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Antidiabetic Agents

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Title: Antidiabetic Agents


1
Antidiabetic Agents
  • Insulin
  • Oral Hypoglycemics

Fall 2013
2
Insulin
  • Insulin is a hormone produced in the beta cells
    of the pancreas, secreted at a rate of 0.5 to 1
    unit per hour. Average insulin secretion in adult
    is 30-50 Units per day.
  • Insulin is required for entry of glucose into
    skeletal and heart muscle and fat.
  • Insulin is important in protein and lipid
    metabolism.
  • Decrease in insulin decrease in glucose into
    cell hyperglycemia
  • Beef and pork discontinued in US in 2005
  • Biosynthetic insulins are now available for most
    patients

3
Insulin Concentration
  • 100 Units per mL
  • Regular insulin may come 100 Units / mL or
  • 500 Units / mL for IV use
  • ONLY USE INSULIN SYRINGE

4
Mechanism of Action
  • Exogenous insulin works the same as endogenous
    insulin
  • Transports glucose FROM the blood to the INSIDE
    of cells and
  • Takes excess glucose to the liver for storage
  • This results in LOWERING of the blood glucose
    level

5
Therapeutic uses
  • Insulin is the drug of choice for type 1 and type
    2 uncontrolled by diet, exercise or oral
    hypoglycemic agents
  • Hormonal replacement - remember insulin is a
    hormone
  • Goal - maintain stable blood glucose levels

6
Administration
  • Subcutaneous injection
  • Syringe and needle
  • Pen injectors
  • Jet injectors
  • Inhalation
  • Exubera
  • Subcutaneous infusion
  • Portable insulin pumps
  • Implantable insulin pumps
  • Intravenous infusion

7
Adverse Effects
  • The most significant adverse effect is
    HYPOGLYCEMIA
  • The signs symptoms are the same for any
    hypoglycemic reaction / state
  • BLOOD GLUCOSE MUST BE MONITORED

8
dosage
  • INDIVIDUALIZED
  • Insulin dosage is tailored to each patient
    specifics metabolic needs to achieve stable blood
    glucose levels

9
Insulin Peak / Onset / Duration
  • It is important to know the insulins onset, peak
    and duration
  • Onset- time required for the med to have an
    initial effect
  • Peak when agent will have the maximum effect
  • Duration length of time the agent remains
    active in the body

10
Rapid Acting
  • Humalog (lispro) or (Novolog) aspart
  • Synthetic form
  • Clear solution
  • Can be given separately or mixed with
    intermediate or long acting insulins
  • More rapid and shorter acting than human regular
    Insulin
  • Onset / Peak / Duration 10 min / 1 -3 hr / 3-6
    hrs
  • Administer within 10 15 minutes of a meal
  • Apidra (insulin glulisine)
  • Onset / Peak / Duration 10-15 min / 1-1.5 hr /
    3-5 hrs
  • Give within 15 min before meal
  • Can be used in insulin pump
  • Can be mixed with NPH for subcutaneous injection

11
Short Duration
  • Regular Insulin
  • Humulin R, Novolin R
  • Onset / Peak / Duration 30 to 60 min / 1-5 /
    6-10 hrs
  • Can be given Sub Q and IV
  • Routes IV, sub Q, IM, inhalation
  • Administer no sooner than 30 minutes before meal
  • Exubera inhaled insulin
  • Onset / Peak / Duration 15 to 30 min / 0.5-1.5
    hrs / 6.5 hrs
  • Fine powder of regular insulin

12
Intermediate Acting Insulins
  • NPH (Neutral protamine Hagedorn)
  • Onset / Peak / Duration 2-4 / 4-12 / 16-20 hrs
  • Contains specific amounts of regular insulin and
    protamine
  • Onset is delayed and action is extended.
  • Cloudy solution, must be gently agitated before
    drawing up.
  • Usually administered twice daily

13
Premixed Insulin Combinations
  • Humalog Mix 75 25 (75 Lispro protamine
    solution with 25 Lispro solution)
  • Rapid onset with intermediate duration
  • Onset / Peak / Duration
  • 15-30 min / 1-6.5 /12-24 hrs
  • Humulin 50/50 (R50, N50)
  • Humulin 70/30, Novolin 70/30, (N70, R30)
  • 30 min / 2-12 hr / 24 hr

