CHAPTER 3 Sam shakes his head sadly. “I’m so lucky. I’m age of 40, but it can also occur in children and IN CHILDREN older and only have to swallow a pill. I don’t young adults as well.5 know what I would have done if I had gotten (4 CONTACT HOURS) The symptoms of can be quite diabetes when I was just a kid.” By Farah Harajli, BA, has worked as a pharmacy mild, and the disease can remain undetected professional for a national chain and has an in-depth Diabetes affects people of all ages, races, and for a number of years. The disease may not be knowledge of the pharmacy process. socioeconomic groups. It requires lifelong diagnosed until abnormal results are noted in Author Disclosure: Farah Harajli and Elite management and necessitates lifelong changes in blood or urine glucose levels.5 Professional Education do not have any actual or behavior as well. The adjustment to these changes potential conflicts of interest in relation to this lesson. Diabetes 2 alert! Type 2 diabetes is often linked can be difficult at any age; however, in children, with obesity. Obesity can cause blood glucose Universal Activity Number (UAN): there are special challenges: peer pressure, the levels to increase and resistance to occur.5 0761-9999-13-247-H01-P fear of being “different” from others, and the Activity Type: Knowledge-based need to take medication (especially via injection) (GDM) Initial Release Date: July 30, 2013 for the rest of their lives can be particularly GDM occurs during pregnancy and is Expiration Date: July 30, 2015 daunting. The potential for complications puts characterized by high blood glucose levels that Target Audience: Pharmacists in a community-based further pressure on diabetic children as well as usually return to normal after delivery.3 GDM setting. their family and friends. occurs in one out of 25 pregnancies throughout To Obtain Credit: A minimum test score of 70 percent the world and is “associated with complications This education program provides information is needed to obtain a credit. Please submit your answers in the period immediately before and after birth.”5 about diabetes in children, its impact, and how either by mail, fax, or online at pharmacy.elitecme.com. The children of women who have GDM are these young patients and their families effectively at a greater risk for the development of type 2 Questions regarding statements of credit and other deal with the disease through pharmacological diabetes later in life.5 Women who have GDM are customer service issues should be directed to 1-888- treatment. Although pharmacological treatment is 666-9053. This lesson is $16.00. also at greater risk for developing type 2 diabetes. one of the last steps during a child’s entrance into It is estimated that these women have a 40-60 Educational Review Systems is accredited diabetic care, it is still one of the most important. percent chance of developing type 2 diabetes by the Accreditation Council of Pharmacy While diabetic children may visit their physicians within five to 10 years after child delivery.3,5 Education (ACPE) as a provider of often, the use of medication is something they continuing pharmaceutical education. This program is approved for 4 hours (0.4 will have to experience daily. To learn how In addition to these three major types of diabetes, CEU’s) of continuing pharmacy education credit. Proof to best help young patients with diabetes, it is there are variations known as “other specific of participation will be posted to your NABP CPE important to first learn what they go through. types.”3 These include:3  Diabetes that is a result of a genetic defect. profile within 4 to 6 weeks to participants who have Differentiating among the different types successfully completed the post-test. Participants must  Diabetes that is due to a dysfunction of an participate in the entire presentation and complete the of diabetes endocrine gland. course evaluation to receive continuing pharmacy Traditionally, when people hear the phrases  Diabetes that is due to exposure to some education credit. “childhood diabetes” or “diabetes in children,” drugs or chemicals. Learning objectives they automatically think of , a condition characterized by the failure of the Incidence and prevalence of diabetes !! Differentiate among the different types of pancreas to produce insulin.7 In fact, until only The National Diabetes Information diabetes. a few years ago, it was actually believed that the Clearinghouse (NDIC) has compiled National !! Discuss the incidence and prevalence of existence of type 2 diabetes (formerly referred to Diabetes Statistics, 2011 (the most current diabetes. as adult-onset diabetes) in children was indeed statistics available as of this writing). These !! Identify risk factors for the development of rare. Today, however, we know that people statistics were obtained from a number of data diabetes in children. younger than 20 years of age are affected by type systems, including the Centers for Disease !! Correlate the complications of diabetes with 2 diabetes. It is estimated that about 215,000 Control and Prevention (CDC), the Indian Health their causes. people younger than 20 had either type 1 diabetes Service’s (HIS’s) National Patient Information !! Identify how the diagnosis of diabetes in or type 2 diabetes in 2010 in the United States.10 Reporting System, the U.S. Renal Data System children is made. ! of the National Institutes of Health (NIH), and ! Explain pharmacological treatments for Type 1 diabetes the U.S. Census Bureau and published studies.5 diabetes in children. There are three major types of diabetes. Type 1 According to this database:5 Introduction diabetes, formerly known as insulin-dependent  Diabetes affects 8.3 percent of the population or juvenile-onset diabetes, is caused by the Sam Hall is 46 years old and was diagnosed of the United States, or about 25.8 million destruction or the suppression of the beta cells with type 2 diabetes a few years ago. Thanks to people. in the pancreas. This leads to a failure of the a treatment plan that involves oral medication,  It is estimated that 7 million people have pancreas to release insulin, which is necessary for diet, and exercise, Sam is healthy and coping well diabetes but have not yet been diagnosed. human survival.5,7,11 with the diagnosis. Today, Sam sits in an exam  Diabetes is the leading cause of kidney room at his physician’s office, waiting to see the Type 1 diabetes can affect people of all ages, but failure, new cases of blindness, and non- doctor for a routine check-up. Suddenly, he hears it is usually diagnosed in children or very young traumatic lower limb amputations in adults in a loud scream and sobbing. Startled, he leaves adults.5 Persons with type 1 diabetes are insulin- the United States. the exam room and looks out into the hallway to dependent. They and their families must learn to  Diabetes is a significant cause of see what is happening. A young girl who appears inject insulin, monitor blood glucose levels, and cardiovascular and cerebrovascular disease. to be about 13 years old is crying and attempting monitor their intake of carbohydrates.7  Diabetes is the seventh leading cause of death to run down the hallway and out of the office. in the United States. Type 2 diabetes Her mother and one of the nurses try to calm her. The vast majority of diabetics are affected by Diabetes in people younger than 20 years She is crying uncontrollably and shouts, “I can’t type 2 diabetes.10 Type 2 diabetes, formerly of age be sick! I just can’t be! I won’t give myself shots referred to as non-insulin dependent diabetes or As of 2010, an estimated 215,000 people less for the rest of my life for this diabetes thing! I’d adult-onset diabetes, is characterized by insulin than 20 years of age had diabetes, type 1 or type rather be dead!” As the nurse and the mother deficiency and . Diagnosis of 2. This figure represents 0.26 percent of all young lead the girl into one of the other exam rooms, type 2 diabetes is usually made in people over the people in this age group.10

Page 35 Elite A number of statistics on the incidence of an autoimmune attack on the beta cells of decreased and delayed as well. This reduces diabetes in people younger than 20 years of age the pancreas. This leads to a pancreatic the body’s ability to metabolize glucose. Thus, have been compiled thanks to SEARCH for inflammatory response called insulitis. the elderly patient is more prone to experience Diabetes in Youth, a multicenter study funded by abrupt concentrations of glucose and somewhat In the immune-mediated form of type 1 diabetes, the CDC and the NIH. The purpose of the study prolonged .3 antibodies may be present for some time was to investigate the incidence and prevalence before symptoms appear. By the time signs and Risk factors for the development of of type 1 and type 2 diabetes in children and symptoms are evident, it is believed that about 80 diabetes in children adolescents in the United States. 11 percent of the beta cells are destroyed. Robert and Sandra have been happily married for Some of the findings from this study include:10 It is believed that persons who are genetically 15 years. They have three children, one of whom  During the years from 2002 through 2005, susceptible to type 1 diabetes may experience is 12-year-old Scott. Lately, they have been a bit 15,600 young people were newly diagnosed a triggering event, such as exposure to a virus, worried about Scott. He has been unusually tired annually with type 1 diabetes, and 3,600 which causes the body to produce auto-antibodies and irritable and has been losing weight despite were newly diagnosed annually with type 2 against the pancreatic beta cells. Beta cells are eating large amounts of food. Scott’s pediatrician diabetes. 4 suspects that Scott may have type 1 diabetes. He  destroyed, and insulin is not secreted.  The rate of new cases of type 1 diabetes asks Robert and Sandra about any family history among children less than 10 years of age Type 1 diabetes alert! Once symptoms become of the disease. Both parents deny any history. was 19.7 per 100,000 each year and 0.4 per apparent, type 1 diabetes generally becomes But Robert, who was raised by his mother and 100,000 for type 2 diabetes. evident at a rapid pace, with the swift progression stepfather, wonders about the health history of his  4  The rate of new cases among young people of significant signs and symptoms. biological father, who died when Robert was just older than 10 years of age was 18.6 per Development of type 2 diabetes a toddler. Robert calls his mother who relays that 100,000 per year for type 1 diabetes and 8.5 Type 2 diabetes is a chronic disease that is his father did indeed have diabetes “since he was per 100,000 for type 2 diabetes. the result of impaired secretion of insulin, very young.”  