog)

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Novolog is indicated for control of hyperglycemia in patients with Type 1 or Type 2 DM. The

DM medication lowers blood glucose by (a) stimulating glucose uptake in skeletal muscle and fat, and (b)

inhibiting hepatic glucose production. As well, insulin is responsible for the inhibition of lipolysis and

proteolysis, which prevents the breakdown of fats and proteins, thereby preventing glucose production.

Insulin aspart also creates enhanced protein synthesis. When more proteins are being built up, than broken

down, there is less chance of hyperglycemia. Compared to other forms of insulin, Novolog is a rapid-

acting form, which allows for faster onset, and a shorter duration of the drug. Typically, Novolog is

combined with an intermediate acting insulin for better diabetic control outcomes. Unfortunately, insulin

aspart is contraindicated in patients with (a) hypoglycemia, (b) allergy, or (c) hypersensitivity to the

medication. Due to the action of insulin aspart, it is possible it could cause the body to overcompensate,

and result in hypoglycemia. Patients must be informed about signs of hypoglycemia and what to do in the

case they acquire the condition. There is a lot of teaching related to insulin that needs to be completed

prior to the patient going home. They must learn (a) proper administration, (b) storage of the medication,

(c) rotation of injection sites, and (d) technique of mixing insulins in the case of a prescription of insulin

aspart and an intermediate acting insulin. (Vallerand et al., 2017)

Insulin glargine (Lantus)

The long-acting insulin is indicated for control for hyperglycemia in patients with Type 1 or Type

2 DM. The drug’s mechanism of action is the same as insulin aspart (Novolog): (a) stimulating glucose

uptake in skeletal muscle and fat, (b) inhibiting hepatic glucose production, (c) inhibition of lipolysis and

proteolysis, and (d) creates enhanced protein synthesis. The difference between the two insulins is the

onset, peak, and duration of each drug. Insulin glargine has an onset of one to two hours, and has a

duration of twenty-four hours, but it can be given every twelve hours. The major difference is insulin

glargine has no peak level, as it provides the same levels overtime to keep a constant glucose level.
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Administration is contraindicated in patients with: (a) hypersensitivity, (b) hypoglycemia, (c) history of

pancreatitis, (d) end-stage renal disease, or (e) gastroparesis. The same patient teachings as insulin aspart

(Novolog) apply: (a) proper administration, (b) storage of the medication, and (c) rotation of injection

sites. The patient does not need to learn about mixing insulins, because long-acting insulins are not mixed

with any others, due to its constant levels. As well, patients should be taught that if they miss a dose, they

must wait and take the next dose at their scheduled time. There should be no double dosing. And just like

many of the other DM medications, this drug does not cure DM, but helps control the hyperglycemia that

may occur with it, and is usually a long term therapy. (Vallerand et al., 2017)

Sitagliptin (Januvia)

Sitagliptin is indicated for Type 2 DM, in addition to diet and exercise to improve glycemic

control. It can be used alone or in combination with other DM drugs such as metformin. Its action in

managing glycemic control is much different from other drugs. Sitagliptin inhibits an enzyme, which

slows down the inactivation of a hormone, thereby increasing the hormone level, that is released by the

intestine constantly. The hormone is involved in the regulation of glucose. With prolonged and high

levels of the hormone, then there is an increase in insulin release, resulting in a decrease of glucagon

levels. All this allows for improved control of blood glucose. The drug is contraindicated in: (a) Type 1

DM, (b) Diabetic ketoacidosis, and (c) hypersensitivity. Patients taking sitagliptin must be instructed that

if a dose is missed, then they must take it as soon as they remember, or if it is time for their next dose,

they must skip it. They should never double dose the medication. Again, this medication does not cure

DM, it just helps control hyperglycemia, and patients should be made aware this may be a long-term

therapy. (Vallerand et al., 2017)

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Summary

While working with our patient Baby Ruth, who like many others are diagnosed with DM every

year, this project provided the authors with the chance to learn about disadvantaged populations,

resources in Auburn for diabetics, and the importance of thorough education and prevention measures. By

understanding how disadvantaged populations can affect DM care, we can better prevent future

complications in our patients and promote better patient outcomes. Various journal articles and Davis’s

drug guide provided the authors with not only the necessary information to complete this project, but also

to enhance the authors’ understanding and ability to treat and educate patients with DM. In relation to

nursing practice, the authors agreed that using the teach-back method when providing medication

education is vital, especially in patients with DM. This can increase compliance with medication regimen

and allow the authors to determine patient understanding. The authors also learned that in some cases,

noncompliance can stem from a variety of health disparities and not of the patient’s volition. This

highlights the importance of a thorough history assessment and therapeutic communication to foster open

communication with the patient. Baby Ruth’s diagnosis gave the authors the chance to learn more about

the outside factors that play a large role in the prevention and management of DM.
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References

