Diabetes mellitus pharmacology vc – Flashcards
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Diagnosis of diabetes
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Fasting blood glucose greater than 126 on 2 or more occasions. HA1C greater than 6.5%. Random glucose greater than 200
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Normal fasting glucose
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60-99 mg/dL
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Fasting plasma glucose
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FPG
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Fasting blood sugar
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FBS
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Finger stick blood sugar
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FSBS. Before meals=ac. After meal=PP
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Blood sugar goals
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70-130 mg/dL before meal-correction insulin needed if elevated. Less than 180 mg/dL two hours after starting a meal. Less than 7% hemoglobin (A1C) level
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Hemoglobin A1C
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A serum blood test which measures the average glucose level over the preceding 2-3 months. Better indicator of glycemic control over time than the blood sugar. Extra glucose attaches to hemoglobin.
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Target sites
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Pancreas. Liver. Intestine. Adipose tissue. Muscle. Kidneys
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Pre-diabetes
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100-125 mg/dL
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Diabetes
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Greater than 126 mg/dL on 2 or more occasion
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Oral agents
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Type II diabetes only. Usually started after diet and exercise fail to adequately control blood sugar. Can typically reduce HbA1C by 0.5-2.0%.
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Oral agents indications
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The treatment of type 2 diabetes mellitus
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Oral agents mechanism of action
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Addresses the symptoms of diabetes rather than the underlying pathophysiology.
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Oral agents side effects
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Beta cell function tends to worsen over time. Often affects adherence (hypoglycemia, nausea & vomiting, peripheral edema, weight gain)
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Agents used to treat diabetes
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Oral agents. Insulins. Injectable agents. Inhaled insulin. Agents to raise blood sugar
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Types of oral agents
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Sulfonylureas. Biguanides. Thiazolidinediones. Incretin mimics. DPP-4 inhibitors. SGLT2 inhibitors.
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Types of insulins
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Rapid acting. Short acting. Intermediate acting. Long acting. Mixed
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Oral agents nursing implications
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Monitoring of glucose levels and glycosylated hemoglobin (HA1C). Assessing for sulfa hypersensitivity (sulfonylureas)-allergies. Administering most agents with meals-understanding the onset of action, peak, and duration associated with oral agents. Assessing patient teaching needs. Assessing for hypoglycemia.
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Hypoglycemia
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Insulin reaction. Low blood sugar. Due to relative excess of insulin in the blood. Characterized by below normal serum glucose levels less than 60-when most people become symptomatic. Usually results from insulin injections, but can also result from some oral hypoglycemic agents (anti-diabetic medications).
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Clinical manifestations of hypoglycemia
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Sudden onset. Lab findings-low serum glucose. FSBS is also low-less than 60. Autonomic nervous system responses: hunger, anxiety, sweating, skin pale, cool, tachycardia. Impaired cerebral function: H/A, altered emotional behavior, difficulty problem solving, feelings of vagueness, slurred speech, impaired motor function, seizures, coma
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Nursing interventions for hypoglycemia
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Attempt to give 15 grams of carbohydrate to raise blood sugar. If patient is not alert enough to eat, try jelly, sugar tablets, honey. May need order for IV 50% dextrose or glucagon if no response to above interventions
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Rule of 15
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Used when the blood glucose is 70 mg/dL or below. Treat the hypoglycemia with 15 grams of carbohydrates-check blood glucose in 15 minutes. If still less than 70 mg/dL, give another 15 grams of carbohydrate and re-check blood glucose in 15 minutes
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Hyperglycemia
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High blood sugar. Fasting blood glucose levels of greater than 126 on 2 or more occasions. Blood glucose normally rises after food consumption-should return to near normal in 2 hours.
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Sulfonylureas mechanism of action
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Oral agent. Act in pancreas to increase insulin production-insulin secretogogues. Increase insulin output from the pancreas-has potential to cause hypoglycemia.
