Drug Therapy for Diabetes Mellitus PDF

Chapter 41 Drug Therapy for Diabetes Mellitus  Classifications Diabetes Mellitus oType 1 Overview #1 oType 2 Characterized by hyperglycemia Differ in oOnset, course...

Chapter 41 Drug Therapy for Diabetes Mellitus  Classifications Diabetes Mellitus oType 1 Overview #1 oType 2 Characterized by hyperglycemia Differ in oOnset, course oPathology, treatment Copyright © 2025 Wolters Kluwer. All rights reserved. 2  Type 1 Diabetes Mellitus oCommon chronic disorder of childhood Overview #2 oAutoimmune disorder that destroys pancreatic beta cells difficult to control oSudden onset; peak incidence at ages 10 to 12 years for females, 12 to 14 years for males oHigh incidence of complications oRequires exogenous insulin administration Copyright © 2025 Wolters Kluwer. All rights reserved. 3  Type 2 Diabetes Mellitus oCharacterized by hyperglycemia and insulin Overview #3 resistance oHistorically, onset after age 40 years Increasing prevalence among children and adolescents oGradual onset with less severe symptoms o90% of people with diabetes have type 2 disease o20% require exogenous insulin at some time Copyright © 2025 Wolters Kluwer. All rights reserved. 4  Type 2 (cont.) Diabetes Mellitus oRisk factors for development Overview #4 Obesity, ingestion of excess calories Presence of metabolic syndrome Abdominal obesity Low HDL Hypertriglyceridemia Hypertension and/or impaired fasting glucose Copyright © 2025 Wolters Kluwer. All rights reserved. 5  Type 2 (cont.) Diabetes Mellitus oEthnicities at high risk for type 2 Overview #5 development Asian Americans (8%) Non-Hispanic blacks (12.7%) Non-Hispanic whites (7.4%) Hispanics (12.1%) Native Americans/Alaskans (15.1%) Copyright © 2025 Wolters Kluwer. All rights reserved. 6  Chronic, systemic disease characterized by Diabetes Mellitus oMetabolic abnormalities Overview #6 oVascular abnormalities Major clinical manifestation of metabolic abnormalities oHyperglycemia Fasting blood glucose levels greater than 126 mg/dL Copyright © 2025 Wolters Kluwer. All rights reserved. 7  Major clinical manifestation of metabolic Diabetes Mellitus abnormalities (cont.) Overview #7 oImpaired fasting glucose (IFG) (i.e., prediabetes) Fasting blood glucose levels between 100 and 125 mg/dL Recommended blood glucose level for those with diabetes o80 to 130 mg/dL before meals and at bedtime (adults) o90 to 150 mg/dL before meals and at bedtime (children and adolescents) oA1C goal < 7% Copyright © 2025 Wolters Kluwer. All rights reserved. 8  Major clinical manifestation of metabolic Diabetes Mellitus abnormalities (cont.) Overview #8 oMacrovascular abnormalities Hypertension Myocardial infarction Stroke Peripheral vascular disease (PVD) Copyright © 2025 Wolters Kluwer. All rights reserved. 9  Major clinical manifestation of metabolic Diabetes Mellitus abnormalities (cont.) Overview #9 oMicrovascular abnormalities Retinopathy Blindness Chronic kidney disease Copyright © 2025 Wolters Kluwer. All rights reserved. 10  Signs and symptoms Diabetes Mellitus oHyperglycemia Overview #10 Glycosuria Polydipsia (abnormal thirst) Polyuria (excessive urination) Dehydration Polyphagia (eating excessively) Copyright © 2025 Wolters Kluwer. All rights reserved. 11  Complications Diabetes Mellitus oMyocardial infarction Overview #11 oStroke oBlindness oLeg amputation oKidney failure oDiabetic ketoacidosis (DKA) oHyperosmolar hyperglycemic nonketotic coma (HHNC) Copyright © 2025 Wolters Kluwer. All rights reserved. 12  Is the following statement True or False? Question #1 Diabetes mellitus is a chronic, systemic disease characterized by metabolic abnormalities. Copyright © 2025 Wolters Kluwer. All rights reserved. 13  False Answer to Question #1 Rationale: Diabetes mellitus is a chronic, systemic disease characterized by metabolic and vascular abnormalities. While a major clinical manifestation of DM is hyperglycemia, vascular problems include atherosclerosis throughout the body, which results in hypertension, MI, stroke, and peripheral vascular disease (PVD). Copyright © 2025 Wolters Kluwer. All rights reserved. 14  Protein hormone secreted by pancreas Endogenous oSecretion levels increase after a meal Insulin #1 oSecreted into portal circulation Transported to liver (about ½) Reaches systemic circulation (about ½) Insulin binds with cellular receptors, allowing rapid entry of glucose into cells. oAffects cellular metabolism Copyright © 2025 Wolters Kluwer. All rights reserved. 15  Insulin clears from circulating blood in 10 to Endogenous 15 minutes. Insulin #2 Insulin plays major role in metabolism. oCarbohydrates to glucose oFats to lipids oProteins to amino acids Overall effect is to lower blood glucose levels. Copyright © 2025 Wolters Kluwer. All rights reserved. 16  Regulation of insulin secretion Endogenous oGlucose is a major stimulus. Insulin #3 oSeveral hormones raise blood glucose levels. oInsulin secretion is inhibited. Stimulation of specific adrenergic receptors Stress conditions Copyright © 2025 Wolters Kluwer. All rights reserved. 