PRESENTATION ON AAN3: DIABETES NURSING

St. Paul University Philippines

Tuguegarao City, Cagayan 3500
GRADUATE SCHOOL PROGRAM
Master of Science in Nursing
DIABETES NURSING

21ST CENTURY ANTI- DIABETEC DRUGS AND ALTERNATIVE DRUGS USED TO

MANAGE DIABETES MELLITUS

DONAH JANNIN MADRIAGA AGUSTIN, RN

MSN STUDENT

ELIZABETH C. BAUA, DNS

PROFESSOR

PRESENTATION ON AAN3: DIABETES NURSING

1

21st Century Anti-Diabetic Drugs

Different kinds of diabetes pills work in different ways to control
your blood sugar (blood glucose).
Combining two different kinds of diabetes pills can work better to
lower your blood sugar than a single medicine.
But combining two kinds of diabetes pills can make it more likely
that your blood sugar will drop too low (hypoglycemia).
Agents used in diabetic therapy include the following:
1

Sulfonylureas

Stimulate your pancreas to make more insulin, which helps

lower your blood glucose.

Available sulfonylureas include:

Amaryl (glimepiride)
DiaBeta (glyburide)
Diabinese (chlorpropamide)
Glucotrol (glipizide)
Glucotrol XL (glipizide long-acting)
Glynase (glyburide)
Micronase (glyburide)
tolazamide
tolbutamide

o Possible side effects of the sulfonylureas are:

o Low blood
glucose

o Skin rash

o Upset stomach

o Weight gain

Biguanides

These agents are considered the first choice for oral type 2
diabetes treatment. They reduce hyperglycemia by
decreasing hepatic gluconeogenesis (primary effect) and
increasing peripheral insulin sensitivity (secondary effect).

Biguanides are absorbed from the intestines and are not

bound to plasma proteins. They are not metabolized and are
rapidly eliminated by the kidneys.

PRESENTATION ON AAN3: DIABETES NURSING

1

Available Biguanides include:

Glucophage
(metformin)
Glucophage XR
(metformin long-acting)

Riomet (metformin
liquid)


o Possible side effects of the biguanides are nausea and Diarrhea
when you are first start taking this type of Medicine.

Alpha-glucosidase inhibitors
- Alpha-glucosidase inhibitors work by slowing down the
digestion of foods high in
carbohydrate, such as
rice, potatoes, bread, milk and fruit.

Available alpha-glucosidase inhibitors include:

Glyset (miglitol)
Precose (acarbose)

o Possible side effects of the alpha-glucosidase inhibitors are:

stomach pain, gas, bloating, or diarrhea these symptoms
usually go away gradually

Thiazolidinediones (TZDs)

Make you more sensitive to insulin.

Available thiazolidinediones include:

Actos (pioglitazone)
Avandia (rosiglitazone)

NOTE:

If you have heart failure, you should not take this type of pill.
This type of pill can cause congestive heart failure.
Studies have shown that Avandia is associated with an
increased risk for heart attacks and chest pain or discomfort
from blocked blood vessels.

o Possible side effects of include:

o congestive heart failure is the most serious side effect,
o Anemia,
o an increased risk of getting pregnant even if youre taking birth
control pills
o increased risk of bone fracture in women

5 Meglitinide derivatives
-

Meglitinides stimulate your pancreas to make

insulin.

more


The only available meglitinide is:

Prandin (repaglinide)

o Possible side effects of Prandin are:

o low blood glucose
o weight gain
o upset stomach
o back pain or a headache

D-Phenylalanine Derivatives
-

Help your pancreas make more insulin quickly for a short

period of time right
after meals. The only available Dphenylalanine derivative is: Starlix (nateglinide)

o Possible side effects of Starlix are:

o low blood glucose
o weight gain
o dizziness
7

DPP-IV Inhibitors
-

Lower your blood glucose by helping your body make

more insulin when it s needed, especially right after meals.
It also helps keep your liver from putting stored glucose
into your blood.
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors are usually
prescribed for people with
type 2 diabetes who have not
responded well to drugs such as metformin and
sulfonylureas.
The only available DPP-IV Inhibitor is Januvia (sitagliptin)

o Possible side effects of Januvia are:

o runny nose
o sore throat
o Headache

How do they work?


