of Physiology Serum Glucose Control Body prefers glucose as primary energy source Normal fasting range for serum glucose is 60 100 mg/dL, but body usually regulates to fall between 80-90 mg/dL. Prototype Drug: Glucagon (GlucaGen) Therapeutic Classification Hormone: hypoglycemic agent Pharmacologic Classification Pancreatic hormone Pregnancy Category B Mechanism of Action Increases glucose levels by increasing glycogenolysis Stimulates uptake of amino acids and increases their conversion to glucose (gluconeogenesis) Promotes lipolysis in the liver, with the release of fatty acids and glycerol Indications o Emergency treatment of severe hypoglycemia in diabetic patients who are unconscious or unable to swallow food or liquids o Used for radiographic studies to relax the smooth muscle of the GI tract Contraindications o Sensitivity to protein compounds o Depleted glycogen stores or with insulinoma or pheochromocytoma Precautions o Coronary artery disease o Prototype Drug: Glucagon (GlucaGen) o Drug Interactions o Antidiabetic agents o Beta-adrenergic blockers o Prototype Drug: Glucagon (GlucaGen) Adverse Effects o Nausea o Vomiting o Hypersensitivity reactions o Transient changes in blood pressure (hypotension, hypertension) o Serious Adverse Effects o Tachycardia o Hypoglycemia o Hypokalemia Nursing Responsibilities o Assess the patient's blood glucose level before, during, and after glucagon administration. o Assess patient's ability to self-administer the drug and monitor blood glucose correctly. o Assess the patient's adherence to the prescribed dietary and exercise regimen. o Determine appropriate dosage and administer drug.
o Administer IV glucose solution if patient fails to respond. o Administer supplemental oral carbohydrates once consciousness has been achieved. o Instruct the patient on the proper use of the GlucaGen emergency kit. Patient/Family Teaching o Immediately report the signs of impending hypoglycemia. o At the first signs of hypoglycemia, eat sugar or a sweet food. o Do not mix the GlucaGen solution with the powder until it is ready to be used. o Discard any unused portion. o Wear a medical alert bracelet that identifies the medical condition and its treatment. Insulin Fundamental principle: o Right amount of insulin given when glucose available in the blood Key nursing role o Help patient plan meals, activities, and insulin doses Prototype Drug: Human Regular Insulin (Humulin R, Novolin R) Therapeutic Classification o Antidiabetic agent, pancreatic hormone Pharmacologic Classification o Short-acting hypoglycemic agent Pregnancy Category C (Insulin Glargin) and Category B (Other Forms of Insulin) Mechanism of Action o Insulin decreases blood glucose levels by increasing cellular uptake of glucose and stimulating storage of glucose as glycogen o Inhibits release of glucagon Indications Monotherapy to lower blood glucose levels in patients with type 1 diabetes In combination with oral antidiabetic agents in patients with type 2 diabetes Emergency treatment of DKA or hyperosmolar hyperglycemic state Gestational diabetes Contraindications Hypoglycemia Precautions Renal impairment or failure Thyroid disease Pregnancy The elderly Children or infants Hypokalemia Drug Interactions Agents that can produce hypoglycemia: sulfonylureas, meglitinides, beta-adrenergic blockers, salicylates, anabolic steroids, MAOIs, alcohol Dextrothyroxine, corticosteroids, epinephrine or norepinephrine, furosemide, thiazide diuretics
ACE inhibitors Many other drugs can influence blood glucose; the nurse should consult current drug references. Chromium Garlic, black cohosh, bitter melon, bilberry, ginseng, rosemary, cocoa Prototype Drug: Human Regular Insulin (Humulin R, Novolin R) Adverse Effects Irritation at injection site Lipohypertrophy Weight gain Serious Adverse Effects Hypoglycemia Rebound hyperglycemia Hypokalemia Nursing Responsibilities Obtain a complete drug history, including the use of herbs and dietary supplements; note any medications that could alter the affects of insulin. Assess the patient's alcohol intake. Assess the patient's blood glucose level and level of consciousness. Do not administer when blood glucose levels are less than 70 mg/dL or if the patient exhibits signs of hypoglycemia. Obtain periodic hemoglobin A1C level to assess serum glucose levels over the past 2 to 3 months. Prior to administering, ensure that the patient has consumed, or is capable of consuming, adequate food to prevent a hypoglycemic reaction. Prepare injection. Rotate injection sites weekly to prevent lipodystrophy but use the same locations consistently. Assess patient's knowledge of insulin therapy, diet, and exercise, and how these affect serum glucose levels. Administer only regular insulin intravenously. Monitor patient for hypoglycemia, particularly at the time of peak action for the type of insulin used. Assess the patient for signs and symptoms of long-term diabetes complications. Document the type of insulin and the amount, using the full term units, and the site used to administer the drug. Teach the patient how to properly prepare an insulin dose. Patient/Family Teaching Use low-dose syringes for doses of less than 30 units. Carefully follow the recommended diet and exercise program. Notify the health care provider before beginning a new diet or exercise program. Recognize symptoms of hypoglycemia and hyperglycemia; report any adverse effects to the health care provider. Always carry a supply of readily available sugar or quick-acting carbohydrate for unexpected episodes of hypoglycemia.
