2 Insulin and Antidiabetic Drugs

When is insulin used? Who prescribes them?

• Required for Type 1

• Used in Type 2 and gestational

• Precribed by endocrinologist

When is a standing dose insulin used? Long acting?

• Standing dose → with meals

• Long-acting → at night

When are sliding scales used for insulin?

For short-acting → fix BS immediately

Rapid Acting Insulin?

• Examples?

• Onset?

• Peak?

• Duration?

• Examples? Lispro, Aspart, Gluisine (LAG)

• Onset: 15-30 mins

• Peak: 1-2 hours

• Duration: 4 hours

• Given per sliding scales ac and bedtime

• Used if there eat something that is super high in sugar and BS peaks quickly

• Wait until you have tray in room and in front of pt to give

Short Acting Insulin?

• Examples?

• Onset?

• Peak?

• Duration?

Regular insulin

• Onset: 1 hr

• Peak: 2-3 hours

• Duration: 4-6 hours

• Given per sliding scale

• Given when breakfast tray gets to floor

• Only insulins that can given IV push - make sure you flush well bc it tends to stick to tubing

• ** Give if going to surgery

Intermediate Acting Insulin

• Examples?

• Onset?

• Peak?

• Duration?

• Considerations?

• Examples? NPH

• Onset? 1.5 hour

• Peak? 4-12 hrs → usually 8, is when blood sugar drops

• Duration? 24 hours

• Considerations?

  • If patient takes NPH at breakfast (8 am) will peak around 4 → most people do not eat dinner at 4

    • Build in an afternoon snack into their diet bc NPH peaks in afternoon

  • Given twice a day at morning or night

  • Does not need to be given with meals

  • Take food around time of onset and peak

Long Acting Insulin?

• Examples?

• Onset?

• Peak?

• Duration?

Glargline, Lantus, detemir

• Onset: about 4-5 hours

• NO peak, stays steady

• Duration: 24 hrs

• Basal dose → given to try and keep glucose steady throughout whole day

• Often still on sliding scale with short or rapid acting in addition to basal dose

• Most of the time given in the evening towards bedtime

• Cannot be mixed

Lispro

• Rapid, intermediate, or long acting?

• Indication?

• Onset?

• Peak?

• Duration?

• Considerations?

• Rapid, intermediate, or long acting? Rapid

• Onset? Within 15 mins

• Peak? 1-2 hours

• Duration? 4 hours

• Considerations? Give when you see food tray

Aspart

• Rapid, intermediate, or long acting?

• Indication?

• Onset?

• Peak?

• Duration?

• Consideration?

• Rapid, intermediate, or long acting? Rapid

• Indication?

• Onset? Within 15 mins

• Peak? 1-3 hours

• Duration? 3-4 hours

• Considerations? Give when you see food tray

Glulisine

• Rapid, intermediate, or long acting?

• Indication?

• Onset?

• Peak?

• Duration?

• Considerations?

• Rapid, intermediate, or long acting? Rapid

• Indication?

  • Rapid reduction of glucose

  • Treat postprandial hyperglycemia

  • Prevent nocturnal hypoglycemia

• Onset? 5-15 min (within 15 min)

• Peak? 1 hr

• Duration? 5 hours

• Considerations? Give when you see food tray

Humulin R

• Rapid, intermediate, short, or long acting?

• Indication?

• Onset?

• Duration?

• Considerations?

• Rapid intermediate, or long acting? Short acting

• Indication?

  • Rapid reduction of glucose

  • Treat postprandial hyperglycemia

  • Prevent nocturnal hypoglycemia

• Onset? 45 mins

• Duration? 4-6 hrs

• Considerations?

  • Give if going to surgery

  • Can give before meals

  • Administed IV

Glargine/Lantus

• Rapid, intermediate, or long acting?

• Indication?

• Onset?

• Peak?

• Duration?

• Considerations?

• Rapid, intermediate, or long acting? Long

• Indication? Basal dose (long acting)

• Onset? 4-5 hrs

• Peak? Does not peak, continuous

• Duration? 24 hours

• Considerations?

  • Given once a day

  • Do not give long acting or intermediate if going to surgery

  • Brings down and maintains sugar steady

  • May need short or rapid dose

  • Give to patient if they only eat one meal a day and that stays steady

Afrezza

• Rapid, intermediate, or long acting?

• Onset?

• Peak?

• Duration?

• Considerations?

• Rapid, intermediate, or long acting? Rapid Inhaled Powder

• Onset? Less than 15 mins

• Peak? 1 hr

• Duration? 2-3 hours

• Considerations?

  • Administer at beginning of meal

  • Make sure food tray is there

  • Inhaled through lungs

  • Contraindicated for: smokers, chronic lung disease

When will we give anti diabetics and to who?

• For Type 2

• After exercise and diet has not been effective

** ”-ide” ending

• Examples?

