non insulin meds

selective sodium glucose transporter 2 inhibitors (SGLT2i) indications

ex: dapagliflozin (fargixa), empagliflozin (jardiance), canagliflozin (invokana)

• first line therapy for people with cardiovascular disease, heart failure, and chronic kidney disease

• decrease the progression of diabetic kidney disease

• dapaglifloxin and empagliflozin are FDA approved for treatment of HFrEF and HFpEF even if not T2DM

• approved for type 2 diabetes in adults and children aged 10 years and older

SGLT2i contraindications

• hx diabetic ketoacidosis

• high risk for bone fractures

• pregnancy

(glucose lowering efficacy is intermiate to high)

SGLT2i mech of action

glucose transport protein located in proximal renal tubules that facilitates glucose reabsorption

• SGLT2 inhibitors prevent glucose reabsorption in kidneys, preventing urinary glucose excretion and thereby lowering BG levels

• SGLT2 inhibitors promote sodium excretion, leading to reduction in intravascular circulating blood volume and decreasing preload

SGLT2i side effects

• genital fungal infection (vulvovaginal candidiasis)

• necrotizing faciitis on perineum (rare)

• UTI including severe UTI with pyelonephritis and urosepsis (rare)

• hypotension and dehydration (lead to AKI but rare)

• bone fractures

SGLT2i nursing admin considerations

• teach pt to monitor for genital fungal infection and UTI

• monitor volume status, BP, and renal function

• DKA rare but discont and treat promptly if suspected (can have DKA with normal BG)

• discont 3-5 days before scheduled surgery, during criticalm illness, and prolonged fastign to mitigate potential risk

glucagon like peptide 1 receptor agonist (GLP-1 RA) indications

(ex: semaglutide, dulaglutide, liraglutide)

• rec along lifestyle interventions for people w/concurrent CVD, HF, and/or CKD

• GLP-1 RA first line therapy for DM2 along w/lifestyle interventions for ppl who overweight or obese

• FDA approved for tx of MASH

GLP-1 RA contraindications

• ppl with personal or family hx of medullary thyroid cancer (thyroid c-cell tumor)

• ppl with MEN2 due to association w/medullary thyroid cancer

• high risk for pancreatitis and/or gallbladder disease

• not for people w/gastroparesis

• pregnancy

• not approved anybody <18

GLP-1 RA mech of action

activates receptors on incretin hormone glucagon-like peptide-1 to lower blood glucose by multiple mechanisms:

• stimulates glucose dependent release of insulin

• inhibits release of glucagon after a meal (postprandial)

• slows gastric emptying

suppresses appetite

GLP-1 RA also improves insulin sensitivity by multiple mechanisms (partly due to weight loss)

GLP-1 RA common side effects

• GI intolerance common (n/v, abd discomfort, decreased appetite, diarrhea, constipation) diminish over time

• fatigue

• AKI due to dehydration w/severe GI reactions

• sarcopenia

• potential for ileus

• pancreatitis and gallbladder disease

• injection site irritation

• possible early worsening of diabetic retinopathy and other eye issues → blindness

GLP-1 RA nursing admin considerations

• dose initially titrated up to minimize GI distress (teach to decrease meal size, stop eating once full, reduce high fat spicy foods)

• monitor for abd pain assoc. with pancreatitis or gallbladder disease

• delays gastric emptying (can leave food in stomach despite fasting and increase risk aspiration during anesthesia or deep sedation)

• rec close monitoring retinopathy in high risk adults (older adults and those with T2DM for > 10 yrs)

• rotate injection site

dual glucose dependent insulinotropic polypeptide (GIP) agonist and glucagon like peptide-1 (GLP-1) receptor agonist (dual GIP and GLP-1 RA) indications

ex: tirzepatide

• may be preferred over GLP-1 when main goals are greater A1C reduction and weight loss

• has been found to decrease kidney disease, HF, and MASH

• mounjaro is approved for type 2 diabetes in adults and children aged 10+

same contraindications and side effects as GLP-1 RA

dual GIP and GLP-1 RA mech of action

binds to and activates both GIP and GLP-1 receptors. dual activation leads to several beneficial metabolic effects

• stimulates glucose dependent insulin secretion from pancreas

• improves insulin sensitivity in peripheral tissues

• reduces glucagon secretion, which helps lower BG levels

• delays gastric emptying, slowing absorption of glucose

• decreases appetite and food intake, contributing to weight loss

together, these actions help lower both fasting and postprandial blood glucose levels and support weight management in ppl w/type 2 diabetes or obesity

dual GIP and GLP-1 RA nurse admin considerations

• same as GLP-1 RA

• may reduce effectiveness of oral hormonal contraceptives bc it delays gastric emptying

• use nonoral contraceptive or add barrier method for 4 weeks after initiation and after each dose escalation

biguanides indications

ex: metformin or glucophage XR

• used for type 2 diabetes when glucose lowering is the primary treatment needed

• considered for diabetes prevention in selected high risk adults w/pre-diabetes

• may reduce risk of major adverse cardiovascular events

• does not reduce or increase dev or progression of diabetic kidney disease, HF, or MASH

biguanides contraindications

ppl with kidney disease (eGFR < 30 mL/min/2.73m² )

biguanides mech of action

• mostly suppresses gluconeogenesis. inhibits glucose production in the liver

• increases glucose uptake in skeletal muscle, fat, and liver cells to decrease insulin resistance

• slightly reduces intestinal glucose absorption

• can lower serum lipids, including LDL and triglycerides

biguanides side effects

• GI intolerance dt nausea, abd discomfort, diarrhea (diminishes over time)

• long term use associated w/b12 deficiency

• lactic acidosis (rare but more common in those w/renal insufficiency)

biguanides nursing admin considerations

• dose initially titrated up to minimize GI distress

• admin w/meals to reduce GI distress

• glycemic indices (A1C, fasting BG) and kidney function are routinely monitored in all pt with type 2 DM

• metformin should be withheld before admin of contrast media and for 48 hrs afterward. if pt develops contrast induced kidney failure, metformin can cause fatal lactic acidosis

dipeptidyl peptidase-4 inhibitors (DDP-4i) indications

ex: sitagliptin (januvia)

• add on drug therapy for pt who are inadequately controlled on metformin alone (ex: janumet is combo of sitagliptin and metformin)

• should not be combined w/GLP-1 agonists

• can be used as monotherapy when pt cannot tolerate or have contraindications to metformin

• DDP-4 inhibitors do not reduce or increase cardiovascular events

• do not significantly impact development or progression of diabetic kidney disease

DDP-4i contraindications

• pregnancy

• not FDA approved for treating children with type 2 diabetes

DDP-4i mech of action

• enhance action of incretin hormones GLP-1 and GIP

• block action of dipeptidyl peptidase-4 (DD-4) an enzyme that inactivates incretin hormones, therefore, they lower blood glucose by prolonging effect of incretins

DDP-4i side effects

generally well tolerated

• inflamed skin rash that can blister (rare)

• joint pain

• pancreatitis (rare)

DDP-4i nursing admin considerations

• monitor for hypersensitivity reaction (anaphylaxis or angioedema)

• observe pt for signs and symptoms of pancreatitis

thiazolidinediones (TZDs or glitazones) indications

ex: pioglitazone (actos)

prescribed to pt with coexisting metabolic dysfunctrion associated steatohepatitis (MASH)

TZDs or glitazones contraindications

HEART FAILURE

high risk bone fracture

active or history of bladder cancer

pregnancy

TZDs or glitazones mech of action

• increases insulin sensitivity by acting on adipose tissue and muscle to increase glucose utilization

• may also reduce glucose production in liver

• improves fibrosis and decreases inflammation and steatosis with NASH

TZDs or glitazones side effects

generally well tolerated

• fluid retention and subsequent HF (rare)

• decreased bone density and increased fracture risk

• increased risk bladder cancer

• liver failure (rare)

TZDs or glitazones nursing admin considerations

teach pt to monitor for edema, weight gain, and S/S of HF

sulfonylureas (second gen) indications

ex: glipizide, glyburide, glimepiride

• sulfonylureas are cheap and highly effective at lowering BG

• use is associated w/hypoglycemic episodes and they lose effectiveness over time

• newer noninsulin meds are preferred for glycemic control

• NOT recommended with CKD

only contraindication is pregnancy

sulfonylureas mech of action

lowers BG by stimulating the release of insulin from the pancreas

sulfonylureas side effects

• hypoglycemia, they lower BG regardless of serum BG level

• hypoglycemia more likely in ppl w/CKD or liver failure

sulfonylureas nursing admin considerations

• monitor for signs of hypoglycemia

• beta blockers can mask s/s hypoglycemia

• inform pt that when combined w/alc can result in disulfiram-like reaction (n/v, abd cramps, flushing, dizziness, headache, and hypoglycemia)

insulin indications

preferred initial insulin regimen for T2DM is a once daily basal insulin analog

• considered when glucose goals are not achieved w/other therapies or when severe hyperglycemia or symptomatic

• GLP-1 receptor agonists and dual GIP/GLP-1 receptor agonists are usually preferred over insulin when severe hyperglycemia or hyperglycemic crisis is absent

• if A1C is above goal and person already on GLP-1 RA or dual GIP/GLP-1 RA and basal insulin, then prandial insulin is initiated

• during pregnancy, insulin is preferred med for managing T2DM

insulin mech of action

maintains normal BG levels by facilitating cellular glucose uptake

• also stimulates liver to store glucose as glycogen

insulin common side effects

risk for hypoglycemia

injection site irritation

insulin nursing admin considerations

• monitor s/s of hypoglycemia

• to minimize hypoglycemia in pt w/DM2 who are starting insulin, start w/low basal dose and titrate gradually

• analog insulins cause less hypoglycemia and weight gain and lower A1C than human insulins