-most common, some beta cell production, some insulin secretion

-tx w/ oral hypoglycemics

-pregnancy induced by hormone changes

-may disappear after pregnancy, but some develop DM

-protein secreted from beta cells in pancreas

-0.2-0.5 units/kg/day; the higher caloric intake, the more insulin secreted (obesity, stress, tissue insulin resistance)

-promotes uptake of glucose, converts to glycogen & stored in liver & muscle

-Normal serum glucose is 70-110; >180=glycosuria, polyuria

-beef/pork insulin (less allergenic)

-human insulin (DNA technology)-absorbed faster, shorter duration than beef/pork

-100 units/mL or 500 units/mL

-roll vial, don't shake

-WATCH HERBALS

-SQ or IV (only Regular), never oral (destroyed by gastric secretions)

-45-90 degree angle SQ

-heat/massage ^ absorption, cooling decreases absorption

-greatest absorption in abd & deltoid; thigh & buttock=lesser absorption

-rotate injection sites to avoid lipodystrophy (more common in women & children)

-lipohypertrophy-raised bump/knot (more common in males)

-illness/stress increase demands for insulin; do not hold for illness

-rapid-acting

-short-acting

-intermediate-acting

-long-acting

-combination

-hypoglycemia w/ aspirin, warfarin, alcohol, oral hypoglycemic, beta-blockers, TCA, MAOI, tetracycline

-hyperglycemia w/ thiazides, steroids, oral contraceptives, thyroid drugs, smoking

-clear

-give no more than 5 mins before meal

-onset is 5-15 mins, peak is 30-60 mins, duration is 3-4 hours

-need intermediate type also to control glucose

-lispro (Humalog), insulin aspart (Novolog)

-clear

-give 30 mins before meal

-onset 30-60 mins, peak 2-4 hours, duration 6-8 hours

-Humulin R - SQ & IV

-cloudy

-give in AM

-onset 1-2 hours, peak 6-12 hours, duration 18-24 hours

-NPH, Humulin N (protamine)-prolongs action, Lente, Humulin L (zinc)-slows onset & prolongs action,

-Lantus

-Levemir

-long-acting insulin

-given at bedtime

-onset 1 hour, no peak, duration 24 hours

-pre-filled pen said to be more painful

-long-acting insulin

-peaks 6-8 hours, duration 12-24 hours

-pre-filled pen

-do not need to refrigerate insulin pens for 10 days (hospital)

-Humulin 70/30 (70% NPH, 30% Regular)

-Novolin 70/30, Humulin 50/50, Humalog 75/25

-antibodies develop over time, slowing onset of action & extending duration

-obesity contributes to insulin resistance

-can also develop insulin allergy (Human & Regular insulins have less allergic response)

-unopened vial are refrigerated

-opened vials kept at room temp for 4 weeks, 12 weeks in refrigerator

-less irritating to tissues if injected at room temp

-DO NOT FREEZE, do not place in heat/direct sunlight

-prefilled syringes kept in refrigerator and used w/ in 1-2 weeks (at home)

-blood glucose checked before meals & bedtime

-insulin dose given according to glucose level

-rapid or short-acting insulin used for sliding scale (coverage)

-occurs when more insulin is administered than what is needed

-s/s: nervous, trembling, cold/clammy skin, headache, lack of coordination, foggy thinking, combative, incoherent

-blood sugar < 60

-Tx: IV or oral glucose

-hyperglycemia on awakening

-headache, night sweats, nightmares

-increase bedtime insulin

-hypoglycemia at 2-4 am

-reduce bedtime insulin

-fatty acids (ketones) are being used for energy due to sugar not being utilized

-s/s: thirst, polyuria, fruity breath, rapid & thready pulse, dry mucous membranes, Kussmaul respirations (deep, rapid, labored)

-blood sugar > 250

-looks like fountain pen, more $$

-disposable, insulin-filled syringe

-disposable needle

-151-300 units in pen

-examples: Novolog Flex-Pen, Lantus Solostar, Humalog-Pen, Apidra OptiClik, Levemir FlexPen

