Chap 32 Antidiabetic Drugs

Question 1

What is Diabetes

Answer 1

too much sugar in the blood*

problems start when body no longer makes enough insulin**

insulin helps sugar move from blood into cell
w/o insulin, cells cant get sugar they need to keep healthy**

Type 1
body no longer makes insulin**

diabetes - medical word for people with high blood sugar problem**

Type 1 need to take insulin*

most type 1 are children or young adults*

Type 2
body makes some insulin but not enough**
or insulin in body does not work right**

food changed into sugar, glucose,

if not enough insulin to move sugar from blood into cell, sugar level in blood goes up

type 2 more common in adults, but number of children and young adults with type 2 is growing8

EATING HEALTHY* and being physically active can help blood sugar.

diabetes cannot be cured** but can be controlled**

Question 2

Diabetes Mellitus

Answer 2

Diabetes Mellitus: Elevated fasting blood glucose (higher than 126 mg/dL) or a hemoglobin A1C (HbA1C) level greater than or equal to 6.5%
*S/S:
Polyuria, Polydipsia, Polyphagia, Glycosuria, Unexplained weight loss, Fatigue, Blurred vision**
Type 1 DM:
Lack of insulin production* or production of defective insulin (Fewer than 10% of cases)
Type 2 DM
: Caused by insulin deficiency** and insulin resistance** (90% of all cases)

Question 3

Treatment

Answer 3

Glycemic goal of treatment: HbA1C** of less than 7%, Fasting blood glucose goal for diabetic patients of 70 to 130 mg/dL
Type 1
: Always requires insulin therapy
Type 2: **
Lifestyle changes** (Weight loss, Improved dietary habits, Smoking cessation, Reduced alcohol consumption, Regular physical exercise)
Oral* drug therapy
Insulin* when the above no longer provide glycemic control

Question 4

Types of Antidiabetic Drugs

Answer 4

Insulins*

Oral* hypoglycemic drugs

Some new injectable hypoglycemic drugs may be used in addition to insulin or antidiabetic drugs.

Question 5

Insulins**

Answer 5

Function as a substitute* for the endogenous hormone
Effects are the same as normal endogenous insulin
Restores the diabetic patient’s ability to:**
Metabolize carbohydrates, fats, and proteins
Store glucose in the liver
Convert glycogen to fat stores
Exogenous insulin does not reverse defects in insulin receptor sensitivity.
Human insulin
Derived using recombinant DNA technologies
Recombinant insulin produced by bacteria and yeast

Question 6

Types of Insulin

Answer 6

rapid acting insulin*
works 10-15 mins after injection
peaks 1-1.5hrs
lasts 3-5 hrs
aspart(Novolog)*
Insulin glulisine(apidra)*
insulin lispro(humalog)**

Regular or short acting insulin*
within 30-45 mins of injection
peaks 2-3 hrs
effective 3-6.5 hrs
Humulin R, Novolin R, Velosulin R***

Intermediate acting insulin
reaches bloodstream 1-3 hours after injection
peaks 5-8 hrs
effective 14-18 hrs
NPH* Humulin N, Novolin N, ReliOn**

Ultra long acting
reaches blood stream 6 hrs
does NOT peak**
lasts 36 hrs or longer
glargine U-300(Toujeo)

Question 7

How to take insulin?

Answer 7

Syringe
rapid acting

Pen
regular-short acting

Pump
intermediate acting

Inhaler
long acting

Question 8

MIXING INSULIN

Answer 8

Draw up the clear*
clear and fasting*

Before* the Cloudy*
Cloudy and long acting

to prevent contamination a short-acting with long acting

Question 9

Insulins

Answer 9

Rapid-acting** treatment for types 1 and 2 DM
Most rapid onset of action (5 to 15 minutes)**
Peak:* 1 to 2 hours
Duration: 3 to 5 hours
Patient must eat a meal after injection
Insulin lispro (Humalog) **
Similar action to endogenous insulin
Insulin aspart (NovoLog)**
Insulin glulisine (Apidra)**
May be given subcutaneously (SQ) or via continuous SQ infusion pump (but not intravenously [IV])

