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NAPLEX 2024 > Chapter 44: DM Agents > Flashcards

Chapter 44: DM Agents Flashcards

1
Q

GLP1 and GIP Agonist

What are they/ general MOA

A
  1. GLP-1 (Glucagon like peptide 1) - agonist are analongs of the incretin hormone GLP-1, which ↑ glucose dependent insulin secretion, ↓ glucagon secretion, slow gastric emptying, improve satiety (reduce weight)
  2. GIP (Glucose-dependent insulinotropic polypeptide agonist are analog of GIP, which has similar effects as GLP-1

Both are SC injection

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2
Q

GLP1 Agonist

Liraglutide: brands, doses/SIGs

A

Liraglutide
1. Victoza
2. Saxenda (weight loss)
0.6 mg SC DAILY x 1 week, then increase to 1.2mg SC DAILY

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3
Q

GLP1 Agonist

Dulaglutide: brand, dose/SIG

A

Dulaglutide (Trulicity): 0.75 mg SC once WEEKLY, then increase to 1.5 mg SC once weekly

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4
Q

GLP1 Agonist

Semaglutide: brands, doses/SIGs

A

Semaglutide
1. Ozempic (SC)
2. Wegovy (SC - weight loss)
SC Dosing: 0.25 mg SC once WEEKLY x 4 weeks; then increase to 0.5 mg SC weekly (max 2 mg SC weekly)
3. Rybelsus (oral) : 3 mg PO DAILY

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5
Q

GLP1 Agonist

Exenatide: Brands, doses/SIGs

A

Exenatide
1. Byetta - 5mcg SC BID x 1 month; then can increase to 10mcg
2. Exenatide ER (Bydureon BCise) - 2mg SC once WEEKLY
Both are not recommended for poor renal function!!! (CrCl < 30)

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6
Q

DUAL GLP1 + GIP Agonist

Tirzepatide: Brand, doses/SIGs

A

Tirzepatide (Mounjaro): 2.5 mg SC WEEKLY x 4 weeks; then increase to 5 mg SC WEEKLY (max 15mg)

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7
Q

GLP1 and GIP Agonist Boxed Warning

A

ALL (except Byetta): Increase risk of thyroid C-Cell carcinomas! Do not use if patient has personal or family hx of medullary thyriod carnoma or have multiple endocrine neoplasia syndrome

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8
Q

GLP1 and GIP Agonist Warnings/ SEs

A
  1. Warnings: pancreatitis (risk factors: alcoholism, gallstones, high TGs); NOT recommended for patients with severe GI disease (including gastroparesis)
  2. SEs: Weight loss, nausea
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9
Q

GLP1 and GIP Agonist General Notes

A
  • Decrease A1C: 0.5-1.5% (low hypoglycemia risk)
  • DO NOT give with DPP-4 inhibitors
  • Pen needles are NOT provided with the daily injections (Byetta and victoza) But it’s provided for all others weekly ones)
  • Liraglutide, dulaglutide, and SC semaglutide are recommended for patients with ASCVD (or high risk)
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10
Q

GLP1 injection counseling

A
  1. Administered SC in abdomen (alternatively in the back of upper arms, outer thighs or upper buttocks).
  2. Attach a new pen needle for every injection (if not already attached)
  3. After cleaning hands and injection site, pinch a portion of injection area and insert needle at 90 degrees
  4. Press injection button and count 5-10 secs before removing needle
  5. Rotate injection site with each injection
  6. Dispose needles in sharps disposal container. DO NOT store pens with a needle attached to it!
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11
Q

SGLT2 Inhibitors

SGLT2 Inhibitor: General MOA

A

The sodium glucose cotransporter 2 (SGLT2) protein, expressed in the proximal renal tubules, is responsible for the the reabsorption of glucose. By inhibiting SGLT2, these drugs reduce reabsorped glucose and increase glucose excretion via urine! Most guidelines recommend using if eGRF > 20! These drugs ends with “-gliflozin”.

