1 Drugs used for Diabetes Mellitus

2 Introduction There are 2 types of diabetes mellitus: There are 2 types of diabetes mellitus: Type 1: Insulin-dependent diabetes mellitus (IDDM) Type 1: Insulin-dependent diabetes mellitus (IDDM) Destruction of pancreatic beta cells Destruction of pancreatic beta cells Is the result of an autoimmune process Is the result of an autoimmune process Type 2: Non-insulin dependent diabetes mellitus (NIDDM) Type 2: Non-insulin dependent diabetes mellitus (NIDDM) Results from a combination of insulin resistance and altered insulin secretion Results from a combination of insulin resistance and altered insulin secretion

3 Characteristics of Type 1 & Type 2 Diabetes Mellitus

4 Oral Antidiabetic Drugs For the treatment of type 2 (non-insulin- dependent) diabetes mellitus For the treatment of type 2 (non-insulin- dependent) diabetes mellitus Use only after diet modification & exercise fail to produce glycemic control Use only after diet modification & exercise fail to produce glycemic control Should be used to augment the effect of diet & exercise, not to replace them Should be used to augment the effect of diet & exercise, not to replace them

5 Evidence-based targets for managing cardiovascular risk factors Fasting blood glucose </= 6mmol/l HbA 1c < 7% Total cholesterol < 5mmol/l LDL cholesterol < 3 mmol/l Blood pressure threshold for intervention -Target for treatment -if significant proteinuria 140/90mmHg </= 140/80mmHg </= 125/75mmHg Recent guidelines recommend statin and low-dose aspirin treatment where the 10- year coronary heart disease ridk is less than 15% -before adding aspirin ensure blood pressure is controlled -combination antihypertnsive treatment is necessary in the majority of patients to achieve blood pressure targets -other recommendations include HDL>1.2mmol/l and fasting triglycerides 1.2mmol/l and fasting triglycerides<1.7mmol/l Summary of treatment targets for cardiovascular risk factor intervention in diabetic patients

6 Sulphonylureas Act mainly by augmenting insulin secretion Act mainly by augmenting insulin secretion May also increase tissue response to insulin May also increase tissue response to insulin Effective only when some residual pancreatic beta-cell activity is present Effective only when some residual pancreatic beta-cell activity is present Considered for patients who are not overweight, or in whom Metformin (Glucophage®) is contraindicated or not tolerated Considered for patients who are not overweight, or in whom Metformin (Glucophage®) is contraindicated or not tolerated

7 Short-acting: Short-acting: Tolbutamide: g daily in divided doses, with or immediately after breakfast; Max: 2 g daily Tolbutamide: g daily in divided doses, with or immediately after breakfast; Max: 2 g daily Gliclazide (Diamicron®): mg daily in divided doses, with breakfast; Max: 320 mg daily Gliclazide (Diamicron®): mg daily in divided doses, with breakfast; Max: 320 mg daily Intermediate-acting: Intermediate-acting: Glipizide (Minidiab®): mg daily in divided doses, before breakfast; Max: 20 mg daily Glipizide (Minidiab®): mg daily in divided doses, before breakfast; Max: 20 mg daily Sulphonylureas (Cont‘d)

8 Long-acting: Long-acting: Chlorpropamide (Diabinese®): 250 mg daily with breakfast; Max: 500 mg Chlorpropamide (Diabinese®): 250 mg daily with breakfast; Max: 500 mg Glibenclamide (Daonil®): 5 mg daily with or immediately after breakfast; Max: 15 mg daily Glibenclamide (Daonil®): 5 mg daily with or immediately after breakfast; Max: 15 mg daily Glimepiride (Amaryl®): 1-4 mg daily shortly before or with first main meal; Max: 4 mg daily Glimepiride (Amaryl®): 1-4 mg daily shortly before or with first main meal; Max: 4 mg daily Sulphonylureas (Cont‘d)

9 Contraindications: Contraindications: Severe hepatic and renal impairment Severe hepatic and renal impairment Breast-feeding and pregnancy Breast-feeding and pregnancy Elderly (Chlorpropamide, glibenclamide) Elderly (Chlorpropamide, glibenclamide) Adverse effects: Adverse effects: Nausea, vomiting, diarrhoea and constipation Nausea, vomiting, diarrhoea and constipation Increased appetite and weight gain Increased appetite and weight gain Hypoglycaemia Hypoglycaemia Hypersensitivity Hypersensitivity Sulphonylureas (Cont‘d)

