EXPLAIN 5 Pharmacology NSG 220 Antidiabetic Medications Copyright © 2019 by Elsevier Inc. All rights reserved. Oral and injectable noninsulin antidi

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EXPLAIN 5 Pharmacology
NSG 220
Antidiabetic Medications

Copyright © 2019 by Elsevier Inc. All rights reserved.

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
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Copyright © 2019 by Elsevier Inc. All rights reserved.

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.
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Oral and Injectable Noninsulin Antidiabetic Medications
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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

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Insulins & Oral Hypoglycemics
Insulin
Syringe
Pen

Oral Hypoglycemics
Numerous with different MOA

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Insulin is supplied in two concentrations:
U 100 (100 units/mL)
U 500 (500 units/mL) (rarely ordered)
Parenteral Antidiabetic Medications: Insulin Products
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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
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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

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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

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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
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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
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Achieves blood glucose levels that are relatively steady
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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

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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)

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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)
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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
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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

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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).

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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)
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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)
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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)
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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
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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
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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)
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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
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Cloudy refers to intermediate suspension
Clear refers to short-acting preparation
Sequence for Preparing
Insulin Mixes
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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

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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
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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
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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

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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

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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

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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
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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

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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”
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“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

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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
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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
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