EXPLAIN 5

InsulinOralHypoglycemicAgents_Updated.pptx

Home >Chemistry homework help >Pharmacology homework help >EXPLAIN 5

Pharmacology NSG 220

Antidiabetic Medications

Oral and injectable noninsulin antidiabetic medications are a growing number of hypoglycemic agents with varying pharmacologic properties

Target specific problems of glucose metabolism for patients with type 2 diabetes mellitus.

Many are available in more than one concentration. Some examples of these agents are:

Oral and Injectable Noninsulin Antidiabetic Medications

Insulin is a hormone produced by the gland called the pancreas. It’s located behind the stomach. Once you eat, insulin is excreted breaking down carbohydrates (glucose) which allows your body to use for energy. The digestive tract breaks down carbohydrates and changes them into glucose. There are Diabetes I and type II people who either do not produce insulin at all and those type II who don’t produce enough or their cells are resistant to insulin.

Oral and Injectable Noninsulin Antidiabetic Medications

Parenteral Antidiabetic Medications: Insulin Products

Insulin is supplied in:

Rapid-onset forms

Intermediate-acting forms

Long-acting forms

Most often prescribed and administered subcutaneously

IV route is reserved for specific acute care situations

Insulins & Oral Hypoglycemics

Insulin

Syringe

Pen

Oral Hypoglycemics

Numerous with different MOA

Insulin is supplied in two concentrations:

U 100 (100 units/mL)

U 500 (500 units/mL) (rarely ordered)

Parenteral Antidiabetic Medications: Insulin Products

Short- and rapid-acting insulins are administered to treat:

Current blood glucose elevation or

An anticipated elevation (e.g., after the next meal, nourishment, or HS snack)

Nursing Implications

Take blood glucose before meal

ALWAYS take blood glucose before administering the medication

Provide a meal immediately for the patient

Short- and Rapid-Acting Insulins

Lispro (Humalog)

Onset: 15-30 mins

Peak: 0.5-2.5 hours

Duration: 3-6 hours

Aspart (Novolog)

Onset: 10-30 mins

Peak: 0.5-2.5 hours

Duration: 3-6 hours

Glulisine

Onset: 10-30 mins

Peak: 0.5-2.5 hours

Duration: 3-6 hours

Short- and Rapid-Acting Insulins

Rapid Acting, Short Duration

Insulin Regular (Humulin R, Novolin R)

Onset: 30-60 mins

Peak: 1-5 hours

Duration: 3-5 hours

Prepared

U 100 (100 units/mL)

U 500 (500 units/mL) (rarely ordered)

Administered: Subcutaneous, IV infusion

Patients receiving intermediate-acting insulin products usually receive two injections per day: one in the AM and one in the PM

Mixture of regular insulin and protamine (a large protein)

Causes a delay in action and duration is extended

Usually given 2-3 times daily

Provides glycemic control between meals and during the night

The only insulin suitable for mixing with short-acting insulin

Onset: 30-60 mins

Peak 6-14 hours

Duration: 16-24

**Supplied as a cloudy suspension that must be agitated. Not shaken.

**Administered subQ only

**Available without a prescription, 10 ml vials and pre-filled syringe

Intermediate-Acting Insulins

Medications: U-100 Insulin Glargine (Lantus), Isulin Detemir (Levemir)

Supplied: clear solution 10 ml vials containing 100 units/ml and in pre-filled pens

Usage: Administered to patients unresponsive to intermediate-acting insulins

Patients with early morning fasting elevations

Patients who cannot tolerate multiple daily injections

Administration:

Subcutaneously Only, Never to be given IV infusion or mixed with other insulins

Usually administered once daily (some may be required to take twice daily to achieve a full 24 hour base coverage

Can be administered anytime of the day, but should be given the same time of the day

Long-acting insulins are released more slowly than the fast- and intermediate-acting insulins

Patients should be given a bedtime snack

Long-acting insulins cannot be given IV because they contain additives to extend the action

Long-Acting Insulins

Achieves blood glucose levels that are relatively steady

Steps to Prepare Doses for Insulin Syringe

Obtain current blood glucose value

Hold insulin if BG is low according to prescriber’s directions

Check the order for:

Name, type, dose, time, and route

Select appropriate insulin/insulin syringe

Insulin syringe matches the number of units/mL on label of insulin bottle

Steps to Prepare Doses for Insulin Syringe

Examine medication vials for clump and precipitation

Check expiration date

Check discard date if already opened multidose vial

If suspension insulin, gently roll to disperse the content

Draw the appropriate amount of air units in the insulin syringe and inject into vial

Draw same ordered units of insulin into syringe (exchange air for insulin)

Mixed insulins provide:

Blood glucose coverage for meals with a small amount of short-acting insulin and between meal coverage

Plus an added amount of slower release, intermediate-acting insulin

The first number indicates the percentage of slower, intermediate-acting insulin

The second number indicates the percentage of short- or rapid-acting insulin

Order: Novolin Mix 70/30, 18 units subQ 30 minutes ac breakfast and dinner

Short- and Intermediate-Acting Insulins: Insulin Fixed-Combination Mixes (1 of 2)

