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Drugs used for Diabetes Mellitus

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Drugs used for Diabetes Mellitus Introduction There are 2 types of diabetes mellitus: Type 1: Insulin-dependent diabetes mellitus (IDDM) Destruction of pancreatic ... – PowerPoint PPT presentation

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Title: Drugs used for Diabetes Mellitus


1
Drugs used for Diabetes Mellitus
2
Introduction
  • There are 2 types of diabetes mellitus
  • Type 1 Insulin-dependent diabetes mellitus
    (IDDM)
  • Destruction of pancreatic beta cells
  • Is the result of an autoimmune process
  • Type 2 Non-insulin dependent diabetes mellitus
    (NIDDM)
  • Results from a combination of insulin resistance
    and altered insulin secretion

3
Characteristics of Type 1 Type 2 Diabetes
Mellitus
4
Oral Antidiabetic Drugs
  • For the treatment of type 2 (non-insulin-dependent
    ) diabetes mellitus
  • Use only after diet modification exercise fail
    to produce glycemic control
  • Should be used to augment the effect of diet
    exercise, not to replace them

5
Summary of treatment targets for cardiovascular
risk factor intervention in diabetic patients
Evidence-based targets for managing cardiovascular risk factors Evidence-based targets for managing cardiovascular risk factors
Fasting blood glucose lt/ 6mmol/l
HbA1c lt 7
Total cholesterol lt 5mmol/l
LDL cholesterol lt 3 mmol/l
Blood pressure threshold for intervention -Target for treatment -if significant proteinuria 140/90mmHg lt/ 140/80mmHg lt/ 125/75mmHg
Recent guidelines recommend statin and low-dose aspirin treatment where the 10-year coronary heart disease ridk is less than 15 -before adding aspirin ensure blood pressure is controlled -combination antihypertnsive treatment is necessary in the majority of patients to achieve blood pressure targets -other recommendations include HDLgt1.2mmol/l and fasting triglycerideslt1.7mmol/l Recent guidelines recommend statin and low-dose aspirin treatment where the 10-year coronary heart disease ridk is less than 15 -before adding aspirin ensure blood pressure is controlled -combination antihypertnsive treatment is necessary in the majority of patients to achieve blood pressure targets -other recommendations include HDLgt1.2mmol/l and fasting triglycerideslt1.7mmol/l
6
Sulphonylureas
  • Act mainly by augmenting insulin secretion
  • May also increase tissue response to insulin
  • Effective only when some residual pancreatic
    beta-cell activity is present
  • Considered for patients who are not overweight,
    or in whom Metformin (Glucophage) is
    contraindicated or not tolerated

7
Sulphonylureas (Contd)
  • Short-acting
  • Tolbutamide 0.5-1.5 g daily in divided doses,
    with or immediately after breakfast Max 2 g
    daily
  • Gliclazide (Diamicron) 40-160 mg daily in
    divided doses, with breakfast Max 320 mg daily
  • Intermediate-acting
  • Glipizide (Minidiab) 2.5-15 mg daily in divided
    doses, before breakfast Max 20 mg daily

8
Sulphonylureas (Contd)
  • Long-acting
  • Chlorpropamide (Diabinese) 250 mg daily with
    breakfast Max 500 mg
  • Glibenclamide (Daonil) 5 mg daily with or
    immediately after breakfast Max 15 mg daily
  • Glimepiride (Amaryl) 1-4 mg daily shortly
    before or with first main meal Max 4 mg daily

9
Sulphonylureas (Contd)
  • Contraindications
  • Severe hepatic and renal impairment
  • Breast-feeding and pregnancy
  • Elderly (Chlorpropamide, glibenclamide)
  • Adverse effects
  • Nausea, vomiting, diarrhoea and constipation
  • Increased appetite and weight gain
  • Hypoglycaemia
  • Hypersensitivity

10
Biguanides
  • Decreasing gluconeogenesis in the liver
  • Increase peripheral utilisation of glucose by
    muscle
  • Acts only in the presence of endogenous insulin
  • Metformin (Glucophage) is the only available
    biguanide
  • Is antihyperglycemic, not hypoglycemic
  • Recommended for obese or insulin resistant
    diabetic patients

