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Drugs used for Diabetes Mellitus 1 Introduction There are 2 types of diabetes mellitus: Type 1: Insulin-dependent diabetes mellitus (IDDM) Destruction of pancreatic beta cells Is the result of an autoimmune process Type 2: Non-insulin dependent diabetes mellitus (NIDDM) Results from a combination of insulin resistance and altered insulin secretion 2 Characteristics of Type 1 & Type 2 Diabetes Mellitus Age of onset Acuteness of onset Presenting features Body habitus Control of diabetes Ketoacidosis Insulin requirement Control by oral agents Control by diet alone Complications Type 1 Type 2 Usually < 25 years Usually sudden Polyuria, polydipsia, polyphagia, acidosis Often thin Difficult Frequent Always Never Never Frequent Usually > 40 years Usually gradual Often asymptomatic Usually overweight Easy Seldom, unless under stress Often unnecessary Frequent Frequent Frequent 3 Oral Antidiabetic Drugs For the treatment of type 2 (non-insulindependent) diabetes mellitus Use only after diet modification & exercise fail to produce glycemic control Should be used to augment the effect of diet & exercise, not to replace them 4 Summary of treatment targets for cardiovascular risk factor intervention in diabetic patients Evidence-based targets for managing cardiovascular risk factors Fasting blood glucose </= 6mmol/l HbA1c < 7% Total cholesterol < 5mmol/l LDL cholesterol < 3 mmol/l Blood pressure threshold for intervention 140/90mmHg -Target for treatment </= 140/80mmHg -if significant proteinuria </= 125/75mmHg Recent guidelines recommend statin and low-dose aspirin treatment where the 10year coronary heart disease ridk is less than 15% -before adding aspirin ensure blood pressure is controlled -combination antihypertnsive treatment is necessary in the majority of patients to achieve blood pressure targets 5 -other recommendations include HDL>1.2mmol/l and fasting triglycerides<1.7mmol/l Sulphonylureas Act mainly by augmenting insulin secretion May also increase tissue response to insulin Effective only when some residual pancreatic beta-cell activity is present Considered for patients who are not overweight, or in whom Metformin (Glucophage®) is contraindicated or not tolerated 6 Sulphonylureas (Cont‘d) Short-acting: Tolbutamide: 0.5-1.5 g daily in divided doses, with or immediately after breakfast; Max: 2 g daily Gliclazide (Diamicron®): 40-160 mg daily in divided doses, with breakfast; Max: 320 mg daily Intermediate-acting: Glipizide (Minidiab®): 2.5-15 mg daily in divided doses, before breakfast; Max: 20 mg daily 7 Sulphonylureas (Cont‘d) Long-acting: Chlorpropamide (Diabinese®): 250 mg daily with breakfast; Max: 500 mg Glibenclamide (Daonil®): 5 mg daily with or immediately after breakfast; Max: 15 mg daily Glimepiride (Amaryl®): 1-4 mg daily shortly before or with first main meal; Max: 4 mg daily 8 Sulphonylureas (Cont‘d) Contraindications: Severe hepatic and renal impairment Breast-feeding and pregnancy Elderly (Chlorpropamide, glibenclamide) Adverse effects: Nausea, vomiting, diarrhoea and constipation Increased appetite and weight gain Hypoglycaemia Hypersensitivity 9 Biguanides Decreasing gluconeogenesis in the liver Increase peripheral utilisation of glucose by muscle Acts only in the presence of endogenous insulin Metformin (Glucophage®) is the only available biguanide Is antihyperglycemic, not hypoglycemic Recommended for obese or insulin resistant diabetic patients 10 Biguanides (Cont’d) Metformin: 500 mg bd-tid; Max: 3 g, usually limit to 2 g daily Contraindications: Hepatic or renal impairment (must withdraw) Ketoacidosis Predisposition to lactic acidosis: severe dehydration, which is most likely to occur in patients with renal impairment 11 Biguanides (Cont’d) Contraindications (Cont’d): Infection, shock, trauma, heart failure, respiratory failure, recent myocardial infarction, severe peripheral vascular disease Hepatic impairment, alcohol dependency Use of iodine-containing x-ray contrast media (do not restart melformin until renal function returns to normal) Pregnancy and breast-feeding 12 Biguanides (Cont’d) Adverse effects: Decreased appetite Nausea, vomiting