exam 5 - ch 9,10,16, 20 (pharm)

indications of blood glucose control

-FBG less than 100 mg/dL

-HgbA1c 4% to 6%

incretin hormones

secreted in response to presence of food in stomach

-works with insulin to prevent blood glucose from becoming to high after meals

-actions: increase insulin secretion, inhibit glucagon secretion, slow rate of gastric emptying

glucagon

hormone of starvation; release triggered by low blood glucose

glucose stored in liver and muscles

as glycogen

fats stored in fat cells

stored as triglycerides

noninsulin antidiabetic drugs

for type II DM

-hypoglycemia is considered an adverse effect

insulin stimulators

-lowers blood glucose levels by triggering the release of preformed insulin from beta cells

-second gen sylfonylurea agents: glimepiride, glipzide, glyburide

-meglitinide agents: nateglinide, repaglidine

insulin stimulators s/e and adverse reactions

-s/e: heartburn, n/v, abdominal pain, diarrhea, increased sun sensitivity; meglitinides URIs, back and joint pain, dizziness

-adverse: hypoglycemia; increase liver enzyme levels; over long periods, can cause beta cells to stop producing insulin

insulin stimulators drug interactions

-drugs that enhance hypoglycemic effect: aspirin, NSAIDs, beta blockers, antibiotics, warfarin

-drugs that reduce effectiveness: corticosteroids, furosemide, thiazide diuretics

insulin stimulators patient teaching/nursing implications

-sulfonylureas may decrease the effectiveness of certain contraceptive drugs

-assess for s/s of hypoglycemia BEFORE giving the drug

-do not give drug at same time as a drug that can increase hypoglycemic effect

-give drug with meal; if pt NPO, do not give

-patient should always carry sugar with them

indications of hypoglycemia

headache, hunger sensation, difficulty concentrating, nervousness, tremors, pale clammy skin, rapid heart rate, anxiety, confusion

biguanides

lower blood glucose levels by reducing the amount of glucose the liver releases and by reducing how much and how quickly the intestines absorb glucose in food

-metformin (immediate and extended release)

biguanides pt teaching/nursing implications

-do not take 24 hours before and 48 hrs after test that uses radioactive dye

-take with food

-does not alone cause hypoglycemia

-safe during pregnancy

-avoid alcohol- increases chance of lactic acidosis

-long term use associated with increased homocysteine levels

biguanides s/e and adverse reactions

-s/e: diarrhea, nausea, flatulence, and weight loss

-adverse reactions: lactic acidosis (s/s: n/v, vomiting, rapid and deep breathing, weakness)

insulin sensitizers (TZDs)

lower blood glucose levels by making insulin receptors more sensitive to insulin, which increases cellular uptake and use of glucose

-pioglitazone, rosiglitazone

insulin sensitizers- black box warning

drugs are not to be used by patients who have symptomatic heart failure or other specific types of cardiovascular disease

insulin sensitizers s/e and adverse reactions

-s/e: headache, sneezing, sore throat, hypoglycemia

-adverse: severe cardiovascular side effects, fluid retention, liver problems, macular edema

insulin sensitizers drug interactions

gemfibrozil, rifampn, and drugs used to treat HTN

-avoid alcohol; can affect blood glucose

alpha-glucosidase inhibitors

lowers blood glucose by preventing enzymes in the intestinal tract from breaking down starches and more complex sugars into glucose

-acarbose, miglitol

alpha-glucosidase inhibitors s/e and adverse reactions

-s/e: gas, bloating diarrhea

-adverse: worsening conditions associated with inflammation of bowel (colitis, crohn’s disease, intestinal obstruction), liver damage

alpha-glucosidase inhibitors nursing implications

-give these drugs at start of meal

-primarily prescribed to patients who have high blood glucose after meals

-work independently of insulin-can be used for type I

incretin mimetics

injectable drugs that act like natural gut hormones that are secreted in response to food in the stomach

-work with insulin to prevent blood glucose levels from become too high after meals by increasing insulin secretion, decreasing glucagon secretion and slowing the rate of gastric emptying (provide satiety)

