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Treatment for DM:
Type 1:
insulin therapy
Type 2:
lifestyle changes
oral drug therapy
insulin when above no longer provies glycemic control
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Types of antidiabetic drugs:
Insulins
Oral hypoglycemic agents
Goal: normal or correct BG levels
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Oral Antidiabetic Drugs:
used for type 2
lifestyle changes: diet, exerices, smoking cessation,
oral antidiabetic drugs may NOT be effective unless the patient makes behavioral or lifestyle changes
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Indications:
used alone or in combination with other dugs and/or diet and lifestyle changes to lower blood glucose levels in patients with type 2
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Oral Antidiabetic Drugs:
Sulfonylureas:
-Most used
First generation:
-Diabinase (chlorpropamide)
-Tonilase (tolazamide)
-Orinase (tolbutamide)
Second generation:Amaryl (glimepiride)
-Glucotrol (glipizide)
-Diabeta (glyburide)
Meglitinides:
-Repaglinide (Prandin)
-Nateglinide (Starlix)
Biguanides:
-Metformin (Glucophage)
Thiazolidinediones:
-Pioglitazone (Actos)
-Rosiglitazone (Avandia)
-Also known as “glitazones”
Alpha-glucosidase inhibitors:
Acarbose (Precose)
Miglitol (Glyset)
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Mechanism of action
Sulfonylureas:
-Stimulate insulin secretion from beta cells of pancreas
-Beta cell function must be present for these drugs to -work
-Improve sensitivity to insulin in tissues
-Result: Lower blood glucose levels
-First-generation drugs not frequently used
Meglitinides:
-Action similar to sulfonylureas
-Increase insulin secretion from pancreas *most effective within one hour of taking
Biguanides:
-Decrease production of glucose
-Increase uptake of glucose by tissues
-Does NOT increase insulin secretion from pancreas (does not cause hypoglycemia)
Thiazolidinediones:
-Decrease insulin resistance
-Are known as “insulin sensitizing drugs”
-Increase glucose uptake and use in skeletal muscle
-Inhibit glucose and triglyceride production in liver
Alpha-glucosidase inhibitors:
-Reversibly inhibit the enzyme “alpha-glucosidase” in small intestine
-Result: Delayed absorption of glucose
-Must be taken with meals to prevent excessive postprandial (post meals) blood glucose elevations (with the “first bite” of a meal)
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Sulfonylureas -- 2nd generation: Glipizide (Glucotrol), Glimepiride (Amaryl):
Onset of action: 1- 1 1/2 hours
Peak: 1-3 hours
Half life: 2 -4 hours
Duration: 10-24 hour
Meglitinide (Prandin):
Onset of action : 30 minutes
Peak: 1- 1 ½ hours
Duration: < 4 hours
Half-life: 1 hour
Biguanides (metformin):
Onset of action:
Peak: 1–3 hours
Half-life: 1 ½ - 5 hours
Duration: 6-20 hours
Thiazolidinediones (pioglitazone, actos):
Maximal reduction in blood glucose after 12 weeks
Half-life: 3-7 hours
Duration: 16-24 hours
Alpha-glucosidase inhibitor:
Peak: 1 hour
Half –life: 2 hours
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Adverse Side Effects:
Sulfonylureas:
-Hypoglycemia, hematologic effects, nausea, epigastric fullness, heartburn, many others
Meglitinides:
-Headache, hypoglycemic effects, dizziness, weight gain, joint pain, URI or flu-like symptoms
Biguanides (Metformin):
-Primarily affects GI tract: abdominal bloating/fullness, nausea, cramping, diarrhea
-May also cause metallic taste, reduced vitamin B12 levels (form of pernicious anemia)
-Lactic acidosis is rare, but lethal if it occurs
-Does NOT cause hypoglycemia
Thiazolidineediones:
-Moderate weight gain, edema, mild anemia
-Hepatic toxicity – monitor ALT levels closely
Alpha-glucosidase inhibitors:
-Flatulence, diarrhea, abdominal pain
-Do NOT cause hypoglycemia, hyperinsulinemia, or weight gain
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Interactions: (ppt only shows sulfonylureas)
Sulfonylureas:
-Hypoglycemic effect increases when taken with alcohol, anabolic steroids, and many other drugs
-Adrenergics, corticosteroids, & thiazides may reduce hypoglycemic effects
-Allergic cross-sensitivity may occur with loop diuretics & sulfonamide antibiotics
-May interact with alcohol
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Insulins:
-Function as substitute for the endogenous form
-Effects are same as normal endogenous insulin
-Restores diabetic patient’s ability to:
-Metabolize carbohydrates, fats & proteins
-Store glucose in liver
-Convert glycogen to fat stores
-Derived from porcine or beef sources
-Most are human-derived, using recombinant DNA technologies
-GOAL: Tight glucose control
-To reduce the incidence of long-term complications
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Human-Based Insulins:
Rapid-Acting
-Insulin aspart (Novolog)
-Insulin lispro (Humalog)
-Insulin glulisine (Apidra)
-All may be given SC or via continuous SC infusion pump (NOT IV)
