FINALS COVERAGE

I. ANTIDIABETIC AGENTS

ANTIDIABETIC AGENTS, as the name implies, are used to treat diabetes mellitus, the most common of all metabolic disorders.
Insulins and sulfonylureas are the most common antidiabetic agents

INSULIN is the only parenteral antidiabetic agent available for exogenous replacement of low levels of insulin. It is used to treat type 1
diabetes and to treat type 2 diabetes in adults who have no response to diet, exercise, and other agents.
Examples insulin analog or lispro (Humalog), insulin aspart (NovoLog), insulin glargine (Lantus), insulin glulisine (Apidra), insulin
detemir (Levemir), regular insulin (Humulin R), and NPH insulin (Humulin N).
Actions Insulin is a hormone that promotes the storage of the body’s fuels, facilitates the transport of various metabolites and
ions across cell membranes, and stimulates the synthesis of glycogen from glucose, of fats from lipids, and of proteins
from amino acids. Insulin does these things by reacting with specifi c receptor sites on the cell.
Indications Treatment of type 1 diabetes mellitus; treatment of type 2 diabetes mellitus in patients whose diabetes cannot be
controlled by diet or other agents; treatment of severe ketoacidosis or diabetic coma; treatment of hyperkalemia (in
conjunction with a glucose infusion to produce a shift of potassium into the cells [polarizing solution]); also used for
short courses of therapy during periods of stress (e.g., surgery, disease) in patients with type 2 diabetes, for newly
diagnosed patients being stabilized, for patients with poor control of glucose levels, and for patients with gestational
diabetes
Adverse The most common adverse effects related to insulin use are hypoglycemia and ketoacidosis, which can be controlled
Reactions with proper dose adjustments. Local reactions at injection sites, including lipodystrophy, also can occur. This effect is
lessened by rotation of injection sites
Contraindications Because insulin is used as a replacement hormone, there are no contraindications. Care should be taken during
and Cautions pregnancy and lactation to monitor glucose levels closely and adjust the insulin dose accordingly. Insulin does not
cross the placenta; therefore, it is the drug of choice for managing diabetes during pregnancy. Insulin does enter
breast milk, but it is destroyed in the GI tract and does not affect the nursing infant. However, insulin-dependent
mothers may have inhibited milk production because of insulin’s effects on fat and protein metabolism. The
effectiveness of nursing the infant should be evaluated periodically
Nursing ➢ Ensure that the patient is following a dietary and exercise regimen and using good hygiene practices to improve
Responsibilities the effectiveness of the insulin and decrease adverse effects of the disease.
➢ Gently rotate the vial containing the agent and avoid vigorous shaking to ensure uniform suspension of insulin.
➢ Select a site that is free of bruising and scarring to ensure good absorption of the insulin.
➢ Give maintenance doses by the subcutaneous route only and rotate injection sites regularly to avoid damage to
 muscles and to prevent subcutaneous atrophy.
➢ Give regular insulin intramuscularly or intravenously in emergency situations. Monitor response carefully to avoid
adverse effects; blood glucose monitoring is the most effective way to evaluate insulin dose.
➢ Monitor the patient for signs and symptoms of hypoglycemia, especially during peak insulin times, when these
signs and symptoms would be most likely to appear, to assess the response to insulin and the need for dose
adjustment or medical intervention.
➢ Always verify the name of the insulin being given because each insulin has a different peak and duration, and the
names can be confused.
➢ Use caution when mixing types of insulin; administer mixtures of regular and NPH insulins within 15 minutes after
combining them to ensure appropriate suspension and therapeutic effect.
➢ Store insulin in a cool place away from direct sunlight to ensure effectiveness. Predrawn syringes are stable for 1
week if refrigerated; they offer a good way to ensure the proper dose for patients who have limited vision.
➢ Monitor the patient during times of trauma or severe stress for potential dose adjustment needs.
➢ Monitor the patient’s food intake; ensure that the patient eats when using insulin to ensure therapeutic effect and
avoid hypoglycemia.
➢ Monitor the patient’s exercise and activities; ensure that the patient considers the effects of exercise in
relationship to eating and insulin dose to ensure therapeutic effect and avoid hypoglycemia
➢ Protect the patient from infection, including good skin care and foot care, to prevent the development of serious
infections and changes in therapeutic insulin doses.
➢ Monitor the patient’s sensory losses to incorporate his or her needs into safety issues, as well as potential
problems in drawing up and administering insulin. Help the patient to deal with necessary lifestyle changes,
including diet and exercise needs, sensory loss, and the impact of a drug regimen that includes giving injections,
to help encourage compliance with the treatment regimen.
➢ Instruct patients who are also receiving beta-blockers about ways to monitor glucose levels and signs and
symptoms of glucose abnormalities to prevent hypoglycemic and hyperglycemic episodes when SNS and warning
signs are blocked.
➢ Provide thorough patient teaching, including diet and exercise needs; measures to avoid adverse effects,
including proper food care and screening for injuries; warning signs of problems, including signs and symptoms
of hypoglycemia and hyperglycemia; the importance of increased screening when ill or unable to eat properly;
proper administration techniques and proper disposal of needles and syringes; and the need to monitor disease
status, to enhance patient knowledge about drug therapy and promote compliance.
SULFONYLUREAS AND OTHER ANTIDIABETIC AGENTS
Examples Sulfonylureas - chlorpropamide (Diabinese), tolazamide (Tolinase), and tolbutamide (Orinase), glimepiride (Amaryl),
glipizide (Glucotrol), and glyburide (DiaBeta

