Insulin & Anticoagulants & HTN

Fast Blood Glucose (FBS) Levels

*Pt must begin fasting 8 hrs prior to lab draw of FBS lvls

Normal: 70-100mg

Pre-Diabetes: 101- 125 mg/dL

Diabetes: 126mg/dL or higher

A1C levels

*Monitored twice annually

Normal: Less than 5.7%

Pre-diabetes: 5.7% to 6.4%

Diabetes: 6.5% or higher

OGTT Level (oral glucose tolerance test)

*Tests BS before & 2hrs after ingesting sweet drink; performed as needed)

Normal: Less than 140 mg/dL

Pre-diabetes: 140-199 mg/dL

Diabetes: 200 mg/dL or higher

Rapid-Acting Insulin Analogues

Type: Lispro (Humalog&Ademlog), Aspart (fiasp, NovoLog), Glulisine (Apidra)

Onset: 10-15mins

Peak: 60mins

Duration: 2-4hrs

Role: covers insulin needs for meals eaten at the same time as ingection. Myabe be used in addition to long-acting & intermediate-acting insulin. Can be used in insulin pumps.

Short-Acting Insulin (Regular)

Type: Regular INsulin (Humulin R, Novolin R, Velosulin R)

Onset: 30mins

Peak: 2-3hrs

Duration: 3-6hrs

Role: Covers insulin needs for meals eaten within 30mins. May be given IV and via insulin drip or insulin pump. May be mixed with NPH for SC injection

Intermediate-Acting Insulin

Type: NPH (Humulin N, Novalin N, ReliOn)

Onset: 2-4 hrs

Peak: 4-12 hrs

Duration: 12-18hrs

Role: covers insulin needs for about ½ day or overnight. Can be combined with rapid- or short-acting insulin

Long-Acting Insulin Anaogues

Type: Determir (Levemir), glargine (Basaglar, Lantus)

Onset: 2-4hrs

Peak: does not peak

Duration: up to 24hrs

Role: covers insulin needs for about 1 full day. This type of insulin is often combined, when needed, with rapid- or short-acting insulin (though NEVER mixed together in the same syringe). Lowers glucose levels fairly easily.

Ultra Long-Lasting Insulin

Type: Degludec (tresiba), glargine u300 (toujeo)

Onset: 6hrs

Peak: does not peak

Duration: lasts 36+ hours

Role: is typically concentrated, allowing for the administration of large doses in less volume, improving absorption. Offer sustained coverage with low potential for hypoglycemia. Lower glucose levels fairly easily.

Most insulin concentrations are?

U100 (100 units per mL)

The administration of insulin places the patient at risk of hypoglycemia begins upon?

onset

What indicates the time of greatest risk for hypoglycemia?

peak

How do we know how long the risk for hypoglycemia is present?

Duration of action

How many signatures are needed when administering insulin?

Signatures of 2 licensed RNs

Enoxaparin (Lovenox)

Indication for use: Prophylaxis & treatment of DVT

Action: DIRECT; The drug helps antithrombin shut down factor Xa, which slows or prevents blood clotting.

Onset: unknown

Duration (after dicountiuned): 24hrs

Treatment: usually short-term

Route: Subcutaneous

Lab test: Not Required

Normal times: N/A

Therapeutic lvls: N/A

Adverse effects: Bleeding heparin-induced thrombocytopen

Antidote: Protamine Sulfate

Heparin

Indication for use: Treatment of VTE (PE, DVT); prevents further extension of exiting thrombi or new clot formation; no effect on existing clots

Action: INDIRECT: Enhances inhibitory effects of anti-thrombin III, preventing the conversion of fibrinogen to fibrin, prothrombin to thrombin

Onset: Rapid: 20-60 mins (SC); IV is immediate

Duration (after dicountiuned): SC= 12-24hrs; IV= 2-6hrs

Treatment: as needed

Route: SC or IV

Lab test: PTT

Normal times: PTT 30-40 sec

Therapeutic lvls: PTT: 1.5- 2.5 times normal

Adverse effects: Bleeding, HIT

Antidote: Protamine Sulfate

Warfarin (Coumadin)

Indication for use: Prophylaxis & treatment of VTE (PE/DVT)’ stroke preventin in persons with AF, or cardiac valve replacement

Action: Vitamin K Antagonists: Interferes w/ hepatic synthesis of vitamin K- dependent clotting factors II, VII, IX, X

