Chapter Antidiabetic032 - CHAPTER 32 ANTIDIABETIC AGENTS Diabetes Mellitus Two types Type 1 Type 2 Hyperglycemia Fasting plasma glucose equal to or >126

Chapter Antidiabetic032 - CHAPTER 32 ANTIDIABETIC AGENTS...

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Unformatted text preview: CHAPTER 32 ANTIDIABETIC AGENTS Diabetes Mellitus • Two types • Type 1 • Type 2 • Hyperglycemia • Fasting plasma glucose equal to or >126 mg/dL • Hypoglycemia • Blood glucose level <50 mg/dL • Gestational diabetes Table 31-1 Type 1 and Type 2 Diabetes: Characteristics Type 1 Diabetes Mellitus • Lack of insulin production or • Production of defective insulin • Affected patients need exogenous insulin • Complications • Retinopathy, nephropathy, neuropathy • Oral antidiabetic agents not effective Type 2 Diabetes Mellitus • Most common type • Caused by insulin deficiency & insulin resistance • Many tissues are resistant to insulin • Reduced number insulin receptors • Insulin receptors less responsive Type 2 Diabetes Mellitus (cont'd) • Several comorbid conditions • Glucose intolerance • Obesity • Dyslipidemia • Hypertension • Insulin resistance Type 2 Diabetes Mellitus (cont'd) • Several comorbid conditions • Hyperinsulinemia • Microalbuminemia (protein in the urine) • Enhanced conditions for embolic events (blood clots) • Heart disease • Collectively known as metabolic syndrome Diabetic Ketoacidosis • Breakdown of fatty acids for fuel when no insulin • • • • • • • • present to use glucose for energy – stress or illness often a trigger Extreme hyperglycemia but less than 800 mg/dL usually Ketones Acidosis Dehydration Electrolyte imbalance Can lead to coma & death -3-10% mortality Insulin therapy required in most cases Fluid & electrolyte replacement Hyperosmolar Nonketotic Syndrome (HNKS) • Usually older, type 2 • Symptoms last longer than 5 days • Serum glucose higher than 800 mg/dL • Normal pH • Less ketosis • 10-20% mortality • Insulin therapy may not be needed. Goal of Treatment • Hemoglobin A1C (HbA1C) level < 7% • Indicates control over preceding 2-3 months Types of Antidiabetic Agents • Insulins • Oral hypoglycemic agents • Both aim to produce normal blood glucose states Insulins • Function as a substitute for the endogenous hormone • Effects are the same as normal endogenous insulin • Restores the diabetic patient’s ability to: • Metabolize carbohydrates, fats, & proteins • Store glucose in the liver • Convert glycogen (from excess glucose) to fat stores Human-Based Insulins • Rapid acting • Most rapid onset of action (15 minutes) • Shorter duration • Insulin aspart (NovoLog) • Insulin lispro (Humalog) • Insulin glulisine (Apidra) Human-Based Insulins (cont'd) • Short acting • Regular insulin (Humulin R, Novolin R) • The only insulin product that can be given by IV bolus, IV infusion, or even IM Human-Based Insulins (cont'd) • Intermediate acting • Isophane insulin suspension (also called NPH) (Humulin N, Novolin N) • Both have a cloudy appearance • Slower in onset and more prolonged duration than endogenous insulin Human-Based Insulins (cont'd) • 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) • Insulin lispro protamine suspension 50% and insulin lispro 50% (Humalog Mix 50/50) • Novalog 70/30 Human-Based Insulins (cont'd) • Long acting • Glargine (Lantus) • Clear, colorless solution • Insulin detemir (Levemir) • Not interchangeable, duration of action dose dependent= lower doses require twice daily dosing and higher doses may be given once a day Sliding-Scale Insulin Dosing • SC regular insulin doses adjusted according to blood glucose test results • Typically used in hospitalized diabetic patients • Subcutaneous regular insulin is ordered in an amount that increases as the blood glucose increases • Example: • No insulin for a blood glucose of less than 140 mg/dL • 2 units for a blood glucose value of 141 to 199 mg/dL • 4 units for a blood glucose value of 200 to 249 mg/dL • 6 units for a blood glucose value of 250 to 299 mg/dL • 8 units for a blood glucose value of 300 mg/dl or higher Table 31-2 Comparison Actions of Human Insulins and Analogs Table 31-3 Insulin Mixing Compatibilities Oral Antidiabetic Agents • Used for type 2 diabetes • Treatment for type 2 diabetes includes lifestyle modifications • Diet, exercise, smoking cessation, weight loss • Metformin (Glucaphage) • If acceptable HgA1C not reached in 2-3 months, add insulin or either a sulfonylurea (preferred) or a thiazolidinedione Biguanide Metformin (Glucophage) • First line and most common drug with lifestyle changes for DM2 • Decreases glucose production in the liver • May also decrease intestinal absorption of glucose • May improve insulin receptor sensitivity • Does not stimulate insulin secretion so is not associated with hypoglycemia & weight gain Biguanide (cont.) • Contraindicated with renal disease (creatinine higher than 1.5 in males and 1.4 in females) • Side Effects • GI (abdominal bloating, nausea, cramping, feeling of fullness, diarrhea) • Less common –metallic taste, reduced B12 levels • Lactic acidosis – 50% lethal • DC day of and 48 after use of contrast media Sulfonylureas • Sulfonylureas – oldest, second-line when metformin not effective • First-Generation (no longer used) • Chlorpropamide (Diabinese), tolazamide (Tolinase), tolbutamide (Orinase) • Second-Generation • Glimepiride (Amaryl), glipizide (Glucotrol), glyburide (DiaBeta) • Stimulate release of insulin & decrease secretion of glucagon • Garlic, ginger, & ginseng may increase risk of hypoglycemia Sulfonylureas (cont). • Side Effects • Hypoglycemia • Weight gain • Skin rash • Nausea • Epigastric fullness • Heartburn • TAKE 30 MINUTES BEFORE MEALS GLINIDES • Repaglinide (Prandin) • Nateglinide (Starlix) • Increase insulin secretion • Short duration • Never give with sulfonylureas (similar action) • Adverse