10 Biguanides Decreasing gluconeogenesis in the liver Decreasing gluconeogenesis in the liver Increase peripheral utilisation of glucose by muscle Increase peripheral utilisation of glucose by muscle Acts only in the presence of endogenous insulin Acts only in the presence of endogenous insulin Metformin (Glucophage®) is the only available biguanide Metformin (Glucophage®) is the only available biguanide Is antihyperglycemic, not hypoglycemic Is antihyperglycemic, not hypoglycemic Recommended for obese or insulin resistant diabetic patients Recommended for obese or insulin resistant diabetic patients

11 Metformin: Metformin: 500 mg bd-tid; Max: 3 g, usually limit to 2 g daily 500 mg bd-tid; Max: 3 g, usually limit to 2 g daily Contraindications: Contraindications: Hepatic or renal impairment (must withdraw) Hepatic or renal impairment (must withdraw) Ketoacidosis Ketoacidosis Predisposition to lactic acidosis: severe dehydration, which is most likely to occur in patients with renal impairment Predisposition to lactic acidosis: severe dehydration, which is most likely to occur in patients with renal impairment Biguanides (Cont’d)

12 Contraindications (Cont’d): Contraindications (Cont’d): Infection, shock, trauma, heart failure, respiratory failure, recent myocardial infarction, severe peripheral vascular disease Infection, shock, trauma, heart failure, respiratory failure, recent myocardial infarction, severe peripheral vascular disease Hepatic impairment, alcohol dependency Hepatic impairment, alcohol dependency Use of iodine-containing x-ray contrast media (do not restart melformin until renal function returns to normal) Use of iodine-containing x-ray contrast media (do not restart melformin until renal function returns to normal) Pregnancy and breast-feeding Pregnancy and breast-feeding Biguanides (Cont’d)

13 Biguanides (Cont’d) Adverse effects: Adverse effects: Decreased appetite Decreased appetite Nausea, vomiting and diarrhoea Nausea, vomiting and diarrhoea Lactic acidosis (rarely) Lactic acidosis (rarely) Decreased absorption of vitamin B 12 and folic acid Decreased absorption of vitamin B 12 and folic acid Allergic skin reactions Allergic skin reactions

14 Biguanides (Cont’d) Nursing alerts: Nursing alerts: Take metformin with meals and increase dosage slowly to minimise GI adverse effects 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 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 Alpha glucosidase inhibitor Delay the digestion & absorption of starch & sucrose by inhibition of intestinal alpha glucosidase in the intestine Delay the digestion & absorption of starch & sucrose by inhibition of intestinal alpha glucosidase in the intestine Acarbose (Glucobay®) Acarbose (Glucobay®) mg tid; Max: 200 mg tid mg tid; Max: 200 mg tid

16 Contraindications: Contraindications: Pregnancy and breast-feeding Pregnancy and breast-feeding Inflammatory or malabsorptive intestinal disorders Inflammatory or malabsorptive intestinal disorders Hepatic impairment Hepatic impairment Severe renal impairment Severe renal impairment Alpha glucosidase inhibitor (Cont’d)

17 Alpha glucosidase inhibitor (Cont’d) Adverse effects: Adverse effects: Flatulence, soft stools, diarrhoea, abdominal distention and pain Flatulence, soft stools, diarrhoea, abdominal distention and pain Liver dysfunction Liver dysfunction

18 Nursing alerts Nursing alerts Tablets should be taken with first mouthful of food 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 Absorption of sugar (sucrose) is blocked by acarbose. When hypogylcaemia occurs, only glucose should be given Alpha glucosidase inhibitor (Cont’d)

19 Metglitinides Stimulate insulin release Stimulate insulin release Rapid onset of action & short duration Rapid onset of action & short duration Taken shortly before meals Taken shortly before meals

20 Repaglinide (NovoNorm®): Repaglinide (NovoNorm®): 500 mcg – 4 mg daily within 30 min before main meals; Max: 16 mg daily 500 mcg – 4 mg daily within 30 min before main meals; Max: 16 mg daily Nateglinide: Nateglinide: 60 mg tid within 30 min before main meals; Max: 180 mg tid 60 mg tid within 30 min before main meals; Max: 180 mg tid Metglitinides (Cont’d)

