1. What is diabetes?
    • Elevated blood glucose is the classic sign of diabetes mellitus and is associated with many complications.
    • Normal: 100mg/dL
    • Hyperglycemia: 140-160mg/dL
  2. What are some of the long-term complications of diabetes?
    • Vascular Disease: Increased incidence of hypertension, angina, heart attack and stroke, Peripheral vascular disease can lead to intermittent claudication, skin ulcers and gangrene
    • Ocular Complications (Retinopathy): Poor circulation to the retina of the eye, Leading cause of blindness in people under 65
    • Kidney Disease (Nephropathy): Caused by thickening of capillary membranes in the glomerulus, Leads to end-stage renal dysfunction, A major cause of death in diabetic patients
    • Nervous System Disease (Neuropathy): Peripheral neuropathy characterized by paresthesia, pain and decreased feeling in legs and feet, Effects of autonomic nervous system include nausea, diarrhea and urinary retention
  3. Differentiate between the different types of insulin.
    • Beef, horse insulin
    • human insulins (Humulin, Novolin, Humalog, Lantus)
  4. Which are rapid acting, short acting, intermediate acting and long acting?
    • RAPID ACTING: Lispro (Humalog�), Aspart (Novolog�), Glulisine (Apidra�)
    • SHORT ACTING: Regular (Humulin R�, Novolin R �)
    • INTERMED ACTING: Lente (Humulin L�, Novolin L�)
    • LONG ACTING : Glargine (Lantus�), Insulin Detemir, (Levemir�), Ultralente (Humulin U�)
  5. By what route is each administered?
    • Sq, Upper arm, thigh and stomach
    • Rotated to reduce complications at site
  6. What are some of the special handling requirements for insulin?
    • Regular insulin should be clear, all others should be cloudy
    • Insulin bottle should be rotated gently, never shaken vigorously
    • Regular, NPH, Lente and Ultralente (Humulin�, Novolin�) insulin does not have to be refrigerated, but refrigeration enhances stability. Patients are often instructed to keep the current vial they are using at room temperature, and store any remaining supply in the refrigerator.
    • Unopened vials of insulin lispro (Humalog�), insulin aspart (Novolog�), insulin glulisine (Apidra�) and insulin glargine (Lantus�) should be stored in the refrigerator. Opened vials may be stored at room temperature for 28 days.
    • Many pharmacies store all their insulins in the refrigerator.
  7. Insulin
    • Produced by Langerhans cell in the pancreas
    • Burn glucose for energy, combines with membrane receptors to allow glucose uptake,
    • Enhances transport and incorporation of amino acids into protein
    • Increase ion transport into tissues
    • Inhibits fat breakdown
  8. Dosing
    • Individualized
    • Often given as a combination of rapid acting and intermediate acting preparations
    • Usually given twice a day, 10 to 15 minutes before meals
    • Sliding scale dosing
  9. Hypoglycemia (Insulin Reaction)
    • Occurs with blood sugars < 70 mg/dl
    • Often sudden in onset
    • Symptoms include:
    • Sweating
    • Irritability, Confusion
    • Hunger
    • Headache
    • Blurred vision
  10. The leading cause of blindness in the U.S
  11. Sulfonylureas
    • Stimulate release of insulin from the beta cells of the pancreas.
    • 1st: Chlorpropamide (Diabenese�)
    • 2nd: Glyburide (Diabeta�, Micronase�, Glynase�)
    • May cause allergic reactions in some patients
    • Should be administered 30 minutes before meals
    • Associated with a number of drug interactions
    • May cause weight gain
    • May cause hypoglycemia
  12. Biguanides
    • Unknown, but may modify the insulin receptor effect. Do not stimulate insulin release from the beta cells of the pancreas.
    • Metformin (Glucophage�): Only commercially available biguanide, Associated with lower incidence of side effects than phenformin
    • Often used in combination with sulfonylurea
    • Possible drug interactions include cimetidine and anticoagulants
    • Side effects include metallic taste in the mouth, stomach upset and lactic acidosis
  13. Alpha Glucosidase Inhibitors
    • Inhibits digestion of starches thereby delaying absorption of glucose.
    • Miglitol (Glyset?)
    • May be used as monotherapy
    • Often used in combination with sulfonylurea
    • Must be taken at the start of each meal
    • GI side effects very common
  14. Thiazolidinediones
    • Enhances insulin action in skeletal muscle, liver and fat tissue. Also lower blood pressure and triglycerides.
    • Pioglitazone (Actos?)
    • May be used as monotherapy
    • Often used in combination with sulfonylurea
    • May be taken with or without food
    • Decreased blood levels of oral contraceptives
    • May cause weight gain
    • May cause increase risk of fractures in women
  15. Meglitinides
    • Stimulate release of insulin from the beta cells of the pancreas.
    • Repaglinide (Prandin?)
    • May be used as monotherapy
    • Often used in combination with metformin
    • Should be administered 15 to 30 minutes before meals
    • May cause hypoglycemia
    • May cause weight gain
  16. Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
    • Increase insulin secretion and decrease glucagon secretion.
    • Sitagliptin (Januvia�)
    • May be used as monotherapy
    • Often used in combination with other agents
  17. Incretin Mimetic Agents
    • Mimic effects of incretins leading to increased insulin secretion and other antihyperglycemic effects.
    • Exenatide Injection (Byetta�)
    • Used in combination with sulfonylureas, metformin or thiazolidinediones
    • May increase likelihood of hypoglycemia when used with sulfonylureas
    • May lead to weight loss
    • Take 60 minutes prior to meals
    • May keep pen patient is currently using at room temperature, store any remaining supply in the refrigerator
    • Discard pen 30 days after opening
    • Pancreatitis reported with both drugs
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