-albiglutide, dulaglutide, exenatide, ozempic and mounjaro

incretin mimetics s/e and adverse reactions

-s/e: n/v, diarrhea, upper respiratory tract symptoms

-adverse: allergic reactions, pancreatitis in obese pt with type II, increased risk of thyroid cancer

s/s of pancreatitis

severe upper abdominal pain that radiates to the back, indigestion, n/v, bloating with distended abdomen, rapid heart rate, elevated amylase and lipase levels

incretin mimetics drug interactions

sulfonylureas increase risk for hypoglycemia, slow absorption of other drugs (i.e. antibiotics and contraceptives), take other drugs 1 hour before these

amylin analogs

injectable, non-insulin anti-diabetic drugs that are similar to natural amylin, which is a hormone produced by pancreatic beta cells that works with and is co-secreted with insulin

-prevent hyperglycemia by delaying gastric emptying and making the patient feel full

-pramlintide (symlin)

amylin analogs s/e and adverse reactions

-s/e: n/v, headache, abdominal pain, weight loss, fatigue

-adverse: dizziness; severe hypoglycemia esp if used with insulin (within 3 hours post injection)

amylin analogs drug interactions

can interfere with antibiotics and birth control, other drugs should be taken 1 hour before these

DPP-4 inhibitors

non-insulin antidiabetic drugs that help prevent hyperglycemia by reducing the amount of the enzyme DPP-4, which inactivates normal incretins, glucagon-like peptide and gastric inhibitory peptide

-this action allows the naturally produced incretins to be present and work with insulin to control BG levels

-alogliptin, linagliptin, saxaglipton, sitaglipton

DPP-4 inhibitors s/e and adverse reactions

-s/e: nasopharyngitis with cold like symptoms, diarrhea

-adverse: allergic reactions, acute or fatal pancreatitis, increased risk of HF with saxagliptin and alogliptin, severe joint pain, bullous pemphigoid

sodium-glucose cotransport inhibitors

lowers BG by preventing the kidney from reabsorbing glucose that was filtered from the blood into the urine- glucose in the urine is excreted rather than being moved back into the blood

-canaglifozin, dapagliflozin, empagliflozin, entrugliflozin

sodium-glucose cotransport inhibitors s/e and adverse

-s/e: increased need to urinate, positive glucose result on glucose strip for urine, weight loss

-adverse: vaginal yeast infections, UTI, kidney failure, hyperkalemia, ketoacidosis, increased risk of bladder cancer, allergic reactions, hypotension, dehydration

rapid acting insulin

lispro, aspart, glusiline

-onset: 30 mins

-peak 30-1,5hrs (asapart: 1-3 hrs)

short acting insulin

regular human insulin (humulin R, novolin R)

-onset: 30 mins

-peak: 2-4 hours

intermediate acting

mixes (novolin 70/30)

-onsets vary: 30mins-4 hrs

-peaks vary: 1-14hrs

long acting insulin

-glargine (lantus), detemir (levemir)

-onset: 2-4 hours

-peak: 12 hours (**lantus has none)

insulin s/e and adverse reactions

-s/e: mild allergic reaction around injection site; lipodystrophy

-adverse: hypoglycemia

mixing insulins

-clear: rapid and short acting, lantus and levemir

-all others are cloudy

-NEVER mix lantus and levemir with other insulins

-always draw up clear → cloudy

thiazides and thiazide-like diuretics

work at the distal convoluted tubule

-increases urine output by preventing water, sodium, potassium and chloride from being reabsorbed into the blood through the walls of the nephron

-chlorothiazide, hydrochlorothiazide, indapamide, metolazone

loop diuretics

works at the ascending loop of henle

-increases urine output by blocking active transport of chloride, sodium, potassium into the ascending loop

-can be ototoxic; discontinuing reverses changes

-bumetanide, furosemide

potassium sparing diuretics

works at the collecting duct

-increases excretion of water and sodium, leading to increased urine output without the loss of potassium in urine

-amiloride, spironolactone, triamterene

diuretics s/e and adverse reactions

-s/e: urinary urgency and frequency, dry mouth, increased thirst, lightheadedness, fluid and electrolyte imbalance; thiazide can increase uric acid- gout flare up

-adverse: dehydration (increased hr, low bp, decreased urine output, dry mouth w sticky coating on tongue, tenting of chest and forehead), hypokalemia, hyperkalemia (w K+ sparing)

