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Ch. 36 pharm book
Drugs used to treat diabetes mellitus
| Question | Answer |
|---|---|
| Diabetes Mellitus is… | *a group of diseases characterized by hyperglycemia (fasting plasma glucose level >100 mg/dL) and *abnormalities in fat, carbohydrate, and protein metabolism |
| Diabetes Mellitus can lead to… | *microvascular, *macrovascular, *neuropathic complications |
| Those with a predisposition to developing diabetes include… | *relatives with diabetes *Obese people *Older people |
| The incidence of diabetes is higher in… | *African Americans *Hispanics *American Indians *Native Alaskans *Women |
| Diabetes is classified by… | the underlying pathology causing hyperglycemia |
| Type I diabetes was formally known as… | insulin dependent diabetes mellitus (IDDM) *present in 5-10% of diabetic population *occurs more frequently in juveniles |
| Type I diabetes is caused by… | an autoimmune destruction of the beta cells in the pancreas. |
| The onset of type I diabetes… | usually a rapid progression of symptoms (a few days to a few weeks) |
| Type I diabetes is characterized by… | *polydipsia (↑ thirst) *polyphagia (↑appetite) *polyuria (↑urination) *↑frequency of infection *loss of wt/strength *irritability *ketoacidosis |
| Because there is no insulin secretion from the pancreas in Type I diabetes, pts require… | administration of exogenous insulin. |
| It is common for Type I diabetes pts to… | go into remission in the early stages of the disease, requiring little exogenous insulin called “honeymoon” period |
| Type II diabetes mellitus was formally known as… | non-insulin-dependent diabetes mellitus (NIDDM) *makes up about 90% of diabetic population |
| Type II diabetes is characterized by… | *decrease in beta cell activity (insulin deficiency) *insulin resistance (reduced uptake of insulin by peripheral muscle cells) *increase in glucose production by liver |
| Most people with type II diabetes mellitus also have a metabolic syndrome known as… | insulin resistance syndrome and syndrome X |
| Type II diabetes onset… | *usually more insidious *pancreas still maintains some capability to produce and secrete insulin |
| Since the onset of type II diabetes is prolonged, usually the three symptoms of polyphagia, polydipsia, and polyuria are… | minimal or absent for a prolonged period. |
| In type II diabetes, fasting hyperglycemia can be controlled by… | diet in some pts, but most require some type of supplemental insulin or oral ant diabetic agent such as motorman or glyburide. |
| The onset of type II diabetes is usually in… | the 4th decade of life, but can occur in younger pts who do not require insulin for control. |
| A third subclass of diabetes mellitus includes additional types of diabetes that are… | part of other disease processes such as acromegaly, Cushing’s syndrome, infection, malnutrition, drugs/chemicals |
| Fourth category of Diabetes… | Gestational Diabetes Mellitus (GDM)abnormal glucose tolerance during pregnancy. Also, does not include diabetic women who become pregnant. |
| Women who get gestational diabetes during pregnancy also have a greater risk for developing diabetes… | 5-10 yrs after pregnancy. |
| What is prediabetes? | an intermediate stage between normal glucose homeostasis and diabetes |
| Normal Fasting glucose levels | <100 mg/dL |
| Impaired Fasting glucose levels | >or=to at 100 mg/dL or greater, but less than<16 mg/dL |
| Impaired Glucose Tolerance levels | a 2-hour plasma glucose level at 140 or greater but less than 199 mg/dL |
| Long standing hyperglycemia and abnormalities in fat, carbohydrate, and protein metabolism lead to… | microvascular, macrovascular, and neuropathic complications. |
| Microvascular Complications | those that arise from destruction of capillaries in:*eyes *kidneys *peripheral tissues |
| Diabetes has become the leading cause of… | end stage renal disease and adult blindness |
| Macrovascular Complications | those associated with atherosclerosis of middle to large arteries, such as those in heart and brain |
| Macrovascular complications, stroke, MI, and peripheral vascular disease account for __ to __ % of mortality in pts with diabetes… | 75-80% |
