Chapter 33

Antidiabetic Drugs
 Diabetes (1 of 2)
 Often regarded as a syndrome rather than a
disease
 Two types
 Type 1
 Type 2
 Diabetes (2 of 2)
 Signs and symptoms
 Elevated fasting blood glucose (higher than 7 mmol/L)
or a hemoglobin A1c (HbA1c) level greater than or
equal to 6.5%
 Polyuria
 Polydipsia
 Polyphagia
 Glycosuria
 Weight loss
 Fatigue
 Blurred vision
 Type 1 Diabetes
 Lack of insulin production, or production of
defective insulin
 Affected patients need exogenous insulin.
 Fewer than 10% of all cases are type 1.
 Complications
 Diabetic ketoacidosis
 Hyperosmolar hyperglycemic state
 Type 2 Diabetes (1 of 2)
 Most common type (90% of all cases)
 Caused by insulin deficiency and insulin
resistance
 Many tissues are resistant to insulin.
 Reduced number of insulin receptors
 Insulin receptors less responsive
 Type 2 Diabetes (2 of 2)
 Several comorbid conditions
 Obesity
 Coronary heart disease
 Dyslipidemia
 Hypertension
 Microalbuminemia (protein in the urine)
 Increased risk for thrombotic (blood clotting) events
 These comorbidities are collectively referred to
as metabolic syndrome or cardiometabolic
syndrome.
 Gestational Diabetes
 Hyperglycemia that develops during pregnancy
 Insulin must be given to prevent birth defects.
 Usually subsides after delivery
 30% of patients may develop type 2 diabetes
within 10 to 15 years.
Major Long-Term Complications of
Both Types of Diabetes
 Macrovascular (atherosclerotic plaque)
 Coronary arteries
 Cerebral arteries
 Peripheral vessels
 Microvascular (capillary damage)
 Retinopathy
 Neuropathy
 Nephropathy
 Screening for Diabetes
 Prediabetes
 Categories of increased risk
• HbA1c of 6.0 to 6.4%
• Fasting plasma glucose levels higher than or equal to 6.1
mmol/L but less than 6.9 mmol/L
• Impaired glucose tolerance test (oral glucose challenge)
 Screening recommended every 3 years for all
patients 40 years of age and older
 Nonpharmacological Treatment
Interventions
 Type 1: Always requires insulin therapy
 Type 2
 Weight loss
 Improved dietary habits
 Smoking cessation
 Reduced alcohol consumption
 Regular physical exercise
 Glycemic Goal of Treatment
 HbA1c of less than 7%
 Fasting blood glucose goal for diabetic patients:
4 to 7 mmol/L
 2-hour postprandial target of 5 to 10 mmol/L
 Treatment for Diabetes
 Type 1
 Insulin therapy
 Type 2
 Lifestyle changes
 Oral drug therapy
 Insulin when the above no longer provide glycemic
control
 Types of Antidiabetic Drugs
 Insulins
 Oral hypoglycemic drugs
 A combination of oral antihypoglycemic and
insulin controls glucose levels.
 Some new injectable hypoglycemic drugs may
be used in addition to insulin or antidiabetic
drugs.
 Insulins (1 of 3)
 Function as a substitute for the endogenous
hormone
 Effects are the same as those of normal
endogenous insulin
 Restores the diabetic patient’s ability to:
 Metabolize carbohydrates, fats, and proteins
 Store glucose in the liver
 Convert glycogen to fat stores
 Insulins (2 of 3)
 Human insulin
 Derived using recombinant deoxyribonucleic acid
(DNA) technologies
 Recombinant insulin produced by bacteria and yeast
 Goal: tight glucose control
 To reduce the incidence of long-term complications
 Insulins (3 of 3)
 Rapid-acting treatment for types 1 and 2
diabetes
 Most rapid onset of action (10 to 15 minutes)
 Peak: 1 to 2 hours
 Duration: 3 to 5 hours
 Patient must eat a meal after injection
 Insulin lispro (Humalog®)
• Action similar to that of endogenous insulin
 Insulin aspart (NovoRapid®)
 Insulin glulisine (Apidra®)
 May be given subcutaneously or via continuous
subcutaneous infusion pump (but not intravenously)
 Short-Acting Insulins
 Regular insulin (Humulin R®, Novolin ge
Toronto®)
 Routes of administration: intravenous (IV) bolus,
IV infusion, intramuscular, subcutaneous
 Onset (subcutaneous route): 30 minutes
 Peak (subcutaneous route): 2 to 3 hours
 Duration (subcutaneous route): 6.5 hours
 Intermediate-Acting Insulins
 Insulin isophane suspension (also called NPH)
 Cloudy appearance
 Often combined with regular insulin
 Onset: 1 to 3 hours
 Peak: 5 to 8 hours
 Duration: up to 18 hours
 Long-Acting Insulins (1 of 2)
 Long acting
 Insulin glargine (Lantus®)
 Clear, colourless solution
 Constant level of insulin in the body
 Usually dosed once daily
 Can be dosed every 12 hours
 Referred to as basal insulin
 Onset: 90 minutes
 Peak: none
 Duration: 24 hours
 Long-Acting Insulins (2 of 2)
 Insulin detemir
 Duration of action is dose dependent.