21 Contraindications: Contraindications: Ketoacidosis Ketoacidosis Pregnancy and breast-feeding Pregnancy and breast-feeding Severe hepatic impairment (for repaglinide) Severe hepatic impairment (for repaglinide) Metglitinides (Cont’d)

22 Metglitinides (Cont’d) Adverse effects: Adverse effects: Hypoglycaemia Hypoglycaemia Hypersensitivity reactions including pruritus, rashes and urticaria Hypersensitivity reactions including pruritus, rashes and urticaria Abdominal pain, diarrhoea, constipation, nausea and vomiting (repaglinide) Abdominal pain, diarrhoea, constipation, nausea and vomiting (repaglinide) Nursing alert: Nursing alert: Administration must always be associated with meals Administration must always be associated with meals

23 Thiazolidinediones Also known as Glitazones Also known as Glitazones Reduce peripheral insulin resistance by enhancing uptake of glucose by skeletal muscle cells Reduce peripheral insulin resistance by enhancing uptake of glucose by skeletal muscle cells Rosiglitazone (Avandia®): Rosiglitazone (Avandia®): 4 mg daily in combination with metformin or a sulphonylurea; Max: 8 mg daily when with metformin 4 mg daily in combination with metformin or a sulphonylurea; Max: 8 mg daily when with metformin Pioglitazone (Actos®): Pioglitazone (Actos®): mg daily mg daily

24 Contraindications: Contraindications: Hepatic impairment Hepatic impairment History of heart failure, combination of insulin History of heart failure, combination of insulin Pregnancy and breast-feeding Pregnancy and breast-feeding Thiazolidinediones (Cont’d)

25 Adverse effects: Adverse effects: GI disturbances, headache, anaemia GI disturbances, headache, anaemia Weight gain Weight gain Oedema Oedema Hypoglycaemia (less common for Pioglitazone) Hypoglycaemia (less common for Pioglitazone) Liver dysfunctions (rare) Liver dysfunctions (rare) Thiazolidinediones (Cont’d)

26 Nursing Alerts: Nursing Alerts: Monitor liver function before treatment, then every 2 months for 1 year and periodically thereafter 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 Seek immediate medical attention if symptoms such as nausea, vomiting, abdominal pain, fatigue & dark urine develop Discontinue if jaundice occurs Discontinue if jaundice occurs Monitor closely for oedema & other signs of congestive heart failure Monitor closely for oedema & other signs of congestive heart failure Thiazolidinediones (Cont’d)

27 Non-oral antidiabetic drugs Insulin: Insulin: Supplement the insulin secreted by pancreas Supplement the insulin secreted by pancreas Promote uptake of glucose in muscle Promote uptake of glucose in muscle Facilitate conversion of glucose to glycogen in liver, inhibit gluconeogenesis & glycogenolysis in liver Facilitate conversion of glucose to glycogen in liver, inhibit gluconeogenesis & glycogenolysis in liver

28 Actions of Insulin Glucose transport into muscle & fat cells. Glucose transport into muscle & fat cells. Increased glycogen synthesis. Increased glycogen synthesis. Inhibition of gluconeogenesis. Inhibition of gluconeogenesis. Inhibition of lipolysis & increased formation of triglycerides. Inhibition of lipolysis & increased formation of triglycerides. Stimulation of membrane-bound energy- dependent ion transporters (e.g. Na/K ATPase). Stimulation of membrane-bound energy- dependent ion transporters (e.g. Na/K ATPase). Stimulation of cell growth Stimulation of cell growth

29 Insulin (Cont’d) They are divided into short, intermediate & long-acting preparations: They are divided into short, intermediate & long-acting preparations: Short-acting: Short-acting: Neutral/soluble insulin Neutral/soluble insulin E.g. Actrapid®HM, Humulin R® E.g. Actrapid®HM, Humulin R® Insulin Lispro Insulin Lispro E.g. Humalog® E.g. Humalog® Insulin Aspart Insulin Aspart E.g. NovoRapid® E.g. NovoRapid®