| Comorbid diseases that often arise in pts with diabetes: | *HTN *Cardiovascular Disease leading to MI or stroke *Retinopathy leading to blindness *Renal diseaseendstage renal failure and need for dialysis *PAD leading to non-healing ulcers, infections, lower extrm. Amputations |
| Comorbid diseases cont’d… | *sexual dysfunction *bladder incontinence *paresthesis *Periodontal disease |
| Symptoms associated with complications of diabetes that may be the first indication of the presence of diabetes… | *wt gain/loss *blurred vision *paresthesia *loss of sensation *orthostatic hypotension *impotence *vaginal yeast infections *neurogenic bladder |
| Nonhealing ulcers may indicate… | chronic vascular disease |
| The minimum purpose in the treatment for diabetes is to prevent… | ketoacidosis and symptoms resulting from hyperglycemia. |
| Major determinants to stop progression of diabetes are… | *balanced diet *insulin or oral antidiabetic therapy *routine exercise *good hygiene |
| People with type I diabetes will always require insulin as well as… | dietary control because the pancreas has lost the capability to produce and secrete insulinthe aims of dietary control are the prevention of excess postprandial hyperglycemia and the prevention of hypoglycemia. |
| Diet should also be adjusted to… | reduce elevated cholesterol and triglyceride levels in attempt to retard the progression of atherosclerosis |
| What contributes significantly to the ultimate outcome of the disease and the quality of life that the pt may lead? | *intelligence *motivation *their awareness of potential complications |
| What is a common precipitating cause of ketosis and acidosis and must be treated promptly… | Infection (especially in skin, feet and teeth…hygiene folks…is key) |
| Patients normally controlled with oral antidiabetic agents require insulin during situations of… | increased physiologic and psychological stress such as: *pregnancy *surgery *infections |
| Pts with diabetes should test blood glucose level… | before each meal and at bedtime while insulin and food intake are being regulated. |
| Oral antidiabetic medication is recommended for pts who diabetes… | cannot be controlled thru diet/exercise alone and who are not prone to develop ketosis, acidosis, or infections. |
| Pts most likely to benefit from oral antidiabetic medications… | those who have developed diabetes after age 40 and who require less than 40 units/day |
| The different oral antidiabetic agents working by different mechanisms to successfully control hyperglycemia: | *secretogogues *Biguanides *Thiazolidinediones *Alpha-glucosidase Inhibitors *Incretin-based therapy |
| Secretogogues | *The sulfonylureas-->glyburide, glipizide *The meglitinide-->repaglinide, nateglinide |
| Action of Secretogogues… | *stimulate pancreas to secrete more insulin *sulfonylureas also diminish hepatic glucose production and metabolism of insulin by the liver. |
| Biguanides | Only one is metformindecreases glucose production by inhibiting glycogenolysis and gluconeogenisis *also ↓absorption of glucose from small intestine *also ↑insulin sensitivity in muscle/fat cells |
| Thiazolidinediones (TZD’s) | pioglitazone, rosiglitazone↑tissue sensitivity to insulin *also diminishes glucose production in liver. |
| Alpha-glucosidase inhibitors: | Acarbose, miglitol-->inhibit enzymes in the small intestine that metabolize complex carbs |
| Incretin-based therapy: | two classes of agents that ↑ incretin activity: *and incretin mimetic: exenatide *a dipeptidyl peptidase-4 (DPP-4) inhibitor: sitagliptin |
| Actions of incretin hormones: | act in the GI tract to control blood glucose levels by: *enhancing secretion *suppressing glucagon secretion from liver *delaying gastric emptying which then slows carb/lipid absorption |
| What must be discussed when doing an assessment on a pt with diabetes? | *description of current s/s *pts understanding of DM *Psychosocial assessment *Nutrition *Activity/exercise *Meds *Monitoring *Physical assessment |
| When performing your physical assessment on a diabetes pts, it is important to ask questions regarding… | *hyperglycemia/hypoglycemia *illness/stress *vascular changes *Neuropathy *smoking hx |
