NR 565 Final Exam Study Guide:
Practice & Preparation for Chamberlain University Students, United states
Chapter 48
Glycemic Goals in Type 2 Diabetes
● Goal:
○ Maintain blood glucose levels to prevent long-term complications
like nephropathy, retinopathy, neuropathy, and cardiovascular
disease
● Target A1C:
○ Generally aim for an A1C of <7% for most adults, individualizing based on
patient characteristics.Less than 8% in patients with severe hypoglycemia
■ Some may have a less stringent target, especially elderly patients or
those with severe hypoglycemia risks.
■ The goal of therapy should be individualized based on patient-specific
factors, including the duration of diabetes, age, comorbid conditions, and
other risk factors.
● Fasting Plasma Glucose:
○ Typically aim for 80-130 mg/dL.
○ Diabetes may be diagnosed with a fasting plasma glucose of greater than 126
and a random plasma glucose of greater than 200.
● Postprandial Glucose:
○ Aim for <180 mg/dL at 1-2 hours after meals.
● Patients with A1C greater than 10% and fasting blood glucose of 300 or more may be
started on combination injectable therapy immediately.
Diabetic Nephropathy Prevention
● Approach:
○ Optimize glycemic control (A1C <7%).
○ Control blood pressure (target <140/90 mmHg) using ACE inhibitors or
ARBs, especially if proteinuria is present.
■ These drugs reduce the risk of kidney damage by lowering blood
pressure and reducing proteinuria
○ Monitor renal function regularly, especially in patients with existing diabetes
and hypertension.
Sulfonylureas
● Mechanism of Action (MOA):
○ Stimulate insulin secretion from beta cells in the pancreas by blocking
ATP- sensitive potassium channels, which leads to depolarization of the
cell membrane allowing calcium to enter the cell and promoting insulin
release
○ Should not be used in pregnancy, renal impairment, or hepatic impairment
, ● Two types 1 & 2 (SEE BELOW)
● Contraindications:
○ Type 1 diabetes.
○ Patients with a history of severe hypoglycemia
○ Diabetic ketoacidosis.
○ Severe renal or hepatic impairment
○ Pregnancy
■ Generally avoided as insulin is preferred due to a better safety profile.
● Side Effects:
○ Hypoglycemia (especially if meals are skipped, or dosage is too high)
○ Weight gain.
○ Increased risk of cardiovascular events (due to electrolyte shifts)
○ Gastrointestinal upset.
1st Generation vs 2nd Generation Sulfonylureas
● 1st Generation:
○ Examples: Tolbutamide, Chlorpropamide.
○ Were the initial class of antidiabetic agents
○ These drugs work by promoting the release of insulin from pancreatic β cells, a
mechanism that effectively lowers blood glucose levels.
○ Require higher doses to achieve therapeutic effects
○ Less potent and have a higher risk of adverse effects.
○ More likely to cause frequent and severe drug interactions
■ Especially drugs that are metabolized by liver or excreted by the kidneys -
leading to unpredictable effects on blood glucose levels
● 2nd Generation:
○ Examples: Glipizide, Glyburide, Glimepiride.
○ More potent, require lower doses, and have fewer side effects.
○ While both generations can cause hypoglycemia, second-generation
sulfonylureas are less likely to lead to severe hypoglycemic episodes when used
appropriately
○ Generally have a longer duration of action, which provides more stable blood
glucose control throughout the day
DDP4 Inhibitors (DPP4I)
● Prototype: Sitagliptin (januvia)
● Mechanism of Action (MOA):
○ Inhibit the enzyme dipeptidyl peptidase-4 (DPP-4), increasing levels of incretin
hormones, which in turn stimulate insulin secretion and decrease glucagon
secretion. By inhibiting DPP-4, these drugs prolong the activity of incretins,
leading to improved insulin secretion, reduced glucagon release, and
decreased hepatic glucose production
■ DPP-4 is responsible for breaking down incretin hormones, which are
essential for glucose homeostasis
● Adverse Effects: Generally well-tolerated; potential side effects include:
○ Mild upper respiratory infections.