and diarrhoea Lactic acidosis (rarely) Decreased absorption of vitamin B12 and folic acid Allergic skin reactions 13 Biguanides (Cont’d) Nursing alerts: Take metformin with meals and increase dosage slowly to minimise GI adverse effects Lactic acidosis, characterised by drowsiness, malaise, bradycardia and hypotension is a rare but serious adverse effect. Since this is a medical emergency, report to the physician immediately if suspected 14 Alpha glucosidase inhibitor Delay the digestion & absorption of starch & sucrose by inhibition of intestinal alpha glucosidase in the intestine Acarbose (Glucobay®) 50-100 mg tid; Max: 200 mg tid 15 Alpha glucosidase inhibitor (Cont’d) Contraindications: Pregnancy and breast-feeding Inflammatory or malabsorptive intestinal disorders Hepatic impairment Severe renal impairment 16 Alpha glucosidase inhibitor (Cont’d) Adverse effects: Flatulence, soft stools, diarrhoea, abdominal distention and pain Liver dysfunction 17 Alpha glucosidase inhibitor (Cont’d) Nursing alerts Tablets should be taken with first mouthful of food Absorption of sugar (sucrose) is blocked by acarbose. When hypogylcaemia occurs, only glucose should be given 18 Metglitinides Stimulate insulin release Rapid onset of action & short duration Taken shortly before meals 19 Metglitinides (Cont’d) Repaglinide (NovoNorm®): 500 mcg – 4 mg daily within 30 min before main meals; Max: 16 mg daily Nateglinide: 60 mg tid within 30 min before main meals; Max: 180 mg tid 20 Metglitinides (Cont’d) Contraindications: Ketoacidosis Pregnancy and breast-feeding Severe hepatic impairment (for repaglinide) 21 Metglitinides (Cont’d) Adverse effects: Hypoglycaemia Hypersensitivity reactions including pruritus, rashes and urticaria Abdominal pain, diarrhoea, constipation, nausea and vomiting (repaglinide) Nursing alert: Administration must always be associated with meals 22 Thiazolidinediones Also known as Glitazones Reduce peripheral insulin resistance by enhancing uptake of glucose by skeletal muscle cells Rosiglitazone (Avandia®): 4 mg daily in combination with metformin or a sulphonylurea; Max: 8 mg daily when with metformin Pioglitazone (Actos®): 15-30 mg daily 23 Thiazolidinediones (Cont’d) Contraindications: Hepatic impairment History of heart failure, combination of insulin Pregnancy and breast-feeding 24 Thiazolidinediones (Cont’d) Adverse effects: GI disturbances, headache, anaemia Weight gain Oedema Hypoglycaemia (less common for Pioglitazone) Liver dysfunctions (rare) 25 Thiazolidinediones (Cont’d) Nursing Alerts: Monitor liver function before treatment, then every 2 months for 1 year and periodically thereafter Seek immediate medical attention if symptoms such as nausea, vomiting, abdominal pain, fatigue & dark urine develop Discontinue if jaundice occurs Monitor closely for oedema & other signs of congestive heart failure 26 Non-oral antidiabetic drugs Insulin: Supplement the insulin secreted by pancreas Promote uptake of glucose in muscle Facilitate conversion of glucose to glycogen in liver, inhibit gluconeogenesis & glycogenolysis in liver 27 Actions of Insulin Glucose transport into muscle & fat cells. Increased glycogen synthesis. Inhibition of gluconeogenesis. Inhibition of lipolysis & increased formation of triglycerides. Stimulation of membrane-bound energydependent ion transporters (e.g. Na/K ATPase). Stimulation of cell growth 28 Insulin (Cont’d) They are divided into short, intermediate & long-acting preparations: Short-acting: Neutral/soluble insulin E.g. Actrapid®HM, Insulin Lispro E.g. Humulin R® Humalog® Insulin Aspart E.g. NovoRapid® 29 Insulin (Cont’d) Intermediate-acting: Isophane insulin E.g. Protaphane®HM, Humulin N® Insulin zinc suspension E.g. Monotard®, Humulin L® 30 Insulin (Cont’d) Long-acting: Crystalline insulin zinc E.g. Ultratard®HM Insulin glargine E.g. Lantus® 31 Insulin (Cont’d) Mixed Insulins: Biphasic isophane insulin 30% E.g. Mixtard ®30, Humulin ®70/30 20% soluble insulin/70% isophane insulin soluble insulin/80% isophane insulin E.g. Mixtard ®20 32 Insulin (Cont’d) Dose: Given through subcutaneous injection According to the requirements Short-acting: Usually inject 15-30 min