Drug treatments for diabetes Glucose homeostasis in blood
Drug treatments for diabetes
Glucose homeostasis in blood Gluconeogenesis in liver (making glucose from non-carbohydrate sources, e. g. , lactate)
Oral antidiabetic medication • Insulin sensitisers – Biguanides – Thiazolidinediones • Secretagogues – Sulphonylureas – Meglitinides • Alpha glucosidase inhibitors • Dipeptidylpeptidase-4 inhibitors • Glucosurics – Sodium glucose co-transporter 2 inhibitors
Biguanides • Metformin (Glucophage®; Glucophage SR®) • Exerts effect by decreasing gluconeogenesis (manufacture of glucose in the liver from non-carbohydrate sources, e. g. , lactate in muscle) and increasing peripheral utilisation of glucose without increasing insulin levels • Does not cause hypoglycaemia or weight gain • Common side effects: abdominal pain, anorexia, diarrhoea, nausea, taste disturbance, vomiting • Concerns: renal impairment, contrast, surgery, lactic acidosis • Administration: To be taken with meals • Usual dose: metformin 500 mg three times a day or 1 g twice a day; metformin MR 1 g-2 g once daily • Cost: £ 5 -10/month
Thiazolidinediones • Pioglitazone (Actos®) • Reduces peripheral insulin resistance, leading to improved uptake of glucose by cells and reduction in blood glucose concentration • Rosiglitazone removed from market due to cardiac adverse effects in 2010 • Concerns: fluid retention, heart failure • Usual dose: one tablet once a day • Cost: <£ 5/month
Sulphonylureas • Glibenclamide, Gliclazide (Diamicron®), Glimepiride, Glipizide (Monodiab®) • Act on pancreas to stimulate insulin secretion • Side effects: hypoglycaemia, weight gain • Administration: To be taken with meals • Usual dose: gliclazide 40 -160 mg once to twice daily with meals, other drugs less frequently used • Cost: <£ 5/month
Meglitinides Nateglinide (Starlix®), Repaglinide (Prandin®) Act on pancreas to stimulate insulin secretion Reduces post-prandial hyperglycaemia Side effects: hypoglycaemia, weight gain Administration: Must be taken with or just before meals • Usual dose: one tablet three times a day • Cost: £ 10 -25/month • • •
Alpha glucosidase inhibitors • Acarbose (Glucobay®) • Inhibits intestinal alpha glucosidases to delay digestion and absorption of starch and sucrose • Hypoglycaemic episodes must be treated with glucose • Common side effects: abdominal distension, abdominal pain, diarrhoea, flatulence, soft stools • Administration: tablets must be chewed with first mouthful of food or swallowed whole immediately before food • Usual dose: 50 -100 mg three times a day • Cost: £ 10 -20/month
Dipeptidylpeptidase-4 (DPP 4) inhibitors • Alogliptin (Vipidia®), Linagliptin (Trajenta®), Saxagliptin (Onglyza®), Sitagliptin (Januvia®), Vildagliptin (Galvus®) • Inhibits DPP 4 which breaks down incretin • Incretin is secreted by the gut in response to consumption of a meal containing glucose • Incretin increases insulin secretion and lowers glucagon secretion • Low risk of hypoglycaemia • Side effects: Headache, nausea, ? heart failure • Linagliptin can be used in severe renal impairment • Usual dose: one tablet once daily, except vildagliptin, one tablet twice daily • Cost: £ 25 -35/month
Sodium glucose co-transporter 2 (SGLT 2) inhibitors • Canagliflozin (Invokana®), Dapagliflozin (Forxiga®), Empaglifozin (Jardiance®) • Reversibly inhibits SGLT 2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion • Contraindication: diabetic ketoacidosis (DKA) • Side effects: urinary tract infections, genital candidal infections, glucosuria • Usual dose: one tablet once a day • Cost: £ 40 -50/month
Injectable antidiabetic medication • Glucagon-like Peptide-1 receptor agonists • Insulin
Glucagon-like Peptide-1 (GLP 1) receptor agonists • Dulaglutide (Trulicity®), Exenatide (Byetta®, Bydureon®), Liraglutide (Victoza®), Lixisenatide (Lyxumia®) • Binds to and activates the GLP 1 receptor to increase insulin secretion, suppresses glucagon secretion, and slows gastric emptying • Common side effects: nausea, weight loss • Usual dose: One injection twice daily (Byetta®), once daily (liraglutide, lixisenatide), once weekly (Bydureon®, dulaglutide) • Cost: £ 25 -35/month • NOTE: Some also licensed for treatment of obesity