○ Headaches
○ Nasopharyngitis
, ○ Rare risk of pancreatitis and hypersensitivity reactions
Sitagliptin
● Side Effects: See above.
Glucagon-like Peptide-1 (GLP-1) Receptor Agonists
● Prototype: Exenatidine (Byetta)
● Mechanism of Action (MOA):
○ Mimic the actions of the endogenous incretin hormone glucagon-like peptide-1
(GLP-1)
■ Activate GLP-1 receptors, leading to:
● Slowed gastric emptying.
● Increased glucose-dependent insulin secretion.
● Suppress postprandial glucagon secretion/release
● Appetite suppression.
● Monitoring:
○ Regular blood glucose monitoring to prevent hypoglycemic events
○ Watch for signs of gastrointestinal side effects and pancreatitis
○ Renal function should also be monitored as these drugs can affect kidney
function
Glycemic Control Targets
● General Recommendations:
○ Aim for individualized A1C targets based on age, comorbidities, and risk
of hypoglycemia
○ General target of HbA1C of less than 7% for nonpregnant adults with diabetes
○ Premeal plasma glucose target: 70 - 130 mg/dL
○ Peak Postmeal Plasma Glucose target: less than 180 mg/dL
Incretin Mimetics
● Overview:
○ Mimic incretin hormones (e.g., GLP-1) to enhance insulin secretion in response
to meals, suppress glucagon release, delay gastric emptying, and promote
satiety. These actions improve postprandial glucose levels and may lead to
weight loss
● Pregnancy:
○ Should be used cautiously; risks versus benefits must be evaluated due to limited
data on safety.
■ Insulin is the preferred treatment for managing diabetes during
pregnancy to ensure both maternal and fetal safety
Meglitinides vs Sulfonylureas
● Meglitinides
○ Prototype: Repaglinide
○ MOA:
, ■ Short-acting insulin secretagogues that stimulate rapid insulin
secretion from the pancreas.
○ They are taken with meals to control postprandial blood glucose levels and have
a lower risk of causing hypoglycemia compared to sulfonylureas because of their
shorter duration of action.
● Sulfonylureas:
○ Two types, see prototypes above
○ MOA:
■ Long-acting insulin secretagogues that stimulate insulin release
from pancreatic beta cells throughout the day
○ They are more likely to cause hypoglycemia, especially if a meal is skipped or
delayed
○ Usually taken once/twice a day, where as meglitinides are taken before each
meal
Repaglinide (Meglitinide)
● Patient Education:
○ Administration:
■ Repaglinide should be taken 15-30 minutes before each meal to ensure
proper control of postprandial glucose levels. It is critical that patients eat
soon after taking the medication to avoid hypoglycemia. Advise patients
to adjust doses based on meal timing (skip doses if meals are missed).
○ Hypoglycemia Risk:
■ Skipping meals or delaying food intake after taking repaglinide can lead to
hypoglycemia. Patients should be educated on recognizing symptoms like
sweating, dizziness, or confusion.
Metformin
● Class: Biguanides
● Mechanism of Action (MOA):
○ Metformin lowers blood glucose by three main mechanisms:
● It inhibits glucose production in the liver.
● It improves insulin sensitivity in peripheral tissues, particularly in
skeletal muscle and adipose tissue.
● It slightly decreases glucose absorption in the intestines. Unlike
sulfonylureas, metformin does not stimulate insulin secretion,
which means it has a lower risk of causing hypoglycemia.
● Pregnancy:
○ One of the few oral antidiabetic agents that is generally considered safe during
pregnancy. It can be used in women with T2DM or for managing gestational
diabetes as an alternative to insulin therapy
● Side Effects:
○ Common: Gastrointestinal disturbances
■ N/V/D
■ Decreased appetite
■ Side effects tend to decrease over time
○ Rare: Lactic acidosis, particularly in patients with renal impairment.Should not be
used in these patients due to the risk of lactic acidosis.