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12
Q

SGLT2 Inhibitor Drug

Canagliflozin: Brand/dosing

A

Canagliflozin (Invokana): 100 mg QD prior to first meal of the day (can increase to 300 mg QD) but if eGFR 30-59: max is 100 mg QD

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13
Q

SGLT2 Inhibitor Drug

Dapagliflozin : Brand/ dosing

A

Dapagliflozin (Fargixa): 5mg QD in the morning; can increae up to 10 mg QD

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14
Q

SGLT2 Inhibitor Drug

Empagliflozin: Brand/ Dosing

A

Empagliflozin (Jardiance): 10 mg QD in the morning; can increase up to 25mg QD

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15
Q

SGLT2 Inhibitor: C/I and warnings and SEs

A
  1. C/I: Dialysis
  2. Warnings: Ketoacidosis, genital mycotic infections, urosepsis, pyelonephritis, nec fas, hypotension, AKI…. Canagliflozin has an increased risk of foot amputation and fractures!
  3. SEs: weight loss, increase urination, increase thirst
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16
Q

SGLT2 Inhibitor: DDI

A
  • increases the risk of intravascular volume depletion (causing hypotension) and AKI if use in combo with diuretics, RAAS inhibitors, NSAIDs
  • Uridine diphos glucuronosyltransferase (UGT) inducers (rifampin, phenytoin, phenobar) can decrease the level of canagliflozin
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17
Q

Biguanide: Metformin - MOA

A

Works by decreasing hepatic glucose production, increase insulin sensitivity, and decrease absorption of glucose. Metformin is 1st line and can be used for prediabets. Use of metformin is dependent of eGFR

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18
Q

Biguanide - Metformin: brands/ dosings

A

Metformin (Glucophage, Fortamet, Glumetza)
- IR comes in 500, 850, and 1000mg
- ER comes in 500, 750, and 1000mg
Dosing: IR 500mg QD or BID; ER 500-1000mg QD; Titrate weekly to max dose of 1000mg BID (2g) GIVE WITH MEAL TO DECREASE GI UPSET

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19
Q

Metformin: Boxed Warning

A

Lactic Acidosis - risk increase with renal impairment, contrast dye, excessive alcohol or drugs

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20
Q

Metformin: C/I

A

eGFR < 30, acute/ chronic metabolic acidosis (DKA)

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21
Q

Metformin: Warnings

A
  • Not recommended if eGFR is 30-45, reassess if already taking and eGFR falls under 45
  • Vitamin B12 deficiency (symps can include perpheral neuropathy/ cog impairment
  • GI effects
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22
Q

Metformin: NOTE

A
  • Decrease A1C: 1-2%, weight neutral, no hypoglycemia! :)
  • ER form can leave ghost tablet (empty shell) in stool
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23
Q

Metformin: DDI

A
  • Intra-arterial iodinated contrast media can increase risk of lactic acidosis. D/C metformin before using contrast; restart metformin after 48hrs!
  • Alcohol can increase risk of lactic acidosis
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24
Q

Insulin Secretagogues: what are they? MOA?

A

Sulfonylureas and Meglitinides are known as insulin secretagogues: they work by stimulating insulin secretion from beta cells in the pancreas to decrease post prandial BG. Meglitnides have a faster onset (15-60mins and a shorter duration of action when compared to Sulfonylureas! Sulfonylureas and Meglitinides should NOT be combo!!! due to risk of hypoglycemia.

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25
Q

Insulin Secretagogues:Sulfonylureas

Sulfonylureas- Glipizide: brands/doses

A

Glipizide (Glucotrol): IR 5mg QD (max 40mg); XL 5mg QD (max 20mg)

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26
Q

Insulin Secretagogues:Sulfonylureas

Sulfonylureas - Glimepiride : brand/ doses

A

Glimepiride (Amaryl): 1-2mg QD (max 8mg)

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27
Q

Sulfonylureas: C/I, Warnings, and SEs

A
  1. C/I: Sulfa allergies (not likely to cross rxn)
  2. Warning: Hypoglycemia
  3. SEs: Weight gain, nausea
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28
Q

Sulfonylureas: Notes

A
  • Decrease A1C 1-2%
  • For Glipizide IR: take 30 mins before meal! all other products can be taken with breakfast.
  • Glimep and Glyburide NOT perf in old ppl (Beer’s)
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29
Q

Insulin Secretagogues: Meglitinides

Repaglinide: dosing

A

0.5-2 mg TID AC take 30 mins before meal

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30
Q

Insulin Secretagogues: Meglitinides

Nateglinide: dosing

A

60-120mg TID AC (1-30mins beore meal)

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31
Q

Dipeptidyl Peptidase 4 Inhibitors (DPP4I): MOA

A

DPP4 inhibitors prevent the enzyme DPP4 from breaking down incretin hormones like GLP1 and GIP! These hormones help to regulate BG levels by increasing insulin release from the beta cells and decreasing glucagon secretionfrom alpha cells from pancreas. these drugs ends with “-gliptin)

