Reference — Endocrine
Diabetes Medications Reference
Major diabetes medication classes — mechanism, hypoglycemia risk, key side effects, nursing considerations, and NCLEX pearls for metformin, sulfonylureas, GLP-1 agonists, SGLT2 inhibitors, DPP-4 inhibitors, and insulin.
Educational use only. Medication selection and dosing are provider decisions; verify every dose against current orders and facility policy before administration. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Hypoglycemia risk key: Insulin and sulfonylureas are the primary agents that cause hypoglycemia — they stimulate insulin release or replace insulin directly. GLP-1, SGLT2, and DPP-4 agents have glucose-dependent mechanisms and carry low monotherapy hypoglycemia risk.
Biguanides
Hypoglycemia: No (monotherapy) — does NOT stimulate insulin releaseExamples: Metformin (Glucophage)
Mechanism: Decreases hepatic glucose production (gluconeogenesis); improves peripheral insulin sensitivity
Key Effects / Side Effects
- ✦GI upset (nausea, diarrhea, bloating) — take with food
- ✦Lactic acidosis (rare but serious — hold for contrast dye, surgery, renal impairment)
- ✦Weight neutral or modest weight loss
- ✦B12 deficiency with long-term use
Nursing Considerations
- →Stop at the time of (not in advance of) IV contrast or surgery, withhold for 48 hours after, and restart once renal function is confirmed stable; for IV contrast with eGFR ≥30 and no AKI, current ACR/FDA guidance is that no hold is required
- →Monitor eGFR — contraindicated if eGFR <30 mL/min
- →First-line therapy for Type 2 DM per ADA guidelines
- →Check B12 levels annually in long-term users
NCLEX: Hold metformin before IV contrast and procedures. Risk: lactic acidosis.
Sulfonylureas
Hypoglycemia: YES — high risk, especially glyburideExamples: Glipizide, Glyburide, Glimepiride
Mechanism: Stimulates insulin release from pancreatic beta cells (independent of blood glucose) → can cause hypoglycemia
Key Effects / Side Effects
- ✦Hypoglycemia (most important concern)
- ✦Weight gain
- ✦Glyburide = highest hypoglycemia risk; avoid in elderly
- ✦Glipizide = shorter duration, safer in elderly
Nursing Considerations
- →Monitor blood glucose closely — especially with illness, missed meals, exercise
- →Teach patient to always eat when taking sulfonylurea
- →Glyburide — avoid in renal impairment and elderly (Beers Criteria)
- →Alcohol + sulfonylurea: flushing reaction (Antabuse-like) with chlorpropamide (older, rarely used)
NCLEX: Sulfonylureas cause hypoglycemia. Must eat meals when taking. Avoid glyburide in elderly.
GLP-1 Receptor Agonists
Hypoglycemia: Low risk (glucose-dependent) — hypoglycemia possible if combined with insulin or sulfonylureaExamples: Liraglutide (Victoza), Semaglutide (Ozempic, Wegovy), Exenatide (Byetta), Dulaglutide (Trulicity)
Mechanism: Mimics GLP-1 hormone: ↑ insulin secretion (glucose-dependent), ↓ glucagon, slows gastric emptying, ↑ satiety
Key Effects / Side Effects
- ✦Nausea/vomiting (especially early in treatment)
- ✦Significant weight loss (clinically important)
- ✦Pancreatitis (rare but serious — stop if abdominal pain)
- ✦Not for Type 1 DM
- ✦Cardiovascular benefit (liraglutide, semaglutide)
Nursing Considerations
- →Inject subcutaneously (all SQ or oral semaglutide)
- →Teach injection technique and rotation
- →Warn about nausea — start low dose, escalate slowly
- →Hold if pancreatitis suspected (severe abdominal pain radiating to back)
- →Contraindicated: personal/family history of medullary thyroid cancer or MEN2
NCLEX: GLP-1 agonists: weight loss, minimal hypoglycemia, GI side effects, pancreatitis risk.
SGLT2 Inhibitors
Hypoglycemia: Low risk (mechanism is glucose-dependent/renal)Examples: Empagliflozin (Jardiance), Dapagliflozin (Farxiga), Canagliflozin (Invokana)
Mechanism: Blocks glucose reabsorption in the kidney → glucosuria (glucose excreted in urine) → lowers blood glucose
Key Effects / Side Effects
- ✦Genital mycotic infections (yeast infections — glucosuria feeds Candida)
- ✦UTI risk
- ✦Euglycemic DKA (SGLT2-associated DKA with near-normal glucose)
- ✦Urinary frequency/polyuria
- ✦Cardiovascular and renal protection
- ✦Weight loss, modest BP lowering
Nursing Considerations
- →Teach genital hygiene; expect urinary frequency
- →Hold before surgery (canagliflozin/dapagliflozin/empagliflozin 3 days, ertugliflozin at least 4 days per FDA) or prolonged fasting — risk of euglycemic DKA
- →Monitor for UTI symptoms; treat promptly
- →Canagliflozin: increased lower extremity amputation risk — monitor foot care
- →Check eGFR — glucose-lowering effect diminishes in renal impairment
NCLEX: SGLT2 inhibitors: yeast infections, UTI, euglycemic DKA. Hold before surgery.
DPP-4 Inhibitors
Hypoglycemia: Very low riskExamples: Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), Alogliptin (Nesina)
Mechanism: Inhibits DPP-4 enzyme that degrades GLP-1 → prolongs GLP-1 action → ↑ insulin (glucose-dependent), ↓ glucagon
Key Effects / Side Effects
- ✦Upper respiratory infections
- ✦Nasopharyngitis
- ✦Pancreatitis (rare)
- ✦Joint pain
- ✦Weight neutral
Nursing Considerations
- →Well-tolerated overall — few major nursing concerns
- →Monitor for upper respiratory symptoms
- →Hold if pancreatitis suspected
- →Saxagliptin/alogliptin: may increase heart failure hospitalizations — monitor if HF history
NCLEX: DPP-4 inhibitors: minimal side effects, no hypoglycemia. Upper respiratory infections.
Insulin (overview)
Hypoglycemia: YES — all insulins can cause hypoglycemiaExamples: Rapid (lispro, aspart), Short (regular), Intermediate (NPH), Long-acting (glargine, detemir)
Mechanism: Replaces or supplements endogenous insulin → facilitates cellular glucose uptake; suppresses hepatic glucose production
Key Effects / Side Effects
- ✦Hypoglycemia (most critical side effect)
- ✦Weight gain
- ✦Injection site lipohypertrophy with poor rotation
- ✦Hypokalemia (insulin drives K⁺ into cells)
Nursing Considerations
- →HIGH-ALERT medication — verify dose with second nurse
- →Rotate injection sites; inspect injection sites
- →Rapid-acting: give with meals or hold if patient cannot eat
- →Long-acting: never mix with other insulins
- →Monitor glucose per protocol — before meals and bedtime minimum
NCLEX: Insulin = HIGH-ALERT. Know onset/peak/duration. Hypoglycemia is the primary risk.
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Fact-checked Jun 20, 2026This page is written to align with American Diabetes Association (ADA) Standards of Care · American Association of Clinical Endocrinology (AACE). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →