Antidiabetic Drugs. Mosby items and derived items 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

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1 Antidiabetic Drugs Mosby items and derived items 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

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3 Diabetes Mellitus Two types Type 1 Type 2

4 Type 1 Diabetes Mellitus Lack of insulin production or production of defective insulin Affected patients need exogenous insulin Fewer than 10% of all diabetes cases are type 1 Complications Diabetic ketoacidosis (DKA)

5 Type 2 Diabetes Mellitus Most common type: 90% of all cases Caused by insulin deficiency and insulin resistance Many tissues are resistant to insulin Reduced number of insulin receptors Insulin receptors less responsive

6 Type 2 Diabetes Mellitus (cont d) Several comorbid conditions Obesity Coronary heart disease Dyslipidemia Hypertension Microalbuminemia (protein in the urine) Increased risk for thrombotic (blood clotting) events

7 Major Long-Term Complications of DM (Both Types) Macrovascular (atherosclerotic plaque) Coronary arteries Cerebral arteries Peripheral vessels Microvascular (capillary damage) Retinopathy Neuropathy Nephropathy

8 Gestational Diabetes Hyperglycemia that develops during pregnancy Insulin must be given to prevent birth defects Usually subsides after delivery 30% of patients may develop Type 2 DM within 10 to 15 years

9 Treatment for DM Type 1 Insulin therapy Type 2 Lifestyle changes Oral drug therapy Insulin when the above no longer provide glycemic control

10 Types of Antidiabetic Drugs Insulins Oral hypoglycemic drugs Both aim to produce normal blood glucose states

11 Insulins: mechanism of action 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

12 Types of insulins Rapid-acting Insulin lispro Insulin aspart Insulin glulisine Short-acting Regular insulin Intermediate-acting Neutral protamine hagedorn (NPH) insulin Long-acting Insulin glargine Insulin detemir Insulin combinations

13 Types of insulins Rapid-acting Most rapid onset of action (5 to 15 minutes) Shorter duration Patient must eat a meal after injection Insulin lispro (Humalog) Similar action to endogenous insulin Insulin aspart (NovoLog) Insulin glulisine (Apidra) Newest May be given SC or via continuous SC infusion pump (but NOT IV)

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15 Types of insulins Short-acting Regular insulin (Humulin R) Onset 30 to 60 minutes The only insulin product that can be given by IV bolus, IV infusion, or even IM

16 Types of insulins Intermediate-acting Isophane insulin suspension (also called NPH) Cloudy appearance Slower in onset and more prolonged in duration than endogenous insulin

17 Types of Insulins (cont d) Long-acting Glargine (Lantus) Detemir (Levemir) Clear, colorless solution Referred to as basal insulin

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19 Combination insulin products NPH 70% and regular insulin 30% (Humulin 70/30, Novolin 70/30, Novolog 70/30) NPH 50% and regular insulin 50% (Humulin 50/50)

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22 Adverse reactions of insulin.

23 Interactions -Corticosteroids, thiazide and loop diuretics, sympathomimitic drugs, and thyroid hormones. -Alcohol, anabolic steroids, sulfa drugs, and salicylates.

24 Interactions Nonselective bata-blockers. Insulin increases the risk of hypoglycemia when administered with other hypoglycemic drugs.

25 Oral Antidiabetic Drugs Used for type 2 diabetes Treatment for type 2 diabetes includes lifestyle modifications Diet, exercise, smoking cessation, weight loss Oral antidiabetic drugs may not be effective unless the patient also makes behavioral or lifestyle changes

26 Oral Antidiabetic Drugs (cont d) Insulin Secretagoguses Useful for patient with DM after age of 40 and DM less than 5 year Promote release of insulin from B-cells Sulfonylureas First generation: chlorpropamide (Diabinese), tolazamide (Tolinase) Second generation: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta, Micronase) Duration of action: hrs Excreted by liver or kidney: should be used with caution in renal and hepatic insuffiency Glyburide: minimal cross of placenta barriers: may be used as alternative to insulin in pregnancy

27 Oral Antidiabetic Drugs (cont d) Insulin Secretagoguses Glinides repaglinide (Prandin), nateglinide (Starlix) Absorbed orally after taken 30 minutes before meals Must be used with caution in patients with hepatic impairment Insulin sensitizers Improves target cell response to insulin Increase glucose uptake Biguanides metformin (Glucophage)

28 Oral Antidiabetic Drugs (cont d) Insulin sensitizers Biguanides: metformin (Glucophage) Reduces hepatic glucose output by inhibiting hepatic glucoeogensis Reduces intestinal absorption of glucose Drug of choice for newly diagnosed DM2 Contraindication in renal and hepatic impairment Should be used with caution in patient over 80 years Should not be used in patients with MI, CHF

