Chapter 32: Antidiabetic Drugs Flashcards
Type 1 Diabetes patients require _______ insulin because ____________.
exogenous
they have absolute lack of insulin
Exogenous Insulin
(outside pancreas)
- effects are the same as endogenous insulin
- required for DM type 1
Exogenous insulin is prescribed for DM type 2 pts who
cannot control blood glucose by medications
Regular insulin is used for
acute management of hyperglycemia (i.e DKA, HNKS)
Benefits of Insulin
- cost-effective
- decreased allergic reaction (human insulin)
Preparation for Insulin Vary based on
- onset of action
- time of peak effect
- duration
- expressed in units rather than mL
- 100 USP units/mL
1mL = ? units
100 units
4 Types of Insulin
- Rapid Acting
- Short Acting
- Intermediate-Acting
- Long-Acting
Rapid Acting Insulin
- Insulin Lispro (Humalog)
- Insulin Aspart
- Insulin Glulisine
Short Acting Insulin
Regular insulin (Humulin R, Novolin R)
Rapid Acting Insulin: route, onset, peak, elimination and duration
Route: SQ Onset: 15 minutes Peak: 2.5 hours Elimination: N/A Duration: 6-10 hours
Short Acting Insulin is used for
DKA, or coma associated w/ uncontrollable type 1 diabetes
Short Acting Insulin: route, onset, peak, elimination and duration
Route: SQ (can be given IV bolus, IV infusion, IM) Onset: 30-60 minutes Peak: 2.5 hours Elimination: N/A Duration: 6-10 hours
Intermediate-Acting Insulin includes
- Insulin NPH (insulin isophane suspension)
- Humulin N
- Novolin N
Intermediate-Acting Insulin
- appears cloudy or opaque
- often combined with regular insulin
Intermediate-Acting Insulin: route, onset, peak, elimination and duration
Route: SQ Onset: 1-2 hours Peak: 4-8 hours Elimination: N/A Duration: 10-18 hours
Long-Acting Insulin
- DO NOT MIX WITH OTHER INSULIN
- Given once daily, very seldom twice daily depending on pt’s glycemic response
Long-Acting Insulin includes
-Insulin Glargine
-Insulin Detemir
Aka basal insulin
Insulin Glargine
Long-acting insulin
- provides constant level of insulin in body
- enhances safety
- once daily
Insulin Detemir
Long-acting insulin
- dose-dependent
- lower doses require twice a day dosing/higher doses given once a day
Long-Acting Insulin: route, onset, peak, elimination and duration
Route: SQ Onset: 1-2 hours Peak: None Elimination: N/A Duration: 24 hours
Fixed Combinations
Onset: 1-2 hours
Contains one intermediate and rapid acting/short acting
Used to increase effects of insulin (synergy)
Fixed Combinations include
Humulin 70/30 Humulin 50/50 Novolin 70/30 Humalog Mix 75/25 Humalog 50/50 NovoLog 70/30
Slide-scale Insulin
- giving short-acting or regular insulin dosage that is dependent on the patient’s blood glucose level
- ordered in an amount that increases as the blood glucose increases
Sliding-scale insulin is typically used in
hospitalized diabetic patients (w/ infections, surgery, NPO, etc) or those on total parenteral nutrition (TPN) or enteral tube feedings.
Disadvantage of Slide-acting insulin
delays insulin administration until hyperglycemia occurs
Basal-Bolus Insulin
- Preferred to sliding-scale
- Mimics a healthy pancreas by delivering basal insulin constantly as a basal and then as needed as a bolus.
Long-acting insulin (Glargine) is not recommended for
NPO due to high risk for hypoglycemia
Bolus Insulin (Lispro or Aspart) is
rapid acting.
Blood glucose levels are monitored
frequently
Administration of Insulin: Routes
Can be given SQ or IV
What type of insulin is given IV?
regular insulin is administered intravenously (ONLY during emergency situations)
Potential Problems With Insulin
- hypoglycemia (headache is the first sign)
- lipodystrophy
- somogyi effect
- dawn phenomenon
S&S of Hypoglycemia
- HEADACHE and tachycardia
- confusion , sweating and drowsiness
- convulsions, shakiness, palpitations
- light headedness, coma, death
Lipodystrophy
- slight pitting of skin d/t selective loss of body fat that affects absorption
- rotate sites to avoid
Somogyi effect
- secondary to rebound hypoglycemia
- patient wakes up with hyperglycemia due to hypoglycemia
- has such low level of blood sugar that body tries to compensate and turns into hyperglycemia
Dawn Phenomenon
- patient wakes up and has an early rise of blood glucose levels (between 5-8 am)
- D/T reduced tissue sensitivity to insulin
Insulin Pumps
- used for multiple day SQ injections
- are consistent, convenient, and control delivery
- change every 2-3 days
Sites to inject insulin
- subcutaneous fat on back of the arm
- vastus lateralis
- abdomen
Mechanism of Action: Insulin
- replaces insulin in pancreas that isn’t made or is made defectively.
