Students are expected to behave respectfully and considerately toward lecturers and fellow students. Disruptive behaviors like talking and using electronic devices without silencing them will be kept to a minimum, as they distract from the classroom environment. The lecturer reserves the right to end the class at any time due to disruptive or rude behavior.

1. Civility Clause….
Students are expected to behave toward
lecturers and fellow students with courtesy and
consideration. This means that talking and
disruptive behavior will be kept to a minimum.
Cell phones, pagers, and other electronic
devices should be silenced in the classroom. I
reserve the right to end a class at any time, for
any reason, including the disruptive or rude
behavior of anyone in the classroom.

2. Starting with insulin

3. Figure 3 The feedback loops of the insulin axis involve a number of different tissues.
Maloney C A , and Rees W D Reproduction 2005;130:401-
410
© 2005 Society for Reproduction and Fertility

5. Goals of therapy in diabetes
• To normalize blood sugar levels to minimize
risk of long-term complications
• To avoid instances of hypoglycemia
• To promote normal carbohydrate, fat and
protein metabolism

6. Non-insulin drugsInsulins
Drugs for diabetes
biguanides
secretagogues
sulfonylureas
meglitinides
α -glucosidase
inhibitors
TZDs
amylin
analogues
incretin
modulators
GLP-1
analogues
DPP-4
inhibitors
Others

7. Therapy with insulin
• Insulin is the PRIMARY treatment for Type 1
diabetes – insulin administration replaces
insulin that is not produced by B cells
• Also used in Type 2 as B cells fail and disease
progresses

8. Therapy with insulin
• USED TO TREAT
– Type I or type 2 diabetes
• CONTRAINDICATED IN
– Allergy to a specific insulin product
– hypoglycemia

9. Types of insulin
• Ultra short acting or rapid acting
– Rapid onset, short duration
• Short-acting
– Rapid onset
• Intermediate-acting
• Long-acting
– Slow onset

10. Insulins
Insulin aspart (Novolog®) - C
Insulin lispro (Humalog®) - B
Insulin glulisine (Apidra®) - C
Pharmacology
(Mechanism of action)
Replaces insulin;
Promotes cellular
uptake of glucose, fatty
acids and amino acids;
Promotes storage of
glycogen, triglycerides
and proteins
Adverse Effects Pharmacokinetics

11. Insulins
Regular insulin (Humulin-R®, Novolin-R®)
Pharmacology
(Mechanism of action)
Replaces insulin;
Promotes cellular
uptake of glucose, fatty
acids and amino acids;
Promotes storage of
glycogen, triglycerides
and proteins
Adverse Effects Pharmacokinetics

12. Insulins
Isophane insulin suspension (NPH®, Novolin-N®, Humulin-N)
Insulin zinc suspension (Lente) (Humulin-L®; Novolin-L®)
Pharmacology
(Mechanism of action)
Replaces insulin;
Promotes cellular
uptake of glucose, fatty
acids and amino acids;
Promotes storage of
glycogen, triglycerides
and proteins
Adverse Effects Pharmacokinetics

13. Insulins
Insulin glargine (Lantus®)
Insulin detemir (Levemir®)
Pharmacology
(Mechanism of action)
Replaces insulin;
Promotes cellular
uptake of glucose, fatty
acids and amino acids;
Promotes storage of
glycogen, triglycerides
and proteins
Adverse Effects Pharmacokinetics

14. Insulins - Mixtures
NPH70% + regular insulin 30% (Humulin 70/30 ®; Novolin 70/30®)
NPH50% + regular insulin 50% (Humulin 50/50®)
Insulin lispro protamine suspension 75% + insulin lispro 25%
(Humalog Mix 75/25®)
Pharmacology
(Mechanism of action)
Replaces insulin;
Promotes cellular
uptake of glucose, fatty
acids and amino acids;
Promotes storage of
glycogen, triglycerides
and proteins
Adverse Effects Pharmacokinetics
http://forecast.diabetes.org/files/images/InsulinChart_4.pdf

17. http://www.ourdiabetes.com/insulin-therapy.htm

18. Adverse Effects of Insulin
• Hypoglycemia
– Sympathatic activation produces palpitations,
sweating, nervousness, weakness
– Serious hypoglycemia produces CNS effects,
including mental confusion, incoherent speech,
blurred vision, coma
• Weight gain

19. Role of the nurse
(Abrams, pp. 726-730)
• Teach the patient how to administer insulin
correctly
– Choice of administration techniques
– Using a syringe
– Choice of injection sites
– When and how often to inject
– How to store