29 Oral Antidiabetic Drugs (cont d) Insulin sensitizers Thiazolidinediones (TZDs) or glitazones Pioglitazone (Actos), rosiglitazone (Avandia) Improves insulin sensitivity in adipose tissue, liver and skeletal muscle Save in renal impairment patient Should not be used in nursing mother

30 Oral Antidiabetic Drugs (cont d) Alpha-glucosidase inhibitors Acarbose (Precose), miglitol (Glyset) They delaying the digestion of carbohydrates: lower postprandial glucose level Must be taken with meals to prevent excessive postprandial blood glucose elevations (with the first bite of a meal) Metabolized by the intestinal bacteria Patients with inflammatory bowel disease, colonic ulceration, or intestinal obstruction should not use this group

31 New Antidiabetic Drugs Amylin mimetics pramlintide (Symlin) Incretin mimetics exenatide (Byetta) Dipeptidyl peptidase IV inhibitors sitagliptin (Januvia)

32 Newer oral Antidiabetic Drugs: Amylin mimetic Mimics the natural hormone amylin Slows gastric emptying Suppresses glucagon secretion, reducing hepatic glucose output Centrally modulates appetite and satiety Used when other drugs have not achieved adequate glucose control Subcutaneous injection immediately or 1hr before the meal

33 Newer Oral Antidiabetic Drugs: Incretin mimetic Mimics the incretin hormones Incertin hormone is responsible for about 70% of postprandial insulin Enhances glucose-driven insulin secretion from beta cells of the pancreas Only used for Type 2 diabetes Exenatide: Injection pen device

34 Newer Oral Antidiabetic Drugs Dipeptidyl peptidase-iv (DPP-IV) inhibitors (Sitagliptin (januvia) and vildagliptin (Galvus)): Mechanism of action: These drugs inhibit the enzyme DDP-IV, which is responsible for the inactivation of incretin hormones such as glucagonlike peptide-1 GLP-1. Prolonging the activity of incretin hormones, results in increase insulin releasing in response to meals and a reduction in inappropriate secretion of glucagon. They can be used as a monotherapy or in combination with other drugs. Taken once daily with or without food.

35 Hypoglycemia Abnormally low blood glucose level (below 50 mg/dl) Mild cases can be treated with diet higher intake of protein and lower intake of carbs to prevent rebound postprandial hypoglycemia

36 Hypoglycemia Symptoms Early Confusion, irritability, tremor, sweating Late Hypothermia, seizures Coma and death will occur if not treated

37 Glucose-Elevating Drugs Oral forms of concentrated glucose Buccal tablets, semisolid gel 50% dextrose in water (D 50 W) Glucagon

38 Nursing Implications Before giving drugs that alter glucose levels, obtain and document: A thorough history Vital signs Blood glucose level, A1c level Potential complications and drug interactions

39 Nursing Implications (cont d) 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 physician to clarify orders for antidiabetic drug therapy

40 Nursing Implications (cont d) Keep in mind that overall concerns for any diabetic patient increase when the patient: Is under stress Has an infection Has an illness or trauma Is pregnant or lactating

41 Nursing Implications (cont d) Thorough patient education is essential regarding: Disease process Diet and exercise recommendations Self-administration of insulin or oral drugs Potential complications

42 Nursing Implications (cont d) When insulin is ordered, ensure: Correct route Correct type of insulin Timing of the dose Correct dosage Insulin order and prepared dosages are secondchecked with another nurse

43 Nursing Implications (cont d) Insulin 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

44 Nursing Implications (cont d) Insulin (cont d) When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting insulin first Provide thorough patient education regarding selfadministration of insulin injections, including timing of doses, monitoring blood glucose levels, and injection site rotations

45 Nursing Implications (cont d) 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

46 Nursing Implications (cont d) Assess for signs of hypoglycemia If hypoglycemia occurs: If the patient is conscious, give oral form of glucose Give the patient glucose tablets or gel, corn syrup, honey, fruit juice, or nondiet soft drink or have the patient eat a small snack such as crackers or a half sandwich If the patient is unconscious, give D 50 W or glucagon, intravenously Monitor blood glucose levels

47 Nursing Implications (cont d) Monitor for therapeutic response Decrease in blood glucose levels to the level prescribed by physician Measure hemoglobin A1c to monitor long-term compliance with diet and drug therapy Monitor for hypoglycemia and hyperglycemia

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