17  Is the following statement True or False? Question #2 Insulin is a lipid hormone secreted by beta cells in the pancreas. Copyright © 2025 Wolters Kluwer. All rights reserved. 18  False Answer to Question #2 Rationale: Insulin is a protein hormone secreted by beta cells in the pancreas that allows rapid entry of glucose into cells. Copyright © 2025 Wolters Kluwer. All rights reserved. 19  Insulin (regular insulin) Antidiabetic Oral hypoglycemics Medications oSulfonylureas oBiguanide oAlpha-glucosidase inhibitors oThiazolidinediones oMeglitinides Dipeptidyl peptidase 4 (DPP-4) inhibitors Amylin analogs Incretin mimetics Sodium glucose cotransporter 2 inhibitors Copyright © 2025 Wolters Kluwer. All rights reserved. 20  Human insulins only—in the United States Insulin #1 oSynthetic product is identical to endogenous insulin. Insulin analogs oSynthesized in laboratories by altering the type or sequence of amino acids Copyright © 2025 Wolters Kluwer. All rights reserved. 21  Administration Insulin #2 oCannot be given orally oMost given sub-Q oRegular can also be administered IV Differ in onset and duration of action Copyright © 2025 Wolters Kluwer. All rights reserved. 22  Rapid acting Insulin #3 oRapid onset (15 min or less), short duration of action (4 to 8 hours) Intermediate, long acting oSlower absorption, prolonged action Several mixtures of intermediate and short acting are available and commonly used. Copyright © 2025 Wolters Kluwer. All rights reserved. 23  Main insulin concentration is U-100. Insulin #4 oIn the United States oMeasured with orange-tipped syringe Sub-Q injection absorbed most rapidly oAbdomen Followed by upper arm, thigh, buttocks Copyright © 2025 Wolters Kluwer. All rights reserved. 24  Is the following statement True or False? Question #3 Insulin plays a major role primarily in the metabolism of carbohydrate. Copyright © 2025 Wolters Kluwer. All rights reserved. 25  False Answer to Question #3 Rationale: Insulin plays a major role in the metabolism of carbohydrate, fat, and protein where the nutrients are broken down into simpler molecules (glucose, lipids, and amino acids, respectively). Copyright © 2025 Wolters Kluwer. All rights reserved. 26  Prototype: glyburide Sulfonylureas Mechanism of action: stimulate secretion of insulin Indications for use: elevated serum glucose Adverse effects: hypoglycemia Nursing process implications: contraindicated during pregnancy, with abnormal kidney function or hepatic impairment, and critical illness Copyright © 2025 Wolters Kluwer. All rights reserved. 27  Prototype: metformin (antihyperglycemic Biguanide rather than a hypoglycemic) Mechanism of action: reduces production of glucose by the liver, decreases intestinal absorption of glucose to increase insulin sensitivity. Does not cause hypoglycemia Indications for use: insulin resistance Adverse effects: lactic acidosis Nursing process implications: no hypoglycemia; monitor for potentially fatal lactic acidosis Copyright © 2025 Wolters Kluwer. All rights reserved. 28  Prototype: acarbose Alpha- Mechanism of action: delay digestion of Glucosidase complex carbohydrates Inhibitors Indications for use: decrease in postprandial glucose (may need to combine with insulin or an oral agent) Adverse effects: hypoglycemia, gastric upset, leukopenia, thrombocytopenia, and anemia Nursing process implications: contraindicated for patients with hepatic disease, inflammatory and malabsorptive disorders Copyright © 2025 Wolters Kluwer. All rights reserved. 29  Prototype: rosiglitazone maleate Thiazolidinedione Mechanism of action: decrease insulin s (Glitazones) resistance Indications for use: insulin resistance (but rarely used due to risk of heart failure (HF) and atherosclerotic cardiovascular events Pioglitazone may be administered as a second- or third-line therapy when other oral agent combination are not provided adequate glycemic control. Nursing process implications: monitor liver function studies, and closely monitor patients for signs of HF Copyright © 2025 Wolters Kluwer. All rights reserved. 30  Prototype: repaglinide Meglitinides Mechanism of action: stimulate pancreatic stimulation of insulin Indications for use: elevated serum glucose Adverse effects: hypoglycemia although less so than sulfonylureas Nursing process implications: proper medication administration including holding the medication if a meal is held Copyright © 2025 Wolters Kluwer. All rights reserved. 