Chapter 32: Diabetes Drugs

Question 1

Pancreas

Answer 1

Located behind the stomach

Exocrine and endocrine gland

Produce insulin and glucagon which are important in glucose homeostasis

Glycogen: excess glucose stored in liver and skeletal muscle tissue

Glycogenolysis: conversion of glycogen to glucose when needed

Question 2

Insulin

Answer 2

Direct effect on fat metabolism

Stimulates Lopo genesis and inhibits lipolysis

Stimulates protein synthesis

Promotes intracellular shift of K and Mg into cells

Cortisol, epinephrine, and GH work synergistically with glucagon to counter the effects of insulin

Question 3

What is Diabetes Mellitus (DM)?

Answer 3

A group of progressive changes in the body as a result of glucose elevation. For this reason, DM can be considered a syndrome rather than a disease

Two types: type 1 and type 2

Question 4

Signs and symptoms of DM

Answer 4

• Elevated fasting blood glucose (>126 mg/dL) or a hemoglobin A1C (HbA1C) level > or = 6.5%
• Polyuria, polydipsia, or polyphagia

Glycosuria

Unexplained weight loss

Fatigue

Blurred vision

Question 5

What is Type 1 DM?

Answer 5

*A lack of insulin production or production of defective insulin

Affected patients need exogenous insulin

Fewer than 10% of all DM cases are Type 1

*Complications: diabetic ketoacidosis (DKA)

Question 6

What is Type 2 DM?

Answer 6

Most common type: 90% of cases

• Caused by insulin deficiency and insulin resistance
• Many tissues are resistant to insulin: reduced # of receptors OR insulin receptors are less responsive
• Complication: hyperosmolar nonketotic syndrome (HHNS)

Question 7

Why does Type 2 DM occur?

Answer 7

Several comorbid conditions:
* Obesity, coronary heart disease, dyslipidemia, hypertension, microalbuminemia (protein in the urine), increased risk for thrombotic events (metabolic syndrome is a combo of these)

These comorbidities are collectively referred to as metabolic syndrome, insulin-resistance syndrome, or syndrome X

Question 8

What is Gestational Diabetes?

Answer 8

*Hyperglycemia that develops during pregnancy

Insulin must be given to prevent birth defects

Usually subsides after delivery

*30% of patients may develop Type 2 DM within 10 to 15 years

The infant is at risk for developing diabetes as well

Insulins will he started because they are a naturally occurring hormone within the body and will not harm the mother or fetus during pregnancy

Question 9

Long-term complications of both types of diabetes

Answer 9

• Macrovascular (atherosclerotic plaque) of the coronary arteries, cerebral arteries, and peripheral vessels
• Microvascular (capillary damage) including retinopathy, neuropathy, and nephropathy

Question 10

Acute Diabetic Conditions

Answer 10

*DKA (Seen in Type 1 DM) manifests as hyperglycemia, ketones one the serum, acidosis, dehydration, and electrolyte imbalances

DKA is seen in ~25-30% of patients that are newly diagnosed with Type 1 DM

*HHNS (Seen in Type 2 DM) manifests as hyperglycemia (very high- over 600) and severe dehydration. It has a high mortality rate and develops over a long period of time.

Question 11

Screening for Diabetes

Answer 11

Prediabetes puts patients in a category of increased risk for DM. HbA1C of 5.7-6.4%. Fasting levels > or = to 100mg/dL but less than 126 mg/dL. Impaired glucose tolerance test (oral glucose challenge).