Wear a medical alert bracelet or carry a medical alert card. Take insulin exactly as prescribed. Patient/Family Teaching Store insulin as recommended by the health care provider. Store unopened vials in refrigerator but do not freeze them. Lower the dose of insulin if you are unable to eat, but do not omit the dose. An increased dose may be necessary during periods of high stress or illness. Inspect feet regularly for signs of infection, irritation, and abrasions, and report any slowhealing wounds. Similar Drugs to Human Regular Insulin Insulin Aspart (NovoLog) o Rapid onset of action and shorter duration of action than regular insulin Insulin Detemir (Levemir) o Long-acting insulin with a slow onset and dose-dependent duration of action o Used to provide basal glycemic control o Not injected before meals to control postprandial hyperglycemia o Cannot be mixed with any other type of insulin Insulin Glargine (Lantus) o Newer recombinant insulin analog o Constant, long-duration insulin activity o Provides for the maintenance of steady blood levels o May also help improve the lipid profiles and A1C levels of type 2 diabetes when added to therapy (Schwartz, 2007) Insulin Glulisine (Apidra) o Rapid onset and short duration (3 to 5 hours) o Given by SC injection only Insulin Lispro (Humalog) o Rapid-acting analog of regular insulin o Helps control the rise in blood glucose brought on by a meal o Not given IV; often used with insulin infusion pumps Isophane Insulin (NPH, Humulin N) o Only intermediate-acting insulin o Has slower onset of action than regular insulin o Used to provide a basal level of insulin coverage Oral Antidiabetic Agents Prototype Drug: Glyburide (DiaBeta, Glynase, Micronase) Therapeutic Classification o Antidiabetic agent Pharmacologic Classification o Hypoglycemic agent, sulfonylurea Pregnancy Category C Prototype Drug: Glyburide (DiaBeta, Glynase, Micronase) Mechanism of Action o Stimulates release of insulin from pancreatic beta cells o Increases sensitivity of peripheral tissues to insulin
Prototype Drug: Glyburide (DiaBeta, Glynase, Micronase) Indications Lowers blood glucose levels in patients with type 2 diabetes Contraindications Sensitivity to sulfa drugs or thiazide diuretics As primary treatment for type 1 diabetes, or for diabetic coma or DKA Precautions Renal or hepatic disease If used during pregnancy, discontinue at least 1 month before delivery. Drug interactions Alcohol Oral anticoagulants, MAOIs, probenecid, sulfonamides Chloramphenicol, oxyphenbutazone, phenylbutazone Salicylates, clofibrate Rifampin Thiazides Ginseng, garlic, black cohosh, juniper berries, fenugreek, coriander, dandelion root Adverse Effects Nausea Vomiting Heartburn Dizziness Urticaria Pruritis Serious Adverse Effects Hypoglycemia Hepatotoxicity Cholestatic jaundice Aplastic anemia Leucopenia Thrombocytopenia Agranulocytosis Nursing Responsibilities (All Oral Antidiabetic Agents) Monitor serum glucose levels. Monitor for signs and symptoms of illness or infection. Review laboratory studies for liver function abnormalities. Administer oral hypoglycemics as directed by the prescriber. Assess patients for hypoglycemia, hyperglycemia, adverse drug effects, adherence to therapy, and the ability for self-care. Identify patients at increased risk for effects adverse of drug therapy: Sulfonylureas: contraindicated in women who are pregnant or breast-feeding; persons with renal or liver disease Metformin: contraindicated in persons who consume excessive alcohol, or who have renal or liver disease or any condition predisposing them to lactic acidosis Meglitinides: used with caution in persons with liver disease Glitazones: contraindicated in persons with severe heart failure