- doesn’t reverse defects in insulin receptor sensitivity.
What do insulin pumps do?
- provides small continuous doses of short acting insulin
- pt. can give bolus of additional dose before meals
Indications for Insulin
Treats type 1 or type 2, but is individualized to each patient. Must be in conjunction with lifestyle modifications.
Insulin Contraindications
- known drug allergy
- never administer to an already hypoglycemic patient.
- blood glucose must always be tested prior to administration
Adverse Effects of Insulin
- Hypoglycemia
- Damage, shock and possible death
- Weight gain
- Lipodystrophy at site of injections
- Allergic Reactions (rare)
Insulin Interactions
check exam 3 study guide from mentor
Oral Antidiabetic Drugs include
Biguanides Sulfonylureas Glinides Thiazolidinediones (Glitazones) alpha-Glucosidase inhibitors Dipeptidyl peptidase-IV (DPP-IV) inhibitors Amylin agonists Incretin mimetics SGLT2 inhibitors
Goal of LDL
100 mg/dL
ADA new-onset type 2 diabetes may be treated with both
lifestyle interventions and oral biguanide drug metformin (if no contraindications)
Biguanide includes
Metformin (only drug)
Biguanide
- first line drug
- good for type 2 and overweight
- doesn’t stimulate pancreas
Mechanism of Action: Biguanide
- Decreases glucose production by the liver
- Decreases intestinal absorption of glucose
- Improves insulin receptor sensitivity
- Increase peripheral glucose uptake and use
- Decreased hepatic production of triglycerides and cholesterol
Indications of Biguanide
newly diagnosed type 2 who are overweight/obese
Contraindications of Biguanide
- renal disease or renal dysfunction
- alcoholism, metabolic acidosis, hepatic disease, heart failure
Why is renal disease or dysfunction a contraindication for biguanide?
metformin is excreted from kidneys so accumulation occurs and increases risk of lactic acidosis.
Need to check creatinine levels!
Lactic acidosis S&S
hyperventilation cold/clammy skin muscle pain abdominal pain dizziness irregular heart beat
Adverse effects of Biguanide
- GI related: abdominal bleeding, nausea, cramping, feeling of fullness, and diarrhea
- Weight loss
- Less common metallic taste, hypoglycemia, reduction in vit B12
Interactions of Biguanide
- hypoglycemic drugs, diuretics and steroids additive effects additive hypoglycemia
- cimetidine inhibits metabolism -> increased effects
- contrast media -> decreased excretion lactic acidosis (discontinue metformin 48 hours before giving contrast due to possible kidney failure)
Nursing Management for patients taking biguanide
- assess blood glucose levels, medication hx, allergies
- sliding scale
- doesn’t matter when given pertaining to meals
Sulfonylureas include
“ide”
Glyburide
Glimepiride
Glipizide
Characteristics of Sulfonylureas
second-generation (has longer duration and fewer side effects)
Mechanism of Action: Sulfonylureas
- stimulates insulin secretion from beta cells of pancreas -> increased insulin levels
- beta cell function must be present
- decreases liver glycogenolysis and gluconeogenesis
- increase cellular sensitivity to insulin
Indications for Sulfonylureas
- second-step drug of type 2 whose A1C levels remain elevated after metformin
- can be used in conjunction with metformin and thiazolidinediones
- must have working pancreas
Contraindications of Sulfonylureas
- hypoglycemia; and conditions predisposing you to hypoglycemia like reduced caloric intake (NPO)
- ethanol use
- advanced age
- beta blockers
Adverse Effects of Sulfonylureas
- hypoglycemia: degree depends on dose, diet and eating habits
- weight gain: because of stimulation of insulin
- Photosensitivity, skin rash, nausea, epigastric fullness, heartburn
Interactions of Sulfonylureas
- alcohol, herbal (ginger, garlic, ginseng) enhances effects of hypoglycemia
- carbamazepine, phenobarbital, phenytoin, rifampin increased metabolism -> decreased effects
Nursing management for pts taking sulfonylureas
give 30 minutes before meals
Glinides include
“glinide”
Nateglinide
Repaglinide
Characteristics of Glinides
quick onset, short duration of action
Mechanism of Action: Glinides
similar to sulfonylureas
stimulates pancreas to release insulin
have shorter duration of action
Indications for Glinides
- Type 2 diabetes
- can be used with metformin and thiazolidinediones
Contraindication of Glinides
- hypoglycemia; NPO
- ethanol use
- advanced age
Adverse Effects of Glinides
- Hypoglycemia (food not eaten after dose)
- Photosensitivity, weight gain
Interactions of Glinides
sulfonylureas -> antagonistic effects (double dosing)
Nursing Management for patients taking Glinides
- given 30 minutes before meals
- sunscreen
- orange juice ready for patient
- patient education
- check blood glucose levels
- if pt. does not eat, can skip dose
A-glucosidase inhibitors include
Acarbose, Miglitol
Mechanism of Action for A-glucosidase inhibitors
- decreased absorption of carbohydrates in small intestines -> delayed absorption of glucose.
