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

Explore the different forms of concentrated glucose and when to use them in the treatment of hypoglycemia. Understand the nursing implications for administering medications such as IV D50W and SUBQ Glucagon.