Effects • Hypoglycemia • Weight gain • GIVE WITH MEALS THIAZOLIDINEDIONES • Glitizones • Pioglitazone (Actos) • Rosiglitazone (Avandia) *MI • • • • Decrease insulin resistance “Insulin sensitizing agents” Increase glucose uptake and use in skeletal muscle Inhibit glucose and triglyceride production in the liver • Slow onset over several weeks, adverse effects, cost when metformin & sulfonylureas don’t work • Side Effects • • • Increase risk of heart failure Peripheral edema & weight gain Osteoporosis • Monitor liver enzymes Alpha-glucosidase Inhibitors • Acarbose (Precose) • Miglitol (Glyset) • Reversibly inhibit the enzyme alpha-glucosidase in the small intestine • Result: delayed absorption of glucose • Must be taken with meals to prevent excessive postprandial blood glucose elevations • Side Effects – GI • Do not cause hypoglycemia or weight gain GLUCOSE-ELEVATING DRUGS • D50W • Glucagon –SQ –may cause vomiting Antidiabetic Agents: Nursing Implications • Before giving any drugs that alter glucose levels, obtain and document: • A thorough history • Vital signs • Blood glucose level • Potential complications and drug interactions Nursing Implications • Before giving any drugs that alter glucose levels: • Assess the patient’s ability to consume food • Assess for nausea or vomiting • Hypoglycemia may be a problem if antidiabetic agents are given and the patient does not eat • If a patient is NPO for a test or procedure, consult physician to clarify orders for antidiabetic drug therapy Nursing Implications • 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 Nursing Implications • Thorough patient education is essential regarding: • Disease process • Diet and exercise recommendations • Self-administration of insulin or oral agents • Potential complications Nursing Implications • When insulin is ordered, ensure: • Correct route • Correct type of insulin • Timing of the dose • Correct dosage • Insulin order and prepared dosages are second- checked with another nurse Nursing Implications • Insulin • Check blood glucose level before giving insulin • Roll vials between hands instead of shaking them to mix suspensions • Ensure correct storage of insulin vials • ONLY insulin syringes, calibrated in units, are to be used to measure and give insulin • Ensure correct timing of insulin dose with meals Nursing Implications • Insulin (cont'd) • When drawing up two types of insulin in one syringe, always withdraw the regular insulin first • Provide thorough patient education regarding selfadministration of insulin injections, including timing of doses, monitoring blood glucoses, and injection site rotations Nursing Implications • Oral antidiabetic agents • 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 Nursing Implications • Assess for signs of hypoglycemia • If hypoglycemia occurs: • Give glucagon • Have the patient eat glucose tablets or gel, corn syrup, honey, fruit juice or nondiet soft drink • Or have the patient eat a small snack such as crackers or half a sandwich • Monitor blood glucose levels Nursing Implications • Monitor for therapeutic response • Decrease in blood glucose levels to the level prescribed by physician • Measure hemoglobin A1c to monitor long-term compliance to diet and drug therapy • Watch for hypoglycemia and hyperglycemia CASE STUDY A 25 year-old male has recently been diagnosed with type 1 DM. In addition to a 2300-calorie ADA diet, he was started o an insulin administration program that includes 5 units of regular insulin and 10 units of NPH insulin each morning with 5 units of regular insulin and 5 units of NPH before the evening meal. He is also instructed in the procedure for self-monitoring of blood glucose. He is advised to check his blood sugar in the morning before his insulin dose and in the late afternoon before supper. CASE STUDY (CONT.) One month after beginning treatment, he came to the ER at 6:00 PM with profuse sweating, tremors, headache, and an elevated BP. His blood sugar by finger stick was 45mg/dl. He is given an IV bolus of 50 cc of 50% dextrose. In interviewing him before he is released from the ER, you discover that he had not eaten his usual meals that day because of nausea and diarrhea. CASE STUDY (CONT.) He also admits that the has not been testing his blood sugar at home because he is too rushed in the morning. He frequently eats out in the evening with friends and is too embarrassed to test his blood sugar “in front of my friends.” He says he follows his diet and finds no problems in balancing his food intake. QUESTIONS 1. 2. 3. What is the significance of the time of day the he experienced his hypoglycemia? Outline the instructions you will give him about managing his diabetes on days when he is sick. Explain the importance of self-monitoring of blood glucose for diabetes management. CASE STUDY (CONT.) After his first hypoglycemic episode, he began monitoring his blood glucose twice a day as he had been instructed. One year later he reports that his sugars have been increasing both in the morning and the evening. He denies change in food or activity. He says he follows his diet faithfully. His insulin regimen is changed to add 5 units of regular insulin to the morning dose of NPH. He is also to take 10 units of NPH and 5 units of regular insulin in the evening, before supper. QUESTIONS He asks why he can’t take pills for diabetes the way his grandfather did for diabetes. How will you respond? 5. What are the differences between NPH and regular insulin that he needs to learn? 6. List the steps you will teach him about preparing the two insulin's for injection. 7. What additional points will you review with him regarding his insulin administration technique? 4. ...
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  • Winter '16
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