- must be taken with first-bite of meal
Indications of A-glucosidase inhibitors
Type 2
Contraindications for A-glucosidase inhibitors
- inflammatory bowel disease
- malabsorption syndromes
- intestinal obstruction
Adverse effects for A-glucosidase inhibitors
- flatulence, diarrhea, abdominal pain
- high doses -> elevated levels of hepatic enzymes
Interactions of A-glucosidase inhibitors
-bioavailability of digoxin, ranitidine, and propranolol may be reduced (digoxin and beta blockers
Nursing Management for patients taking A-glucosidase inhibitors
- monitor liver and liver function tests
- med must be taken with first-bite of meal
Thiazolidinediones include
“glitazone”
Rosiglitazone
Pioglitazone
Mechanisms of Action: Thiazolidinediones
- decreases insulin resistance
- increases glucose uptake and use in skeletal muscles (makes skeletal muscles sensitive to insulin)
- inhibits glucose production in liver
- often used in combination with metformin
Indications for Thiazolidinediones
type 2
Contraindications for Thiazolidinediones
- new york heart association class III and IV heart failure
- caution with liver/kidney disease
Adverse Effects for Thiazolidinediones
- increase risk for heart failure
- peripheral edema (lower extremities), weight gain, fluid overload
Interactions of Thiazolidinediones
- antifungals
- grapefruit juice
- polypharmacy
- pioglitazone is partly metabolized by cytochrome P-450 enzyme (CYP3A4); pioglitazone concentrations may increase if concurrently taken with a CYP3A4 inhibitor (ketoconazole or erythromycin)
Nursing Management for patients taking Thiazolidinediones
-INO, monitor for weight gain, monitor for cardiac function
Dipeptidyl Peptidase IV (DDP-4) Inhibitors include
“gliptin”
Sitagliptin
Sazagliptin
Linagliptin
Mechanism of Action: Dipeptidyl Peptidase IV (DDP-4) inhibitors
- inhibits DPP-4 causing insulin secretion and suppression of glucagon secretion.
- lowers blood glucose
Indications for Dipeptidyl Peptidase IV (DDP-4) inhibitors
type 2
Contraindications for Dipeptidyl Peptidase IV (DDP-4) inhibitors
known drug allergy
Adverse Effects of Dipeptidyl Peptidase IV (DDP-4) inhibitors
- upper respiratory infection, headache, diarrhea
- hypoglycemia
- cases of pancreatitis have been reported.
Interactions of Dipeptidyl Peptidase IV (DDP-4) inhibitors
- increase digoxin levels
- sulfonylureas and glinides -> increase risk of hypoglycemia
SGLT2 Inhibitors include
Invokana
Mechanism of Action: SGLT2 Inhibitors
- inhibits SGLT2
- blocks absorption of glucose in kidneys, increase glucose excretion -> lowers blood glucose levels
- works like diuretics
Indications of SGLT2 Inhibitors (Canagliflozin)
- type 2
- must have working kidneys, patient will have “sugary urine”
Contraindications of SGLT2 Inhibitors (Canagliflozin)
kidney failure/disease
Adverse Effects of SGLT2 Inhibitors (Canagliflozin)
yeast infection, UTI (due to sugary urine), dehydration and hypoglycemia
Interactions of SGLT2 Inhibitors (Canagliflozin)
alcohol, sulfonylureas, diuretics
Amylin Agonist
- amylin is a natural hormone secreted by beta cells along w/ insulin in response to food.
