Download File - Caring for Clients with Disorders of the Endocrine

ANTIDIABETIC AGENTS
INSULIN
O R A L H Y P O G LYC E M I C S
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 2005
Biosynthetic 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
Mechanism of Action
Exogenous insulin works the same as endogenous
insulin
Transports glucose FROM the blood to the INSIDE of
cells and
Takes excess glucose to the liver for storage
 This results in LOWERING of the blood
glucose level
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
Goal - maintain stable blood glucose
levels
ADMINISTRATION
Subcutaneous injection
 Syringe and needle
 Pen injectors
 Jet injectors
Inhalation
 Exubera
Subcutaneous infusion
 Portable insulin pumps
 Implantable insulin pumps
Intravenous infusion
ADVERSE EFFECTS
The most significant adverse effect is
HYPOGLYCEMIA
The signs & symptoms are the same for any
hypoglycemic reaction / state
BLOOD GLUCOSE MUST BE MONITORED
DOSAGE
INDIVIDUALIZED
Insulin 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 ACTING
Humalog (lispro) or (Novolog) aspart
Synthetic form
Clear solution
Can be given separately or mixed with intermediate or long acting
insulins
More rapid and shorter acting than human regular Insulin
Onset / Peak / Duration = 10 min / 1 -3 hr / 3-6 hrs
Administer within 10 – 15 minutes of a meal
Apidra (insulin glulisine)
Onset / Peak / Duration = 10-15 min / 1-1.5 hr / 3-5 hrs
Give within 15 min before meal
Can be used in insulin pump
Can be mixed with NPH for subcutaneous injection
SHORT DURATION
Regular Insulin
Humulin 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, inhalation
Administer 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
Intermediate Acting Insulins
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
PREMIXED INSULIN COMBINATIONS
Humalog Mix 75 – 25 (75% Lispro protamine
solution with 25 % Lispro solution)
Rapid onset with intermediate duration
Onset
/
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 INSULINS
Insulin detemir (Levemir)
 Onset / Peak / Duration
/
6-8 / 12-24
Slow onset and dose dependent duration
Provides basal glycemic control
As compared with NPH, has slower onset and longer
duration
Clear solution
Administered 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 LENTE
Long lasting basal insulin
Slow 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 usually
Steady absorption - NO PRONOUNCED PEAK
Works 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 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’s
SAFE PRACTICE FOR INSULIN ADMINISTRATION
BEFORE ADMINISTERING:
Check the original doctor’s order
KNOW 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 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 MUST be DOUBLE CHECKED by a second LISCENED person
administer insulin only with an insulin syringe calibrated for that concentration of insulin
BEFORE ADMINISTERING:
 check the original doctor’s order
 KNOW 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 ROTATE 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)
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 Order
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 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:
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?
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:
STIMULATE the pancreas to produce more insulin
DECREASE glucose production
INCREASE glucose uptake by the cell by enhancing the effectiveness of insulin
Oral hypoglycemics are usually only given to Type II diabetics
SULFONYLUREA ORAL HYPOGLYCEMICS:
SECOND GENERATION
EXAMPLES Diabeta, Micronase (glyburide); Glucotrol (glipizide),
Amaryl (glimepiride)
Action: Lowers blood sugar by stimulating the release of insulin
from beta cells of the pancreas
Adverse reactions: hypoglycemia, 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:
Decreases glucose released from liver
Decreases intestinal absorption of glucose, metformin
Improves insulin sensitivity
Resulting in improved blood glucose control
USES:
Type II diabetes
May be combined with other antidiabetic agents
SIDE / ADVERSE EFFECTS:
Primarily GI effects - bloating, nausea, cramping, diarrhea
Advantage: Does not cause hypoglycemia, does not cause wt gain,
favorable effect on triglycerides
Increased 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) Avandia
Pioglitazone (pie-oh-GLIT-uh-zone) Actos
Action:
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 cramps
SE unexpected: hypoglycemia, hepatotoxicity, wt. gain
Drug Interactions: Beta Blockers ay ask signs of
hypoglycemia, may cause BC pills to be ineffective
DRUG INTERACTIONS
There are 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
medication regime
signs / symptoms (hypo & hyper glycemia)
blood glucose monitoring
avoidance of alcohol
medic alert identification
measures to deal with sun exposure
(sulfonylureas)
• follow up care
•
•
•
•
•
•

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%
HBA1C: GLYCOSYLATED
HEMOGLOBIN A1C
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
GLUCOSE
TESTING
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