ANTIDIABETIC AGENTSINSULIN INSULIN
ORAL HYPOGLYCEMICSORAL HYPOGLYCEMICS
Fall 2013
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 2005Biosynthetic insulins are now available for
most patients
INSULIN CONCENTRATION
100 Units per mL
Regular insulin may come 100 Units / mL or
500 Units / mL for IV use
ONLY USE INSULIN SYRINGE
Exogenous insulin works the same as endogenous insulin
Transports glucose FROMFROM the blood to the INSIDEINSIDE of cells and
Takes excess glucose to the liver for storage This results in LOWERINGLOWERING of the blood blood
glucoseglucose level
Mechanism of Action
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
GoalGoal - maintain stable blood glucose levels
ADMINISTRATION
Subcutaneous injectionSyringe and needlePen injectors Jet injectorsInhalationExuberaSubcutaneous infusionPortable insulin pumps Implantable insulin pumpsIntravenous infusion
ADVERSE EFFECTS
The most significant adverse effect is HYPOGLYCEMIAHYPOGLYCEMIA
The signs & symptoms are the same for any hypoglycemic reaction / state
BLOOD GLUCOSE MUST BE BLOOD GLUCOSE MUST BE MONITOREDMONITORED
DOSAGE
INDIVIDUALIZEDINDIVIDUALIZEDInsulin dosage is “tailored”
to each patient specifics metabolic needs to achieve stable blood glucose levels
INSULIN PEAK / ONSET / DURATION
It is important to know the insulin’s 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
RAPID ACTINGHumalog (lispro) or (Novolog) aspart
Synthetic formClear solutionCan be given separately or mixed with
intermediate or long acting insulinsMore rapid and shorter acting than human regular
InsulinOnset / Peak / Duration = 10 min / 1 -3 hr / 3-6 hrsAdminister within 10 – 15 minutes of a meal
Apidra (insulin glulisine)Onset / Peak / Duration = 10-15 min / 1-1.5 hr / 3-5
hrsGive within 15 min before mealCan be used in insulin pumpCan be mixed with NPH for subcutaneous injection
SHORT DURATIONRegular InsulinHumulin 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, inhalationAdminister 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
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
Intermediate Acting Insulins
PREMIXED INSULIN COMBINATIONS
Humalog Mix 75 – 25 (75% Lispro protamine solution with 25 % Lispro solution)
Rapid onset with intermediate durationOnset / Peak / Duration 15-30 min / 1-6.5 /12-24 hrs
Humulin 50/50 (R=50, N=50)Humulin 70/30, Novolin 70/30, (N=70,
R=30)30 min / 2-12 hr / 24 hr
LONG ACTING INSULINSInsulin detemir (Levemir)Onset / Peak / Duration / 6-8 / 12-24Slow onset and dose dependent durationProvides basal glycemic controlAs compared with NPH, has slower onset
and longer durationClear solutionAdministered once or twice daily
Long Acting
Humulin U (Ultralente)Onset / Peak / Duration
6-8 / 12-16 / 20-30
VERY LONG ACTING INSULIN
Very Long Acting
Insulin glargine (Lantus)Onset 1 hour no pronounced peak Duration 24 hours
LANTUS
NOT to be confused with LENTELong lasting basal insulinSlow 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 usuallySteady absorption - NO PRONOUNCED
PEAKWorks 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
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)
STOP AND THINK
if you administer 10 units of regular insulin at 7:00 am when should you observe for hypoglycemia?
if you administer 5 units of Humulin R insulin and 22 units of Humulin N at 7:30 am when will you observe for hypoglycemia?
if you administer 7 units of Humulin R at 11:30 am when will you observe for hypoglycemia?
if your patient is NPO for breakfast and is due insulin at 7:30 am what should you do?
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)
NURSING IMPLICATIONS
when mixing insulins - CLEAR TO CLOUDYCLEAR 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 PEAK’sPEAK’s
SAFE PRACTICE FOR INSULIN ADMINISTRATION
BEFORE ADMINISTERINGBEFORE ADMINISTERING:
Check the original doctor’s order
KNOWKNOW your patient’s 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
REVIEW ADMINISTRATION
ADMINISTERED SUBQADMINISTERED 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
NURSING IMPLICATIONS
ALL insulin dosages ALL insulin dosages MUSTMUST be be DOUBLE CHECKED by a second DOUBLE CHECKED by a second LISCENED personLISCENED person
administer insulin only with an insulin syringe calibrated for that concentration of insulin
BEFORE ADMINISTERINGBEFORE ADMINISTERING:
check the original doctor’s order KNOWKNOW your patient’s blood sugar and “trends or patterns”
Check the last time your patient ate Check other drugs patient is taking and question yourself about interactions
SITE ROTATION
Diabetics should be taught to ROTATEROTATE their injection sites
This is done to prevent “lipoatrophy” / scarring at the injection site - which results in variable insulin absorption
SUBCUTANEOUS
INSULIN ADMINISTRATION: METHODS OF DELIVERY: INSULIN PENS
INSULINS THAT CAN BE USED IN PUMPS: REGULAR, LISPRO, ASPART, GLULISINE
INSULIN ADMINISTRATION: METHODS OF DELIVERY: INSULIN INJECTORS
COMPLICATIONS OF INSULIN THERAPY
Local Reactions
Redness, tenderness, swelling, induration
1-2 hours after insulin administration
May occur at beginning of therapy and resolve
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
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) Acting (Regular Insulin)
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
Sliding Scale OrderBlood glucose < 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 > 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?
