Chlorpropamide

Nutrients Depleted: Coenzyme Q10

U.S. Brand Names: Diabinese®

Use: Control blood sugar in adult onset, noninsulin-dependent diabetes (type II)

Pregnancy Risk Factor and Implications: D; Enters breast milk/contraindicated

Contraindications: Cross sensitivity may exist with other hypoglycemics or sulfonamides; do not use with type I diabetes or with severe renal, hepatic, thyroid, or other endocrine disease

Dietary Considerations:

Warnings/Precautions: Patients should be properly instructed in the early detection and treatment of hypoglycemia; long half-life may complicate recovery from excess effects.

Adverse Reactions:

Greater than 10% experience:

Central nervous system: Headache, dizziness
Gastrointestinal: Anorexia, constipation, heartburn, epigastric fullness, nausea, vomiting, diarrhea

1% to 10% experience:

Dermatologic: Skin rash, urticaria, photosensitivity

Less than 1% experience: Edema, hypoglycemia, hyponatremia, SIADH, blood dyscrasias, aplastic anemia, hemolytic anemia, bone marrow suppression, thrombocytopenia, agranulocytosis, cholestatic jaundice

Overdose/Toxicology: Symptoms of overdose include low blood glucose levels, tingling of lips and tongue, tachycardia, convulsions, stupor, and coma. The antidote is glucose. Prolonged effects lasting up to 1 week may occur with chlorpropamide.

Acetohexamide

Nutrients Depleted: Coenzyme Q10

U.S. Brand Names: Dymelor®

Use: Adjunct to diet for the management of mild to moderately severe, stable, noninsulin-dependent (type II) diabetes mellitus.

Pregnancy Risk Factor and Implications: D; Excretion in breast milk unknown/not recommended.

Contraindications: Diabetes complicated by ketoacidosis, therapy of type I diabetes, hypersensitivity to sulfonylureas.

Dietary Considerations: Avoid use of alcohol.

Warnings/Precautions: Advise patient to avoid alcohol or prducts containing alcohol; monitor for signs and symptoms of hypoglycemia (fatigue, excessive hunger, profuse sweating, or numbness of extremities).

Adverse Reactions:
Greater than 10% experience:
Central nervous system: Headache, dizziness.
Gastrointestinal: Constipation, diarrhea, heartburn, anorexia, epigastric fullness.

1% to 10% experience: Dermatologic: rash, urticaria, photosensitivity.

Less than 1% experience: Hypoglycemia, aplastic anemia, hemolytic anemia, bone marrow suppression, thrombocytopenia, agranylocytosis.

Overdose/Toxicology: Symptoms of overdose include low blood sugar, tingling of the lips and tongue, nausea, yawning, confusion, agitation, tachycardia, sweating, convulsions, stupor, and coma. Hypoglycemia should be managed with 50 mL I.V. dextrose 50% followed immediately with a continuous infusion of 10% dextrose in water (administer at a rate sufficient enough to approach a serum glucose level of 100 mg/kL). The use of coricosteroids to treat hypoglycemia is controversial, however, adding 100 mg of hydrocortisone to the dextrose infusion may prove helpful.

Glimepiride

Nutrients Depleted: Coenzyme Q10

U.S. Brand Names: Amaryl®

Use: Management of noninsulin-dependent diabetes mellitus (type II) as an adjunct to diet and exercise to lower blood glucose. Use in combination with insulin to lower blood glucose in patients whose hyperglycemia cannot be controlled by diet and exercise in conjunction with an oral gypoglycemic agent.

Pregnancy Risk Factor and Implications: C; Excretion in breast milk unknown/contraindicated.

Contraindications: Hypersensitivity to glimepiride or any component, other sulfonamides; diabetic ketoacidosis (with or without coma).

Warnings/Precautions: The administration of oral hypoglycemic drugs (ie, tolbutamide) has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or diet plus insulin. All sulfonylurea drugs are capable of producing severe hypoglycemia. Hypoglycemia is more likely to occur when caloric intake is deficient, after severe or prolonged exercise, when alcohol is ingested, or when more than one glucose-lowering drug is used.

Adverse Reactions:
1% to 10% experience: Central nervous system: Headache

Greater than 1% experience: Edema, rash, urticaria, photosensitivity, hypoglycemia, hyponatremia, anorexia, nausea, vomiting, diarrhea, epigastric fullness, constipation, heartburn, blood dyscrasias, aplastic anemia, hemolytic anemia, bone marrow suppression, thrombocytopenia, agranulocytosis, cholestatic jaundice, diuretic effect.