Question 10

Rapid-Acting Insulins

Answer 10

Afrezza**
Rapid-acting insulin that is inhaled
Peak of 12 to 15** minutes
Short duration of action of 2 to 3 hours
Administered within 20 minutes before each meal
Must be given in conjunction with long-acting insulins or oral diabetic agents (for type 2 DM)
Side effects: hypoglycemia, cough and throat pain
Contraindicated: smokers and those with chronic lung diseases
Black-box warning regarding the risk of acute bronchospasms

Question 11

Short-Acting Insulins**

Answer 11

Short acting
Regular insulin (Humulin R)**
Routes* of administration: IV bolus, IV infusion,** intramuscular (IM), SQ
Onset* (SQ route): 30 to 60 minutes
Peak* (SQ route): 2.5 hours**
Duration (SQ route): 6 to 10 hours

Question 12

Intermediate-Acting Insulins**

Answer 12

Intermediate acting
Insulin isophane suspension (also called NPH)
Cloudy appearance
Often combined with regular insulin**
Onset*-1-2 hours
Peak- 4-8 hours**
Duration- 10-18 hours

Question 13

Long-Acting Insulins **

Answer 13

Insulin glargine (Lantus)**
Clear, colorless solution**
Constant level of insulin in the body
Usually dosed once daily
Can be dosed every 12 hours
Referred to as basal insulin*
Onset: 1 to 2 hours*
Peak: none
Duration: 24 hours*

Insulin detemir (Levemir)**
Duration of action is dose dependent
Lower doses require twice-daily dosing.
Higher doses may be given once daily.

Question 14

DKA

Answer 14

Onset 4-10 hrs

Breath smells fruity**
thirsty dehydration*
Hypotension*
Acidosis*

High blood sugar >240
Hyperkalemia*
Polyuria*

Hydration
Insulin
Electrolyte
Replacement

Question 15

Oral Antidiabetic Drugs

Answer 15

2013 American Diabetes Association guidelines

New-onset type 2 DM treatment **
Lifestyle* interventions
Oral biguanide** drug metformin
If lifestyle** modifications and the maximum tolerated metformin dose do not achieve the recommended HbA1C goals after 3 to 6 months, additional treatment should be given *with a second oral agent, GLP-1 agonist (liraglutide, exenatide, abliglutide) or insulin.

Question 16

Oral Antidiabetic Drugs (Cont.)

Answer 16

Biguanide
Sulfonylureas
Glinides
Thiazolidinediones (Glitazones)
Alpha-Glucosidase Inhibitors
Dipeptidyl Peptidase IV (DPP-IV) Inhibitors

Question 17

BIGUANIDE
“Metformin (Glucophage)”

Answer 17

First line drug for type 2 diabetes** (not used for type 1 diabetes)

Works by deceasing glucose production by the liver; May also decrease intestinal absorption of glucose and improve insulin receptor sensitivity. ***

Increased peripheral glucose uptake and use; decreased production of triglyceride and cholesterol; helps with moderate weight loss

Adverse effects**
Abdominal bloating, nausea, cramping, a feeling of fullness, and diarrhea; less common-metallic taste, hypoglycemia, and a reduction in vitamin B12 levels after long-term use; Lactic acidosis** is an extremely rare complication.

Contraindications**
Metformin is contraindicated in patients with renal **disease or renal dysfunction (serum creatinine level higher than 1.5 mg/dl in males or higher than 1.4 mg/dl in females); Other contraindications include alcoholism, metabolic acidosis, hepatic disease, heart failure or other conditions that can predispose to hypoxia and increase risk of lactic acidosis.

Question 18

SULFONYLUREAS**
“glimepiride (Amaryl), glipizide (Glucotrol)*, glyburide (DiaBeta)”

Answer 18

Oldest oral antidiabetic drug
Second generation drugs currently used have better potency and adverse effect profile

Sulfonylurea bind to specific receptors on beta cells in the pancreas to *stimulate the release of insulin.**
Appears to decrease the secretion of glucagon

“patient needs* to still have functioning beta cells in the pancreas”- so only used in early stages of type 2 diabetes and not in type 1 diabetes.