Other antidiabetic agents - acarbose (Precose) and miglitol (Glyset); the biguanide metformin (Glucophage); the
meglitinides repaglinide (Prandin) and nateglinide (Starlix); the thiazolidinediones pioglitazone (Actos) and
rosiglitazone (Avandia); the incretin mimetics exenatide (Byetta) and liraglutide (Victoza); the human amylin
pramlintide (Symlin); and the DDP-4 inhibitors linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia)
Actions The sulfonylureas stimulate insulin release from the beta cells in the pancreas. They improve insulin binding to insulin
receptors and may actually increase the number of insulin receptors. The other antidiabetic agents may delay glucose
absorption, increase glucose uptake or decrease insulin resistance
Indications They are indicated as an adjunct to diet and exercise to lower blood glucose levels in type 2 diabetes mellitus. They
have the off-label use of being an adjunct to insulin to improve glucose control in type 2 diabetics.
Adverse The most common adverse effects related to the sulfonylureas are hypoglycemia (caused by an imbalance in levels of
Reactions glucose and insulin) and GI distress, including nausea, vomiting, epigastric discomfort, heartburn, and anorexia.
(Anorexia should be monitored because affected patients may not eat after taking the sulfonylurea, which could lead
to hypoglycemia.) Allergic skin reactions have been reported with some of these drugs, and, as mentioned earlier,
there may be an increased risk of cardiovascular mortality, particularly with the fi rstgeneration agents.
Contraindications ➢ Sulfonylureas are contraindicated in the presence of known allergy to any sulfonylureas to avoid hypersensitivity
and Cautions reactions and in diabetes complicated by fever, severe infection, severe trauma, major surgery, ketoacidosis,
severe renal or hepatic disease, pregnancy, or lactation, which require tighter control of glucose levels using
insulin.
➢ These drugs are also contraindicated for use in type 1 diabetics, who do not have functioning beta cells and
would have no benefit from the drug. These drugs are not for use during pregnancy. Insulin should be used if an
antidiabetic agent is needed during pregnancy.
➢ Some of these drugs cross into breast milk, and adequate studies are not available on others. Because of the risk
of hypoglycemic effects in the baby, these drugs should not be used during lactation. Another method of feeding
the baby should be used. The safety and efficacy of these drugs for use in children have not been established.
Nursing ➢ Administer the drug as prescribed in the appropriate relationship to meals to ensure therapeutic effectiveness.
Responsibilities ➢ Ensure that the patient is following diet and exercise modifications to improve effectiveness of the drug and
decrease adverse effects.
➢ Monitor nutritional status to provide nutritional consultation as needed.
➢ Monitor response carefully; blood glucose monitoring is the most effective way to evaluate dose. Obtain blood
glucose levels as ordered to monitor drug effectiveness.
 ➢ Monitor liver enzymes of patients receiving pioglitazone or rosiglitazone very carefully to avoid liver toxicity;
arrange to discontinue the drug to avert serious liver damage if liver toxicity develops.
➢ Monitor patients during times of trauma, pregnancy, or severe stress, and arrange to switch to insulin coverage
as needed.
➢ Provide thorough patient teaching, including drug name, dosage, and schedule for administration; administration
technique if appropriate; need for food intake within specifi ed time period; signs and symptoms of hypo- and
hyperglycemia; skin assessment, including daily inspection of feet; signs and symptoms to report immediately;
measures to use when ill or unable to eat; proper diet and exercise program; hygiene measures; recommended
schedule for follow-up and disease monitoring; and the need for follow-up lab testing, to enhance patient
knowledge of drug therapy and to promote compliance.

GLUCOSE - ELEVATING AGENTS

Examples diazoxide (Proglycem) and glucagon (GlucaGen). (Glutose, InstaGlucose, and BD Glucose)
Actions These agents increase the blood glucose level by decreasing insulin release and accelerating the breakdown of
glycogen in the liver to release glucose.
Indications They are indicated for the treatment of hypoglycemic reactions related to insulin or oral antidiabetic agents, for the
treatment of hypoglycemia related to pancreatic or other cancers, and for short-term treatment of acute
hypoglycemia related to anterior pituitary dysfunction
Adverse Glucagon is associated with GI upset, nausea, and vomiting. Diazoxide has been associated with vascular effects,
Reactions including hypotension, headache, cerebral ischemia, weakness, heart failure, and arrhythmias; these reactions are
associated with diazoxide’s ability to relax arteriolar smooth muscle.
Contraindications Diazoxide has been associated with adverse effects on the fetus and should not be used during pregnancy. There are
and Cautions no adequate studies on glucagon and pregnancy, so use should be reserved for those situations in which the benefits
to the mother outweigh any potential risks to the fetus. Caution should be used during lactation because the drugs
may cause hyperglycemic effects in the baby. Caution should be used in patients with renal or hepatic dysfunction or
cardiovascular disease.
Nursing ➢ Monitor blood glucose levels to evaluate the effectiveness of the drug.
Responsibilities ➢ Have insulin on standby during emergency use to treat severe hyperglycemia if it occurs as a result of overdose.
➢ Monitor nutritional status to provide nutritional consultation as needed.
➢ Monitor patients receiving diazoxide for potential cardiovascular effects, including blood pressure, heart rhythm
and output, and weight changes, to avert serious adverse reactions.
➢ Provide thorough patient teaching, including drug name, dosage, and schedule for administration; signs and
symptoms of hyperglycemia; administration technique if indicated; signs and symptoms of adverse effects; need
for follow-up monitoring and laboratory testing if indicated; nutritional measures; and blood glucose monitoring,
to improve patient knowledge and increase compliance to drug regimen.