Overdose/Toxicology: Symptoms of overdose include low blood sugar, tingling of lips and tongue, nausea, yawning, confusion, agitation, tachycardia, sweating, convulsions, stupor, and coma. Intoxication with sulfonylureas can cause hypoglycemia and are best managed with glucose administration (oral for milder hypoglycemia or be injection in more severe forms). Patients should be monitored for a minimum of 24-48 hours after ingestion.

Glipizide

Nutrients Depleted: Coenzyme Q10

U.S. Brand Names: Glucotrol®; Glucotrol® XL

Use: Management of noninsulin-dependent diabetes mellitus (type II)

Pregnancy Risk Factor and Implications: C; Excretion in breast milk unknown/contraindicated.

Contraindications: Hypersensitivity to glipizide or any component, other sulfonamides, type I diabetes mellitus.

Dietary Considerations:
Alcohol: A disulfiram-like reaction characterized by flushing, headache, nausea, vomiting, sweating, or tachycardia; avoid use.
Food: Food delays absorption by 40%; take glipizide before meals.
Glucose: Decreases blood glucose concentration. Hypoglycemia may occur. Educate patients how to detect and treat hypoglycemia. Monitor for signs and symptoms of hypoglycemia. Administer glucose if necessary. Evaluate patient's diet and exercise regimen. May need to decrease or discontinue dose of sulfonylurea.
Sodium: Reports of hyponatremia and SIADH. Those at increased risk include patients on medications or who have medical conditions that predispose them to hyponatremia. Monitor sodium serum concentration and fluid status. May need to restrict water intake.

Warnings/Precautions: Use with caution in patients with severe hepatic disease; a useful agent since few drug to drug interactions and not dependent upon renal elimination of active drug.

Adverse Reactions:
Greater than 10% experience:
Central nervous system: Headache.
Gastrointestinal: Anorexia, nausea, vomiting, diarrhea, epigastric fullness, constipation, heartburn.

1% to 10% experience: Dermatologic: Rash, urticaria, photosensitivity.

Less than 1% experience: Edema, hypoglycemia, hyponatremia, blood dyscrasias, aplastic anemia, hemolytic anemia, bone marrow suppression, thrombocytopenia, agranulocytosis, cholestatic jaundice, diuretic effect.

Overdose/Toxicology: Symptoms of overdose include low blood sugar, tingling of lips and tongue, nausea, yawning, confusion, agitation, tachycardia, sweating, conmulsions, stupor, and coma. Intoxication with sulfonylureas can cause hypoglycemia and are best managed with glucose administration (oral for milder hypoglycemia or by injection in more severe forms).

Glyburide

Nutrients Depleted: Coenzyme Q10

U.S. Brand Names: Diaßeta®; Glynase™ PresTab™; Micronase®.

Use: Management of noninsulin-dependent diabetes mellitus (type II ).

Pregnancy Risk Factor and Implications: C; Excretion in breast milk unknown/contraindicated.

Contraindications: Hypersensitivity to glyburide or any component, or other sulfonamides; type I diabetes mellitus, diabetic ketoacidosis with or without coma.

Dietary Considerations:
Alcohol: A disulfiram-like reaction characterized by flushing, headache, nausea, vomiting, sweating, or tachycardia; avoid use.
Food: Food does not affect absorption; glyburide may be taken with food.
Glucose: Decreases blood glucose concentration. Hypoglycemia may occur. Educate patients how to detect and treat hypoglycemia. Monitor for signs and symptoms of hypoglycemia. Administer glucose if necessary. Evaluate patient's diet and exercise regimen. May need to decrease or discontinue dose of sulfonylurea.
Sodium: Reports of hyponatremia and SIADH. Those at increased risk include patients on medications or who have medical conditions that predispose them to hyponatremia. Monitor sodium serum concentration and fluid status. May need to restrict water intake.

Warnings/Precautions: Use with caution in patients with hepatic impairment. Elderly: Rapid and prolonged hypoglycemia (Greater than 12 hours) despite hypertonic glucose injections have been reported; age and hepatic and renal impairment are independent risk factors for hypoglycemia; dosage filtration should be made at weekly intervals. Use with caution in patients with renal and hepatic impairment, malnourished or debilitated conditions, or adrenal or pituitary insufficiency. The administration of oral hypoglycemic drugs (ie, tolbutamide) has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or diet plus insulin.