Obtain and interpret current blood glucose level

Read order for name, type, dose, time, route

Select appropriate insulin type, and if using opened bottle, check discard date

Select appropriate insulin syringe calibrated for same concentration (i.e., U100)

Examine for clumps and precipitate; if present, discard and use fresh vial

If in suspension, gently roll to disperse contents

Calculations are not needed for single insulin injections

Steps to Prepare Doses for Insulin Syringes

Matching Insulin Concentration and Syringes

Match insulin syringe to number of units per mL on the insulin bottle label U-100 to insulin syringe calibrated to 100 units per mL

Prepare insulin with an insulin syringe only

Do not use regular uncalibrated syringes for insulin injections, as only the insulin syringe is calibrated in units

Insulin syringes come in various capacities

30-unit (3/10 mL), 50-unit (1/2 mL), and 100-unit (1 mL) sizes

Markings can come as even or odd number calibrations

Sites for Insulin Injection

Insulin may be administered subcutaneously in fatty tissue of abdomen in a 2-in radius away from umbilicus, in the thigh, in fatty tissue of posterior upper arm, or in fatty tissue of the buttocks (See Figure 11-13).

Sliding-scale short-acting insulins are titrated to patient’s current blood glucose levels

Usually ordered q6h or AC, or AC&HS

q6h usually ordered for patients NPO or on tube feedings, TPN, or PPN

AC or AC&HS prescribed for patients taking PO

Scales are adjusted as mild, intermediate, and aggressive to provide coverage for “sliding” glucose levels

Requires blood glucose checks at least 3 to 4 times daily

Sliding-Scale Insulin (1 of 3)

Example sliding scale

Blood Sugar (mg per dL) Insulin Amount

70 to 150 0 units

151 to 200 4 units

201 to 250 6 units

251 to 300 10 units

301 to 350 12 units*

351 to 400 15 units*

>400 Call physician and draw plasma blood glucose

*Recheck blood glucose level 1 hour after administration

Sliding-Scale Insulin (2 of 3)

Sliding-scale, short-acting insulins are titrated to patient’s current blood glucose levels

Order: Insulin NPH 15 Units subcutaneously AC&HS per sliding scale

Morning blood glucose level 255

Give: 10 U Humulin R subcutaneously

Sliding-Scale Insulin (2 of 2)

Occasionally, the nurse must prepare an insulin mix, drawing up two different insulins in one syringe

Common combination:

Regular and intermediate-acting insulins

Always check the order and compatibility of the two types of insulin

Mixing Insulins: Short- and Fast-Acting & Slower-Acting and Intermediate Mixes

Order:

Total dose of this injection is 26 units

Read both product labels to ensure compatibility

Do NOT confuse Humulin with Humalog

Mixing Insulins: Short- and Fast-Acting and Slower-Acting and Intermediate Mixes

Identify the vials, verify the order, shake intermediate suspension gently, and clean tops of vials with alcohol swabs

Insert air equal to the amount of insulin ordered into each vial

Start with the intermediate-acting insulin

Followed by the short-acting insulin

Withdraw the clear, short-acting insulin first and verify the correct amount

Technique for Preparing Insulin Mixes (1 of 2)

After gently mixing suspension from the intermediate-acting insulin, withdraw the exact amount of insulin

Gently tap out any air bubbles and verify the precise combined amount

Discard and start over if the total amount is incorrect

Technique for Preparing Insulin Mixes

Cloudy refers to intermediate suspension

Clear refers to short-acting preparation

Sequence for Preparing Insulin Mixes

Intravenous Insulin Infusions

Insulin infusions are administered in the hospital for acute hyperglycemia

Regular or Humalog insulin (fresh/unopened bottle) is used when preparing an insulin infusion according to the prescribed order

Insulin should be administered on its own separate line via pump set to insulin infusion

The IV solution should be labeled with the number of units and concentration typically 1 unit per mL (occasionally 0.5 unit per mL) in NS

Typical solution is 100 units in 100 mL NS

Ordered: Humulin R insulin IV at 3 units/hr

Available: Humulin R insulin 100 units in 100 mL 0.9% NaCl solution

Estimated flow rate in mL/hr? _______________

Ordered flow rate in mL/hr?

