Pharm-DM. chemo, opioids Flashcards
who are oral antidiabetic agents used for?
Stable Type 2 diabetics with NO KETONES who can’t control BG with diet alone
never use oral antidiabetics in
pts who make no inuslin (Type 1) Pt must make their won insulin to use oral agents
Sulfonylurea action
Bind to Beta cells of pancreas and stimulate insulin release
second generation sulfonylureas are better than 1st generation because
more potent, less interactions, less side effects
2nd gen sulfonylureas end in
-ide
glimepiride
Amaryl; sulfonylurea
glipizide
Glucotrol; sulfonylurea
glyburide
Micronase, DiaBeta,
sulfonylurea
major adverse effect of sulfonylureas
Hypoglycemia
side effects of sulfonylureas besides HoG
itchy rash, increased sun sensitivity
heartburn, anorexia, n/v
sulfonylureas should be taken
30 minutes before a meal
except Glucotrol XL and Amaryl-qday
Glucotrol + metformin
Metaglip
gluburide +metformin
Glucovance
sulfonylurea + biguanide combo drugs (2)
Metaglip and Glucovance
sulfonylurea + TZD combo drugs (2)
Avandaryl and Duetact
Amaryl + Avandia
Avandaryl
Amaryl + Actos
Duetact
Meglitinides action
“jumper cables”
stimulate insulin release from pancreas, faster and shorter duration than sulfonylureas
esp good for controlling ppBG
Major adverse effect of meglitinides
hypoglycemia
Meglitinide use contraindicated in
pregnancy and breastfeeding
Admininster meglitinide when?
within 15 minutes of meal; only give if meal is eaten
metformin and Januvia
Januvamet
metformin and Avandia
Avandamet
Biguanide action
decreases hepatic glucose production (gluconeogenesis) and
increases cellular uptake of glucose
Adverse effects of biguanides are rare if
pt has good renal and hepatic function
Potentially fatal AE of biguanide use
Lactic Acidosis
due to excess drug accumulation
Labs before and every 6 months with biguanide use
Liver and Kidney function tests
Stop biguanide use immediately if
dehydration, severe infection, surgery
contrast dye use (stop 48 hours prior)
excessive Etoh
hepatic or renal disease
s/s Lactic acidosis
fatigue, weakness dizzyness
dyspnea
GI discomfort
bradycardia, arrythmia
Most common side effect of biguanide use
GI symptoms: diarrhea, n/v, bloating, anorexia, metallic taste
SO: take with meals
HoG can result from biguanide use if
it is taken with a sulfonylurea, excessive alcohol
elderly and/or malnourished pt
alpha-glucosidase inhibitors action
“Starch Blockers”
slow CHO digestion and glucose absorption by blocking carbohydrase enzyme; prevents surges in BG
Side effects of alpha-glucosidase inhibitors
GI: diarrhea, gas, abd pain (“gas pills”
HoG when used with sulfonylureas
acarbose
Precose
miglitol
Glyset
starch blocker
when HoG is cause by starch blocker use, treat with
oral glucose or milk, NOT sucrose because its digestion will be slowed
Administer starch blockers
with first bite of meal.
metformin
Glucophage
TZDs action
Insulin sensitizers; decrease insulin resistance at the cellular level by increasing uptake of glucose by skeletal muscle and decreasing glucose production by the liver. Overall: increases effectiveness of circulating insulin, DOES NOT stimulate secretion of insulin
TZD taken off market in 2000
Rezulin
TZD generic names end in
-glitazone
rosiglitazone
Avandia
TZD
pioglitazone
Actos
TZD
indication for TZD use
Type 2 DM pt on insulin >30 units/day still with inadequate BG control
TZDs don’t cause HoG but can damage
the liver. LFTs monthly at first, then q6mos
decreases action of oral contraceptives and can cause ovulation in premenopausal anovulatory pts
Actos
avoid in severe cardiac disease bc can worsen HF
TZDs
exenatide
Byetta; incretin mimetic
incretin hormones released by/action
GI tract; in response to food. They: Stimulate insulin secretion decrease pp glucagon production slow gastric emptying increase satiety to decrease intake
incretin mimetic action
improves glycemic control in Type 2 DM pt by decreasing fasting and pp BG by mimicking incretin hormone action
indication for incretin mimetic use
Type 2 DM pt adjunct to metformin or sulfonylureas when pt is still not getting enough BG control
Admin of incretin mimetic
SubQ injection within 1 hour of am and pm meals
side effects of Byetta
decreased appetite, intake, and weight
nausea, especially with first use
DDP-4 inhibitor action
enhance incretin system
(DDP-4 enzyme inactivates incretins)
DDP-4 inhibitors generic names end in
-gliptin
sitagliptin
Januvia
DDP-4 inhibitor
saxagliptin
Onglyza
DDP-4 inhibitor
indications for use of DDP-4 inhibitors
with metformin (Januvamet) or TZDs or solo Adjunct to diet and exercise to increase glycemic control
Side effects of DDP-4 inhibitors
Headache
URIs, sore throat
diarrhea
Do not use these with sulfonylureas because of increase risk of HoG
DDP-4 inhibitors
Admin of DDP-4 inhibitors
PO qday
injecable med for Type 1 and Type 2 pts; used with insulin to help lower ppBG by slowing food movement through stomach
pramlintide (Symlin)
administer Symlin
dont mix with insulin, prepare two different syringes
side effects of Symlin
HoG, nausea
glucagon action
pancreatic hormone that raises BG by stimulating glycogen breakdown
glucagon use
treat HoG when oral treatment isn’t possible
to admin glucagon
reconstitute, not stable in liquid form
IM or SubQ injection, repeat 1x in 20 min
who must have glucagon on hand at all times?
