·         Normal blood glucose is 

• Principal hormone for proper use of carbohydrates
• Controls storage and utilization of AAs and fatty acids
• Lowers blood glucose by inhibiting glucose formation in liver
• Helps glucose enter cells or striated muscle and adipose tissue
• Stimlates glycogen synthesis in liver
• Promotes protein synthesis
• helps body store fat by preventing it's breakdown for energy
• Onset, peak and duration are clinically important aspects of insulin; there are different preparations with different values 

Recombinant DNA somehow using e.coli

Less allergic reactions than  animal sources (used much less now)

Humalog

analog insulin

rapid acting

NovoLog

analog insulin

rapid acting

NPH

intermediate acting

Lente

intermediate acting

Ultralente

long acting

a.       Type I

b.       Uncontrolled type II

c.        Tx severe diabetic ketoacidosis (DKA) or diabetic coma

d.       tx hyperkalemia in combination with glucose

• hypoglycemia
• allergic rxn to protein additives, or even insulin iteself
• insulin resistance from antibody production against insulin, may require high doses of insulin

a.       hypersensitivity to any ingredient

b.       when pt is hypoglycemic

a.       renal/hepatic impaiment

b.       pregnancy/lactation

c.        Most are preg cat b, except insulin glargine and aspart are preg cat C

d.       Insulin may inhibit lactation, so may need adjustment if lactating

e.        Pregnancy makes diabetes more difficult to manage requiring freq monitoring

1.       - there are many!  Some decrease effect of insulin some enhance effect of insulin (pg 412)

• Before first dose ever of insulin, take BP, P, RR, weight
• Assess skin, mucous membranes and extremities for sores, cuts, signs infection and poor healing
• Obtain dietary habits, family hx diabetes
• Type and duration of sxs
• Review labs and antidiabetic drugs already used (if present)
• Review blood glucose levels
• Evaluate past compliance

 
Doses are adjusted according to needs

Assess for signs of hypo/hyper glycemia; hypo can occur up to 24 hours after admin

Regular blood glucose levels, usually before meals and before bed

Must notify PCP if above 400 mg'dL

• close observation needed, esp. with new dx, is pregnant, surgery, ill, poor diet; must recognize hypoglycemia and treat ASAP
• NURSING ALERT – especially check for hypoglycemia at peak action time of insulin, although can occur at other time
• Give sugar
• GLUCAGON by subcut, IM or IV
• glucose IV
• follow order and policies; some pts may not be able to swallow and can aspirate
• Notify PCP, what did to terminate hypo, etc and closely observe afterwards, understanding durations of specific insulin given

• Body breaks down fat b/c extremely low insulin unable to break down glucose, extreme hyperglycemia
• ketones produced, disrupts acid'base balance (acidosis)
• extreme fluid loss, hypotension

• Only use one type, source and brand
• keep spare vial 
• explain that no prescription is needed to purchase insulin 
• Needle and syringe – same brand, dispose of properly
• Medical identification needed

Incretin hormone

GI hormones that stimulate insulin secretion after eating, even before blood glucose increases

First generation

Second generation

Meglitinide

acetohexamide

chloropropamide

tolazamide

tolbutamide

§glimepiride

§glipizide

§glyburide or glibenclamide

nateglinide

repaglinide

alpha-Glucosidase Inhibitors

Biguanides

Thiazolidinediones (thiazol-id-in-ed-iones) 

Nonsulfonylurea (decreases insuling resistance)

Includes

rosiglitagone (Avandia)

pioglitazone (Actos)

troglitazone (Rezalin)  THIS HAS BEEN REMOVED DUE TO LIVER FAILURE

Main side effect is water retention, with CV complications.

Actos associated with increased bladder cancer.

sitagliptin (Januvia)

exenatide

§are 5 that mix metformin with another agent

§are 2 that mix glimepiride with another agent

glucagon

a.only for type II, uncontrolled by diet and exercise (although some type II get insulin)

b.Sometimes 2 orals are used, usually a sulfonylurea and metformin

c.Pts are started with diet exercise, if inadequate, then a sulfonylurea or metformin, if inadequate, both a sulf/met, if inadequate add insulin or another oral

“appear to lower glucose” by stimulating B cells to release insulin

Are ineffective if pancreas unable to release insulin

First generation not used as much bc of long duration and more adverse reactions and interactions

i.hypoglycemia, anorexia, N/V, epigastric discmfort, weight gain, heartburn

ii.vague neuro sxs like extremity numbness and weakness

iii.usually controlled by reducing dose, if cannot control, may need insulin

i.upper resp infection, headache, rhinitis, bronchitis, back pain, hypoglycemia

• GI upset,ab bloating, nausea, cramping, flatulence, diarrhea, metallic taste
• Can be reduced with lower doses and slow increase, and taking with meals
• Hypoglycemia rare when used alone, but at greater risk when combined with another antidiabetic

i.upper resp infections, sinusitis, headache, pharyngitis, myalgia, diarrhea, back pain

