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1781207887.pptx just the introduction to DM
1.
2. • 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. T e2
2cuencs oioneí
Ptevent n featuics
Body habitu
Retoac dosis Fiequen Seldom, unless under stres
OftCnuiineces ary
tiequen
4. • For the treatment of type 2 (non-insulin-
dependent) diabetes mellitus
• Use only after diet modification 8 exercise
fail to produce glycemic control
• Should be used to augment the effect of
diet & exercise not to replace them
6. • 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
tolerated
7. • Short-acting:
• Tolbutamide: 0.5-1.5 g daily in divided doses with or
immediately after breakfast; Max: 2 g daily
• Gliclazide (Diemicro ): 40-160 mg daily in divided
doses with breakfast; Max: 320 mg daily
• Intermediate-acting:
• Glipizide (MinidiaŁØ): 2.5-15 mg daily in divided
doses before breakfast; Max: 20 mg daily
8. • Long-acting:
• Chlorpropamide (Diabines ): 250 mg daily
with breakfast; Max: 500 mg
• Glibenclamide (Daoni ): 5 mg daily with or
immediately after breakfast• Max: 15 mg daily
• Glimepiride (Amary ):1-4 mg daily shortly
before or with first main meal•Max: 4 mg daily
9. • 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
Hype sensitivity
10. • Decreasing gluconeogenesis in the liver
• Increase peripheral utilisation of glucose by
• Acts only in the presence of endogenous insulin
• Metformin (G/ucophag ) is the only available
biguanide
• Is antihyperglycemic, not hypoglycemic
• Recommended for obese or insulin resistant
diabetic patients
11. • Metformin:
• 500 mg bd-tid; Max: 3 g, usually limit to 2 g daily
• Contraindications:
• Hepatic or renal impairment (must withdraw)
Ketoacidosis
• Predisposition ło lactic acidosis: severe dehydration
which is most likely to occur in patients with renal
impairment
12. • Contraindications (Cont d):
• 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
eturns to normal)
Pregnancy and breast-feeding
13. « Adverse effects:
• Decreased appetite
• Nausea, vomiting and diarrhoea
• Lactic acidosis (rarely)
• Decreased absorption of vitamin B 2 Înd folic
acd
• Allergic skin reactions
14. • 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. • Delay the digestion & absorption of starch
& sucrose by inhibition of intestinal alpha
glucosidase in the intestine
• õ0-100 mg tid• Max: 200 mg tid
16. • Contraindications:
• Pregnancy and breast-feeding
• Inflammatory or malabsorptive intestinal
disorders
• Hepatic impairment
• Severe renal impairment
18. « 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. • Stimulate insulin release
• Rapid onset of action & short duration
• Taken shortly before meals
23. Thiazolidmediones
• 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 metformín
• Pioglitazone (ACtO )•
15-30 mg daily
24. • Contraindications:
• Hepatic impairment
• History of heart failure, combination of insulin
• Pregnancy and breast-feeding
25. « Adverse effects:
• GI disturbances, headache anaemia
• Weight gain
Oedema
• Hypoglycaemia (less common for
Pioglitazone)
• Liver dysfunctions (rare)
26. • 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. • 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. • 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. • They are divided into short, intermediate &
long-acting preparations:
• Short-acting:
• Neutral soluble insulin
E.g. Actrapid@HM,Humulin R6
• Insulin Lispro
E.g. Humalog6
• Insulin Aspart
E.g. NovoRapid@
33. • Dose:
• Given through subcutaneousinjection
• 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 Injection 2h-4h Oh-I2h
lscjahane insulin 5h-12h
lnsulin zinc suspension 3h-f›h 12h-16h
Insrili n zJnc .suspend itan 5h- Uh ?
4
h
-
3
+
)
h
solubleñ isopha re 3h-8h
35. • Precautions:
• may decrease requirements in renal or
hepatic impairment, some endocrine
disorders coeliac disease
36. • 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. « Nursing Alerts (Cont'd):
• Storage
Penfill
• Cartridges not in use shOUld be stored between 2-8 L
• 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 bekept at room temp for 28days (Lilly)
38. • Nursing Alerts:
• Observe for and teach the patient about signs
and symptoms of hypoglycaemia
Tachycardia, palpitałions
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.
40.
41. • 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.