30 Intermediate-acting: Intermediate-acting: Isophane insulin Isophane insulin E.g. Protaphane®HM, Humulin N® E.g. Protaphane®HM, Humulin N® Insulin zinc suspension Insulin zinc suspension E.g. Monotard®, Humulin L® E.g. Monotard®, Humulin L® Insulin (Cont’d)

31 Insulin (Cont’d) Long-acting: Long-acting: Crystalline insulin zinc Crystalline insulin zinc E.g. Ultratard®HM E.g. Ultratard®HM Insulin glargine Insulin glargine E.g. Lantus® E.g. Lantus®

32 Mixed Insulins: Mixed Insulins: Biphasic isophane insulin Biphasic isophane insulin 30% soluble insulin/70% isophane insulin 30% soluble insulin/70% isophane insulin E.g. Mixtard ®30, Humulin ®70/30 E.g. Mixtard ®30, Humulin ®70/30 20% soluble insulin/80% isophane insulin 20% soluble insulin/80% isophane insulin E.g. Mixtard ®20 E.g. Mixtard ®20 Insulin (Cont’d)

33 Dose: Dose: Given through subcutaneous injection Given through subcutaneous injection According to the requirements According to the requirements Short-acting: Short-acting: Usually inject min before meals Usually inject min before meals Intermediate- & long-acting: Intermediate- & long-acting: Once or twice daily Once or twice daily Can be given in conjunction with short-acting insulin Can be given in conjunction with short-acting insulin Insulin (Cont’d)

34 Insulin Formulations

35 Precautions: Precautions: may decrease requirements in renal or hepatic impairment, some endocrine disorders, coeliac disease may decrease requirements in renal or hepatic impairment, some endocrine disorders, coeliac disease Insulin (Cont’d)

36 Nursing Alerts: 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 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 Rotate the injection site within the general area employed. Allow about 1 inch between sites Insulin (Cont’d)

37 Nursing Alerts (Cont’d): Nursing Alerts (Cont’d): Storage Storage Penfill Penfill Cartridges not in use should be stored between 2-8 ℃ Cartridges not in use should be stored between 2-8 ℃ Cartridges used in the pen or carried as spare can be used for up to one month Cartridges used in the pen or carried as spare can be used for up to one month Vial Vial Vials not in use should be stored between 2-8 ℃ Vials not in use should be stored between 2-8 ℃ Vial in use can be kept at room temp for 6 weeks (Novo Nordisk) Vial in use can be kept at room temp for 6 weeks (Novo Nordisk) Vials in use can be kept at room temp for 28 days (Lilly) Vials in use can be kept at room temp for 28 days (Lilly) Insulin (Cont’d)

38 Hypoglycaemia Nursing Alerts: Nursing Alerts: Observe for and teach the patient about signs and symptoms of hypoglycaemia Observe for and teach the patient about signs and symptoms of hypoglycaemia Tachycardia, palpitations Tachycardia, palpitations Sweating Sweating Nervousness, headache, confusion, drowsiness Nervousness, headache, confusion, drowsiness Fatigue Fatigue Rapid treatment is required Rapid treatment is required Patient is conscious: oral glucose should be given Patient is conscious: oral glucose should be given Patient is unconscious: IV glucose should be used Patient is unconscious: IV glucose should be used

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40 Drugs that affect the gastrointestinal system

41 Introduction Drugs used in gastrointestinal system or digestive disorder primarily exert their action by altering GI Drugs used in gastrointestinal system or digestive disorder primarily exert their action by altering GI Secretion Secretion Absorption Absorption Motility Motility They may act systemically or locally in the GI tract They may act systemically or locally in the GI tract

42 Cell activated by physical, chemical, or hormone stimuli Arachidonic acid Physiologic prostaglandins Pathologic prostaglandins Cyclooxygenase-1 (COX-1)Cyclooxygenase-2 (COX-2) GI protection (↓gastric acid,↑mucus production, maintain blood flow to mucosa) Renal protection (help maintain blood flow and function) Regulate smooth muscle tone in blood vessels (e.g., vasodilation) and lungs (e.g., bronchodilation) Regulate blood clotting Inflammation Vasodilation, ↑Capillary permeability Edema Pain Leukocytosis Activatye white blood cells to release inflammatory cytokines Traditional NSAIDs Block COX-1 and COX-2 enzymes COX-2inhibitor NSAIDs Block COX-2 enzyme Physiologic and pathologic (i.e. inflammatory) prostaglandins

