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Pharmacology: Exam 1 > Module 3: Diabetes Mellitus > Flashcards

Module 3: Diabetes Mellitus Flashcards

1
Q

Type 1 Diabetes Mellitus (T1DM)

A

Immune-mediated or idiopathic pancreatic beta cell destruction, resulting in severe or absolute insulin deficiency

Most pts are <30 yrs. old when diagnosed

Insulin is necessary to sustain life; interruption of insulin can lead to DKA and/or death

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2
Q

Type 2 Diabetes Mellitus (T2DM)

A

Characterized by tissue resistance and declining beta cell production

Mostly diagnosed in adults, but can occur at any age (on the rise in children)

Most pts do not require insulin replacement to survive (up to 30% may benefit)

Uncontrolled T2DM can lead to nonketotic hyperosmolar coma

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3
Q

Diabetes Mellitus (DM)

A

DM is associated with other conditions:

  1. Pancreatic disease
  2. Drug-induced diabetes (i.e. thiazide diuretics, corticosteroids)
  3. Malnutrition

Gestational diabetes (GDM): develops in 5-7% of all pregnant women and disappears after delivery; it is associated with increased risk of developing T2DM later in life

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4
Q

Complications of DM

A

Short-term complication: Hyperglycemia

Long-term complications:

  1. Macrovascular issues — stroke, atherosclerosis, altered lipid metabolism
  2. Microvascular issues (damage to the small vessels) — retinopathies, neuropathies, nephropathies
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5
Q

AEs of Diabetic Meds.

A

Hallmark S/S of hypoglycemia:

  1. Hunger
  2. Fatigue
  3. Weakness
  4. Nervousness
  5. Confusion
  6. Tremor
  7. Sweating
  8. HA
  9. Tachycardia
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6
Q

Treatment Goals of T1DM and T2DM

A

Treatment goals: Keep an individual in a normal glycemic state, and minimize any sort of complications from diabetes

RN interventions:

  1. Monitor BP, kidney function, and nerve function
  2. Lipid management
  3. Diet
  4. Exercise 150 min./week — increases cellular response to insulin and decreases insulin intolerance
  5. Eye exam

Tx (Addressing the insulin problem):
1. Replace insulin — only acceptable method for T1DM pts; appropriate for some T2DM pts

  1. Increase insulin release by pancreas — Sulfonylureas, Meglitinides, Incretin mimetics, DPP-4 inhibitors
  2. Decrease glucose absorption — Alpha-glycosidase inhibitors, Biguanides
  3. Decrease liver glucose production and increase peripheral insulin sensitivity — Biguanides, Thiazolididiones (TZDs)
  4. Prolong activity of incretins which stimulate insulin release and inhibit glucagon release — DPP-4 inhibitors
  5. Promote glucose excretion via kidneys — SGLT-2 inhibitors
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7
Q

Drugs to Treat Diabetes

A

Injectable drugs:

  1. Insulin
  2. Not Insulin — Incretin mimetic (GLP-1 receptor agonists) and Amylin mimetic

Oral drugs:

  1. Biguanides
  2. Sulfonylureas
  3. Meglitinides
  4. Thiazolidinediones (TZDs)
  5. Alpha-glucosidase inhibitors
  6. DPP-4 inhibitors (gliptins)
  7. SGLT-2 inhibitors
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8
Q

Insulin

A

MOA:

  1. Promotes the transport of glucose into muscle, liver, and adipose tissue
  2. Suppresses the release of fatty acids from adipose tissue, preventing the formation of ketone bodies
  3. Accelerates potassium uptake into muscle cells
  4. Promotes incorporation of amino acids into protein

Therapeutic use:

  1. T1DM (required)
  2. T2DM: if symptoms not improved by diet and exercise, oral hypoglycemics, or during major stress/surgery
  3. GDM with sub-optimal control with diet or oral agents
  4. Parenteral nutrition, tube feeds
  5. Hyperglycemic crisis (IV)
  6. Hyperkalemia (i.e. renal pts) — insulin shifts potassium into cells
  7. Diagnosis of GH deficiency

AEs:

  1. Hypoglycemia
  2. Lipohypertropy: hardening of admin. site due to repeated injection

DDIs:

  1. Oral hypoglycemics
  2. Hyperglycemic agents
  3. Beta blockers — can mask hypoglycemia (tachycardia)

Dosage: Match dose to needs — Request reduction of basal dose if NPO, pre-op, eating poorly, or pt is hypoglycemic (40%)