43. • Antacids
• Drugs that neutralize or reduce the acidity of
stomach & duodenal contents by combining
with HCI & 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
• Aluminium Hydroxide (500mg tablet
6% suspension)
1-2 tablets chewed qid
• Magnesium trisilicate (Mixture)
5% BP Mixture: 10mI tid po
47. • Relax smooth muscle
• Relieve GI smooth muscle
spasm
• Include antimuscarinics &
others
48. • Antimuscarinics:
• Hyoscine Butylbromide (Buscopan6)
Adult: 20 mg qid po;
Child: 10 mg tid po
• Propantheline bromide
15 mg łid at least 1 hr belore meals & 30 mg at
night Max: 120 mg daily
Not recommended for children
49. • Side effects:
• Constipation
• Urinary urgency and retention
• Dry mouth
• Transient bradycardia
50. • Others:
• Mebeverine HCI (DuspatalinØ)
Adult & child over 10 years: 135-150 mg tid
preferably 20 min before meals
• Peppermintoil (0.2 ml capsule)
1-2 capsules tid
Not recommended for children under 15 years
51. • 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 (N&V)
52. N&V:
adult: 10-20 mg q4-8h
Child: 200-400 mcg/kg q4-8h
• Functional dyspepsia
10-20 mg tid before food & 10-20 mg ał night
Not recommended for children
53. • 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. • Side effects:
May raised prolactin concentration
Rashes & other allergic reactions
Acute dystonic
reaction reported
Extrapyramidal effects
(Metoclopramide more prominent)
55. « 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. • Peptic ulceration commonly involves the
stomach, duodenum lower oesophagus
• Due to imbalance between cell-destructive
& cell-protective effects
• Helicobacter pyIO I & NSAIDs can weaken
the defences
• Relapse is common when treatment
ceases
57.
58. H2-receptorantagonists
• Histamine acts on receptors located on
parietal cells to increase production of HCI
• 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. • 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
• Niza idine
• 150-300 mg bd
• Not recommended for children
• Ranitidine
• Adult: 150 mg bd
• Child: 2-4 mg kg bd; Max: 300 mg daily
60. • Side effects:
• Diarrhoea & other GI
disturbances
• Altered liver function tests
• Headache, dizziness, rash
61. • 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
ambulatoryactivities
62. he ates complexes
• Sucralfate
• ComplEłx 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
65. • Dose:
• 800 mcg daily in 2-4 divided doses
• For prophylaxis of NSAID-induced
gastric & duodenal ulcer
200 mcg 2-4 times daily
66. • 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 (Cont d)
« Nursing Alerts (Cont'd):
• 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. • 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-receptorantagonists
69. • 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
Not recommended for childien
• Lansoprazo/e
15-30 mg daily
• Not recommended fOf Children
• Pantoprazole
20-40 mg daily
Not recommended for children
• Rabep azole
10-20 mg daily
Not recommended for children
70. • Side effects:
• GI disturbances
Headache
• Hypersensitivity reactions
71.
72. • 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. • Check out the contents of the preparation if brand name
is used before prescribing dispensing or administration
74. To: Assoc. Prof. WilliamC .CHUI
Chief ofPharmacy Scarier, HKW Cluster,HA
Reply of Drug Incident Report September 2004
40a
75. • IV Mitoxantrone was prescribed
• The abbreviation MTX’ was put on the label
• An injection of Methotrexatewas prepared
instead according to the abbreviation on the
label
• Methotrexate was administered to the patient as
a result
76. • Write drug name in full
• Do not use unauthorised abbreviations
• Cross check the dose & name of the drug before
preparation & administration
77. • Patient was given a Pethidine injection at ARE 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. • Pethidine Is a Dangerous Drug & should not be ordered
through verbal o ders
• 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 Do for double checking
79. • Patient was transferred from medical ward ło ICU with
high plasma level of Paracetamol
• Patient was treated with N-acetylcysteine infusion as an
antidołe
• Patient later admitted that she had taken approximately
15 tabs of Paracetamol (private medications) in the
medical ward to relieve her leg pain
80. • Put patients brought-in medicines into safe custody
• Do not administer the patient's own medicines in hospital
unless they have been positively identified specifically
prescribed & when supplies are not immediately
available inside the hospitals
81. • 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
GBibencla ide
82. • 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. • Martindale 1 drop tds both eyes was prescribed
• Martindale is the name of the drug company that
makes the eye drops
84. • Prescribe in generic rather than trade name as trade
names don't usually give indications of their constituents
85. • A10 month old baby was prescribed Cotrimoxazole
suspension 20mg bd
• Cotrimoxazole is a combination product containing
Sulphamethoxazole 200mg & Trimethoprim 40mg per
Sml
• 240mg per 5 ml & 20mg - 0.42mI
• it was later clarified that the dose 20mg refers to the
Trimethoprim component
• Thus 120mg cotrimoxazoleshould have been prescribed
86. • Should clearly specify drug dosage especially for
combination product
• Clarify with prescriber if in doubt