43 Antacids & Simethicone Antacids Antacids Drugs that neutralize or reduce the acidity of stomach & duodenal contents by combining with HCl & producing salt & water Drugs that neutralize or reduce the acidity of stomach & duodenal contents by combining with HCl & producing salt & water Relieve symptoms in dyspepsia, gastro- oesophageal reflux disease (GERD), peptic ulcers Relieve symptoms in dyspepsia, gastro- oesophageal reflux disease (GERD), peptic ulcers Simethicone Simethicone Added to antacids as an antifoaming agent to relieve flatulence Added to antacids as an antifoaming agent to relieve flatulence

44 Antacids Antacids Aluminium Hydroxide (500mg tablet /6% suspension) Aluminium Hydroxide (500mg tablet /6% suspension) 1-2 tablets chewed qid 1-2 tablets chewed qid Magnesium trisilicate (Mixture) Magnesium trisilicate (Mixture) 5% BP Mixture: 10ml tid po 5% BP Mixture: 10ml tid po Antacids & Simethicone (Cont’d)

45 Antacids combination products: Antacids combination products: Triact tablet Triact tablet Al(OH) 3 Dried Gel 200 mg & Mg(OH) mg & Simethicone 25 mg Al(OH) 3 Dried Gel 200 mg & Mg(OH) mg & Simethicone 25 mg Chew 1-2 tab q4-6h Chew 1-2 tab q4-6h Gastrocaine suspension Gastrocaine suspension Oxethazaine 10mg, Al(OH) 3 Dried Gel 300mg, Mg(OH) 2 100mg in 5 ml Oxethazaine 10mg, Al(OH) 3 Dried Gel 300mg, Mg(OH) 2 100mg in 5 ml Alumag suspension Alumag suspension Al(OH) 3 & Mg Trisilicate Al(OH) 3 & Mg Trisilicate Antacids & Simethicone (Cont’d)

46 Antacids combination products (Cont’d): Antacids combination products (Cont’d): Gelusil tablet Gelusil tablet Mg Trisilicate+ Dried Aluminium Hydroxide gel Mg Trisilicate+ Dried Aluminium Hydroxide gel Mylanta tablet / suspension Mylanta tablet / suspension CaCO 3 & Mg(OH) 2 CaCO 3 & Mg(OH) 2 Simethicone Simethicone Dimethylpolysiloxane (Gasteel® 40 mg tablet) Dimethylpolysiloxane (Gasteel® 40 mg tablet) Antacids & Simethicone (Cont’d)

47 Relax smooth muscle Relax smooth muscle Relieve GI smooth muscle spasm Relieve GI smooth muscle spasm Include antimuscarinics & others Include antimuscarinics & others Antispasmodics

48 Antispasmodics (Cont’d) Antimuscarinics: Antimuscarinics: Hyoscine Butylbromide (Buscopan®) Hyoscine Butylbromide (Buscopan®) Adult: 20 mg qid po; Adult: 20 mg qid po; Child: 10 mg tid po Child: 10 mg tid po Propantheline bromide Propantheline bromide 15 mg tid at least 1 hr before meals & 30 mg at night; Max: 120 mg daily 15 mg tid at least 1 hr before meals & 30 mg at night; Max: 120 mg daily Not recommended for children Not recommended for children

49 Side effects: Side effects: Constipation Constipation Urinary urgency and retention Urinary urgency and retention Dry mouth Dry mouth Transient bradycardia Transient bradycardia Antispasmodics (Cont’d)

50 Others: Others: Mebeverine HCl (Duspatalin®) Mebeverine HCl (Duspatalin®) Adult & child over 10 years: mg tid preferably 20 min before meals Adult & child over 10 years: mg tid preferably 20 min before meals Peppermint oil (0.2 ml capsule) Peppermint oil (0.2 ml capsule) 1-2 capsules tid 1-2 capsules tid Not recommended for children under 15 years Not recommended for children under 15 years Antispasmodics (Cont’d)