DA equation:

IV Infusions

Prefilled pens

Contain regular insulin, intermediate-acting insulin, and mixtures of the two

Have single-use finer needles, 30G, 31G, or 33G

Work well for low-vision patients due to easier-to-read dials

Large dial also allows for reduced strength or fine motor coordination (See Figure 11-18)

Other antidiabetic medication pens for injection :

Apidra® SoloStar®

Byetta®

SymlinPen® 60 & 120

Victoza®

Humalog® KwikPen™

HumaPen® LUXURA™ HD

Humulin® Pen

Lantus® Solostar®

Levemir® FlexPen®

NovoLog® Mix FlexPen®

NovoPen 3®/NovoPen Junior®

AutoPen®

Insulin Administration Devices

Insulin Pumps

Devices worn by patients who are unresponsive to intermittent subcutaneous injection

The insulin pump allows a programmed, continuous, subcutaneously injected basal dose of short-acting insulin to be delivered throughout the day and night

Added boluses are administered on the pump to cover meals and glucose elevations

Oral Hypoglycemics

Medication: Biguanide

Metformin (Glucophage)

MOA:

Decreases glucose production by the liver

increases tissue response to insulin“

No risk of hypoglycemia

Monitor labs:

BUN & Creatinine

Nursing Implications:

Hold 48 hours before and after IV contrast to reduce kidney injury

Use with caution in patients with renal insufficiency

Side effects:

Decreased appetite

Diarrhea

Oral Hypoglycemics

Sulfonylureas (Glipizide, Glyburide, Glimepiride)

MOA:

Increases insulin released by the pancreas

May also increase tissue response to the insulin

Uses:

Should use in conjunction with diet and exercise programs to

Monitor labs:

BUN & Creatinine

Nursing Implications

Teach patient to avoid alcohol

Monitor blood glucose levels to maintain glucose controls

Side Effects

Weight Gain

Hypoglycemia

Contraindications and precautions

Pregnancy and breast-feeding

Not effective in patients with type 1 diabetes

Thiazolidinediones (Glitazones)

Pioglitazone (Actos), Rosiglitazone (Avandia)

MOA: "Decrease insulin resistance and thereby increase glucose uptake by muscle and adipose tissue, and decrease glucose production by the liver“

Side Effects:

Hypoglycemia, but only in the presence of excessive insulin

Fluid retention (avoid in patients with HF)

Bladder cancer

Fractures (in women)

Ovulation, and thus possible unintended pregnancy"

Meglitinides

Nateglinide (Starlix), Repaglinide (Prandin, GlucoNorm)

MOA:

Promote insulin secretion by the pancreas

Side effects:

Weight gain

Hypoglycemia

Oral Hypoglycemics

Oral Hypoglycemic (cont.)

DPP-4 Inhibitors

Increase insulin release and decrease glucagon release

Alpha-glucosidases Inhibitors

Delay of carbohydrase absorption, so decrease postprandial blood glucose

SGLT-2 Inhibitors

Promotes excretion of glucose by kidneys via urine

Anti-Hypoglycemics

Medication: Glucagon

Class: Antihypoglycemic

Therapy: Rapid treatment of hypoglycemia is mandatory: If hypo-glycemia is allowed to persist, irreversible brain damage or even death may result.

Side/effects: Nausea/vomitting

Use:

Oral: conscious patients (e.g., glucose tablets, orange juice, sugar cubes, honey, corn syrup, non-diet soda).

Intravenous- Severe hypoglycemia (below 60 mg/dl) or patient is unable to swallow. IM is an alternative treatment

****Alert

Patients who take insulin or some oral hypoglycemics should always keep glucagon on hand too

Patients should carry some sort of identification (e.g., Medic Alert bracelet) to inform emergency personnel of their condition"

"Hypoglycemia (generally defined clinically as a blood glucose below 70mg/dL)** occurs when insulin levels exceed insulin needs. A major cause of insulin excess is overdose. Imbalance between insulin levels and insulin needs can also result from reduced intake of food, vomiting and diarrhea (which reduce absorption of nutrients), excessive consumption of alcohol (which promotes hypoglycemia), unusually intense exercise (which promotes cellular glucose uptake and metabolism),and childbirth (which reduces insulin requirements). Patients with diabetes and their families should be familiar with the signs and symptoms of hypoglycemia. "Page 691

Page 705

Post-prandial-occurring after a meal

Ac/hs- before meals and at bedtime

Subcutaneous

hgA1C- lab that measures your average blood sugar level over the past 3 months.

IDDM,NIDDM

Basal Rate –continuous dosage of medication (insulin). Usually seen when insulin pump is used

Blood glucose, blood sugar

Glucometer- equipment used to measure blood glucose

Bolus- an extra amount of insulin taken to cover an expected rise in blood glucose, often related to a meal or snack.

Brittle diabetes (diabetic)- unstable blood sugars

Charcot Good – condition in which the joints and soft tissue in the foot are destroyed, resulting from damage to the nerves seen in diabetics

Dawn phenomenon – the early morning rise in blood sugar level

Common words heard in diabetes

Dextrose- glucose – simple sugar found in the blood that serves as the body's main source of energy

Diabetes mellitus causes high blood glucose, or blood sugar, resulting from the body's inability to use blood glucose for energy.

People with diabetes insipidus have normal blood glucose levels; however, their kidneys cannot balance fluid in the body. Typically, this form is treated with a man-made hormone called desmopressin (DDAVP, Minirin, others). This medication replaces the missing anti-diuretic hormone (ADH) and decreases urination. You can take desmopressin as a nasal spray, as oral tablets or by injection

Diabetes Mellitus versus Diabetes Insipidus