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 ofAntidiabetic &

Hypoglycemic Agents?

•Treat Diabetes•Lower Blood Sugar

ANTIDIABETIC & HYPOGYLCEMIC AGENTS

•Insulin•Oral Agents

Endogenous Insulin

• Protein Hormone• Secreted Beta Cells-

Pancreas• 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

and a background level of insulin and extra insulin is needed

After a meal

Just to function normally

the blood sugar risesthe body needs a constant level of sugar in the blood

Basic Requirements What happenswhen you eat

Normal Insulin Profiles

Mealtime insulin

Background insulin

Blood sugar

Daily Requirements

Breakfast 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 PreparationsAll insulin in UK is 100 units/ml

• Short Acting– Regular- Humulin RALWAYS 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 InsulinGlargine (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 eitheryeast (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• Improved dose accuracy

• More convenient

– Easy to use

– Portable

– Quick and discreet

• May improve client self-management/compliance

• Preferred by patients

Disadvantages• Cannot mix insulin in a

free-mixing regimen

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 COMPARISONTYPE 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 DiabetesEtiology

• 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 thatcannot get fit into the lock

(cells)!!!!

MedicationsAging

INSULIN RESISTANCE

Atherosclerosis

Genetics

Obesity and inactivity

Raredisorders

PCOS

Dyslipidemia

Hypertension

Type 2diabetes

Insulin Resistance: Causes and Associated Conditions

©1998 PPS

C

Type 2 DiabetesSigns 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

BiguanidesSide 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

GlitazonesSide 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

0

5

10

15

20

25

0

5

10

15

20

25

CHD mortalityIncidence (%) in 3.5 years

All CHD eventsIncidence (%) in 3.5 years

HbA1c HbA1c

Low<6%

Middle6-7.9%

High>7.9%

Low<6%

Middle6-7.9%

High>7.9%

HbA1c Predicts CHD in Type 2

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 protocol1. 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 deficit1. 1 liter of isotonic saline over 1 hour 2. 1 liter of hypotonic saline over 6 to 8 hrs3. 1 liter of hypertonic solution (D51/2NS) over

8 to 12 hrs.

Drug therapy for DKA

• Insulin therapy: lower BG by 75-150mg/dl/hr1. Regular insulin IV bolus dose of .1u/kg followed by

IV drip of .1u/kg/hr.

2. SQ insulin when client can eat and ketosis has ended.

• Electrolyte replacement1. Potassium

2. Bicarbonate

THE END!!!!