Type 1 pt or meds that have risk of HoG
class of controlled pain mgmt meds; natural or synthetic chemicals based on morphine
opioids
narcotic
any drug capable of causing physical dependence
opioid action
stimulate opioid receptors in CNS causing a combo of analgesia, sedation, mood change and euphoria specific to the receptor involved
opioid receptor that causes analgesia, sedation, and euphoria and whose major side effect of stimulation is respiratory depression
M (mu)
opioid receptor whose stimulation causes mainly analgesia and drowsiness and whose main side effect is decreased GI motility
K (kappa)
opioid receptor stimulated by endogenous endorphins
delta
specific effects of each opioid are determined by
it’s particular affinity for the different opioid receptors
indications for opioid use (5)
Pain relief: mod-severe
Cough suppression (medullary center inhibition)
Cardiac-decreased workload due to claming effect and peripheral vasodilation
Antidiarrheal-bind intestinal opioid receptors
Anxiety decreased
agonist action
binds receptor to activate and produce a response
partial agonist (agonist-antagonist) action
mixed effects result in a weaker response than agonist; used when max effects would be dangerous
antagonist action
Blocks receptor response
opioid antidote
naloxone (Narcan)
naltrexone (Trexan)
given if RR <8 usually, precipitates withdrawal in dependent patients
why are oral morphine doses higher than IV/IM?
First Pass Effect in Liver
Analgesic standard for potency to which all opioids are compared
morphine
methadone use and action
used for detox and maintenence of heroin or other opioid addicts; decreases intensity of withdrawal symptoms
advantage of buprenorphine (Suboxone, Subtrex) over methadone
can give prescription to go home instead of regular visit to clinic
antihistamines are used as adjuvant meds with opioids because
sedation, potentiate analgesia
antidepressants are used as adjuvant meds with opioids because
decrease pain perception and induce sleep
anxiolytics are used as adjuvant meds with opioids because
decrease anxiety, induce sleep, promote amnesia
antipsychotics are used as adjuvant meds with opioids because
decrease pain perception, induce sleep, counter delerium
anticonvulsants are used as adjuvant meds with opioids because
stabilize neuronal membranes and potentiate analgesia
Often used for chronic pain
Ex-Neurontin
opioid contraindications
acute respiratory distress decreased liver or kidney function Head injury (increased risk of respiratory depression)
opioid side effects
*Respiratory Depression n/v drowsiness dry mouth miosis (pupil constriction) orthostatic HoTN diaphoresis pruritis (some histamine release, not true anaphylaxis) urinary retention (esp. morphine) constipation
adverse reactions of opioids
seizures tinnitus (often concurrent with Tylenol) jaundice facial Edema confusion tachycardia severe respiratory depression (give Narcan)
dependence
response to ongoing exposure that can produce withdrawal syndrome
early s/s opioid withdrawal
anxiety
tearing and runny nose
clammy skin and goosebumps
late s/s opioid withdrawal
irritability
n/v and diarrhea
involuntary leg movement
very late s/s opioid withdrawal (can last months)
agitation, insomnia, fatigue
tolerance
adaptation; need increased dose for same effect
addiction
drug seeking for euphoriia, not pain mgmt
when to admin opioids before a painful activity
PO: 30 min before
IV/IM: 3-5 min before
anaplasia
absence of normal cellular differentiation
myelosuppression
suppression of bone marrow function, which can result in dangerously low levels of rbs, wbcs, and plts
normal plt count
150-400
normal Hgb
males: 14-18
females: 12-16
normal Hct
males 42-52%
females 37-47%
normal wbc count
4200-12500 (4.2-12.5)
nadir
lowest wbc count after count had been depressed by chemo; time to nadir can be reduced and duration can be increased in subsequent rounds of chemo
carcinomas are malignant neoplasms of
epithelial tissue (skin, GI lining, bronchial lining, other linings)
sarcomas are malignant neoplasms of
connective tissue (bone, fibrous, fatty, muscle, vascular, neuro). often present as painless swellings
leukemia
cancers that arise from bone marrow; marrow cells replaced by leukemic blasts resulting in abnormal numbers and forms of immature wbs.
goal of chemo
find best combination of meds for that particular cancer cell type to achieve the highest cell kill ratio possible.
induction therapy
first dose of chemo
pt reponse often dictates course of treatment
standard insulin units/mL
100 units/mL
never dilute or mix
Lantus
insulin coverage is always with
rapid-acting or short-acting
draw venous blood sample to confirm BG if it is
500
the only insulin given IV is
short-acting (regular)
insulin syringe specs
1/2-5/8 inch
25-30 G
when mixing insulins draw up
regular first, then NPH (RN)
systematic rotation of injection sites is necessary
to prevent scar tissue formation and ensure adequate absorption
insulin injection sites separated by ? and use not more than?
1 inch
every 3 weeks
medications that can increase hypoglycemic effects of insulin
alcohol; MAOIs; salicylates
two types of lipodystrophy
lipoatrophy–loss of subq fat; seen as dimpling
lipohypertrophy—development of fatty masses at injection site
Both caused by prolonged use of the same site, not rotating properly
complication sometimes seen after diabetic control is suddenly established in a client who has prolonged uncontrolled DM
Insulin Edema–generalized retention of fluid
most common cause of insulin resistance
obesity
true insulin resistance is a daily insulin requirement of
200+ units
treatment for insulin resistance
purer preparation
prednisone treatment
an opened bottle of insulin is good for
28 days at rt
insulin pumps use only
rapid-acting insulin
get accucheck within ? minutes of meals
30 minutes
