Chapter 41 Drug Therapy for Diabetes Mellitus Diabetes

Chapter 41 Drug Therapy for Diabetes Mellitus

Diabetes Mellitus • Classifications – Type 1 – Type 2 • Characterized by hyperglycemia

Diabetes Mellitus (cont. ) • Type 1 – Common chronic disorder of childhood – Autoimmune disorder that destroys pancreatic beta cells difficult to control – Sudden onset between ages 4 and 20 years – High incidence of complications – Requires exogenous insulin administration Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Type 2 – Characterized by hyperglycemia and insulin resistance – Historically, onset after age 40 years • Increasing prevalence among children and teens – Gradual onset with less severe symptoms – 90% of people with diabetes have type 2 disease Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Type 2 (cont. ) – Risk factors for development • Presence of metabolic syndrome (estimated greater than 50 million Americans) • Abdominal obesity low HDL • Hypertriglyceridemia • Hypertension and/or impaired fasting glucose Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Type 2 (cont. ) – Ethnicities at high risk for type 2 development • African Americans (13. 3%) • Hispanics (greater than 13. 9%) • Commonly undiagnosed • Native Americans/Alaskans (12. 8%) • Caucasians (8. 7%) Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Chronic, systemic disease characterized by – Metabolic abnormalities – Vascular abnormalities • Major clinical manifestation of metabolic abnormalities – Hyperglycemia • Fasting blood glucose levels greater than 126 mg/d. L Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Major clinical manifestation of metabolic abnormalities (cont. ) – Impaired fasting glucose (IFG) (i. e. , prediabetes) • Fasting blood glucose levels between 100 and 125 mg/d. L • Recommended blood glucose level for those with diabetes – 80 to 120 mg/d. L before a meal – 100 to 140 mg/d. L HS Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Major clinical manifestation of metabolic abnormalities (cont. ) – Macrovascular abnormalities • Hypertension • Myocardial infarction • Stroke • Peripheral vascular disease (PVD) Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Major clinical manifestation of metabolic abnormalities (cont. ) – Microvascular abnormalities • Retinopathy • Blindness • Nephropathy Copyright © 2018 Wolters Kluwer · All Rights Reserved

Diabetes Mellitus (cont. ) • Signs and symptoms – Hyperglycemia • Glycosuria • Polydipsia

Diabetes Mellitus (cont. ) • Complications – Myocardial infarction, stroke – Blindness – Leg amputation – Renal failure – Hyperosmolar hyperglycemic nonketotic coma (HHNC) Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question • Is the following statement True or False? • Diabetes mellitus is a

Answer • False • Rationale: Diabetes mellitus is a chronic, systemic disease characterized by metabolic and vascular abnormalities. While a major clinical manifestation of DM is hyperglycemia, vascular problems include atherosclerosis throughout the body, which results in hypertension, MI, stroke, and peripheral vascular disease (PVD). Copyright © 2018 Wolters Kluwer · All Rights Reserved

Endogenous Insulin • Protein hormone secreted by pancreas – Secretion levels increase after a meal – Secreted into portal circulation • Transported to liver (about ½) • Reaches systemic circulation (about ½) • Insulin binds with cellular receptors, allowing rapid entry of glucose into cells. – Affects cellular metabolism Copyright © 2018 Wolters Kluwer · All Rights Reserved

Endogenous Insulin (cont. ) • Clears from circulating blood in 10 to 15 minutes. • Insulin plays major role in metabolism. – Carbohydrates to glucose – Fats to lipids – Proteins to amino acids • Overall effect is to lower blood glucose levels. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Endogenous Insulin (cont. ) • Regulation of insulin secretion – Glucose is a major stimulus. – Several hormones raise blood glucose levels. – Insulin secretion is inhibited. • Stimulation of specific adrenergic receptors • Stress conditions Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question • Is the following statement True or False? • Insulin is a lipid

Answer • False • Rationale: Insulin is a protein hormone secreted by beta cells

Antidiabetic Medications • Insulins • Oral hypoglycemics • Amylin analogs • Incretin mimetics •

Hypoglycemic Medications • Insulin – Human insulins only—in the United States • Synthetic product is identical to endogenous insulin. • Insulin analogs – Synthesized in laboratories by altering the type or sequence of amino acids Copyright © 2018 Wolters Kluwer · All Rights Reserved

Hypoglycemic Medications (cont. ) • Insulin (cont. ) – Administration • Cannot be given orally • Most given sub-Q • Regular can also be administered IV – Differ in onset and duration of action Copyright © 2018 Wolters Kluwer · All Rights Reserved

Hypoglycemic Medications (cont. ) • Insulin (cont. ) – Short acting • Rapid onset, short duration of action – Intermediate, long acting • Slower absorption, prolonged action – Several mixtures of intermediate and short acting are available and commonly used. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Hypoglycemic Medications (cont. ) • Insulin (cont. ) – Main insulin concentration is U-100. • In the United States • Measured with orange-tipped syringe – Sub-Q injection absorbed most rapidly • Abdomen • Followed by upper arm, thigh, buttocks Copyright © 2018 Wolters Kluwer · All Rights Reserved

Hypoglycemic Medications (cont. ) • Oral hypoglycemics – Sulfonylureas – Alpha-glucosidase inhibitors – Biguanide – Thiazolidinediones – Meglitinides Copyright © 2018 Wolters Kluwer · All Rights Reserved

