Prandin
repaglinide
Pharmacologic class: Meglitinide
Therapeutic class: Hypoglycemic
Pregnancy risk category C
Action
Inhibits alpha-glucosidases, enzymes that convert oligosaccharides and disaccharides to glucose. This inhibition lowers blood glucose level, especially in postprandial hyperglycemia.
Availability
Tablets: 0.5 mg, 1 mg, 2 mg
Indications and dosages
➣ Adjunct to diet and exercise in type 2 (non-insulin-dependent) diabetes mellitus uncontrolled by diet and exercise alone, or combined with metformin in type 2 diabetes mellitus uncontrolled by diet, exercise, and either repaglinide or metformin alone
Adults: 0.5 to 4 mg P.O. before each meal; may adjust at 1-week intervals based on blood glucose response. Maximum daily dosage is 16 mg.
Contraindications
• Hypersensitivity to drug or its components
• Diabetic ketoacidosis
• Type 1 (insulin-dependent) diabetes mellitus
• Administration with gemfibrozil
Precautions
Use cautiously in:
• renal or hepatic impairment; adrenal or pituitary insufficiency; stress caused by infection, fever, trauma, or surgery
• concurrent use of CYP2C8 inhibitors (such as trimethoprim, gemfibrozil, montelukast)
• concurrent use of CYP3A4 inhibitors (such as ketoconazole, itraconazole, erythromycin)
• concurrent use of CYP3A4 or CYP2C8 inducers (such as rifampin, barbiturates, carbamazepine)
• elderly or malnourished patients
• pregnant or breastfeeding patients
• children.
Administration
• Give 15 to 30 minutes before meals. Administer two, three, or four times daily, if needed, to adapt to patient's meal pattern.
Adverse reactions
CNS: headache, paresthesia
CV: angina, chest pain
EENT: sinusitis, rhinitis
GI: nausea, vomiting, diarrhea, constipation, dyspepsia
GU: urinary tract infection
Metabolic: hyperglycemia, hypoglycemia
Musculoskeletal: joint pain, back pain
Respiratory: upper respiratory infection, bronchitis
Other: tooth disorder, hypersensitivity reaction
Interactions
Drug-drug. Barbiturates, carbamazepine, rifampin: decreased repaglinide blood level
Beta-adrenergic blockers, chloramphenicol, MAO inhibitors, nonsteroidal antiinflammatory drugs, probenecid, sulfonamides, warfarin: potentiation of repaglinide effects
Calcium channel blockers, corticosteroids, estrogens, hormonal contraceptives, isoniazid, phenothiazines, phenytoin, nicotinic acid, sympathomimetics, thyroid preparations: loss of glycemic control
Clarithromycin: increased repaglinide area under the curve and Cmax
Cyclosporine: increased repaglinide plasma concentration
Erythromycin, ketoconazole, miconazole: decreased repaglinide metabolism, increased risk of hypoglycemia
Gemfibrozil, itraconazole: significantly increased repaglinide exposure
Simvastatin: increased repaglinide level
Drug-food. Any food: decreased drug bioavailability
Drug-herbs. Aloe gel (oral), bitter melon, chromium, coenzyme Q10, fenugreek, gymnema sylvestre, psyllium, St. John's wort: additive hypoglycemic effects
Glucosamine: poor glycemic control
Patient monitoring
• Monitor blood glucose and glycosylated hemoglobin levels.
• Monitor patient's meal pattern. Consult prescriber about adjusting dosage if patient adds or misses a meal.
• Assess for angina, shortness of breath, or other discomforts.
• Watch for signs and symptoms of bronchitis and upper respiratory, urinary, and EENT infections.
Patient teaching
• Tell patient to take 15 to 30 minutes before each meal.
• Instruct patient to monitor blood glucose level carefully. Teach him to recognize signs and symptoms of hypoglycemia and hyperglycemia.