RN management:

  1. Refrigerate unopened insulins; opened insulin may be kept at room temp. for a month
  2. Pre-filled syringes should be kept in a refrigerator in a glass container with the needle up to prevent clogging
  3. Rotating within the site (fat distribution affects absorption)
  4. Monitoring for AEs (hypoglycemia)
  5. Monitoring BG — obtaining sample from IV line is NOT acceptable; know S/S of hyper/hypoglycemia, and know hypoglycemic treatment

Insulin sites: Rotate within a site — maintains absorption consistency

RN implications:

  1. Admin. — always roll vile of cloudy NPH insulin preparation between palms, and rotate sites
  2. Storage requirements
  3. Elements of pt/family education
  4. Methods to minimize AEs (especially hypoglycemia)

Med. safety concerns:

  1. High alert drug
  2. Hypoglycemia
  3. Concentration confusion
  4. Infection risk if insulin pens are used for multiple pts
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9
Q

Insulin Preparations

A

Rapid-acting:

  1. ASPART (Novolog, Fiasp) — Onset: 10-20 min., 2 min. (Fiasp); Peak: 1-3 hrs; Duration 3-5 hrs.
  2. LISPRO (Humalog) — Onset 15-30 min.; Peak: 30 min.-3 hrs.; Duration 3-6 hrs.
  3. GLULISINE (Apidra)

Short-acting:
1. REGULAR (Humulin R, Novolin R) — Onset: 30-60 min.; Peak: 1-5 hrs.; Duration: 6-10 hrs.

Intermediate-acting:
1. NPH (Humulin N) — Onset: 1-2 hrs.; Peak: 6-14 hrs.; Duration: 16-24 hrs. (cloudy)

Long-acting:

  1. GLARGINE (Lantus, Touejo, Basaglar) — Onset: 70 min.; Duration: 18-24 hrs.
  2. DETEMIR (Levemir)
  3. DEGLUDEC (Tresiba)
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10
Q

Insulin Storage

A

Insulin storage guidelines:
1. Refrigerate; do not freeze (prevent clumping of the suspension)

  1. Stable at room temp. for 30 days
  2. Mixture in syringes may be stored (needle up) in refrigerator/room temp. (duration varies)
  3. Always observe expiration date on vial
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11
Q

Treatment of T2DM

A

T2DM diagnosis & treatment plan:
1. Dx: Lifestyle modifications & metformin prescribed

  1. At 3 mos. (Assess if H1A1c within normal range): Add second drug (injectable, oral, or basal insulin) based on efficacy, cost, and AEs
  2. At 6 mos. (Assess H1A1c): Add third drug
  3. At 9 mos. (Assess H1A1c): Consider combination injectable therapy with insulin and a GLP-1 receptor agonist
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12
Q

Incretin Mimetic: Glucagon Like Peptide-1 (GLP-1) Receptor Agonists

A

Prototype: Exenatide

MOA: Activates GLP-1 receptors; similar effects as incretin

Mechanisms of incretin:

  1. Stimulates glucose-dependent insulin release
  2. Inhibits glucagon release
  3. Slows gastric emptying

Therapeutic use:

  1. T1DM (in combination with insulin)
  2. T2DM (adjunctive therapy)

AEs:

  1. Hypoglycemia
  2. N/V/D (common)
  3. Pancreatitis — upper abdominal pain, fever
  4. Renal impairment
  5. Allergy

DDIs:

  1. Oral contraceptives & antibiotics — impair absorption
  2. Sulfonyureas — increase risk for hypoglycemia

Individual variation:

  1. Avoid in ESRD
  2. Not used in pregnancy
  3. Gastroparesis
  4. Avoid if Hx of thyroid cancer

Dosage form: SQ injection pen; ER

RN implications:

  1. Educate pts on S/S of hypoglycemia & pancreatitis
  2. Proper storage (fridge) and protect from light
  3. SQ (Byetta): Attach needle and admin. bid, 60 min. prior to meal
  4. ER (Bydureon): Admin. once a week
  5. Rotate injection sites
  6. Do not inject next to insulin injection site
  7. Resistant to metabolism/inactivation by DPP-4 enzymes
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13
Q

Amylin Mimetics

A

Prototype: Pramlintide

MOA:

