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-
Regular (Natural Insulin)
- unmodified, relatively rapid onset and short
- duration, clear solution. Only form that can be administered IV* Administered
- SC absorption is slightly delayed. Does not need to be refrigerated.
Adm. 30-60 minutes before meals
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Lispro Insulin (Humalog)
- rapid acting analog. Effects begin within
- 15-30 minutes of SC inj. Last 3-6 hours.
- Acts faster than Regular insulin.
- Adm. Immediately before eating.
- Use in combination with intermediate or long acting insulin preparations.
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Insulin Aspart (Novolog)
- analog of human insulin with a rapid onset (10-20 minutes) and short duration (3-5 hours).
- Inject immediately before meals.
- Can be mixed with other preparations (NPH)
-
Neutral Protamine Hagedorn (NPH)
Insulin:
- Prepared by conjugating regular insulin with Protamine (a large molecule).
- The presence of the large molecule retards absorption, resulting in delayed onset of action.
-
Lente Insulin/Ultralente
- Produced by complexing reg. insulin with Zinc, which changes the physical state , thereby reducing solubility.
- Less allergenic than NPH
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Insulin Glargine ( Lantus)
- Modified human insulin with a prolonged duration of action (atleast 24 hours). Indicated for once daily injections SC. Administer at bedtime.
- Slowly absorbed, relatively steady levels over 24 hours.
- Cannot be mixed with other insulins even
- though it is clear !
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Oral Hypoglycemic Agents:
Type II Diabetes
Sulfonylureas
Meglitinides
Biguanides ( Metformin )
Thiazolidinediones (Glitazones)
Alpha Glucosidase Inhibitors
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-
Name/ Duration/ Action/ Side Effects
-
orals cont...
Glucophage
Avandia
-
Sulfonylureas
Promote insulin release
Derived from sulfonamide antibiotics
Maybe used alone or in combination
First & second generation ( 2nd. Generation more potent)
Amaryl(Glimeperide), Diabeta(Glyburide)
- Glucotrol XL(Glipizide)
- Use in patients with Type II DM
Stimulates release of insulin from pancreas
Readily absorbed after oral administration
Peak levels in 3-5 hours
- Hepatic metabolism & renal excretion
- monitor for renal impairment ( Cr.Cl)
-
Meglitinides
Indicated for Type II DM
Stimulate release of insulin from pancreas
Similar mechanism of action like sulfonylureas
Blood levels peak within 1 hour
Side effect is hypoglycemia
- Repaglinide(Prandin), Nateglinide(
- Starlix)
-
Biguanides (Metformin
- Metformin (Glucophage) lowers blood glucose 1° by decreasing production of glucose from
- the liver. Suppresses gluconeogenesis. Enhances glucose uptake.
- Does not cause hypoglycemia
- Excreted renally; monitor renal function
- Use alone or in combination
- Side Effects: Decreased appetite, nausea and
- diarrhea, decreased absorption of B12 and folic acid
- Lactic Acidosis
- Metformin and the Biguanides
- inhibit mitochondrial oxidation of lactic acid and can cause lactic acidosis.
- Avoid in patients with liver disease, ETOH XS., heart failure and shock
-
Thiazolidinediones (Glitazones)
-
Rosiglitazone (Avandia), Pioglitazone (Actos)
- Reduce glucose by decreasing insulin
- resistance.
- Glitazones cause volume increase which can lead to heart failure and edema
- Benefits take several weeks to develop
- Mixed effects on plasma lipid levels: raises
- LDL, and HDL, lowers triglycerides
-
Alpha-Glucosidase Inhibitors
-
Acarbose (Precose)
- Act to delay the absorption of CHO
- Use in Type II DM
- Reduces the rise in glucose
- Maybe used in combination with other drugs
- Causes flatulence, cramps and abdominal
- distention, borborygmus
- and diarrhea
-
TRMT for DKA
- Insulin Replacement ¨Initial IV bolus (.1U/kg BW) followed by continuous infusion at.1U/kg/hr.