51 Motility stimulants Dopamine antagonists Dopamine antagonists Stimulate gastric emptying & small intestinal transit Stimulate gastric emptying & small intestinal transit Enhance strength of oesophageal sphincter contraction Enhance strength of oesophageal sphincter contraction Sometimes used in non-ulcer dyspepsia Sometimes used in non-ulcer dyspepsia Useful in non-specific & in cytotoxic- induced nausea & vomiting (N&V) Useful in non-specific & in cytotoxic- induced nausea & vomiting (N&V)

52 Domperidone (Motilium®) Domperidone (Motilium®) N&V: N&V: adult: mg q4-8h adult: mg q4-8h Child: mcg/kg q4-8h Child: mcg/kg q4-8h Functional dyspepsia Functional dyspepsia mg tid before food & mg at night mg tid before food & mg at night Not recommended for children Not recommended for children Motility stimulants (Cont’d)

53 Metoclopramide (Maxolon®) Metoclopramide (Maxolon®) Adult: 10 mg tid Adult: 10 mg tid yrs under 60 kg: 5 mg tid yrs under 60 kg: 5 mg tid 1-14 yrs: 1 mg bd to 5 mg tid depend on age 1-14 yrs: 1 mg bd to 5 mg tid depend on age Diagnostic procedures: Diagnostic procedures: Adult: mg five to ten min before exam Adult: mg five to ten min before exam Child: 1-5 mg depends on age Child: 1-5 mg depends on age Motility stimulants (Cont’d)

54 Side effects: Side effects: May raised prolactin concentration May raised prolactin concentration Rashes & other allergic reactions Rashes & other allergic reactions Acute dystonic reaction reported Acute dystonic reaction reported Extrapyramidal effects (Metoclopramide more prominent) Extrapyramidal effects (Metoclopramide more prominent) Motility stimulants (Cont’d)

55 Nursing Alert: Nursing Alert: For patients under 20 yrs 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 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 Dose based on basis of body-weight Motility stimulants (Cont’d)

56 Ulcer-healing drugs Peptic ulceration commonly involves the stomach, duodenum & lower oesophagus Peptic ulceration commonly involves the stomach, duodenum & lower oesophagus Due to imbalance between cell-destructive & cell-protective effects Due to imbalance between cell-destructive & cell-protective effects Helicobacter pylori & NSAIDs can weaken the defences Helicobacter pylori & NSAIDs can weaken the defences Relapse is common when treatment ceases Relapse is common when treatment ceases

57 Include several groups of drugs Include several groups of drugs H 2 -receptor antagonists H 2 -receptor antagonists Chelates & complexes Chelates & complexes Prostaglandin analogues Prostaglandin analogues Proton pump inhibitors Proton pump inhibitors Ulcer-healing drugs (Cont’d)

58 H 2 -receptor antagonists Histamine acts on receptors located on parietal cells to increase production of HCl Histamine acts on receptors located on parietal cells to increase production of HCl Block histamine H 2 -receptors Block histamine H 2 -receptors Heal gastric & duodenal ulcers by reducing gastric acid output Heal gastric & duodenal ulcers by reducing gastric acid output Relieve gastro-oesophageal reflux disease Relieve gastro-oesophageal reflux disease May occasionally be used for patients with frequent severe recurrences & for the elderly who suffer ulcer complications May occasionally be used for patients with frequent severe recurrences & for the elderly who suffer ulcer complications

59 H 2 -receptor antagonists (Cont’d) Cimetidine Cimetidine Adult: 400 mg bd; Max: 2.4 g daily (rarely) Adult: 400 mg bd; Max: 2.4 g daily (rarely) Child: mg/kg daily in divided dose Child: mg/kg daily in divided dose Famotidine Famotidine mg bd mg bd Not recommended for children Not recommended for children Nizatidine Nizatidine mg bd mg bd Not recommended for children Not recommended for children Ranitidine Ranitidine Adult: 150 mg bd Adult: 150 mg bd Child: 2-4 mg/kg bd; Max: 300 mg daily Child: 2-4 mg/kg bd; Max: 300 mg daily

60 Side effects: Side effects: Diarrhoea & other GI disturbances Diarrhoea & other GI disturbances Altered liver function tests Altered liver function tests Headache, dizziness, rash Headache, dizziness, rash H2-receptor antagonists (Cont’d)

