Antidiabetic Agents

Chapter 31
Joe Padilla
Rhonda Schantz
Valerie Horton

Diabetes Mellitus
* Complex disorder of carbohydrate, fat, and protein
metabolism primarily resulting from the lack of insulin
secretion by the beta cells of the pancreas or from
defects of the insulin receptors; commonly referred to
more simply diabetes. There are two major types of
diabetes: Type 1 and Type 2.

Type 1 diabetes mellitus

* A genetically determined autoimmune disorder involving
a complete or nearly complete lack of insulin production;
most commonly arises in children or adolescence.

* Formerly referred to as insulin dependent diabetes

mellitus (IDDM) or juvenile onset diabetes.

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 Type 2 diabetes mellitus
*A type of diabetes that most commonly presents in middle
age. The disease may be controlled by lifestyle
modifications, oral drug therapy, and/or insulin, but
patients are not necessarily dependent on insulin.

*May also be referred to as non-insulin dependent diabetes

mellitus (NIDDM) or adult onset diabetes.

Hypoglycemia
Hyperglycemia
*Hypoglycemia-a condition involving a blood glucose
level less that of 50mg/dL.

*Hyperglycemia- a condition involving a fasting blood

glucose level greater than or equal to 126mg/dL or any
blood glucose level greater than or equal to 200mg/dL.

Insulin
Short-Acting Insulin

* Regular insulin (Humulin R)-

dosage SC only- 0.5-1 unit/kg/day
doses are highly individualized to desired glycemic
control. SC doses of regular insulin are best given 30-
60 minutes before a meal.

*** Only insulin IV as a continuous infusion***

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 Intermediate-Acting Insulin
Rapid-Acting Insulin
* Isophane insulin suspension (NPH)
* Insulin zinc suspension (Lente)
- dosage 0.5-1 unit/kg/day SC only

* Insulin lispro (Humalog)

* Insulin aspart
- dosage 0.5-1 unit/kg/day SC only

Long-Acting Insulin
*Extended insulin zinc
suspension (Humulin
U Ultralente)
- dosage 0.5-1
unit/kg/day SC only
*Approved for once
daily dosage at
bedtime

Insulin
*Primary action- Exogenously
administered insulin functions
as a substitute for the
endogenous hormone. It
replaces the insulin that is
either not made at all or is
made defectively in the body
of a diabetic patient.
Exogenously administered
insulin restores the diabetic
patients ability to metabolize
carbohydrates, fats and
proteins, to store glucose in
the liver and to convert
glycogen to fat stores.
*Indications: Type 1 and Type 2
Diabetes

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 Side Effects/Adverse Reactions
* Hypoglycemia resulting from an insulin
overdose can result in shock and possibly
death.
* Adverse: Tachycardia, Headache,
lethargy, tremors, weakness, fatigue,
delirium, sweating, hypoglycemia, blurred
vision, dry mouth, hunger, nausea,
flushing rash, urticaria, anaphylaxis.

Sliding Scale Method

* This method, subcutaneous regular insulin
doses are adjusted according to blood
glucose test results.
* They are typically used in hospitalized
diabetic patients whose insulin
requirements may vary drastically because
of stress (e.g., infections, surgery, acute
illness), inactivity, or variable caloric
intake.

Oral Antidiabetic Agents

* Class: Biguanide
Metformin- (Glucophage,Glucophage
XR)
- dosage: PO 500 mg bid or 850 mg
qd;
max daily dose 2550 mg
* Class: Second generation sulfonylurea
Glipizide-(Glucotrol, Glucotrol XL)
-dosage: PO 5-40 mg qd (max single
dose
15 mg)
Gliburide-(Diabeta, Micronase,
Glynase Prestab)
-dosage: PO 1.25-20 mg/day divided
qd-bid
* Class: Combination
sulfonylurea/Biguanide
Gliburide/metformin
(Glucovance)
-dosage: PO 1-2 tabs qd-bid

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 Sulfonylureas
* Primary Action- is to force your pancreas to
make more insulin, which lowers your blood
sugar in order for this drug to work your
pancreas, must make some insulin.
* Indications: Type 2 diabetes
* Side Effects- low blood sugar, upset stomach,
skin rash, itching and weight gain.

Biguanides
* Primary Action- it lowers sugar by making
sure the liver doesn’t make too much sugar.
Lowers the amount of insulin in your body.
* Indications- Type 2 diabetes
* Side Effects- agranulocytosis, hemolytic
anemia, thrombocytopenia, cholestatic jaundice,
nausea, epigastric fullness, heartburn
• ***Combination (gliburide/metformin)-primary action and side
effects are the same***

Assessment
* Because various types of insulin are available, it is
always critical to patient safety to assess the type, dose,
and timing of the dosage before giving the drug.
* Before administering any type of insulin it is important
for the nurse to assess his or her own knowledge about
the disease processes and recommended treatment.
* Insulin is used to treat type 1 diabetes always and may
be used to treat type 2 diabetes who need the
medication when the oral agents are not therapeutic.
* Assessment of the order for the insulin is important so
that the correct route, type of insulin (e.g., clear [rapid
or regular] and cloudy [intermediate or NPH]), and
individualized of treatment is implemented.

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 Nursing Diagnoses
* Nursing diagnoses appropriate for patients receiving
insulin or the oral antidiabetic agents include the
following:
z Risk for injury related to changes in sensorium from the
pathology of diabetes.
z Risk for infection related to diabetes and it’s pathologic impact
on every cell of the body.
z Imbalanced nutrition, more than body requirements, related to
the disease process.
z Deficient knowledge related to diabetes mellitus, its
management, and the prevention of its complications.
z Ineffective therapeutic regimen management related to lack of
experience with significant daily treatment regimen.

Planning
* Goals for patients receiving insulin or oral
antidiabetic agents include the following:
• Patient remains free from self-injury and
complications of diabetes.
• Patient remains free from infection.
• Patient maintains adequate weight control
and dietary habits in the overall management
of diabetes.
• Patient states the effects of diabetes on body
function.

Planning
cont’d
z Patient remains compliant with the medical regimen.
z Patient states the importance of compliance to
medication regimens, lifestyle changes, dietary
restrictions, and high-risk behaviors.
z Patient states the action and side effects of insulin or
the oral hypoglycemic agents.

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 Implementation
* The nurse needs to always check blood glucose levels
(and other related lab values) before administering the
agent so that accurate baseline levels are documented.

* The nurse should always check any medication order at

least three times before administering the drug, and with
insulin there should be an additional check of the order.

* Insulin should be administered subcutaneously at a 90

degree angle unless the patient is emaciated, in which
case it is administered at a 45 degree angle.

Evaluation
* Most often, fasting blood glucose levels (>60 and <120,
or level designated by the physician) are used to
measure the degree of glycemic control.
* Patients with diabetes need to be monitored to make
sure they are complying with therapy.
* The nurse needs to watch the patient for manifestations
of hypoglycemia or hyperglycemia and monitor for
insulin allergy, which is manifested by local swelling,
itching, and redness at the injection site.

Research
* More than 800,000 Americans are diagnosed
annually with type 2 diabetes mellitus. Type 2
diabetes has reached epidemic proportions in
the United States and worldwide. An estimated
10% of American adults and almost 20% of
senior citizens have been diagnosed with type 2
diabetes, and 50% of total cases go undetected
each year.