The highest rate of new cases of type 1 inappropriate hepatic glucose production, or diabetes among young people occurred in There are a number of risk factors for both type peripheral insulin receptor insensitivity.4 Under non-Hispanic white youths. 1 and type 2 diabetes. Family history is one such normal conditions, insulin molecules bind to  The occurrence of type 2 diabetes was quite factor. It is important that parents know and preceptors on the body’s cells. Insulin triggers the rare among children less than 10 years of age. understand the implications of risk factors for the opening of portals to allow glucose to enter the Rates were higher among youths 10-19 years development of diabetes. cell, where it is converted to energy. However, of age than in younger children. Rates were in type 2 diabetes, cells develop a resistance to Risk factors for type 1 diabetes higher among minority populations than in insulin that makes it harder for glucose to enter The exact cause of type 1 diabetes is not known. non-Hispanic whites. cells. Without adequate glucose, the cells do However, research indicates that in the majority Boston Children’s Hospital posts the following not receive enough energy, glucose builds up of people with type 1 diabetes, the child’s own statistics on incidence and prevalence on its in the blood vessels, and all organs of the body immune system actually destroys the beta website:2 experience some degree of damage.4,11 insulin-producing cells of the pancreas. Thus, the  Approximately one in every 600 children in pancreas of a type 1 diabetic produces very little Type 2 diabetes alert! The onset of type 2 the United States develops type 1 diabetes. or no insulin, which, under normal conditions, diabetes is usually slow and subtle, and signs and  Type 1 diabetes is one of the most common facilitates the transport of glucose into the cells symptoms are often not evident.4 chronic diseases in children. of the body. Thus glucose builds up in the  Type 1 diabetes most often occurs during Development of other forms of diabetes bloodstream leading to various, sometimes life- 4,7,11 puberty; ages 10 to 12 in girls and ages 12 to So-called secondary forms of diabetes are those threatening, complications. 14 in boys. However, it is increasing in very caused by conditions such as pancreatic disease, As research shows, genetics and family history young children less than 5 years of age. pregnancy, hormonal or genetic problems, and play a part in the development of most if not   Type 1 diabetes tends to occur within various drugs or chemicals. Common causes all diseases and disorders. Type 1 diabetes is no families. include:4,11 exception. Family history of type 1 diabetes,  The development of diabetes  Physical or emotional stress: Stress especially that of a parent or sibling, increases the may elevate the levels of stress hormones 3,7 It is important for learners to know about the risk of developing the disease. (cortisol, epinephrine, glucagon, and growth normal functioning of the body before they hormone), which elevate blood glucose levels Genetic testing for certain genes may also can comprehend the processes involved in the and increase the demands placed on the become more common in the future. It is believed development of diabetes. The specific factors pancreas. that the presence of particular genes increases related to diabetes vary with the type of diabetes  Pregnancy: Gestational diabetes is the risk for diabetes 1. As of this writing, genetic affecting the patient.4,11 characterized by glucose intolerance, possibly testing for type 1 diabetes is generally done as 7 Development of type 1 diabetes due to placental hormones counteracting part of a clinical trial. Type 1 diabetes is caused by destruction or insulin. Genetics and family history are agreed-upon suppression of the beta cells of the pancreas. It  The use of certain drugs: The use of certain risk factors. There are a number of other may also be caused by a primary defect in the drugs, such as hormonal contraceptives and possible risk factors for the development of functioning of the beta cells that causes insulin adrenal corticosteroids, may antagonize the type 1 diabetes. Exposure to viruses such as the release failure and inadequate transport of effects of insulin. Epstein-Barr virus, coxsackievirus, mumps virus, glucose.3,4  Viral infections: Viral infections, such and cytomegalovirus may spark autoimmune as rubella, mumps, adenovirus, and CMV destruction of islet cells. It is also possible that Type 1 diabetes can be subdivided into idiopathic (cytomegalovirus), have been associated with the viruses themselves infect the islet cells.7 and immune-mediated types.3,4 secondary diabetes.  Idiopathic type 1 diabetics have a permanent Adequate levels of vitamin D may help to protect deficiency of insulin without evidence of Elderly patient alert! With age, the cells of against the development of type 1 diabetes. autoimmunity. the body become more resistant to insulin, Conversely, inadequate levels of vitamin D may  Immune-mediated type 1 diabetics are and the release of insulin from the pancreas is increase the risk for development of the disease. affected by a deficit or defect that causes

Elite Page 36 However, an interesting finding is that early  Hypertension (children as well as adults may  Sweating. consumption of cow’s milk (a source of vitamin be hypertensive).  Weakness. D) is associated with an increased risk for the  Elevated triglycerides. Untreated, may lead to fainting, development of type 1 diabetes.7 seizures, and even coma.1,3,8 Breast-feeding and diabetes 2 alert! Research Some dietary factors have been linked to an shows that babies who are breast-fed have Treatment involves checking blood glucose level increased risk of developing type 1 diabetes. a lower risk for developing type 2 diabetes (if possible) and giving the child a quick-acting These include:7 compared to those who are formula fed.17 carbohydrate, such as fruit juice or hard candy.1 If  Consuming water that contains nitrates may symptoms do not subside or worsen after giving Complications of diabetes and bodily also increase the risk of type 1 diabetes. carbohydrates, emergency medical assistance is  Introducing cereal as part of the baby’s diet changes needed. may affect risk. Results from a clinical study There are a number of potential complications of Hypoglycemia alert! Family and friends need indicated that the optimal time for adding diabetes, many of which can be life-threatening. to be taught to recognize the symptoms of cereal to the diet is between the ages of 4 It is important that parents and other caregivers hypoglycemia and how to intervene. and 7 months. The introduction of cereal are aware of these complications and what and other solid foods is continually being actions to take to prevent their occurrence. As Hyperglycemia evaluated. The infant’s physician should be children develop intellectually, they, too, must be Scott is an outgoing teenager who also happens the primary guide on diet. taught how to avoid complications of the disease. to have type 1 diabetes. He is usually careful to   Consuming certain types of baby formulas Hypoglycemia adhere to his dietary restrictions and takes his may influence the risk of type 1 diabetes. Allison is 16 years old and was diagnosed with insulin faithfully. However, the past week or so, Research findings indicate that giving babies type 1 diabetes two years ago. Allison is one of Scott has been less careful. He has been going formulas that are easier to digest (such as the stars on her field hockey team. The team is out with friends after sporting events and going hydrosolate) when they are between 6 and competing for a state title, and every practice to see various movies at the local cinema. Part of 8 months old may reduce the risk of type 1 session is important. Practice is scheduled for 10 these social activities involves, of course, eating. diabetes. But this same study did not link a.m. on this Saturday morning, but Allison’s day Scott has been, as he puts it, “cheating on his cow’s milk formulas to an increased risk of is off to a bad start. She cannot find her hockey diet,” indulging in pizza, buttered popcorn, and type 1 diabetes. stick, and after searching for it for 20 minutes, carbonated soft drinks. Breast-feeding and diabetes type 1 alert! Some she discovers that her little brother has hidden it After a few days, Scott begins to complain of research studies suggest that breast-feeding can as a “joke.” being thirsty all of the time; he needs to get up 17 reduce the risk of type 1 diabetes in children. Her father has to take her siblings to their several times at night to go to the bathroom, and he feels nauseous. His parents quiz him about his Risk factors for type 2 diabetes various activities as well as drive Allison to activities and quickly help him to return to his The single greatest risk for type 2 diabetes in practice. He tells her to hurry. Her mother, a normal dietary intake. children is excess weight.13 Sadly, obesity has nurse at the local hospital, is at work. Allison reached epidemic proportions among children in quickly injects herself with her normal dose of It can be challenging to adhere to a carefully the United States. Almost one in five children is insulin. She means to grab some fruit to eat in the controlled diet. It can be especially difficult considered overweight, and once a child is found car, but in her haste, she forgets. for teenagers who are diabetics. They want to to be overweight, his or her chance of developing As her father drops her off at practice he socialize, have fun, and be like their friends. Even type 2 diabetes is doubled.13 asks, “Did you take your insulin? Did you eat the most cautious young diabetics will cheat now and then on their diets. They and their parents It makes sense, therefore, that factors that breakfast?” Not wanting to miss practice, Allison and friends need to be able to recognize signs that contribute to being overweight or obese also nods her head. About midway through practice, hyperglycemia is occurring and how to react. contribute to the risk of acquiring type 2 Allison begins to feel “shaky.” Her heart is diabetes.13 Unhealthy eating habits, such as beating