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Sulfonylureas adverse effects
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Nausea, vomiting, epigastric discomfort, heartburn, skin rash, hypoglycemia, photosensitivity, hematologic problems, weight gain
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Sulfonylureas contraindications
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Allergy to sulfa
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Biguanide mechanism of action
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Oral agent. Decrease intestinal absorption of glucose. Decrease hepatic glucose production. Increase insulin sensitivity by increasing glucose uptake in tissue. Advantage over sulfonylureas: little effect on pancreatic output-not as much concern with hypoglycemia. Onset: several days, peak: 2-4 weeks
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Biguanide adverse effects
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Some weight loss expected (5-10 lbs). Abdominal bloating. Nausea, vomiting, abrupt diarrhea. Diarrhea can be uncontrollable; fecal incontinence issues for some "metformin moment". Risk for lactic acidosis in patients with increased creatinine-poor kidney function-can be life threatening.
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Biguanide nursing implications
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Recognize that it will not immediately lower blood glucose. Monitor serum glucose level. Give 30 minutes before a meal. Hold before any test which requires IV contrast dye due to risk of lactic acidosis
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Thiazolidinediones mechanism of action
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Oral agent. Decreases insulin resistance by increasing sensitivity of insulin receptors and increasing glucose uptake and use in skeletal muscle-help insulin get into cells. Decreases fatty acid output in adipose tissue. Decreases glucose output in the liver. Onset: unknown, peak: unknown, duration: 12-24 hours. Advantage: does not cause hypoglycemia since they do not have an effect on pancreatic production of insulin, may preserve some beta cell function, may have protective vascular effects (lowering cholesterol). Disadvantage: may be toxic to the liver-must have LFTs (ALT and AST) monitored
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Thiazolidinediones adverse effects
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Edema. Weight gain. mild anemia. May cause liver damage
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GLP-1
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One of several naturally occurring incretin compounds released by the body during digestion. Lowers both glucose and glucagon levels. Cannot be used as a drug because it is broken down in less than 2 minutes by the enzyme DPP-4
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GLP-1 agonist mechanism of action
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Mimic the actions of glucagon-like peptide 1. Act like GLP-1 but are not broken down as quickly. Slows glucose absorption from the gut. Increases insulin secretion for the pancreas when the glucose is high. Lowers glucagon levels after meals. Suppresses a receptor located in the hypothalamus to reduce appetite. Increases beta cell mass and first phase insulin release.
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Incretin mimetics
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Subcutaneous injection. Mimic the response of endogenous incretin. Results in lower glucose levels. Not a substitute for insulin.
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Incretin
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Intestinal hormones released in response to ingestion of food. Increase the insulin response-increase pancreas output and depress the gluconeogenesis-decrease glucose levels & decrease glucagon secretion in the liver. Increased insulin and decreased glucose = lower blood glucose. Naturally decrease appetite, lose weight-suppresses appetite, increase feelings of fullness. Diminished response in type II diabetics
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Incretin mimetics side effects
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Nausea. Hypoglycemia. Altered kidney function-renal insufficiency. Pancreatitis/pancreatic cancer. Average weight loss is 5-10 pounds
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DPP-4 inhibitor mechanism of action
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Oral agent. Blocks DPP-4. Slow the degradation of incretins thus prolonging the action of the incretins, increasing/enhancing incretin levels, increasing endogenous levels of GLP-1. The result is an increase in output of insulin from the pancreas and a decrease in glucagon output from the liver. End result is lower glucose levels. Once a day oral agent
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DPP-4
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Breaks down the hormone incretin.
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DPP-4 inhibitors adverse reactions
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Nausea, vomiting, diarrhea. Flu like symptoms. Rash. Pancreatitis & pancreatic cancer
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Sodium-glucose co-transporter inhibitor mechanism of action
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Oral agent. Inhibits SGLT2 resulting in decreased glucose reabsorption and increased urinary glucose excretion
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SGLT2 protein transporter
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Expressed in proximal renal tubules. Responsible for majority of reabsorption of filtered glucose
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SGLT2 inhibitor warning and precautions
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Hypotension. Renal impairment. Elderly. Low blood pressure. Diuretic therapy. ACEI or ARB therapy. Monitor renal function during therapy
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Combination drugs
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glyburide/metformin = Glucovace. rosiglitazone/metformin = Avandamet. Januvia/metformin = Janumet. 1.25/250; 2.5/500; 5/500
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Insulin therapy
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Effects similar to the endogenous insulin produced from the pancreas. Past: made from pork, beef. Now: human source insulin-more effective, cause fewer side effects and has a lower incidence of resistance. Type I and type II diabetes mellitus. Towards end of treatment after oral agents. Goal: mimic what the body does.