11
Biguanides (Contd)
  • Metformin
  • 500 mg bd-tid Max 3 g, usually limit to 2 g
    daily
  • Contraindications
  • Hepatic or renal impairment (must withdraw)
  • Ketoacidosis
  • Predisposition to lactic acidosis severe
    dehydration, which is most likely to occur in
    patients with renal impairment

12
Biguanides (Contd)
  • Contraindications (Contd)
  • Infection, shock, trauma, heart failure,
    respiratory failure, recent myocardial
    infarction, severe peripheral vascular disease
  • Hepatic impairment, alcohol dependency
  • Use of iodine-containing x-ray contrast media (do
    not restart melformin until renal function
    returns to normal)
  • Pregnancy and breast-feeding

13
Biguanides (Contd)
  • Adverse effects
  • Decreased appetite
  • Nausea, vomiting and diarrhoea
  • Lactic acidosis (rarely)
  • Decreased absorption of vitamin B12 and folic
    acid
  • Allergic skin reactions

14
Biguanides (Contd)
  • Nursing alerts
  • Take metformin with meals and increase dosage
    slowly to minimise GI adverse effects
  • Lactic acidosis, characterised by drowsiness,
    malaise, bradycardia and hypotension is a rare
    but serious adverse effect. Since this is a
    medical emergency, report to the physician
    immediately if suspected

15
Alpha glucosidase inhibitor
  • Delay the digestion absorption of starch
    sucrose by inhibition of intestinal alpha
    glucosidase in the intestine
  • Acarbose (Glucobay)
  • 50-100 mg tid Max 200 mg tid

16
Alpha glucosidase inhibitor (Contd)
  • Contraindications
  • Pregnancy and breast-feeding
  • Inflammatory or malabsorptive intestinal
    disorders
  • Hepatic impairment
  • Severe renal impairment

17
Alpha glucosidase inhibitor (Contd)
  • Adverse effects
  • Flatulence, soft stools, diarrhoea, abdominal
    distention and pain
  • Liver dysfunction

18
Alpha glucosidase inhibitor (Contd)
  • Nursing alerts
  • Tablets should be taken with first mouthful of
    food
  • Absorption of sugar (sucrose) is blocked by
    acarbose. When hypogylcaemia occurs, only glucose
    should be given

19
Metglitinides
  • Stimulate insulin release
  • Rapid onset of action short duration
  • Taken shortly before meals

20
Metglitinides (Contd)
  • Repaglinide (NovoNorm)
  • 500 mcg 4 mg daily within 30 min before main
    meals Max 16 mg daily
  • Nateglinide
  • 60 mg tid within 30 min before main meals Max
    180 mg tid

21
Metglitinides (Contd)
  • Contraindications
  • Ketoacidosis
  • Pregnancy and breast-feeding
  • Severe hepatic impairment (for repaglinide)

22
Metglitinides (Contd)
  • Adverse effects
  • Hypoglycaemia
  • Hypersensitivity reactions including pruritus,
    rashes and urticaria
  • Abdominal pain, diarrhoea, constipation, nausea
    and vomiting (repaglinide)
  • Nursing alert
  • Administration must always be associated with
    meals

23
Thiazolidinediones
  • Also known as Glitazones
  • Reduce peripheral insulin resistance by enhancing
    uptake of glucose by skeletal muscle cells
  • Rosiglitazone (Avandia)
  • 4 mg daily in combination with metformin or a
    sulphonylurea Max 8 mg daily when with
    metformin
  • Pioglitazone (Actos)
  • 15-30 mg daily

24
Thiazolidinediones (Contd)
  • Contraindications
  • Hepatic impairment
  • History of heart failure, combination of insulin
  • Pregnancy and breast-feeding

25
Thiazolidinediones (Contd)
  • Adverse effects
  • GI disturbances, headache, anaemia
  • Weight gain
  • Oedema
  • Hypoglycaemia (less common for Pioglitazone)
  • Liver dysfunctions (rare)

26
Thiazolidinediones (Contd)
  • Nursing Alerts
  • Monitor liver function before treatment, then
    every 2 months for 1 year and periodically
    thereafter
  • Seek immediate medical attention if symptoms such
    as nausea, vomiting, abdominal pain, fatigue
    dark urine develop
  • Discontinue if jaundice occurs
  • Monitor closely for oedema other signs of
    congestive heart failure