Screening is recommended every 3 years for all patients 45 years and older

Question 12

Nonpharmacologic Tx interventions

Answer 12

• Type 1: always requires insulin therapy
• Type 2: weight loss, improved dietary habits, smoking cessation, reduced alcohol consumption, and regular physical exercise

Question 13

Clinical Tx goal

Answer 13

*HbA1C <7%

<5.7%= normal; 5.7-6.4%= prediabetes; >6.5%= Type 2 Diabetes

Fasting blood glucose goal for diabetic patients of 70-130 mg/dL (slightly elevated; usually 70-100)

Estimated average glucose

Question 14

Diabetes Tx

Answer 14

• Type 1: insulin therapy

* Type 2: lifestyle changes, oral drug therapy, insulin when the others no longer provide glycemic control

Question 15

Types of Antidiabetic Drugs

Answer 15

• Insulin
• Oral hypoglycemic drugs: both aim to produce normal blood glucose states

Some new injectable hypoglycemic drugs may be used in addition to insulin or antidiabetic drugs

Question 16

Insulins

Answer 16

Function as a substitute for the endogenous hormone

Effects are the same as normal endogenous insulin

Restores the diabetic patients ability to: metabolize carbs/ fats/ protein, store glucose in the liver, and convert glycogen to fat stores

*Goal: tight glucose control to reduce the incidence of long-term complications

All insulins are human derivatives

Question 17

Rapid-Acting Tx for Types 1 & 2 DM

Answer 17

Most rapid onset of action (5-15 minutes)

Peak: 1-2 hours

Duration: 3-5 hours

Patient must eat a meal after injection

*Insulin Lispro (Humalog)- similar action to endogenous insulin

Insulin Aspart (NovoLog), Insulin Glulisine (Apidra)

*May be given SQ or via continuous SQ infusion pump (but not IV)

Patients blood sugar will begin to drop quickly right away but also clears the body quickly; prevents huge drops in blood glucose

Question 18

Rapid-Acting Insulins: Drug Profile (Afrezza)

Answer 18

Rapid-Acting Insulin that is inhaled

Peak: 12-15 minutes

Short DOA: 2-3 hours

Administered within 20 minutes before each meal

Must be given in conjunction with long acting insulin’s or oral diabetic agents (for Type 2 DM)

Side Effects: hypoglycemia, cough and throat pain

Contraindicated in smokers and those with chronic lung disease

*BBW: regarding the risk of acute bronchospasms

Question 19

Short-Acting Insulins

Answer 19

• Regular Insulin (Humulin R)
• Routes of admin: IV bolus, IV infusion, IM, SQ

Onset (SQ): 30-60 minutes

Peak (SQ): 2.5 hours

DOA (SQ): 6-10 hours

These are usually for pumps or pens; insulin syringes are orange and must not use a different color!!

Question 20

Intermediate-Acting Insulins

Answer 20

• Insulin Isophane Suspension (also called NPH)
• Cloudy appearance
• Often combined with regular insulin

Onset: 1-2 hours

Peak: 4-8 hours

DOA: 10-18 hours

Question 21

Long-Acting Insulins

Answer 21

*Insulin Glargine (Lantus) is a clear, colorless solution; constant level of insulin in the body; usually dosed once daily; referred to as basal insulin, and has no peak because it is given at a steady rate of delivery because it develops micro deposits that are slowly released over 24 hours when given SQ
Can be dosed every 12 hours; onset: 1-2 hours; has a duration of 24 hours. Toujeo is more concentrated U-300

Insulin Detemir (Levemir): DOA is dose dependent, lower doses require BID dosing, higher doses may be given once daily

Insulin Glargine (Basaglar): Biosimilar insulin; U-100

Insulin Degludec (Tresiba): Ultra long acting, once daily, U-100 or U-200

Question 24

Fixed combination Insulins

Answer 24

Humulin 70/30 or 50/50
Novolin 70/30
Humalog Mix 75/25
Humalog 50/50
NovoLog 70/30

Mix them by rolling the vial between your hands

Each contains 2 different insulins: one intermediate and one rapid or short acting.

