Patients of medication to treat blood glucose levels

Patients living with diabetes mellitus are either
inclined to insulin resistance or when insufficient insulin is produced from
the pancreas, resulting to hyperglycaemia and leading to various microvascular
and macrovascular complications including ‘hypertension’ 1-2. This assignment
will demonstrate the use of two classes of medication to treat blood glucose levels
and hypertension.

 

Medication for
Blood Glucose Control

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1. Metformin
(Biguanides)

Mode of Action

 

Metformin is an antidiabetic drug that
contains the ingredient metformin hydrochloride, which belongs to the chemical drug
class of biguanide 3. Metformin is the first line and initial drug therapy prescribed
specifically to newly diagnosed patients living with type 2 diabetes,
especially overweight and obese patients who don’t have adequate control over their
diet and exercise or are not feasible, which results in uncontrolled blood
glucose 4-5. Metformin medication helps promote normal blood sugar levels and
helps maintain it constantly 4,6. This is enhanced by reducing the quantity
of glucose from the liver that’s released into the bloodstream and declines the
amount of glucose captivated by the intestines; therefore, making the body
cells become more adequate and responsive to insulin and enhances the
sensitivity mechanisms of the muscle cells to insulin 4,7-8. Metformin also
utilises its constructive effects on glycaemic control, by enhancing peripheral
and hepatic sensitivity to insulin 9-11 and can enhance modest weight loss or
keep current weight stable 12. Metformin alone works to decrease postprandial
blood glucose, fasting plasma glucose, HbA1c levels and prevents hypoglycaemia episodes
13. Metformin medication initially starts from taking once daily dose with breakfast;
the dose then steadily increases to 2-3 times a day with main meals 14-15.

 

 

 

 

 

 

 

Side Effects

 

Common side effects with metformin are
usually: drowsiness, dizziness, tiredness, muscle pains and cramps, abdominal discomfort,
vomiting, diarrhea and nausea; not all of these side effects may manifest 16.
Lactic acidosis is the most serious side effect that’s predominately due to
accumulation of metformin in the body but it’s very rare this side effect occurs
17.

 

Cautions

 

Several precautions should be taken account
when prescribing metformin. Patients with kidney complications could suffer
from lactic acidosis due to higher quantities of metformin in the system,
resulting in the kidneys unable to function adequately 17-18. Secondly,
patients with heart complications shouldn’t take metformin due to the heart
unable to send sufficient amount of blood to the kidneys, which stops the
kidneys from eliminating metformin from the body, resulting in the risk of lactic
acidosis 17. However, GP’s may test the kidneys and prescribe metformin if appropriate
17. Drinking high amounts of alcohol alongside metformin could cause lactic
acidosis and hypoglycaemia; thus, it’s vital to educate patients towards
alcohol health effects whilst taking metformin 17.

 

Monitoring

 

Metformin can predispose to vitamin B12
deficiency, resulting in homocysteine concentrations 18. However, this can be
preventable and regular measurements of vitamin B12 monitoring should be
considered during long-term metformin therapy 18. It’s vital to identify if
patients have any allergic reaction to metformin ingredients before prescribing
19.

 

Counselling points

 

It’s important to counsel patients to take metformin
at the same time everyday with meals 20. Secondly, making patients aware of
hypoglycaemia and how to overcome low sugar levels. Even though metformin is
unlikely to cause hypoglycaemia, other medications patients may take alongside
metformin may predispose to low sugar levels, therefore its important to make
patients aware to monitor blood sugar levels regularly, especially before
driving and exercising 20.  Lastly, its
important that patients are aware of all minor and major side effects (especially
lactic acidosis) with metformin and explain what actions should be considered
if these side effects arise 16-17.

 

2. Sitagliptins (DPP-4
Inhibitors)

 

Sitagliptin is an anti-diabetic drug of the
dipeptidyl peptidase-4 (DPP-4) inhibitor medication class, which is generally
prescribed to patients living with type 2 diabetes mellitus to help lower blood
sugar levels, which can also be combined with other anti-diabetic drugs e.g.
metformin 21.

 

Mode of Action

 

Sitagliptins main role is to block the
action of DPP-4, which is an enzyme that predominantly destroys gastrointestinal
hormone incretins. Incretins is a hormone which produces insulin when it’s
required (after eating) and decreases the production of glucagon by the liver
organ when it’s isn’t necessary (during digestion) 22. Glucagon-like
peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) support
the action of incretin 23. Patients living with diabetes mellitus do not make
sufficient amount of incretin than individuals without diabetes 24.  Thus, Sitagliptin medication plays its part by
inhibiting DPP-4 that essentially supports the hormone incretin to stay longer
in the body, which helps improves meal enthused active GLP-1 AND GIP levels
approximately two to threefold 25. A single dose of 100mg of sitagliptin provides
persistent 24-hour prevention of DPP-4 enzyme, which increases activation of
GLP-1 and GIP prominent to increase in insulin and C-peptide decline glucogons,
which improves in oral glucose tolerance 26. As a result, this inclines insulin to be released that
helps lower blood glucose levels to a healthy range, slows down digestion and
decreases appetite 24-27. DPP-4 inhibitor (Sitagliptin) can help lower HbA1c
to approximately by 0.5% – 0.8% 28.

 

Side Effects

 

There are many adverse side effects that
manifest with sitagliptins (DPP-4) such as: headaches, diarrhoea, nausea,
stomach pains, sore throat, skin reactions may manifest and can increase risk
of pancreatitis (constant abdominal pain) which disposes to vomiting and nausea
22.

 

 

 

 

 

 

Monitoring

 

Inform patients to consider regular physical
examinations e.g. blood tests, urine tests to be certain that any medication
(in this case: DPP-4 medications) are not causing any severe adverse effects to
the patients health and be confident that the prescribed medication is suited
to the patient effectively 29. Doctors would monitor kidney function with patients
with renal complications and may prescribe lower dosages (normally 25 – 50mg)
30-31.

 

Cautions

 

DPP-4 medication should not be prescribed
as first line of diabetes therapy but second e.g. after metformin. 30-31. Sitagliptins
should not be prescribed to patients living with type 1 diabetes for treating
diabetes ketoacidosis 32. Sitagliptins is associated with acute pancreatitis
discomfort; health care professions should inform patients about severe
abdominal discomfort and if suspected sitagliptins should be discontinued
straight away as well as any allergic reactions 32. Patients with a history
of pancreatitis, cautions should be used straight away 32. There is a dosage
order for sitagliptins when prescribed to patients with renal complications,
therefore, patients need to take renal function assessments before being prescribed
sitagliptins amongst other anti-diabetic medication and should be assessed again
after being prescribed a suitable dose, in order to keep track of renal
function 32.

 

Counselling Points

 

Counselling patients to take sitagliptin
regularly with the prescribed dose given, if patients accidently missed a dose
it should be taken as soon as possible 33. If it’s nearer to the next dose,
patients should eliminate double dose and get back to regular dosing agenda
33.

 

 

 

 

 

 

 

 

 

Medication for
Blood Pressure Control

 

1. Acebutolol (Beta
Blockers)

 

Mode of Action

 

Acebutolol is a medication belongs to the
group of medicines of beta-blockers to treat hypertension and irregular heart
beat that works on the heart and blood vessels 34. Acebutolol works by
slowing down the action of the heart by preventing messages sent by the nerve
to the heart 34-35. This is by blocking the beta-adrenergic receptors where
the messages are acknowledged by the heart, which results in the heart beating
more slowly with essentially less force that support blood vessels and the
heart to stay relaxed 34-35. This therefore, reduces hypertension by decreasing
the pressure of blood within the blood vessels and because the heart is using
lesser energy it also supports to reduce chest pains if patients suffer from
angina; also works to lower heart rate and for the hearts request for oxygen 34-35.

