Agents Used to Treat Hyperglycemia and Hypoglycemia Chapter 35 Agents Used to Treat Hyperglycemia and Hypoglycemia

Diabetes Mellitus Disorder of the pancreas Results in hyperglycemia Treatment Insulin Oral hypoglycemics

Diabetes Mellitus Can precipitate - cardiovascular disease - kidney damage - nerve damage - vision loss due to diabetic retinopathy

Diabetes Mellitus Pancreatic beta cells Excrete an insufficient amount of insulin, or no insulin at all Flawed carbohydrate, fat, and protein metabolism

Diabetes Mellitus Two types: Type 1 (formerly known as insulin- dependent diabetes mellitus, IDDM) Type 2 (formerly known as noninsulin- dependent diabetes mellitus, NIDDM)

Diabetes Mellitus Type 1 diabetes mellitus Treated with insulin subcutaneous injections Type 2 diabetes mellitus Treated with oral hypoglycemic agents

Symptoms of Diabetes Mellitus Polyuria (increased urine output) Polydipsia (excessive thirst) Polyphagia (excessive hunger)

Treatment for Diabetes Mellitus Dietary management Close monitoring Weight reduction Insulin Oral agents

Insulin Promotes: Glucose transport across cell membranes (think of this as an “escort service”!) Conversion of glycogen into glucose Utilizes fatty acids and inhibits lipolysis Enhances protein synthesis and inhibits protein breakdown Blood glucose rises as carbs are digested

Normal Physiology of Insulin Function Release of insulin is triggered and promotes: - transport of glucose across cell membranes - conversion of glycogen to glucose - utilization of fatty acids by cells - inhibition of lipolysis (breakdown of fats to fatty acids) - amino acid utilization enhances synthesis of protein - protein breakdown is inhibited

Insulin Function Continued release of insulin reduces blood glucose Will eventually produce a hypoglycemic state Insulin is inhibited and hormones are released Glucose rises and evens out

Insulin Malfunction Blood glucose remains high after a meal Blood glucose level >180 can cause glucose to spill into urine Water is drawn into the urinary tract Increased urination Fluid depletion Increased thirst Glucose in urine is a medium for bacteria culture

Insulin Malfunction Body is not utilizing circulating glucose Other nutrients breakdown to provide fuel Fatty acids are converted to ketones Proteins breakdown to amino acids

Liver glycogen is broken down into glucose Development of ketoacidosis Insulin Malfunction (cont’d) Liver glycogen is broken down into glucose Development of ketoacidosis Wasting muscle tissue Higher blood glucose levels

Insulin malfunction Diabetic ketoacidosis Inadequate or no insulin -> hyperglycemia too much fat is being burned for fuel instead – waste products from this fat builds up to toxic levels in the bloodstream  ketones or ketoacidosis

Regular insulin is the only insulin typically used IV Insulin Therapy Usually available in 100 units per milliliter 500 units per milliliter is also available Prescription/insulin pumps/for patients requiring large daily doses Regular insulin is the only insulin typically used IV

Insulin Therapy Insulin preparations differ by (cont’d) Insulin preparations differ by - onset and duration of action - degree of purity - source (cow, pig, or human) Human insulin most prevalent Insulin is administered parenterally

Insulin Synthetic human insulin Produced either by: Recombinant DNA synthesis of human insulin Conversion of pig to human insulin Human in origin Humulin, Novolin, and Lispro Older versions Pig or cow in origin

Four Preparations of Insulin Rapid- Acting Fast- Intermediate- Long- Lispro Aspart Regular Humulin-R Novolin-R NPH Lente Humulin-L Ultralente Humulin-U Glargine- Lantus Note the differences in onset, peak, and duration of action.

Adverse Effects of Insulin Allergic reactions Lipodystrophy Insulin resistance

Nursing Implications Several drugs antagonize the hypoglycemic effects of insulin. Check your drug manual before administering any drug agent. Type 2 diabetics (NIDDM) may still need insulin if NPO for surgery or illness

Hypoglycemia Blood glucose is low (< 40 mg/dL) Produced from Skipped or irregularly scheduled meals Excessive exercise Insulin administration errors

Signs and Symptoms of Hypoglycemia Sweating Confusion Tachycardia Headache Hunger Weakness Poor muscle control Emotional instability Coma and death

Hypoglycemia Treatment Glucagon (intramuscular, intravenous, or subcutaneous) IV dextrose 50%, also known as D50W

Treatment for Type 2 Diabetes Oral antidiabetic agents Sulfonylureas (oldest category) First generation Second generation Biguanides Meglitinides Alpha-glucosidases Thiazolidinediones

Oral Hypoglycemic Agents Stimulates pancreatic beta cells to excrete insulin May increase binding between insulin and insulin receptors May increase number of receptors

Oral Hypoglycemic Agents Need some pancreatic function For Type 2 diabetics Used when diet alone is not controlling blood glucose and patient does not want to take insulin

Oral Hypoglycemic Agents May have a link to risk for cardiovascular death Decline in popularity Certain patients respond to oral agents better - diagnosed after age 40 - not overweight - would require less than 40 units per day of insulin

Sulfonylureas Action: stimulate the beta cells of the pancreas to secrete more insulin Glipizide (Glucotrol), glyburide (DiaBeta, Micronase,Glynase), glimepiride (Amaryl)

Biguanides Action: inhibit hepatic glucose production and increase the sensitivity of peripheral tissue to insulin May be given with sulfonylureas Metformin Hcl (Glucophage)

Repaglinide (Prandin) Meglitinide Action Stimulate the beta cells of the pancreas to secrete insulin Minimal risk of hypoglycemia More rapid onset than sulfonylureas TID a/c meals Repaglinide (Prandin)

Alpha-glucosidase Inhibitors Action: inhibit an enzyme called alpha- glucosidase (enzyme responsible for the hydrolysis of saccharides to be converted to glucose) Must be taken with meals May be given with sulfonylureas

Thiazolidinediones (Glitazones) Action Decrease insulin resistance by decreasing gluconeogenesis, glucose output, and triglyceride synthesis in the liver Monitor for hepatic toxicity. May be given with sulfonylureas

Side Effects Biguanides Abdomen bloating, nausea, cramping, and diarrhea Alpha-glucosidase inhibitors Flatulence, diarrhea, and abdominal pain Thiazolidinediones Hepatic toxicity, weight gain, edema, and mild anemia

Nursing Considerations Alcohol use by patients on sulfonylureas can cause flushing, nausea, and/or palpitations Diabetes education is an ongoing process of assessment, evaluation, and teaching A-1-C serum levels should be monitored Normal adult values 3.5%-6.0% Assess for presence of depression

Nursing considerations Weight assessments Skin assessment (especially to lower legs and feet) Teaching of self-care skills Teaching injection skills When drawing up two compatible types of insulin in the same syringe, withdraw the clear one first and then the cloudy one

Treating for Hypo or Hyperglycemia If unsure whether patient is having low or high blood sugar symptoms, treat for low blood sugar If patient able to swallow, give juice followed by complex carbohydrate food Glucagon can be administered parenterally Do not give insulin when patient fasting Beta-blockers can mask symptoms of hypoglycemia