61 Nursing Alerts: Nursing Alerts: Cimetidine is a CYP450 inhibitor, avoid in patients on warfarin, phenytoin & theophylline 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 ambulatory activities Patients may experience dizziness or drowsiness during early therapy, especially in the elderly. Assistance may be required for ambulatory activities H2-receptor antagonists (Cont’d)

62 Chelates & complexes Sucralfate Sucralfate Complex of AL(OH) 3 & sulphated sucrose Complex of AL(OH) 3 & sulphated sucrose Minimal antacid properties Minimal antacid properties Protect the mucosa from acid-pepsin attack in gastric & duodenal ulcers 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 2 g bd or 1 g qid 1 hr before meals & at bedtime; Max: 8 g daily Not recommended for children Not recommended for children

63 Side effects: Side effects: Constipation, diarrhoea, gastric discomfort Constipation, diarrhoea, gastric discomfort Dry mouth Dry mouth Headache, nausea Headache, nausea Hypersensitivity reactions Hypersensitivity reactions Chelates & complexes

64 Prostaglandin analogues Misoprostol Misoprostol Synthetic prostaglandin analogue (Prostaglandin E) Synthetic prostaglandin analogue (Prostaglandin E) Antisecretory & protective properties Antisecretory & protective properties Inhibit gastric acid secretion Inhibit gastric acid secretion Increase mucus & bicarbonate secretion Increase mucus & bicarbonate secretion Promote healing of gastric & duodenal ulcers Promote healing of gastric & duodenal ulcers

65 Prostaglandin analogues (Cont’d) Dose: Dose: 800 mcg daily in 2-4 divided doses 800 mcg daily in 2-4 divided doses For prophylaxis of NSAID-induced gastric & duodenal ulcer For prophylaxis of NSAID-induced gastric & duodenal ulcer 200 mcg 2-4 times daily 200 mcg 2-4 times daily Not recommended for children Not recommended for children

66 Side effects: Side effects: Diarrhoea (may require withdrawal) Diarrhoea (may require withdrawal) Abdominal pain, dyspepsia, flatulence, nausea & vomiting Abdominal pain, dyspepsia, flatulence, nausea & vomiting Abnormal vaginal bleeding Abnormal vaginal bleeding Nursing Alerts: Nursing Alerts: Incidence of diarrhoea may be lessened by taking dose right after meals Incidence of diarrhoea may be lessened by taking dose right after meals Prostaglandin analogues (Cont’d)

67 Nursing Alerts (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 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 Patients should take effective contraceptive measures & be advised the risks of taking misoprostol if pregnant Prostaglandin analogues (Cont’d)

68 Proton pump inhibitors Inhibit gastric acid by irreversibly blocking the hydrogen-potassium adenosine triphosphatase enzyme system (“proton pump”) of gastric parietal cell 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 Indicated for gastric & duodenal ulcers & gastro-oesophageal reflux disease Suppress gastric acid more strongly & for a longer time than H 2 -receptor antagonists Suppress gastric acid more strongly & for a longer time than H 2 -receptor antagonists

69 Omeprazole Omeprazole Adult: mg daily Adult: mg daily Child over 2 yrs: mg/kg daily; Max: 40 mg daily Child over 2 yrs: mg/kg daily; Max: 40 mg daily IV injection or infusion is not recommended for children IV injection or infusion is not recommended for children Esomeprazole Esomeprazole mg daily mg daily Not recommended for children Not recommended for children Lansoprazole Lansoprazole mg daily mg daily Not recommended for children Not recommended for children Pantoprazole Pantoprazole mg daily mg daily Not recommended for children Not recommended for children Rabeprazole Rabeprazole mg daily mg daily Not recommended for children Not recommended for children Proton pump inhibitors (Cont’d)

70 Proton pump inhibitors (Cont’d) Side effects: Side effects: GI disturbances GI disturbances Headache Headache Hypersensitivity reactions Hypersensitivity reactions

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72 Unawareness of drug’s brand name Patient has a documented allergy to Zyloric ® Patient has a documented allergy to Zyloric ® Allopurinol was prescribed to this patient Allopurinol was prescribed to this patient The doctor prescribing was not aware that Zyloric ® was the brand name for Allopurinol The doctor prescribing was not aware that Zyloric ® was the brand name for Allopurinol