Practice & Preparation for Chamberlain University Students, United states
Chapter 48
Glycemic Goals in Type 2 Diabetes
● Goal:
○ Maintain blood glucose levels to prevent long-term complications
like nephropathy, retinopathy, neuropathy, and cardiovascular
disease
● Target A1C:
○ Generally aim for an A1C of <7% for most adults, individualizing based on
patient characteristics.Less than 8% in patients with severe hypoglycemia
■ Some may have a less stringent target, especially elderly patients or
those with severe hypoglycemia risks.
■ The goal of therapy should be individualized based on patient-specific
factors, including the duration of diabetes, age, comorbid conditions, and
other risk factors.
● Fasting Plasma Glucose:
○ Typically aim for 80-130 mg/dL.
○ Diabetes may be diagnosed with a fasting plasma glucose of greater than 126
and a random plasma glucose of greater than 200.
● Postprandial Glucose:
○ Aim for <180 mg/dL at 1-2 hours after meals.
● Patients with A1C greater than 10% and fasting blood glucose of 300 or more may be
started on combination injectable therapy immediately.
Diabetic Nephropathy Prevention
● Approach:
○ Optimize glycemic control (A1C <7%).
○ Control blood pressure (target <140/90 mmHg) using ACE inhibitors or
ARBs, especially if proteinuria is present.
■ These drugs reduce the risk of kidney damage by lowering blood
pressure and reducing proteinuria
○ Monitor renal function regularly, especially in patients with existing diabetes
and hypertension.
Sulfonylureas
● Mechanism of Action (MOA):
○ Stimulate insulin secretion from beta cells in the pancreas by blocking
ATP- sensitive potassium channels, which leads to depolarization of the
cell membrane allowing calcium to enter the cell and promoting insulin
release
○ Should not be used in pregnancy, renal impairment, or hepatic impairment
, ● Two types 1 & 2 (SEE BELOW)
● Contraindications:
○ Type 1 diabetes.
○ Patients with a history of severe hypoglycemia
○ Diabetic ketoacidosis.
○ Severe renal or hepatic impairment
○ Pregnancy
■ Generally avoided as insulin is preferred due to a better safety profile.
● Side Effects:
○ Hypoglycemia (especially if meals are skipped, or dosage is too high)
○ Weight gain.
○ Increased risk of cardiovascular events (due to electrolyte shifts)
○ Gastrointestinal upset.
1st Generation vs 2nd Generation Sulfonylureas
● 1st Generation:
○ Examples: Tolbutamide, Chlorpropamide.
○ Were the initial class of antidiabetic agents
○ These drugs work by promoting the release of insulin from pancreatic β cells, a
mechanism that effectively lowers blood glucose levels.
○ Require higher doses to achieve therapeutic effects
○ Less potent and have a higher risk of adverse effects.
○ More likely to cause frequent and severe drug interactions
■ Especially drugs that are metabolized by liver or excreted by the kidneys -
leading to unpredictable effects on blood glucose levels
● 2nd Generation:
○ Examples: Glipizide, Glyburide, Glimepiride.
○ More potent, require lower doses, and have fewer side effects.
○ While both generations can cause hypoglycemia, second-generation
sulfonylureas are less likely to lead to severe hypoglycemic episodes when used
appropriately
○ Generally have a longer duration of action, which provides more stable blood
glucose control throughout the day
DDP4 Inhibitors (DPP4I)
● Prototype: Sitagliptin (januvia)
● Mechanism of Action (MOA):
○ Inhibit the enzyme dipeptidyl peptidase-4 (DPP-4), increasing levels of incretin
hormones, which in turn stimulate insulin secretion and decrease glucagon
secretion. By inhibiting DPP-4, these drugs prolong the activity of incretins,
leading to improved insulin secretion, reduced glucagon release, and
decreased hepatic glucose production
■ DPP-4 is responsible for breaking down incretin hormones, which are
essential for glucose homeostasis
● Adverse Effects: Generally well-tolerated; potential side effects include:
○ Mild upper respiratory infections.