27
Non-oral antidiabetic drugs
  • Insulin
  • Supplement the insulin secreted by pancreas
  • Promote uptake of glucose in muscle
  • Facilitate conversion of glucose to glycogen in
    liver, inhibit gluconeogenesis glycogenolysis
    in liver

28
Actions of Insulin
  • Glucose transport into muscle fat cells.
  • Increased glycogen synthesis.
  • Inhibition of gluconeogenesis.
  • Inhibition of lipolysis increased formation of
    triglycerides.
  • Stimulation of membrane-bound energy-dependent
    ion transporters (e.g. Na/K ATPase).
  • Stimulation of cell growth

29
Insulin (Contd)
  • They are divided into short, intermediate
    long-acting preparations
  • Short-acting
  • Neutral/soluble insulin
  • E.g. ActrapidHM, Humulin R
  • Insulin Lispro
  • E.g. Humalog
  • Insulin Aspart
  • E.g. NovoRapid

30
Insulin (Contd)
  • Intermediate-acting
  • Isophane insulin
  • E.g. ProtaphaneHM, Humulin N
  • Insulin zinc suspension
  • E.g. Monotard, Humulin L

31
Insulin (Contd)
  • Long-acting
  • Crystalline insulin zinc
  • E.g. UltratardHM
  • Insulin glargine
  • E.g. Lantus

32
Insulin (Contd)
  • Mixed Insulins
  • Biphasic isophane insulin
  • 30 soluble insulin/70 isophane insulin
  • E.g. Mixtard 30, Humulin 70/30
  • 20 soluble insulin/80 isophane insulin
  • E.g. Mixtard 20

33
Insulin (Contd)
  • Dose
  • Given through subcutaneous injection
  • According to the requirements
  • Short-acting
  • Usually inject 15-30 min before meals
  • Intermediate- long-acting
  • Once or twice daily
  • Can be given in conjunction with short-acting
    insulin

34
Insulin Formulations
35
Insulin (Contd)
  • Precautions
  • may decrease requirements in renal or hepatic
    impairment, some endocrine disorders, coeliac
    disease

36
Insulin (Contd)
  • Nursing Alerts
  • Teach patients how to prepare use the
    subcutaneous (SC) injection, and the usual areas
    used for SC injection including abdomen, thigh
    upper arm
  • Rotate the injection site within the general area
    employed. Allow about 1 inch between sites

37
Insulin (Contd)
  • Nursing Alerts (Contd)
  • Storage
  • Penfill
  • Cartridges not in use should be stored between
    2-8 ?
  • Cartridges used in the pen or carried as spare
    can be used for up to one month
  • Vial
  • Vials not in use should be stored between 2-8 ?
  • Vial in use can be kept at room temp for 6 weeks
    (Novo Nordisk)
  • Vials in use can be kept at room temp for 28 days
    (Lilly)

38
Hypoglycaemia
  • Nursing Alerts
  • Observe for and teach the patient about signs and
    symptoms of hypoglycaemia
  • Tachycardia, palpitations
  • Sweating
  • Nervousness, headache, confusion, drowsiness
  • Fatigue
  • Rapid treatment is required
  • Patient is conscious oral glucose should be
    given
  • Patient is unconscious IV glucose should be used

39
BREAK
40
Drugs that affect the gastrointestinal system
41
Introduction
  • Drugs used in gastrointestinal system or
    digestive disorder primarily exert their action
    by altering GI
  • Secretion
  • Absorption
  • Motility
  • They may act systemically or locally in the GI
    tract