14
Long Acting Insulins
  • Insulin detemir (Levemir)
  • Onset / Peak / Duration
  • / 6-8 / 12-24
  • Slow onset and dose dependent duration
  • Provides basal glycemic control
  • As compared with NPH, has slower onset and longer
    duration
  • Clear solution
  • Administered once or twice daily
  • Long Acting
  • Humulin U (Ultralente)
  • Onset / Peak / Duration
  • 6-8 / 12-16 / 20-30

15
Very Long Acting Insulin
  • Very Long Acting
  • Insulin glargine (Lantus)
  • Onset 1 hour
  • no pronounced peak
  • Duration 24 hours

16
Lantus
  • NOT to be confused with LENTE
  • Long lasting basal insulin
  • Slow steady release of insulin needed to control
    blood glucose keep cells supplied with energy
    when no food is being digested
  • ONCE-A-DAY - AT BEDTIME usually
  • Steady absorption - NO PRONOUNCED PEAK
  • Works twice as long as NPH (Lantus 24 hrs, NPH
    14.5 hrs)
  • Used for adults with Type 2 or children and
    adults with Type 1

17
  • LANTUS
  • Does NOT replace short-acting insulins
  • Can be used with oral anti-diabetic medications
  • MUST NOT be diluted or mixed with any other
    insulin or solution
  • MUST use U-100 syringe
  • NOT intended for IV use
  • Patients experience same side effects
    (hypoglycemia injection-site reactions)

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19
Stop and Think
  • if you administer 10 units of regular insulin at
    700 am when should you observe for hypoglycemia?
  • if you administer 5 units of Humulin R insulin
    and 22 units of Humulin N at 730 am when will
    you observe for hypoglycemia?
  • if you administer 7 units of Humulin R at 1130
    am when will you observe for hypoglycemia?

20
  • if your patient is NPO for breakfast and is due
    insulin at 730 am what should you do?

21
Insulin Storage
  • Insulin should not be allowed to freeze, nor be
    heated above room temperature.
  • Insulin should be stored in the refrigerator
    until opened, then may be stored at room
    temperature until gone.
  • At sustained temperatures above room temperature,
    insulins lose potency rapidly.
  • Excess agitation should be avoided to prevent
    loss of potency, clumping or precipitation.
  • All insulins except Regular, Lispro and Aspart
    should be gently rolled in the palms to resuspend
    solution. (Do not shake)

22
Nursing Implications
  • when mixing insulins - CLEAR TO CLOUDY
  • do not shake insulin vial to resuspend cloudy
    mixtures - gently rotate / roll vial in palm of
    hand or swirl, avoids bubbles
  • insulin must be stored in a stable temperature,
    refrigeration prolongs shelf life, in clinical
    settings - opened vial MUST be dated initialed
  • schedule snacks to coincide with insulin PEAKs

23
Safe Practice for Insulin Administration
  • BEFORE ADMINISTERING
  • Check the original doctors order
  • KNOW your patients blood sugar and trends or
    patterns
  • Check the last time your patient ate (what how
    much)
  • Check other drugs patient is taking and question
    yourself about interactions

24
Review Administration
  • ADMINISTERED SUBQ (unless emergency and then ONLY
    Short ACTING insulin can be given IV)
  • 45 or 90 degree angle
  • 27 - 25 G needle (microfine) (Only administer in
    an insulin syringe)
  • 5/8 inch
  • do not have to aspirate

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Nursing Implications
  • ALL insulin dosages MUST be DOUBLE CHECKED by a
    second LISCENED person
  • administer insulin only with an insulin syringe
    calibrated for that concentration of insulin
  • BEFORE ADMINISTERING
  • check the original doctors order
  • KNOW your patients blood sugar and trends or
    patterns
  • Check the last time your patient ate
  • Check other drugs patient is taking and question
    yourself about interactions

33
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34
Site Rotation
  • Diabetics should be taught to ROTATE their
    injection sites
  • This is done to prevent lipoatrophy / scarring
    at the injection site - which results in variable
    insulin absorption

35
Subcutaneous
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Insulin Administration Methods of Delivery
Insulin Pens
38
Insulins that can be used in pumps regular,
lispro, aspart, glulisine
39
Insulin Administration Methods of Delivery
Insulin Injectors
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41
Complications of Insulin Therapy
  • Local Reactions
  • Redness, tenderness, swelling, induration
  • 1-2 hours after insulin administration
  • May occur at beginning of therapy and resolve

42
Complications of Insulin Therapy Insulin
Lipodystrophy
  • Localized reaction
  • Lipoatrophy
  • loss of subcutaneous fat, appears as dimpling or
    pitting in of subcutaneous fat
  • Lipohypertrophy
  • the development of fibrofatty masses at the
    injections site.
  • Caused by repeated use of same injections site.
  • Insulin injected into scarred areas, absorption
    is delayed

