Pharm. Diabetic and cancer test

Diabetes Mellitus

• Type 1 diabetes mellitus:
  • Lack of insulin production or production of defective insulin
  • Affected patients need exogenous (human-produced) insulin
  • Fewer than 10% of all DM cases are type 1
• Type 2 diabetes:
  • Insulin deficiency and insulin resistance
  • Most common type: 90% of all cases
  • Many tissues are resistant to insulin:
    • Reduced number of insulin receptors
    • Insulin receptors less responsive
• Major long-term complications of both types of diabetes:
  • Macrovascular (atherosclerotic plaque):
    • Coronary arteries
    • Cerebral arteries
    • Peripheral vessels
  • Microvascular (capillary damage):
    • Retinopathy (bleeding inside the eye, blurred vision)
    • Neuropathy (hands and feet, numbness, and tingling sensations)
    • Nephropathy (kidney damage)

Nonpharmacologic Treatment Interventions for Type 1 and Type 2

• Type 1:
  • Always require insulin therapy
• Type 2:
  • Weight loss
  • Improved dietary habits
  • Smoking cessation
  • Reduced alcohol consumption
  • Regular physical exercise
• Glycemic goal of treatment:
  • Understand the difference between fasting blood glucose and HBA1c
  • HbA1c of less than 7%
  • A1c goals are higher in those with multiple comorbidities or living in an institution, such as a nursing home

Insulins

• Rapid-acting:
  • Most rapid onset of action (5-15 minutes)
  • Peak: 1-2 hours
  • Duration: 3-5 hours
  • Patient must eat a meal after injection
  • Examples:
    • Insulin LISPRO (Humalog)
    • Insulin ASPART (Novolog)
    • Insulin GLULISINE (Apidra)
• Short-acting:
  • Onset: 30-60 minutes
  • Peak: 2-5 hours
  • Duration: 6-10 hours
  • Routes of administration:
    • IV bolus
    • IV infusion
    • IM
    • SUBQ
• Intermediate-acting:
  • Insulin isophane suspension (also called NPH)
  • Cloudy appearance
  • Often combined with regular insulin
  • Onset: 1-2 hours
  • Peak: 4-8 hours
  • Duration: 10-18 hours
• Long-acting:
  • Insulin GLARGINE (LANTUS)
  • Clear, colorless solution
  • Constant level of insulin in the body
  • Usually dosed once daily
  • Can be dosed every 12 hours
  • Referred to as basal insulin
  • Examples:
    • Toujeo: more concentrated U-300 form
    • Insulin DETEMIR (Levemir): duration of action is dose-dependent
    • Insulin GLARGINE (lantus or basaglar): biosimilar insulin U100

Non-Insulin Antidiabetic Drugs

• Biguanides:
  • Metformin
  • Used for Type 2 diabetics, PCOS, metabolic syndrome
  • NOT USED FOR TYPE 1
  • MOA:
    • Decrease production of glucose by the liver
    • Decrease intestinal absorption of glucose
    • Increase uptake of glucose by tissues
  • Adverse effects:
    • Primarily affects GI tract: abdominal bloating, nausea, cramping, diarrhea, feeling of fullness
    • May also cause metallic taste, reduced vitamin B-12 levels
  • Contraindications:
    • Renal or hepatic disease
• Thiazolidiones (glitazones):
  • Rosiglitazone (Avandia)
  • Pioglitazone (Actos)
  • Indicaton: TYPE 2 DM
  • MOA:
    • Insulin-sensitizing drugs
    • Increase glucose uptake and use in skeletal muscle
    • Inhibit glucose and triglyceride production in the liver
  • Adverse effects:
    • Can cause or exacerbate heart failure
    • Peripheral edema
    • Weight gain (fluid retention and increased adipose tissue)
    • Decreased bone marrow density with increased risk for fractures
• Alpha-glucosidase inhibitors:
  • Acarbose
  • Miglitol
  • Adverse effects:
    • Flatulence
    • Diarrhea
    • Abdominal pain
  • Contraindications:
    • Certain bowel disorders
• Dipeptidyl peptidase-IV (DPP-IV) inhibitors:
  • Saxagliptin (Onglyza)
  • Linagliptin (Tradjenta)
  • Alogliptin (Nesina)
  • Sitagliptin (Januvia)
  • Adverse effects:
    • Upper respiratory tract infections
    • Headache
    • Diarrhea
  • Hypoglycemia can occur and is more common when used with a sulfonylurea
• GLP-1 receptor agonists:
  • Exenatide (Byetta)
  • Liraglutide (Victoza)
  • Dulaglutide (Trulicity)
  • Albiglutide (Tanzeum)
  • Lixisenatide (Adlyxin)
  • Semaglutide (Ozempic)
  • MOA:
    • Enhance glucose-dependent insulin secretion
    • Suppress elevated glucagon secretion
    • Slow gastric emptying
  • Adverse effects:
    • Nausea
    • Vomiting
    • Diarrhea
  • Black box warning: risk of developing thyroid C-cell tumors