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32
Q

DPP4 inhibitor

Sitagliptin- brand/ dosing

A

Sitagliptin (Januvia): 100 mg QD (50mg if eGFR 30-45)

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33
Q

DPP4 Inhibitor

Linagliptin - brand/dosing

A

Linagliptin (Tradjenta) : 5mg QD (no renal adjustment)

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34
Q

DDP4 Inhibitor

Saxagliptin - brand/dosing

A

Saxagliptin (Onglyza): 2.5-5mg QD

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35
Q

DDP4 Inhibitors: Warnings

A
  • Pancreatitis, severe arthralgia (joint pain), acute renal failure, bullous pemphigoid (blisters)
  • RISK OF HEART FAILURE (seen with saxagliptin and alogliptin) but warning is for the whole class! Avoid DDP4 inhibitors if patient has heart failure.
  • Do not use with GLP1 agonists
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36
Q

Thiazolidinediones: MOA

A

TZDs are peroxisome proliferation activated receptor gamma (PPARy) agonist that increase peripheral insulin sensitivity. PIOGLITAZONE IS THE ONLY ONE AVAILABLE (not rosiglitazone)

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37
Q

Pioglitazone: brand/dose

A

Pioglitazone (Actos): 15-30mg QD (max 45mg)

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38
Q

Pioglitazone: Boxed warnings, warnings, SEs

A
  1. Boxed warnings: can worsen heart failure! do NOT use with NYHA class 3-4
  2. Warnings: edema, risk of fractures, hepatic failure, can increase risk of bladder cancer
  3. SEs: weight gain, edema
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39
Q

Otehr DM medications that are not routinely used but just know their names

A
  1. Alpha-Glucosidase Inhibitors (acarbose)
  2. Bile Acid Binidng Resins (colesevelam)
  3. Dopamine agonist
  4. Amylin analog
40
Q

Common Combination DM Drugs: Brand/ generic

A
  1. Metformin + pioglitazone (Actoplus Met)
  2. Metformin + Sitagliptin (Jaumet)
  3. Metformin + Canagliflozin (Invokamet)
41
Q

Insulin: what is it? How does insulin injection help DM patients?

A

In patients without DM, the pancreas controls the release of insulin in the body!. It provides a consistent level (or basal amount) of insulin at all times, then releases more insulin when BG is elevated postprandially (post meal)
.
In patient’s with DM, insulin injections can mimic the normal physiologic process. Insulin cannot be given orally and is given SC, (sometimes IV for super high BG like in DKA), and inhaled (very uncommon).
.
Insulin injection is a high alert medication = meaning high risk of causing harm + requires extra care when administering/ handling. Why? it’s prone to human errors such as misreading measurments, using the wrong type/ strength/ frequency/ dose and skipping meals!

42
Q

Provide the graph/ overview of all insulin types/ their description (including peak, onset, duration)

A

Basal and rapid acting insulins are called: insulin analogs; when basal insulin is used with mealtime rapid acting insulin, the prfile is analogous and similar to the natural pattern of insulin seretion from the pancreas!
1. BASAL INSULIN: glargine, detemir, and super heckin long acting degludec. These insulin are “peak-less”. Onset 3-4 hrs and duration is >24hrs. They mainly impact fasting glucose.
2. INTERMEDIATE ACTING INSULIN: Insulin NPH - intermed acting. Onset 1-2hrs. Peak 4-12hrs (which can cause hypoglycemia)…duration is also unpredictable (14-24hrs). The “P” in NPH stands for PROTAMINE which helps delay/ extend duration.
3. RAPID and SHORT ACTING: Rapid Acting includes: aspart and lispro - these provides bolus doses - similar to pancreas releasing burst of insulin in response to food. **Fast onset 15 mins, peak 1-2hrs and duration of 3-5 hrs **. Short acting: Regular insulin! onset 30mins, peak 2hrs, duration 6-10hrs

43
Q

Insulin Safety Issues and Notes: Appiles to all injectable insulin (except when noted)

A
  • C/I: Do not give hypoglycemia
  • Warning: hypoglycemia, hypokalemia (can be use to treat hyperkalemia!)
  • SE: weight gain, lipoatrophy (loss of sc fat at injection site = disfigure) and lipohypertrophy (accumulation of fat lumps) avoid both by rotating site!
  • Storage/ Administration:
    1. Most vials = 10mL, most pens = 3mL. Insulin concentration is 100U/mL (uness noted otherwise in future notecards)
    2. Unopen vials/ pens should be stored in fridge, but open ones can be store outside (cold insulin is painful to inject!)
44
Q

Rapid Acting (Bolus) Insulin: brands/generic, dose, notes?