○ Headaches
○ Nasopharyngitis
, ○ Rare risk of pancreatitis and hypersensitivity reactions
Sitagliptin
● Side Effects: See above.
Glucagon-like Peptide-1 (GLP-1) Receptor Agonists
● Prototype: Exenatidine (Byetta)
● Mechanism of Action (MOA):
○ Mimic the actions of the endogenous incretin hormone glucagon-like peptide-1
(GLP-1)
■ Activate GLP-1 receptors, leading to:
● Slowed gastric emptying.
● Increased glucose-dependent insulin secretion.
● Suppress postprandial glucagon secretion/release
● Appetite suppression.
● Monitoring:
○ Regular blood glucose monitoring to prevent hypoglycemic events
○ Watch for signs of gastrointestinal side effects and pancreatitis
○ Renal function should also be monitored as these drugs can affect kidney
function
Glycemic Control Targets
● General Recommendations:
○ Aim for individualized A1C targets based on age, comorbidities, and risk
of hypoglycemia
○ General target of HbA1C of less than 7% for nonpregnant adults with diabetes
○ Premeal plasma glucose target: 70 - 130 mg/dL
○ Peak Postmeal Plasma Glucose target: less than 180 mg/dL
Incretin Mimetics
● Overview:
○ Mimic incretin hormones (e.g., GLP-1) to enhance insulin secretion in response
to meals, suppress glucagon release, delay gastric emptying, and promote
satiety. These actions improve postprandial glucose levels and may lead to
weight loss
● Pregnancy:
○ Should be used cautiously; risks versus benefits must be evaluated due to limited
data on safety.
■ Insulin is the preferred treatment for managing diabetes during
pregnancy to ensure both maternal and fetal safety
Meglitinides vs Sulfonylureas
● Meglitinides
○ Prototype: Repaglinide
○ MOA:
, ■ Short-acting insulin secretagogues that stimulate rapid insulin
secretion from the pancreas.
○ They are taken with meals to control postprandial blood glucose levels and have
a lower risk of causing hypoglycemia compared to sulfonylureas because of their
shorter duration of action.
● Sulfonylureas:
○ Two types, see prototypes above
○ MOA:
■ Long-acting insulin secretagogues that stimulate insulin release
from pancreatic beta cells throughout the day
○ They are more likely to cause hypoglycemia, especially if a meal is skipped or
delayed
○ Usually taken once/twice a day, where as meglitinides are taken before each
meal
Repaglinide (Meglitinide)
● Patient Education:
○ Administration:
■ Repaglinide should be taken 15-30 minutes before each meal to ensure
proper control of postprandial glucose levels. It is critical that patients eat
soon after taking the medication to avoid hypoglycemia. Advise patients
to adjust doses based on meal timing (skip doses if meals are missed).
○ Hypoglycemia Risk:
■ Skipping meals or delaying food intake after taking repaglinide can lead to
hypoglycemia. Patients should be educated on recognizing symptoms like
sweating, dizziness, or confusion.
Metformin
● Class: Biguanides
● Mechanism of Action (MOA):
○ Metformin lowers blood glucose by three main mechanisms:
● It inhibits glucose production in the liver.
● It improves insulin sensitivity in peripheral tissues, particularly in
skeletal muscle and adipose tissue.
● It slightly decreases glucose absorption in the intestines. Unlike
sulfonylureas, metformin does not stimulate insulin secretion,
which means it has a lower risk of causing hypoglycemia.
● Pregnancy:
○ One of the few oral antidiabetic agents that is generally considered safe during
pregnancy. It can be used in women with T2DM or for managing gestational
diabetes as an alternative to insulin therapy
● Side Effects:
○ Common: Gastrointestinal disturbances
■ N/V/D
■ Decreased appetite
■ Side effects tend to decrease over time
○ Rare: Lactic acidosis, particularly in patients with renal impairment.Should not be
used in these patients due to the risk of lactic acidosis.