• lactic acidosis (rare), is usually pts with kidney problems, sxs are malaise, ab pain, rapid respirations, SOB, muscular pain
• may also decrease vit B12
• weight loss

• DKA
• severe infection
• severe endocrine disease
• First generation contraindicated with cADD or liver/renal dysfunction
• Cross sensitivity with sulfanomides

Increased hypoglycemic effect with

a.anticaogulants

b.chloramphenicol

c.clofibrate

d.fluconazole

e.histamine H2 antagonists

f.methyldopa

g.MAOIs

h.NSAIDS

i.salicylates

j.sulfanamides

k.tricyclics

decreased hypoglycemic effect

a.B-blockers

b.calcium channel blockers

c.cholestyramine

d.corticosteroids

e.estrogens

f.hydantoins

g.isoniazid

h.oral contraceptives

i.phenothiazines

j.rifampin

k.thiazide diuretics

l.thyroid agents

1.dced for surgery until renal funx restored

2.also can be cause renal failure if use iodinated contrast material for radiolical studies - so is stopped 48 hours before and after

3.with glucocorticoids --> increases risk of lactic acidosis

• maintain beta cell function
• enhance insulin secretion
• supresses glucagon from liver
• delays gastric emptying to slow carb absorption
• sitagliptin (Januvia) enhances endogenous incretin secretion
• exenatide (Byetta) mimics incretin

not studied in pregnant women "but believed to be cat b from animal studies"

a.chronic kidney disease

b.elderly

c.lactation

• Weight, BP, P, RR
• general skin,mucouse membranes, extremities paying attention to cuts, poor healing, ulcerations, etc
• diet, family hx of diabetes
• type, duration sxs
• review labs, dx tests
• if already taking antidiabetic, note it, dose, etc
• blood glucose test results
• adherence to regimen

a.most important is ptq 2-4hrs for hypoglycemia, symptoms table 43.1, esp. initial therapy pr change of dose

b.VS

c.adv reactions, notify PCP

d.weight,notify if sig change

e.Blood glucose monitored regularly – best to assess long-term control is HbA1c

• No fixed doses, is individualized by effect and tolerance and max recommended
• Older adults more sensitive to these drugs, and may need lower doses
• After taking a while, may have SECONDARY FAILURE, which is loss of drug effectiveness – either more diabetes or less drug effect – may need yet another drug
• Usually given with food

• no fixed doses, is individualized by effect and tolerance and max recommended
• acarbose and miglitol 3Xday with first bite of meal, bc food increases absorp; some start lower dose then increase to minimize GI distress like flatulence and diarrhea
• metformin 2-3timesa day, or 1 ER
• hiazolidinediones no regard to food, but if taken, must eat or may become hypoglycemic

• MUST IMMEDIATELY STOP A HYPOGLYCEMIC REACTION and notify PCP bc may need different dose
• If hypoglycemic with an alpha glucosidase inhibitor, give glucose, and not sucrose (sugar) bc these drugs block absorption of sugar (sucrose)
• EXAMPLES
• acorbose
• miglitol
• Hypoglycemia more likely in eldery, ill,malnourished, debilitated
• Hypoglycemia more difficult to detect in elderly (and they are more prone).  

notify if above 200 or ketones in urine

a.oral antidiabetic no substitute for insulin

b.avoid alcohol and even strenuous exercise!  I wonder why

c.med ID

d.notify if sxs hypoglycemia, hyperglycemia, + results ketones, pregnancy, elevated glucose levels, serious illnesses

e.know how to tc hypoglycemia and hyperglycemia

f.edu re metformin lactic acidosis, dc use and notify, describe sxs 

Lower glucose levels by delatying card digestion/absorption

Carb blockers

increases insulin sensitivity of liver to decrease liver sugar production

also increases glucose uptake of muscles

Mimics amylin

Amylin is a hormone cosecreted with insulin from the pancreatic β-cells in the ratio of approximately 100:1. Amylin plays a role in glycemic regulation by slowing gastric emptying and promoting satiety, thereby preventing post-prandial spikes in blood glucose levels.

A nonsolfonylurea oral antidiabetic drug

meglitinides

What are they and what do they do?

