·    Carbohydrate, fat, and protein metabolism are all affected by diabetes

·    All people with type 1 diabetes require insulin for management of blood glucose

·    People with type 2 diabetes require insulin when undergoing surgery, experiencing high levels of physiologic stress (e.g. infection), and during pregnancy.

·    Insulin is classified two ways:

·     Type – How it’s made

·   Natural or regular

·   Addition of protein to prolong duration (NPH)

·     Insulin analogs

·   Lispro and Aspart insulins have shorter durations than Regular insulin

·   Glargine insulin has a longer duration than Regular insulin.

·     Group – Time-course-of-action

·    Oral hypoglycemics used for type 2 diabetes when diet/exercise are not enough

Agent

Adverse Effect

Sulfonylureas

Meglitinides (fast, short-lived)

1^st generation

Repaglinide (Prandin)

Tolbutamide (Orinase)

(30m ac 1^st meal) (ò risk hypo)

Chlorpropamide (Diabinese)

2^nd generation (ñ duration)

Biguanides (take ĉ food)

Glipizide (Glucotrol) – 30 min ac 1^st meal

Metformin (Glucophage)

Glyburide (DiaBeta) – QD with 1^st meal

(Don’t promote insulin release \ don’t - hypoglycemia)

Glimepiride (Amaryl) – QD with 1^st meal

Thiazolidinediones

α-Glucosidase Inhibitor

Rosiglitazone (Avandia)

Acarbose (Precose)

(Given ŝ regard to food, usually 1x/day)

(With 1^st bit at 3 meals/day)

Type

Duration

Route

Time

Onset

Peak

Lispro

(Humalog)

Short, Quick

(3 - 6 h)

SC / Pump

15 m ac

15 – 30 m

½ – 2½ hr

Aspart

(Novolog)

Short, Quick

(3 – 5 h)

SC / Pump

5-10 m ac

10 – 20 m

1 – 3 hr

Regular

(Humulin R)

Short, Slower

(6 – 10 h)

SC / Pump / IH / IM / IV

30 m ac

30 – 60 m

1 – 5 hr

NPH

(Humulin N)

Intermediate

(16 – 24 h)

SC

2x/day

(same time)

1 – 2 hr

6 – 14 hr

Glargine

(Lantus)

Long

(24 h)

SC

1x/day

(same time)

70 min

None

·  Insulin: promotes cellular GLC uptake // GLC-GLYC // moves K⁺ into cells

·  Type 2 may need insulin: severe renal/liver disease // neuropathy // Severe stress

·  Insulin also used: Tx of hyperkalemia // Tx of DKA and HHNS.

Adverse Effects:

·  Hypoglycemia

·  Lipohypertrophy

Contraindications/Precautions:

♀ (?)

[image]  Only regular insulin by IV

Interactions:

·   

·  Additive GLC decrease effect with sulfonylurea, meglitinides, β-blocker, EtOH

·  Thiazide diuretics, glucocorticoids  -decrease glucose-reducing effects

Education:

·   

·  When mixing short-acting and long-acting - draw short-acting first and then longer-acting in order to keep longer-acting from contaminating shorter-acting.

·  Disperse particles in suspension before drawing insulin.

·  Glargine is never IV and should not be mixed

·  Use one general area to produce consistent results (rate inc thigh-arm-abdomen)

·  GLC 90-130 mg/dL preprandial, < 180 mg/dL postprandial. HgA1c < 7%

Expected Action:

Proto: 1^st – tolbutamide / 2^nd – glipizide

Others: 1^st – chlorpropamide, 2^nd – glyburide

·  Promote insulin release from the pancreas

Therapeutic Uses:

·  With diet/exercise, control blood GLC in type 2 diabetes

Adverse Effects:

·  Hypoglycemia (abrupt-SNS / slow-CNS symptoms)

Contraindications/Precautions:

♀ (C)

[image]   Pregnancy/lactation

[image]   Diabetic ketoacidosis

[image]  Renal/liver dysfunction

Interactions:

·  EtOH: disulfiram-like reaction

·  EtOH, NSAIDs, sulfonamides, ranitidine, cimetidine - additive hypoglycemic

·  Concurrent use of β-blockers may mask awareness of hypoglycemic, specifically SNS symptoms of tachycardia, palpitations, and diaphoresis.

