1781207887.pptx just the introduction to DM
- 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
- 5. Summary of ticatincnt targets for cardiovascrtl r risk factor
- 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
- 17. « Adverse effects: • Flatulence, soft stools, diarrhoea, abdominal distention and pain • Liver dysfunction
- 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
- 21. • Contraindications: • Ketoacidosis • Pregnancy and breast-feeding • Severe hepatic impairment (for repaglinide)
- 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@
- 30. • Intermediate-acting: • Isophane insulin E.g. Protaphane@HM Humulin N@ • Insulin zinc suspension E.g. Monotard% Humulin L%
- 31. • Long-acting: • Crystalline insulin zinc E.g. UltratardÅHM • Insulin glargine E.g. Lantus@
- 32. • Mixed Insulins: • Biphasic isophane insulin 30% soluble insulin 70% isophane insulin • E.g. Mixtard 630, Humulin %70 30 20% soluble insulin 80% isophane insulin • E.g. Mixtard 620
- 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
- 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
- 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
- 45. • Antacids combination products: • Triact tablet AI(OH)t Dried Gel 200 mg & Mg(OH)2 150 mg & Simethicone25 mg Chew 1-2 tab q4-6h • Gastrocaine suspension Oxethazaine 10mg, AI(OH)3 Dried Gel 300mg, Mg(OH)2 100mg in 5 ml Alumag suspension AI(OH) & Mg Trisilicate
- 46. • Antacids combination products (Cont d): Gelusil łableł • Mg Trisilicate+ Dried Aluminium Hydroxide gel My anta tablet suspension • CaCO3 & Mg(OH)2 • Simethicone • Dimethylpolysiloxane (GasteelC› 40 mg tablet)
- 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
- 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
- 63. • Side effects: • Constipation, diarrhoea, gastric discomfot • Dry mouth • Headache nausea • Hypersensitivity reactions
- 64. • Misoprostol • Synthetic prostaglandin analogue (Prostaglandin E) • Antisecretory & protective properties Inhibit gastric acid secretion Increase mucus & bicarbonate secretion • Promote healing of gastric & duodenal ulcers
- 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
- 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