Drug Therapy for Diabetes Mellitus (2023) PDF

DRUG THERAPY FOR DIABETES MELLITUS (2023) Chapter 41 I. Overview of diabetes mellitus the most common endocrine disorder DM is a disorder of CHO metabolism, but also protein and lipid metabolism. Deficiency in insulin, results in sustained hyperglycemia II. Types of diabetes Basic info Age at onset...

DRUG THERAPY FOR DIABETES MELLITUS (2023) Chapter 41 I. Overview of diabetes mellitus the most common endocrine disorder DM is a disorder of CHO metabolism, but also protein and lipid metabolism. Deficiency in insulin, results in sustained hyperglycemia II. Types of diabetes Basic info Age at onset Speed of onset Family history Symptoms TYPE 1 Approximately 5% ( or 10%) Beta cells are destroyed Believed to be autoimmune Usually childhood or adolescence Usually sudden TYPE 2 Approximately 90-95% Beta cells available but not working correctly Usually older than 40 years, but increasing in children Gradual Frequently negative Frequently positive Polyuria, polydipsia, polyphagia, weight loss Body Usually thin and composition undernourished at diagnosis Complications Ketoacidosis (DKA) Renal failure TreatInsulin replacement Ment mandatory; along with strict diet control III. May be asymptomatic initially Frequently obese Strokes, MI Treat often with oral antidiabetics and/or insulin; in combo with diet and exercise Complications of Diabetes Short term complications of diabetes o Hyperglycemia—high blood sugar, usually dose insufficient o Hypoglycemia—low blood sugar; too much insulin o Ketoacidosis—can occur when hyperglycemia is severe, potentially fatal; usually Type 1, rare for Type 2 Long term complications of diabetes (sometimes takes years) o Macrovascular—Cardiovascular disease. This is the leading cause of death—DM causes risk for hypertension, heart disease and stroke. o Microvascular—destruction of the small blood vessels ▪ Retinopathy: blindness due to damage to retinal capillaries; Nurses recommend eye exams ▪ Nephropathy: kidney damage, results in proteinuria, increase BP, and decreased GFR. Diabetic nephropathy is the most common cause of ESRD which leads to dialysis. ▪ Neuropathy: nerve degeneration; Causes tingling, pain, and loss of sensation ▪ Gastroparesis: autonomic neuropathy which is injury to the nerves that control motility. Delays stomach emptying. Results in n/v and distention ▪ Amputations secondary to Infection: DM is major cause of amputations; Recommend regular foot check IV. Diagnosis of diabetes mellitus (tests are based on blood glucose levels) Fasting plasma glucose ≥ 126 fasting for 8 hours Casual plasma glucose ≥ 200 done any time, with symptoms Oral glucose tolerance test ≥ 200 not done often, blood draw two hours after ingesting glucose Hemoglobin A1C (glycosylated hemoglobin)—average blood glucose level over the previous 2 – 3 months. ≥ 6.5% V. Overview of Treatment for Diabetes Both Type 1 and Type 2 utilize self-monitoring BS with glucometer. Type 1 diabetes o Dietary measures are the cornerstone of treatment o Physical activity is an important part o Insulin replacement is required for survival for Type 1 o Better to have “tight control” Type 2 diabetes o Major change is we no longer wait to use drugs o Treatment is started with lifestyle measures plus drug therapy, usually starting with metformin. o “Tight control” not as useful. May help microvascular complications, but not the macrovascular which cause death PROTOTYPE DRUGS FOR DIABETES INSULINS Differ by onset, peak and duration Short duration—rapid acting Short duration—slower acting Intermediate duration Long duration & ultra-long duration lispro, aspart regular insulin NPH insulin glargine, detemir See Table 41.2 for information on the onset, peak and duration for each of the above insulins. Important to note: Peak action is when the adverse effects are most likely to occur, and long duration insulins do not have any peak. There are also premixed vials for the most common combinations o Administration—subcutaneous with syringe and needle; insulin pens and injectors infusion devices such as IV pumps. o Storage—unopened is kept in refrigerator o Dosage schedules are changing. In addition to scheduled doses, often use sliding scale to individualize dose based on blood sugar (using a blood glucose meter) o Insulin needs are increased with increased caloric intake, weight gain, pregnancy, decreased activity, infections, and some medications. o Insulin needs are decreased with decreased caloric intake, weight reduction, increased physical activity, and when stopping some medications. o Complications of insulin treatment—hypoglycemia ORAL DRUGS—Tables starting with 41.4 1. Biguanides: metformin—lowers blood sugar; may actually prevent diabetes especially in younger and obese patients. Reduces production of glucose by the liver and increases sensitivity to insulin. Side effects: n/v, cramping, diarrhea. Lactic acidosis. No alcohol. **Does not cause hypoglycemia 2. Sulfonylureas: glyburide—second generation drugs have replaced first generation drugs because they are more potent and have less drug-drug interactions. Chemically related to sulfonamide antibacterial meds. Side effects: Hypoglycemia and weight gain; promotes insulin release 3. Alpha-Glucosidase Inhibitors: acarbose—acts on intestine. Delays absorption of CHO, so reduces rise in blood sugar after eating. Side effects: gastric upset 4. Meglitinides (glinides): repaglinide Same mechanism of action as sulfonylureas—stimulates insulin release, but these are more short acting. Side effects: Hypoglycemia, also upper respiratory congestion, GI upset 5. Thiazolidinediones (glitazones): rosiglitazone Also called insulin sensitizer since they decrease insulin resistance. Adverse effects: liver injury and diarrhea; upper respiratory tract infections, headache, sinusitis, and myalgia 6. Peptidase inhibitors (gliptins): sitagliptin Minimizes the rate of inactivation of the hormone that stimulates insulin release. Side effects: has less hypoglycemia; runny nose, sore throat and headache Non insulin injectable agents—adjunctive treatment Amylin analogs (pramlintide) Given with mealtime insulin to help regulate glucose post prandial Can use in Type 1 and Type 2 Incretin mimetics (exenatide) Given to patients with Type 2 diabetes, already taking an oral med Given to stimulate the pancreas to secrete the right amount of insulin based on the food just eaten. DRUG THERAPY FOR THYROID CONDITIONS I. Hypothyroidism (myxedema in adults, cretinism in infants)—low thyroid Signs/symptoms: Decreased temperature, decreased heart rate, brittle hair, expressionless face. The lab test TSH (thyroid stimulated hormone) is elevated with hypothyroid levothyroxine—replacement therapy II. Hyperthyroidism (Grave’s disease, also called toxic goiter) Signs/symptoms: Increased heart rate, dysrhythmias, stimulates CNS so insomnia and nervousness also occur. propylthiouracil 2023