1. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Agents to Control Blood Glucose Levels Chapter 38

2. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Function of the Pancreas Gland Endocrine Gland –Produces hormones in the islets of Langerhans Exocrine Gland –Releases sodium bicarbonate and pancreatic enzymes directly into the common bile duct to be released into the small intestine –Neutralizes the acid chyme from the stomach and aids digestion

3. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin Definition –Hormone produced by beta cells of the islets of Langerhans Action –Released into circulation when the levels of glucose around these cells rise –Stimulates the synthesis of glycogen, the conversion of lipids into fat stored in the form of adipose tissue, and the synthesis of needed proteins from amino acids

4. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Metabolic Changes Occurring When Insufficient Insulin is Released Hyperglycemia: Increased blood sugar Glycosuria: Sugar is spilled into the urine Polyphagia: Increased hunger Polydipsia: Increased thirst Lipolysis: Fat breakdown Ketosis: Ketones cannot be removed effectively Acidosis: Liver cannot remove all of the waste products

5. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Diabetes Mellitus Characteristics –Complex disturbances in metabolism –Affects carbohydrate, protein, and fat metabolism Clinical Signs –Hyperglycemia (fasting blood sugar level greater than 126 mg/dL) –Glycosuria (the presence of sugar in the urine)

6. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders Associated With Diabetes Atherosclerosis: Heart attacks and strokes related to the development of atherosclerotic plaques in the vessel lining Retinopathy: With resultant loss of vision as tiny vessels in the eye are narrowed and closed Neuropathies: With motor and sensory changes in the feet and legs and progressive changes in other nerves as the oxygen is cut off Nephropathy: With renal dysfunction related to changes in the basement membrane of the glomerulus

7. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Classifications of Diabetes Mellitus Type 1, Insulin-Dependent Diabetes Mellitus (IDDM) –Usually a rapid onset; seen in younger people –Connected in many cases to viral destruction of the beta cells of the pancreas Type 2, Non–Insulin-Dependent Diabetes Mellitus (NIDDM) –Usually occurs in mature adults –Has a slow and progressive onset

8. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Signs and Symptoms of Hyperglycemia Fatigue Lethargy Irritation Glycosuria Polyphagia Polydipsia Itchy Skin

9. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Signs of Impending Dangerous Complications of Hyperglycemia Fruity breath as the ketones build up in the system and are excreted through the lungs Dehydration as fluid and important electrolytes are lost through the kidneys Slow, deep respirations (Kussmaul’s respirations) as the body tries to rid itself of high acid levels Loss of orientation and coma

10. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hypoglycemia Definition –Blood sugar concentration lower than 40 mg/dL Occurrence –Starvation –Lowering the blood sugar too far with treatment of hyperglycemia

11. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is a clinical manifestation of hyperglycemia? A. Edema B. Lack of thirst C. Itchy skin D. Hyperexcitability

12. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Itchy skin Rationale: Clinical signs and symptoms of hyperglycemia: fatigue; lethargy; irritation; glycosuria; polyphagia; polydipsia; itchy skin

13. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Insulin

14. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin Actions –Hormone that promotes the storage of the body’s fuels –Facilitates the transport of various metabolites and ions across cell membranes –Simulates the synthesis of glycogen from glucose –Reacts with specific receptor sites on the cells

15. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin (cont.) Indications –Treatment of type 1 diabetes mellitus –Treatment of type 2 diabetes mellitus in patients whose diabetes cannot be controlled by diet or other agents Pharmacokinetics –Various insulins available are processed within the body like endogenous insulin –Peak, onset, and duration vary based on preparation

16. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin (cont.) Contraindications –There are no contraindications Caution –Pregnancy and lactation Adverse Effects –Hyperglycemia and ketoacidosis

17. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Insulin (cont.) Drug-to-Drug Interactions –When given with any drug that decreases glucose levels –Beta blockers

18. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Site of Action of Drugs Used to Treat Diabetes

19. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sulfonylureas First Generation –Associated with increase risk of cardiovascular disease Second Generation –Advantage over 1 st generation drugs Excreted in urine and bile Do not interact with as many protein bound drugs Longer duration of action

20. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sulfonylureas (cont.) Actions –Stimulate insulin release from the beta cells in the pancreas –They improve binding to insulin receptors Indications –Adjunct to diet and exercise to lower blood glucose levels in type 2 diabetes

21. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sulfonylureas (cont.) Pharmacokinetics –Rapidly absorbed from the GI tract and undergo hepatic metabolism –Excreted in the urine –Peak and duration varies with each drug Contraindications –Allergy –Diabetic complications –Type 1 diabetes mellitus

22. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Sulfonylureas (cont.) Adverse Effects –Hypoglycemia –GI distress –Allergic skin reactions Drug-to-Drug Interactions –Drugs that acidifies the urine –Beta blockers –Alcohol

23. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Please answer the following statement as true or false. Second generation sulfonylureas have several advantages over first generation sulfonylureas including the fact that they interact with more protein bound drugs.

24. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Second generation sulfonylureas: Advantage over 1 st generation drugs would be they are excreted in urine and bile; do not interact with as many protein bound drugs; longer duration of action

25. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nonsulfonylureas Actions, Indications, Pharmacokinetics, Contraindications, Caution, Adverse Effects, Drug-to-Drug Interactions –Vary with the drug that is given

26. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Glucose Elevating Agents Actions –Increase the blood glucose levels by decreasing insulin release and accelerating the breakdown of glycogen in the liver to release glucose Indications –Treatment of hypoglycemia Pharmacokinetics –Rapidly absorbed and distributed throughout the body –Excreted in the urine

27. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Glucose Elevating Agents (cont.) Contraindications –Known allergy –Pregnancy and lactation Caution –Hepatic dysfunction or cardiovascular disease Adverse Effects –GI upset –Vascular effects Drug-to-Drug Interactions –Thiazide diuretics –Anticoagulants

28. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Use of Antidiabetic Agents Across the Lifespan

29. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is a primary action of glucose lowering agents? A. Accelerate the breakdown of glycogen B. Increase insulin release C. Improve binding to insulin receptors D. Decrease use of incretins

30. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Accelerate the breakdown of glycogen Rationale: The action of glucose elevating agents is to increase the blood glucose levels by decreasing insulin release and accelerating the breakdown of glycogen in the liver to release glucose.

31. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prototype Insulin

32. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prototype Sulfonylureas – First Generation

33. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prototype Sulfonylureas – Second Generation

34. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prototype Nonsulfonylureas

35. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Considerations for Insulin Assessment: History and Physical Exam Nursing Diagnosis Implementation Evaluation

36. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Considerations for Oral Antidiabetic Agents Assessment: History and Physical Exam Nursing Diagnosis Implementation Evaluation

37. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Considerations for Glucose Elevating Agents Assessment: History and Physical Exam Nursing Diagnosis Implementation Evaluation