before meals Intermediate- & long-acting: Once or twice daily Can be given in conjunction with short-acting insulin 33 Insulin Formulations Duration of action Examples Peak effect (h) Duration of action (h) Short Insulin Injection (soluble insulin) 2h-4h 6h-12h Intermediate Isophane insulin Insulin zinc suspension (amorphous) 5h-12h 3h-6h 12h-24h 12h-16h Long Insulin zinc suspension (crystalline) 5h-14h 24h-30h Mixed Variable portions of soluble & isophane insulins 2h-10h 3h-8h 18h-20h 16h-24h 34 Insulin (Cont’d) Precautions: may decrease requirements in renal or hepatic impairment, some endocrine disorders, coeliac disease 35 Insulin (Cont’d) Nursing Alerts: Teach patients how to prepare & use the subcutaneous (SC) injection, and the usual areas used for SC injection including abdomen, thigh & upper arm Rotate the injection site within the general area employed. Allow about 1 inch between sites 36 Insulin (Cont’d) Nursing Alerts (Cont’d): Storage Penfill Cartridges not in use should be stored between 2-8 ℃ Cartridges used in the pen or carried as spare can be used for up to one month Vial Vials not in use should be stored between 2-8 ℃ Vial in use can be kept at room temp for 6 weeks (Novo Nordisk) Vials in use can be kept at room temp for 28 days (Lilly) 37 Hypoglycaemia Nursing Alerts: Observe for and teach the patient about signs and symptoms of hypoglycaemia Tachycardia, palpitations Sweating Nervousness, headache, confusion, drowsiness Fatigue Rapid treatment is required Patient is conscious: oral glucose should be given Patient is unconscious: IV glucose should be used 38 39 Drugs that affect the gastrointestinal system 40 Introduction Drugs used in gastrointestinal system or digestive disorder primarily exert their action by altering GI Secretion Absorption Motility They may act systemically or locally in the GI tract 41 Physiologic and pathologic (i.e. inflammatory) prostaglandins Cell activated by physical, chemical, or hormone stimuli Traditional NSAIDs Block COX-1 and COX-2 enzymes Arachidonic acid COX-2inhibitor NSAIDs Block COX-2 enzyme Cyclooxygenase-1 (COX-1) Cyclooxygenase-2 (COX-2) Physiologic prostaglandins Pathologic prostaglandins •GI protection (↓gastric acid,↑mucus production, maintain blood flow to mucosa) •Renal protection (help maintain blood flow and function) •Regulate smooth muscle tone in blood vessels (e.g., vasodilation) and lungs (e.g., bronchodilation) •Regulate blood clotting •Inflammation Vasodilation, ↑Capillary permeability •Edema Pain •Leukocytosis •Activatye white blood cells to release inflammatory cytokines 42 Antacids & Simethicone Antacids Drugs that neutralize or reduce the acidity of stomach & duodenal contents by combining with HCl & producing salt & water Relieve symptoms in dyspepsia, gastrooesophageal reflux disease (GERD), peptic ulcers Simethicone Added to antacids as an antifoaming agent to relieve flatulence 43 Antacids & Simethicone (Cont’d) Antacids Aluminium Hydroxide (500mg tablet /6% suspension) 1-2 tablets chewed qid Magnesium trisilicate (Mixture) 5% BP Mixture: 10ml tid po 44 Antacids & Simethicone (Cont’d) Antacids combination products: Triact tablet Al(OH)3 Dried Gel 200 mg & Mg(OH)2 150 mg & Simethicone 25 mg Chew 1-2 tab q4-6h Gastrocaine suspension Oxethazaine 10mg, Al(OH)3 Dried Gel 300mg, Mg(OH)2 100mg in 5 ml Alumag suspension Al(OH)3 & Mg Trisilicate 45 Antacids & Simethicone (Cont’d) Antacids combination products (Cont’d): Gelusil tablet Mg Trisilicate+ Dried Aluminium Hydroxide gel Mylanta tablet / suspension CaCO3 & Mg(OH)2 Simethicone Dimethylpolysiloxane (Gasteel® 40 mg tablet) 46 Antispasmodics Relax smooth muscle Relieve GI smooth muscle spasm Include antimuscarinics & others 47 Antispasmodics (Cont’d) Antimuscarinics: Hyoscine Butylbromide (Buscopan®) Adult: 20 mg qid po; Child: 10 mg tid po Propantheline bromide 15 mg tid at least 1 hr before meals & 30 mg at night; Max: 120 mg daily Not recommended for children 48 Antispasmodics (Cont’d) Side effects: Constipation Urinary urgency and retention Dry mouth Transient bradycardia 49 Antispasmodics (Cont’d) Others: Mebeverine HCl (Duspatalin®) Adult & child over 10 years: 135-150 mg tid