Hyperglycemia and Hypoglycemia

• Hyperglycemia:
  • Elevated blood glucose levels
  • Signs and symptoms:
    • Polyuria
    • Polydipsia
    • Polyphagia
    • Fatigue
    • Blurred vision
• Hypoglycemia:
  • Blood glucose levels < 70 mg/dL
  • Signs and symptoms:
    • Early symptoms:
      • Confusion
      • Irritability
      • Tremor
      • Sweating
    • Late symptoms:
      • Hypothermia
      • Seizures
      • Coma
      • Death

Glucose-Elevating Drugs

• Oral forms:

  • Buccal tablets
  • Semisolid gel

• Intravenous:

  • 50% dextrose in water (D50W)

• SUBQ:

  • Glucagon

• Appropriate time to use them:

  • If patients' glucose has dropped below their baseline
  • If signs and symptoms are evident and a glucose check has been completed and considered low for the patient's normal
  • If the patient has not been able to eat or drink something to increase the glucose levels
  • If the patient is unconscious, you would deliver the IV D50W or SUBQ Glucagon.### Type 1 vs Type 2 Diabetes Mellitus

• Type 1 diabetes: Lack of insulin production or production of defective insulin, requires exogenous insulin, fewer than 10% of all DM cases

• Type 2 diabetes: Insulin deficiency and insulin resistance, most common type (90% of all cases), characterized by insulin resistance and reduced insulin receptors

Complications of Diabetes

• Macrovascular complications: Atherosclerotic plaque in coronary arteries, cerebral arteries, and peripheral vessels
• Microvascular complications: Retinopathy (bleeding inside the eye, blurred vision), neuropathy (numbness, tingling sensations in hands and feet), and nephropathy (kidney damage)

Nonpharmacologic Treatment Interventions for Type 1 and Type 2

• Type 1: Always requires insulin therapy
• Type 2: Weight loss, improved dietary habits, smoking cessation, reduced alcohol consumption, and regular physical exercise
• Glycemic goal of treatment: HbA1c < 7%, with individualized goals for those with comorbidities or living in institutions

Insulins

• Rapid-acting:
  • Insulin LISPRO (Humalog)
  • Insulin ASPART (Novolog)
  • Insulin GLULISINE (Apidra)
  • Insulin AFREZZA (inhaled, rapid-acting, with peak action in 12-15 minutes and short duration of 2-3 hours)
• Short-acting: Insulin (Humulin R)
• Intermediate-acting: Insulin isophane suspension (NPH)
• Long-acting: Insulin GLARGINE (LANTUS), Insulin DETEMIR (Levemir), and Insulin DEGLUDEC (Tresiba)

Patient Education

• Inform patients about blood glucose management, healthy eating, and regular exercise
• Teach patients to administer injectable insulin and monitor blood glucose levels

Non-Insulin Antidiabetic Drugs

• Biguanides: Metformin (used for Type 2, PCOS, and metabolic syndrome)
• Thiazolidiones (glitazones): Pioglitazone (Actos) and Rosiglitazone (Avandia)
• Alpha-glucosidase inhibitors: Acarbose (Precose) and Miglitol (Glyset)
• Dipeptidyl peptidase-IV (DPP-IV) inhibitors: Saxagliptin (Onglyza), Linagliptin (Trajenta), and Sitagliptin (Januvia)
• Injectable GLP-1: Exenatide (Byetta), Liraglutide (Victoza), and Albiglutide (Tanzeum)
• SGLT2 inhibitors: Canagliflozin (Invokana), Dapagliflozin (Farxiga), and Empagliflozin (Jardiance)

Hyperglycemia and Hypoglycemia

• Hyperglycemia: Elevated blood glucose levels, with signs and symptoms including confusion, irritability, and increased thirst and urination
• Hypoglycemia: Low blood glucose levels, with signs and symptoms including hunger, shakiness, and sweating, and late symptoms including seizures, coma, and death if not treated

Acid-Related Distress

• Antacids: Neutralize acid in the stomach, with types including aluminum salts (Basaljel), magnesium salts (Mylanta), and calcium salts (Tums)
• Histamine-2 (H2) blockers: Reduce acid secretion, with examples including Cimetidine (Tagamet), Ranitidine (Zantac), and Famotidine (Pepcid)
• Proton pump inhibitors (PPIs): Block acid production, with examples including Omeprazole (Prilosec), Lansoprazole (Prevacid), and Esomeprazole (Nexium)
• Miscellaneous acid-controlling drugs: Sucralfate (Carafate), Misoprostol (Cytotec), and Simethicone (Mylicon)

Cancer and Chemotherapy

• Chemotherapy: Pharmacologic treatment of cancer, with two types of antineoplastic drugs: cell-cycle nonspecific and cell-cycle specific
• Chemotherapy side effects: Alopecia, nausea, vomiting, fatigue, and stomatitis
• Patient education: Inform patients about potential side effects, monitor for complications, and ensure safe and isolated environment
• Targeted drug therapy: Medication used for one specific type of cancer
• Dose limiting adverse effects: Highest dose of medication that can be given without causing severe side effects
• Extravasation: IV sites that cause necrosis of the tissue, caused by a infiltrated chemo IV line