uncomfortably fast, her head aches, and Hyperglycemia is not always caused by a failure consumption of fast foods that are high in fat and her vision begins to blur. Allison is experiencing to adhere to dietary restrictions. It can be caused calories, a lack of fruits and vegetables, and an hypoglycemia. by illness, inadequate dosage of insulin, and the 1 excess of carbohydrates, all facilitate unhealthy Hypoglycemia occurs when the blood glucose lack of recommended physical activity. weight gain. Weight gain, in turn, increases the level is too low. Allison’s failure to eat breakfast 13 Signs and symptoms of hyperglycemia are risk of type 2 diabetes. even though she administered her normal similar to those of diabetes and include:1,3 A lack of physical activity is also a risk factor dose of insulin led to the development of this  Excessive thirst. for type 2 diabetes (and weight gain).13 Research . Vomiting and diarrhea can also  Excessive urination and possible bedwetting. shows that physical activity has positive health reduce intake of proper nutrients and lead to  Nausea and vomiting. benefits on all body systems. A lack of exercise hypoglycemia. If the child is ill and unable  Weight loss. to ingest proper amounts of nutrients, his or increases the risk of illness, including type 2 If these signs and symptoms appear, the child’s diabetes.3,13 her insulin dose may need to be adjusted. The child’s physician should be notified and urine is checked for ketones and his or her blood Other medical conditions, hormonal influences, guidance obtained about any medication dosage glucose level is checked. and genetics may also play a role in a child’s adjustments.1,3,8 Hyperglycemic alert! If the signs and symptoms weight. Additionally, children’s risk for type 2 3,8 of hyperglycemia are accompanied by deep, rapid diabetes seems to be linked in particular to excess Signs and symptoms of hypoglycemia include:  respirations and a rapid heart rate, the child may abdominal weight.13  Anxiety.  Double or blurred vision. be deteriorating and experiencing the medical 1 Other risk factors for type 2 diabetes in children  Fatigue. emergency condition of ketoacidosis. 3,13  include:  Headache.  Being female.   Hunger. Diabetic ketoacidosis is a medical emergency  Being part of certain ethnic groups (African-   Irritability. that, if left untreated, may lead to coma or death.3 American, Asian American, Hispanic, Pacific   Numbness or tingling of the skin. Most common in patients with type 1 diabetes, Islander, and Native American).   Rapid, pounding heartbeat. diabetic ketoacidosis may actually be the first   Shaking or trembling. sign of previously undiagnosed type 1 diabetes.3

Page 37 Elite In ketoacidosis, there is an absolute, acute to feel nauseous and anxious. After he arrives an adverse effect on many, if not most, of the deficiency of insulin.3 Insulin is necessary for at the gym, he develops what he describes as a systems of the body. the transport of glucose into the cells. Without “suffocating” chest pain. One of his students  Review family medical history. Find out insulin, the cells do not have glucose to use for calls 911. At the emergency room, Anthony is whether there is a family history of heart energy, so the body breaks down fat in an attempt diagnosed as having had a myocardial infarction disease and at what age signs and symptoms to find an energy source. As fats are broken (heart attack). of heart disease became evident. down, acids called ketones build up in both  Adhere to a treatment regimen. Diabetics Heart disease is a common complication of the blood and urine. High levels of ketones are are already dealing with a multitude of diabetes. Children and teenagers who are poisonous to the body.3,9 treatment interventions such as medication, diabetics need to work hard to stay physically fit diet, exercise, and so forth. Adding heart At the same time, the levels of blood glucose because diabetes does have a negative effect on disease interventions may be perceived become alarmingly high, usually greater than 300 the cardiovascular system. as too overwhelming. All patients need mg/dL, because the liver manufactures glucose Adults who have diabetes have heart disease- encouragement and support to take the in an attempt to deal with the buildup of ketones. related deaths about two to four times greater actions that will help them to achieve their However, the cells cannot accept glucose without than adults without diabetes.10 “In 2004, heart maximum state of health and wellness. the help of insulin, which is not present.9 disease was noted on 68 percent of diabetic-  Stop smoking, or do not start smoking! Although patients with type 2 diabetes can related death certificates among people ages 65  Drink alcohol moderately or not at all. develop ketoacidosis, it is rare and may be years or older.”10 In other words, the risk of heart a response to a severe illness or infection. disease increases dramatically for those who are Hypertension Hispanics and African-Americans experience diagnosed with diabetes. Monica is a 40-year-old local television news diabetic ketoacidosis more often than other racial reporter. She has also been a type 1 diabetic since High levels of blood glucose can cause groups.9 she was 17 years old. Monica has always done arteriosclerosis, which further increases the risk her best to reduce her risk of complications from Primary symptoms of diabetic ketoacidosis of heart attack.3 Children and their parents and diabetes. She exercises regularly and carefully include:3,9 caregivers should be taught about the dangers of monitors her diet. She neither smokes nor drinks   Abdominal pain. heart disease and actions to take to reduce its risk alcoholic beverages. Unfortunately she has also   Deep, rapid respirations (Kussmaul’s as soon as possible after diagnosis. Even young developed hypertension. Monica is angry and respirations). children can learn to avoid high-fat foods and tells her physician that she has always taken   Dry mouth. to incorporate exercise into their daily routines. good care of herself and now has to deal with   Dry skin. Today, technology facilitates sitting in front of a “new” problem. Her doctor assures her that   Facial flushing. a computer or other devices through which they she is doing exactly what she should do, but she   Fruity smelling breath. can access the Internet and play various video has a family history of hypertension as well as   Nausea and vomiting. games. The dangers of a sedentary lifestyle seem diabetes, and the important thing is to monitor to increase with each new technological advance. Additional symptoms include:9 her blood pressure and take an anti-hypertensive Children need to be encouraged to go outside and  Decreased level of consciousness that may as prescribed. play games that require physical activity! progress to coma. Hypertension is yet another potential   Excessive thirst. Many of the healthy lifestyle actions overlap complication of diabetes. Statistics available from   Fatigue. from risk factor to risk factor. Obesity and lack of the National Diabetes Information Clearinghouse   Headache. exercise contribute to the risk of heart disease as (NDIC) include findings that between 2005 and   Lack of appetite. well as many other diseases. Here is a summary 2008, 67 percent of adults ages 20 or older with   Muscle pain or stiffness. of actions that have been shown to reduce the risk self-reported diabetes had blood pressure equal  3,4,11,18  Respiratory difficulty. of heart disease. to or greater than 140/90 mm Hg (millimeters of    Urinary frequency.  Adhere to diabetic treatment plan to mercury) or used prescription medications to treat control blood glucose levels. Significantly 10 Insulin must be administered to decrease hypertension. fluctuating blood glucose levels increase the dangerously high blood glucose levels. Fluid patient’s risk for complications. The preventive or management tactics for and electrolytes lost via vomiting and frequent  Monitor blood pressure. Avoid excessive hypertension are the same as for heart disease. urination may need to be replaced. Treatment amounts of caffeine and sodium, which can These interventions, such as exercise, diet, of existing infections or illnesses is necessary facilitate the elevation of blood pressure. If stress management, and adherence to treatment because such conditions can trigger diabetic hypertension does develop, follow treatment regimens, are part of a healthy lifestyle for many, ketoacidosis.9 interventions as prescribed by health care if not most, diseases. Ketoacidosis alert! Diabetic ketoacidosis is providers. Hypertension is generally referred to as a “silent” a medical emergency requiring immediate  Monitor cholesterol. If medication is needed problem. It generally produces no symptoms treatment. Patients, families, friends, and to control cholesterol levels, adhere to until blood pressure is so high that patients have teachers must be taught to recognize the signs prescribed treatment regimens. strokes or other catastrophic manifestations of the and symptoms of this serious complication and to  Exercise regularly. Exercise should be part condition. The American Diabetes Association obtain immediate medical assistance. of everyone’s routine. Children who learn to recommends that patients have their blood Heart disease engage in an active lifestyle at an early age pressure checked at every physician’s office visit are more likely to continue such behavior into 19 Anthony is a 50-year-old high school basketball or at least two to four times a year. adulthood. coach. He has also been dealing with a diagnosis Current blood pressure classifications identified  Achieve and maintain optimal weight. of type 1 diabetes since he was a teenager. by The National Institutes of Health (NIH) are as  Adhere to a diet that facilitates blood Anthony has worked hard to stay physically fit, follows:3 glucose control. Avoid foods high in fat, salt, but does cheat on his diet a “little more than I  Normal: Less than 120/80 mm Hg. cholesterol, and excess carbohydrates. should.” He exercises regularly and does not  Pre-hypertension: 120-139 mm Hg systolic  Reduce stress as much as possible. Learn drink alcohol. Anthony does, however, smoke or 80 to 89 mm Hg diastolic. coping skills and seek out support groups for 5-10 cigarettes a day. One afternoon, on his  Hypertension stage 1: 140-159 mm Hg diabetics and families of diabetics. Stress has way to his team’s practice session, he begins systolic or 90 to 99 mm Hg diastolic.