A

1. Aspart (Novolog)
2. Lispro (Humalog, Admelog)
- Dosing: Inj SC 5-15mins before meal (lispro can also be used right after a meal)
- These are the pref insulin for insulin pumps!
- Aspart and Lispro can also come premixed with protamine “P” to be intermediate acting
- Used as prandial insulin and for correction dose when BG is high (often by sliding scale)
- colorless and clear!

45
Q

Inhaled insulin (Afrezza)?

A

Do not used un ppl with lung conditions! COPD/asthma as it can cause brochospasm. Need to monitor lung fucntions

46
Q

Short Acting (Bolus) Insulin: brand/generic, dose, notes

A
  1. Regular (Humulin R, Novolin R)
    - Injecrt SC 30mis before meal
    - Used as prandial insulin and for correction dose when BG is high (often by sliding scale)
    - Preferred for IV infusion, including in PTN, its also less expensive!
    - Often give with NPH BID, 30 mins before breakfast/dinner (lunch still covered by NPH) ..the insulin can be mixed!
    - Clear/colorless
    .
  2. Concentrated regular insulin U-500: 5x concentrated!!! many saftey risk. Only recommended when patient needs +200 U insulin QD .. DO NOY MIXED WITH OTHER INSULIN
47
Q

Intermediate Acting (Basal) Insulin: brand/generic, dose, notes

A
  1. NPH (Humulin N, Novolin N)
    - CLOUDY!!!
    - Given as basal, typically doses BID as an add on to oral drugs, can be a less expensive alternative but has more hypoglycemia
48
Q

Long Acting (Basal) Insulin: Brand/generic, dose, notes

A
  1. Insulin detemir (Levemir)
  2. Insulin Glargine (Lantus, Toujeo, Basaglar)
    - Inject ONCE DAILY (detemir may need BID)
    - CAUTION: Lantus is 100u/mL but Toujeo is more concentrated at 300u/mL
    - DO NOT MIX WITH OTHER INSULIN
    - ULTRA long acting?: Decludec (Tresiba) vial =100u/ml, pen comes in both 100u/ml and 200u/ml… Tresiba is useful when detemir and glargine causes noctural hypoglycemia
49
Q

Premixed Insulins?: Names/brand/generic

A
  1. 70/30 mixes
    70% NPH/ 30% Regular (Humulin R or Novolin R)
  2. 75/25 Mix or 50/50 Mix (75% lispro protamine/ 25% lispro) - Humalog Mix 75/25 or (50% lispro protamine/ 50% lispro) - Humalog Mix 50/50 (know that the 75/25 and 50/50 contain rapid acting)
    .
    NOTE: the percentage of NPH or protamine will be the first number!!!
50
Q

Premixed Insulins: Dosing/ how to give them? Notes?

A
  • Give BID (before breakfast and dinner), or sometimes TID (with rapid acting ones 75/25 or 50/50)
  • Rapid acting mixture (75/25 and 50/50) give 15 mins before meal
  • Regular acting mixture (70/30) give 30 mins before meal
  • NPH or protamine make the mixture cloudy!
51
Q

Case scenario

A 35 year old female injects Humulin 70/30 - 60 units before breakfast and 20 units before dinner. What is her TDD of REGULAR insulin?

A
  1. breakfast: 30% of 60? = 0.30 x 60 = 18 units
  2. dinner: 30% of 20? = 0.30 x 20 = 6
  3. Total?: 18 + 6 = 24 units
52
Q

Insulin OTC?

A

Regular, NPH, and premixed (70/30) can be sold OTC or dispensed with a prescription for insurance coverage. But all basal and rapid actings are rx only

53
Q

When is insulin initiated? What is preferred?

A

If patient needs injectable medication? GLP1 is preferred. Insulin is typically started to treat very high BG at diagnosis (A1C >10% or BG >300). If insulin is needed? combine with GLP1 is prefrred for great effectivness

54
Q

Starting insulin for DM2: Dosing Guidelines

A
  1. Add Basal insulin: 10u SC QD or 0.1-0.2u SC/kg/day (titrate based on fasting glucose
  2. If not at goal? may add prandial insulin: 4 u r 10% of basal dose SC QD prior to largest meal
  3. If still nto at goal? can do full basal/bolus regimen (basal + bolus before each meal) OR mixed insulin regimen (BID NPH + short/rapid acting)
55
Q

Staring insulin for DM1: general

A

People with DM1 are required insulin! Rapid or long acting is prefered over short and intermediate acting because they have less hypoglycemia risk/ better mimic the body’s natural physiology.

