Drug therapy for diabetes Flashcards
Glucose
Sugar in the blood
Body’s primary energy source
Brain almost exclusively uses glucose for energy
2 major hormones stabilize glucose levels
Glucagon and Insulin
Alpha Cells
Glucagon secreting cells
Increase blood glucose levels
Stimulates the liver to turn glycogen into glucose so that the body can use it
Beta Cells
Insulin secreting cells
Insulin allows your body to use glucose. Cannot use glucose until the insulin arrives
Allows cells to start using the glucose in the blood
Decrease blood glucose levels
islets of langerhans
Location in the Pancreas where Alpha and Beta cells are located
Glucagon
secreted when the body has low blood glucose.
Helps to maintain glucose levels between meals
Kicks in when you haven’t had any meals
Tells the liver to release some of the store glycogen
Insulin
secreted after a meal, pancreas recognizes rising glucose
Secretes insulin to lower the blood glucose
Without insulin, glucose unable to enter cells
Acts as a transport to allow cells to access glucose
Glycogenesis
liver stores glycogen for the future
Hormones that can increase blood glucose
Epinephrine
Thyroid hormone
Growth Hormone (decreases how much muscle is using glucose)
Glucocorticoids
Drugs that Increase blood glucose
Phenytoin
Beta blockers
NSAIDS
Diuretics
Drugs that can decrease blood glucose
Alcohol
Lithium
ACE inhibitors
Diabetes Mellitus
Chronic metabolic disorder in which there is deficient insulin secretion or decreased sensitivity of insulin receptors resulting in hyperglycemia
Classification of DM
Type 1 and Type 2
Type 1 Diabetes
more chronic condition in childhood
Autoimmune disorder that destroys pancreatic beta cells
Difficult to control and there are a lot of complications
Sudden onset from ages between 4-20
High incidence of complications
Requires exogenous insulin administration***
Insulin dependent diabetes
Type 2 Diabetes
Characterized by high blood sugar
Caused by insulin resistance
Insulin is present, but the insulin is not working well
Historically, the onset is 40+ years old
90% of people with DM have type 2
This is not an autoimmune disorder
Insulin Resistance
Insulin receptors are not responding to insulin because there has been an influx of insulin for so long that the body is no longer excited about it
Risks for Type 2 Diabetes
Obesity
Sedentary lifestyle
Presence of metabolic syndrome
Abdominal obesity
Low HDL
Hypertriglyceridemia
Hypertension and/or impared fasting glucose
Ethnicities at risk for type two diabetes
African Americans: 13.3%
Hispanics greater than 13.9%
DM Clinical Manifestations
Polyuria
Hyperglycemia (fasting glucose greater than 126)
Polyphagia: frequent hunger
Polydipsia: frequent thirst
Glucosuria: so high that your kidneys start eliminating sugar
Weight loss
Fatigue
DM Chronic Complications from Untreated Diabetes
Nephropathy: damage to kidneys
Retinopathy: damage to eyes
Neuropathy: damage to nerves in the peripheral nervous system. Can lead to complete loss of feeling in certain limbs
Increased number and severity of infection
Poor wound healing
Diabetic foot ulcers
Poor sensation from nerve damage
DKA: diabetic Ketoacidosis
Life threatening, severe insulin deficiency, usually type 1
Fat broken down for energy, results in ketones
Fruity breath
Ketones in the urine
Drop in PH
Polyuria
Polydipsia
Coma
N+V
DKA: diabetic ketoacidosis Glucose level
Hyperglycemia (240+)
diabetic ketoacidosis treatment
lots of IV fluid and insulin
HHNC: Hyperosmolar Hyperglycemic Nonketotic Coma
Life threatening severe hyperglycemia, usually seen in type two diabetes
Excessive glucose and electrolytes
Severe dehydration
Typically because they do not know they are diabetic
HHNC: Hyperosmolar Hyperglycemic Nonketotic Coma
Polyuria: peeing so much
Dehydration
Drowsiness
Confusion
Coma
Diabetic Ketoacidosis Symptoms
Fruity breath
Ketones in the urine
Drop in PH
Polyuria
Polydipsia
Coma
N+V
Glucose level of HHNC
greater than 600
Abnormal fasting blood sugar
greater than 126