• GI hormones
• Cause increase in insulin after eating, BEFORE blood glucose is elevated
• Slow gastric emptying, thereby reducing food intake
• Inhibit glucagon release of alpha cells of pancreas (glucagon triggers liver gluconeogenesis)

Head to Toe

General -- Fatigued, weak

Skin -- Diaphoretic (cool, moist, pale)

CNS -- Nervous, confused, agitated

HEENT-- Headache, dizzy, diplopia, lips/tongue tingling/numb

Respiratory -- Shallow breaths (or normal)

GI -- Hungry, nauseas

Can occur from too little insulin, or emotional stree, infection, surgery, pregnancy, acute illness

Gradual onset

glucose is above 200

drowsiness, dim vision

deep and rapid breating

thrist

N/V, ab pain, anorexia

skin id dry, flushed and warm

pulse is rapid and weak

acetone breath

excessive urination

• Is normally secreted by the alpha cells of the pancreas
• Given parenterally (IM, IV)
• Stimulates conversion of glycogen in liver to glucose
• Only useful if there is glycogen available in liver
• Taks 5-20 min

• Mailaise
• Abdominal pain
• rapid respirations
• SOB
• Muscular pain

• Should be bt 70 and 120 mg/dL

• At room temp, not in direct heat or light uf used within 1 month
• If refrigerated can be kept 3 months
• Prefilled only stable for a week under refrigeration;
• Keep vertical or oblique with needle upward to avoid plugging needle
• Slightly mix first

• Prep for admin – aseptic technique, how to hold, withdraw insulin, measure, mix, expel bubble, etc
• Admin – rotate sites, angle of admin, when to admin. 
• Site rotation to prevent injury to skin and fatty tissue
• Use upper/outer arms, stomach, except 2 inches around umbilical, just below waist, back, right and left sides, upper thighs, front and side
• From last site, place side of thumb and measure about an inch to select next site
• Use same area for about 10-15 injections, then go to another site

• Insulin needs may change with illness, esp. with vomiting and fever.  Also during stress, surgery, etc.  Contact PCP when these things occur.
• Know s/s of hypo/hyper-glycemia; must tell PCP immediately
• Know how to manage hypo/hyper-glycemia
• Important for good skin and foot care
• Frequent dental checkups
• Routine eye exams
• Moderate exercise and follow recommended diet

• Increased glucose
• Ketone in urine
• Pregnant
• Illness, vomiting, diarrhea
• New problems like ulcers, numbness, weight changes, etc

acarbose and miglitol

renal impairment

IBS

Crohn's

other GI disorders

edema

CV disease

liver or kidney disease

• Strengths of insulin
• Normally use U100
• U500 is 5 times as strong (more concentrated)
• Those who use U500 may have antibodies to insulin, requiring very strong insulin, for example

GLYCOSYLATED HEMOGLOBIN 

HbA1c Blood test

• Blood test to monitor average blood glucose over 3-4 month period
• When glucose high, attaches to hemoglobin of RBCs, and
• This lasts life of RBC which is about 4 months
• When well controlled, HbA1c should be normal or slightly elevated; when poorly controlled, levels of HbA1c are high
• Normal bt 2.5% and 6% indicate good control
• 10% or higher are poor control (for last 4 month)

For rapid onset and short-duration

Usually taken 10 minutes before mealtimes

Can be used in addition to other forms

Can cause cough, dry mouth, sore throat, chest discomfort, SOB

Cannot be used by those with breathing difficulties including smokers

• Rotate to prevent lipodystrophy (atrophy of subcut fat) which can interfere with insul absorption - less common with human insulins - slight indentation/dimple
• Arms, thigh, ab, butt 
• Absorption rates differs at diff sites, abdomen fastest, then upper arm, then thigh, then butt
• Some recommend rotating within same site for same absorb rate
• Plan injection site pattern, document and check before admin; document after admin where
• Inspect for inflame after injection, report if signs ASAP bc may need different insulin

infection

stress

fever

surgery

trauma

Januvia (sitagliptin) 

Byetta (exenatide)

glucose elevating agent (like glucagon)

 = Proglycem

HbA1C

Glycosylated Hemoglobin (how much sugar attached to hemoglobin)

Normal is 2.5%-5% glycosylated Hb

High is over 10%

Blocks absorption of sucrose

Must give glucose if hypglycemic

Increase insulin secretion

Must have some functioning pancreatic beta-cells

Normal is 2.5 to 6

Over 10% indicates poor control

Within 5 minutes of mixing

Do not mix glargine, will become ineffective

Caused by many insulin injections

Appearance

Reason is bad

LIPODYSTROPHY = atrophy of SQ fat

DIMPLES

INTERFERES WITH ABSORPION OF INSULIN

2 inches aroung umbilicus

Non CDI

malaise

abdominal pain

rapid RR and SOB

myalgia

r/t metformin (biguanide)