Elite Page 38  Hypertension stage 2: Equal to or greater diabetes who are over 50 years old have an can affect anyone who has than 160 mm Hg systolic or equal to or ABI to screen for PAD. type 1 or type 2 diabetes. Initially, there may be greater than 100 mm Hg.  An angiogram involves the injection of dye no or only mild visual symptoms. However, as into the blood vessels to determine whether the disorder progresses, visual deficits increase Stroke arteries are narrowed or blocked. and blindness may eventually occur.23 Two out of three people with diabetes die from  An ultrasound uses sound waves to produce stroke or heart disease.20 High glucose levels There are two major categories of diabetic images of blood vessels for assessment. can promote the development of arteriosclerosis, retinopathy.22,23  An MRI (magnetic resonance imaging) is which is a risk factor for both stroke and heart  Nonproliferative diabetic retinopathy performed to identify any blockages within disease.3 Just being diabetic increases the risk of (NPDR): NPDR is sometimes referred blood vessels. stroke. to as early diabetic retinopathy and is the Exercises, such as walking, can be part of the most common type of diabetic retinopathy. Other stroke risk factors include:20 treatment for PAD and may even help to prevent With NPDR, new retinal blood vessels fail  Abnormal cholesterol levels. it. Other measures to manage or prevent PAD to grow or proliferate. The walls of the  Family history of stroke. include blood glucose control, not smoking, existing retinal blood vessels weaken. Small  Hypertension. controlling blood pressure, and keeping bulges (microaneurysms) protrude from the  Personal history of stroke or transient cholesterol within normal limits. In some cases, vessel walls and cause leakage of blood and ischemic attack (TIA). surgical interventions such as angioplasty and other fluids into the retina. As the disorder  Smoking. artery bypass graft may be performed.21 progresses, retinal nerve fibers begin to Interventions to reduce risk are similar to those swell. Blood and fluids leak into the macula, PAD alert! Some research studies indicate that mentioned in the sections on heart disease and the central portion of the retina that focuses anti-platelet medications such as aspirin may hypertension. As already discussed, healthy vision. The macula swells (macular edema) lower the risk of heart attacks and strokes in lifestyle interventions and adherence to diabetic and vision becomes blurred, and may even be people with PAD.21 (and other medical conditions) treatment completely lost. NPDR is classified as mild, regimens are essential for individual states of Eye problems moderate, and severe, as more and more health and wellness. Persons with diabetes are at significant risk of eye blood vessels become affected. NPDR in its complications, and most will develop some type less severe forms does not usually require Peripheral arterial disease (PAD) of retinopathy, which is the result of damage to treatment. However, macular edema must be Peripheral arterial disease, also referred to as blood vessels of the retina.22,23 Here is a summary treated to stop, and sometimes even reverse, arterial occlusive disease, is the obstruction or of the most common eye problems affecting vision loss. narrowing of the lumen of the aorta and its major people who have diabetes.  Advanced diabetic retinopathy or branches. This causes interference with blood 3 proliferative retinopathy: Proliferative flow, especially to the legs and feet. Glaucoma retinopathy (PDR) is the most serious The longer someone has had diabetes, the greater People with diabetes are quite likely to have form of diabetic retinopathy. At this stage the probability of developing glaucoma. In fact, PAD. It is estimated that one out of every three of retinopathy, new but abnormal blood diabetics are 40 percent more likely to acquire people with diabetes over the age of 50 has PAD. vessels begin to grow in the retina. These glaucoma than those without the disease.22 Other factors that increase the risk of this disease new vessels are weak and can grow or leak include smoking, hypertension, being overweight, Glaucoma is actually a group of disorders that are blood into the vitreous, the clear, jelly-like lack of physical activity, and personal or family characterized by damage to the optic nerve. This substance that “fills” the center of the eye. history of stroke or heart disease.21 damage is most often linked to a high intraocular Scar tissue forms as a result of stimulation pressure (IOP).3 The pressure slows the drainage from new blood vessel growth. This scar Although this complication generally occurs after of aqueous humor, causing it to build up in the tissue can distort the retina or cause it to the age of 50, it is important that young diabetics eye’s anterior chamber. The pressure “pinches” detach from the back of the eye (retinal become aware of complications (when they are the blood vessels carrying blood to the retina and detachment). The new blood vessels may also ready to learn about them) and steps to take to optic nerve. A gradual loss of vision occurs as the interfere with the normal flow of fluid out of reduce their risk. retina and optic nerve are damaged.23 the eye, causing an increase in pressure that Many diabetics who have PAD do not experience leads to glaucoma. Unfortunately, the retina Treatment of glaucoma includes drug therapy, any signs or symptoms. This makes it especially can be significantly damaged before any laser treatments, and surgery.3 important for people to be aware of this vision changes occur. Thus it is imperative complication and how to screen for it.21 Cataracts that persons with diabetes have regular eye examinations by specialists who are Some persons may have mild leg pain, especially Diabetics are 60 percent more likely to develop accustomed to treating diabetics. when walking or during exercise. This pain cataracts than those without diabetes. They usually disappears after resting for a few minutes. often develop cataracts at a younger age, and the There are several factors that can increase the risk 22 People may also experience numbness, tingling, cataracts progress more quickly. for diabetic retinopathy. These include:22,23 or coldness in the lower legs or feet. Infections, Cataracts are the most common cause of  Duration of diabetes: The longer someone sores, or lacerations on the feet or legs may heal correctable vision loss. Cataracts are gradually has diabetes, the greater the risk of diabetic slowly.21 developing opacities of the lens of the eye or retinopathy.  Elevated cholesterol. As young diabetics reach middle age, they of the lens capsule. Generally, surgical removal  Hypertension. may need to be screened for PAD, even if they of the lens of the eye or eyes affected by the  Poorly controlled blood glucose levels. have no symptoms. PAD is diagnosed via the cataracts improves vision. However, after such  Pregnancy. following diagnostic tests.21 surgery, retinopathy may become worse in 3,22  Use of tobacco products.  Ankle brachial index (ABI) compares blood diabetics, and glaucoma may begin to develop. pressure in the ankle to blood pressure in Retinopathy Retinopathy alert! Nearly all persons who the arm. If the blood pressure in the ankle Diabetic retinopathy refers to disorders of the have type 1 diabetes will develop some degree is less than the pressure in the arm, PAD retina caused by diabetes.22 It is characterized of NPDR. Most people who have type 2 diabetes is a possibility. The American Diabetes by damage to the blood vessels of the retina, the will also develop the disorder. However, Association recommends that people with light-sensitive tissue located at the back of the the occurrence of the more serious PDR is 22 eye.23 significantly less common. Page 39 Elite Diabetic retinopathy usually affects both eyes. the patient may need to remain in a prone  Diabetic dermopathy: Diabetes-related Persons with diabetes should be taught that in position until the bubble dissipates. An eye changes in the small blood vessels may lead the early stages of diabetic retinopathy, there are patch is worn for a few days, and medicated to diabetic dermopathy. This condition causes usually no symptoms. As the disease progresses, eye drops may be prescribed. light brown, scaly patches that are oval or symptoms that may appear include:23 circular. Often mistaken for age spots, this Diabetes alert! People between 10 and 29  Blurred vision. condition usually occurs on the front of both years of age and who have had diabetes for at  Dark or empty areas in visual fields. legs. The patches do not cause discomfort, least five years should have an annual dilated  Difficulty distinguishing colors. itch, or become open areas on the skin. eye exam. Blood pressure should be monitored  Floaters (dark spots or “strings” that seem to  Eruptive xanthomatosis: This skin condition and controlled within normal limits because float in the visual fields). is caused by diabetes that is uncontrolled. hypertension can make eye problems worse!34  Vision loss. Yellow, pea-size areas appear on the skin. Nephropathy (kidney disease) Each of these “bumps” has a surrounding Diabetic retinopathy is diagnosed most Under normal conditions, the kidneys filter red halo and may be itchy. The bumps show effectively with a dilated eye exam. During this waste products from the body and excrete them up most often on the backs of the hands, exam, the physician will look for:23 as part of the urinary output. Useful substances, feet, arms, legs, and buttocks. This problem  Abnormal blood vessels. such as proteins, remain in the blood. High most often occurs in young men who have  Abnormalities of eye pressure. levels of blood glucose, however, can cause the type 1 diabetes and elevated cholesterol. The  Bleeding into the vitreous. kidneys to filter excessive amounts of blood. condition subsides when glucose control is  Cataracts. This extra workload places strain on the kidneys achieved or restored.  