- injectable
Amylin Agonist includes
Pramlintide acetate
Mechanism of Action: Amylin Agonist
- slows gastric emptying
- suppresses glucagon secretion and hepatic glucose production
- increases satiety (feeling full)
Indications for Amylin Agonist
type 1 or type 2
Contraindications for Amylin Agonist
- gastroparesis
- taking drugs that alter GI motility
Adverse effects of Amylin Agonist
-GI related: nausea, vomiting, anorexia, headache
Interactions of Amylin Agonist
- if given: preprandial rapid or short acting insulin, insulin needs to be reduced 50%
- if given: oral drugs, it can delay oral absorption taken at same time.
- given at least one hour before other medications
Nursing Management for patients taking Amylin Agonists
- council on nutrition and intake
- take before any major meal
Incretin Mimetics include
“tide”
Extenatide
Liraglutide
Pramlintide
Pramlintide
synthetic form of amylin (same MOA as amylin)
Characteristics of Incretin Mimetics
injectable
Mechanism of Action: Incretin Mimetics
- stimulates insulin secretion
- reduces postprandial glucagon production
- slow gastric emptying
- increases satiety (fullness)
Indications for Incretin Mimetics
- type 2
- given 60 minutes before meal
Contraindications of Incretin Mimetics
known allergy
Adverse Effects of Incretin Mimetics
- GI related: nausea, vomiting and diarrhea
- Weight loss
- Rare: hemorrhagic or necrotizing pancreatitis
Interactions of Incretin Mimetics
delay absorption of other orally administered drugs by slowing gastric emptying
Combination Treatments
- Glyburide + Metformin
- Avandia + Metformin
- Januvia + Metformin
Injectable Antidiabetic Drugs
- amylin agonists
- incretin mimetics
Drugs Affecting Blood Glucose Levels
- Beta Blockers
- Thiazide diuretics
- Loop Diuretics
- Corticosteroids
How do beta blockers affect blood glucose levels?
- interact with INSULIN and oral hypoglycemic agents
- can mask S&S of hypoglycemia
How do corticosteroid affect blood glucose levels?
increase blood glucose levels
Why is it important to monitor blood glucose?
self management
increases compliance and team work
When should you monitor blood glucose levels?
- 3-4 times a day until glucose levels are stabilized
- 1-2 times a day before meals when compliant and stabilized
Nursing Implications: Nurses should obtain what information before administering antidiabetic drugs?
thorough hx, VS, blood glucose levels, A1C levels, potential complications, and drug interactions prior to administering.
Nursing Implications: Assess
- pt ability to consume food
- for N/V
- signs of hypoglycemia
Nursing Implications: Monitor
- blood glucose levels
- for therapeutic response (A1C to monitor long-term compliance)
If patient who needs antidiabetic drugs is NPO, the nurse should
consult primary care provider to clarify orders
Concerns for patient increase when the patient
is under stress, has an infection, has an illness/trauma or is pregnant/lactating
Nursing Implications: Teaching
- Educate patient on disease process, diet/exercise recommendations, self-administration of insulin/oral drugs, potential complications
- Teach patient to limit alcohol consumption, report symptoms of anorexia or fatigue, and to notify physician if blood glucose rises above recommended level.
What steps should the nurse do when preparing insulin?
- Check for correct route, type, timing and dosage.
- Always second-check insulin with another nurse.
- Check blood glucose levels before giving.
- Roll vials between hands (DO NOT SHAKE)
- Ensure correct storage of vials
- Only use insulin syringes
- Ensure correct timing of meals
- Withdraw regular, then withdraw modified.
When preparing to give oral medications the nurse must do what?
- check blood glucose levels before
- administered usually 30 minutes before meals
The nurse would treat hypoglycemia with
- glucagon
- administer oral form if pt is conscious
- give patient glucose tablets, corn syrup, honey, fruit juice, small snack
- deliver D50W or glucagon IV if pt is unconscious.
Biguanides DO NOT
DO NOT AFFECT BETA CELLS
DO NOT INCREASE INSULIN SECRETION FROM PANCREAS
DO NOT CAUSE IMMEDIATE HYPOGLYCEMIA