Insulin • Mealtime insulin: – Rapid-acting analogue – Short-acting – Pre-mixed insulin • Basal insulin: – Intermediate-acting basal – Long-acting basal MEALTIME INSULINS Rapid-acting analogue insulin Apidra Insulin glulisine Humalog Insulin lispro Novo. Rapid Insulin aspart Short-acting insulin Actrapid Humulin S Soluble insulin Insuman Rapid Pre-mixed insulin (human) Humulin M 3 Insuman Comb 15 Biphasic insulin Insuman Comb 25 Insuman Comb 50 Pre-mixed insulin (analogue) Humalog Mix 25 Humalog Mix 50 Biphasic insulin Novo. Mix 30 BASAL INSULINS Intermediate-acting basal insulin Humulin I Insulatard Isophane insulin Insuman Basal Long-acting basal insulin Abasalgar Insulin glargine Lantus Levemir Insulin detemir Tresiba Insulin degludec
Insulin drug therapy guidelines • Available guidelines: – – Concentrated Insulin Glucose-Insulin-Potassium (GIK) Intravenous Infusions Insulin Storage and Expiry Insulin (Subcutaneous) – Inpatient Prescribing and Admin • Where to find them on the intranet • What information they contain Please take time to read these guidelines thoroughly Most incidents involving insulin could have been AVOIDED by following the guidelines and by use of the additional information included
Click here
NOTE: RENAL STAFF Couple of patients on imported VIALS of Humulin R U-500 (500 units/ml) Not covered by this guideline Ensure pharmacist and diabetes specialist nurse aware of admission UK licensed concentrated insulins only available in pre-filled pen and MUST be given using the pen with a pen needle None are stocked by pharmacy Instructions to follow if the patient has not brought their own concentrated insulin into hospital with them or runs out whilst an inpatient
Alternative insulin if unavailable Yellow stickers for pink insulin chart. Available from diabetes nurse specialists who should be informed of admission
Ward stock VIALS only Keep in ward fridge Expire 28 days after opening
Patient’s own vials or pens Keep in POD locker DO NOT PUT IN WARD FRIDGE Expiry 28 days after taking out of fridge
Blood glucose range 5 -11 mmol/l PRESCRIBING INFORMATION Ensure front page of pink chart completed as fully as possible Prescribe usual insulin as soon as possible after admission
Alternative prescriptions Short-term prescriptions Self-administration determination Meal-time insulins and basal insulins must be prescribed in the correct boxes Administer ALL doses of basal insulin to patients with Type 1 diabetes Permissible dose range
Short-term ‘as required’ doses Daily prescription review ADMINISTRATION INFORMATION Valid prescription on pink chart Availability of insulins Substitute preparations Ensure front page fully completed Initial prescription valid for up to 7 days
Self-administration competence Administer ALL doses of basal insulin in patients with Type 1 diabetes Permissible dose range No numerical missed dose codes * with explanation in exceptions section Monitor blood glucose FOUR times daily
During 2016, a midwife on maternity used a normal syringe to give insulin, resulting in a TENFOLD overdose (20 units instead of 2 units)
Patients who take two different meal-time insulins, e. g. , Humalog Mix 25 am and Humalog Mix 50 lunch and pm, will require two pink charts per week
Unless admitted due to their diabetes or incapacitated, allow the patient to selfmanage, don’t touch the pump!
Vials are available of ALL recommended substitute insulins in the emergency drug cupboard Insulin must NEVER be recorded as 3 - ‘Stock unavailable’
Who is responsible for prescription, administration and signing the pink chart? Level 2 can be signed for by nursing staff Level 3 must be signed by the prescriber and patient
Information for prescribers on adjustment of insulin doses
Adjustment of single dose of insulin at point of administration for patients with hypoglycaemia or persistent hyperglycaemia
Administration information
Criteria used for audits of insulin usage within the Trust For incident investigation and audit, if it wasn’t clearly documented, it didn’t happen
- Slides: 37