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Antidiabetic and Hypoglycemic Agents Lilley Pharmacology Text: Chapter 30 Original Text modified by: Anita A. Kovalsky, R.N., M.N.Ed., Professor of Nursing Original PPT by: Professor Pat Woodbery, ARNP, CS Syllabus Assistive Guides: • Prototype Drugs: Antidiabetic: pg. 33 • Learning Questions: pg. 34 Review of Glossary Terms: Lilley pg. 468 • • • • • • • • Diabetes mellitus Diabetic ketoacidosis Glucagon Glucose Glycogen Glycogenolysis Hyperglycemia Hypoglygemia • • • • • • • • • • Insulin Ketones Neuuropathy Nephropathy Polydipsia Polyphagia Polyuria Retinopathy Type 1 diabetes mellitus Type 2 diabetes mellitus What is the Purpose of Antidiabetic & Hypoglycemic Agents? • Treat Diabetes • Lower Blood Sugar ANTIDIABETIC & HYPOGYLCEMIC AGENTS • Insulin • Oral Agents Endogenous Insulin • Protein Hormone • Secreted Beta CellsPancreas • 1-2 Units per hour • 4-6 Units per meal – 1 units x 24hrs + – 4 units x 3 meals • Total 36 Units per day What Does Insulin Do? • Metabolism of Carbohydrates, Fats, Protein Pancreas • Endocrine • Exocrine • Islands of Langerhans secretes 3 hormones: – Glucagon (alpha cells) – Insulin (beta cells) – Delta cells - somatostatin Normal Insulin Production • Pancreas releases insulin into the bloodstream • Blood carries it to all cells in the body Normal Insulin Profiles Basic Requirements What happens when you eat After a meal Just to function normally the body needs a constant level of sugar in the blood and a background level of insulin the blood sugar rises and extra insulin is needed Normal Insulin Profiles Daily Requirements Breakfast Blood sugar Mealtime insulin Background insulin Lunch Evening Meal Insulin Lowers Blood Sugar • Decreases breakdown of glycogen in the liver Insulin Decreases the breakdown of fat to fatty acids in adipose tissue Insulin Decreases protein breakdown in muscle Exogenous Insulin • Commercial Insulin – Has the same effect as endogenous insulin Normoglycemia!!! • We are trying to mimic action of pancreas by giving Commercial Insulin (Exogenous Insulin) in clients who cannot produce their own insulin!!!!! What Type of Patient Requires Exogenous Insulin? • Patients who’s Beta Cells become – Overwhelmed: Disease – Exhausted: Stress or Drugs – Destroyed: Virus, Cancer Type 1 Diabetes Mellitus Etiology • Results from an autoimmune disorder that destroys pancreatic beta cells • Also called Insulin Dependent Diabetes Mellitus IDDM Type 1 Diabetes Signs and Symptoms • Disorder of Carbohydrate Metabolism – Glucosuria – Polydipsia – Polyuria – Polyphagia Insulin Treatment • Insulin preparations – Onset of action – Duration of action – Degree of purity – Source Insulin Preparations All insulin in UK is 100 units/ml • Short Acting – Regular- Humulin R ALWAYS USED FOR SLIDING SCALE COVERAGE!!!!!! • Intermediate Acting – NPH-Humulin N • Mixtures – 70/30= 70 Units NPH & 30 Units Regular • Long Acting – Lantus Short-Acting Insulin • • • • • Soluble Clear Onset 30 minutes Peak 1 - 3 hours Duration up to 8 hours Intermediate Acting Insulin • Crystals in suspension (need re-suspending) • Cloudy • NPH or Isophane (NPH = Neutral Protamine Hagedorn) • Onset 1 1/2 hours • Peak 4 - 12 hours • Duration up to 24 hours Pre-mixed Insulin • Pre-mixed combinations of short and intermediate acting insulins (biphasic) • Cloudy (needs re-suspending) • 5 different combinations (10, 20, 30, 40, 50) – e.g. 30/70 Mixture = 30% fast acting + 70% intermediate acting • Onset 30 minutes • Peak 2 - 8 hours • Duration up to 24 hours Long-Acting Insulin Glargine (Lantus) Synthetic Human Insulin – Do not mix with any other insulin – Long Acting Up to 24 hours – NO PEAK – Given at BEDTIME Species of Insulin • Human - Genetically engineered using either yeast (pyr) or e.coli (prb) • Animal – Beef - Increased incidence of allergic problems – Pork - Less antigenic than beef (Kurtz et al. 1980) - Available as purified insulin Storage of Insulin • Before use Store in fridge • In-use vials Store in fridge (3 months) Out of fridge at max 25 C (4-6 weeks) • In-use pens Out of fridge at max 25 C (4 weeks) Insulin Delivery • Insulin devices (pens) – Durable (replace insulin cartridge) – Disposable (no need to replace cartridge) • Insulin vials and syringes Insulin Devices Advantages Disadvantages • Improved dose accuracy • More convenient • Cannot mix insulin in a free-mixing regimen – Easy to use – Portable – Quick and discreet • May improve client selfmanagement/compliance • Preferred by patients Who is a good candidate for an Insulin Pump? Insulin Pumps • • • • • • Continuous subcutaneous insulin infusion (CSII) Battery operated Programmable computer Basal insulin throughout day Bolus insulin before meals Needles/catheters changed every 2-3 days Effects of EXERCISE on Blood Glucose • By increasing the uptake of glucose by body muscles, exercise does what to Blood Glucose? Lowers it by increasing the number of insulin receptors!!!! Effects of ILLNESS on Blood Glucose • • • • • • Fever Flu Infections N&V Surgery Sunburn Being sick usually makes blood sugar HIGH! • Stress increases Blood Glucose • Never OMIT normally ordered insulin!!! Interventions for ILLNESS • Check Blood Glucose q4 hr >240? Check for ketones!!! • Ketones: call MD!!!! • Sick Day Guidelines… DIABETES COMPARISON TYPE 1 TYPE 2 • Autoimmune Process: Beta cells destroyedInsulin deficiency • Has no insulin • Idiopathic • Genetic predisposition • < Age 30 • Insulin resistancehas some insulin • Obesity is risk factor • Physical inactivity • Genetic predisposition • Adult onset Type 2 Diabetes Etiology • There is abnormally high level of glucose • Pancreas does produce insulin • Body resists the insulin’s effects As a result, the glucose circulating cannot enter the cells, so that the glucose cannot be used for energy!!!!!! Therefore, there is INSULIN RESISTANCE!!! Insulin is like the key that cannot get fit into the lock (cells)!!!! Insulin Resistance: Causes and Associated Conditions Aging Obesity and inactivity Medications Rare disorders Genetics INSULIN RESISTANCE Type 2 diabetes Hypertension ©1998 PPS PCOS Atherosclerosis Dyslipidemia C Type 2 Diabetes Signs and Symptoms • • • • • • • Hyperglycemia Polyuria Polydipsia Blurred vision Fatigue Paresthesias Skin infections Type 2 Diabetes • 80% are obese • 10% non-obese • 10% unstable: may look more like a Type 1 Diabetic Oral Agents • Sulfonylureas • Biguanides • Glitazones Sulfonylureas • Increase secretion of insulin in the pancreas Sulfonylureas Side Effects • Hematologic effects • GI effects • Hypoglycemia Biguanides • Increase the use of glucose by muscles and fat cells Biguanides Side Effects • GI • Metallic Taste • Decreased Vitamin B12 • Rare Lactic Acidosis • DOES NOT CAUSE Hypoglycemia Glitazones • Decrease Insulin Resistance – Stimulate receptors on muscle, fat and liver cells – Increase effectiveness of circulating insulin Glitazones Side Efects • Weight Gain • Hepatic Toxicity Nursing Assessment for All Diabetic Clients • What time will the insulin/oral agent act? • What carbohydrates are available? • Observe for Therapeutic Effects • What are the Adverse Effects? Lab Assessment for All Diabetic Clients • Blood tests 1. Fasting Blood Glucose Test (Cavenaugh pg. 105) 2. Blood Glucose Monitor Systems 2. Oral Glucose Tolerance Test (Cavenaugh pg. 109) 3. Glycosylated Hemoglobin Assays (Cavenaugh pg. 112) 4. Glycosylated Serum Proteins and Albumin (Cavenaugh pg. 114) Checking Blood Glucose • • • • CBGs AccuChecks Glucometer Glucoscan Hemoglobin A1c • A blood test that shows glucose levels for the past 3 months • No preparation needed i.e. fasting, etc. Values for HbA1c • Non-diabetic <6 % • Diabetic with good control <7 % • Diabetic out of control >8 % ADA Treatment Goals • Hgb A1C maintained at 7% or below • Premeal blood glucose level 70 to 110mg/dl • Blood glucose at bedtime 100-140mg/dl HbA1c Predicts CHD in Type 2 CHD mortality Incidence (%) in 3.5 years All CHD events Incidence (%) in 3.5 years 25 20 15 10 5 0 25 20 15 10 5 0 Low <6% Middle High 6-7.9% >7.9% HbA1c Low <6% Middle High 6-7.9% >7.9% HbA1c Client Teaching related to Antidiabetic & Hypoglycemic Therapy • Observe for Therapeutic Effects • Observe for Adverse Effects • Observe Injection Site • Signs of Hypoglycemia • (see handout) • Nursing Interventions • Signs of Hyperglycemia • (see handout) • Nursing Interventions Management of Hypoglycemia • Hypoglycemic protocol 1. Mild hypoglycemia (BG < 60 and symptomatic) - 10 to 15g of carbohydrate - Recheck BG in 15minutes 2. Moderate (BG < 40 and symptomatic) -15 to 30g of rapidly absorbed CHO 3. Severe (BG < 20 and unable to swallow) - 1mg of glucagon IM/SQ or amp of D50 IVP Treatment for DKA • • Frequent assessment of client: LOC, V/S, blood glucose levels, fluid and electrolyte status Correct fluid volume deficit 1. 2. 3. 1 liter of isotonic saline over 1 hour 1 liter of hypotonic saline over 6 to 8 hrs 1 liter of hypertonic solution (D51/2NS) over 8 to 12 hrs. Drug therapy for DKA • Insulin therapy: lower BG by 75-150mg/dl/hr 1. 2. • Regular insulin IV bolus dose of .1u/kg followed by IV drip of .1u/kg/hr. SQ insulin when client can eat and ketosis has ended. Electrolyte replacement 1. 2. Potassium Bicarbonate THE END!!!!