Adverse effects**
Hypoglycemia ** (depends on dose, eating habits, presence of hepatic or renal disease).
Weight gain, skin rash, nausea, epigastric fullness, and heartburn**

Contraindications**
Hypoglycemia** or conditions that can predispose to hypoglycemia (NPO, ethanol use or advanced age)
Allergy to sulfonamide antibiotics (Cross-allergy)

Question 19

GLINIDES
“Repaglinide (prandin) & Nateglinide (Starlix)”

Answer 19

Used for Type 2 diabetes **

Maybe particularly useful for diabetic patients with *high post prandial glucose** level and low circulating insulin

Structurally different from the sulfonylureas but have similar mechanism of action which is to increase insulin secretion from the pancreas

Shorter duration and must be *given with each meal *

Adverse effects**
Hypoglycemia* and weight gain

Contraindications
Same as Sulfonylureas (Hypoglycemia or conditions that can predispose to hypoglycemia)

Question 20

THIAZOLIDINEDIONES (GLITAZONES)
“Pioglitazone (Actos) & Rosiglitazone (Avandia)”

Answer 20

Used for Type 2 diabetes

Some preservation of beta cell function, slowing progression of disease progression in type 2 **diabetes

Acts by regulating genes involved in glucose and lipid metabolism (slow onset over several weeks; maximal effect may take several months)

Insulin-sensitizing drugs; they work to *decrease insulin resistance by enhancing the sensitivity of insulin receptors**

Directly stimulate peripheral glucose uptake and storage**, as well as inhibit glucose and triglyceride production in the liver

Adverse effects**
Can cause or exacerbate heart failure*- not recommended in patients with symptomatic heart failure.
Peripheral edema** and weight gain**, reduced bone mineral density and increased risk of fractures.

Contraindications**
Contradicted in patient with *class III or class IV heart failure** or patients with liver or kidney disease. **

Question 21

ALPHA- GLUCOSIDASE INHIBITORS
“Acarbose (Precose) and Miglitol (Glyset)

Answer 21

Less commonly used; They must be taken with food (when an alpha-glucosidase inhibitor is taken with a meal, excessive post prandial blood glucose “spike” can be prevented or reduced)-
does not work towards lowering fasting blood glucose- taken with first bite of meal

Works by reversibly inhibiting the enzyme alpha-glucosidase that is found in small intestine. This enzyme is responsible for the hydrolysis of oligosaccharides and disaccharides to glucose (*when this enzyme is blocked, glucose absorption is delayed)

Adverse effects
High incidence of flatulence, diarrhea and abdominal pain. At high dosages, they may also elevate levels of hepatic enzymes (transaminases).
Do not cause hypoglycemia or weight gain (in rare instances if hypoglycemia occurs- complex carbs cannot be given as it will be blocked, so IV or oral glucose must be administered)

Contraindications
Because of adverse GI effects, it is not recommended for use in patients with inflammatory bowel disease, malabsorption syndromes or intestinal obstruction

Question 22

DIPEPTIDYL PEPTIDASE IV (DPP-IV) Inhibitors- gliptins
“Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), and Alogliptin (Nesina)”

Answer 22

Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes
Reduce fasting and postprandial glucose concentrations

*DPP-IV) inhibitors work by delaying the breakdown of incretin hormones by inhibiting the enzyme DPP-IV. **
Incretin hormones are released throughout the day and are increased after a meal. When blood glucose concentration are normal or high, the incretin hormones increase insulin synthesis and lower glucagon secretion.

Adverse effects**
Upper respiratory tract infection**, headache and diarrhea; few cases of pancreatitis have been reported.

Hypoglycemia can occur if used in conjunction with sulfonylurea and insulin.