• Advise patient to report signs and symptoms of infection.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, foods, and herbs mentioned above.
repaglinide
(re-pag-gli-nide) repaglinide,Gluconorm
(trade name),Prandin
(trade name)Classification
Therapeutic: antidiabeticsPharmacologic: meglitinides
Indications
Action
Therapeutic effects
Pharmacokinetics
Time/action profile
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | within 30 min | 60–90 min | <4 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Cardiovascular
- angina
- chest pain
Endocrinologic
- hypoglycemia
- hyperglycemia
Interactions
Drug-Drug interaction
Ketoconazole, miconazole, gemofibrozil, itraconazole, clarithromycin, and erythromycin may ↓ metabolism and ↑ risk of hypoglycemia; concurrent use with gemofibrozil contraindicated.Levels and effects may also be ↑ by NSAIDs, cyclosporine, hormonal contraceptives, simvastatin, sulfonamides, chloramphenicol, warfarin, probenecid, deferasirox, MAO inhibitors, and beta blockers.Effects may be ↓ by corticosteroids, phenothiazines, thyroid preparations, estrogens, hormonal contraceptives, phenytoin, nicotinic acid, sympathomimetics, isoniazid, and calcium channel blockers.Glucosamine may worsen blood glucose control.Chromium and coenzyme Q-10 may produce ↑ hypoglycemic effects.Route/Dosage
Renal Impairment
Oral (Adults) Severe renal impairment—start with 0.5 mg/day and titrate carefully.Availability (generic available)
Nursing implications
Nursing assessment
- Observe patient for signs and symptoms of hypoglycemic reactions (abdominal pain, sweating, hunger, weakness, dizziness, headache, tremor, tachycardia, anxiety). Hypoglycemia may be difficult to recognize in geriatric patients and in patients taking beta blockers. Hypoglycemia is more likely to occur with insufficient caloric intake, following intense prolonged exercise, or when alcohol or more than 1 hypoglycemic agent is used.
- Lab Test Considerations: Monitor fasting serum glucose and glycosylated hemoglobin periodically during therapy to evaluate effectiveness.
Potential Nursing Diagnoses
Imbalanced nutrition: more than body requirements (Indications)Noncompliance (Patient/Family Teaching)
Implementation
- Do not confuse Prandin (repaglinide) with Avandia (rosiglitazone).
- Patients stabilized on a diabetic regimen who are exposed to stress, fever, trauma, infection, or surgery may require administration of insulin. Withhold repaglinide and reinstitute after resolution of acute episode.
- Repaglinide therapy should be temporarily discontinued for patients requiring surgery involving restricted intake of food and fluids.
- There is no fixed dose of repaglinide. Dose is based on periodic monitoring of blood glucose and long-term response is based on glycolysated hemoglobin levels. If adequate response is not achieved, metformin may be added to regimen. If combination therapy is unsuccessful, oral hypoglycemic therapy may need to be discontinued and replaced with insulin.
- When replacing other oral hypoglycemic agents, repaglinide may be started on the day following discontinuation of the other agent. Monitor blood glucose closely. Discontinuation of long-acting oral hypoglycemics may require monitoring for a week or more.
- Short-term repaglinide therapy may be used for patients well controlled with diet experiencing transient loss of control.
- Oral: Administer up to 30 min before meals. Patients who skip a meal or add an extra meal should skip or add a dose, respectively, for that meal.
Patient/Family Teaching
- Instruct patient to take repaglinide before each meal, exactly as directed.
- Explain to patient that repaglinide helps control hyperglycemia but does not cure diabetes. Therapy is usually long term.
- Encourage patient to follow prescribed diet, medication, and exercise regimen to prevent hyperglycemic or hypoglycemic episodes.
- Review signs of hypoglycemia and hyperglycemia with patient. If hypoglycemia occurs, advise patient to take a glass of orange juice or 2–3 tsp of sugar, honey, or corn syrup dissolved in water, and notify health care professional.
- Instruct patient in proper testing of blood glucose. These tests should be monitored closely during periods of stress or illness and a health care professional notified if significant changes occur.
- Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications and alcohol.
- Advise patient to inform health care professional of medication regimen prior to treatment or surgery.
- Insulin is the recommended method of controlling blood glucose during pregnancy. Counsel female patients to use a form of contraception other than oral contraceptives and to notify health care professional promptly if pregnancy is planned or suspected.
- Advise patient to carry a form of sugar (sugar packets, candy) and identification describing disease process and medication regimen at all times.
- Emphasize the importance of routine follow-up exams and regular testing of blood glucose and glycosylated hemoglobin.
Evaluation/Desired Outcomes
- Control of blood glucose levels without the appearance of hypoglycemic or hyperglycemic episodes.