SLIDING SCALE ORDER
EXAMPLE:EXAMPLE:
Blood glucose < 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 > 300 call Dr.
At 1130 your patient’s blood sugar is 284, how much insulin will you give?
What type of Insulin is ordered for sliding Scale?
Sliding Scale Order
Blood glucose < 200 - give 0 u
Blood glucose 201 - 249 give 4 u
Blood glucose 250 - 299 give 6 u
Blood glucose > 300 call Dr.
Order: Regular Insulin per sliding scale AC & HS
Order: Lantus 10 Units sub Q at bedtime.
Your patient’s blood glucose at 2100 is 278, how much insulin will you give?
How would you administer it?
ORAL HYPOGLYCEMICS
Oral hypoglycemic agents work in one of three ways:
STIMULATESTIMULATE the pancreas to produce more insulin
DECREASEDECREASE glucose production
INCREASEINCREASE glucose uptake by the cell by enhancing the effectiveness of insulin
Oral hypoglycemics are usually only given to Type II diabeticsType II diabetics
SULFONYLUREA ORAL HYPOGLYCEMICS: SECOND GENERATION
EXAMPLES EXAMPLES Diabeta, Micronase (glyburide); Glucotrol (glipizide), Amaryl (glimepiride)
Action: LowersAction: Lowers blood sugar by stimulating the release of insulin from beta cells of the pancreas
Adverse reactions: hypoglycemiahypoglycemia, 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
BIGUANIDE ORAL HYPOGLYCEMIC AGENTS
metformin (GLUCOPHAGE)Action:Action:Decreases glucose released from liverDecreases intestinal absorption of glucose, metforminImproves insulin sensitivityResulting in improved blood glucose controlUSES:Type II diabetesMay be combined with other antidiabetic agentsSIDE / ADVERSE EFFECTS:Primarily GI effects - bloating, nausea, cramping, diarrheaAdvantage: Does not cause hypoglycemia, does not cause
wt gain, favorable effect on triglyceridesIncreased risk for lactic acidosis and renal failure, Stop
Metformin 48 h prior to and 48 h after diagnostic procedures using a contrast agent.
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
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
THIAZOLIDINEDIONE ORAL HYPOGLYCEMICS (TZD)(THIGH-A-ZOE-LID-EEN-DIE-OWN)Rosiglitazone (row-sih-GLIT-uh-zone) AvandiaPioglitazone (pie-oh-GLIT-uh-zone) Actos
ActionAction: 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 crampsSE unexpected: hypoglycemia, hepatotoxicity,
wt. gainDrug Interactions: Beta Blockers ay ask signs of
hypoglycemia, may cause BC pills to be ineffective
DRUG INTERACTIONS
There are SIGNIFICANT 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
TEACHING PLAN
HBA1C: GLYCOSYLATED HEMOGLOBIN A1C
Monitor lab test to determine BS control
An accurate long term index of the patient’s 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 = > 8%
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
TEST YOUR KNOWLEDGE
A patient in the ICU requires intravenous insulin. The nurse is aware that:
A. insulin aspart or glargine can be administered IV.
B. any form of insulin can be used IV at the same dose ordered for subcutaneous administration.
C. insulin should never be given IV, and this order should be questioned.
D. only regular insulin can be administered IV.
TEST YOUR KNOWLEDGE
A type 1 diabetic patient on insulin reports taking propranolol for hypertension. This provokes the concern that:
A. the beta blocker can produce insulin resistance.
B. the two agents used together will increase the risk of ketoacidosis.
C. propranolol will increase insulin requirements because of receptor blocking.
D. the beta blocker can mask the symptoms of hypoglycemia.
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.
A. Hypoglycemia
B. Flatulence
C. Elevated iron levels in the blood
D. Fluid retention
E. Diarrhea
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
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:
A. 9 to 11 AM
B. 1 to 7 PM
C. 7 to 11 PM
D. Midnight to 6 AM