 

Side Effects

 

Like any other medication, acebutolol has
many side effects and the most common ones are: headaches, blurred vision,
dizziness, diarrehea, indigestion, fatigue and muscle pains 34-35. When blood
pressure and heart rate is low, patients could suffer from severe dizziness and
fainting, therefore patients may need medication attention 35.

 

Monitoring

 

NICE guidelines
suggest health care professions should monitor lung and kidney function for
patients who have a history of airway and renal disease before prescribing
acebutolol 36. This is to monitor if these organs are working well, which
would help decide if this drug would be safe to use and also if the dose needs
to be lowered 35-36.

 

 

 

 

 

 

 

Cautions

 

Before prescribing acebutolol to female
patients, health care professions should examine if they are pregnant or
planning to get pregnant, as acebutolol shouldn’t be used during pregnancy because
it could cause a harmful risk to the unborn baby 35. Patients with asthma,
heart, hyperthyroidism and renal deficiencies; doctors would either put
patients on a small dose of acebutolol with a caution, change the medication or
completely avoid it depending on the situation 35-36. Special cautions should
be suggested to patients with a history of hypersensitivity, as beta-blockers
could cause sensitivity to allergic reactions, which could cause severe
hypersensitivity reactions 36.

 

Counselling Points

 

Counselling patients to take this
medication regularly as prescribed and don’t stop this medication suddenly, as
it could incline patients to hypertension and other heart related disorders
37. Patients living with diabetes mellitus should regularly monitor their
blood glucose levels, as this medication could possibly predispose to
hypoglycaemia symptomology 37. 

 

2. Benazepril (ACE
Inhibitors)

 

Mode of Action

 

Benazepril is essentially an angiotensin
converting enzyme (ACE) inhibitor medication therapy to treat hypertension
38-39. ACE is an enzyme, which produces the development of angiotensin II in
the human body 38. Angiotensin II triggers contraction of the muscles that
surrounds and narrows the arteries, which causes hypertension 40. Thus,
benazepril is a ACE inhibitor medication that supports to lower blood pressure
by stopping the formation of angiotensin II, which essentially relaxes the
arteries that’s consequential to lowering blood pressure and also progresses pumping
productivity of a failing heart, which is an additional advantage for patients
with heart failure conditions 40.

 

 

 

 

 

 

Side Effects

 

There are several side effects that may
manifest with benazepril: dizziness, light headed, tiredness, sweating, fever,
headaches, loss of appetite, shortness of breath, rash, chest pains, nausea,
joint or muscle pain 40-41. In rare occasions, jaundice and liver dysfunction
have been reported from ACE inhibitor medication 40. Thus, Benazepril
shouldn’t be taken if patients have these known side effects and allergies with
ACE inhibitors and seek medical attention if these common side effects still
continue 40.

 

Monitoring

 

Its important to monitor patients renal
function who are being treated with benazepril, as changes in renal functioning
can include acute renal failure, which can predominantly be caused by drugs
that prevent renin-angiotensin system 41. Regular blood pressure assessments
should be taken with patients to ensure benazepril is working effectively 42.

 

Cautions

 

Patients renal function that depends on the
action of the renin-angiotensin system such as: patients who suffer from kidney
disease, heart failure, artery stenosis, volume depletion can be at potential
risk of emerging acute renal failure when on benazepril 42.  Thus, health care professionals may either
withhold or stop benazepril therapy to those patients who develop significant
decrease in renal functioning 42. Doctors should investigate if female
patients who are pregnant or planning to get pregnant before prescribing
benazepril, as it is a pregnancy category D medication, which could have
potential health risks to the unborn baby 43.

 

Counselling Points

 

Counsel patients to avoid taking potassium
supplementation or salt alternatives with potassium is important, as potassium
in the blood could incline to hazardous levels, which could affect the patient’s
health 43. Its vital to inform patients to report any indications of
infections (e.g. fever, sore throat etc.) straightaway, as it could be signs of
neutropenia 44.