Education:

·   

·  GLC 90-130 mg/dL preprandial, < 180 mg/dL postprandial. HgA1c < 7%

Expected Action:

Proto: repaglinide (Prandin) — Others: nateglinide (Starlix)

·  Promote insulin release from pancreas

Therapeutic Uses:

·  Type 2 diabetes, with diet and exercise

·  Often use with metformin

Adverse Effects:

·  Hypoglycemia

·   

Contraindications/Precautions:

♀ (C)

[image]   Diabetic ketoacidosis

[image]  Hepatic dysfunction

Interactions:

·   

·  Gemfibrozil (Lopid) - inhibition of repaglinide metabolism

Education:

·   

·  GLC 90-130 mg/dL preprandial, < 180 mg/dL postprandial. HgA1c < 7%

Expected Action:

Proto: Metformin (Glucophage)

·  Inhibit gluconeogenesis in liver

·  inc. muscular uptake and use of glucose

Therapeutic Uses:

·  Type 2 diabetes

·  Polycystic ovarian syndrome (PCOS)

Adverse Effects:

·  GI effects (nausea, vomiting, weight loss 6-8 lb)

·  Vitamin B₁₂ and folate deficiency d/t altered absorption

·  Lactic acidosis (hyperventilation, myalgia, sluggishness) – 50% mortality

Contraindications/Precautions:

♀ (B)

   Diabetic ketoacidosis

   Renal, hepatic, cardiac failure

   Severe infection, shock, hypoxia

Interactions:

·  EtOH - inc. risk lactic acidosis with concurrent use

Education:

·   

·  GLC 90-130 mg/dL preprandial, < 180 mg/dL postprandial. HgA1c < 7%

Expected Action:

Proto: rosiglitazone (Avandia) — Others: pioglitazone (Actos)

·  Increased cellular response to insulin by dec. insulin resistance

Therapeutic Uses:

·  Type 2 diabetes with diet and exercise

Adverse Effects:

·  Fluid retention

·  inc. LDL

·  Hepatotoxicity

Contraindications/Precautions:

♀ (C)

   DKA & heart failure

  Mild heart failure d/t fluid retention effects

Interactions:

·  Insulin - inc. risk for hypoglycemia

·  Gemfibrozil (Lopid) -V metabolism of rosiglitazone - inc.hypoglycemia

Education:

·   

·  GLC 90-130 mg/dL preprandial, < 180 mg/dL postprandial. HgA1c < 7%

Expected Action:

Proto: acarbose (Precose) — Others: miglitol (Glyset)

·  Slow carbohydrate absorption and digestion

Therapeutic Uses:

·  Control postprandial blood sugar in type 2 diabetes

Adverse Effects:

·  Risk for anemia d/t  dec. iron absorption

·  Hepatotoxicity with long-term use

·  Intestinal effects (abdominal distention, cramping, hyperactive bowel sounds, diarrhea, flatulence)

Contraindications/Precautions:

♀ (B)

   Diabetic ketoacidosis

   GI disorders (inflammatory disease, ulceration, obstruction)

Interactions:

·  Insulin, sulfonylureas -inc. risk of hypoglycemia

·  Metformin - Additive GI effects and risk for hypoglycemia with concurrent use.

Education:

·  Take medication with first bite.

·  Postprandial blood glucose < 180 mg/dL

·  HgA1c < 7%

Expected Action:

Proto: Glucagon

·  inc. glycogenolysis

·  dec. glycogenesis

·  inc.gluconeogenesis

Therapeutic Uses:

·  Hypoglycemia 2º insulin overdose

·  dec. GI motility while undergoing radiological procedures of stomach / intestines

Adverse Effects:

·  GI distress (turn on left side to dec. risk of aspiration)

Contraindications/Precautions:

♀ (?)

[image]    

   Pheochromocytoma d/t catecholamine stimulating effects

·  Ineffective for starvation-related hypoglycemia because depleted glycogen stores.

Education:

·  Provide food as soon as patient is able to eat.

Expected Action:

Proto: levothyroxine (Synthroid) — Others: liothyronine, liotrix

·  Synthetic thyroxine - inc. metabolic rate, protein synthesis, cardiac output, renal perfusion, oxygen use, body temperature, blood volume, and growth processes.