Detached retina. and interferes with the normal filtering process,  Digital sclerosis: Digital sclerosis is  Growth of new blood vessels and the ultimately causing protein to be filtered into the characterized by tight, thick, “waxy” presence of scar tissue. urine instead of remaining in the blood.3,24 looking skin on the backs of the hands and  Optic nerve abnormalities. occasionally on the toes and forehead. The  Vision abnormalities. Small amounts of protein in the urine joints of the fingers become stiff and difficult (microalbuminuria) are an indication of early Some diagnostic studies that may be performed to move normally. kidney disease (nephropathy) and have treatment include:23 options focused on keeping blood glucose within  Fluorescein angiography: During this test, Neuropathy normal limits and controlling blood pressure.25 the pupils are dilated and pictures are taken (diabetic nerve damage) 27 of the interior of the eye. Dye is then injected As nephropathy progresses, larger affects nearly half of all persons with diabetes. into a blood vessel in the arm. As the dye amounts of protein are found in the urine Over the years, elevated blood glucose levels circulates to and through the eyes, images are (macroalbuminuria). This indicates later-stage causes injury to the walls of the blood vessels, taken and abnormalities of the blood vessels disease and ultimately progresses to end-stage thus interfering with proper circulation to nerve are identified. renal disease (ESRD). At this point, the kidneys fibers. Elevated glucose levels interfere with the  Optical coherence tomography (OTC): ability of the nerves to transmit messages to and are unable to filter waste products, and the 27,28 This is an imaging test that produces images kidneys fail. Dialysis or kidney transplantation from the brain to various parts of the body. As of the retina to assess retinal thickness and becomes necessary.24 nerve fibers are damaged, a variety of symptoms whether blood and fluids have leaked into the appear. These can range from mild to severe and 28 retina. Skin problems can even be fatal. It is estimated that about one-third of persons There are four major types of diabetic Treatment options depend on the severity of the affected by diabetes will develop some type of 23 neuropathy. People may have only one type or be retinopathy. Options include: skin problem caused or affected by diabetes at affected by multiple types.26,27  Focal laser treatment (photocoagulation): some point in their lifetime.26 Fortunately, many  Peripheral neuropathy: This is the most This involves treating leakage from abnormal of these problems can be prevented or effectively common type of diabetic neuropathy. Feet blood vessels with laser treatment. Generally treated if identified early. accomplished in a single session in a clinic and legs are usually affected first, followed or physician’s office, this treatment causes Many of these problems are fairly common in by the hands and arms. Signs and symptoms blurry vision that generally subsides within a the general population. However, people with include reduced ability to feel pain or day. Patients may also see small spots in their diabetes are more prone to infections than the changes in temperature; pain and weakness visual fields that subside within a few weeks. general population. Good skin care and hygiene when walking; acute sensitivity to even the Outcomes are not assured. Some persons may is essential for all diabetics. Children who have lightest touch (e.g., the weight of a sheet never recover their normal vision, but others diabetes must be taught how to take care of their in bed); and pain, numbness, weakness, or skin. Even very young children can learn how to tingling in the hands and feet. may actually experience improved vision.   Scatter laser treatment (the entire wash their hands, always to wear shoes, and to  Autonomic neuropathy: The autonomic retina): This form of laser treatment shrinks take care of (or seek help to take care of) cuts, nerves of the body control the function scrapes, and other skin injuries. They also need to of the heart, bladder, lungs, stomach, abnormal blood vessels and is performed 3,26 in the physician’s office or eye clinic. The be taught how to avoid injuring their skin. intestines, eyes, and sexual organs. Damage to these nerves can cause bowel and bladder treatment is generally accomplished in two Some of the skin complications related to problems; nausea and vomiting; trouble or more sessions. Vision is blurry for a few diabetes include:3,26 swallowing; vaginal dryness; erectile days. There may be loss of night vision or  Bacterial infections: Common bacterial dysfunction; diaphoresis; tachycardia; vision peripheral vision following the procedure. infections include sties, boils, infections problems; and the inability of the body  Vitrectomy: This procedure requires general around the nails, around the hair follicles, and to make necessary adjustments to body anesthesia and is performed in a surgery deep within the skin. temperature, heart rate, and blood pressure to center. The procedure is performed to remove  Fungal infections: Most fungal infections maintain homeostasis. scar tissue and blood in the eye, which are affecting persons with diabetes are caused by  Radiculoplexus neuropathy (diabetic replaced with a saline solution to maintain Candida albicans, which frequently affects amyotrophy): This type of neuropathy the eye’s normal shape. A gas bubble may moist areas of the skin, such as under the affects nerves in the thighs, hips, buttocks, be placed in the eye to facilitate retinal breasts, between fingers and toes, and in the and legs. It is more common in older adults reattachment. If a gas bubble is inserted, axilla and groin. and in persons who have type 2 diabetes.

Elite Page 40 Symptoms, which usually occur on one side Diabetes causes blood vessels to narrow and Gastroparesis of the body, include abrupt severe pain in the harden. This damage inhibits circulation to the Gastroparesis is a form of neuropathy hips, thighs, or buttocks, weak and atrophied extremities and makes persons with diabetes not characterized by damage to the vagus nerve, thigh muscles, trouble getting up from a only more susceptible to infection but also makes which controls movement of food and liquids sitting position, weight loss, and abdominal it more difficult for infections to heal.3,29 through the digestive tract. The movement of swelling. Diabetes alert! Amputations of the lower foods and liquids is slowed or even stopped.  Mononeuropathy: This type of neuropathy extremities are far more common among people Patients with gastroparesis experience heartburn, causes damage to a specific nerve in the face, with diabetes than the general population. nausea and vomiting, weight loss, bloating, torso, or leg. It develops abruptly and is most 32 Impaired circulation and decreased sensation to anorexia, and gastric spasms. common in older adults. Mononeuropathy the lower extremities facilitate the development of Gastroparesis affects persons with both type 1 causes severe pain that usually resolves itself ulcers, calluses, and infections, which may fail to and type 2 diabetes. It can be treated with proper over a period of several weeks to several heal and progress to the point that amputation is management of blood glucose levels, mediations, months. Signs and symptoms depend on the necessary.3,29 and diet. Severe cases of gastroparesis may nerve affected and may cause paralysis on require insertion of a feeding tube.32 one side of the face (Bell’s palsy); pain in the Hyperosmolar hyperglycemic nonketotic shin, foot, or front of the thigh; double vision; syndrome (HHNS) Diagnosis of diabetes difficulty focusing the eyes; aching eyes; or Hyperosmolar hyperglycemic nonketotic Signs and symptoms of type 1 diabetes in chest or abdominal pain. syndrome (HHNS) is a complication seen most children Foot problems often in older adults. It can occur in people with Signs and symptoms of type 1 diabetes in either type 1 or type 2 diabetes, but most often Foot problems are very common among people children usually develop quickly over a period is seen in people with type 2 diabetes. HHNS is who have diabetes. Such problems are closely of several weeks. These signs and symptoms usually triggered by another illness or infection.30 3,7 linked to diabetic neuropathy and can lead include:  to serious complications, such as infection, HHNS is characterized by high, uncontrolled  Increased thirst and fluid intake.  foot ulcers, reduced arterial blood flow, and blood glucose levels. The body attempts to  Increased urination (polyuria).  amputation of the foot or leg. compensate by excreting glucose in increasingly  Excessive hunger.  high amounts in the urine. Large amounts of  Weight loss. Why are these serious problems so common  urine are excreted, resulting in excessive fluid  Unusual fatigue and lethargy. among diabetics? Here are some explanations:3,29  and electrolyte loss and dehydration. Unchecked,  Changes in behavior.  Neuropathy: Neuropathy, or diabetic nerve  HHNS causes severe dehydration, seizures, and  Irritability. damage, can cause significant pain. However,  ultimately death. Symptoms of HHNS include  Blurred vision. damaged nerves may also interfere with the  blood glucose levels over 600 mg/dl; severe  Yeast infections (girls may develop genital ability to sense pain, heat, and cold. This thirst; warm, dry skin; high fever; vision loss; yeast infections, and infants may develop means that patients may burn themselves hallucinations; and weakness on one side of the diaper rash caused by yeast). (e.g., walking on a sandy beach or hot body. sidewalk), have chafing of the feet in shoes Signs and symptoms of type 2 diabetes in that do not fit properly, walk with a pebble The best way to deal with HHNS is to prevent children in the shoe, or experience other annoyances it by keeping blood glucose levels under Compared to signs and symptoms development they are not aware of because of the decrease control. Even though this is a problem affecting in persons with type 1 diabetes, those of type in sensation. These annoyances can turn into older adults, all persons with diabetics (at all 2 diabetes develop slowly. In fact, children serious problems. People with diabetes may age levels) should be aware of this serious (and adults) may not even feel that anything not sense a minor injury until the skin breaks complication.3,30 is wrong. Type 2 diabetes may be present for down and becomes infected, thus turning into several months or even years before a diagnosis a major injury. Hearing loss associated with diabetes is made.13,14  Skin changes such as calluses, corns, The NIH reports that the rate of hearing loss is Signs and symptoms associated with type 2 and ulcers: Diabetes can cause the skin to 30 percent higher among people with diabetes diabetes include:13,14 become quite dry, peel, crack, and become compared to those with normal blood sugar 31  Unusual fatigue. easily injured. This is most likely caused by levels. Such hearing loss occurs at any age,  Nausea. damage to the nerves that control the oil and even among children. Assessment of hearing is  Blurred vision. moisture in the feet. The pressure on the feet an ongoing part of regular physical examinations  Increased thirst. from walking can cause callus formation. for persons who have diabetes.  