-for diuretics + thiazides- monitor glucose levels, can cause elevated BS

benign prostatic hyperplasia

is a noncancerous growth of prostate gland, frequently seen as men age, and can have problems urinating

alpha 1-adrenergic receptor blockers

relax smooth muscle of the prostate and bladder outlet

testosterone inhibitors

shrink the prostate

dihydrotestosterone inhibitors (DHT)

shrink prostate by working as a counterfeit drug that mimics testosterone and binds to the enzyme that normally converts testosterone to DHT (less DHT = gland shrinks)

-dutasteride, finasteride

selective alpha 1 blockers

relax smooth muscle tissue in the prostate gland, neck of bladder, and urethra by binding to the alpha 1-adrenergic receptors in these tissues

-receptors activated - smooth muscle constricts- tightens prostate

-receptors bound to alpha1 blockers- smooth relaxes

-alfuzosin, silodosin, tamulosin, terazosin 1

DHT inhibitors nursing implications

-most common s/e is decreased interest in s*xual activity

-report breast enlargement, nipple drainage, or pain in testicles

-pregnant women should not handle drugs (men wear condoms)

selective alpha 1 blockers nursing implications

-ask patients whether they have a sulfa allergy (tamulosin)

-most common s/e is decreased interest in sexual activity

-change positions slowly- can cause low bp and cause dizziness

bladder anesthetics

oral drugs that get excreted into the urine and act as a local anesthetic on the mucous membranes of the urinary tract (used for UTI pain/burning)

-phenazopyridine (aspirin for bladder)

-can turn urine an orange-red color

-does not treat cause!!

urinary antispasmodics

-inhibit involuntary nerve-induced contractions of the detrusor muscle in the bladder wall

-oxybutynin, tolterodine, solifenacin, darifenacin, trospium chloride

urinary antispasmodic nursing implications

-s/e can include dry mouth, dry eyes, headache, constipations

-adverse reactions- irregularities of hr and chest pain

-avoid taking antihistamines- urinary retention and constipation

-these drugs decrease sweating and increase risk for heatstroke

HMG-CoA reductase inhibitors (statins)

drugs that lower blood LDL levels by slowing cholesterol production in the liver- do NOT remove dietary cholesterol from blood

-artovastatin, fluvastatin, lovastatin, pravastatin, rosuvastain

statins s/e and adverse reactions

-s/e: abdominal pain, headache, diarrhea, muscle pain

-adverse: liver function is affects; with high doses- rhabdomyolysis (muscle pain, soreness, stomach pain, brown urine and kidney failure)

statins nursing implications

-pt with diabetes may experience elevated BG levels

-contraindicated during pregnancy

-educate pt to stay on low cholesterol diet

-avoid grapefruit juice

-monitor signs of liver problems

selective cholesterol absorption inhibitors

stays in intestinal wall and acts on the epithelial cells to limit absorption of cholesterol from food and other sources in the body

-ezetimibe

fibric acid derivatives (fibrates)

effective in lower triglyceride levels and increasing HDL; little effect in lowering LDL levels

-can cause liver toxicity and gallstones

-gemfibrozil and fenofibrate

bile acid sequestrants

increase excretion of cholesterol and reduce LDL levels; form a solid compound with bile salts, which increases bile loss through feces

-normal fat digestion is disturbed- uncomfortable GI s/e

-reduce absorption of fat-soluble vitamins

niacin

one of the B complex vitamins found in animal proteins, green vegetables, and whole wheat

-s/e of flushing (take aspirin 30 mins before to reduce)

antihypertensives- general nursing implications

-review labs- kidney tests (BUN and creatinine), serum sodium and potassium

-assess for fluid imbalance, including edema or signs of dehydration

-change positions slowly- can cause orthostatic hypotension

-monitor potassium levels

-monitor BP every 4-8 hours at beginning of therapy

-take drug at same time; missed doses can cause rebound HBP

RAAS drugs (renin-angiotensin-aldosterone system)

decrease vasoconstriction and fluid volume, which lowers blood pressure

-ACE: captopril, enalapril, lisinopril, quinapril

-ARBs: losartan, valsartan

RAAS drugs nursing implications

-avoid sudden changes in position

-can cause hyperkalemia- avoid high potassium foods

-ACE can cause dry cough, will switch to ARBs

-report swelling of eyes, mouth, face, or tongue (angioedema)

