PHARMEXAM1(diabetes)

What is diabetes

What is diabetes

a disorder of carbohydrate metabolism

Type I & Insulin

deficiency of insulin (NOT PRODUCING)

Type II & Insulin

resistance to action of insulin

• may produce → but insulin doesn’t work as well

What is Type I Diabetes?

Most common in children

• destruction of pancreatic beta cells

• decrease insulin levels (early in disease) → soon they will fall to zero

  • RISK FOR KETOACIDOSIS

What is Type II Diabetes?

• insulin resistance/impaired insulin secretion (making it & NOT releasing it)

• overtime hyperglycemia leads to reduced beta cell function

  • little risk for ketoacidosis

Diabetes Short Term Complications

• hyperglycemia & hypoglycemia

Diabetes Long Term Complications

• macro vascular

• Heart Disease

• hypertension

• stroke

bc of the amount of glucose → makes blood more viscous

Diabetes Long Term Complications

• microvascular

• retinopathy

• nephropathy

• gastroparesis

• amputations

• neuropathy

  • erectile dysfunction

Diagnosing Diabetes

• check glucose levels

• x-cessive plasma glucose

  • PT must be tested on 2 separate days and must be (+) on both

What are the 3 tests for diagnosing diabetes

• fasting plasma glucose (FPG) ≥126mg/dL

• causal plasma glucose ≥200mg/dL (plus symptoms of diabetes)

  • take after eating

• oral glucose tolerance (OGTT): 2 Hr plasma glucose ≥200mg/dL

What does Hemoglobin A1C determine

avg. blood glucose level over a period of time/long terms glycemic control

• (2-3months)

What A1C Value is considered a diagnostic of diabetes

≥ 6.5%

Primary Treatment Goal

• prevention of complications

• maintain glycemic control (70-130mg/dL b4 meals)

• Target A1C levels 6.5%

Type I & II Treatment

• diet

• exercise

• insulin replacement

• monitoring treatment

  • self-monitoring blood glucose level

Short Duration (rapid action) Insulins

Starts working in 5-15min

• insulin lispro (humalog)

• insulin aspart (novalog)

• insulin glulisine (apidra)

Short Duration (slow acting) Insulin

regular insulin

Starts working in 30 min

• Humulin R

  • Novalin R

Intermediate Duration

Takes 90 min to work

• insulin glargine

• U100 (lantus)

• insulin detemir (levemir)

Long Duration

starts working in 6 hrs

lasts 24hr

• insuluin glargine

• U300 (toujeo)

• insulin degludee (tresiba)

If you give insulin @ the peak what do you put the PT at risk for?

@ risk for hypoglycemia

What Insulins can you mix?

• NHP & Regular

• NHP & lispro

• NPH & aspart

• NPH & glulisine

How do you draw up insulins when mixing

draw clear to cloudy

• short acting can go into long acting

Insulin Administration

• SQ: syringe & needle, pen injectables, jet injectors

• SQ Infusion: portable insulin pump, implantable insulin pump

• IV infusion

  • Inhalation

Rapid Acting onset/peak/duration

onset: 15 min

peak: 1 hr

duration: 3 hr

Short Acting onset/peak/duration

onset: 30 min

peak: 2 hr

duration: 8 hr

Intermediate Acting onset/peak/duration

onset: 2 hrs

peak: 8 hrs

duration: 16 hrs

Long Acting onset/peak/duration

onset: 2 hr

peak: NONE

duration: 24 -48 hrs

Storage of Insulin

• Unopened Vial: stored in fridge

• Open vials: can be stored up to 1 mo. w/o significant loss of activity

• always write time & date when vial is opened

• prefilled syringe should be kept in fridge

What is insulin used for in diabetes?

tight glucose control

• attention

• motivation

• education

• defined glycemic target

Increased Insulin Needs…

• increased calorie intake

• infection

• obesity

• stress

• adolescent growth spurt

• pregnancy (after 1st trimester)

Decreased Insulin Needs…

• decrease calorie intake

• increase physical activity

• 1st trimester of pregnancy

Diabetes Complications

• hypoglycemia

• hypokalemia

• lipodystrophy (A loss and/or redistribution of body fat)

  • rotate injection site

Oral Agents Type II Diabetes

• Biguanaides

Metformin (glucophage)

• type of choice for INITIAL therapy

• started immediately

• used alone of in combo

Metformin’s Mechanism of Action

• lowers blood sugar

• inhibits glucose production in liver

• increases cell ability to take in glucose whenever insulin is present

• decreases the amount of blood sugar that the liver produces and that the intestines or stomach absorb.

Metformin Pharmacokinetics

• absorbed from small intestine

• excreted (unchanged) by the kidney

Metformin Side Effects

• ↓ appetite

• nausea

• diarrhea

• ↓ B12 absorption

• ↓ folic acid absorption

Metformin Toxicity

lactic acidosis

Metformin Drug Interactions

• alcohol (dangerously lowers BS)

• iodinated Radiocontrast Media

Sulfonylureas

• first generation

tolbutamide (orinase)

Sulfonylureas

• second generation

• Glipizide (glucontrol)

• Glyburide (diabeta, micornase)

• Glimepiride (amaryl)

Sulfonylureas Mechanism of Action

• stimulates release of insulin from pancreatic islets

• insulin release is glucose dependent

Sulfonylureas Therapeutic Uses

• type II

• can be combined Sulfonylureas

• w/ other hypoglycemic agents

Sulfonylureas Pharamacokinetics

• metabolized in liver

• excreted in the kidney

Sulfonylureas Adverse Drug Events

• hypoglycemia

• CV toxicity

Sulfonylureas Interactions

• alcohol

• beta blockers

• other hypoglycemic agents

Sulfonylureas Lifespane COnsideration

• CONTRAINDICATED in pregnancy

• sustained hypoglycemia for neonate if taken close to birth

What are the Different Oral Anti-diabetic Agents?