They work by blocking the action of DPP-4, an enzyme
which destroys a group of gastrointestinal hormones called Incretins.
This incretins help stimulate the production of insulin when it is needed
(e.g. after eating) and reduce the production of gucagon by the liver
when it is not needed (e.g. during digestion). They also slow down
digestion and increase appetite. So by protecting incretins from
damage, DPP-4 inhibitors help regulate blood glucose levels.
8

Combination Diabetes Pills

1. Actoplus Met is a combination of Actos (pioglitazone)

and Glucophage (metformin)

2. Avandamet is a combination of Avandia (rosiglitazone)

and Glucophage (metformin)

3. Avandaryl is a combination of Avandia (rosiglitazone)

and Amaryl (glimepiride)

4. Duetact is a combination of Actos (pioglitazone) and

Amaryl (glimepiride)

5. Glucovance is a combination of Glucophage

(metformin) and Micronase (glyburide)

6. Janumet is a combination of Januvia (sitagliptin) and

Glucophage (metformin)

7. Metaglip is a combination of Glucotrol (glipizide) and

Glucophage (metformin)

Note: one pill helps your body make more insulin. The other pill
lowers the amount of glucose made by your liver and helps your
insulin work the way it should.
Bile acid sequestrants

- Colesevelam is FDA approved as an adjunctive therapy to

improve glycemic control in adults with type 2 diabetes mellitus.

- Colesevelam is a high-capacity bile acid sequestrant. It is

indicated as an adjunct to diet and exercise to improve
glycemic control in adults with type 2 diabetes mellitus. The
precise mechanism by which colesevelam improves glycemic
control is largely
unknown.

10 Insulins

Antidiabetics, Rapid-Acting Insulins

Rapid-acting insulins have a short duration of action

and are
appropriate for use before meals or when
blood glucose levels exceed target levels and

correction doses are needed. These

agents are
associated with less hypoglycemia than regular insulin.

Insulin aspart (NovoLog)

- Insulin aspart has a short onset of action of 5-15

minutes and a short duration of action of 3-5 hours. The
peak effect occurs within 30-90 minutes.
Insulin aspart
is FDA approved for use in insulin pumps.

Insulin glulisine (Apidra)

- Insulin glulisine has a rapid onset of action of 515 minutes and a short duration of action of 3-5 hours. The
peak effect occurs within 30-90 minutes. Insulin glulisine is
FDA approved for use in insulin pumps.

Insulin inhaled (Afrezza)

- Orally inhaled rapid-acting insulin in powder

form.

Insulin lispro (Humalog)

- Insulin lispro has a rapid onset of action of 5-15

minutes and a short duration of action of 4 hours.

Antidiabetics, Short-Acting Insulins

- Short-acting insulins are commonly used when a

slower onset of action or a longer duration of action is
desired.

Regular insulin (Humulin R, Novolin R)

- Regular insulin has a rapid onset of action of 0.51 hours and duration of action of 4-6 hours. The peak
effects are seen within 2-4 hours.

- Preparations that contain a mixture of 70%

neutral protamine Hagedorn
(NPH) and 30% regular
human insulin (ie, Novolin 70/30, Humulin 70/30) are also
available

Antidiabetics, Long-Acting Insulins

- These insulins provide a longer duration

of action, and, when combined with rapid- or short-acting
insulins, they provide better glucose control.
Insulin detemir (Levemir)


- Insulin detemir is indicated for onceor twice-daily dosing in patients with type 1 or 2 diabetes
mellitus. The duration of action is up to 24 hours.

Insulin Glargine (Lantus)

- Insulin glargine has an onset of action

of 4-8 hours and duration of action of 24 hours. Peak
effects occur within 16-18 hours.
Alternative Medicines

2.
3.
4.
5.
6.
7.
8.