56
Q

Starting a basal-bolus insulin regimen in DM1: dosing guideline

A

The typical starting dose for DM1: 0.5 units/kg(TBW)/day
Commonly 50% of total daily dose (TTD) is administired as basal and 50% as bolus, follow the following steps
- Calculate TTD (0.5 units/kg/day) using TBW
- Divide TTD by half = 50% bolus and 50% basal
- And then further divide the bolus by 3 for 3 meals a day!

57
Q

DM1 Calc Example

Start a basul-bolus gimen of lantus and humalogin a DM1 patient that weights 84kg.

A
  1. 0.5 x 84 = 42 TTD
  2. 42 TTD / 2 = 21 units lantus and 21 units Humalog
  3. 21 units Humalog / 3 for meal = 7 units before each meals
    Answer: 21 units of Lantus QD and 7 units of Humalog TID AC
58
Q

Why should you not start insuling regimen with NPH (intermediate) or Regular insulin (short acting)? and if needed to be given..what’s the dosing guideline?

A

Niether profile can mimic the natural insulin release. However, they are cheaper.
.
The starting TDD of insulin is the same as the bolus-basal regimen but 2/3 of TDD is NPH and 1/3 is regular insulin

59
Q

Treatment with Insulin Pump: general, how does it work?

A

Pumps provides excellent BG control but users have to be motivated to test BG frequently. Prior experience with multiple day injections is required before switching to pump.
.
Pumps hold insulin reservoir that runs out of pump through tubing to a small infusion set placed on skin, usually at the abdomen through a small cannula (needle). The reserivor, tubing, and infusion set needs to be replaced regularly.
.
Insulin pump deliver rapid acting insulin by 2 methods = continous and bolus dosing
1. Continous: small amount of insulin are released every few mins to provide basal level.
2. Bolus: releases # of insulin units to match carbohydrates in meal. Bolus dose is calculated by the patient’s insulin to carbo ratio (ICR). Bolus doses is adjusted based on BG levels.

60
Q

Adjusting Basal Insulin?

A

FASTING high or low means adjustment needed for basal insulin.
- LOW fasting BG: Decrease long acting/ basal or NPH
- HIGH fasting BG: Increase long acting/ basal or NPH

61
Q

Adjusting Mealtime Insulin (bolus)

A

If BG is high or low AFTER a meal (postprandial)?
- High postprandial BG? INCREASE regular(short) or rapid acting insulin taken before meal
- Low postprandial BG? DECREASE regular(short) or rapid acting insulin taken before meal
.
If BG high or low BEFORE a meal (Preprandial)?
If your preprandial BG is high or low, you should increase or decrease insulin taken beforehe previous meal (eg. breakfast)

62
Q

Meal Time (bolus) Insulin Dosing Options… can use the same insulin dose everytime (thsi assumes the same gram of carbs for every meal…can causes issues if carbs are not the same…) what’s a more accurate method?

A

CALCULATE AN INSULIN DOSE AT EACH MEAL USING ICR!
- ICR indicates the grams of carbohydrates covered bt 1 unit of insulin
- There are 2 variations of ICR: Regular insulin uses Rule of 450 and Rapid acting uses Rule of 500

63
Q

Mealtime Insulin Dosing Case Scenario

ST is a 70kg female with DM1 who uses an insulin lispro pump. The continous (basal) dose delivered by the pump in 24 hrs is 26 units of lispro. The average daily amount of insulin lispro admnistered as bolus doses with meals is 24 units. Calculate the ICR.

A

Lispro is a rapid acting… so use the rule of 500!
- 500/ TDD = grams of carb covered by 1 unit of rapid insulin
- 500/ 24 + 26 = 500/50 = 10 grams of carbs is covered by 1 unit of insulin. Which means the ICR is 1:10

64
Q

Mealtime Insulin Dosing Case Scenario Cont.

ST is a 70kg female with DM1 who uses an insulin lispro pump. The continous (basal) dose delivered by the pump in 24 hrs is 26 units of lispro. The average daily amount of insulin lispro admnistered as bolus doses with meals is 24 units. The ICR is 1:10
.
ST wil eat a hamburger (24 g of carbs) and fries 28 g carbs) for lunch. How many units of insulin lispro needed?

A

total carbs/ # grams of carbs covered per 1 unit = 24+28/10 = 52/10 = 5.2 units of insulin will be injected via pump! (if she was using a pen or syringe she would round to the nearest unit so in this case would be just 5 units)

65
Q

Correction Doses for Elevated BG. What’s the steps/ formulas?