When to check blood sugar
before meals and before bedtime (AC and HS)
Diabetic AC blood sugar normal levels
70-130
Hemoglobin A1C
Measures average blood glucose over 3 month period
Hemoglobin A1C % that indicates diabetic
Over 7% means that the person is diabetic
s/sx of Hyperglycemia
Three ps
Fatigue
Weakness
Dry Skin
s/sx of hypotension
Sweating
Tremors
Tachycardia
Hunger
Confusion
Drowsiness
Seizures
Goal of Diabetic Drug Therapy
Control glucose levels and manage complications
tx for type 1 diabetes
insulin and insulin only
Insulin route
SubCue
Can be given IV
Rapid Acting Insulin Types
Lispro and Aspart
Rapid Acting Insulin OPD
O: 15-30 Min
P: 30-2.5h
D: 3-6H
Short Acting Type
Regular (only one that is able to be given IV)
Short Acting Insulin OPD
O: 30-60min
P: 1-5h
D: 6-10h
Intermediate Acting insulin Type
NPH
Intermediate Acting Insulin OPD
O: 1-2h
P: 4-12h
D: 16h
Long Acting Insulin Types
Glargine, Detemir
Long Acting Insulin OPD
O: 3-4h
P: continuous
D: 24h
Ultra Long Acting insulin Type
Degludec
Onset of insulin
when the insulin hits the bloodstream
Peak of Insulin
when the insulin is at its strongest blood sugar lowering level
Duration of insulin
how long you are gonna have the benefits from the insulin
Contraindication for insulin
low blood sugar
Nursing Consideration for insulin
Plan onset to start when the meal is being eaten.
I.e give lispro 20-30 minutes before you eat breakfast
I.e regular insulin should be taken 30-60 minutes before a meal
We might need a snack when the blood sugar is lowest. When would this be
The Peak
Drug to Drug Interaction with insulin
Beta blocker
Aspirin
NSAIDS
Nursing Implications for insulin
Rotate injection site
Know onset and peak
Abdomen is the best injection site
Monitor for s/sx of hypoglycemia while they are sleeping
Insulin pumps Function
provide basal dose of insulin (continuous underlying dose)
Programmed insulin:
Set amount of insulin given to cover for the meal. Given with the meals. Regardless of blood sugar. The patient needs to be eating to receive programmed insulin
Sliding Scale Insulin
Based on current blood sugar level
Example:
61-150=0 units
151-200=3 units
201-250=5 unites
Patient Teaching with insulin
Weight control and exercise can reduce the glucose running in your bloodstream
Diet is important with new diabetic
Know signs and symptoms of hyper/hypo glycemia
Teach family what to do
Keep follow up appointments
Test blood glucose as ordered
What to do if you are sick
Proper SQ injection technique
Sulfonylureas Example
Glyburide
Sulfonylureas action
Stimulates pancreas to release insulin
Bind to K+ channels on pancreatic beta cells
Increase number of insulin receptors
Sulfonylurea Indications for use
elevated blood sugars
*Must have some functioning beta cells
Sulfonylurea Route
Oral
Sulfonylurea Contraindications
Sulfa allergy
Renal failure
Liver failure
Drug-Drug interactions with Sulfonylurea
Beta Blockers
Alcohol
Alpha-Glucosidase inhibitor Example
Acarbose
Alpha-Glucosidase inhibitor action
Delays digestion of complex carbohydrates
Decreases the increase in blood sugar after meals
Give it at the beginning of the meal because it works in the GI tract
Alpha-Glucosidase inhibitor Adverse Effect
Hypoglycemia
GI upset
Gas
Diarrhea
Cramping
Alpha-Glucosidase inhibitor Indication for Use
decrease postprandial glucose
Alpha-Glucosidase inhibitor Contraindications
Liver disease
Bowel problem
Alpha-Glucosidase inhibitor drug-to-drug interaction
Can DECREASE digoxin levels
Biguanides Example
Metformin
Biguanides Action
Decreases hepatic glucose production
Increases use of glucose by muscle and fat cells, decreases intestinal absorption of glucose
Overall decrease in blood glucose level
Biguanide Indications for use
Insulin resistance
Common first choice for type 2 diabetes
Used to treat PCOS (Poly cystic ovarian syndrome)
Biguanide Adverse Effects
Lactic acidosis
GI upset
Does not have anything to do with hypoglycemia*
Biguanide Contraindications
Avoid using in older adults (80+) BLACK BOX