  1. Slows gastric emptying
  2. Suppresses post-prandial glucagon secretion, leading to decreased hepatic glucose release

Therapeutic uses: Adjunctive therapy for T1DM & T2DM

AEs: Hypoglycemia & N/V

DDIs: Drugs that slow GI motility (i.e. anticholinergics, opioids) — impair absorption of oral drugs

Dosage form: Pre-filled pen; admin. prior to a major meal (in conjunction with insulin)

RN implications:

  1. Store unused pens in fridge until opened and protect from light
  2. Store used pens in either fridge or room temp. for up to 30 days
  3. Do not use if cloudy or particles present
  4. Do not freeze
  5. Dispose needle after each use
  6. Inject SQ for 10 seconds
  7. Admin. before a meal with at least 30 g. of carbs
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14
Q

Biguanides

A

Prototype: Metformin

MOA:

  1. Inhibits hepatic glucose production
  2. Increases glucose uptake by muscles/fat
  3. Reduces glucose absorption in gut
    * *Does NOT stimulate insulin release

Therapeutic use:

  1. Initial therapy for T2DM (drug of choice)
  2. Polycystic Ovarian Syndrome — endocrine/metabolic disorder characterized by excess androgen and insulin resistance

PK: Eliminated unchanged by kidneys — monitor kidney function

AEs:

  1. Decreased appetite
  2. N/V/D
  3. Abdominal bloating
  4. Flatuence
  5. Lactic acidosis (rare, but life-threatening) — S/S: Exhaustion, fatigue, N/D, abdominal pain, decreased appetite, HA; Early S/S: hyperventilation, myalgia, unusual somnolence

DDIs:

  1. Cimetidine (treats PUD) & alcohol — increased risk of lactic acidosis
  2. Iodinated contrast dyes — discontinue use on day of study and restart 48 hrs. later

Individual variation:

  1. Renal disease — discontinue if serum creatinine is >1.5 mg/dl (males) or >1.4 (females); contraindicated with GFR <30 ml/min
  2. Avoid in pts prone to lactic acidosis — CHF (requiring treatment), renal or liver dysfunction, or excessive alcohol ingestion

RN implications:

  1. Decrease GI symptoms by giving with food, and starting at a low dose, then gradually increasing titration
  2. Decreases absorption of B12 and folic acid — increased risk of peripheral neuropathy
  3. Educate pts on S/S of lactic acidosis and report to provider ASAP
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15
Q

Sulfonylureas

A

Prototype: Glipizide

MOA: Stimulate release of insulin from pancreatic beta cells

Therapeutic uses: T2DM alone or in combination

AEs:

  1. Hypoglycemia
  2. GI disturbances
  3. Pruritus
  4. Rash
  5. Neurological symptoms
  6. Weight gain

DDIs:

  1. Alcohol (disulfiram-like reaction) — flushing, diaphoresis, palpitations, nausea
  2. Hypoglycemic drugs
  3. Beta blockers — suppress insulin release and mask hypoglycemia (specifically tachycardia)

Individual variation:

  1. Renal dysfunction
  2. Chronic liver disease
  3. Pregnancy
  4. Lactation

RN implications:

  1. Admin. once a day with meal to prevent hypoglycemia
  2. DDIs
  3. Avoid alcohol
  4. Do not admin. if pregnant or lactating
  5. Do not crush or cut ER tablet
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16
Q

Meglitinides

A

Prototype: Repaglinide

MOA: Stimulate the release of insulin from the pancreas

Therapeutic use: T2DM alone or in combination with metformin

PK: Peak: 1 hour; admin. tid with meal

AEs: Hypoglycemia & weight gain

DDIs: Gemfibrozil (treats hypertriglyceridemia) — can inhibit metabolism

Individual variation: Increased risk of hypoglycemia with liver dysfunction

RN implications:

  1. Admin. up to 30 min. before each meal
  2. Educate on S/S of hypoglycemia
17
Q

Thiazolidinediones (TZDs)

A

Prototype: Pioglitazone

MOA: Reduces insulin resistance and inhibits hepatic glucose production by activating insulin responsive genes that regulate carb. and lipid metabolism

Therapeutic use: T2DM

AEs:

  1. URI
  2. HA
  3. Sinusitis
  4. Myalgia
  5. Weight gain
  6. Elevated LDL and HDL
  7. Fluid retention and HF
  8. Hepatotoxicity
  9. Bladder CA
  10. FXs
  11. Ovulation

Individual variation:

  1. HF — avoid if severe
  2. Hx of bladder CA

RN implications:

  1. Monitor fluid status (edema, weight, lung sounds), LFTs
  2. Educate S/S of HF, bladder CA (blood in urine), use of contraception in post-menopausal women
  3. Encourage bone health — exercise, vitamins
18
Q

Alpha-Glucosidase Inhibitors

A

Prototype: Acarbose

MOA: Slows carb. absorption and digestion, by inhibiting alpha-glucosidase (an enzyme that breaks down complex carbs.)