1. Ginseng
Cinnamon
Aloe Vera
Bitter Melon
Fenugreek
Ginger
Okra
Sambong/Banaba

1. Ginseng
-

So far, scientific support for the claim that any

remedy can treat diabetes is lacking. It's important to note
that self-treating with alternative medicine and avoiding or
delaying standard care may be harmful for your
health. Here are some natural treatments that are being
explored.

Although there are several different types

of ginseng, most of the
promising
studies on ginseng and diabetes have
used North American ginseng (Panax
quinquefolius).

Those studies have shown that North

American ginseng may improve blood
sugar control and glycosylated hemoglobin
(a form of hemoglobin in the blood used to
monitor blood glucose levels over time)
levels.

Health Benefits of American Ginseng

American ginseng may help regulate blood sugar,
according to a 2000 study published in Archives of Internal
Medicine. In a small experiment involving nine diabetes
patients and 10 people without diabetes, researchers found

that taking American ginseng supplements prior to eating

helped keep post-meal blood sugar levels in check.

2. Cinnamon
- A couple of studies have found that
cinnamon improves blood glucose
control in people with type 2
diabetes. In the first study, 60 people
with type 2 diabetes were divided
into six
groups. Three groups took
1, 3 or 6 g of cinnamon a day and
the
remaining
three
groups
consumed 1, 3 or 6 g of placebo capsules. After 40 days, all
three doses of cinnamon significantly reduced
fasting
blood glucose, triglycerides, LDL cholesterol, and total
cholesterol.
- In another study, 79 people with type 2 diabetes (not on
insulin
therapy but treated with other diabetes
medication or diet) took
either a cinnamon extract
(equivalent to 3 g of cinnamon powder) or a placebo
capsule three times a day. After four months, there was a
slight but statistically significant reduction in fasting blood
glucose levels in people who took the cinnamon (10.3%)
compared with the placebo group (3.4%), however, there
was no significant difference in glycosylated hemoglobin
or lipid profiles.

3. Aloe Vera
- Although aloe Vera gel is better
known as a home
remedy for
minor
burns
and
other
skin
conditions,
recent animal studies
suggest that aloe Vera gel may
help people with diabetes.

- A Japanese study evaluated the

effect of aloe Vera gel on blood
sugar.
Researchers
isolated
a
number
of
active
phytosterol
compounds from the gel that were found to reduce blood
glucose and glycosylated hemoglobin
levels.

Aloe has also been linked with:

Decreased blood lipids (fats) in patients with

abnormally high levels of these molecules in the blood (e.
g. some people with type 2 diabetes) and/or acute
hepatitis (liver disease)

Decreased swelling and faster healing of

wound injuries.

( Leg wounds and ulcers are common

complications of diabetes, and they typically take longer
time to heal than in healthy non-diabetic individuals.)

These positive effects are thought to be due to the

presence of compounds such as lectins, mannans and
anthraquinones.

4. Bitter Melon
- Bitter melon, also known as bitter gourd
or karela (in India), is a unique
vegetable-fruit that can be used as food
or medicine.
- It is the edible part of the plant
Momordica
Charantia,which
is
considered the most bitter among
all fruits and vegetables.

- The plant thrives in tropical and subtropical regions,

including

South America, Asia, parts of Africa and the

Caribbean

- The bitter melon itself grows off the vine as a green,

oblong-shaped fruit with a distinct warty exterior - though
its size,
texture and bitterness vary between the
different regions in
which it grows - and is rich in
vital vitamins and minerals.

How does it affect diabetes?

- In addition to being a food ingredient, bitter melon

has also long
been used as a herbal remedy for a
range of ailments, including type 2 diabetes.

- The fruit contains at least three active substances

with anti-diabetic
properties, including charantin, which
has been confirmed to have
blood glucoselowering effect, vicine and an insulin-like compound
known as polypeptide-p.
-

These substances either work individually or together to

help reduce blood sugar levels.