Avoid using with patients with renal failure
HOLD METFORMIN 48H BEFORE AND AFTER ANYTHING WITH A CONTRAST MEDIA
Nursing implications for metformin
Take with meals
Increased effects when taken with:
Digoxin
Furosemide
Vancomycin
Monitor Renal function
Thiazolidines Examples
Rosiglitazone
Thiazolidines (TZDs) Action
Stimulates insulin receptors on muscle, fat, and liver cells
Helps body use the insulin better
Used in combination with insulin, sulfonylureas, or biguanides
Thiazolidines (TZDs) Indication for use
Insulin Resistance
Thiazolidines (TZDs) Adverse Effects
Hepatotoxicity
Congestive Heart Failure
Weight Gain
Liver disease (Black Box)
CV disease (Black Box)
Thiazolidines Nursing Implications
Take with meals
Monitor Liver function studies
Monitor patients for signs of heart failure
Gemfibrozil may increase effects
May take 12 weeks to reach maximum effect
Meglitinides example
Repaglinide
Meglitinides Action
Stimulates pancreatic stimulation of insulin (need working beta cells)
Used in combination with TZDs or Biguanides
Meglitinides Adverse Effects
Hypoglycemia
GI upset
Meglitinides Contraindications
Renal and liver disease
Type 1 diabetes
Meglitinides Nursing considerations
Give this medication just before meals. If we skip the meal we need to skip the dose
Dipeptidyl Peptidase 4 inhibitors (DPP4) Example
Sitagliptin
Dipeptidyl Peptidase 4 inhibitors (DPP4) Action
Balance the release of insulin and limit the release of additional glucose from the liver, inhibition of glucagon secretion, delayed gastric emptying, induction of satiety
NEED WORKING BETA CELLS
May take in combo with TZD and Biguanides
Dipeptidyl Peptidase 4 inhibitors (DPP4) Adverse Effects:
Respiratory tract infection
Heart Failure
Dipeptidyl Peptidase 4 inhibitors (DPP4) Contraindication
Using insulin
Renal failure
Type 1 diabetes
Amylin Analogs Example
Pramlintide
Amylin Analogs Action
Suppresses postprandial glucagon secretion and increases sense of satiety
Used in addition to insulin, sulfonylureas, and biguanides
Injection
Amylin Analogs Adverse effects
Risk of hypoglycemia
BLACK BOX WARNING
Amylin Analogs Nursing Implications
Monitor blood sugar closely
Avoid giving this with other anticholinergics because if will slow down GI
May promote weight loss
SQ injection before meals
Incretin Mimetic Example
Exenatide
Incretin Mimetic Action
Stimulates the pancreas to secrete the right amount of insulin based on the food that was just eaten
Sensitive to when you are eating
Gut is more sensitive to your food coming in
Incretin Mimetic Indications for use
postprandial glucose elevation
Incretin Mimetic Adverse Effects
Hypoglycemia
Gi distress
Pancreatitis
Incretin Mimetic Contraindications
Liver disease
Black box warning: risk for thyroid cancer
Incretin Mimetic Nursing implications
SQ injection within 1 hour of breakfast and dinner
Must be refrigerated
Some Extended Release versions available only need 1 weekly injection
May promote weight loss
Sodium Glucose Cotransporter 2 Inhibitor Example
Canagliflozen
*New
Sodium Glucose Cotransporter 2 Inhibitor (SGLT2) Action
Blocks reabsorption of glucose in the kidney, promotes excretion of glucose in the urine
Used in combination with other antidiabetics
Sodium Glucose Cotransporter 2 Inhibitor (SGLT2) Adverse Effects
Dehydration*
Hypotension*
Electrolyte imbalance
Bone loss
Increased risk for limb amputation
Sodium Glucose Cotransporter 2 Inhibitor (SGLT2) Contraindication
Renal failure
Sodium Glucose Cotransporter 2 Inhibitor (SGLT2) Nursing implication
Take with the first meal of the day
Caustius giving this with other meds that might decrease blood pressure
Care for risk of dehydration or syncope
Education for Hyperglycemia:
Call doctor if blood sugar is higher than 250
Call doctor if ketones in urine
Fever above 101
Vomiting or Diarrhea
Miss multidoses of meds
Education Hypoglycemia
Alert:
Glucose gel
Orange juice or soda
2-3 glucose tabs
Unable to swallow:
Dextrose 50% half ampule
Glucagon SQ