A

BG that is higher than the targeted range can be corrected with a bolus called a correction dose
1. Calculate the correction factor (which indicates how much BG will be lowered by 1 unit of insulin)
- Correction Factor - 1500 RULE (REGULAR)
1500/TDD = correction factor for 1 unit of regular insulin
- Correction Factor - 1800 RULE (RAPID)
1800/TDD = correction factor for 1 unit of rapid acting insulin
.
2. Now calcualte the correction dose (which the total unit needed to return BG back to target range. Thsi formula is the same for regular or rapid insulin
-Corection Dose = (BG now)-(target BG) / Correction Factor

66
Q

Correction Dose Insulin Case Scenario

JJ is a 35y/o male wiht DM2 currently treated with Lantus 50 units SC QHS and novolog 15 units SC TID AC… What is JJ’s correction factor?

A

Novolog is a rapid acting! So use Correction Factor -1800 Rule!
1800/ TDD (50 u lantus + 15 +15+15 units of humalog) = 1800/ 95 = 18.94 or 19. JJ corection factor is 19 units (which means 1 unit of rapid acting insulin will lower his BG by 19 mg/dL

67
Q

Correction Dose Insulin Case (Cont.)

JJ is a 35y/o male wiht DM2 currently treated with Lantus 50 units SC QHS and novolog 15 units SC TID AC…JJ’s correction factor is 19..
JJ has a target premeal BG of 120 mg/bl. He checks his BG before dinner and it was 200! What does of Novolog should JJ administer before dinner?

A

BG now - Target bBG divided by correction factor
.
200-120 = 80/19 = 4.21 or 4 units …now add that 4 units to his usual novolog dose of 15 units so 4+15 = 19 UNITS needed before dinner!

68
Q

Insulin Conversion: Converting between Insulins

A

MOST INSULIN CONVERSIONS ARE 1:1
- exception #1: NPH dosed BID –> insulin glargine dosed daily (so use 80% of the NPH dose) ex. NPH 30 units AC breakfast, then 20 units AC dinner = 50 NPH total (where as insulin glargine would be 50 units QHS)
- exception #2: Insulin Glargine (Toujeo) –> insulin glargine (lantus, basaglar) or insulin detemir (Levemir) (use 80% of the Toujeo dose)
.
Basically the regimen just needs to be split up differently

69
Q

Insulin Strenghts and Container; and use of concentrated insulin?

A

Most insulin products contain 100 units/mL of insulin. Some wil have >100units/ ml (these are called concentrated insulins. Insulins are available in:
- Vials (usually 10mL…but Humulin-R 500 comes in 20mL vials)
- Pens: are dialed to desired units. All pens contain 3 mL (except toujeo which comes in 1.5 and 3 mL). All Insulin pens are multi-dose and needles must be dispensed with all insulin pens
.
Concentrated insulin reduces the volume of insulin needed to be injected but is higher risk. Comes in both vial and pen. Concentrated insulin is useful for patient taking >200 units/ day. Ways to avoid error? only dispense with U-500 syringes

70
Q

Dispensing Insulin: If a patient is taking 35 units of Lantus daily, how many Lantus Solostar pens is needed to be dispensed to provide 30 day supply?

A

100 u/ml and pens have 3 ml so that is 300 units per pen!
.
Patient takes 35 units per day x 30 day supply = 1050 units needed/ 300 units per pen = 3.5 pens so round up to 4 pens.
.
REMEMBER: Insulin pens require priming prior to each dose (2 units). it’s not standard practice to account for that dose tho so this wont effect our final calc.

71
Q

Insulin Stability/ Storage: general

A
  • Unused insulin vials, pens are stored in refrigerator. The expiration date of insulin stored in fridge is the manufacturs’s expiration’s date on the label!
  • Once insulin s in room temp the manufactur’s date no longer applies and MUST be used within a specific #s of days (next slide). Notice that most insulin is stable at room temp for 28 days including all rapid acting
72
Q

Insulin Room Temperature Stability of Each Insulin

A
73
Q

Selecting an insulin syringe

A
  1. 0.3ml syringe for less than 30 units
  2. 0.5mL syringes for 30-50 units
  3. 1mL syringes for 51-100 units
    .
    Humulin R U-500 can only be dispensed in U-500 syringe (green cap). and U-100 syringes have orange caps
74
Q