-external; needle SQ in abd, upper thigh, upper arm

-continuous SQ insulin infusion (CSII)

-battery operated

-Regular insulin only

-basal insulin (usually 3/day) w/ boluses for meals

-programmed by patient

-can be disconnected to bathe, swim; not for more than 1-2 hours

-even glucose levels w/ less hypoglycemia & long-term complications

-delivered w/o needle

-sting, burning

-not for children or elderly

-$$

-surgically implanted in abd (intraperitoneal or IV)

-delivers basal insulin and bolus doses w/ meals

-controlled glucose levels, less hypoglycemia

-for Type II Diabetes only

-1st & 2nd generation Sulfonylureas

-nonsulfonylureas

-alpha-glucosidase inhibitors

-thiazolidinediones

-meglitinides

-incretin modifier

-not common anymore

-stimulate beta cells in pancreas to secrete more insulin

-contraindicated in pregancy, lactation, DKA, infection/stress

-no alcohol...severe hypoglycemia

-warfarin, ASA, MAO, some NSAID (increase action)

-phenytoin, warfarin, steroids, INH (decrease action)

-Short-acting: tolbutamide (Orinase)-500-3000 mg/day in 2-3 doses

-Intermediate-acting: acetohexamide (Dymelor)-251 mg/day before breakfast

-tolazamide (Tolinase)-100-251 mg/day

-Long-acting: chlorpropamide (Diabinese)-100-510 mg/day; may cause fluid retention

-more common, work better than 1st generation

-increase tissue response to insulin

-decrease glucose production by liver

-greater hypoglycemic potential than 1st generation (elderly)

-longer duration, fewer side effects

-do not use w/ liver/renal issues

-less protein-binding issues w/ warfarin, ASA

-No alcohol

-drug-drug: same as 1st generation

-2nd generation sulfonylureas, directly stimulate beta cells

-improves post-prandial levels

-used w/ insulin in Type II

-SE: abd cramping, diarrhea

-biguanides

-alpha-glucosidase inhibitors

-thiazolidinediones

-meglitinides

-incretin modifier

-decreases liver production of glucose from stored glycogen

-decreases glucose absorption from small intestine

-increases insulin receptor sensitivity

-does not produce hyper- or hypoglycemia

-do not use w/ renal insufficiency

-hold drug 48 hours before & after IV contrast dye due to lactic acidosis or ARF

-dose: 510 mg qd, increase slowly

-SE: bloating, cramping, diarrhea

-adverse: malabsorption of B12

-many drug-drug reactions

-inhibits enzyme in small intestine that releases glucose from complex carbs in diet; cannot absorb carbs & are passed through to large intestine

-no systemic effects

-used in conjunction w/ diet, 25 mg w/ meals

-absorbed from GI tract

-does not cause hypoglycemia unless taken w/ insulin or sulfonylurea

-25-100 mg w/ meals

-SE: GI

-decrease insulin resistance & improve glucose control

-Actos, Avandia

-may be combined w/ insulin or sulfonylureas

-SE: hepatotoxic; monitor LFTs

-may be combined w/ metformin (Avandamet)

-SE: hepatotoxic, monitor LFTs, recent increase in cardiac deaths

-stimulate beta cells to release insulin

-short-acting

-do not use w/ liver dysfunction

-repaglinide (Prandin), nateglinide (Starlix); take before meals, may use w/ metformin (Glucophage)

-increase insulin secretion, reduce glucagon secretion

-reduces fasting & postprandial glucose levels

-sitagliptin (Januvia)-100 mg qd

-antidiabetic agent; improves beta-cell response

-injectable, not insulin, mimics incretin

-slows gastric emptying

-suppresses appetite --> weight loss

-SE: jittery

-5-10 mcg SQ before meal

-antidiabetic agent

-never given in arm

-emergency hyperglycemic agent

-treat insulin-induced hypoglycemia

-SQ, IM, IV; onset 5-20 mins

-hyperglycemic agent, related to thiazides

-treat hypoglycemia due to islet cell (pancreatic) cancer or hyperplasia