| Recommended exercise regimen for someone living with DM? | moderate to vigorous activity 3x’s a week with resistance training 3x’s/week targeting all muscle groups. |
| Resistance training improves… | insulin sensitivity and is associated with greater cardiovascular risk reduction. |
| Nursing implementation that needs to be practiced when working with someone with DM… | *answer questions *encourage expression of feelings *address pts concerns *encourage adequate nutrition/fluid intake *encourage activity/exercise *administer meds |
| Type I diabetes mellitus results from… | damage to beta cells of pancreas where insulin is normally produced. |
| Insulin is needed to… | transport the glucose required by the body cells from the bloodstream to the individual cells to be used as energy |
| Without beta cells…. | no insulin would be produced and buildup of glucose in bloodstream occurshyperglycemia |
| A person living with type I diabetes must… | follow a prescribed diet and exercise program, perform glucose testing, and when hyperglycemia is present, test for ketones in urine. |
| Type II diabetes is an illness characterized by… | *abnormal beta cell function *resistance to insulin action *increased hepatic glucose production |
| Type II diabetes requires… | *prescribed diet/exercise program *wt loss to near-ideal body level *glucose testing *an oral antidiabetic agent or antihyperglycemic agent if diabetes cannot be controlled with diet/exercise |
| Recommended consumption of alcohol by someone living with diabetes… | no more than 2 drinks daily for men and 1 for women--> 12 oz. can beer/ 5 oz. wine/1.5 oz shots/considered 1 beverage of 15 g of alcohol. |
| Hypoglycemia | low blood sugar |
| Hypoglycemia can occur… | from too much insulin (sulfonylurea) *insufficient food intake *imbalances caused by such things as vomiting and diarrhea, excessive exercise. |
| Symptoms of hypoglycemia: | *nervousness *tremors *HA *apprehension *sweating *cold/clammy skin *blurred vision *lack of coordination *incoherence/coma/death |
| Treatment for hypoglycemia: | *2-4 oz. fruit juice or *1 c. skim milk *4 oz. nondiet softdrink *candy such as gumdropwait 15 minutes and then reassess situation and repeat if necessary. |
| IF the pt is unable to swallow the juices, ect., you should… | have a family member who is acquainted with pt administer glucagon or 20-50 mL of glucose 50% IV(only qualified person) |
| Hyperglycemia | elevated blood sugar |
| Hyperglycemia occurs when… | *glucose available in the body cannot be transported into the cells for use b/c of lack of insulin necessary for the transport mechanism |
| Hyperglycemia can be caused by… | *nonadherence *overeating *acute illness *acute infection |
| Symptoms of Hyperglycemia: | *HA *N/V *abdominal px *dizziness *rapid pulse *rapid/shallow respirations *fruity odor to breath from acetone. |
| Glucose levels higher than 240 mg/dL and ketones present in the urine are early indications of.. | diabetic ketoacidosis |
| Treatment of hyperglycemia | close monitoring of…*hydration status *administration of IV fluids *insulin *blood glucose *urine ketones *potassium levels. |
| Hyperglycemia usually occurs because of another cause, therefore… | the problem, often an infection must also be identified and treated to control it. |
| The best time to check blood glucose levels is… | *just before meals *1-2 hrs after meals *before bed *between 3-4 AM. |
| Be aware that confusion and lethargy are signs of __________________ but may sometimes be overlooked in older adults with the thought that slowness and confusion are just symptoms of “age”. | hypoglycemia |
| Teach pts to perform urine testing for ketones at least… | 4 times daily during times of stress, infection, or when s/s of hyperglycemia is suspected/present. |
| Ketone testing should be done when the blood glucose level is consistently… | *higher than 300 mg/dL *during pregnancy *when s/s of ketoacidosis are present (N/V, abd.px, ) |
| Suggest increasing what when ketones are present in urine? | fluid intake |
| A1C testing measures… | the % of hemoglobin that has been irreversibly glycosylated d/t hi blood sugar levels. |
| Complications associated with DM: | *Cardiovascular disease *Peripheral Vascular Disease *Visual Alterations *Blindness *Renal Disease *Infection *Neuropathies *Impotence *HTN |