Contraindications
Known Drug Allergy

Question 23

Sodium Glucose Cotransporter (SGLT2) Inhibitors

Answer 23

Inhibition of SGLT2 leads to a decrease in blood glucose caused by an increase in renal glucose excretion. **
SGLT2 inhibitors: new class of oral drugs for the treatment of type 2 DM
Canaglifozin (Invokana), dapaglifozin* (Farxiga), and empagliflozin (Jardiance)**
Action: work independently of insulin to prevent glucose reabsorption from the glomerular filtrate, resulting in a reduced renal threshold for glucose and glycosuria

Adverse effects: **
common: *genital yeast infection, urinary tract infection and increased urination**
most serious: hypotension, hypovolemia, hyperkalemia, and increase in LDL cholesterol, risk of ketoacidosis (risk of ketoacidosis)

Question 24

Injectable Antidiabetic Drugs: Amylin Agonist

Answer 24

Pramlintide (Symlin, Pregnancy category C) is the only available amylin agonist (used in patients with type 1 or type 2 diabetes receiving mealtime insulin who failed to achieve optimal glucose control with insulin); Given before major meals, SQ injection

Contradicted in patients with gastroparesis or taking drugs that alter GI motility.

Adverse effects: Nausea, vomiting, anorexia and headache.

Insulin dosage** needs to be *reduced by 50% to prevent hypoglycemia**; it can delay the oral absorption of any drug taken at the same time and needs to given at least 1 hour before other medications.

Question 25

Injectable Antidiabetic Drugs: Incretin Mimetics

Answer 25

Incretin mimetics are best given 60 minutes before meals

Contraindications: **
Hypersensitivity to drug or any component, history or family history of medullary *thyroid carcinoma** and patient with multiple endocrine neoplasia** syndrome type 2

Adverse effects:*
black box warning** (thyroid C-cell tumors), Nausea, Vomiting, Diarrhea, weight loss; rare cases- hemorrhagicor necrotizing pancreatitis**.

Question 26

Nursing Implications **

Answer 26

Keep in mind that overall concerns** for any patient with DM increasewhen the patient:
Is under stress*
Has an infection*
Has an illness or trauma
Is pregnant or lactating**

Question 27

Hypoglycemia**

Answer 27

Abnormally low blood glucose level (below 50 mg/dL)**

Early detection
Confusion, irritability, tremor, sweating**

Late
Hypothermia, seizures**
Coma and death will occur if not treated**

Glucose Elevating Drugs: Oral forms of concentrated glucose; Buccal tablets, Semisolid gel; 50% dextrose in water (D50W); Glucagon

Question 28

Nursing Implications**

Answer 28

Before giving drugs that alter glucose levels, obtain and document:**
A thorough history**
Vital signs
Blood glucose level, HbA1C level
Potential complications and drug interactions**

Before giving drugs that alter glucose levels:
Assess the patient’s ability to consume food.
Assess for nausea or vomiting.
Hypoglycemia may be a problem if antidiabetic drugs are given, and the patient does not eat.
If a patient is NPO for a test or procedure, consult the primary care provider to clarify orders for antidiabetic drug therapy.

Insulin**
Double check insulin with another nurse **
Check blood glucose level before giving insulin.**
Roll vials between hands instead of shaking them to mix suspensions.
Ensure correct storage of insulin vials.
Only use insulin syringes, calibrated in units, to measure and give insulin.
Ensure correct timing of insulin dose with meals.
When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting insulin first.**
Provide thorough patient education regarding self-administration of insulin injections, including timing of doses, monitoring blood glucose levels, and injection site rotations.

Oral antidiabetic drugs
Always check blood glucose levels before giving**
Usually given 30 minutes before meals**
Alpha-glucosidase inhibitors are given with the first bite of each main meal.
Metformin* is taken with meals to reduce GI effects.
Metformin* will need to be discontinued** if the patient is to undergo studies with contrast dye because of possible renal effects**; check with the prescriber.

Monitor for therapeutic** response:
Decrease in blood glucose levels to the level prescribed by physician
Measure HbA1C** to monitor long-term compliance with diet and drug therapy.
Monitor for hypoglycemia and hyperglycemia.