Increased urination. These calluses need to be trimmed by a Persons with hearing loss may not even be aware  Increased appetite. health care provider to avoid breakdown of that there is any problem. Family members and  Heavy breathing. the calluses, which may lead to ulcers and friends as well as the patients themselves should  Pruritis. infection. be alert to the following signs of hearing loss in  Slow healing of cuts, scrapes, or sores. persons with diabetes.31  Diabetes alert! Patients should not   Numbness or tingling in the hands or feet. attempt to trim or remove calluses or corns  Often asking others to repeat themselves.  Complaining that others are mumbling. American Diabetes Association criteria for themselves. Only a trained health care  provider should do this!  Difficulty following conversations that diagnosis involve more than two people. According to the American Diabetes Association   Ulcers of the feet: Ulcers are found most  Turning the volume of the television, radio, (ADA), diabetes can be diagnosed if any of the frequently on the ball of the foot or on the or other devices to very high levels. following factors exist.3 bottom of the big toe. They may also form  Signs and symptoms indicative of diabetes Diabetes alert! Children may experience on the sides of the feet if shoes fit poorly. All plus a non-fasting (random) blood glucose difficulty in school, such as deterioration in ulcers, no matter how small or even if they level greater than or equal to 200 mg/dl. grades, because they are having trouble hearing do not cause pain or other discomfort, should  A fasting blood glucose level greater than or their teachers. be evaluated by a health care provider. Ulcers equal to 126 mg/dl. may become infected and lead to serious  A plasma glucose level problems, even amputation. greater than or equal to 200 mg/dl. Page 41 Elite Diabetes alert! The ADA classifies fasting blood treatment and the importance of adhering to the require extra measures to guarantee accuracy in glucose levels as follows: normal: less than 100 individualized treatment regimen. their treatment. mg/dl; pre-diabetes: 100 to 125 mg/dl; diabetes: Pharmacological treatment of diabetes Patients with diabetes also will likely visit the greater than or equal to 126 mg/dl.3 About two months ago, 9-year-old Joanna began pharmacy each month for their insulin and If testing is inconclusive, the child’s physician experiencing bouts of extreme dehydration as needles, so it is helpful to young patients if may order a (A1C) test. well as drastic weight changes. Concerned with they are familiar with the staff who will assist This test measures the percentage of blood her daughter’s symptoms, Joanna’s mom Angela them. Remember that these are children who are glucose attached to hemoglobin. The higher the took her to see their primary physician. After experiencing an often lifelong disease at such a glucose levels, the more hemoglobin there is that physically examining Joanna and collecting young age, a disease that many of their peers in has sugar attached. The test indicates the average blood samples, the physician diagnosed the school will not have to experience. Nothing will blood glucose levels for the previous two to three young girl with type 2 diabetes. Once she help ease this scary process more than a little months. An A1C result of 6.5 percent or higher overcame the initial shock of her daughter’s compassion and a smile. on two separate tests indicates diabetes.7 diagnosis, Angela needed to know what to When children with diabetes enter a pharmacy, Non-pharmacological treatment of do next. She wasn’t familiar with diabetes in they will not be the only ones facing a new children, and she had only known that frequent diabetes challenge. Parents or guardians of children with blood tests and injections were involved because The goals of treatment are to normalize diabetes can feel overwhelmed by the situation: of her grandmother’s struggle with the disease. and control blood glucose and to decrease their young child has been diagnosed with a complications.3 These goals are achieved through After their primary physician directed them chronic disease that even most adults struggle to a combination of medication, diet, exercise, and to a physician who specialized in diabetes, handle. 7 healthy lifestyle behaviors. Angela and Joanna had to begin visiting their While many adults with diabetes are able to local pharmacy – a pharmacy they had only monitor their glucose levels and diets as well as previously used on occasion for their annual Persons with diabetes must learn to monitor administer their own blood tests, this is not as flu shots. Overwhelmed by the prospect of their easy for children less than 14 years of age. When their blood glucose levels, a procedure that must new routine, Angela didn’t even know where to be performed for the rest of their lives. Blood children face diabetes, so do their parents. From begin after a pharmacy technician filled out more the early symptoms to the physician’s office, a glucose testing can seem overwhelming, and it of their information in the system. Joanna was may be tempting to skip testing. It is imperative diabetic child’s care process is cyclical and made similarly distraught at the thought of having to much less daunting once parents are in the know that children, their parents, other caregivers, and use injection cartridges for her insulin. teachers know how to check blood glucose levels. and master the routine. This can be especially critical if the children To help Angela and Joanna with this new phase Regardless of whether the parents of newly are displaying signs of hyper- or hypoglycemia in their lives, the technician called the pharmacist diagnosed diabetic children ask for a consultation (see sections on complications for detailed over for a consultation. After the pharmacist gave upon their first visit to the pharmacy, one should information). the mother and daughter a thorough tutorial on be given. It could be that a parent is in a state of insulin and its possible side effects, the technician Depending on the type and severity of diabetes, anxiety over all of this new information and feels then explained the limitations of Joanna’s new timid about asking, or it could be that the parent it may be necessary to check and record blood government-provided insurance to Angela. With glucose levels at least three times a day and even does not know that some type of consultation Angela and Joanna both seeming much calmer with the pharmacist is available to them. And more often. This is often accomplished by “finger than when they had first walked in, the pharmacy sticks,” although some blood glucose meters regardless of whether your pharmacy requires technician lowered her head to Joanna and consultations with every prescription (which allow testing to be performed on sites other than explained, “My name is Sarah. If you ever need the fingers.7 can often be forgotten in the hustle and bustle anything or just want to call to say ‘Hi’, we’ll all of a pharmacy), remember that a consultation Continuous glucose monitoring (CGM) is a be here for you, Joanna.” with parents and their newly diagnosed diabetic newer way to monitor blood glucose levels, but Once children and their families have worked child is a must. Apart from the collective staff’s is not yet as accurate as traditional or “standard” with a physician to create their regimen of compassion, a substantial amount of information monitoring. Therefore, it is used in addition to treatment and fully understand the treatment, they will smooth this transition for the families of 7 traditional monitoring. are then directed to the pharmacy for medication. diabetic patients. CGM involves the insertion of a fine needle For patients diagnosed with type 1 diabetes, Outlined below are the various medications that just under the skin. The needle is attached to it is impossible to control the disease without you will be distributing to patients with all forms the CGM device, and blood glucose levels are insulin, which is available at pharmacies. Patients of diabetes. measured every few minutes.7 diagnosed with type 2 diabetes may be able to control their glucose levels through weight Oral medications A record should be kept listing the date, time, consistency, exercise, and a specific diet, but this Children (and adults) with type 2 diabetes and results of glucose monitoring. Any unusual is very difficult to do, so either insulin or oral generally use oral medications (in conjunction circumstances, such as illness, acute stress, or medication is oftentimes the safest option.37 with diet, exercise, and healthy lifestyle acute exercise, should also be recorded. Such behaviors) to control blood glucose levels. When patients with diabetes begin using the circumstances may affect blood glucose levels However, some children with type 2 diabetes may pharmacy for their medication necessities, it and require and adjustment to medication dose require insulin.6 (especially insulin) and the need for carbohydrate is especially important to keep their patient intake. files up-to-date and whole. For patients who Children and parents must be taught that oral transfer to your pharmacy, it is imperative that medications are NOT a form of insulin. These The child’s physician will work with the child, the pharmacist correspond with their former medications act by stimulating the release of parents and caregivers, diabetes educators, pharmacies to ensure that all of the correct files insulin from functioning pancreatic beta cells nurses, and dieticians to determine the target were transferred and that their entire history and by increasing the sensitivity of the body’s range for blood glucose levels and dietary needs. is in your possession. While such file-keeping peripheral tissues to insulin.12 Examples of Diabetes alert! Children MUST be involved in procedures are necessary for all pharmacy oral anti-diabetic medications are Glucotrol® all aspects of treatment. Compliance depends on patients, patients with diabetes are likely to be in (glipizide), Glucophage® (metformin), and the child’s understanding of the disease and its the system for most of their lives and therefore DiaBeta® (glyburide). 12

