Pharmacology chapter 45 Drugs for diabetes mellitus

Intermediated-acting insulin

NPH insuline (Humulin N®, Novolin N®)

Antihyperglycemic Agents : Biguanides

- *Metformin (Glucophage)* is the only oral anti-diabetic of this type currently on the market - reduces fasting and postprandial glucose levels by decreasing the hepatic production of glucose (called gluconeogenesis) and reducing insulin resistance. It does not promote insulin release from the pancreas

Long-acting insulin

- *basal control* - provides basal levels of insulin and facilitates control of glycemia throughout the day - slower and more prolonged duration of action with less of a peak effort

Antihyperglycemic Agents : Alpha-glucosidase inhibitors

- Act by blocking enzymes in the small intestine that are responsible for breaking down complex carbohydrates into monosaccharides. Because carbohydrates must be in the monosaccharide form to be absorbed, digestion of glucose is delayed.

Antihyperglycemic Agents : Types

- Biguanides - Alphaglucosidase inhibitors - thiazolidinediones - incretin mimetics and DDP-4 inhibitors - amylin analogues

Antihyperglycemic Agents : *Biguanides* : Adverse Effects

- GI disturbances are most common (diarrhea in up to 30% of pt) • nausea, • vomiting, • abdominal discomfort, • metallic taste, • diarrhea, • anorexia. • headache, • dizziness, • agitation, • fatigue. - rarely causes lactic acidosis

Rapid-Acting Insulin : Types

- Insulin aspart (Novolog®) - Insulin lisper (Humalog) - Insulin glulisine (Apidra®)

Antihyperglycemic Agents : *Thiazolidinediones* : Adverse Effects

- The most common adverse effects are fluid retention, headache, and weight gain. - - Hypoglycemia does not occur with drugs in this class. - May be hepatotoxic;

Short-Acting Insulin

- Used at mealtimes - has slower onset and longer duration compared to rapid-acting insulin - Regular insulin can be given IV to treat DKA - onset occurs 30-60 mins after injection; duration is 5-8 hrs; peak @2-5hr

Antihyperglycemic Agents : *Alpha-glucosidase inhibitors* : Adverse Effects and Interactions

- abdominal cramping, diarrhea, and flatulence. - liver function should be monitored because a small incidence of liver impairment has been reported. - Hypoglycemia may occur when these drugs are combined with insulin or a sulfonylurea. If hypoglycemia does develop, it must be treated with glucose and not sucrose (table sugar). - Concurrent use of garlic and ginseng may increase the hypoglycemic action of alpha-glucosidase inhibitors.

Hypoglycemic Agents : Sulfonylurea Drugs

- act by stimulating the release of insulin from pancreatic islet cells and by increasing the sensitivity of insulin receptors on target cells

Insulin : Types

- rapid-acting insulin - short-acting insulin - intermediated-acting insulin - long-acting insulin - inhaled insulin

Hypoglycemic Agents : Meglitinide Drugs

- act by stimulating the release of insulin from pancreatic islet cells in a manner similar to that of the sulfonylureas

Hypoglycemic Agents

- act primarily by increasing insulin secretion - excessive doses can cause plasma glucose to drop below normal range - classes include sulfonylureas, alpha-glucosidase inhibitors, thiazolidinediones (or glitazones), biguanides, alpha-glucosidase inhibitors, meglitinides, and incretin enhancers and miscellaneous agents

Antihyperglycemic Agents

- act to prevent or reduce hyperglycemia but don't typically cause hypoglycemia

Long-acting insulin : Insulin glargine (Lantus and Levemir)

- doesn't exhibit a peak effect - usually administered once or twice daily - often combined with rapid-acting insulin given at meal times

Antihyperglycemic Agents : *Incretin Mimetics* actions.

- hormones secreted by the mucosa of the small intestine following a meal, when blood glucose is elevated. - Signal the pancreas to increase insulin secretion and the liver to stop producing glucagon.

Rapid-Acting Insulin

- human insulin analogues - used to control post-prandial glycemia - hypoglycemic effect begins 10-20 mins after subq injection - often sued as a part of a regimen that includes a long-acting insulin

Hypoglycemic Agents : *Sulfonylurea Drugs* : Adverse Effects

- hypoglycemia

Long-acting Insulin : Types

- insulin glargine (Lantus®) - insulin deter (Levemir®)

Antihyperglycemic Agents : *DDP-4 Inhibitors*

- prevent the breakdown of natural incretins, allowing the hormone levels to rise and produce a greater response. - Given orally and are effective at lowering blood glucose with few adverse effects. - Work well with other antidiabetic drugs and do not cause hypoglycemia.

Antihyperglycemic Agents : Thiazolidinediones

- reduce blood glucose by decreasing insulin resistance and inhibiting hepatic gluconeogenesis. - Optimal lowering of blood glucose may take 3 to 4 months of therapy.

Antihyperglycemic Agents : *Incretin Mimetics* : Types

- those that mimic the effects of endogenous incretins - those that inhibit the breakdown of GLP-1

Insulin

- used to treat all type 1 DM patients, many type II DM patients - primarily obtained from pork and beef pancreas OR produced using recombinant DNA technology - most come in 100U per mL

Insulin : Administration

- usually injected subq or administered continuously with a pump - the site should be switched often bc of risk of lipodystrophy (increased fat in the area) and decreased absorption - Regular insulin can be given IV to treat DKA

Antihyperglycemic Agents : *DDP-4 Inhibitors* : Adverse Effects

- well tolerated, does not cause hypoglycemia or GI side effects - can be used in pt with renal infuse

What patient education should the nurse provide to the patient with diabetes who is planning an exercise program? Select all that apply. 1. Monitor blood glucose levels Before & After exercise. 2. Eat a complex carbohydrate prior to strenuous exercise. 3. Exercise may increase insulin needs. 4. Withhold insulin prior to engaging in strenuous exercise. 5. Take insulin prior to exercise.