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45
Diabetics in the Hospital Setting
  • Hospitalization may drastically affect insulin
    requirements because of stress (infections,
    surgery, acute illness, inactivity, variable food
    intake)
  • It is often used to monitor patients on
    hyperalimentation
  • Blood glucose checks are ordered at specific
    intervals - most often ac at bedtime
  • The insulin dose is then adjusted to a
    predetermined scale ordered by the physician
  • The ONLY type of insulin used in sliding scale is
  • Short Acting (Regular Insulin)

46
Sliding Scale
  • Method of insulin dosing
  • Dose is adjusted according to blood glucose
    results
  • This method of dosing is most often used for
    hospitalized diabetics

47
  • Sliding Scale Order
  • Blood glucose lt 200 - give 0 units Regular
    Insulin
  • Blood glucose 201 - 249 give 4 units Regular
    Insulin
  • Blood glucose 250 - 299 give 6 units Regular
    Insulin
  • Blood glucose gt 300 call Dr.
  • At 0730 your patient is scheduled to receive 20
    units of Humulin N and 5 units of Humulin R,
    their blood sugar level is 247, what will you
    give?

48
Sliding Scale Order
  • EXAMPLE
  • Blood glucose lt 200 - give 0 units Regular
    Insulin
  • Blood glucose 201 - 249 give 4 units Regular
    Insulin
  • Blood glucose 250 - 299 give 6 units Regular
    Insulin
  • Blood glucose gt 300 call Dr.
  • At 1130 your patients blood sugar is 284, how
    much insulin will you give?
  • What type of Insulin is ordered for sliding
    Scale?

49
  • Sliding Scale Order
  • Blood glucose lt 200 - give 0 u
  • Blood glucose 201 - 249 give 4 u
  • Blood glucose 250 - 299 give 6 u
  • Blood glucose gt 300 call Dr.
  • Order Regular Insulin per sliding scale AC HS
  • Order Lantus 10 Units sub Q at bedtime.
  • Your patients blood glucose at 2100 is 278, how
    much insulin will you give?
  • How would you administer it?

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Oral Hypoglycemics
  • Oral hypoglycemic agents work in one of three
    ways
  • STIMULATE the pancreas to produce more insulin
  • DECREASE glucose production
  • INCREASE glucose uptake by the cell by enhancing
    the effectiveness of insulin
  • Oral hypoglycemics are usually only given to Type
    II diabetics

52
Sulfonylurea Oral Hypoglycemics Second
Generation
  • EXAMPLES Diabeta, Micronase (glyburide)
    Glucotrol (glipizide), Amaryl (glimepiride)
  • Action Lowers blood sugar by stimulating the
    release of insulin from beta cells of the
    pancreas
  • Adverse reactions hypoglycemia, nausea,
    heartburn, bloating, flatulence, anorexia, skin
    reactions, photosensitivity, allergic reaction,
    CNS - paresthesia, tinnitus, dizziness, wt gain,
    edema
  • Contraindicated with Sulfonamide allergy
  • Monitor for hepatotoxicity, blood dyscrasias,
    dermatologic reactions
  • Drug interactions Beta Blockers may mask
    hypoglycemic reactions, alcohol may result in
    Anabuse like reaction

53
Biguanide Oral hypoglycemic agents
  • metformin (GLUCOPHAGE)
  • Action
  • Decreases glucose released from liver
  • Decreases intestinal absorption of glucose,
    metformin
  • Improves insulin sensitivity
  • Resulting in improved blood glucose control
  • USES
  • Type II diabetes
  • May be combined with other antidiabetic agents
  • SIDE / ADVERSE EFFECTS
  • Primarily GI effects - bloating, nausea,
    cramping, diarrhea
  • Advantage Does not cause hypoglycemia, does not
    cause wt gain, favorable effect on triglycerides
  • Increased risk for lactic acidosis and renal
    failure, Stop Metformin 48 h prior to and 48 h
    after diagnostic procedures using a contrast
    agent.