Patient/Family Teaching (All Oral Antidiabetic Agents) Recognize, report, and treat signs and symptoms of hypoglycemia. Take sulfonylureas with food if nausea, vomiting, or stomach pain occurs. Do not take alcohol with sulfonylureas (disulfiram reaction). Wear a medical alert bracelet to notify emergency personnel of diabetes. Recognize and report signs of lactic acidosis with metformin therapy, such as hypoventilation, malaise, body aches, and sleepiness. GI upset and diarrhea are common adverse effects of metformin but will subside. Take vitamin supplements as directed by the health care provider. Take medications exactly as prescribed. Immediately report shortness of breath, sudden weight gain, fatigue, or swelling of the hands, feet, or ankles to the health care provider. Similar Drugs to Glyburide First-generation sulfonylureas: Chlorpropamide (Diabinese) Longest acting of the first-generation sulfonylureas Treatment of type 2 diabetes & neurogenic diabetes insipidus Pregnancy category C Tolazamide (Tolinase, Tolamide) Structurally related to tolbutamide but five times more potent Pregnancy category C Tolbutamide (Orinase) Short-acting sulfonylurea Used for patients on insulin who fail to respond to other sulfonylureas Pregnancy category C Second-generation sulfonylureas: Glimepiride (Amaryl) Used alone or in combination with insulin for patients with type 2 diabetes Duetact is glimepiride and pioglitazone. Avandaryl is glimepiride and rosiglitazone. Glipizide (Glucotrol) Used for patients with type 2 diabetes who do not achieve glucose control with diet alone Used for short-term therapy for those who normally can control their glucose levels by diet Metaglip is glipizide and metformin. Prototype Drug: Metformin (Glucophage, Glucophage XR, Glumetza) Therapeutic Classification Antidiabetic agent Pharmacologic Classification Hypoglycemic agent; biguanide Pregnancy Category B Mechanism of Action Reduces blood glucose levels by reducing gluconeogenesis, thereby suppressing hepatic production of glucose
Decreases intestinal reabsorption of glucose and increases the cellular uptake of glucose
Indications Lowers blood glucose levels in patients with type 2 diabetes who are unable to control glucose levels by diet and exercise Contraindications Impaired renal function Heart failure, liver failure, history of lactic acidosis Concurrent serious infection Any condition that predisposes patient to hypoxemia Precautions Anemia, diarrhea, vomiting, dehydration, fever, gastroparesis, GI obstruction Older adults Hyperthyroidism, pituitary insufficiency, trauma Pregnancy and lactation Drug Interactions Alcohol Captopril, furosemide, nifedipine IV radiographic contrast Amiloride, cimetidine, digoxin, dofetilide, midodrine, morphine, procainamide, quinidine, ranitidine, triamterene, trimethoprim, vancomycin Acarbose Vitamin B12 and folic acid Garlic and ginseng Adverse Effects GI-related effects (nausea, vomiting metallic taste, diarrhea, abdominal pain) Headache Dizziness Fatigue Serious Adverse Effects Lactic acidosis Currently, metformin is the only biguanide available. Oral Combination Products Glyburide/metformin (Glucovance) Glipizide/metformin (Metaglip) Rosiglitazone/metformin (Avandamet) Prototype Drug: Repaglinide (Prandin) Therapeutic Classification Antidiabetic agent Pharmacologic Classification Hypoglycemic agent; meglitinide Pregnancy Category C Prototype Drug: Repaglinide (Prandin) Mechanism of Action Lowers glucose levels by stimulating insulin release from pancreatic beta cells Indications
Lowers blood glucose levels in patients with type 2 diabetes as an adjunct to diet and exercise Contraindications Type 1 diabetes or DKA Precautions Hepatic impairment Pregnancy or lactation Systemic infection, surgery, or trauma Elderly patients Drug Interactions: Drugs that induce hepatic CYP3A4 enzyme, such as barbiturates, carbamazepine, rifampin, pioglitazone Drugs that inhibit CYP3A4 enzyme, such as erythromycin, ketoconazole, miconazole Gemfibrozil Isophane insulin Grapefruit juice Garlic Ginseng Adverse Effects Nausea Vomiting Diarrhea Dyspepsia Headache Paresthesias Rhinitis Back pain Serious Adverse Effects Hypoglycemia Similar Drugs to Repaglinide Nateglinide (Starlix) Actions and uses are similar to repaglinide Primarily renally excreted, so should be used with caution in patients with renal impairment. Pregnancy category C Prototype Drug: Rosiglitazone (Avandia) Therapeutic Classification Antidiabetic agent Pharmacologic Classification Thiazolidinedione Pregnancy Category C Prototype Drug: Rosiglitazone (Avandia) Mechanism of Action Lowers blood glucose levels by increasing cellular sensitivity to insulin, thereby reducing insulin resistance Decreases gluconeogenesis by the liver