---Onset of action: 5 to 15 minute
---Peak: 1-2 hours
---Half Life: 80 minutes
---Duration : 3-5 hours
---Shorter duration
Short-Acting:
-Regular insulin (Humulin R, Novolin R)
-Is the ONLY insulin product that can be given by IV bolus, continuous IV infusion
---Onset of action: 30 to 60 minutes
---Peak 2-5 hours
---Half life: unknown
---Duration: 6-10 hours
Intermediate-Acting:
-Isophane insulin suspension (also called NPH) (Humulin N, Novolin N)
-Insulin zinc suspension (also called Lente) (Humulin L, Novolin L)
-Both have a cloudy appearanceSlower in onset and more prolonged duration of action than endogenous insulin
---Onset of action: 1-2 hours
---Peak: 4-8 hours
---Half life : Unknown
---Duration: 10-18 hours
Long-Acting:
-Glargine (Lantus)
----Dosed: once a day or twice a day
----Slowly absorbed
----Clear, colorless solution
-Extended insulin zinc suspension (Ultralente, Humulin U)
----White, opaque solution
Combination Insulin Products:
-NPH 70% and regular insulin 30% (Humulin 70/30, Novolin 70/30)
-NPH 50% and regular insulin 50% (Humulin 50/50)
-Insulin lispro protamine suspension 75% and insulin lispro 25% (Humalog Mix 75/25)
---Onset of action: 1-2 hours
---Peak: none
---Half-life: unknown
---Duration: 24 hours
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Sliding-Scale Dosing
-Sliding Scale short-acting (Lispro) or regular insulin doses adjusted according to blood glucose test results
-Typically used in hospitalized diabetic patients, or in patients on TPN or enteral tube feedings
-SC insulin is ordered in an amount that increases as the blood glucose increases
-Example:
2 units for glucose value: 141-199mg/dl
4 units for glucose value 200-249 mg/dl
6 units for glucose value 250-299mg/dl
8 units for a glucose value of 300 mg/dl Greater than 300 call the physician
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Other Diabetic Drugs
Amylin Mimetic: Pramlintide (Symlin)
-Mimics the natural hormone amylin (important for glucose metabolism)
-Slows gastric emptying
-Suppressed glucagon secretion, reducing hepatic glucose output
-Centrally modulates appetite & satiety
-Used when other drugs have not achieved adequate glucose control
Incretin Mimetic: Exenatide (Byetta)
-Mimics the incretin hormones
-Enhances glucose-driven insulin secretion from beta cells of pancreas
-ONLY used for Type 2 diabetes
-Given with injection pen device
Inhaled insulin: Exubera
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Hypoglycemia
-Abnormally low blood glucose level (below 50 mg/dl)
-Mild cases treated with diet – higher intake of protein & lower intake of carbs (to prevent rebound postprandial hypoglycemia)
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Glucose-Elevating Drugs
-Oral forms of concentrated glucose
--Buccal tablets, semisolid gel
-50% dextrose in water (D50W)
-Glucagon
-Diazoxide
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Nursing Implications
-Before giving any drugs that alter glucose levels, obtain & document:
-Thorough history
-Vital signs
-Blood glucose level, HbA1c level
-Potential complications & drug interactions
-Before giving any drugs that alter glucose levels:
-Assess the patient’s ability to consume food
-Assess for nausea or vomiting
-Hypoglycemia will be a problem if antidiabetic drugs are given & patient does not eat
-If patient is NPO for a test or procedure, consult physician to clarify orders for antidiabetic drug therapy
-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
-Thorough patient education is ESSENTIAL regarding:
-Disease process
-Diet and exercise recommendations
-Self-administration of insulin or oral drugs
-Potential complications
-Insulin order and prepared dosages should be second-checked with another nurse
-When insulin is ordered, ensure:
-Correct route
-Correct type of insulin
-Correct Time and timing
-Correct dosage : in Units!
-Correct Patient
Insulin
-Check blood glucose level BEFORE giving insulin
-Roll vials between hands instead of shaking them to mix suspensions
-Ensure correct storage of insulins
-ONLY insulin syringes, calibrated in units, should be used to measure & give insulin
-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 glucoses, & rotating injection sites
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
-Always assess for signs of hypoglycemia after giving an antidiabetic drug
-If hypoglycemia occurs:
-Give glucagon OR
-Have patient eat glucose tablets or gel, corn syrup, honey, fruit juice, or non diet soft drink OR
-Have patient eat small snack such as crackers of half a sandwich
-Monitor blood glucose level AFTER treating per Protocol
-Monitor for therapeutic response
-Measure Hemoglobin A1c (HgbA1c) to monitor long-term compliance with diet and drug therapy
-Watch for hypoglycemia & hyperglycemia – as the nurse, you need to be able to distinguish between each!!
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