54
Alpha-Glucosidase Inhibitors
  • accarbose (Precose), miglitol (Glyset)
  • Action Delay absorption of complex carbohydrates
    in intestine, slow entry of glucose into systemic
    circulation, does not increase insulin secretion.
  • SE hypoglycemia, GI affects
  • Administration taken with first bite of food
  • Monitor LFT
  • Not systemically absorbed

55
Non-Sulfonyrea Insulin Secretagogues
  • Examples
  • Repaglinide (Prandin) (SE hypoglycemia)
  • Nateglinide (Starlix)
  • Action Stimulate release of insulin from beta
    cells in the pancreas
  • Rapid action and short half life
  • Taken before each meal

56
Thiazolidinedione oral hypoglycemics
(TZD) (thigh-a-zoe-lid-een-die-own)
  • Rosiglitazone (row-sih-GLIT-uh-zone) Avandia
  • Pioglitazone (pie-oh-GLIT-uh-zone) Actos
  • Action
  • Increases sensitivity of muscle and fat tissue to
    insulin, allowing more glucose to enter the cells
  • May inhibit hepatic glycogenesis and decrease
    hepatic glucose output
  • SE Expected N/V, anorexia, Abd cramps
  • SE unexpected hypoglycemia, hepatotoxicity, wt.
    gain
  • Drug Interactions Beta Blockers ay ask signs of
    hypoglycemia, may cause BC pills to be
    ineffective

57
Drug Interactions
  • There are SIGNIFICANT potential drug interactions
    between oral hypoglycemics and multiple
    classifications
  • Sulfonylureas alcohol, oral anticoagulants,
    antibiotics (sulfa), corticosteroids, thiazides,
    furosemide, thyroid drugs
  • Biguanides furosemide, digoxin, nifedipine,
    cimetidine
  • Thiazolidinediones reduces effectiveness of BC

58
Teaching Plan
  • medication regime
  • signs / symptoms (hypo hyper glycemia)
  • blood glucose monitoring
  • avoidance of alcohol
  • medic alert identification
  • measures to deal with sun exposure
    (sulfonylureas)
  • follow up care

59
HbA1C glycosylated hemoglobin A1C
  • Monitor lab test to determine BS control
  • An accurate long term index of the patients
    average blood glucose level
  • Reflects the average blood glucose level over the
    past 100-120 days
  • Good control 2.5 5.9
  • Fair Control 6-8
  • Poor control gt 8

60
Glucose Testing
  • Using the Glucometer (Measures capillary blood
    glucose)
  • Wash hands
  • Sterile 2x2, alcohol swab, towel, Glucometer,
    non-sterile gloves
  • Open sterile packages, place in reach, Don gloves
  • Select finger lateral aspect of fingertips
  • Apply warm compress if cold fingers
  • Place towel under hand
  • Cleanse and allow to air dry
  • Puncture finger and squeeze
  • Wipe off 1st drop with 2x2
  • Collect blood on strip cover entire area. 2x2
    to site

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Test Your Knowledge
  • A patient in the ICU requires intravenous
    insulin. The nurse is aware that
  • insulin aspart or glargine can be administered
    IV.
  • any form of insulin can be used IV at the same
    dose ordered for subcutaneous administration.
  • insulin should never be given IV, and this order
    should be questioned.
  • only regular insulin can be administered IV.

63
Test Your Knowledge
  • A type 1 diabetic patient on insulin reports
    taking propranolol for hypertension. This
    provokes the concern that
  • the beta blocker can produce insulin resistance.
  • the two agents used together will increase the
    risk of ketoacidosis.
  • propranolol will increase insulin requirements
    because of receptor blocking.
  • the beta blocker can mask the symptoms of
    hypoglycemia.

64
Test Your Knowledge
  • A nurse counsels a diabetic patient starting
    therapy with an alpha-glucosidase inhibitor. The
    patient should be educated about the potential
    for which adverse reaction(s)? You may select
    more than one answer.
  • Hypoglycemia
  • Flatulence
  • Elevated iron levels in the blood
  • Fluid retention
  • Diarrhea

65
Test Your Knowledge
  • A diabetic client taking daily NPH insulin has
    been started on therapy with dexamethasone
    (Decadron). The nurse anticipates that which of
    the following adjustments in medication dosage
    will be made?
  • 1. Decreased NPH insulin
  • 2. Increased NPH insulin
  • 3. Lower dose of dexamethasone (Decadron) than
    usual
  • 4. Higher dose of dexamethasone (Decadron) than
    usual

66
Test Your Knowledge
  • The nurse monitors the blood glucose level of the
    client who received NPH insulin at 7 AM knowing
    that the client may experience a hypoglycemic
    reaction between
  • 9 to 11 AM
  • 1 to 7 PM
  • 7 to 11 PM
  • Midnight to 6 AM
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