| Cardiovascular Disease and DM: | pts with DM have ↑ risk of dying from thisaspirin therapy is primary prevention (enteric coded) in doses of 81-325 mg/daily taken by pts who are older than 30 |
| Peripheral Vascular Disease and DM: | pts with diabetes and this may have intermittent claudication, numbness/tingling and greater likelihood of foot infection |
| What pts should look for when assessing for PVD: | *color of skin->report cyanosis or reddish-blue discolorationinspect for signs of ulceration in extremities *TEMP:report paleness/coldeness *Edema *Limb px *Care:prevent ulcers, injury,infection in LE |
| Care of lower extremities: | *use lotion to prevent dryness *inspect feet daily for s/s skin breakdown or loss of sensation *cut toenails straight across |
| Visual alterations such as __________ ____________ are often noted in pts with elevated blood sugars… | blurred vision-->once hyperglycemia is controlled, blurred vision usually goes away. |
| Blindness caused by DM happens by… | changes (microangiopathies) in the small blood vessels in the eyes that cause retinal hemorrhages, degeneration of retinal vascular tissue, cataracts, and eventual blindness may occurregular eye exams allow for early tx. |
| Pts with DM are more susceptible to UTI’s as well as… | renal disease-->periodic monitoring of protein I urine determines the presence of renal disease. |
| Pts with both type I and type II diabetes who have microalbuminuria say that even a small reduction in ________ _________ has been shown to improve the glomerular filtration rate and reduce urinary albumin excretion rates… | protein intake |
| Any type of infection can cause a significant… | loss of control of DM-->pts need to carefully check themselves for s/s redness, tenderness, swelling, or drainage that may occur when there is a break in the skinalso immediately report and early s/s of infection such as sore throat/fever. |
| During an infection, the dosage of insulin may require… | an adjustment to compensate for a change in metabolic rate, diet, and exercise. |
| Neuropathies is a complication of the degeneration of nerves that sometimes occurs with DM, and it is important to ask the pt to… | describe sensations (numbness, tingling) in the extremities. |
| It is also important to expect the feet daily for… | blisters, ulcerations, ingrown toenails, or sores. Occasionally, pts may not be aware of these lesions d/t degeneration of the nerves. |
| Impotence is also a complication associated with… | DM |
| All pts with DM should have their blood pressure checked routinely to observe for… | hypertension which is also a complication of DM. The goal BP with antihypertensive therapy is lower than 130/80 mm Hg. |
| Drug Class: Insulins | |
| Insulin is a hormone produced in… | the beta cells of the pancreas |
| Insulin is required for… | the entry of glucose into skeletal and heart muscle and fat. |
| Insulin also plays a significant role in… | protein and lipid metabolism. |
| Insulin is not required for… | glucose transport into the brain, kidney, gastrointestinal or liver tissue. |
| The pancreas secretes insulin at a steady rate of… | 0.5 to 1 unit/hrreleased in greater quantities when blood glucose levels rise above 100 mg/dL. |
| Insulin deficiency reduces the rate of transport of… | glucose into cells, producing hyperglycemia. |
| Other metabolic reactions are also inhibited by the lack of insulin which results in… | gluconeogenisis, hyperlipidemia, ketosis, and acidosis. |
| Gluconeogenisis | conversion of protein to glucose |
| The three factors that are important in the use of insulin… | *onset *peak *duration |
| Onset | the time required for the medication to have an initial effect or action |
| Peak | when the agent will have the maximum effect |
| Duration | how long the agent remains active in the body. |
| Four types of insulin based on onset, peak, and duration: | *rapid-acting *short-acting *intermediate-acting *long-acting |
| Most rapid acting insulins are: | 3*Lispro *Aspart *Glulisineall usually administered within 15 minutes of eating a meal and act within 10 minutes of administration. |
