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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
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Syllabus Assistive Guides:
• Prototype Drugs: Antidiabetic: pg. 33
• Learning Questions: pg. 34
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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
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What is the Purpose ofAntidiabetic &
Hypoglycemic Agents?
•Treat Diabetes•Lower Blood Sugar
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ANTIDIABETIC & HYPOGYLCEMIC AGENTS
•Insulin•Oral Agents
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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
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What Does Insulin Do?
•Metabolism of Carbohydrates, Fats, Protein
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Pancreas
• Endocrine
• Exocrine
• Islands of Langerhans secretes 3 hormones:– Glucagon (alpha cells)– Insulin (beta cells)– Delta cells - somatostatin
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Normal Insulin Production
• Pancreas releases insulin into the bloodstream
• Blood carries it to all cells in the body
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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
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Normal Insulin Profiles
Mealtime insulin
Background insulin
Blood sugar
Daily Requirements
Breakfast Lunch Evening Meal
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Insulin
Lowers Blood Sugar•Decreases breakdown of glycogen in the liver
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Insulin
Decreases the breakdown of fat to fatty acids in adipose tissue
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Insulin
Decreases protein breakdown in muscle
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Exogenous Insulin
•Commercial Insulin–Has the same effect as endogenous insulin
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Normoglycemia!!!
• We are trying to mimic action of pancreas by giving Commercial Insulin (Exogenous Insulin) in clients who cannot produce their own insulin!!!!!
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What Type of Patient Requires Exogenous
Insulin?• Patients who’s Beta Cells become
– Overwhelmed: Disease– Exhausted: Stress or Drugs– Destroyed: Virus, Cancer
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Type 1 Diabetes Mellitus Etiology
•Results from an autoimmune disorder that destroys pancreatic beta cells
•Also called Insulin Dependent Diabetes Mellitus IDDM
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Type 1 Diabetes Signs and Symptoms
•Disorder of Carbohydrate Metabolism–Glucosuria–Polydipsia–Polyuria–Polyphagia
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Insulin Treatment
• Insulin preparations– Onset of action– Duration of action– Degree of purity– Source
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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
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Short-Acting Insulin
• Soluble
• Clear
• Onset 30 minutes
• Peak 1 - 3 hours
• Duration up to 8 hours
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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
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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
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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
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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
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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)
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Insulin Delivery• Insulin devices (pens)
– Durable (replace insulin cartridge)
– Disposable (no need to replace cartridge)
• Insulin vials and syringes
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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
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Who is a good candidate for an Insulin Pump?
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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
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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!!!!
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Effects of ILLNESS on Blood Glucose
• Fever• Flu• Infections• N & V• Surgery• Sunburn
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Being sick usually makes blood sugar HIGH!
• Stress increases Blood Glucose
• Never OMIT normally ordered insulin!!!
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Interventions for ILLNESS
• Check Blood Glucose q4 hr >240? Check for ketones!!!
• Ketones: call MD!!!!• Sick Day Guidelines…
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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
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Type 2 DiabetesEtiology
• There is abnormally high level of glucose
• Pancreas does produce insulin
• Body resists the insulin’s effects
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As a result, the glucose circulating cannot enter the cells, so that the
glucose cannot be used for energy!!!!!!
Therefore, there is
INSULIN RESISTANCE!!!
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Insulin is like the key thatcannot get fit into the lock
(cells)!!!!
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MedicationsAging
INSULIN RESISTANCE
Atherosclerosis
Genetics
Obesity and inactivity
Raredisorders
PCOS
Dyslipidemia
Hypertension
Type 2diabetes
Insulin Resistance: Causes and Associated Conditions
©1998 PPS
C
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Type 2 DiabetesSigns and Symptoms
• Hyperglycemia
• Polyuria
• Polydipsia
• Blurred vision
• Fatigue
• Paresthesias
• Skin infections
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Type 2 Diabetes
• 80% are obese• 10% non-obese• 10% unstable: may
look more like a Type 1 Diabetic
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Oral Agents
•Sulfonylureas
•Biguanides
•Glitazones
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Sulfonylureas
•Increase secretion of insulin in the pancreas
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Sulfonylureas Side Effects
•Hematologic effects
•GI effects•Hypoglycemia
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Biguanides
•Increase the use of glucose by muscles and fat cells
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BiguanidesSide Effects
• GI• Metallic Taste• Decreased Vitamin
B12• Rare Lactic Acidosis• DOES NOT CAUSE
Hypoglycemia
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Glitazones
•Decrease Insulin Resistance –Stimulate receptors on muscle, fat and liver cells
– Increase effectiveness of circulating insulin
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GlitazonesSide Efects
•Weight Gain•Hepatic Toxicity
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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?
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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)
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Checking Blood Glucose
• CBGs
• AccuChecks
• Glucometer
• Glucoscan
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Hemoglobin A1c
• A blood test that shows glucose levels for the past 3 months
• No preparation needed i.e. fasting, etc.
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Values for HbA1c
• Non-diabetic <6 %
• Diabetic with good control <7 %
• Diabetic out of control >8 %
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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
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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
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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
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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
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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.
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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
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THE END!!!!