Elite Page 42 Commonly occurring side effects of oral anti- taken about 30 minutes before meals. It can pressure can also influence dietary intake. diabetic medications include nausea, vomiting, be mixed with intermediate-acting insulin in Health care providers must be continually diarrhea, abdominal pain, changes in the the same syringe. made aware of the patient’s eating patterns. sensation of taste, and loss of appetite. These  Intermediate-acting insulin: Intermediate-  Physical activity: Physical activity usually medications should be taken with food to reduce acting insulin (e.g., NPH® insulin) is used to lowers blood glucose levels and can affect nausea and vomiting.6, 12 control blood glucose levels between meals such levels for up to 12 hours after exercise. and throughout the night. This type of insulin As children add new or make changes in As children grow and develop, their need for begins to work in one to four hours, reaches their physical activities, they may need medications may change. Dosage and even its peak within four to 12 hours, and has a adjustments in their diets and insulin doses. the drugs themselves may need to be adjusted. duration of 10 to 24 hours. Intermediate- For example, a snack may be needed before Children and parents and caregivers should be acting insulin can be mixed with rapid and beginning exercise, or an insulin dosage may taught about the side effects and how to recognize short-acting insulin in the same syringe. need to be lowered. Children and parents hyper- and hypoglycemia. Illness, stress,  Long-acting insulin: Long-acting insulins must work with health care providers to plan exercise, and changes in activities of daily living (e.g., Lantus®) do not peak. They begin to for changes in physical activity. may affect the medication’s effectiveness.3, 6, 12 work within one to two hours and last for  Illness: Some illnesses, such as the common A rare side effect of oral anti-diabetic 18-26 hours. Long-acting insulin is used to cold, cause an elevation in blood glucose medications is lactic acidosis, which generally control blood glucose levels between meals levels. Fever increases metabolism. If these occurs in elderly persons who have multiple and throughout the night. Long-acting insulin types of illnesses occur, children may need health problems. However, it is still a possibility cannot be mixed with other insulin in the larger or more frequent doses of insulin. that lactic acidosis may occur in children. This same syringe. Illnesses that cause vomiting or diarrhea is especially true of young people who take reduce the intake of nutrients, and may Insulin may be administered via subcutaneous these medications and drink alcohol.6 Thus, it is necessitate insulin dosage adjustments. injection or an insulin pen, which is a device that important that everyone who takes oral anti- Children and parents must work with health actually resembles an ink pen but has a cartridge diabetic drugs be aware of lactic acidosis. care providers to develop a plan to manage filled with insulin. An is also an insulin administration during illness. Lactic acidosis is the result of a dangerous option. The insulin pump is about the size of a  Puberty and growth spurts: As children buildup of lactic acid in the blood. Symptoms cell phone and is situated on the outside of the grow and mature, they experience growth include muscle pain, rapid breathing, cool, body. A tube connects an insulin reservoir of spurts and changes related to puberty. clammy skin, sweet or fruity smelling breath, insulin to a catheter inserted under the abdominal Hormonal changes and growth spurts alter nausea, and vomiting.6 This side effect requires skin. Insulin is dispensed in programmed insulin requirements. These issues must be immediate medical attention. Some patients amounts automatically. Programming can monitored and reported to the child’s health need to be hospitalized and receive drug therapy, be adjusted to deliver more or less insulin, care physician so that insulin doses may be intravenous therapy, and supportive measures.33 depending on the patient’s activity level, meals, 7 adjusted. Insulin blood glucose levels, and state of health. Diabetes alert! Some children are at risk for The goal of insulin therapy is to achieve the Recording the administration process is very low blood glucose levels during the night. best possible control of blood glucose levels important. Notes should be kept in patients’ files In these cases, glucose levels should be a bit by matching the type and amounts of insulin of how their insulin injections are administered. higher before bed than during the day. Children administered with the child’s need for insulin, If the injections are given subcutaneously, it is and parents should work with their health care both day and night. The specific type of insulin, helpful to record their regular needle size so that providers to determine appropriate glucose levels the amounts, and frequency of administration the wrong size is not distributed. at bedtime.7 vary according to individual needs. Some Insulin reactions are problems that must be children may need two or more insulin injections Children may experience unexpected, very anticipated and dealt with by affected children every day, while others may use an insulin pump low blood glucose levels that cause confusion, and their families. One of the most common to control blood glucose levels.6 seizures, and loss of consciousness. For children problems is hypoglycemia (see previous section prone to this problem, it may be necessary to The various types of insulin can be categorized as on complications). This problem is most likely to have glucagon available. Glucagon is a hormone follows.6, 7, 12 occur if a person eats less than usual, exercises administered via injection that quickly raises  Rapid-acting insulin: This type of insulin more than usual, or has an illness such as blood glucose levels. Parents, teachers, school (e.g., Humalog®) begins to work within five gastrointestinal upset. Under conditions such as nurses, athletic coaches, and others should know to 15 minutes, and its effect peaks at 30 to these, insulin dosage may need to be decreased. when and how to administer glucagon.6 90 minutes after administration. Duration Health care providers work with children and is about four hours. Rapid-acting insulin Diabetes alert! Children with diabetes should their families to monitor and adjust insulin doses is taken to deal with glucose absorption wear medical identification tags so that in an as necessary.6 Pharmacists work with parents at mealtimes. It is usually administered emergency, caregivers and emergency medical during consultations to increase their awareness immediately before eating but can be given personnel can be made aware they are diabetic. of side effects. Insulin adjustments may also be immediately afterwards. Rapid-acting insulin necessary under the following circumstances: 3, Healthy lifestyle behaviors can be mixed with intermediate-acting insulin 6,7,12 Many healthy lifestyle behaviors help not in the same syringe. To date, the safety and  Taking other medications: Any medications, only with but also with efficacy of rapid-acting insulin have not been including prescription, over-the-counter, the prevention or a reduction in severity of established in children less than 12 years of herbal preparations, vitamins, and other complications, such as heart disease, eye age. Insulin should be prescribed for children supplements may affect blood glucose levels. disorders, and skin problems. only by health care providers with expertise Other medications should never be taken in management of diabetes in children. Diet is often one of the first concerns expressed without the knowledge of the child’s health  Short-acting insulin: These types of insulin by parents and children. But the best diet for care provider. (e.g., Humulin R®) begin to work 30 to 60 children with diabetes is one that the whole  Diet: It is important that the child’s eating minutes after administration and peak occurs family can and should follow. It consists of plenty patterns be considered when insulin is in two to four hours. Duration is about six to of fruits, vegetables, and whole grains. These prescribed. Eating patterns change as the nine hours. Short-acting insulin is generally foods are high in nutrients and low in fat and child grows. Social activities and peer

Page 43 Elite 25. WebMD. (2011). -treatment overview. Retrieved April 24, 2013 calories. Foods derived from animal products and Here are some suggestions to help children with from http://diabetes.webmd.com/tc/diabetic-nephropathy-treatment-overview. those that contain lots of sugar and carbohydrates diabetes and their families maintain mental health 26. American Diabetes Association. (no date given). Skin complications. Retrieved April 2, 2013 from www.diabetes.org/living-with-diabetes/complications/skin-complications. 36, 37 should be limited. and wellness. html.  27. American Diabetes Association. (no date given). Neuropathy (nerve damage).  Encourage children to take an active role Retrieved April 2, 2013 from www.diabetes.org/living-with-diabetes/complications/ This diet is good for the whole family.7 Children, in managing their diabetes. They must be neuropathy. especially teenagers, are concerned with looking 28. Mayo Clinic. (2012). Diabetic neuropathy. Retrieved April 24, 2013 from www. involved in the decision-making process on mayoclinic.com/health/diabetic-neuropathy/DS01045. fit and slim. This diet will help them to do so 29. American Diabetes Association. (no date given). Foot complications. Retrieved April treatment options and lifestyle changes. 2, 2013 from www.diabetes.org/living-with-diabetes/complications/foot-complications. as well as help them to be healthy! This kind 30. American Diabetes Association. (no date given). Hyperosmolar hyperglycemic  Stress the need for lifelong diabetes nonketotic syndrome (HHNS). Retrieved April 2, 2013 from www.diabetes.org/living- of healthy diet is also helpful in facilitating with-diabetes/complications/hyperosmolar-hyperglycemic.html. management. 31. American Diabetes Association. (no date given). Diabetes and hearing loss. cardiovascular health.  