 Lower doses require twice-daily dosing.
 Higher doses may be given once daily.
Fixed-Combination Insulins (1 of 2)
 Fixed combinations
 Humulin 30/70
 Novolin 30/70, 40/60, 50/50
 NovoMix® 30
 Humalog Mix25®
 Humalog Mix50®
Fixed-Combination Insulins (2 of 2)
 Each contains two different insulins, fixed
combinations
 One intermediate-acting type
 Either one rapid-acting type (Humalog, NovoLog) or
one short-acting type (Humulin)
 Sliding-Scale Insulin Dosing
 Subcutaneous rapid-acting (lispro or aspart) or short-
acting (regular) insulins are adjusted according to blood
glucose test results.
 Typically used in hospitalized diabetic patients or those
on total parenteral nutrition or enteral tube feedings
 Subcutaneous insulin is ordered in an amount that
increases as the blood glucose increases.
 Disadvantage: Delays insulin administration until
hyperglycemia occurs, resulting in large swings in
glucose control.
 Recent research does not support sliding-scale use;
nonetheless, sliding scale is still commonly used.
 Basal-Bolus Insulin Dosing
 Preferred method of treatment for hospitalized
patients with diabetes
 Mimics a healthy pancreas by delivering basal
insulin constantly as a basal and then as needed
as a bolus
 Basal insulin is a long-acting insulin (insulin
glargine).
 Bolus insulin (insulin lispro or insulin aspart)
 Injectable Antidiabetic Drugs
 Amylin agonist
 pramlintide (Symlin®)
 Incretin mimetics
 exenatide (Byetta®)
 liraglutide (Victoza®)
 Oral Antidiabetic Drugs (1 of 7)
 Used for type 2 diabetes
 Effective treatment involves several elements:
 Lifestyle changes
 Careful monitoring of blood glucose levels
 Therapy with one or more drugs
 Treatment of associated comorbid conditions such as
high cholesterol and high blood pressure
 Oral Antidiabetic Drugs (2 of 7)
 2013 Canadian Diabetes Association
recommendations
 New-onset type 2 diabetes treatment
 Lifestyle interventions
 Oral biguanide drug metformin
 If lifestyle modifications and the maximum tolerated
metformin dose do not achieve the recommended A1c
goals after 3 to 6 months, additional treatment should
be given with dipeptidyl peptidase 4 (DPP-4) inhibitors
and glucagonlike peptide 1 (GLP-1) receptor agonists
(liraglutide, exenatide, abliglutide) or insulin.
 Oral Antidiabetic Drugs (3 of 7)
 Biguanide
 metformin (Glucophage)
 First-line drug and the most commonly used oral
medication for the treatment of type 2 diabetes
 Not used for type 1 diabetes
 Mechanism of action
 Indications
 Contraindications
 Biguanide: (Metformin)
 Adverse effects
 Abdominal bloating, nausea, cramping, a feeling of
fullness, and diarrhea
 Metallic taste, hypoglycemia, and a reduction in
vitamin B12 levels after long-term use
 Lactic acidosis is an extremely rare complication.
 Interactions
 Oral Antidiabetic Drugs (4 of 7)
 Sulphonylureas
 Second generation: glimepiride (Amaryl), gliclazide
(Diamicron), glyburide (DiaBeta)
 Indications
 Contraindications
 Adverse effects: hypoglycemia, weight gain, skin
rash, nausea, epigastric fullness, and heartburn
 Interactions
 Oral Antidiabetic Drugs (5 of 7)
 Glinides
 repaglinide (GlucoNorm®), nateglinide (Starlix®)
 Indication: type 2 diabetes
 Thiazolidinediones (glitazones)
 pioglitazone (Actos®)
 rosiglitazone (Avandia®)
 Insulin-sensitizing drugs
 Indication: type 2 diabetes
 Oral Antidiabetic Drugs (6 of 7)
 α-Glucosidase inhibitor
 acarbose (Glucobay)
 Indication: type 2 diabetes
 Contraindications
 Adverse effects
 Oral Antidiabetic Drugs (7 of 7)
 Dipeptidyl peptidase 4 (DPP-4) inhibitors
 sitagliptin (Januvia®)
 saxagliptin (Onglyza®)
 linagliptin (Tradjenta®)
 alogliptin (Nesina®)
 Injectable Antidiabetic Drugs:
Mechanism of Action (1 of 2)
 Amylin agonist
 Mimics the natural hormone amylin
 Slows gastric emptying
 Suppresses glucagon secretion, reducing hepatic
glucose output
 Used when other drugs have not achieved adequate
glucose control
 Subcutaneous injection
 Injectable Antidiabetic Drugs:
Mechanism of Action (2 of 2)
 Incretin mimetic
 Mimics the incretin hormones
 Enhances glucose-driven insulin secretion from β
cells of the pancreas
 Used only for type 2 diabetes
 Exenatide: injection pen device
 Injectable Antidiabetic Drugs:
Adverse Effects
 Amylin agonist
 Nausea, vomiting, anorexia, headache
 Incretin mimetics
 Nausea, vomiting, and diarrhea
 Rare cases of hemorrhagic or necrotizing pancreatitis
 Weight loss
 Sodium Glucose Cotransporter 2
Inhibitors (1 of 2)
 A decrease in blood glucose caused by an increase in
renal glucose excretion.