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Insulins indications
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Primary treatment for type I diabetes. May also be used in the management of type 2 diabetes and gestational diabetes-pancreas is exhausted, beta cells can't produce enough to control diabetes
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Insulin
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Allows the glucose to get inside the cell. Without it, glucose stays in the bloodstream causing hyperglycemia
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Rapid acting insulins
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Onset: 0-15 minutes. Peak: 0.5-3H. Duration: 3-5H. Used with sliding scale regimens (SSC)-"correction insulin" "bolus insulin". Higher the blood sugar, more insulin. Doesn't last all day.
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Rapid acting insulins nursing implication
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Decrease risk for hypoglycemia by making sure that the meal is available before administering. Protocol may be give after the meal. Peak indicates time of greatest risk for hypoglycemia. Subcutaneous or intravenous
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Short acting insulins
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Regular-intravenous or subcutaneous use. Onset: 0.5-1H. Peak: 2-3H. Duration: 4-6H. Also used with sliding scale/correction regimens. Doesn't last all day. Peak indicates time of greatest risk for hypoglycemia
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Intermediate acting insulins
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Onset: 1-2 hours. Peak: 4-12 hours. Duration: 18-24 hours. Cloudy insulin. Given twice a day-normally given 30 minutes before first meal of the day (2/3 dose) and 1/3 dose before the evening meal or at bedtime. Comes after clear insulin (regular)
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Long acting "basal" insulins
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Once daily insulins. Can be given in the am or pm. Mimics secretions from body. Must not be mixed with any other insulin
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Mixed/combination insulins
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Developed to more closely simulate varying levels of normal endogenous insulin production. Varying types-Humilin 70/30, 50/50, Novolin 70/30. Contain varying amounts of intermediate and short acting insulin. Premixed. NPH: regular
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Basal insulin
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Controls blood sugar levels between meals and throughout the night. Twice a day NPH can be used if needed. Never hold especially in an insulin deficient patient
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Mealtime (Prandial) insulin
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Insulin that covers blood glucose increases related to food. Give at end of meal as PO intake uncertain in hospitalized patients
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Correction insulin
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Used to correct high blood glucoses based on blood glucose level obtained before the meal. Sliding Scale outdated terminology. Give at same time as meal time insulin. Meal time & correction insulin should be same type of insulin.
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Ideal insulin regimen
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Simulates the body's own normal insulin output. Combines basal insulin with mealtime insulin. Called a basal-bolus regimen. Corrects high blood sugar before a meal-"sliding scale insulin". Uses rapid and short acting (bolus) insulin before meals plus uses a long-acting insulin once a day. Commonly prescribe as 4 injections a day. Helps keep patients within control Most near-normal levels of A1c. Decrease risk for diabetic complications
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Insulin adverse effects
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Hypoglycemia. Causes: med error, patient exercised and insulin peaked, patient doesn't eat after taking, symptoms usually seen when blood glucose 60 or less. Hyperglycemia. Hyperinsulinemia-overdose. Localized allergic reactions at the injection site. Generalized urticarial and swollen lymph glands, hives
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Teaching points
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Monitor glucose levels as directed. Carry a source of simple sugar in case of hypoglycemic reactions. When in doubt if symptoms are due to hyper or hypo glycemia, treat for hypo with sugar source. Eat a 15 gram carbohydrate food for hypoglycemia with symptoms. Rotate insulin sites to prevent lipodystrophy. Do not inject insulin into areas that are raised, swollen, dimpled, or itching. Keep insulin vials that are currently in use at room temperature as it is less irritating to the skin-good for 30 days after opened. Unopened keep refrigerated to keep stabled. Follow prescribed diet strictly. Wear a medic alert bracelet. Use only the prescribe type of insulin. Check urine ketones if blood sugar is greater than 300. Works fastest when administered in abdomen.
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Elevating drugs mechanism of action
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Glucagon & 50% dextrose. Stimulates hepatic production of glucose from glycogen stores. Used to treat hypoglycemia. Raises the blood sugar. Makes liver make more glucose. Patient can't take sugar source. Administered IM, IV, or SC. 50% IVP is also given to raise low blood sugar for severe hypoglycemia.
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Elevating drugs indications
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To treat hypoglycemic reactions
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Elevating drugs adverse effects
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Nausea and vomiting, tachycardia, and anaphyaxis
