Agents to Control Blood Glucose Levels

1. Agents to Control Blood Glucose Levels Chapter 38

2. Function of the Pancreas Gland • Endocrine Gland • Produces hormones in the islets of Langerhans • Exocrine Gland • Releases sodium bicarbonate and pancreatic enzymes directly into the common bile duct to be released into the small intestine • Neutralizes the acid chyme from the stomach and aids digestion

3. Insulin • Definition • Hormone produced by beta cells of the islets of Langerhans • Action • Released into circulation when the levels of glucose around these cells rise • Stimulates the synthesis of glycogen, the conversion of lipids into fat stored in the form of adipose tissue, and the synthesis of needed proteins from amino acids

4. Metabolic Changes Occurring When Insufficient Insulin is Released • Hyperglycemia: Increased blood sugar • Glycosuria: Sugar is spilled into the urine • Polyphagia: Increased hunger • Polydipsia: Increased thirst • Lipolysis: Fat breakdown • Ketosis: Ketones cannot be removed effectively • Acidosis: Liver cannot remove all of the waste products

5. Diabetes Mellitus • Characteristics • Complex disturbances in metabolism • Affects carbohydrate, protein, and fat metabolism • Clinical Signs • Hyperglycemia (fasting blood sugar level greater than 126 mg/dL) • Glycosuria (the presence of sugar in the urine)

6. Disorders Associated With Diabetes • Atherosclerosis: Heart attacks and strokes related to the development of atherosclerotic plaques in the vessel lining • Retinopathy: With resultant loss of vision as tiny vessels in the eye are narrowed and closed • Neuropathies: With motor and sensory changes in the feet and legs and progressive changes in other nerves as the oxygen is cut off • Nephropathy: With renal dysfunction related to changes in the basement membrane of the glomerulus

7. Classifications of Diabetes Mellitus • Type 1, Insulin-Dependent Diabetes Mellitus (IDDM) • Usually a rapid onset; seen in younger people • Connected in many cases to viral destruction of the beta cells of the pancreas • Type 2, Non–Insulin-Dependent Diabetes Mellitus (NIDDM) • Usually occurs in mature adults • Has a slow and progressive onset

8. Clinical Signs and Symptoms of Hyperglycemia • Fatigue • Lethargy • Irritation • Glycosuria • Polyphagia • Polydipsia • Itchy Skin

9. Signs of Impending Dangerous Complications of Hyperglycemia • Fruity breath as the ketones build up in the system and are excreted through the lungs • Dehydration as fluid and important electrolytes are lost through the kidneys • Slow, deep respirations (Kussmaul’s respirations) as the body tries to rid itself of high acid levels • Loss of orientation and coma

10. Hypoglycemia • Definition • Blood sugar concentration lower than 40 mg/dL • Occurrence • Starvation • Lowering the blood sugar too far with treatment of hyperglycemia

11. Question Which of the following is a clinical manifestation of hyperglycemia? A. Edema B. Lack of thirst C. Itchy skin D. Hyperexcitability

12. Answer C. Itchy skin Rationale: Clinical signs and symptoms of hyperglycemia: fatigue; lethargy; irritation; glycosuria; polyphagia; polydipsia; itchy skin

13. Types of Insulin

14. Insulin • Actions • Hormone that promotes the storage of the body’s fuels • Facilitates the transport of various metabolites and ions across cell membranes • Simulates the synthesis of glycogen from glucose • Reacts with specific receptor sites on the cells

15. Insulin (cont.) • 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 • Pharmacokinetics • Various insulins available are processed within the body like endogenous insulin • Peak, onset, and duration vary based on preparation

16. Insulin (cont.) • Contraindications • There are no contraindications • Caution • Pregnancy and lactation • Adverse Effects • Hyperglycemia and ketoacidosis

17. Insulin (cont.) • Drug-to-Drug Interactions • When given with any drug that decreases glucose levels • Beta blockers

18. Site of Action of Drugs Used to Treat Diabetes

19. Sulfonylureas • First Generation • Associated with increase risk of cardiovascular disease • Second Generation • Advantage over 1st generation drugs • Excreted in urine and bile • Do not interact with as many protein bound drugs • Longer duration of action

20. Sulfonylureas (cont.) • Actions • Stimulate insulin release from the beta cells in the pancreas • They improve binding to insulin receptors • Indications • Adjunct to diet and exercise to lower blood glucose levels in type 2 diabetes

21. Sulfonylureas (cont.) • Pharmacokinetics • Rapidly absorbed from the GI tract and undergo hepatic metabolism • Excreted in the urine • Peak and duration varies with each drug • Contraindications • Allergy • Diabetic complications • Type 1 diabetes mellitus

22. Sulfonylureas (cont.) • Adverse Effects • Hypoglycemia • GI distress • Allergic skin reactions • Drug-to-Drug Interactions • Drugs that acidifies the urine • Beta blockers • Alcohol

23. Question Please answer the following statement as true or false. Second generation sulfonylureas have several advantages over first generation sulfonylureas including the fact that they interact with more protein bound drugs.

24. Answer False Rationale: Second generation sulfonylureas: Advantage over 1st generation drugs would be they are excreted in urine and bile; do not interact with as many protein bound drugs; longer duration of action

25. Nonsulfonylureas • Actions, Indications, Pharmacokinetics, Contraindications, Caution, Adverse Effects, Drug-to-Drug Interactions • Vary with the drug that is given

26. Glucose Elevating Agents • Actions • Increase the blood glucose levels by decreasing insulin release and accelerating the breakdown of glycogen in the liver to release glucose • Indications • Treatment of hypoglycemia • Pharmacokinetics • Rapidly absorbed and distributed throughout the body • Excreted in the urine

27. Glucose Elevating Agents (cont.) • Contraindications • Known allergy • Pregnancy and lactation • Caution • Hepatic dysfunction or cardiovascular disease • Adverse Effects • GI upset • Vascular effects • Drug-to-Drug Interactions • Thiazide diuretics • Anticoagulants

28. Use of Antidiabetic Agents Across the Lifespan

29. Question Which of the following is a primary action of glucose lowering agents? A. Accelerate the breakdown of glycogen B. Increase insulin release C. Improve binding to insulin receptors D. Decrease use of incretins

30. Answer A. Acceleratethe breakdown of glycogen Rationale: The action of glucose elevating agents is to increase the blood glucose levels by decreasing insulin release and accelerating the breakdown of glycogen in the liver to release glucose.

31. Prototype Insulin

32. Prototype Sulfonylureas – First Generation

33. Prototype Sulfonylureas – Second Generation

34. Prototype Nonsulfonylureas

35. Nursing Considerations for Insulin • Assessment: History and Physical Exam • Nursing Diagnosis • Implementation • Evaluation

36. Nursing Considerations for Oral Antidiabetic Agents • Assessment: History and Physical Exam • Nursing Diagnosis • Implementation • Evaluation

37. Nursing Considerations for Glucose Elevating Agents • Assessment: History and Physical Exam • Nursing Diagnosis • Implementation • Evaluation