- It is also known that bitter melon contains

a lectin that reduces blood glucose concentrations by

acting on peripheral tissues and suppressing appetite similar to the effects of insulin in the brain.

- This lectin is thought to be a major factor behind

the hypoglycemic effect that develops after eating bitter
melon.
Scientific evidence
- In January 2011, the results of a four-week clinical trial were
published in the Journal of Ethno pharmacology, which showed
that a 2,000 mg
daily dose of bitter melon significantly reduced
blood glucose levels
among patients with type 2 diabetes,
although the hypoglycemic effect was less than a 1,000 mg/day
dose of metformin. [68]
- Other older studies have also suggested an association
between bitter melon intake and improved glycemic control, while
a report published in the March 2008 issue of Chemistry and
Biology found that bitter
melon increased cellular uptake of
glucose and improved glucose tolerance. [69]

5. Fenugreek
- Fenugreek is an aromatic plant that has
many uses, both culinary (fenugreek is a
key ingredient of curries and
other
Indian recipes) - and medicinal.
-The plant, which is widely grown in South
Asia, North
Africa and parts of the
Mediterranean, has small round leaves and
also produces long pods that contain
distinctive bitter-tasting seeds.
-The leaves are either sold as a vegetable (fresh leaves, sprouts,
and microgreens) commonly known as methi, or as an
herb
(dried leaves), while the seeds are used both whole and in
powdered form as a spice.
-As well as being a popular cooking ingredient, fenugreek has a
number of health benefits and is used in both Ayurvedic and
traditional Chinese medicine.

How does it affect diabetes?

- Fenugreek seeds (trigonella foenum graecum) are high in
soluble fibre, which helps lower blood sugar by slowing down
digestion and absorption of carbohydrates. This suggests they
may be effective in treating people with diabetes.

- Multiple studies have been carried out to investigate

the potential anti-diabetic benefits of fenugreek.

- Of these, several clinical trials showed that fenugreek

seeds can improve most metabolic symptoms associated with
both type 1 and type 2 diabetes in humans by lowering blood
glucose levels and improving glucose tolerance.

Scientific evidence
In one study, researchers in India found that adding 100 grams of
defatted fenugreek seed powder to the daily diet of patients with
insulin-dependent (type 1) diabetes significantly reduced
their fasting blood glucose levels, improved glucose tolerance and
also lowered
total cholesterol, LDL or bad cholesterol and
triglycerides.
In another controlled trial, incorporating 15 grams of powdered
fenugreek seed into a meal eaten by people with type 2 diabetes
reduced the rise in post-meal blood glucose, while a separate

study found that taking 2.5 grams of fenugreek twice a day for
three
months lowered blood sugar levels in people with mild,
but not
severe, type 2 diabetes.

6. Ginger

- Ginger is the thick knotted underground stem (rhizome) of the

plant Zingiber officinale that has been used for
centuries in Asian cuisine and medicine.

- Native to Africa, India, China, Australia and

Jamaica, it is commonly used as a spice or
flavouring agent in
cooking, as an alternative
herbal treatment for various ailments such as
nausea and indigestion, and for fragrance in soaps and
cosmetics.

- Ginger rhizome can be used fresh, dried and powdered, or as a

juice or oil. It has a pungent and sharp aroma and adds a strong
spicy flavor to food and drink.

How does it affect diabetes?

Glycemic control
A study published in the August 2012 edition of the natural
product journal Planta Medica suggested that ginger may improve
long-term blood sugar control for people with type 2 diabetes.
Researchers from the University of Sydney, Australia, found that
extracts from Buderim Ginger (Australian grown ginger) rich in
gingerols - the major active component of ginger rhizome - can
increase uptake of glucose into muscle cells without using insulin,
and may therefore assist in the management of high blood sugar
levels.

Insulin secretion
In the December 2009 issue of the European Journal of
Pharmacology,
researchers reported that two different
ginger extracts, spissum and an oily extract, interact with
serotonin receptors to reveres their effect on insulin secretion.
Treatment with the extracts led to a 35 per cent drop in blood
glucose levels
and a 10 per cent
increase in plasma
insulin
levels.