• Meglitinides (glinides)

administer w/meals

• Repaglinide (Prandin)

• Nateglinide (Starlix)

Meglitinides (glinides)

• Mechanism of Action

• promotes insulin release

• faster peak & shorter duration of action (vs sulfonylureas)

  • works faster, lasts less

Meglitinides (glinides)

• Pharmacokinetics

• metabolized in the liver

• biliary excretion

Meglitinides (glinides)

• Drug-Drug Interactions

Gemfibrizol (lopid)

What are the Different Thiazolidinediones (Glitazones)

• Rosiglitazone (avandia)

• Pioglitazone (Actos)

Thiazolidinediones (Glitazones)

• mechanism of action

↓ insulin resistance and improving insulin sensitivity, allowing the insulin that the body produces to work more effectively.

Thiazolidinediones (Glitazones)

• Pharmacokinetics

• metabolism: hepatic

• excretion: fecal (main) & urinary

• administer with or without meals

Thiazolidinediones (Glitazones)

• Adverse Effects

• fluid retention

• bladder cancer

• unintended pregnancy

Alpha-Glucosidase Inhibitors

Acarbose (precose)

• taken @ start of meal

Acarbose (precose)

• Mechanism of Action

• works by slowing the action of certain chemicals that break down food to release glucose (sugar) into your blood

• Slowing food digestion helps keep blood glucose from rising very high after meals

Acarbose (precose)

• adverse effects -

• flatulence, cramps, abd. distension, diarrhea

• may cause liver dysfunction

• Monitor liver function every 3 mo. for the first yr

DipeptidylPeptidase-4 Inhibitors (DDP-4) (Gliptins)

• Sitiglipin (Januria)

  • give med B4 the first meal of the day

Sitiglipin (Januria)

• Mechanism of Action

• blocks reabsorption of glucose in the kidney

• ↑ urinary glucose excretion

Sitiglipin (Januria)

• Adverse Effects

• yeast infection

• UTI’s

• risk of dehydration

• postural hypotension & dizziness

Sitiglipin (Januria)

• drug interactions

poor interaction with diuretics

Non-Insulin Injectable Glucagon-like Peptide (GLP-1)

• Exenatitde (byetta)

• Liraglutide (victoza)

Liraglutide (victoza)

• adjunctive therapy to improve glycemic control in PT’s w Type II

• used to improve glucose control in PT’s taking metformin or sulfonylureas

  • GIVEN SQ B4 MORNING & EVENING MEALS

Liraglutide (victoza)

• adverse effects

• hypoglycemia w/sulfonylurea

• GI effects

• renal impairment

• pancreatitis

Non-insulin injectables Amylin Mimetics

• reduces post prandial levels of glucose

• delays gastric emptying

• suppress glucogen secretions

  • GIVEN SQ

  • GIVEN B4 major meals containing @ least 250kcal or 30 g of CHO

Non-insulin injectables Amylin Mimetics

• adverse effects

• hypoglycemia

• nausea

• injection site reactions

What is Diabetic Ketoacidosis?

body doesn't have enough insulin to allow blood sugar into your cells for use as energy.

Diabetic Ketoacidosis

• altered glucose metabolism leads too…

• hyperglycemia

• water loss

• hemoconcentration

Diabetic Ketoacidosis

• altered fat metabolism leads too…

leads too ketoacids (inc. ketons)

Diabetic Ketoacidosis

• ultimatley leads to…

• death

• coma

• acidosis

Diabetic Ketoacidosis

• Treatments

• 8-10L ) 0.9% NSS

• IV insulin replacement

• correct hyperglycemia & acidosis

• Potassium replacement (drive K+ back into cells)

• Bicarbonate (for acidosis)

Hypoglycemia Cause

• diarrhea

• overdose of insulin

• increased insulin levels exceeds insulin needs

• vomiting

• reduced food intake

• intense exercise/childbirth

What happens if glucose levels fall rapidly

• (activation of SNS)

• tachycardia

• palpitations

• sweating

• nervousness

What happens is glucose levels fall gradually

• activation of CNS

• fatigue

• HA

• Confusion

• drowsiness

what can happen if hypoglycemia persists?

can lead to irreversible brain damage

Hypoglycemia Treatment

• if conscious

fast acting oral sugars

• 3 glucose tabs

• 8ox of OJ/Juice

• 2 sugar packets

• non-diet soda

• 6-7 hard candies

• 1tablespoon of sugar

Hypoglycemia Treatment

• unconscious

• IV glucose (D50)

• parenteral glucagon

Hypoglycemia Rule of 15’s

1. Check Blood Sugar

2. eat 15g of carbs

3. wait 15 min for sugar to get into blood

What is glucagon?

hormone produced by alpha of the pancreas

What does glucagon do?

• breaks down glycogen stores

• opposite effects of insulin

• used in emergencies if IV glucose cannot be given

• GIVEN IV, SQ, IM