Selecting an Insulin Pen Needle

A

Needles are chosen by length and gauge (thickness). The higher the gauge, the thinner it is! (28G is thickest - 32G thinnest). Shorter needles and higher guage causes the least pain.
.
The shortest needles are 4mm and 5mm and is pref for most pen. Does not require pinching of skin (good for thinner patients and children). the 8mm is for most patient and require pinching of skin. the 12.7mm or (1/2 in) needle is for obese patient and requires pinching

75
Q

Insulin Injection Counseling

A
  1. get supplies/ wash hands
  2. check if any particles/ discoloration in insulin (toss if there is)
  3. If insulin is NPH or contains Protamine, its a suspension ans needs to be resuspended (DO NOT SHAKE): vials? roll them in hand, pens? invert/ turn unside down 4-5x
  4. Clean inj site. if vial? wipe top with alcohol wipeafter removing plastic cover.
  5. PEN: use a new needle for each injection, prime pen (2 units), turn pen away from you and press injection button, then turn knob to correct # of units then inject to yourself (see 7)
  6. VIALS: use new syringe for every injection. Inj equal amount of air in vial and the ndraw up amount. If mixing NPH and rapid or regular acting in same syringe? the clear insulin (rapid or regular) should be drawn first before the cloudy one (NPH)
  7. Inject in abdomen area (pref) ALternate sites: posterior upper arm, supiror butt, and lateral thigh area
  8. With needle >5mm, pinch skin 2inches
  9. Insert needleall the way in. Pens: 90 degree, Syringes either 90 or 45 degree (if thin)
  10. Press button or plunger all the way down to inject insulin. count 5-10 secs prior to removing needle
  11. properly discharge needles, syringes, or single use pens in sharps container.
76
Q

Blood Glucose Monitoring: what is it? How to use glucose testing meter?

A

Blood glucose monitor = glucose meter or cont glucose monitor (CGM). CGM is taped on skin and have probe going into fatty tissue to measure glucose level in interstitial fluid.
.
Preparin to use a glucose meter: If recaliberation needed? do so a new canister of test strips is opened. Keep test strips in OG container wiht cap closed make sure to check exp date too. Wash and dry hands! Allow arm to hang down so blood can pool. do not squeeze fingertips.
.
Testing with Glucose Meter: insert strip, prick side of finger with lancet, apply drop of blood, record in log book, dispose of lancet and strip…some meters are approved to test blood from other sites (ie. forearm, palm, thigh = which hurts less!) However, alt testing sites are only useful when BG is steady! So do not use ig BG is changing quickly (ie. after exercise or after eating)

77
Q

Define hypoglycemia and the symptoms

A

Hypoglycemia is when BG < 70! Can cause severe consequences: falls, moter accidents, death, and each episode causes irreversible cognitive damage!
.
S/S: dizziness, anxiety/irritated, shaking, diaphoresis (sweat), hunger, confusion, tachy, tremors, palpatation, blurred vision.
.
Severe hypoglycemia –> SZ, coma, death
.
This is how CGM can be helpful!

78
Q

Hypoglycemia: treatment: for conscious/ able to swallow vs unconscious

A

Treatment if conscious/ can swallow
- glucose gel/ tabs
- forms of carbohydrates that contain glucose (1/2 cup OJ, 1T honey/sugar, 1 cup milk, 3-4 glucose tabs, 1 pack gel, 4oz regular soda)
- follow 15 min rule to treat: Take 15-20 grams glucose, recheck BG in 15 mins, if still hypoglycemia? repeat until normal then eat a small meal/ snack
.
Treat if unconscious
- dextrose (if have IV access) or with glucagon (glucagon 1mg SC inj: Glucagen, Gvoke) or glucagon nasal spray (baqsimi).
- If glucagon is used? put patient in lateral recumbent position (on side) to protect airway/ prevent choking.

79
Q

List of drugs that can cause hypoglycemia

A
  • insulin
  • sulfonylureas and meglitinides (high risk!): glyburide/ glimepiride not recommended for elderly!
  • GLP1 agonist, DPP4 inhibitors, SGLT2I and TZD have low risk when used alone but high when with insulin or sulfon!!!
  • Alcohol (when + insulin or sulfon)
  • CAUTION: Beta blockers, esp non selective! it can mask adrenergic symp of hypoglycemia
  • tramadol
  • quinolones (can also increase)
80
Q

List of drugs that can causes hyperglycemia

A
  • loop diuretic/ thiazides
  • tac/ cyclosporines
  • protease inhibitor
  • steroids
  • Statin
  • Niacin
  • quinolones (can also decrease)
  • Beta blockers (can also decrease)
81
Q

Inpatient glucose control: BG goal, how to treat?, sliding scale?