1, 2.

A 63-year-old patient with type 2 diabetes is admitted to the nursing unit with an infected foot ulcer. Despite previous good control on glyburide, his blood blood glucose has been elevated the past several days and he requires sliding scale insulin. What is most likely the reason for the elevated glucose levels? 1. It is temporary condition related to the stress response with increased glucose release. 2. He is converting to type 1 diabetic. 3. The oral anti-diabetic drug is no longer working for him. 4. Patients with diabetes were admitted to the hospital are switched to insulin for safety and tighter control.

1.

The patient is scheduled to receive 5 units of humalog and 25 units of NPH insulin prior to breakfast. Which nursing intervention is most appropriate for this patient? 1. Make sure the patients breakfast is available to eat before administering this insulin. 2. Offer the patient a high carbohydrate snack in 6 hours. 3. Hold the insulin if the blood glucose level is greater than a 100 MG/DL. 4. Administer the medications in 2 separate syringes.

1.

The nurse is initiating discharge teaching with the newly diagnosed patient with diabetes. Which statement indicates the patient needs additional teaching? 1. If I am experiencing hypoglycemia I should drink 1/2 cup of Apple juice. 2. My insulin needs may increase when I have an infection. 3. I must draw the NPH insulin 1st if I am mixing it with regular insulin. 4. If my blood glucose levels are less than 60Mg/DL, I should notify my health care provider.

3.

A patient receives NPH and regular insulin every morning. The nurse is verifying that the patient understands that there are 2 different peak times to be aware of for this insulin regimen. Why is that an important concept for the nurse to stress? 1. The patient needs to plan the next insulin injection around of the peak times. 2. Additional insulin may be needed at peak times to avoid hyperglycemia. 3. It is best to plan exercise and other activities around the peak insulin activity. 4. The risk for hypoglycemia is greatest around the peak of insulin activity.

4.

A patient with type 2 diabetes has been nothing by mouth since midnight for surgery in the morning. He has been on a combination of oral type 2 antidiebetic drugs. What would be the best action for the nurse to take concerning the administration of the medications? 1. Hold all medications as per the NPO order. 2. Give all the medications with a sip of water. 3. Give him half the original dose. 4. Contact a health care provider for further orders.

4.

Insulin

A hormone produced by the pancreas That acts to decrease blood glucose levels or taken as a medication by many diabetics

Glucagon

A hormone secreted by the pancreatic alpha cells that increases blood glucose concentration

A patient with type 2 diabetes on metformin reports that he takes propranolol for his hypertension. What concerns with the nurse have about this combination of medications? What would the nurse teach the patient?

Beta blocking drugs such as propranolol have the potential to alter the way hypoglycemia is perceived and the normal alarm symptoms may be subtle. Diaphoresis is a common symptom when blood glucose decreases among there was patients on Beta blockers along with their oral anti-diabetic drug. The nurse should teach the patient to be aware that should his blood glucose began to decrease, symptoms normally felt such as nervousness, tremors, or agitation May be perceived differently, and that if sweating occurs he should check his blood sugar immediately.

hyperglycemic effect

CAUSING BLOOD GLUCOSE TO RISE

hypoglycemic effect

CAUSING GLUCOSE TO LEAVE THE BLOOD AND SERUM GLUCOSE TO FALL

type 2 diabetes mellitus

Diabetes in which the body produces insulin, but not enough, or there is insulin resistance. The patient usually is not dependent on insulin for survival.

Antihyperglycemic Agents : *Incretin Mimetics*

Exenetide (Byetta®), Liraglutide (Victoza®)

Hypoglycemic Agents : *Meglitinide Drugs* : Adverse Effects

Hypoglycemia

Antihyperglycemic Agents : Biguanides

Metformin (Glucophage®)

Short-acting insulin

Regular insulin (insulin injection USP)

hyperosmolar hyperglycemic state

Serious condition characterized by hyperglycemia, hyperosmolarity and dehydration and the absence of ketoacidosis that may occur in type 2 diabetes

A 28 year old woman who is pregnant with her 1st child is diagnosed with gestational diabetes. She is concerned about the fact that she might have to take shots. She tells the nurse at public health clinic that she does not think she can self administer an injection and asks if there is a pill that will control her blood sugar. She has heard her grandson talk about pills to control his sugar. What should the nurse explain to this patient?

The nurse should explain that management of gestation all diabetes includes appropriate dietary management, regular exercise, and home blood glucose monitoring. Based on her glucose levels, insulin may be required but not all patients require insulin throughout the entire pregnancy. Research suggests that some oral anti-diabetic drugs may be used safely during pregnancy. Her ob, health care provider or endocrinologist will work with her to determine the most appropriate treatment. Should insulin injections be required, she will be given multiple opportunities for practice, and discomfort during an injection is usually minimal.

ketoacids

acidic waste product of lipid metabolism that lowers the pH of the blood

diabetic ketoacidosis

acidity of the blood caused by the presence of ketone bodies produced when the body is unable to burn sugar; thus, it must burn fat for energy

Islets of Langerhans

cell clusters in the pancreas that form the endocrine part of that organ

Antihyperglycemic Agents : *Biguanides* : Interactions

cimetidine can inhibit drug's metabolism and elevate plasma concentration

type 1 diabetes mellitus

diabetes caused by a total lack of insulin production; usually develops in childhood, and patients require insulin replacement therapy to control the disorder

Gluconeogenesis

formation of glucose from noncarbohydrate sources

insulin analogs

insulin that has had its amino acid sequence altered

insulin resistance

the inability of the cells to respond to insulin