42
Physiologic and pathologic (i.e. inflammatory)
prostaglandins
Cell activated by physical, chemical, or
hormone stimuli
Arachidonic acid
Traditional NSAIDs Block COX-1 and COX-2 enzymes
COX-2inhibitor NSAIDs Block COX-2 enzyme
Cyclooxygenase-1 (COX-1)
Cyclooxygenase-2 (COX-2)
Physiologic prostaglandins
Pathologic prostaglandins
  • Inflammation
  • Vasodilation,
  • ?Capillary permeability
  • Edema
  • Pain
  • Leukocytosis
  • Activatye white blood cells to
  • release inflammatory cytokines
  • GI protection (?gastric acid,?mucus
  • production, maintain blood flow to mucosa)
  • Renal protection (help maintain blood flow
  • and function)
  • Regulate smooth muscle tone in blood
  • vessels (e.g., vasodilation) and lungs
  • (e.g., bronchodilation)
  • Regulate blood clotting

43
Antacids Simethicone
  • Antacids
  • Drugs that neutralize or reduce the acidity of
    stomach duodenal contents by combining with HCl
    producing salt water
  • Relieve symptoms in dyspepsia, gastro-oesophageal
    reflux disease (GERD), peptic ulcers
  • Simethicone
  • Added to antacids as an antifoaming agent to
    relieve flatulence

44
Antacids Simethicone (Contd)
  • Antacids
  • Aluminium Hydroxide (500mg tablet /6 suspension)
  • 1-2 tablets chewed qid
  • Magnesium trisilicate (Mixture)
  • 5 BP Mixture 10ml tid po

45
Antacids Simethicone (Contd)
  • Antacids combination products
  • Triact tablet
  • Al(OH)3 Dried Gel 200 mg Mg(OH)2 150 mg
    Simethicone 25 mg
  • Chew 1-2 tab q4-6h
  • Gastrocaine suspension
  • Oxethazaine 10mg, Al(OH)3 Dried Gel 300mg,
    Mg(OH)2 100mg in 5 ml
  • Alumag suspension
  • Al(OH)3 Mg Trisilicate

46
Antacids Simethicone (Contd)
  • Antacids combination products (Contd)
  • Gelusil tablet
  • Mg Trisilicate Dried Aluminium Hydroxide gel
  • Mylanta tablet / suspension
  • CaCO3 Mg(OH)2
  • Simethicone
  • Dimethylpolysiloxane (Gasteel 40 mg tablet)

47
Antispasmodics
  • Relax smooth muscle
  • Relieve GI smooth muscle spasm
  • Include antimuscarinics others

48
Antispasmodics (Contd)
  • Antimuscarinics
  • Hyoscine Butylbromide (Buscopan)
  • Adult 20 mg qid po
  • Child 10 mg tid po
  • Propantheline bromide
  • 15 mg tid at least 1 hr before meals 30 mg at
    night Max 120 mg daily
  • Not recommended for children

49
Antispasmodics (Contd)
  • Side effects
  • Constipation
  • Urinary urgency and retention
  • Dry mouth
  • Transient bradycardia

50
Antispasmodics (Contd)
  • Others
  • Mebeverine HCl (Duspatalin)
  • Adult child over 10 years 135-150 mg tid
    preferably 20 min before meals
  • Peppermint oil (0.2 ml capsule)
  • 1-2 capsules tid
  • Not recommended for children under 15 years

51
Motility stimulants
  • Dopamine antagonists
  • Stimulate gastric emptying small intestinal
    transit
  • Enhance strength of oesophageal sphincter
    contraction
  • Sometimes used in non-ulcer dyspepsia
  • Useful in non-specific in cytotoxic-induced
    nausea vomiting (NV)

52
Motility stimulants (Contd)
  • Domperidone (Motilium)
  • NV
  • adult 10-20 mg q4-8h
  • Child 200-400 mcg/kg q4-8h
  • Functional dyspepsia
  • 10-20 mg tid before food 10-20 mg at night
  • Not recommended for children

53
Motility stimulants (Contd)
  • Metoclopramide (Maxolon)
  • Adult 10 mg tid
  • 15-19 yrs under 60 kg 5 mg tid
  • 1-14 yrs 1 mg bd to 5 mg tid depend on age
  • Diagnostic procedures
  • Adult 10-20 mg five to ten min before exam
  • Child 1-5 mg depends on age

54
Motility stimulants (Contd)
  • Side effects
  • May raised prolactin concentration
  • Rashes other allergic reactions
  • Acute dystonic
    reaction
    reported
  • Extrapyramidal effects (Metoclopramide more
    prominent)