Therapeutic use: T2DM

AEs:

  1. Severe intestinal effects — flatuence, cramps, diarrhea
  2. Anemia
  3. Hepatotoxicity (15% in long-term)

DDIs: Decreased absorption of iron — increased risk of anemia

Individual variation: Contraindicated for those with GI disorders — i.e. inflammatory bowel disease

RN implications:

  1. Admin. with first bite of meal
  2. Use glucose tablets to treat hypoglycemia
  3. Monitor LFTs every 3 mos.
19
Q

Dipeptidyl Peptidase 4 (DDP-4) Inhibitor

A

Prototype: Stiagliptin

MOA:

  1. Blocks degradation of GLP-1 (incretin)
  2. Stimulates glucose-dependent insulin secretion
  3. Suppresses post-prandial glucagon release

Therapeutic use: T2DM alone or in combination

AEs:

  1. URI
  2. HA
  3. Nasal inflammation
  4. Pancreatitis (rare)
  5. Hypersensitivity (rare)

RN implications: Educate pts on S/S of pancreatitis — fever, abdominal pain

20
Q

Sodium-Glucose Co-Transporter 2 (SGLT-2) Inhibitor

A

Prototype: Canagliflozin

MOA: Reduces reabsorption of glucose in the kidneys (thus increasing glucose excretion in urine)

Therapeutic use:

  1. T2DM
  2. T1DM with insulin

AEs:

  1. Female genital fungal infections
  2. UTIs
  3. Increased urination
  4. Orthostatic hypotension — due to increased output

DDIs:

  1. Inducers decrease efficacy — i.e. rifampin, phenytoin, phenobarbital
  2. Diuretics — increased risk of hypotension and dehydration

RN implications:

  1. Admin. once a day (12 hr. half-life) before the first meal of the day
  2. Monitor kidney function and GFR
21
Q

Hypoglycemia

A
  • Hypoglycemic protocol:
    1. BG 50-70 = Give 4 oz juice or 8 oz milk (15g of carbs.)
    2. BG <50 = Give 8 oz juice or 16 oz milk (30g of carbs.)
  • Recheck glucose in 15 min.:
    1. BG >70 = Give 15g of carbs. if meal occurs >1 hr. AND monitor BG every 2 hrs. (3 times)
    2. BG 50-70 = 15g carbs.
    3. BG <50 = 30g carbs.
  • After second 15 min. recheck:
    1. BG >70 = Give 15g of carbs. if meal occurs >1 hr. AND monitor BG every 2 hrs. (3 times)
    2. BG <70 = Admin. 1L D5 at 42 ml/hr and NHO
  • *Pt is NPO:
    1. BG 50-70 = 12.5g of D50 IV push
    2. BG <50 = 25g of D50 IV push
  • *Repeat after 15 min. recheck if BG 50-70 or <50; >70 monitor 2 hrs. x 3
  • **If no IV access and NPO:
    1. Admin. 1 ml glucagon IM
    2. Obtain IV access
  • **Recheck BG in 15 min. if BG 50-70 (12.5 ml D50) or <50 (25 ml); >70 monitor 2 hrs. x 3
22
Q

Correctional Insulin

A

For pts that are NOT on nutritional insulin, correctional insulin is admin. AC (before meals)

Usually, correctional insulin is adjunctive to nutritional insulin and admin. PC (after meals)

23
Q

Bedtime (HS) Insulin and Hypoglycemia

A

If BG <100, give 15g carb. snack, recheck BG 2 hrs. later

If BG <100 after 2 hr. recheck, NHO

**If a pt is ordered fingersticks AC and HS, and they are NPO, check their fingerstick q4h

24
Q

Reportable Events

A

Report if:
1. Hypoglycemic — treat first

  1. Admin. of D50W
  2. Admin. of glucagon
  3. Admin. of dextrose infusion (D5)

Pharmacology: Exam 1 (9 decks)

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