Diabetes mellitus pharmacology vc

question

Diagnosis of diabetes
answer

Fasting blood glucose greater than 126 on 2 or more occasions. HA1C greater than 6.5%. Random glucose greater than 200
question

Normal fasting glucose
answer

60-99 mg/dL
question

Fasting plasma glucose
answer

FPG
question

Fasting blood sugar
answer

FBS
question

Finger stick blood sugar
answer

FSBS. Before meals=ac. After meal=PP
question

Blood sugar goals
answer

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
question

Hemoglobin A1C
answer

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.
question

Target sites
answer

Pancreas. Liver. Intestine. Adipose tissue. Muscle. Kidneys
question

Pre-diabetes
answer

100-125 mg/dL
question

Diabetes
answer

Greater than 126 mg/dL on 2 or more occasion
question

Oral agents
answer

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%.
question

Oral agents indications
answer

The treatment of type 2 diabetes mellitus
question

Oral agents mechanism of action
answer

Addresses the symptoms of diabetes rather than the underlying pathophysiology.
question

Oral agents side effects
answer

Beta cell function tends to worsen over time. Often affects adherence (hypoglycemia, nausea & vomiting, peripheral edema, weight gain)
question

Agents used to treat diabetes
answer

Oral agents. Insulins. Injectable agents. Inhaled insulin. Agents to raise blood sugar
question

Types of oral agents
answer

Sulfonylureas. Biguanides. Thiazolidinediones. Incretin mimics. DPP-4 inhibitors. SGLT2 inhibitors.
question

Types of insulins
answer

Rapid acting. Short acting. Intermediate acting. Long acting. Mixed
question

Oral agents nursing implications
answer

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.
question

Hypoglycemia
answer

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).
question

Clinical manifestations of hypoglycemia
answer

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
question

Nursing interventions for hypoglycemia
answer

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
question

Rule of 15
answer

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
question

Hyperglycemia
answer

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.
question

Sulfonylureas mechanism of action
answer

Oral agent. Act in pancreas to increase insulin production-insulin secretogogues. Increase insulin output from the pancreas-has potential to cause hypoglycemia.
question

Sulfonylureas adverse effects
answer

Nausea, vomiting, epigastric discomfort, heartburn, skin rash, hypoglycemia, photosensitivity, hematologic problems, weight gain
question

Sulfonylureas contraindications
answer

Allergy to sulfa
question

Biguanide mechanism of action
answer

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
question

Biguanide adverse effects
answer

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.
question

Biguanide nursing implications
answer

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
question

Thiazolidinediones mechanism of action
answer

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
question

Thiazolidinediones adverse effects
answer

Edema. Weight gain. mild anemia. May cause liver damage
question

GLP-1
answer

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
question

GLP-1 agonist mechanism of action
answer

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.
question

Incretin mimetics
answer

Subcutaneous injection. Mimic the response of endogenous incretin. Results in lower glucose levels. Not a substitute for insulin.
question

Incretin
answer

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
question

Incretin mimetics side effects
answer

Nausea. Hypoglycemia. Altered kidney function-renal insufficiency. Pancreatitis/pancreatic cancer. Average weight loss is 5-10 pounds
question

DPP-4 inhibitor mechanism of action
answer

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
question

DPP-4
answer

Breaks down the hormone incretin.
question

DPP-4 inhibitors adverse reactions
answer

Nausea, vomiting, diarrhea. Flu like symptoms. Rash. Pancreatitis & pancreatic cancer
question

Sodium-glucose co-transporter inhibitor mechanism of action
answer

Oral agent. Inhibits SGLT2 resulting in decreased glucose reabsorption and increased urinary glucose excretion
question

SGLT2 protein transporter
answer

Expressed in proximal renal tubules. Responsible for majority of reabsorption of filtered glucose
question

SGLT2 inhibitor warning and precautions
answer

Hypotension. Renal impairment. Elderly. Low blood pressure. Diuretic therapy. ACEI or ARB therapy. Monitor renal function during therapy
question

Combination drugs
answer

glyburide/metformin = Glucovace. rosiglitazone/metformin = Avandamet. Januvia/metformin = Janumet. 1.25/250; 2.5/500; 5/500
question

Insulin therapy
answer

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.
question

Insulins indications
answer

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
question

Insulin
answer

Allows the glucose to get inside the cell. Without it, glucose stays in the bloodstream causing hyperglycemia
question

Rapid acting insulins
answer

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.
question

Rapid acting insulins nursing implication
answer

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
question

Short acting insulins
answer

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
question

Intermediate acting insulins
answer

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)
question

Long acting “basal” insulins
answer

Once daily insulins. Can be given in the am or pm. Mimics secretions from body. Must not be mixed with any other insulin
question

Mixed/combination insulins
answer

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
question

Basal insulin
answer

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
question

Mealtime (Prandial) insulin
answer

Insulin that covers blood glucose increases related to food. Give at end of meal as PO intake uncertain in hospitalized patients
question

Correction insulin
answer

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.
question

Ideal insulin regimen
answer

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
question

Insulin adverse effects
answer

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
question

Teaching points
answer

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.
question

Elevating drugs mechanism of action
answer

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.
question

Elevating drugs indications
answer

To treat hypoglycemic reactions
question

Elevating drugs adverse effects
answer

Nausea and vomiting, tachycardia, and anaphyaxis

Get instant access to
all materials

Become a Member