55
Motility stimulants (Contd)
  • Nursing Alert
  • For patients under 20 yrs
  • Metoclopramide should be used restricted to
    severe intractable vomiting of known cause,
    vomiting of radiotherapy cytotoxics, aid to GI
    intubation, pre-medication
  • Dose based on basis of body-weight

56
Ulcer-healing drugs
  • Peptic ulceration commonly involves the stomach,
    duodenum lower oesophagus
  • Due to imbalance between cell-destructive
    cell-protective effects
  • Helicobacter pylori NSAIDs can weaken the
    defences
  • Relapse is common when treatment ceases

57
Ulcer-healing drugs (Contd)
  • Include several groups of drugs
  • H2-receptor antagonists
  • Chelates complexes
  • Prostaglandin analogues
  • Proton pump inhibitors

58
H2-receptor antagonists
  • Histamine acts on receptors located on parietal
    cells to increase production of HCl
  • Block histamine H2-receptors
  • Heal gastric duodenal ulcers by reducing
    gastric acid output
  • Relieve gastro-oesophageal reflux disease
  • May occasionally be used for patients with
    frequent severe recurrences for the elderly who
    suffer ulcer complications

59
H2-receptor antagonists (Contd)
  • Cimetidine
  • Adult 400 mg bd Max 2.4 g daily (rarely)
  • Child 20-30 mg/kg daily in divided dose
  • Famotidine
  • 20-40 mg bd
  • Not recommended for children
  • Nizatidine
  • 150-300 mg bd
  • Not recommended for children
  • Ranitidine
  • Adult 150 mg bd
  • Child 2-4 mg/kg bd Max 300 mg daily

60
H2-receptor antagonists (Contd)
  • Side effects
  • Diarrhoea other GI disturbances
  • Altered liver function tests
  • Headache, dizziness, rash

61
H2-receptor antagonists (Contd)
  • Nursing Alerts
  • Cimetidine is a CYP450 inhibitor, avoid in
    patients on warfarin, phenytoin theophylline
  • Patients may experience dizziness or drowsiness
    during early therapy, especially in the elderly.
    Assistance may be required for ambulatory
    activities

62
Chelates complexes
  • Sucralfate
  • Complex of AL(OH)3 sulphated sucrose
  • Minimal antacid properties
  • Protect the mucosa from acid-pepsin attack in
    gastric duodenal ulcers
  • 2 g bd or 1 g qid 1 hr before meals at bedtime
    Max 8 g daily
  • Not recommended for children

63
Chelates complexes
  • Side effects
  • Constipation, diarrhoea, gastric discomfort
  • Dry mouth
  • Headache, nausea
  • Hypersensitivity reactions

64
Prostaglandin analogues
  • Misoprostol
  • Synthetic prostaglandin analogue (Prostaglandin
    E)
  • Antisecretory protective properties
  • Inhibit gastric acid secretion
  • Increase mucus bicarbonate secretion
  • Promote healing of gastric duodenal ulcers

65
Prostaglandin analogues (Contd)
  • Dose
  • 800 mcg daily in 2-4 divided doses
  • For prophylaxis of NSAID-induced gastric
    duodenal ulcer
  • 200 mcg 2-4 times daily
  • Not recommended for children

66
Prostaglandin analogues (Contd)
  • Side effects
  • Diarrhoea (may require withdrawal)
  • Abdominal pain, dyspepsia, flatulence, nausea
    vomiting
  • Abnormal vaginal bleeding
  • Nursing Alerts
  • Incidence of diarrhoea may be lessened by taking
    dose right after meals

67
Prostaglandin analogues (Contd)
  • Nursing Alerts (Contd)
  • Manufacturer advises not to be used in women of
    child-bearing age unless the pateint requires
    NASID therapy is at high risk of complications
    from NSAID-induced ulceration
  • Patients should take effective contraceptive
    measures be advised the risks of taking
    misoprostol if pregnant

68
Proton pump inhibitors
  • Inhibit gastric acid by irreversibly blocking the
    hydrogen-potassium adenosine triphosphatase
    enzyme system (proton pump) of gastric parietal
    cell
  • Indicated for gastric duodenal ulcers
    gastro-oesophageal reflux disease
  • Suppress gastric acid more strongly for a
    longer time than H2-receptor antagonists

