1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Introduction to Clinical Pharmacology Chapter 42- Antidiabetic Drugs

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Diabetes Risk factors for type 2 include: –Obesity –Older age –Family Hx –Hx of gestational diabetes –Impaired glucose tolerance –Minimal or no physical activity –Race/ethnicity

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin Hormone manufactured by beta cells of pancreas Controls the storage and utilization of amino acids and fatty acids Lowers blood glucose levels by inhibiting glucose production by liver

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin: Action and Uses *Activates a process that helps glucose molecules enter the cells of striated muscle and adipose tissue Promotes protein synthesis Properties of insulin: Onset, Peak, Duration Controls type 1 diabetes mellitus, type 2 diabetes, Severe diabetic ketoacidosis Treats hypokalemia in combination with glucose

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin: Adverse Reactions, Contraindications, and Precautions Adverse reactions: –Hypoglycemia; Hyperglycemia; Allergic reaction Contraindicated in patients: –With hypersensitivity, hypoglycemia Used cautiously in patients: –With renal and hepatic impairment; During pregnancy and lactation

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Display 42-1 Drugs that alter insulin effectiveness Estrogens Methylprednisolone niacin

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Oral Antidiabetic Drugs Used to treat patients with type 2 diabetes that is not controlled by diet and exercise alone Not effective for treating type 1 diabetes

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Sulfonylureas Action –Lower blood glucose by stimulating the B cells of the pancreas to release insulin –Not affective if B cells cannot release a sufficient amount of insulin to meet the individuals needs –*****Examples: Glucotrol-glipizide DiaBeta-glyburide glimpiride/Amaryl

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nonsulfonylureas **A-glucosidase inhibitors –Precose (acarbose) and Glyset (miglitol0 –Lower blood glucose levels by delaying the digestion of CHO’s and absorption of CHO’s of the intestine **Thiazolidinediones/glitazones decrease insulin resistance and increase insulin sensitivity by modifying several processes Avandia/rosiglitazone and pioglitazone/Actos

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Adverse Reactions Sulfonylureas –Hypoglycemia, anorexia, nausea, heartburn Nonsulfonylureas –Lactic acidosis-buildup with metformin use s/s malaise, abdominal pain, rapid respirations, shortness of breath and muscular pain

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Contraindications, precautions and interactions **Sulfonylureas –Oral antidiabetic drugs are contraindicated in patients with known hypersensitivity to the drugs, DKA (tx is insulin), severe infection, or severe endocrine disease –May have an increased hypoglycemic effect when administered with anticoagulants Nonsulfonylureas –Heart failure, renal disease

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Hormone Mimetic Agents Released in response to increases in glucose that occures after eating Januvia/sitagliptin –Lowers blood glucose level by enhancing the secretion of endogenous incretin hormone

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Assessment Preadministration assessment: –Assess weight, blood pressure, pulse, respiratory rate –Assess skin, mucous membranes, extremities, with special attention given to sores or cuts that appear to be healing poorly and ulcerations or other skin or mucous membrane changes

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Assessment Ongoing assessment: –Monitor vital signs; Observe adverse drug reactions –*monitor q 2-4 hours for s/s of hypoglycemia –Notify primary health care provider if adverse reaction occurs or if there is significant weight gain or loss

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Planning Expected outcomes: –Optimal response to therapy –Support of patient needs related to management of adverse reactions –Reduction in anxiety –Improved ability in coping with diagnosis –Understanding of and compliance with prescribed therapeutic regimen

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Promoting an optimal response to therapy –Administer insulin, care must be taken to use correct insulin –Carefully read all drug labels before preparing any insulin preparation –Read label of the insulin bottle carefully for name, source of insulin, number of units per milliliter U100 has 100 units in each milliliter *Those clients who are resistant to insulin may require larger dose use the U500 concentration

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Promoting an optimal response to therapy –Mixing Insulins: Clarify with primary health care provider if patient is to receive regular insulin and NPH insulin, regular and lente insulin *do not mix or dilute glargine Ask whether insulins were given separately or together if patient had been using insulin mixtures before admission

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Insulin administration –Regular insulin is given 30-60 minutes before a meal to achieve optimal results –Lispro usually lowers the glucose level 1-2 hours after meals –Insulin glargine is given subcutaneously once daily at bedtime

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Promoting an optimal response to therapy –Sulfonylureas: Give glipizide 30 minutes before meal due to food delays –Nonsulfonylureas: acarbose and miglitol are given three times a day with the first bite of the meal, because food increases absorption

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Implementation Monitoring and managing patient needs – Acute confusion: Immediately terminate hypoglycemic reaction Notify primary health care provider if episodes of hypoglycemia occur –Deficient fluid volume: Notify health care provider if blood glucose levels are elevated or if ketones are present in urine

21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Education Older adults taking oral antidiabetic drugs are more susceptible to hypoglycemic reactions which may be difficult to detect Teach to avoid ETOH, dieting, commercial weight loss products and strenuous exercise Teach to perform finger stick on the side of a finger where there are fewer nerve endings*

22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Evaluation Therapeutic drug effect is achieved; Normal or near-normal blood glucose levels are maintained Hypoglycemic reactions are identified, reported, and managed successfully Anxiety is reduced Patient begins to demonstrate ability to cope with disorder and its required treatment