Adult services: Opelika & Auburn, Alabama (AL), EAST Alabama Medical Center. (n.d.).

https://www.eamc.org/find-a-service/diabetes-and-nutrition/adult-services

American Association of Diabetes Educators. (2016, June). Special Considerations in the

Management and Education of Older Persons with Diabetes.

https://www.diabeteseducator.org/docs/default-source/default-document-library/special-

considerations-in-the-management-of-older-persons-with-diabetes.pdf?sfvrsn=0

American Diabetes Association. (2020, February 2). The Burden of Diabetes in America.

http://main.diabetes.org/dorg/docs/state-fact-sheets/ADV_2020_State_Fact_sheets_AL.pdf

Bhavnani. (2020). School of Nursing project enlists canine companions to combat prevalent

metabolic disease. Office of Communications and Marketing. http://ocm.auburn.edu/research-

magazine/2020-fall/articles/canines-combat-metabolic-disease.php

Centers for Disease Control and Prevention. (2020). National Diabetes Statistics Report 2020

Estimates of Diabetes and its Burden in the United States.

https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

Diabetes in children and teenagers: Symptoms and diagnosis. (2020, November 03).

https://www.medicalnewstoday.com/articles/284974

East Alabama Diabetes Brochure. East Alabama Diabeaters. (n.d.). https://campsealeharris.org/wp-

content/uploads/2017/03/East-Alabama-Diabeaters-Brochure.pdf

Hill-Briggs, F., Adler, N. E., Berkowitz, S. A., Chin, M. H., Gary-Webb, T. L., Navas-Acien, A., …

Haire-Joshu, D. (2020). Social determinants of health And Diabetes: A scientific review.

Diabetes Care, 44(1), 258–279. https://care.diabetesjournals.org/content/44/1/258.full

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Lin, L.-Y., Lee, B.-O., & Wang, R.-H. (2019). Effects of a Symptom Management Program for

Patients With Type 2 Diabetes: Implications for Evidence-Based Practice. Worldviews on

Evidence-Based Nursing, 16(6), 433–443. https://doi.org/10.1111/wvn.12400

Pediatric Services: Opelika & Auburn, Alabama (AL), East Alabama Medical Center. East Alabama

Medical Center. (n.d.). https://www.eamc.org/find-a-service/diabetes-and-nutrition/pediatric-

services.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). In Davis’s drug guide for nurses (15th ed.)

In Nursing Central for Apple iOS (Version 1.31) [Mobile application software].

https://nursing.unboundmedicine.com/nursingcentral

What is diabetes? (2020, June 11).https://www.cdc.gov/diabetes/basics/diabetes.html

Appendix

Group #: 8

Member names: Cameron Hill, Maren Stiles, Sydney Wrighte, Emily Waller
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Patient Name: Baby Ruth 3/17/1965

Chronic Condition(s): Diabetes

Medication Dose Route Frequency Indication

Pioglitazone (Actos) 15 mg By mouth Every day Type 2 diabetes mellitus (with diet and
Capsule exercise); may be used with metformin,
sulfonylureas, or insulin.

Metformin (Glucophage) 500 mg By mouth Twice daily Management of type 2 diabetes mellitus; may be
Capsule used with diet, insulin, or sulfonylurea oral
hypoglycemics

Insulin aspart (Novolog) 5 units Sub Q TID before Control of hyperglycemia in patients with type 1
meals or type 2 diabetes mellitus.

Insulin glargine (Lantus) 30 units Sub Q Every day at Control of hyperglycemia in patients with type 1
bedtime or type 2 diabetes mellitus.

Sitagliptin (Januvia) 100mg By Mouth Every Day Adjunct to diet and exercise to improve
Capsule glycemic control in patients with type 2 diabetes
mellitus; may be used as monotherapy or
combination therapy with metformin, a
thiazolidinedione, a sulfonylurea, or insulin.