Therapeutic Uses:

·  Hypothyroidism (all forms)

·  Emergency treatment of myxedema coma by IV

Adverse Effects:

·   

·  Hyperthyroidism (anxiety, tachycardia, palpitations, inc. appetite, heat intolerance, fever, diaphoresis, and weight loss)

Contraindications/Precautions:

♀ (A)

   Thyrotoxicosis and MI

  Cardiovascular problems and pregnancy

Interactions:

·  Levothyroxine breaks down vitamin K - inc. Warfarin effects

·  Many antiseizure and antidepressant meds like carbamazepine, phenytoin, phenobarbital, sertraline  inc. levothyroxine metabolism

·  Binding agents (iron, calcium, antacids, cholestyramine)and sucralfate dec. levothyroxine absorption

Expected Action:

Proto: propylthiouracil — Others: methimazole (Tapazole)

·  Block thyroid hormone synthesis // Prevent oxidation of Iodine // V T₄ - T₃

Therapeutic Uses:

·  Grave’s disease

·  Adjunct to thyroid irradiation

·  Produce euthyroid state prior to thyroid removal

·  Emergency thyrotoxicosis treatment

Adverse Effects:

·  Overmedication -hypothyroidism - (drowsiness, weight gain, edema, bradycardia, cold intolerance, dry skin)

·  Agranulocytosis - Monitor for early signs (fever, pharyngitis) -Tx: Neupogen

Contraindications/Precautions:

♀ (D)

[image]   Pregnancy

[image]  Marrow depression or immunosuppression

Interactions:

·  inc. anticoagulant effects

Education:

·  Take at consistent time and with meals (dec. GI distress)

·  Hyperthyroidism may get β-adrenergic blocker (propranolol) to dec. tremors

Expected Action:

Proto: Radioactive iodine

·  Destroys thyroid cells at high doses

Therapeutic Uses:

·  Hyperthyroidism (inc. dose)

·  Thyroid cancer inc. dose)

·  ò doses: Thyroid function studies

Adverse Effects:

·  Marrow suppression (anemia, leukopenia, thrombocytopenia)

·  Radiation sickness: Hematemesis, epistaxis, intense nausea, vomiting

Contraindications/Precautions:

♀ (X)

[image]   Pregnancy, childbearing age, lactation

Interactions:

·  Reduced uptake with antithyroid meds

Education:

·  Take on empty stomach

·  Void frequently // Limit contact to ½ hr/day/person // inc. fluids

·  Dispose of body wastes per protocol

·  Avoid coughing and expectorating

Expected Action:

Proto: strong iodine solution (Lugol’s solution) — Others: sodium iodide, potassium iodide

·  inc iodide levels - dec. uptake (by thyroid), stops thyroid hormone production, and block release of thyroid hormones into blood stream.

Therapeutic Uses:

·  Development of euthyroid state and dec. size prior to removal

·  Emergency treatment of thyrotoxicosis

Adverse Effects:

·   

·  Iodism symptoms d/t corrosive property (metallic taste, stomatitis, sore teeth and gums, gastric distress). – drink through straw // take ĉ food // OD prevention

Contraindications/Precautions:

♀ (D)

[image]   Pregnancy

Interactions:

·  Foods high in iodine (fish, salt) - Risk for iodism

Education:

·  Dilute Lugol’s solution with juice to improve taste.

Expected Action:

Proto: Somatropin — Others: Somatrem (Protropin)

·  Stimulate overall growth, production of proteins, and dec. use of glucose

Therapeutic Uses:

·  Growth hormone deficiencies

·  Bulking up so you can hit the long ball...

Adverse Effects:

·  Hyperglycemia (polyphagia, polydipsia, polyuria)

Contraindications/Precautions:

♀ (C)

[image]   Obese or respiratory impairment

[image]  Diabetes = Risk for hyperglycemia

[image]  D/c Tx before epiphyseal closure

Interactions:

·  Glucocorticoids can counteract growth-promoting effects

Education:

·  IM or SC (less painful)

Expected Action:

Proto: vasopressin (Pitressin) — Others: desmopressin (DDAVP)

·  Promote H₂O reabsorption in kidneys (desmopressin preferred)

·  Vasoconstriction due to smooth muscle contraction (vasopressin)

Therapeutic Uses:

·  Diabetes insipidus

·  Cardiac arrest

Adverse Effects:

·  Overhydration (sleepiness, pounding headache)

Contraindications/Precautions:

♀ (X)

[image]   Pregnancy

[image]   CAD or dec. peripheral circulation (risk for gangrene)

Education:

·  Monitor site carefully; extravasation can cause gangrene.