CHAPTER 38:

AGENTS TO CONTROL
BLOOD GLUCOSE LEVELS

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 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

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 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)

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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

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 INSULIN #1

•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

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 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

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 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

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CLINICAL SIGNS AND SYMPTOMS OF
HYPERGLYCEMIA
•Fatigue
•Lethargy
•Irritation
•Glycosuria
•Polyphagia
•Polydipsia
•Itchy Skin

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 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

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USE OF ANTIDIABETIC AGENTS
ACROSS THE LIFESPAN

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TYPES OF INSULIN

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SITE OF ACTION OF DRUGS USED TO
TREAT DIABETES

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 QUESTION #1

Which of the following is a clinical manifestation

of hyperglycemia?
A. Edema
B. Lack of thirst
C. Itchy skin
D. Hyperexcitability

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 ANSWER TO QUESTION #1

C. Itchy skin

Rationale: Clinical signs and symptoms of

hyperglycemia: fatigue; lethargy; irritation;
glycosuria; polyphagia; polydipsia; itchy skin

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 INSULIN #2

•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

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 INSULIN #3

• 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

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 INSULIN #4

•Contraindications
• There are no contraindications
•Caution
• Pregnancy and lactation
•Adverse Effects
• Hyperglycemia and ketoacidosis

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 INSULIN #5

•Drug-to-Drug Interactions
•When given with any drug that decreases
glucose levels
•Beta blockers

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 NURSING CONSIDERATIONS FOR INSULIN

• Assess:
• History and Physical Exam
• Known allergy to any insulin and current status of
pregnancy or lactation
• Asthma or COPD, skin lesions; orientation and reflexes;
baseline pulse and blood pressure; respiration
• Exercise amount, skin, Glucose levels, and appropriate lab
values

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PROTOTYPE INSULIN

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 SULFONYLUREAS #1

•Bind to potassium channels on pancreatic beta

cells. They may improve insulin binding to
insulin receptors and increase the number of
insulin receptors
•First Generation
• Chlorpropamide(Diabinese)
• Tolazamide (generic)
• Tolbutamide (generic)

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 SULFONYLUREAS #2

•Second generation
•Glimepiride (Amaryl),
•Glipizide (Glucotrol)
•Glyburide (DiaBeta, and others).

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 SULFONYLUREAS #3

•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

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 SULFONYLUREAS #4

•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

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 SULFONYLUREAS #5

•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

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 SULFONYLUREAS #6

•Adverse Effects
•Hypoglycemia
•GI distress
•Allergic skin reactions
•Drug-to-Drug Interactions
•Drugs that acidifies the urine
•Beta blockers
•Alcohol

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PROTOTYPE SULFONYLUREAS –
FIRST GENERATION

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PROTOTYPE SULFONYLUREAS –
SECOND GENERATION

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 QUESTION #2

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.

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 ANSWER TO QUESTION #2

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

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 NONSULFONYLUREAS

•Several other antidiabetic agents are available. Although

these drugs are structurally unrelated to the sulfonylureas,
they frequently are effective when used in combination
with sulfonylureas or insulin

•Actions, Indications, Pharmacokinetics, Contraindications,

Caution, Adverse Effects, Drug-to-Drug Interactions
• Vary with the drug that is given

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 NURSING CONSIDERATIONS FOR ORAL
ANTIDIABETIC AGENTS

•Assess:
•History and Physical Exam
•Severe renal or hepatic dysfunction, skin, VS,
LS
•Diet and nutritional intake, activity level,
glucose levels and appropriate lab values
•Urinalysis

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PROTOTYPE NONSULFONYLUREAS

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 HYPOGLYCEMIA

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

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 GLUCOSE ELEVATING AGENTS #1

•Raise the blood level of glucose when severe

hypoglycemia occurs (<40 mg/dL)

•Diazoxide (Proglycem)
•Glucagon (GlucaGen)

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 GLUCOSE ELEVATING AGENTS #2

•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
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 GLUCOSE ELEVATING AGENTS #3

•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

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 NURSING CONSIDERATIONS FOR GLUCOSE
ELEVATING AGENTS

•Assess:
• History and Physical Exam
• History of allergy to thiazides if using diazoxide
• Severe renal or hepatic dysfunction and CV disease
• Orientation and reflexes and baseline pulse, blood
pressure, and adventitious sounds
• Glucose levels and appropriate lab values

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 QUESTION #3

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

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 ANSWER TO QUESTION #3

A. Accelerate the 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.

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