Adverse Reactions:
Over 10% experience:
Central nervous system: Headache, dizziness.
Gastrointestinal: Nausea, epigastric fullness, heartburn, constipation, diarrhea, anorexia.
Ocualar: Blurred vision

1% to 10% experience: Dermatologic: Pruritus, rash, urticaria, photosensitivity reaction.

Less than 1% experience: Hypoglycemia, nocturia, leukopenia, thrombocytopenia, hemolytic anemia, aplastic anemia, bone marrow suppression, agranulocytosis, cholestatic jaundice, arthralgia, paresthesia, diuretic effect.

Overdose/Toxicology: Symptoms of overdose include severe hypoglycemia, seizures, cerebral damage, tingling of lips and tongue, nausea, yawning, confusion, agitation, tachycardia, sweating, convulsions, stupor, and coma. Intoxication with sulfonylureas can cause hypoglycemia and is best managed with glucose administration (oral for milder hypoglycemia or by injection in more severe forms).

Metformin (met FOR min)

Nutrients Depleted: Vitamin B12

U.S. Brand Names: Glucophage®

Use: Management of noninsulin-dependent diabetes mellitus (type II) as monotherapy when hyperglycemia cannot be managed on diet alone. May be used concomitantly with a sulfonylurea when diet and metformin or sufonylurea alone do not result in adequate glycemic control.

Pregnancy Risk Factor and Implications: B; Enters breast milk/not recommended.

Contraindications: Hypersensitivity to metformin or any component; renal disease or renal dysfundtion (serum creatinine 1.5 mg/dL in males or 1.4 mg/dL in females or creatinine clearance greater than 60 mL/minute) which may also result from conditions such as cardiovascular collapse, acute myocardial infoarction, and septicemia; acute or chronic metabolic acidosis with or without coma (including diabetic ketoacidosis); should be temporarily withheld in patients undergoing radiologic studies involving the parenteral administration of iodinated contrast materials (potential for acute alteration in renal function).

Dietary Considerations:

Alcohol: Incidence of lactic acidosis may be increased; avoid or limit use.
Food: Food decreases the extent and slightly delays the absorption. Drug may cause GI upset; take with food to decrease GI upset.
Glucose: Decreases blood glucose concentration. Hypoglycemia does not usually occur unless a patient is predisposed. Monitor blood glucose concentration. Exercise caution with administration in patients predisposed to hypoglycemia (eg, cases of reduced caloric intake, strenuous exercise caution with administration in patients predisposed to hypoglycemia (eg, cases of reduced caloric intake, strenuous exercise without repletion of calories, alcohol ingestion or when metformin is combined with abother oral antidiabetic agent).
Vitamin B12: Decreases absorption of Vitamin B12; monitor for signs and symptoms of vitamin B12 deficiency.
Folic acid: Decreases absorption of folic acid; monitor for signs and symptoms of folic acid deficiency.

Warnings/Precautions: Administration of oral antidiabetic drugs has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or diet alone or diet plus insulin. Metformin is substantially excreted by the kidney - the risk of accumulation and lactic acidosis increases with the degree of impaiment of renal function. Patients with renal function below the limit of normal for their age should not receive metformin. In elderly patients, renal function should be monitored regularly. Use of concomitant medications that may affect renal function (ie, affect tubular secretion)may affect metformin disposition. Therapy should be suspended for any surgical procedures. Avoid use in patients with impaired liver function. Metformin should be discontinued at the time of or prior to the procedure in patients undergoing radiologic studies in which intravascular iodinated contrast materials are utilized, and withheld for 48 hours subsequent to the procedure, and reinstituted only after renal function has been re-evaluated and found to be normal.

Adverse Reactions:

Over 10% experience:

Gastrointestinal - Anorexia, nausea, vomiting, diarrhea, epigastric fullness, constipation, heartburn.

1% to 10% experience:

Dermatologic: Rash, urticaria, photosensitivity
Miscellaneous: Decreased vitamin B12 levels

Less than 1% experience: Blood dyscrasias, aplastic anemia, hemolytic anemia, bone marrow suppression, thrombocytopenia, agranulocytosis.

Overdose/Toxicology: Hypoglycemia has not been observed with ingestion up to 85 g of metformin, although lactic acidosis has occurred in such circumstances. Metformin is dialyzable with a clearance of up to 170 mL/minute. Hemodialysis may be useful for removal of accumulated drug from patients in whom metformin overdose is suspected. Treatment is supportive.