-can cause severe birth defects

calcium channel blockers

decrease blood pressure by relaxing vascular smooth muscle in the coronary and systemic arteries, which decreases peripheral resistance

-amlodipine, diltiazem, felodipine, nicardipine, nifedipine, verapamil

calcium channel blockers nursing implications

-report swelling in legs- can be a sign of fluid retention

-avoided in patients with heart failure

-avoid grapefruit

-be alert for signs of stevens-johnson syndrome (life threatening skin condition)

-IV calcium channel blockers- check with RN or hcp regarding a bed with cardiac monitor

adrenergic agents

affect nervous system control of various organs and tissues by activating or blocking receptors that respond to the body’s natural adrenergic substances, epinephrine and norepinephrine

-beta blockers: end in “olol”

-all alpha blockers end with “zosin”

-alpha2-agonists: clonidine, methyldopa

beta blockers nursing implications

-withhold drug if hr is lower than 60, and bp is less than 90

-common s/e are decreased sexual ability, dizziness, drowsiness, difficulty sleeping, weakness, cold hands or feet

-report symptoms of depression

-can make the signs of hypoglycemia (except for sweating)

alpha blockers nursing implications

-s/e of first dose effect can be hypotension (may be given at night)

-s/e can include dizziness, headache, stuffy or runny nose

-weight pt at least 2x/week for fluid retention

alpha-agonists nursing implications

-can affect CNS (only for difficult to manage HBP)

-common s/e is dizziness, fatigue, dry. mouth, nasal congestion

-oral rinses, good oral care and sugarless can help decrease dry mouth

-right time and date on patch before placing on pt

vasodilators

directly affect the arterial and/or venous system to decrease peripheral resistance

-hydralazine, minoxidil

use of antihypertensive drugs

-used alone or in combination with diuretics to decreased elevated blood pressure

-s/e: hypotension, orthostatic hypotension, dizziness, weakness, confusion

-older adults at risk for dizziness- fall precaution

-garlic supplements can increase effect

-black licorice can decrease effects

antianginals

patients with atherosclerosis may experience angina due to plaque within the blood vessel, which leads to lack of blood flow and oxygen to the heart

-improve circulation and reduce cardiac workload: nitrates, beta blockers, calcium channel blockers

nitrates

dilate blood vessels by relaxing vascular smooth muscle in the peripheral venous system and reduce resistance to blood flow in the arterial system

-isosorbide mononitrate, nitroglycerin, topical 2% ointment, transdermal patch

nitrates s/e and adverse reactions

-s/e: throbbing headaches, slight drop in bp

-adverse: severe postural hypotension, reflex tachycardia, paradoxical bradycardia, vertigo, severe weakness

nitrates nursing implications

-monitor bp carefully

-mild headache can be treated with acetaminophen

-make sure to remove patches according to directions because patient need a drug-free period to avoid tolerance

-for patch or paste- choose a hairless area

-drugs for erectile dysfunction, if taken with nitrates, can cause a severe drop in BP

antidysrhythmics

works to make heart rhythm more regular and reduces serious dysrhythmias- affect the cells beating irregularly

-sodium channel blockers, beta blockers, potassium channel blockers, calcium channel blockers

sodium channel blockers

used to treat SVT and ventricular dysrhythmias, a-fib, v-fib

-quinidine, disopyramide, propafenone

sodium channel blockers nursing implications

-can cause hypotension and dysrhythmias

-avoid all OTC drugs

-quinidine can cause significant GI s/e

-older adults can experience dizziness and confusion

-monitor I+O- can cause urinary retention

beta blockers (as antidysrhythmics)

used to treat rapid dysrhythmias that originate above the ventricle

-acebutolol, propanolol, sotalol

beta blockers (as antidysrhythmics) nursing implications

-hold drug if hr is less than 60bpm or sbp is less than 90

-teach patients that stopping can cause serious complications

-can increase or decrease blood sugar levels; can mask signs of hypoglycemia

-depression can be a s/e

potassium channel blockers

used to convert a-fib or a-flutter to NSR; can also be used to treat dangerous ventricular arrhthymias

