RASMUSSEN iCOLLEGE iPHARMACOLOGY iCONCEPTiREVIEW i#2 o Non-insulin-dependentiDM • Normal iBlood iglucose i70-100 • Major isymptoms o Polyuria ▪ Peeingiailot o Polydipsia ▪ Drinkia ilot o Polyphagia ▪ Eatingiailot • Managing ihypoglycemia o Diazoxide ▪ Used iforipatients iwith iChronic ihypoglycemia icaused iby ihyperinsulinism ▪ Not i indicated ifor i hypoglycemic ireaction o Dextrose ▪ Given iIV ▪ Insulin-induced ihypoglycemia o Glucagon ▪ When iitishould ibe iadministered • SubiQi–iwhen iptihas ilosticonsciousness • Feedithemi–iifiptiis istilliawake o i Orange ijuice ▪ Routes • Sub iQ ▪ Assessments ipre iand ipost iadministration • Check iblood isugar • Whatithey ieat ▪ Frequency iofiblood iglucose ichecks • Before iyou igiveiitiandiafteriyourigive iiti–imonitor o i Assessing iitiand iactions • Insulin o Action:iPromoteiuse iofiglucose iby ibody icells,istore iglucose ias iglycogen iinimuscles o Use:iReduceibloodiglucose,icontrolidiabetes imellitus iTypei1 o Interactions ▪ Increase i glucose iwith ithiazides, i glucocorticoids, iestrogen,ithyroid idrugs ▪ Decrease iglucose iwith iTCAs,iMAOIs,iaspirin,ioralianticoagulants o SideiEffects ▪ Low iBlood iSugar,iRash,iWeightiGain i–iwhen ifirstistarting ito iuseiit,iScarringiatinjectionisiteiifisitesiareinotirotatediwell ▪ Hypoglycemia, iinsulin ishock • Tooimuchiinsulin • Nervousness, itremors • Lack iof icoordination • Cold,iclammy iskin • Headache,iconfusion ▪ Somogyiieffect 1 2 • Occurs iin ipredawn ihours • Rapid idecrease iin iblood iglucose iduring inight istimulates ihormonal irelease ito iincrease ibloodiglucose ▪ Lipodystrophy • Lipoatrophyi–idivots • Lipohypertrophy i–ilittleifatibumps ▪ Dawn iphenomenon • Hyperglycemia iupon iawakening • Symptoms o i Headache, inight isweats, inightmares ▪ Diabeticiketoacidosis • Hyperglycemia o Patient iteaching ▪ Teachipatients itoirecognize iandiimmediately ireportisymptoms iofihypoglycemic i(insulin)ireaction—such ias iheadache, inervousness, isweating, itremors, irapid ipulse—and ithose iof ihyperglycemic ireactioni(diabetic iacidosis):ithirst,iincreased iurine ioutput, iand ia isweet, ifruity ibreath iodor. ▪ Adviseipatientsithatihypoglycemicireactionsiareimoreilikelyito ioccuriduring ipeak iaction itime.iMostidiabetic ipatients iknow iwhether ithey iare ihaving ia ihypoglycemic ireaction, ibut isome ihave ia ihigher itolerance ito ilow iblood iglucose iand ican ihave ia isevere ireaction iwithout irealizing iit. ▪ Explainithatiorangeijuice, isugar-containingidrinks, iandihard icandy imayibeiusediwheniaihypoglycemicireactionibegins. ▪ Teachifamilyimembersitoiadministeriglucagonibyiinjectioniif iaipatientihasiaihypoglycemic ireactioniandicannotidrink isugar-icontaining ifluid. ▪ Inform ipatients ithaticertain iherbs imay iinteractiwith iinsulin iand ioral iantidiabetic idrugs.iA ihypoglycemic ior ihyperglycemic ieffectimightioccuri(Complementary iandiAlternative iTherapies