Onset: 2-5 days

Duration (after dicountiuned): 2-5 days

Treatment: Short-term or years

Route: PO

Lab test: PT/INR

Normal Times: PT 11-12.5 sec; INR 0.8-1.1 (a ratio)

Therapeutic lvls: PT 1.5-2 times normal values; INR 2-3

Adverse effects: Bleeding and acute renal failure

Antidote: vitamin K

Rivaroxaban (Xarelto) & Apixaban (Eliquis)

Indication for use: Prevention of stroke & embolism due to non-valvular related AF, prevention of post-ortho surgical VTE

Action: DIRECT; inactivates coagulation factor Xa, thus inhibits clotting

Onset: 1-3 hrs

Duration (after dicountiuned): 12-14hrs

Treatment: years

Route: PO

Lab test: creatinine clearance

Normal times: N/A

Therapeutic lvls: N/A

Adverse effects: Bleeding; acute renal failure

Antidote: Charcoal (within 2-3 hours of last intake) or nonactivated or activated PCC; hemodialysis

Dabigatran (Pradaxa)

Indication for use: Prevention of stroke & embolism du eto non-valvular related AF

Action: DIRECT: potentiates the action of antithrombin

Onset: 1-3hrs

Duration (after dicountiuned): 12-14hrs

Treatment: years

Route: PO

Lab test: creatinine clearance

Normal times: N/A

Therapeutic lvls: N/A

Adverse effects: Bleeding and acute renal failure

Antidote: Charcoal (within 2-3hrs of last intake) or nonactivated PCC; hemodialysis

What is the purpose of antithrombotic therapy?

Reduces the risk of abnormal blood clot formation.

Antithrombotic therapy reduces the risk of which conditions?

• Atrial fibrillation (AF)–related clots

• Stroke

• Acute coronary syndrome (ACS)

• Heart valve disease or valve replacement complications

• Venous thromboembolism (VTE: DVT, PE)

• Hypercoagulable states

• Stent thrombosis

Which vitamin is antagonized by some antithrombotic drugs?

Vitamin K

How long before a procedure are antithrombotic drugs usually discontinued?

5–7 days before the procedure (must clarify with MD/NP/PA)

When are antithrombotic drugs typically resumed after a procedure?

Within 24 hours post-procedure if ordered by MD/NP/PA

Aspirin (ASA) mechanism and use?

Antiplatelet agent used to prevent stroke and sometimes MI

How long does aspirin affect platelets?

7–10 days

What is given to reverse aspirin effects if bleeding occurs?

Platelets

NSAIDs role in antithrombotic therapy?

Antiplatelet effect; primarily used for pain control

What should be done with NSAIDs if bleeding occurs?

Hold the medication

Dipyridamole (Persantine) use?

Antiplatelet agent for stroke prevention

Duration of dipyridamole effect?

2–3 days

What should be done with dipyridamole if bleeding occurs?

Hold the medication

Clopidogrel (Plavix) use?

Prevents MI and stroke, especially in patients with peripheral vascular disease (PVD)

Duration of clopidogrel effect?

3–5 days

What should be done with clopidogrel if bleeding occurs?

Hold the medication

Ticlopidine (Ticlid) use?

Antiplatelet agent

Duration of ticlopidine effect?

10–14 days

What should be done with ticlopidine if bleeding occurs?

Hold the medication

What procedures are considered higher-risk for bleeding?

• Surgeries

• Endoscopic procedures with intervention

• Balloon dilations

• Organ entry

• Variceal treatment

• Cardiac or carotid stent placement

What procedures are considered lower-risk?

• Colonoscopy

• ERCP with stent placement

Why are antithrombotic drugs often stopped before procedures?

To reduce the risk of excessive bleeding during or after the procedure

BP Levels

Normal: less than 120 (systolic) // Less than 80 (diastolic)

Elevated: 120-129 (systolic) // Less than 80 (diastolic)

High BP Stage 1: 130-139 (systolic) // 80-90 (diastolic)

High BP Stage 2: 140 or higher // 90 or higher

Hypertensive Crisis: higher than 180 // higher than 120

Orthostatic hypotension

Orthostatic hypotension is a ≥20 mmHg drop in systolic blood pressure after standing or sitting up from lying down, measured after proper position changes and brief waits

Normal BP Reassess

Reassess in 1 year

Elevated BP reassess

Reassess in 3-6months

Stage 1 HTN reassess

3-6months