Question • Is the following statement True or False? • Insulin plays a major

Answer • False • Rationale: Insulin plays a major role in the metabolism of carbohydrate, fat, and protein where the nutrients are broken down into simpler molecules (glucose, lipids, and amino acids, respectively). Copyright © 2018 Wolters Kluwer · All Rights Reserved

Sulfonylureas • Mechanism of action: increases secretion of insulin • Indications for use: elevated serum glucose • Adverse effects: hypoglycemia • Nursing process implications: contraindicated during pregnancy, with renal or hepatic impairment, and critical illness Copyright © 2018 Wolters Kluwer · All Rights Reserved

Alpha-Glucosidase Inhibitors • Mechanism of action: delay digestion of complex carbohydrates • Indications for use: decrease in postprandial glucose • Adverse effects: hypoglycemia • Nursing process implications: contraindicated for patients with hepatic disease, inflammatory and malabsorptive disorders Copyright © 2018 Wolters Kluwer · All Rights Reserved

Biguanide • Mechanism of action: increases use of glucose by muscle and fat cells, decreases hepatic glucose production, and decreases intestinal absorption of glucose • Indications for use: insulin resistance • Adverse effects: lactic acidosis • Nursing process implications: No hypoglycemia; monitor for potentially fatal lactic acidosis Copyright © 2018 Wolters Kluwer · All Rights Reserved

Thiazolidinediones (Glitazones) • Mechanism of action: stimulate insulin receptors on muscle, fat, and liver cells • Indications for use: insulin resistance • Adverse effects: hepatotoxicity, congestive heart failure, weight gain • Nursing process implications: monitor liver function studies, and closely monitor patients for signs of heart failure Copyright © 2018 Wolters Kluwer · All Rights Reserved

Meglitinides • Mechanism of action: stimulate pancreatic stimulation of insulin • Indications for use: elevated serum glucose • Adverse effects: hypoglycemia although less so than sulfonylureas • Nursing process implications: proper medication administration including holding the medication if a meal is held Copyright © 2018 Wolters Kluwer · All Rights Reserved

Amylin Analogs • Mechanism of action: suppresses postprandial glucagon secretion • Indications for use: regulate the postprandial rise in blood glucose • Adverse effects: hypoglycemia • Nursing process implications: monitor blood sugars closely; this medication increases the sense of satiety, possibly reducing food intake and promoting weight loss Copyright © 2018 Wolters Kluwer · All Rights Reserved

Incretin Mimetics • Mechanism of action: stimulating the pancreas to secrete the right amount of insulin based on the food that was just eaten • Indications for use: postprandial glucose elevations • Adverse effects: GI distress and nausea • Nursing process implications: proper medication administration; monitor for a rare but serious side effect in the development of acute pancreatitis Copyright © 2018 Wolters Kluwer · All Rights Reserved

Dipeptidyl Peptidase 4 Inhibitors • Mechanism of action: balance the release of insulin and limit the release of additional glucose from the liver; it has also been linked to increased beta cell neogenesis, inhibition of beta cell apoptosis, inhibition of glucagon secretion, delayed gastric emptying, and induction of satiety. • Indications for use: elevated serum glucose. • Adverse effects: may complicate renal disease. • Nursing process implications: monitor for common side effects including upper respiratory tract infection, stuffy or runny nose, sore throat, and/or headache. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Angiotensin-converting Enzyme Inhibitors, Angiotensin II Receptor Blockers, and Statins • Pharmacokinetics • Pharmacodynamics • Pharmacotherapeutics Copyright © 2018 Wolters Kluwer · All Rights Reserved

Goals of Antidiabetic Therapy • Blood glucose at normal or near-normal levels • Promote normal metabolism of – Carbohydrate, fat, protein • Prevent acute and long-term complications • Prevent hypoglycemic episodes Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Interventions • Use nondrug measures to improve control of diabetes and to help prevent complications. • Assist the patient in maintaining the prescribed diet. • Assist the patient to develop and maintain a regular exercise program. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Interventions (cont. ) • Perform and interpret blood tests for glucose accurately, and assist the patient and family members to do so. • Test urine for ketones when the patient is sick, when blood glucose levels are greater than 200 mg/d. L, and when episodes of nocturnal hypoglycemia are suspected. Also teach patients and family members to test urine when indicated. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Interventions (cont. ) • Promote early recognition and treatment of problems by observing for signs and symptoms of urinary tract infection, peripheral vascular disease, vision changes, ketoacidosis, hypoglycemia, and others. Teach patients and family members to observe for these conditions and report their occurrence. • Discuss the importance of regular visits to health care facilities for blood sugar measurements, weights, blood pressure measurements, and eye examinations. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Nursing Interventions (cont. ) • Perform and teach correct foot care. • Help patients keep up with newer developments in diabetes care by providing information, sources of information, consultations with specialists, and other resources. • Provide appropriate patient teaching for any drug therapy and combination drug therapy for patients with type 2 diabetes mellitus. Copyright © 2018 Wolters Kluwer · All Rights Reserved

Patients’ Adherence • Complications of diabetes mellitus can be life threatening. • Diabetes is the leading cause of myocardial infarction, stroke, blindness, leg amputation, and kidney failure. • Metabolic abnormalities lead to damage in blood vessels and other body tissues. Copyright © 2018 Wolters Kluwer · All Rights Reserved