Type 2 Diabetes & Sulfonylureas

• Sulfonylureas are indicated for only type 2 diabetes
• Insulin, produced by beta pancreas cells, helps move glucose from the blood to enter cells for energy.
• Excess glucose is stored in liver cells as glycogen or fat, while low blood glucose triggers glucagon release.
• Glucagon releases glucose from the liver into the blood, raising glucose levels.
• Insulin resistance occurs when receptors on target cells are less responsive to insulin signaling.
• Sulfonylureas directly stimulate beta cells to increase insulin release, which helps with insulin deficiency and insulin resistance causing hyperglycemia.
• These drugs are effective at lowering glucose after meals but continue increasing insulin regardless of blood glucose levels.

Medications

• Glyburide
• Glimepiride
• Glipizide

Adverse Effects

• High risk of hypoglycemia
• Weight gain occurs as excess glucose is moved into fat cells.
• Allergic reactions can occur in clients with sulfa allergies

Nursing Intervention

• Check for sulfa allergies

• Recognize symptoms of hypoglycemia

• Give this medication with food to decrease risk of hypoglycemia

• Decrease alcohol intake, to further lower risk of hypoglycemia

• Encourage daily exercise and healthy dietary modifications

• Biguanides, such as Metformin, are for type 2 diabetes and act as "insulin sensitizers."

Action

• Limit glucose entry into the bloodstream by decreasing glucose production in the liver.
• Reduce glucose absorption in the gut
• Sensitize insulin receptors in tissues to increase glucose uptake and utilization, without stimulating the pancreas to release insulin

Adverse Effects

• Nausea, vomiting, and diarrhea are common but transient, and typically subside when taken continuously.
• Slow dose titration is recommended to minimize these effects.
• Lactic acidosis is a life-threatening risk.
  • High doses or accumulation can lead to increased production and decreased elimination of lactate, potentially causing metabolic acidosis.
  • Use with caution in patients with renal insufficiency
  • Co-administration with alcohol or iodinated contrast may lead to lactic acidosis
  • Chronic use may interfere with vitamin B12 absorption, causing deficiency.
• Metformin is not associated with weight gain and has a low risk of hyoglycemia.

Client Teaching

• Can be taken without food but it is still recommended to take with food

• Decrease alcohol intake

• Discontinue metformin 24-48 hours before CT scans with iodinated contrast dye

• Monitor for lactic acidosis symptoms like malaise, myalgia, and tachypnea

• Maintain a healthy lifestyle and diet.

• Incretin hormones are produced in the small intestine in response to glucose influx, increasing glucose-dependent insulin release and decreasing glucagon release to lower blood glucose levels

• Dipeptidyl Peptidase 4 Inhibitors stop the DPP4 enzyme from breaking down incretin hormones, enhancing glucose-lowering effects

-Gliptins (Dipeptidyl Peptidase 4 Inhibitors)

• Alogliptin
• Linagliptin
• Saxagliptin

Adverse Effects

• Acute or chronic pancreatitis is associated with stimulation of the pancreas by incretin hormones, so use cautiously in clients with risk factors for pancreatitis or obesity
• Arthralgia (joint pain) may occur from days to years after starting the drug and may resolve when discontinued
• Severe allergic reactions such as angioedema can occur due to inhibition of the breakdown of proteins that increase vascular permeability.
• Dermatological reactions such as bullous pemphigoid (itchy rash with large blisters) are possible
• Severe cutaneous reactions such as Steven Johnson's Syndrome can occur, resembling a burn

Client Teaching

• Report abdominal pain, nausea, and vomiting immediately

• Insulin replaces or supplements endogenous insulin, facilitating glucose entry into cells

• Exogenous insulin mimics the body's natural insulin production using different types, categorized by onset of action

Types of Insulin

• Premeal Short duration insulins:
  • Rapid-acting (Lispro, aspart, glulisine) is used for postprandial hyperglycemia
  • Short-acting (regular insulin) is given IV for DKA
• Intermediate-acting:
  • NPH (2x daily)
• Long-acting:
  • Glargine, detemir, degludec
• Premixed:
  • Intermediate + either short or rapid acting, reduces the number of injections

Sliding Scale of Insulin

• A sample problem involves administering NPH twice daily, with 12 units at bedtime, and regular insulin SubQ at 8:30 pm based on a sliding scale.
• Fingerstick glucose check: 171 mg/dL
• Insulin NPH 12 units + 3 units regular insulin by sliding scale = 15 units of insulin.
• To draw, withdraw 3 units of clear insulin followed by 12 units of cloudy NPH into the syringe.

Sulfonylureas stimulate beta cells to release insulin, addressing hyperglycemia. Glyburide, glimepiride, and glipizide are common medications. Adverse effects include hypoglycemia, weight gain, and allergic reactions. Nursing interventions are required to manage these effects.