31  Prototype: sitagliptin Dipeptidyl Mechanism of action: increase hormone levels Peptidase 4 of incretin hormones that stimulate insulin Inhibitors release (in response to a meal) which increases and lengthens the release of insulin and decreases hepatic glucose production to promote glycemic control. Indications for use: elevated serum glucose. Adverse effects: upper respiratory tract infection, stuffy or runny nose, sore throat, headache Nursing process implications: monitor for common side effects including upper respiratory tract infection, stuffy or runny nose, sore throat, and/or headache. Monitor for signs of Copyright HF more pronounced © 2025 Wolters Kluwer. All rights reserved.in patients 32  Prototype: pramlintide acetate Amylin Analogs Mechanism of action: suppresses postprandial glucagon secretion Indications for use: regulate the postprandial rise in blood glucose Adverse effects: hypoglycemia, anorexia, nausea, vomiting, headache Nursing process implications: monitor blood sugars closely; this medication increases the sense of satiety, possibly reducing food intake and promoting weight loss Copyright © 2025 Wolters Kluwer. All rights reserved. 33  Prototype: exenatide Incretin Mimetics Mechanism of action: stimulating the pancreas to secrete the right amount of insulin based on the food that was just eaten Indications for use: postprandial glucose elevations Adverse effects: hypoglycemia, GI distress, and nausea Nursing process implications: proper medication administration; monitor for a rare but serious side effect in the development of acute pancreatitis Copyright © 2025 Wolters Kluwer. All rights reserved. 34  Prototype: canagliflozin Sodium glucose Mechanism of action: blocks the absorption of cotransporter 2 glucose in the kidney, allows for greater inhibitors excretion of glucose Indications for use: improve glycemic control Adverse effects: dehydration, hypotension, syncope, and dehydration Nursing process implications: assess hydration level and blood pressure for syncope and hypotension; assess for dysrhythmia; potassium level for possible hyperkalemia Copyright © 2025 Wolters Kluwer. All rights reserved. 35  Combination drug therapy is an increasing trend in type Combination 2 diabetes that is not controlled by diet, exercise, and drugs single-drug therapy. Useful combinations include drugs with different mechanisms of action, and several rational combinations are currently available. Most studies have involved combinations of two drugs; some three-drug combinations are also being used. All combination therapy should be monitored with periodic measurements of fasting plasma glucose and glycosylated hemoglobin levels. If adequate glycemic control is not achieved, oral drugs may need to be discontinued and insulin therapy started. Copyright © 2025 Wolters Kluwer. All rights reserved. 36  Angiotensin-converting enzyme (ACE) inhibitors Adjuvant oPrototype: enalapril maleate Medications Angiotensin II receptor blockers (ARBs) oPrototype: losartan Thiazidelike diuretics oPrototype: hydrochlorothiazide Antiplatelet agent oAspirin HMG-CoA reductase inhibitors oPrototype: simvastatin Copyright © 2025 Wolters Kluwer. All rights reserved. 37  Blood glucose at normal or near-normal levels Goals of Promote normal metabolism of: Antidiabetic oCarbohydrate Therapy oFat oProtein Prevent acute and long-term complications Prevent hypoglycemic episodes Copyright © 2025 Wolters Kluwer. All rights reserved. 38  Use nondrug measures to improve control of Nursing diabetes and to help prevent complications. Interventions #1 Assist the patient in maintaining the prescribed diet. Assist the patient to develop and maintain a regular exercise program. Copyright © 2025 Wolters Kluwer. All rights reserved. 39  Perform and interpret blood tests for glucose Nursing accurately and assist the patient and family Interventions #2 members to do so. Test urine for ketones when the patient is sick, when blood glucose levels are greater than 250 mg/dL, and when episodes of nocturnal hypoglycemia are suspected. Also teach patients and family members to test urine when indicated. Copyright © 2025 Wolters Kluwer. All rights reserved. 40  Promote early recognition and treatment of Nursing problems by observing for signs and Interventions #3 symptoms of urinary tract infection, peripheral vascular disease, vision changes, ketoacidosis, hypoglycemia, and others. Teach patients and family members to observe for these conditions and report their occurrence. Discuss the importance of regular visits to healthcare facilities for blood sugar measurements, weights, blood pressure measurements, and eye examinations. Copyright © 2025 Wolters Kluwer. All rights reserved. 41  Perform and teach correct foot care. Nursing Interventions #4 Help patients keep up with newer developments in diabetes care by providing information, sources of information, consultations with specialists, and other resources. Provide appropriate patient teaching for any drug therapy and combination drug therapy for patients with type 2 diabetes mellitus. Copyright © 2025 Wolters Kluwer. All rights reserved. 42  Complications of diabetes mellitus can be life Patients’ threatening. Adherence Diabetes is the leading cause of myocardial infarction, stroke, blindness, leg amputation, and kidney failure. Metabolic abnormalities lead to damage in blood vessels and other body tissues. Copyright © 2025 Wolters Kluwer. All rights reserved. 43