69
Proton pump inhibitors (Contd)
  • Omeprazole
  • Adult 10-40 mg daily
  • Child over 2 yrs 0.7-1.4 mg/kg daily Max 40 mg
    daily
  • IV injection or infusion is not recommended for
    children
  • Esomeprazole
  • 20-40 mg daily
  • Not recommended for children
  • Lansoprazole
  • 15-30 mg daily
  • Not recommended for children
  • Pantoprazole
  • 20-40 mg daily
  • Not recommended for children
  • Rabeprazole
  • 10-20 mg daily
  • Not recommended for children

70
Proton pump inhibitors (Contd)
  • Side effects
  • GI disturbances
  • Headache
  • Hypersensitivity reactions

71
END
72
Unawareness of drugs brand name
  • Patient has a documented allergy to Zyloric
  • Allopurinol was prescribed to this patient
  • The doctor prescribing was not aware that
    Zyloric was the brand name for Allopurinol

73
Tips
  • Check out the contents of the preparation if
    brand name is used before prescribing, dispensing
    or administration

74
(No Transcript)
75
Improper Drug Abbreviation
  • IV Mitoxantrone was prescribed
  • The abbreviation MTX was put on the label
  • An injection of Methotrexate was prepared instead
    according to the abbreviation on the label
  • Methotrexate was administered to the patient as a
    result

76
Tips
  • Write drug name in full
  • Do not use unauthorised abbreviations
  • Cross check the dose name of the drug before
    preparation administration

77
Repeated Pethidine Injection
  • Patient was given a Pethidine injection at AE
    via a verbal order
  • Nurse forgot to record this order in MAR
  • Prescribing Dr had not confirmed the verbal order
    in the prescription
  • A second dose of Pethidine was administered in
    the ward
  • Patient collapsed as a result of overdose of
    Pethidine

78
Tips
  • Pethidine is a Dangerous Drug should not be
    ordered through verbal orders
  • For other non-DD, give a verbal order only in
    emergency exceptional circumstances
  • Record the verbal instruction in the MAR
    immediately as verbal order
  • After writing down the instruction, read back the
    details to the Dr for double checking

79
Self-medication of Paracetamol
  • Patient was transferred from medical ward to ICU
    with high plasma level of Paracetamol
  • Patient was treated with N-acetylcysteine
    infusion as an antidote
  • Patient later admitted that she had taken
    approximately 15 tabs of Paracetamol (private
    medications) in the medical ward to relieve her
    leg pain

80
Tips
  • Put patients brought-in medicines into safe
    custody
  • Do not administer the patients own medicines in
    hospital unless they have been positively
    identified, specifically prescribed when
    supplies are not immediately available inside the
    hospitals

81
Glibenclamide or Citalopram
  • An in-patient presented with severe hypotension
    vomiting
  • A review of the MAR revealed that Daonil
    (Glibenclamide) was written right above the
    prescription for Citalopram in pencil
  • Upon investigation, it was discovered that some
    nursing staff gave Citalopram to the patient
    whilst others gave Glibenclamide

82
Tips
  • Familiarise with the medication /or the patient
  • If there is uncertainty or confusion about a
    particular prescription, always consult with the
    prescriber
  • Adequate communication between staff is the key
    to preventing errors

83
Wrong Drug Name
  • Martindale 1 drop tds both eyes was prescribed
  • Martindale is the name of the drug company that
    makes the eye drops

84
Tips
  • Prescribe in generic rather than trade name as
    trade names dont usually give indications of
    their constituents

85
Inappropriate Drug Dosage
  • A 10 month old baby was prescribed Cotrimoxazole
    suspension 20mg bd
  • Cotrimoxazole is a combination product containing
    Sulphamethoxazole 200mg Trimethoprim 40mg per
    5ml
  • 240mg per 5 ml 20mg 0.42ml
  • It was later clarified that the dose 20mg refers
    to the Trimethoprim component
  • Thus 120mg cotrimoxazole should have been
    prescribed

86
Tips
  • Should clearly specify drug dosage especially for
    combination product
  • Clarify with prescriber if in doubt
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