73 Tips Check out the contents of the preparation if brand name is used before prescribing, dispensing or administration Check out the contents of the preparation if brand name is used before prescribing, dispensing or administration

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75 Improper Drug Abbreviation IV Mitoxantrone was prescribed IV Mitoxantrone was prescribed The abbreviation ‘MTX’ was put on the label The abbreviation ‘MTX’ was put on the label An injection of Methotrexate was prepared instead according to the abbreviation on the label An injection of Methotrexate was prepared instead according to the abbreviation on the label Methotrexate was administered to the patient as a result Methotrexate was administered to the patient as a result

76 Tips Write drug name in full Write drug name in full Do not use unauthorised abbreviations Do not use unauthorised abbreviations Cross check the dose & name of the drug before preparation & administration Cross check the dose & name of the drug before preparation & administration

77 Repeated Pethidine Injection Patient was given a Pethidine injection at A&E via a verbal order Patient was given a Pethidine injection at A&E via a verbal order Nurse forgot to record this order in MAR Nurse forgot to record this order in MAR Prescribing Dr had not confirmed the verbal order in the prescription Prescribing Dr had not confirmed the verbal order in the prescription A second dose of Pethidine was administered in the ward A second dose of Pethidine was administered in the ward Patient collapsed as a result of overdose of Pethidine Patient collapsed as a result of overdose of Pethidine

78 Tips Pethidine is a Dangerous Drug & should not be ordered through verbal orders Pethidine is a Dangerous Drug & should not be ordered through verbal orders For other non-DD, give a verbal order only in emergency & exceptional circumstances For other non-DD, give a verbal order only in emergency & exceptional circumstances Record the verbal instruction in the MAR immediately as ‘verbal order’ Record the verbal instruction in the MAR immediately as ‘verbal order’ After writing down the instruction, read back the details to the Dr for double checking After writing down the instruction, read back the details to the Dr for double checking

79 Self-medication of Paracetamol Patient was transferred from medical ward to ICU with high plasma level of Paracetamol Patient was transferred from medical ward to ICU with high plasma level of Paracetamol Patient was treated with N-acetylcysteine infusion as an antidote Patient was treated with N-acetylcysteine infusion as an antidote Patient later admitted that she had taken approximately 15 tabs of Paracetamol (private medications) in the medical ward to relieve her leg pain Patient later admitted that she had taken approximately 15 tabs of Paracetamol (private medications) in the medical ward to relieve her leg pain

80 Tips Put patients’ brought-in medicines into safe custody 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 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 Glibenclamide or Citalopram An in-patient presented with severe hypotension & vomiting 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 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 Glibenclamide Upon investigation, it was discovered that some nursing staff gave Citalopram to the patient whilst others gave Glibenclamide

82 Tips Familiarise with the medication &/or the patient Familiarise with the medication &/or the patient If there is uncertainty or confusion about a particular prescription, always consult with the prescriber 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 Adequate communication between staff is the key to preventing errors

83 Wrong Drug Name Martindale 1 drop tds both eyes was prescribed Martindale 1 drop tds both eyes was prescribed Martindale is the name of the drug company that makes the eye drops Martindale is the name of the drug company that makes the eye drops

84 Tips Prescribe in generic rather than trade name as trade names don’t usually give indications of their constituents Prescribe in generic rather than trade name as trade names don’t usually give indications of their constituents

85 Inappropriate Drug Dosage A 10 month old baby was prescribed Cotrimoxazole suspension 20mg bd A 10 month old baby was prescribed Cotrimoxazole suspension 20mg bd Cotrimoxazole is a combination product containing Sulphamethoxazole 200mg & Trimethoprim 40mg per 5ml Cotrimoxazole is a combination product containing Sulphamethoxazole 200mg & Trimethoprim 40mg per 5ml 240mg per 5 ml & 20mg = 0.42ml 240mg per 5 ml & 20mg = 0.42ml It was later clarified that the dose 20mg refers to the Trimethoprim component It was later clarified that the dose 20mg refers to the Trimethoprim component Thus 120mg cotrimoxazole should have been prescribed Thus 120mg cotrimoxazole should have been prescribed

86 Tips Should clearly specify drug dosage especially for combination product Should clearly specify drug dosage especially for combination product Clarify with prescriber if in doubt Clarify with prescriber if in doubt