7. Okra
-

Okra is fast gaining a reputation as a so-called 'superfood' for

people with or at risk of diabetes or cancer.


Okra is a tall-growing vegetable that traces its
origin from ancient Ethiopia (Abyssinia) through
to Eastern Mediterranean, India, the Americas
and the Caribbean.

- Commonly referred to as ladyfingers, or by its

biological
names
Abelmoschus
esculentus
and Hibiscus
esculentus, okra is known to have a positive effect on blood sugar
control, among many other health benefits.

- These tender pods are very low in calories, providing just 30

calories per 100 g, and contain no saturated fats or cholesterol.
They are also rich in nutrients, completely non-toxic, and have no
adverse side effects.

How does it affect diabetes?

-

Evidence of okra having anti-diabetic properties has increased in

recent years, with multiple Vitro (laboratory) and Vivo (animal)
studies confirming okra as a potent blood glucose-lowering (or
anti-diabetic) food.
In one study, published 2011 in the Journal of Pharmacy &
BioAllied Sciences, researchers in India found that diabetic mice
fed dried and ground okra peels and seeds experienced a
reduction in their blood glucose levels, while others showed a
gradual decrease in blood glucose following regular feeding of
okra extract for about ten days.
Outside of scientific research, many people with diabetes have
reported decreasing blood sugar levels after soaking cut-up okra
pieces in water overnight and then drinking the juice in the
morning, while in Turkey roasted okra seeds have been used as a
traditional diabetes medicine for generations.

8. Okra

Banaba is a flowering plant that grows

in warm climate like the Philippines,
India and others. Banaba is widely used
in the Philippines and as herbal
medicine for diabetes. While in India,
Banaba is also used as Ayurvedic
medicine for the treatment of diabetes.
The Banaba leaves and flowers contain
Corrosolic Acid, a substance being studied for its insulin like effect
of lowering the glucose in the body. Banaba is also being studied
as a weight-loss supplement for its ability to delay or reduce the
absorption of carbohydrates. Banaba is also rich in vitamins and
minerals including zinc and magnesium. Banaba is also rich in
dietary fibers.

How to use Banaba Herb for Diabetes:

The following details the preparation and application of Banaba
herbal medicine for diabetes.
1.
2.
3.
4.
5.
6.
7.

Dry Banaba leaves and fruits for about two weeks.

Cut Banaba leaves into pieces
Boil the dried Banaba leaves and fruits in water.
One cup of dried banaba leaves and fruits to one cup water.
Let it steep for 30 minutes,
Strain the leaves and fruits.
Take the Banaba herbal tea for 4 to 6 times daily.

Evidence Based-Practice
Cannabis compound legally sold in pill form for first time
could provide health benefits for people with diabetes.

(September 2015)
"Cannabis pills" have been legally sold in Europe for the
first time. The capsules, which are available to buy online,
could offer health benefits to people with diabetes.

 There is substantial evidence to suggest that Cannabidiol

(CBD), a compound found in cannabis, has beneficial
effects on a number of health conditions, including chronic
pain, cancer, anxiety, diabetes, epilepsy rheumatoid arthritis,
PTSD, sleep disorders, and heart disease.
For
people
with
diabetes,
research
suggests
that CBD reduces the pain of neuropathy and lowers blood
glucose levels. It can also benefit some diabetic
complications, including glaucoma.
The pills, which are sold by MMJ PhyoTech of Australia, do
not provide the "high" of smoking cannabis, which is caused
by tetrahydrocannabinol (THC). They contain only CBD, which
is the specific compound linked to health benefits.
The capsules are manufactured in Switzerland and
registered in Germany. They can be purchased in Europe on
the company's website. A 10mg box can be purchased for
89.00 (or 65.66). A 100mg box costs 579.00 (or 427.22).

Sources:

http://www.diabetes.co.uk
http://altmedicine.about.com
Medscape.com