A

Ipatient glucose goal: 140-180
- Using sliding scale alone is NOT recommended! Need to treat in response to BG levels/ trends..Insulin is used for most hospitalized patients. but it relays on oral intake.
- if oral intake is adequte, regimen with basal, bolus, and correction doses is pref!
- Poor intake: basal+correction dose only
- Correction dose is given when BG is already high (correction dose is patient specific, not like sliding scale) correction dose is based on insulin sensitivity and how much BG will drop with 1 unit of insulin (correction factor!)
.
Sliding Scale
- <60 = hold insulin/ contact MD
- 150-200 = 2 units
- 200-250 = 4 units
- 250-300 = 6 units
- 300-350 = 8 units
- 350-400 = 10 units
- +400 = call MD

82
Q

Hyperglycemia Crisis

Diabetic Ketoacidosis: what is it? symp/ labs?

A
  • High BG (>250), ketoacidosis, and ketouria! ketones smell fruity/ also causes n/v, dehydration, anion gap acidosis (>12), low pH (<7.35)
  • More common in DM1
  • d/t insulin non adherence or subtheraputic insulin level
  • in DKA, x insulin = high glucose/ glucose not being utilize for energy = no energy! have to break down fat/ triglyceride = ketone byproduct = acidic!
83
Q

Hyperglycemia Crisis

Hyperosmolar Hyperglycemia State: what is it? symp/ labs?

A
  • High mortality rate than DKA but not as common
  • HHS mainly occur in DM2
  • d/t illness (infection, stroke), less fluid intake = fluid shift = severe dehydration with altered consciousness, NO KETONES
  • S/s: confusion. BG >600 with high serum osmolality >320, extreme dehydration, pH >7.3
84
Q

Hyperglycemia Crisis

DKA and HHS Treatment

A
  1. Primary TX is agressive fluid (first) and insulin to treat hyperglycemia
  2. Fluid for everyone!: start with NS the when glucose reaches 200..can transition to D5W 1/2 NS
  3. Regular insulin infusion: 0.1 u/kg bolus then 0.1u/kg/hr infusion OR 0.4 u/kg/hr infusion
  4. Prevent hypokalemia!!! Starting insulin will decrease K+ b/c K+ will shift into cell..monitor K+ and keep levels at 4-5 meq/L
  5. Treat acidosis if pH <6.9 - typically corrected by fluids but can use sodium bicarb as well
85
Q

Summary of Drug Safety Issues

If Present: Cancer (thyroid, medullary thyriod carcinoma)
Avoid…

A

GLP1 agonist, GLP1/GIP agonist

86
Q

Summary of Drug Safety Issues

If Present: Gastroparesis/ GI disorders
Avoid…

A

GLP1 agonist, GLP1/GIP agonist, pramlintide

87
Q

Summary of Drug Safety Issues

If Present: UTI, hypotension/ dehydration/ ketoacidosis?
Avoid…

A

SGLT2I

88
Q

Summary of Drug Safety Issues

If Present: Heart Failure
Avoid…

A

TZDs, alogliptin, saxagliptin

89
Q

Summary of Drug Safety Issues

If Present: hypoglycemia
Avoid…

A

Insulin, sulfon, meglitinides, pramlintide

90
Q

Summary of Drug Safety Issues

If Present: hypokalemia
Avoid…

A

Insulin

91
Q

Summary of Drug Safety Issues

If Present: Lactic Acid
Avoid…

A

Metformin (risk increase with alcohol/ renal impairment/ hypoxia)

92
Q

Summary of Drug Safety Issues

If Present: osteopenia/ osteoprosis
Avoid…

A

canagliflozin (decrease BMD, fractures), TZDs (fractures)

93
Q

Summary of Drug Safety Issues

If Present: Pancreatitis
Avoid…

A

GLP1 agonist, GLP1/ GIP agonist, DPP4 inhibitors

94
Q

Summary of Drug Safety Issues

If Present: Periph neuropathy, PAD, foot ulcers
Avoid…

A

canagliflozin

95
Q

Summary of Drug Safety Issues

If Present: Renal Insuff (CrCL <30)
Avoid…

A

Metformin, Exenatide, glyburide, may need to start insulin at a lower dose!

96
Q

Summary of Drug Safety Issues

If Present: weight gain
Avoid…

A

insulin, TZDs, meglitinides, Sulfonylureas

NAPLEX 2024 (28 decks)

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