Always do clear before cloudy! Or rapid/ insulin before drawing up the intermediate insulin solution

Question 25

Sliding scale Insulin

Answer 25

SQ rapid acting (lispro or aspart) or short acting (regular) insulins are adjusted according to blood glucose test results. SQ is ordered in an amount that increases as the blood glucose increases

Commonly used in hospitalized diabetic patients, those on parenteral nutrition, or enteral tube feedings

This delays insulin admin until hyperglycemia occurs resulting in large swings in glucose control

Question 26

Basal bolus Insulin Dosing

Answer 26

Preferred method of Tx for hospitalized patients with DM

Mimics a healthy pancreas by delivering basal insulin constantly as a basal and then as needed as a bolus

Basal insulin is a long acting insulin (Glargine)

Bolus insulin (insulin lispro or aspart)

Question 27

Oral Antidiabetic Drugs

Answer 27

Used for Type 2 DM Effective Tx involves careful monitoring of blood glucose levels, therapy with one or more drugs, Tx of associated comorbid conditions such as high cholesterol and high blood pressure If lifestyle modifications and the max tolerated met form in dose do not achieve the recommended HbA1C goals after 3-6 months, additional Tx should be given with a second oral agent or insulin

Question 28

Other oral Antidiabetic Meds to be used with Metformin

Answer 28

Sulfonylureas, Glinides, Thiazolidinediones, Incretin, and Na Glucose Cotransporter (SGLT2) Inhibitors This is because they act on insulin activity: if they can prevent glucose production/ absorption, they can combine with meds that have an impact on insulin activity Main side effect of insulin producing meds or meds that make insulin more available: hypoglycemia (e.g., Sulfonylureas; NOT Metformin)

Question 29

Metformin (Glucophage) is in the Biguanide class

Answer 29

A 1st line drug for Type 2 DM Tx (not used in Type 1) *They decrease production of glucose by the liver, decrease intestinal absorption of glucose*, increase uptake of glucose by tissues, and do not increase insulin secretion from the pancreas (does not cause hypoglycemia)

Question 30

Biguanides-Metformin Side Effects

Answer 30

Because they decrease the absorption of glucose in intestines, primary side effects are GI related: abd. bloating, nausea, cramping, diarrhea, feeling of fullness Possible metallic taste due to a decrease in vitamin B12 levels Lactic acidosis is rare but lethal and may occur with radiologic diagnostic testing with contrast dye (D/C within 48 hours) and in foods high in iodine (e.g., seafood, tofu, iodine salt, etc.) Does not cause hypoglycemia

Question 31

Hypoglycemia

Answer 31

Below 50 mg/dL Mild cases can be treated with diet— increase protein and decrease carbs— to prevent rebound postprandial hypoglycemia Early S/S: confusion, irritability, tremor, sweating Late S/S: hypothermia, seizures (monitor closely), coma and death will occur if left untreated Given patient glucose tabs/ gel, corn syrup, honey, fruit juice, nondiet soft drink, small snack like crackers or sandwich or any oral forms of sugar if awake and alert and hypoglycemic. If unconscious or comatose, give 50% dextrose in water (D50W) or IV glucagon and monitor blood glucose levels

Question 32

Before giving these meds, obtain and document:

Answer 32

A thorough Hx, VS, blood glucose levels, HbA1C level, and any potential complications and drug interactions

Question 33

What to assess before giving the meds:

Answer 33

Patients ability to consume food N/V Whether patient eats because if not, hypoglycemia may be a problem If NPO for procedure or test— consult provider to clarify orders

Question 34

Other conditions that are concerning because they increase concerns associated with DM:

Answer 34

When the patient is under stress When the patient has an infection When the patient has an illness or has experienced trauma When the patient is pregnant or lactating

Question 35

Insulin NRSG Implications

Answer 35

Order and prepared dosages are double checked with another nurse Check blood glucose before giving insulin Roll vials between hands instead of shaking them to mix suspensions Ensure correct storage: can store at room temp for 1 month ONLY use insulin syringes (calibrated in units) to measure & give insulin When drawing up 2 types into 1 syringe, always withdrawal the regular or rapid-acting insulin first. Or remember clear before cloudy (NPH- intermediate)

Question 36

Oral Antidiabetic NRSG Implications:

Answer 36

Always check blood glucose before giving Metformin is taken with meals to reduce GI effects Metformin will need to be D/C’d if the pt. Is to undergo studies with contrast dye because of possible renal effects- check with prescriber