-amiodarone

*black box warning of hepatic impairment, pulmonary toxicity, and worsened arrhythmias

potassium channel blockers nursing implications

-most common s/e: photosensitivity, n/v, fatigue, hypotension

-monitor respiratory status

-can cause sensitivity to light and to wear dark sunglasses and protective clothing/sunscreen

-long term use may cause bluish discoloration of the face, neck or arms- is reversible

-need eye exams every 6-12 months

-report pain or swelling of scrotum

calcium channel blockers

used to treat SVT by slowing conduction of electrical impulses through SA and AV nodes

-diltiazem, verapamil

calcium channel blockers nursing implications

-avoid sudden changes in position

-do not cure - keep taking

-avoid grapefruit and grapefruit juice

-report swelling- can cause fluid retention

-avoid in pt with HF (d/t fluid retention)

-be alert for stevens-johnson syndrome

-if caring for a pt receiving IV, contact RN regarding cardiac monitor

cardiac glycosides

decrease the speed of conduction through the AV node, decreasing number of atrial polarizations- slow ventricular rate

-digoxin

calcium glycosides nursing implications

-monitor for digoxin toxicity (lack of appetite, n/v, vision changes); optimal levels range between 0.5 and 0.8 ng/mL

-monitor potassium levels

-take apical pulse before giving

inotropic drugs

affects contractility of the myocardium

-are used for symptom management in patients with advanced heart failure and in ICU to increase contractility

positive inotropic drugs

increases contractility and the ability of the heart to pump

-cardiac glycosides (digoxin) and phosphodiesterase inhibitors

-lead to improvement in cardiac output

negative inotropic drugs

decrease contractility and the ability of the heart to pump

inotropic drugs adverse reactions

digoxin toxicity (s/s- anorexia, n/v, visual disturbances, irregular hr); anxiety, depression, confusion

digoxin level and toxicity

-therapeutic level is 0.5 to 2 ng/mL

-for toxicity treatment= stop the drug, treat the symptoms

parkinsons disease

movement disorder associated with presence of Lewy bodies in the brain

-lewy bodies- protein deposits in brain cells associated with thinking, movement, memory- cause dementia

-not enough dopamine to modify excitatory signals

dopamine and dopamine agonists

have same chemical structure as natural dopamine and improve parkinson’s symptoms by increasing levels of dopamine in the brain to restore balance between Ach and dopamine action

-carbidopa/levodopa, pramipexole, ropinirole, rotigotine

dopamine agonists nursing implications

-give with 6-8 ounces of water at least 30-60 mins before eating

-monitor pt for hypoglycemia

-monitor for dysrhythmias and hypotension

-monitor liver function studies and CBC

-skin reactions common with the patch

dopamine agonists s/e and adverse reactions

-s/e: postural and general hypotension, headache, Gi disturbances, insomnia, dream abnormalities, decreased impulse control, confusion

-adverse: dyskinesia (involuntary muscle movements that look like uncoordinated dance movements); delirium, psychosis, hallucinations

COMT inhibitors

reduce the symptoms of PD by suppressing the activity of the COMT enzyme so that naturally occurring dopamine and dopamine agonist drugs remain active in the body longer, helping to restore ach-dopamine balance in the brain

-entacapone, tolcapone

COMT inhibitors s/e and adverse reactions

-s/e: GI upset, discoloration of the urine (brown/orange)

-adverse: can potentiate the dopaminergic adverse effects of levodopa and cause dyskinesia and hypotension; tolcapone leads to higher risk of severe liver failure

COMT nursing implications

-report signs of liver failure to HCP

-notify hcp if symptoms of worsening dyskinesia or psychosis may occur

-cannot be given with nonselective MAO inhibitors because of cardio risk

selective MAO-B inhibitors

allows existing dopamine to remain active in the brain longer by inhibiting MOA-B, which breaks down dopamine in the brain and body

-rasagiline, safinamide, selegiline

MOAB inhibitors s/e and adverse

-s/e: dry mouth, nausea, constipation, lightheadedness, confusion, hallucinations, drowsiness, photosensitivity

-adverse: severe hypotension; tyramine rich foods should be avoided because they can cause severe hypertensive crisis

MOAB inhibitors nursing implications

-avoid foods with large amounts of tyramine

-monitor vs, especially bp

-report s/s of hypertensive crisis (headache, palpitations, n/v)

-report worsening dyskinesia or psychosis