i47.1). ▪ Teachipatients iaboutithe inecessity ioficompliance iwith iprescribed iinsulin itherapy iand idiet. iHbA1c iprovides itheimost iaccurate ipicture iof ioptimal idiabetic icontrol. ▪ Advise ipatients ito icarry ia iMedicAlerticard,itag,ior ibraceletithatiindicates itheihealthiproblemianditheiinsulin idosage. • Self-Administration o Instructipatients ionihowitoicheck ibloodiglucose iwith iaiglucometeri(OneTouch iAccuSure, iGlucoSure,iAccu- iChek). o Teachipatientsiaboutitheicareiofiinsulin icontainers iand isyringes. ▪ InformipatientsitakingiNPHiinsuliniwithiregular insulinithatiregulariinsuliniisidrawniupibefore iNPH iinsulin. • Diet o Adviseipatients itakingiinsulinitoieatitheiprescribed idietioniaiconsistentischedule.iDietiinformation imay ibe iobtained ifrom ithe iADA iorifrom ia inutritionist. o Onset, ipeak iand iduration iof iregular, iNovolog/Humalog, iNPH, iLantus,iLevimer ▪ Rapid-actingiinsulini(clear) • Insulin ilispro, i insulin iaspart, i insulin iglulisine, ioralinhalation iinsulin o Onset iof iaction: i5-30 imin o Peaki30imin:i–i1.5ihrs 2 3 o Duration:i3-5 ihrs ▪ Short-actingiinsulini(clear) • Regular o Onsetiof iaction: i0.5-1 ihr o Peak:i2-5 ihrs o Duration: i4-12 ihrs ▪ Intermediate-acting i(cloudy) • Insulin iisophane iNPH o Onsetiofiaction:i1-2 ihrs o Peak:i4-12ihrs o Duration: i14-24 ihrs ▪ Long-acting • Insulin iglargine o Onsetiofiaction:i1-2 ihrs o Duration:i6-8 ihrs o Administered iatibedtime i-i24 ihrs o Mixing iinsulins iand iobservations ifor ihypoglycemia ▪ Composed iof i short- iand i intermediate-acting • Rapid-i(FIRST)iand iintermediate-acting o Pre-mix ▪ NPHi70/regulari30 ▪ NPHi50/regulari50 ▪ Storage iof i insulin • Keep iin irefrigeratoriuntil iopened. • Avoidistoring iinsuliniinidirectisunlightioriatihigh itemperatures. • Neverishakeiinsulini–ialwaysiroll o Interpreting isliding iscales ▪ Adjusted idoses idependention iindividual iblood iglucose ▪ Monitoribloodiglucose. • Beforeimealsiandiatibedtime ▪ Involves irapidiorishort-acting iinsulin ▪ EX: iIf ibelow i60, inotify iMD • Ifi60i–i124,inoicoverage iIfi125 i–i150,igive itwo iunits If 151 – 200, igive ifour iunits iIf i201 –i250,igiveisixiunits Ifi251i–i300,igiveieightiunits Ifioveri300 inotify ithe iphysician • Oral iantidiabetic iagents o i UseditoitreatiType i2iDiabetes o Notiused iin ipregnancy i(woman imustitake iinsulin) o Notiused iin itype i1 idiabetes o Howitheyiwork ▪ Stimulate ipancreatic ibeta icells ito isecrete imore i insulin ▪ Increase itissue iresponse ito iinsulin ▪ Decrease iin iglucose iproduction o Special iconcerns i(1st idose ihypoglycemia,ietc.) ▪ Criteria ito igo ion ioral iantidiabetic • Onsetiofidiabetes imellitus iatiage i40 iyears ioriolder • Diagnosis iofidiabetes iforiless ithan ifive iyears • Normaliweightiorioverweight • Fasting iblood iglucose i200 img/dL ioriless • Less ithan i40 iunits iofiinsulin irequired iperiday • Normalirenaliandihepaticifunctio