Indications Used to lower blood glucose levels in patients with type 2 diabetes as an adjunct to diet and exercise Contraindications Severe heart failure Liver disease or elevated liver enzymes Pregnancy and lactation Type 1 diabetes or DKA Precautions Children Prototype Drug: Rosiglitazone (Avandia) Drug Interactions: Inducers of hepatic CYP2C8 such as rifampin Inhibitors of CYP2C8 such as azole antifungal agents, fluvoxamine, gemfibrozil, trimethoprim Concurrent use with insulin Other antidiabetic agents Angiotensin II receptor antagonists Nitrates Thiazide diuretics, phenothiazines, antipsychotic drugs Garlic and ginseng Cocoa and rosemary Adverse Effects Upper respiratory infection Headache Myalgia Weight gain Serious Adverse Effects Hypoglycemia Hepatotoxicity Bone fracture Heart failure Myocardial infarction Similar Drugs to Rosiglitazone Pioglitazone (Actos) Actions and uses similar to rosiglitazone More favorable effects on triglyceride and HDL-cholesterol levels than rosiglitazone May decrease serum levels of oral contraceptives Cardiovascular safety of the thiazolidinedione drugs has been questioned black box warnings R/T heart failure and myocardial ischemia were added to labeling in 2007. Pregnancy category C Prototype Drug: Acarbose (Precose) Therapeutic Classification Antidiabetic
Pharmacologic Classification Hypoglycemic agent, alpha-glucoside inhibitor Pregnancy Category B Prototype Drug: Acarbose (Precose) Mechanism of Action Lowers glucose levels by interfering with carbohydrate absorption from the GI tract Indications Lower blood glucose in patients with type 2 diabetes who cannot manage levels by diet and exercise alone Contraindications Inflammatory bowel disease, bowel obstruction, colon ulcers, or those predisposed to bowel obstructions Precautions GI distress Liver disorders Pregnancy or lactation Prototype Drug: Acarbose (Precose) Drug Interactions Sulfonylureas Thiazide diuretics, corticosteroids, phenothiazines, estrogens, phenytoin, or isoniazid Ginseng, garlic, black cohosh, juniper berries, aloe, dandelion root, cocoa, rosemary Adverse Effects Diarrhea Flatulence Abdominal distention Borborygmi Anemia urticaria Erythema Serious Adverse Effects Hypoglycemia Similar Drugs to Acarbose Miglitol (Glyset) Alpha-glucosidase inhibitor Like acarbose, it must be taken with a meal. Adverse effects are similar to acarbose, except does not cause increased liver enzymes. Pregnancy category B Prototype Drug: Sitagliptin (Januvia) Therapeutic Classification Antidiabetic Pharmacologic Classification Hypoglycemia agent, DPP-IV inhibitor Pregnancy Category C Mechanism of Action Inhibits dipeptidyl peptidase-IV (DPP-IV)
Indications Used to help lower glucose levels in patients with type 2 diabetes who are unable to achieve normal glucose levels with diet and exercise Contraindications Type 1 diabetes or DKA Precautions Renal disorder or renal failure Elderly patients Pregnancy or lactation Prototype Drug: Sitagliptin (Januvia) Drug Interactions Digoxin Cocoa and rosemary Adverse Effects Headache Diarrhea Nasopharyngitis Upper respiratory infection Allergic skin reactions Anaphylaxis Serious Adverse Effects Hypoglycemia may occur if used with sulfonylurea or insulin. Similar Drugs to Sitagliptin Exenatide (Byetta) Synthetic peptide that stimulates the release of insulin from pancreatic beta cells Major disadvantage: must be given twice daily by the subcutaneous route Pregnancy category C
Inhibition of DPP-IV reduces the destruction of incretins, which increases levels of incretin hormones. Blood glucose levels decrease.