• Actions?

• Side Effects?

• Considerations?

Second Gen Sul-fon-yl-ureas

“Sulfonylureas stimulate secretion”

• Glipizide, Glyburide, Glimepiride

• Actions? Stimulate beta cells to secrete more insulin

• Side Effects?

  • Weight gain

  • GI & hypoglycemia

• Considerations?

  • Contraindicated for sulfa allergy

  • Can block s+s of hypoglycemia with beta blockers → not a contraindication → just monitor BS more closely with BB (-lols)

  • Only work when taken with first bite of food

Metformin

• Actions?

• Side effects?

• Considerations?

Biguanides

• Actions?

  • Increases sensitivity to insulin

  • Inhibits glucose production by liver

• Side effects?

  • GI & hypoglycemia

• Considerations?

  • Don’t give for renal/liver impairments

  • Hold 48 hours before AND after contrast procedures (CT scan and Cath lab) → lactic acidosis

  • Only work when taken with first bite of food

Acarbose, Miglitol

• Examples?

• Actions?

• Side effects?

• Considerations?

Alpha- Glucosidase Inhibitors

Think “a-carb” → '“a” is without

• Actions?

  • Delay absorption of complex carbs in intestines

  • Does not alter insulin secretion

• Side effects?

  • GI & hypoglycemia

• Considerations?

  • Only works when taken with first bite of food

“-glinide” ending

• Examples?

• Actions?

• Side effects?

• Considerations?

Non- Sulfonylurea Insulin Secretagogues

• Examples? Repaglinide and Nateglinide

• Actions? Stimulates pancreas to secrete more insulin

• Side effects? Hypoglycemia

• Considerations?

  • Taken with each meal (quick onset, short duration)

  • Monitor liver/kidney

“-glitazone” ending

• Examples?

• Actions?

• Side effects?

• Considerations?

Thiazolidinediones

“-Glitazone gets glucose into the cell”

• Examples? Pioglitazone and Rosiglitazone

• Actions? Make tissue more sensitive to insulin → good for insulin resistance

• Side effects?

  • Anemia

  • Liver issues

  • Weight gain

  • Hypoglycemia

• Considerations?

  • Monitor liver for lipid level rise

  • Decreases effectiveness of oral contraceptives

“-gliptin” ending

• Actions?

• Side effects?

• Considerations?

DPP-4 Inhibitors

** Think “lips” for upper respiratory infection

• Actions? Increases hormonal release to increase insulin & decrease glucagon

• Side effects?

  • Monitor for upper respiratory infection and stuffy nose

  • GI & hypoglycemia

• Considerations?

  • Monitor kidneys

“-glutide” ending

• Actions?

• Side effects?

• Considerations?

GLP-1 Agonist

“-Glutide = gulp less”

• Actions? Enhances insulin secretions

• Side Effects

  • Pancreatitis

  • Weight loss due to GI disturbances (lots of N/V/D)

  • Doesn’t cause hypoglycemia as much bc it works over a week period → better at helping hemoglobin A1C

• Considerations?

  • Once a week SQ inj

“-gliflozin” ending

• Actions?

• Side effects?

• Considerations?

SGL-2 Inhibitors

“-Gliflozin” = glucose flows out in urine

• Actions? Prevents kidneys from reabsorbing glucose that it filters out

• Side effects?

  • UTI → kidneys filter out glucose → sits in tubules → UTI

  • May increase LDL (under 100) or HDL (over 60)

• Considerations?

  • Daily before first meal

Pranlintide

• Actions?

• Side effects?

• Considerations?

Amylin Agonist

• Actions?

  • For Type 1 and 2

  • Slows gastric emptying

  • Suppresses post-meal glucagon secretion

  • Increases satiety (feels full/bloated)

• Side effects?

  • Gastoparesis

  • N/V

  • Headache

• Considerations?

  • Given SQ - 2 inches from mealtime insulin inj

  • Given around or with insulin

If there is a peak time →

• Give plate of food

• Monitor for hypoglycemia during insulin peak time

Detemir lasts all year

GLARGine is LARGe-lasting

Lantus is like a lantern - burns all night

Long lasting insulins

• No peak

Regular insulin is ready to go IV

Short acting

Mnemonic for Rapid

“15 minutes feels like an hour during 4 rapid responses”

• Onset: 15

• Peak: 1-2 hr

• Duration: 4 hours

Mnemonic for Short

“Short staffed nurses go from 45 to (2) 4 or 6 patients”

• Onset: 45 mins

• Peak: 2 hours

• Duration: 4-6 hrs

Mnemonic for Intermediate

“Nurses Play Hero 2 (to) 8 and 24 year olds”

• Onset: 2 hrs (1.5 hrs)

• Peak: 8 hrs

• Duration: 24 hrs