306- Pharm: Diabetes

**All Type 1 diabetics

-Uncontrolled type 2 DM

-Hyperkalemia

-Admin. SC, IV

-Scheduled (Basal dose)

-Sliding scale (example BG-100/30 for BG > 200

• --Needed for proper glucose use
• --Facilitate entry of glucose into cells
• --Mimics endogenous insulin

*Destroyed by gastric acid

*No oral administration

*Slow, steady absorption

*Abd. most rapid absorption

*Regular - only one given IV

*Deteriorates if exposed to light

*Store room temp for 1 month

*Longer storage put in refrigerator

*Excreted via kidney

*Hypoglycemia

 *Lipodystrophy

• -Hypoglycemia
• -Sensitivity to insulin components

• ¢Immune state
• ¢Allergies
• ¢History of insulin administration
• ¢OTC drugs
• ¢Complications of DM
• ¢Electrolytes
• ¢CBC
• ¢Blood lipid levels, A1c levels

¢S/S hypo/hyperglycemia

¢Proper dosage

¢Preparing

¢Admin. Technique

¢Room temp 1 month

¢Rotate site

¢If infection, do not reuse needles

¢Must eat with insulin

• Insulin Aspart (Novolog)
• Insulin Lispro (Humalog)
• Insulin glulisine (Apidra)

• *Onset  5 – 15 min.
• *Peak  30 min to 3 hrs
• *Duration  2 to 5 hrs
• *Can be mixed with NPH for SQ (SC) injection
• *Covers glucose levels from meal immediately after injection
• *Given SQ and IV

Regular Insulin (Humulin R, Novolin R)

• -Onset  30 min – 1 hr.  SC —10 – 30 min. IV
• -Peak  2 -4 hrs.
• -Duration  6 – 8 hrs
• -Covers glucose levels from meals immediately after injection
• -Give SQ, IV, Insulin pump

-NPH (Humulin N, Novolin N) 

-Onset 1 – 2 hrs

-Peak  6 – 12 hrs

-Duration 18 – 24 hrs

-Only cloudy insulin

-Should eat at time of onset and peak action

-Covers subsequent meals not covered by rapid and short acting injections

• -Glargine (lantus)
• -Detemir (Levemir)

• -Onset 1 hr
• -Peak  None
• -Duration 24 hrs
• -Basal (absorbed very slowly over 24 hrs)
• -Never mix with any other insulin
• -Administered once daily

• -Compatibility and mixing
• -Storage
• -“Drawing up” from vial
• -Preparing skin
• -Injecting

• -Hypoglycemia
• -Allergic reaction
• -Lipodystrophies

• —Tricyclic antidepressants
• —MAOIs
• —Aspirin
• Oral anticoagulants

• —Thiazide diuretics
• —Glucocorticoids
• —Thyroid drugs
• —Estrogen
• (BCPs)

• -NPH/regular 
•   (—Ex. Humulin 70/30)
• -Insulin aspart protamine/insulin aspart
• -Insulin lispro protamine/insulin lispro
•   (—Ex. Humalog 75/25)

glipizide (Glucatrol), glyburide (DiaBeta)

-Used for patients with type 2 diabetes in conjunction with nutrition therapy

Taken before meal

• -Taken PO before meal
• -Rapid GI absorption
• -Onset within 2 hrs
• -Liver metabolized
• -Urine & feces excreted

• -Primary action-stimulate beta cells  to secrete insulin
• -Decrease liver glycogenolysis
• -Increase peripheral tissue sensitivity to insulin
• -Must have a pancreas that functions

• -Severe hepatic or  renal impairment
• -Sulfa drug allergy

• -Hypoglycemia
• -GI distress

• -S/S hypoglycemia
• -How to tx hypoglycemia
• -Avoid alcohol
• -Consult physician before OTC med use

• -Renal & hepatic function
• -OTC use
• -Herbal preparation use

repaglinide (Prandin), nateglinide (Starlix)

• -Pharmacotherapeutics
•      —Stimulate insulin release
• -Pharmacodynamics
• -Pharmacokinetics
• -Contraindications
•      —Liver dysfunction

-Hypoglycemia

Metformin (Glucophage)

Pharmacodynamics

Facilitates or encourages action of insulin on peripheral receptor sites

Inhibits glucose production by liver

Reduces glucose absorption in gut

Pharmacotherapeutics

Type 2 DM

Up to 2 wks. For therapeutic effect of dose

Pharmacokinetics

Slow absorption from GI

Rapid distribution to tissues

Kidney excretion (unchanged)

Contraindications

Renal  or hepatic impairment

Alcoholism

• GI distress
• Metallic taste sensation
• Lactic acidosis

• Renal  or liver impairment
• Chronic heart failure
• Alcoholism
• Hx. Of lactic  acidosis

• -Renal & Liver function tests
• -Weight

• -Education
• -No alcohol use
• -Take med with meals
• -Consult with MD for OTC meds
• **Hold for 48 hrs with IV contrast dye**

—Inhibits absorption of sugars (carbs) from intestines

Acarbose (Precose), Miglitol (Glyset)

• -GI distress
• -Liver dysfunction

proglitazone (Actos), rosiglitazone (Avandia)

• Severe fluid retention
• Contraceptives
• **Black box warning – pt must sign warning form

• -S/S of liver damage
• -S/S of heart failure

sitagliptin (Januvia)

• —Increases insulin secretion
• —Decreases glucagon secretion to reduce glucose production

Exenatide (Byetta)

•improves beta-cell responsiveness

•Suppresses glucagon secretion

•Slows gastric emptying

•Reduces food intake

•Given by SC injection

•Adverse Effects

•Headache, dizziness, nausea, vomiting, diarrhea, jitteriness

Pramlintide (Symlin)

-Suppresses glucagon secretion – reduces postprandial glucose

-Slows gastric emptying

-Induces satiety

-Given SC ac ONLY in abd or thigh, NEVER arm

• Adverse Effects:
• —Dizziness, anorexia, nausea, vomiting, fatigue

Glucagon

• -Reverse severe hypoglycemia
• -IM, IV, SQ
• -Must be reconstituted

• -Stimulate glycogenolysis in peripheral  tissues
• -Maximum effect with IV 30 minutes

• -½ life 3-10 minutes
• -Liver metabolized
• -Urine & bile excreted
• -May be refrigerated for 48 hours

• -Insulinoma
• -Caution in pregnancy & lactation

-Blood glucose level before and after glucagon admin.

-LOC (level of consciousness)

• -Hypoglycemia prevention measures
• -How to administer glucagon
• -Fast intervention to prevent CNS  damage

• **In hospital will most likely use D50W  IVP for severe
• hypoglycemia

-Reverse severe hypoglycemia

-10-20 g. po, may repeat in 10 min.

-Dextrose 25 or 50% IV bolus

-Provides immediate source of glucose in systemic circulation

• •Blood glucose level before and after admin.
• •LOC (level of consciousness)
• •Cause of hypoglycemia
• •Assess IV site for redness, increased temp, tissue necrosis or sloughing
• •Monitor urine output
• •Give complex carbs/protein when awake