preferably 20 min before meals Peppermint oil (0.2 ml capsule) 1-2 capsules tid Not recommended for children under 15 years 50 Motility stimulants Dopamine antagonists Stimulate gastric emptying & small intestinal transit Enhance strength of oesophageal sphincter contraction Sometimes used in non-ulcer dyspepsia Useful in non-specific & in cytotoxicinduced nausea & vomiting (N&V) 51 Motility stimulants (Cont’d) Domperidone (Motilium®) N&V: adult: 10-20 mg q4-8h Child: 200-400 mcg/kg q4-8h Functional dyspepsia 10-20 mg tid before food & 10-20 mg at night Not recommended for children 52 Motility stimulants (Cont’d) Metoclopramide (Maxolon®) Adult: 10 mg tid 15-19 yrs under 60 kg: 5 mg tid 1-14 yrs: 1 mg bd to 5 mg tid depend on age Diagnostic procedures: Adult: 10-20 mg five to ten min before exam Child: 1-5 mg depends on age 53 Motility stimulants (Cont’d) Side effects: May raised prolactin concentration Rashes & other allergic reactions Acute dystonic reaction reported Extrapyramidal effects (Metoclopramide more prominent) 54 Motility stimulants (Cont’d) Nursing Alert: For patients under 20 yrs Metoclopramide should be used restricted to severe intractable vomiting of known cause, vomiting of radiotherapy & cytotoxics, aid to GI intubation, pre-medication Dose based on basis of body-weight 55 Ulcer-healing drugs Peptic ulceration commonly involves the stomach, duodenum & lower oesophagus Due to imbalance between cell-destructive & cell-protective effects Helicobacter pylori & NSAIDs can weaken the defences Relapse is common when treatment ceases 56 Ulcer-healing drugs (Cont’d) Include several groups of drugs H2-receptor antagonists Chelates & complexes Prostaglandin analogues Proton pump inhibitors 57 H2-receptor antagonists Histamine acts on receptors located on parietal cells to increase production of HCl Block histamine H2-receptors Heal gastric & duodenal ulcers by reducing gastric acid output Relieve gastro-oesophageal reflux disease May occasionally be used for patients with frequent severe recurrences & for the elderly who suffer ulcer complications 58 H2-receptor antagonists (Cont’d) Cimetidine Famotidine 20-40 mg bd Not recommended for children Nizatidine Adult: 400 mg bd; Max: 2.4 g daily (rarely) Child: 20-30 mg/kg daily in divided dose 150-300 mg bd Not recommended for children Ranitidine Adult: 150 mg bd Child: 2-4 mg/kg bd; Max: 300 mg daily 59 H2-receptor antagonists (Cont’d) Side effects: Diarrhoea & other GI disturbances Altered liver function tests Headache, dizziness, rash 60 H2-receptor antagonists (Cont’d) Nursing Alerts: Cimetidine is a CYP450 inhibitor, avoid in patients on warfarin, phenytoin & theophylline Patients may experience dizziness or drowsiness during early therapy, especially in the elderly. Assistance may be required for ambulatory activities 61 Chelates & complexes Sucralfate Complex of AL(OH)3 & sulphated sucrose Minimal antacid properties Protect the mucosa from acid-pepsin attack in gastric & duodenal ulcers 2 g bd or 1 g qid 1 hr before meals & at bedtime; Max: 8 g daily Not recommended for children 62 Chelates & complexes Side effects: Constipation, diarrhoea, gastric discomfort Dry mouth Headache, nausea Hypersensitivity reactions 63 Prostaglandin analogues Misoprostol Synthetic prostaglandin analogue (Prostaglandin E) Antisecretory & protective properties Inhibit gastric acid secretion Increase mucus & bicarbonate secretion Promote healing of gastric & duodenal ulcers 64 Prostaglandin analogues (Cont’d) Dose: 800 mcg daily in 2-4 divided doses For prophylaxis of NSAID-induced gastric & duodenal ulcer 200 mcg 2-4 times daily Not recommended for children 65 Prostaglandin analogues (Cont’d) Side effects: Diarrhoea (may require withdrawal) Abdominal pain, dyspepsia, flatulence, nausea & vomiting Abnormal vaginal bleeding Nursing Alerts: Incidence of diarrhoea may be lessened by taking dose right after meals 66 Prostaglandin analogues (Cont’d) Nursing Alerts (Cont’d): Manufacturer advises not to be used in women of child-bearing age unless the pateint requires NASID therapy & is at high risk of complications from NSAID-induced ulceration Patients should take effective contraceptive