20. Non-insulin drugsInsulins
Drugs for diabetes
biguanides
secretagogues
sulfonylureas
meglitinides
α -glucosidase
inhibitors
TZDs
amylin
analogues
incretin
modulators
GLP-1
analogues
DPP-4
inhibitors
Others

21. Sulfonylureas
Glyburide (Diabeta®, Micronase®)
Glipizide (Glucotrol®)
Glimepiride (Amaryl®)
Pharmacology
(Mechanism of action)
Stimulate insulin release
from the pancreas;
Increases the number
and sensitivity of insulin
receptors;
Decreases
glycogenolysis and
gluconeogenesis
Adverse Effects Pharmacokinetics

22. K+
B cell
basal state
insulin
glucose
K+

23. Sulfonylureas
• Inhibits (closes) a K+-ATP channel, leading to
• Decreased K+ efflux from B-cells which
• Depolarizes the B-cell membrane, leading to
• Increased Ca++ influx and
• Increased exocytosis of insulin from B-cells

24. glipizide
sulfamethoxazole

25. Sulfonylureas
• Serious adverse effects
– Hypoglycemia
– Hematological effects (thrombocytopenia, aplastic
anemia, others)
• Common adverse effects
– Weight gain
– Rash
– Hypoglycemia

26. Biguanides
metformin (Glucophage®)
metformin / glipizide (Metaglip®)
rosiglitazone / metformin (Avandamet®)
Others….
Pharmacology
(Mechanism of action)
Decrease hepatic
glucose production;
Decrease glucose
absorption from GI tract;
Increases insulin
receptor sensitivity
Adverse Effects Pharmacokinetics

27. Biguanides
• USED TO TREAT
– Type 2 diabetes
• CONTRAINDICATED IN
– Hypersensitivity to biguanides
– Hepatic or renal disease
– Alcoholism
– Cardiopulmonary disease

28. Biguanides
• Serious adverse effects
– Lactic acidosis (due to the inhibition of
gluconeogenesis and the buildup of fatty acids) -
rare
• Common adverse effects
– Nausea, vomiting
– Flatulence

29. Thiazolidinediones (Insulin Sensitizers; glitazones; TZDs)
Rosiglitazone (Avandia®) - C
Pioglitazone (Actos®) - C
Pharmacology
(Mechanism of action)
Enhances the effects of
circulating insulin;
Stimulates peripheral
glucose uptake and
storage
Inhibits hepatic glucose
production
NO increase in insulin
levels
Adverse Effects Pharmacokinetics
http://www.fda.gov/Drugs/DrugSafety/ucm255005.htm

30. Thiazolidinediones (TZDs)
• Serious adverse effects
– Congestive heart failure (new or exacerbated) due to
increasing blood volume –
BLACK BOX WARNING
– Hepatic dysfunction or failure
• Common adverse effects
– Mild anemia
– Moderate weight gain
– Upper respiratory infection
– Headache and myalgia

31. Secretagogues (meglitinides)
Repaglinide (Prandia®)
Nateglinide (Starlix®)
Pharmacology
(Mechanism of action)
Stimulates insulin
release from B-cell
through inhibition of
ATP-sensitive K+
channels;
Adverse Effects Pharmacokinetics

32. Alpha-glucosidase inhibitors
Acarbose (Precose®)
Pharmacology
(Mechanism of action)
Reversibly inhibit alpha
glucosidase
Delays absorption of
glucose in the intestine;
Blunts postprandial
elevations in glucose
Adverse Effects Pharmacokinetics

33. Glucagon-like peptide 1 (GLP-1)
Exenatide (Byetta®; Bydureon®) – C
Liraglutide (Victoza®)
Pharmacology
(Mechanism of action)
Incretin mimetic that
binds to GLP receptors;
Increases glucose-
dependent secretion of
insulin from pancreatic B
cells
Adverse Effects Pharmacokinetics
Injected sc

34. Synthetic amylin analog
pramlintide (Symlin®)
Pharmacology
(Mechanism of action)
Amylin slows gastric
emptying;
suppresses glucagon;
Modulates appetite in
the CNS
Adverse Effects Pharmacokinetics
Injected sc

35. DPP-4 inhibitor
Sitagliptin (Januvia®)
Saxagliptin (Onglyza®)
Pharmacology
(Mechanism of action)
Inhibits DPP-4, which
slows inactivation of
incretin hormones GLP-
1 and GIP
Adverse Effects Pharmacokinetics
Oral

36. Figure 1. Key sites of action of diabetes medications.
Martin C L The Diabetes Educator 2007;33:6S-13S
Copyright © by American Association of Diabetes Educators; Published by SAGE Publications