 This inhibitor is a new class (2014) of oral drugs for the
treatment of type 2 diabetes.
 canaglifozin (Invokana®), dapaglifozin (Forxiga®)
 Action: work independently of insulin to prevent glucose
reabsorption from the glomerular filtrate, resulting in a
reduced renal threshold for glucose and glycosuria
 Sodium Glucose Cotransporter
Inhibitors (2 of 2)
 Most frequently reported adverse effects include
vaginal yeast infections and urinary tract
infections.
 Other effects: may increase insulin sensitivity
and glucose uptake in the muscle cells and
decrease gluconeogenesis
 Results: improved glycemic control, weight loss,
and a low risk of hypoglycemia
 Hypoglycemia
 Abnormally low blood glucose level (below
4 mmol/L)
 Mild cases can be treated with diet—higher
intake of protein and lower intake of
carbohydrates—to prevent rebound postprandial
hypoglycemia.
 Hypoglycemia Symptoms
 Adrenergic
 Anxiety, tremors, sensation of hunger, palpitations,
sweating
 Central nervous system
 Difficulty concentrating, confusion, weakness,
drowsiness, vision changes, difficulty speaking,
dizziness and headache
 Later signs
 Hypothermia, seizures
 Coma and death will occur if not treated
 Glucose-Elevating Drugs
 Oral forms of concentrated glucose
 Gel, liquid, or tablet form
 50% dextrose in water (D50W)
 Glucagon
 Nursing Implications (1 of 10)
 Before giving drugs that alter glucose levels,
obtain and document:
 A thorough history
 Vital signs
 Blood glucose levels, HbA1c level
 Potential complications and drug interactions
 Nursing Implications (2 of 10)
 Before giving drugs that alter glucose levels:
 Assess the patient’s ability to consume food.
 Assess for nausea or vomiting.
 Hypoglycemia may be a problem if antidiabetic drugs
are given and the patient does not eat.
 If a patient is to take nothing by mouth (NPO) for a
test or procedure, consult the primary care provider to
clarify orders for antidiabetic drug therapy.
 Nursing Implications (3 of 10)
 Keep in mind that overall concerns for any
patient with diabetes increase when the patient:
 Is under stress
 Is pregnant or lactating
 Has an infection
 Has an illness or trauma
 Nursing Implications (4 of 10)
 Thorough patient education is essential
regarding:
 Disease process
 Diet and exercise recommendations
 Self-administration of insulin or oral drugs
 Potential complications
 Nursing Implications (5 of 10)
 When insulin is ordered, ensure:
 Correct drug
 Correct route
 Correct type of insulin
 Correct dosage
 Insulin order and prepared dosages are second-
checked with another registered nurse (or per
agency policy).
 Nursing Implications (6 of 10)
 Insulin
 Check blood glucose level before giving insulin.
 To mix suspensions, roll vials between hands instead
of shaking them.
 Ensure correct storage of insulin vials.
 Only use insulin syringes, calibrated in units, to
measure and give insulin.
 Ensure correct timing of insulin dose with meals.
 Nursing Implications (7 of 10)
 Insulin
 When drawing up two types of insulin in one syringe,
always withdraw the regular or rapid-acting (clear)
insulin first.
 Provide thorough patient education regarding self-
administration of insulin injections, including timing of
doses, monitoring of blood glucose levels, and
injection site rotations.
 Nursing Implications (8 of 10)
 Oral antidiabetic drugs
 Always check blood glucose levels before
administering.
 Usually given 30 minutes before meals
 α-Glucosidase inhibitors are given with the first bite of
each main meal.
 Metformin is taken with meals to reduce
gastrointestinal effects.
 Metformin will need to be discontinued if the patient is
to undergo studies with contrast dye, because of
possible renal effects; check with the prescriber.
 Nursing Implications (9 of 10)
 Assess for signs of hypoglycemia.
 If hypoglycemia occurs:
 Administer oral form of glucose if the patient is
conscious.
 Give the patient glucose tablets, liquid, or gel; corn
syrup; honey; fruit juice or nondiet soft drink; or have
the patient eat a small snack, such as crackers or a
half sandwich.
 Deliver D50W or IV glucagon if the patient is
unconscious.
 Monitor blood glucose levels.
 Nursing Implications (10 of 10)
 Monitor therapeutic response.
 Decrease in blood glucose levels to the level
prescribed by physician
 Measure HbA1c to monitor long-term compliance with
diet and drug therapy.
 Watch for and monitor hypoglycemia and
hyperglycemia.