- Bicarbonate for Acidosis¨Controversial (pH<6.9-7.1) treat empirically
- Water and Sodium replacement ¨NS or I/2NS 8-10 liters for adults
- Potassium replacement nNormalization of glucose levels
-
Diabetes Diagnostics
FPG diagnostic at > 126mg/dl
2 hour OGTT > 200 mg/dl
Random glucose ( non-fasting) >200
Hgb AIC < 7.0%
-
Basal & bolus regimens (ideal) most closely mimics
endogenous insulin production
- Lispro (Humalog) prior to meals
- Also consider Glargine (Lantus)with 24hr. coverage
-
Somogyi Effect
- Rebound effect in which an overdose of insulin induces
- hypoglycemia, the counterregulatory system will cause an
- increase glucose causing hyperglycemia and in some cases ketosis
- Treatment typically consists of small protein snacks
- before bedtime
-
Dawn Phenomenon
- Characterized by hyperglycemia on awakening due to Counterregulatory secretion of GH
- & cortisol. Most severe during
- adolescence and young adulthood
Adjustment in insulin dosing and timing is needed
-
Diabetic Ketoacidosis
- Worldwide, infection
- is the cause of DKA in about 30-50% of cases, with pneumonia, and UTI being the
- most common etiologies
- Once DKA becomes
- apparent patient will exhibit Kussmaul’s respirations as a result of metabolic acidosis,
- abdominal pain and vomiting
-
HHS
- Less common than DKA but more serious is HHS which is a hyperosmolar state 2° to hyperglycemia
- but with little or no ketosis
- ***Insulin therapy to correct hyperglycemia is always
- secondary to aggressive fluid infusion in HHS
-
DKA
- 12-24 hours prior to the development of DKA the patientmay experience progressive weakness, blurred vision, polyuria and polydipsia
- The patient becomes extremely volume depleted
- His temperature may range from hypothermic to febrile ifinfection precipitated event.
-
DKA cont..
- Profound deficiency of insulin characterized by
- hyperglycemia (>250 mg/dl), ketosis, acidosis, glucosuria and dehydration
May have marked left shift if underlying infection
- Most often seen in TYPE1, may occur in TYPE 2 to a
- lesser degree
When circulating supply of insulin is not sufficient , glucose cannot be properly used for energy
Body breaks down fat stores as a 2nd. Source of fuel
Ketones are acid by-products that build up
Ketosis alters ph= metabolic acidosis
Ketonuria occurs along with depletion of electrolytes while attempting maintain electrical neutrality
-
Goals of Treatment
Restoring perfusion
Arrest ongoing ketoneogensis
Correct electrolyte losses
Avoid hypokalemia
Avoid hypoglycemia
-
Treatment for DKA
- Initial goal is to establish fluid & electrolyte
- replacement, improve volume status
- IV NS (open) titrate for urine output 30-60ml/hr…this
- will correct Na, K, HCO3.
- Replace 50% of the deficit in first 8 hours and
- remaining deficit within next 16 hours
- Early K replacement is essential (insulin deficiency may
- cause K to move extracellularly, total body deficit
- of K)
- Understand that initially K can be alarmingly high but
- will drop with treatment
IV insulin therapy ( bolus of .1-.15U/kg)
-
Hyperosmolar Hyperglycemic Non-Ketotic
Syndrome (HHNS)
- Typically seen in
- Type 2 patients, they can make a certain amount of insulin so they ward off
- KETOSIS
- Have severe
- hyperglycemia
Osmotic diuresis resulting in osmolarity over 300 mosm/kg
- Extracellular fluid
- depletion
- Typically an have
- glucose in XS 900-1000mg/dl. Before manifestations
-
Management of HHNS
Similar to DKA
Fluid hydration .9% NS (greater than in DKA)
Regular Insulin IV
May require some Dextrose to prevent hypoglycemia
-
Dyslipidemia
Type II & metabolic syndrome
- Presence of insulin* increases lipolysis and breakdown of TG
- in adipocytes this results in
- increase in Free Fatty Acids…increase VLDL
- VLDL leads to increase in LDL and circulating
- cholesterol
-
Pancreas Transplantation
Treatment option for patients with type 1 DM
K-P performed together in most instances
Rare to perform only pancreas txpl.
Only partially successful in reversing long term microangiopathies and neuropathies.
- Pancreatic Islet transplant another potential treatment
- measure
-
Glucagon for Insulin Overdose
Produced by the alpha cells
- ¨Increase plasma glucose
- levels and relaxes smooth muscle
- of the GI tract
- ¨Glucagon causes glucose levels to
- rise
- ¨For sever hypoglycemia IV glucose
- is preferred
¨May be administered parenterally IV, IM, SC (0.5-1mg)
-
Sulfonylurea drugs are contraindicated for
use in patients with an allergy to:
(Choices given, answers not given)
¨insulin
¨sulfonamides
¨aminoglycosides
¨penicillin
-
The effects of metformin (Glucophage) include:
(Choices given, answers not given)
- suppression of hepatic glucose
- production
lowering of triglyceride levels
enhanced insulin sensitivity
all of the above
-
Which of the following adverse effects is
SPECIFIC to metformin (Glucophage)?
(Choices given, answers not given)
¨Hypoglycemia
¨GI distress
¨lactic acidosis
¨diarrhea
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Acarbose (Precose) works by:
Choices given, Answer not given
¨sensitizing insulin receptors
- ¨decreasing carbohydrate
- absorption
¨increasing insulin secretion
- ¨decreasing hepatic glucose
- production
n
-
Thiazolidinedione antiglycemics
like rosiglitazone (Avandia) work by:
Choices given, Answer not given
¨enhancing insulin production
¨sensitizing insulin receptors
- ¨decreasing hepatic glucose
- production
¨inhibiting CHO absorption
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