measures & be advised the risks of taking misoprostol if pregnant 67 Proton pump inhibitors Inhibit gastric acid by irreversibly blocking the hydrogen-potassium adenosine triphosphatase enzyme system (“proton pump”) of gastric parietal cell Indicated for gastric & duodenal ulcers & gastro-oesophageal reflux disease Suppress gastric acid more strongly & for a longer time than H2-receptor antagonists 68 Proton pump inhibitors (Cont’d) Omeprazole Esomeprazole 15-30 mg daily Not recommended for children Pantoprazole 20-40 mg daily Not recommended for children Lansoprazole Adult: 10-40 mg daily Child over 2 yrs: 0.7-1.4 mg/kg daily; Max: 40 mg daily IV injection or infusion is not recommended for children 20-40 mg daily Not recommended for children Rabeprazole 10-20 mg daily Not recommended for children 69 Proton pump inhibitors (Cont’d) Side effects: GI disturbances Headache Hypersensitivity reactions 70 71 Unawareness of drug’s brand name Patient has a documented allergy to Zyloric® Allopurinol was prescribed to this patient The doctor prescribing was not aware that Zyloric® was the brand name for Allopurinol 72 Tips Check out the contents of the preparation if brand name is used before prescribing, dispensing or administration 73 74 Improper Drug Abbreviation IV Mitoxantrone was prescribed The abbreviation ‘MTX’ was put on the label An injection of Methotrexate was prepared instead according to the abbreviation on the label Methotrexate was administered to the patient as a result 75 Tips Write drug name in full Do not use unauthorised abbreviations Cross check the dose & name of the drug before preparation & administration 76 Repeated Pethidine Injection Patient was given a Pethidine injection at A&E via a verbal order Nurse forgot to record this order in MAR Prescribing Dr had not confirmed the verbal order in the prescription A second dose of Pethidine was administered in the ward Patient collapsed as a result of overdose of Pethidine 77 Tips Pethidine is a Dangerous Drug & should not be ordered through verbal orders For other non-DD, give a verbal order only in emergency & exceptional circumstances Record the verbal instruction in the MAR immediately as ‘verbal order’ After writing down the instruction, read back the details to the Dr for double checking 78 Self-medication of Paracetamol Patient was transferred from medical ward to ICU with high plasma level of Paracetamol Patient was treated with N-acetylcysteine infusion as an antidote Patient later admitted that she had taken approximately 15 tabs of Paracetamol (private medications) in the medical ward to relieve her leg pain 79 Tips Put patients’ brought-in medicines into safe custody Do not administer the patient’s own medicines in hospital unless they have been positively identified, specifically prescribed & when supplies are not immediately available inside the hospitals 80 Glibenclamide or Citalopram An in-patient presented with severe hypotension & vomiting A review of the MAR revealed that Daonil® (Glibenclamide) was written right above the prescription for Citalopram in pencil Upon investigation, it was discovered that some nursing staff gave Citalopram to the patient whilst others gave Glibenclamide 81 Tips Familiarise with the medication &/or the patient If there is uncertainty or confusion about a particular prescription, always consult with the prescriber Adequate communication between staff is the key to preventing errors 82 Wrong Drug Name Martindale 1 drop tds both eyes was prescribed Martindale is the name of the drug company that makes the eye drops 83 Tips Prescribe in generic rather than trade name as trade names don’t usually give indications of their constituents 84 Inappropriate Drug Dosage A 10 month old baby was prescribed Cotrimoxazole suspension 20mg bd Cotrimoxazole is a combination product containing Sulphamethoxazole 200mg & Trimethoprim 40mg per 5ml 240mg per 5 ml & 20mg = 0.42ml It was later clarified that the dose 20mg refers to the Trimethoprim component Thus 120mg cotrimoxazole should have been prescribed 85 Tips Should clearly specify drug dosage especially for combination product Clarify with prescriber if in doubt 86