Retrieved April 2, 2013 from www.diabetes.org/living-with-diabetes/seniors/hearing-  Teach children as well as their caregivers loss/ The entire family should work with a dietician to 32. American Diabetes Association. (no date given). Gastroparesis. Retrieved April 2, how to manage their diabetic medication 2013 from www.diabetes.org/living-with-diabetes/complications/gastroparesis.html. help develop an appropriate diet that the whole regimen, including administering their own 33. emedtv. (no date given). Metformin and lactic acidosis. Retrieved April 28, 2013 from http://diabetes.emedtv.com/metformin/metformin-and-lactic-acidosis.html. family can follow. It is not a good idea to have a insulin as soon as they are old enough to do 34. American Diabetes Association. (no date given). Eye care. Retrieved April 2, 2013 from www.diabetes.org/living-with-diabetes/complications/eye-complications/eye- “special” meal for the child who is diabetic and so. care.html.  35. American Diabetes Association. (no date given). Mental health. Retrieved April 2, other foods for the rest of the family.  Encourage children to form bonds with their 2013 from www.diabetes.org/living-with-diabetes/complications/mental-health. diabetes team members. 36. American Diabetes Association. (no date given). Stress. Retrieved April 2, 2013 from Diabetes alert! Smoking and alcohol abuse www.diabetes.org/living-with-diabetes/complications/stress.html.  Encourage regular physical exercise. 37. Joslin Diabetes Center at Harvard Medical School. (2013). Can I treat Diabetes significantly increase the risk of diabetes  Without Drugs? Retrieved June 27, 2013 from http://www.joslin.org/info/can_i_treat_ complications.28 Children should learn at a young  Encourage children and families to join diabetes_without_drugs.html. age not to smoke and to avoid large quantities of support groups. Children, especially alcohol as they grow up! teenagers, do not want to be different from their peers. Having a network of other Regular health care examinations are essential, teenagers who have diabetes may be very including dilated eye exams as recommended helpful. by ophthalmologists with expertise in helping  Be alert to the dangers of substance abuse. children who have diabetes. Keeping a People who have diabetes have an increased regular schedule of preventive health exams is risk of developing depression and anxiety and imperative! may turn to alcohol or other drugs as a means Regular physical exercise is important and is of coping. Encourage them to interact with (Final examination questions on next page) a healthy lifestyle habit that would benefit the mental health professionals who are part of whole family. It is often easier for the child to the diabetes team. participate in exercise that is a fun family activity. Diabetes is a diagnosis that requires lifelong Skin care is very important for anyone who management. It affects not only the children who has diabetes. Carefully dry areas that tend to are diagnosed but their families and friends as become moist, such as between the toes, under well. It is important that healthy lifestyle changes the breasts, and the groin area. Creams and oils be incorporated by the entire family to help should not be placed between the toes because promote maximum states of health and wellness it can increase the risk of infection. However, as among all family members! References and works consulted mentioned earlier, the skin on the soles of the feet 1. Boston Children’s Hospital. (2012). Type 1 Diabetes In-Depth. Retrieved March 28, and the surface of the feet can become quite dry, 2013 from http://www.childrenshospital.org/az/Site1797/mainpageS1797P1.html. 2. Boston Children’s Hospital. (2011). Type 1 diabetes: Overview. Retrieved March 20, leading to pealing and cracking of the skin. Some 2013 from http://www.childrenshospital.org/az/Site1797/mainpageS1797P0.html. 3. Durkin, M. T. (Ed.). (2013). Professional guide to diseases (10th ed.). Philadelphia: people find it helpful to apply a thin coat of plain Wolters Kluwer Health/Lippincott Williams & Wilkins. 4. Eckman, M. (Ed.). (2011). Professional guide to pathophysiology (3rd ed.). petroleum jelly over these areas (but not between Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 29 5. International Diabetes Federation. (no date given). Types of diabetes. Retrieved March the toes!). Members of the diabetic health 20, 2013 from www.idf.org/print/types-diabetes. care team can advise children and parents about 6. KidsHealth.org. (2012). Medicines for diabetes. Retrieved March 28, 2013 from http://kidshealth.org/PageManager.jsp?dn=KidsHealth&lic=1&ps=107&c proper skin and foot care. at_id=20722&article_set=41551. 7. Mayo Clinic. (2011). Type 1 diabetes in children. Retrieved May 20, 2013 from www. mayoclinic.com/health/type-1-diabetes-in-children/DS00931/METHOD=print. Diabetes alert! Children should be cautioned 8. MedlinePlus. (2012). Hypoglycemia. Retrieved March 20, 2013 from www.nlm.nih. gov/medlineplus/ency/article/000386.htm. NOT to go barefoot. This can be especially 9. MedlinePlus. (2012). Diabetic ketoacidosis. Retrieved March 20, 2013 from www.nlm. tempting as children play with friends, go nih.gov/medlineplus/ency/article/000320.htm. 10. National Diabetes Information Clearinghouse. (2011). National diabetes statistics swimming, and participate in other activities 2011. Retrieved March 27, 2013 from http://diabetes.niddk.nih.gov/dm/pubs/statistics/ 11. Rosto, E. (Ed.). (2009). Pathophysiology made incredibly easy. (4th ed.). where everyone else is barefoot. However, going Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 12. Spratto, G. R., & Woods, A. L. (2013). 2013 Delmar healthcare drug handbook. barefoot increases the chance of injury and Clifton Park, NY: Delmar. 13. WebMD. (2012). Type 2 diabetes in children. Retrieved March 20, 2013 from http:// should not be done. diabetes.webmd.com/guide/type-2-diabetes-in-children. 14. WebMD. (2010). Type 2 diabetes in children: Symptoms. Retrieved March 20, 2013 Maintaining mental health from http://diabetes.webmd.com/tc/type-2-diabetes-in-children-symptoms. 15. Comerford, K. C. (Ed.). (2013). Anatomy & physiology made incredibly easy (4th The diagnosis of diabetes is often overwhelming. ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 16. MedicineNet.com. (2012). Definition of Islets of Langerhans. Retrieved March 29, Children, particularly teenagers, may resist 2013 from http://www.medterms.com/script/main/art.asp?articlekey=4054. 17. Womenshealth.gov. (2010). Why breastfeeding is important. Retrieved March 31, making the lifestyle changes necessary for proper 2013 from www.womenshealth.gov/breastfeeding/why-breastfeeding-is-important/#op. 18. American Diabetes Association. (no date listed). ABCs of heart disease. Retrieved management of diabetes. Children as well as their April 2, 2013 from http://www.diabetes.org/living-with-diabetes/complications/mens- parents and loved ones may experience a variety health/serious-health-implications/abcs-of-heart-disease.html. 19. American Diabetes Association. (no date listed). High blood pressure (hypertension). of emotions, including anger, denial, and even Retrieved April 2, 2013 from www.diabetes.org/living-with-diabetes/complications/ 35 high-blood-pressure-hypertension.html. clinical depression. 20. American Diabetes Association. (no date listed). Stroke. Retrieved April 2, 2013 from www.diabetes.org/living-with-diabetes/complications/stroke.html. The normal stressors of growing up compounded 21. American Diabetes Association. (no date listed). Peripheral arterial disease (PAD). Retrieved April 2, 2013 from www.diabetes.org/living-with-diabetes/complications/ by the diagnosis of diabetes can increase stress peripheral-arterial-disease.html. 22. American Diabetes Association. (no date given). Eye complications. Retrieved April to dangerous levels. Stress hormones can 9, 2013 from www.diabetes.org/living-with-diabetes/complications/eye-complications/ 23. Mayo Clinic. (2012). Diabetic retinopathy. Retrieved April 9, 2013 from www. directly affect blood glucose levels. Additionally, mayoclinic.com/health/diabetic-retinopathy/DS00447/ 24. American Diabetes Association. (no date given). Kidney disease (nephropathy). people under stress may not take good care of Retrieved April 2, 2013 from http://www.diabetes.org/living-with-diabetes/ themselves and engage in unhealthy behaviors.36 complications/kidney-disease-nephropathy.html. Elite Page 44 DIABETES IN CHILDREN 8. Which type of insulin is used to control Final Examination Questions blood glucose levels throughout the night Choose the best answer for questions and between meals? 1 through 10 and mark your answers a. Rapid-acting insulin. online at pharmacy.elitecme.com. b. Short-acting insulin. c. Long-acting insulin. d. Intermediate-acting insulin. 1. Type 2 diabetes is often linked with which of the following? 9. Insulin adjustments: a. Obesity. a. Are seldom necessary, once a dosage is b. Malnourishment. established. c. Age. b. May be necessary when a patient d. Gender. is taking other medications or supplements. 2. The destruction or suppression of which of c. Are normally made annually. the following types of cells in the pancreas d. Seldom needed when children causes type 1 diabetes? undertake new physical activities. a. Pancreas cells. b. T-cells. 10. Stress hormones can directly affect: c. Acidic cells. a. Insulin levels. d. Beta cells. b. The beta cell count. c. Blood glucose levels. 3. The single greatest risk for type 2 diabetes d. The white blood cell count. in children is: a. Being underweight. b. Being obese. c. Being male. d. Being a non-Hispanic white person.

4. In ketoacidosis, there is an absolute, acute deficiency of which of the following? a. Beta cells. b. Insulin. c. Amino acids. d. White blood cells.

5. Which of the following measurements of blood glucose levels is considered pre-diabetes? a. 100 to 125 mg/dl. b. 125 to 150 mg/dl. c. 150 to 175 mg/dl. d. 75 to 100 mg/dl.

6. It is possible to leave type 2 diabetes pharmacologically untreated if the patient: a. Maintains weight consistency. b. Exercises. c. Maintains a specific diet. d. Does all of the above.

7. Why is it especially important to keep a diabetic patient’s file complete and up-to-date? a. To ensure they are not stealing their substances from the pharmacy. b. Diabetic patients need to be reminded of their regimens. c. Physicians are not involved in the pharmacological aspect of diabetic care. d. These patients are likely to be in the system most of their lives and require extra measures to ensure accuracy. RPUS04DCE13

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