| Consequently, these newer shorter acting insulins are primarily used to control… | hyperglycemia associated with meals without having longer lasting effects with the potential of hypoglycemia. |
| What type of insulin is the only one approved to be injected by both IV and subq routes of administration… | regular insulin-->usually administered 30-60 min. before a meal. |
| When a person is taking insulin, what would cause hypoglycemia? | insulin overdose or decreased carbohydrate intake. |
| Metformin | class of antihyperglycemic agent known as biguanides. |
| Action of Metformin | *↓ hepatic glucose production by inhibiting glycogenolysis and gluconeogenisis *↓absorption of glucose in small intestine *↑insulin sensitivity in peripheral muscle and fat cells |
| Insulin must be present for metformin to be active, and therefore is not… | effective in type I diabetes. |
| Metformin has two other beneficial effects: | *does not cause wt. gain *produces modest decrease in concentrations of serum triglycerides LDL and a moderate increase in HDL. |
| Dosage form of Metformin… | PO |
| Common side effects of metformin | *N/V *Anorexia *Abdominal Cramps *Gas |
| Acarbose (Precose) | drug class: Alpha-Glucosidase Inhibitor Agent |
| Acarbose is an enzyme inhibitor that… | inhibits pancreatic alpha-amylase and gastrointestinal alpha-glucoside hydrolase enzymes used in the digestion of sugars. |
| In pts with diabetes, the use of acarbose results in… | delayed glucose absorption and a lowering of postprandial hyperglycemia. |
| Acarbose is used as an adjunct to diet to… | lower blood glucose levels in pts with type II diabetes. |
| Acarbose has a particular advantage in that…. | It does not cause hypoglycemia (it can also be used with metformin to help lower blood glucose levels because they work by different mechanisms) |
| Route of Acarbose | PO |
| Common side effects of Acarbose | Abdominal cramps, diarrhea., gas |
| Exenatide (Byetta) | Drug class: Incretin mimetic agent |
| Exenatide is a synthetic version of the naturally occurring… | GLP-1 hormone-->it mimics the actions of this incretin hormone for self-regulating glycemic control |
| Action of exenatide… | results in an increase in serum insulin and reduction in glucose concentrations. |
| Use of exenatide… | used as additional therapy to reduce elevated fasting and postprandial hyperglycemia in pts with type II diabetes who could also be taking metformin and have not achieved adequate glycemic control. |
| Particular benefits of exenatide… | *enhances insulin secretion only in presence of hyperglycemia *insulin secretion decreases as the blood glucose level approaches normal levels. |
| Rout of exenatide… | subq, thigh, abdomen, upper arm5 mcg/dose administered twice daily at any time during the 60-min. period before the morning and evening meals. **DO NOT administer after a meal. |
| Common side effects of exeanide | N/V/D |
| Sitagliptin (Januvia) | Drug class: Dipeptidyl Peptidase-4 Inhibitor |
| Sitagliptin actions… | prolongs the life of active GLP-1 and GIP, prolonging the beneficial effects of the incretin hormones in reducing hyperglycemia |
| Use for sitagliptin… | as a monotherapy or additional therapy to reduce elevated fasting and postprandial hyperglycemia in pts with type II diabetes who also could be taking metformin but have not achieved adequate glycemic control. |
| Benefits of sitagliptin… | *it enhances insulin secretion only in presence of hyperglycemia *insulin secretion decreases as blood glucose levels approach normal levels again. |
| Route of sitagliptin: | PO 100 mg tab once daily w/ or w/o food. |
| Common side effects of sitagliptin: | *Nausea *abdominal cramps *diarrhea *HA *URI *nasopharyngitis |
| Glucagon: | Drug class: Antihypoglycemic Agents |
| Glucagon is a hormone secreted by the… | alpha cells of the pancreas that breaks down stored glycogen in the liver to glucose. *also aids in converting amino acids to glucose |
| Glucagon is dependent on the presence of what for its action?… | glycogen |
| Use of glucagon… | to tx hypoglycemic rxns in pts with diabetes mellitus |
| Route of glucagon… | Subq, IM, IVadminister 1 mg and response should be observed within 15-20 min. |
| Common side effects of glucagon… | N/V |
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