Medications for Glucose Regulation NUR 328 UAB

Insulin MOA

• Promotes cellular uptake and use of glucose

• Converts glucose into glycogen

• Stops release of fats, stops gluconeogenesis, and starts producing glycogen and fat

• Converts amino acids into proteins

• Converts fatty acids into triglycerides

Insulin CI/C

• hypoglycemia (under 50)

• Caution: elderly, kidney disease, dialysis, liver disease

• Pregnancy Cat C (except metformin, acarbose, sitagliptin which are Cat B)

Insulin Recommendation

Recommended for pregnancy and lactation -> does NOT cross the placenta

Insulin AE

• hypoglycemia

• lipodystrophy

• hypokalemia

Insulin DI

• Beta blockers, MAOIs, salicylates (aspirin)

• alcohol - decreases glucose

• thiazides, steroids - increases glucose

• Other DM meds - decrease BS

Insulin Administration

• Sliding scale in the hospital

• Insulin pump

• Inhaled

Insulin Therapeutic Effects

Hgb A1C < less than 7

Insulin Patient Teaching

• Complications/ sickness

• Monitor labs

• Rotate administration sites to prevent lipodystrophy

• Lifelong treatment

• Medical alert bracelet

• Storage:

  • Unopened - fridge

  • Opened - room temp up to 1 month

• Glargine CANNOT be mixed with any other insulin

Herbal Supplements that increase risk of hypoglycemia w/ insulin...

Juniper berries, ginseng, garlic, fenugreek, coriander, dandelion root, celery

Other Antidiabetic Med Commonalities

• Adjusts to diet and exercise

• Mostly oral (some SQ)

• Most require working pancreas/Type 2

  • Newer meds work in GI tract and do not require pancreas

• AE: hypoglycemia (except metformin)

• Pts may need to switch to insulin in high stress situations

Other Antidiabetic Med Commonalities Teaching

• Monitor BG

• Wear medic alert bracelet

• Take prior to meals

• Monitor Hgb A1C

• Diet/exercise

• Carry dextrose or glucose at all times

Combination Insulins

• Humalog 50/50

• Humalog 75/25

• Novolog 70/30

• Humulin 70/30

• Novolin 70/30

Combination Insulins Onset Peak

• Onset:

  • 30-60 min, then 1-2 hrs

• Peak:

  • 2-4 hrs, then 6-12 hrs

Combination Insulins Administration

Administer mixtures of reg. insulin and NPH insulin within 15 minutes post combining them to ensure appropriate suspension and therapeutic effect

Drawing Up Two Different Insulins

Draw the short-acting insulin first, then the intermediate-acting insulin (clear to cloudy, regular-NPH)

Insulin Therapy in Children

• Need to be carefully monitored for hypo/hyperglycemia and treated quickly because of fast metabolism and lack of body reserves -> push them into SEVERE state quickly

• Insulin dose difficult to calibrate in infants.

• Insulin often needs to be diluted to fit into a syringe and a second person should ALWAYS check the calculations/ dose of insulin for small children

Insulin Therapy in Teens

• Desire to be “normal” often leads to resistance to dietary restrictions and insulin injections

• Metabolism constantly changing -> complications regulating dose

• Metformin only oral antidiabetic drug for children 10 years or older

Insulin Therapy in Older Adults

• Poor vision and coordination -> difficult to prepare a syringe and food

• Dietary deficiencies - changes in taste, absorption, or attitude may lead to difficulty in glucose regulation

• Greater incidence of renal/ hepatic impairment -> kidney/ liver function be evaluated before starting meds

• More likely to experience end organ damage from diabetes

  • loss of vision, kidney problems, CAD, and infections

• Need to screen for drug interactions

Insulin Administration Route

• SQ

• Regular only -> IV/IM

RAPID: Aspart/ Lispro

• Onset:

  • 15 - 30 mins

• Peak:

  • 0.5 - 3 hours

SHORT: Regular

• Onset:

  • 30 - 60 mins

• Peak:

  • 2 - 4 hours

INTERMEDIATE: NPH

• Onset:

  • 1 - 2 hours

• Peak:

  • 4 - 12 hours

LONG-ACTING: Glargine, Lantus

• Onset:

  • 2 - 4 hours

• Peak:

  • None (think -gine = "gone")

When to give insulin? ASPART

within 5-10 minutes of a meal

When to give insulin? REGULAR

within 30 minutes of a meal

When to give insulin? GLARGINE

1-2x a day at the same time everyday

Sulfonylureas Prototype

Glipizide

Glipizide MOA

• stimulates release of insulin from the pancreas

• increases number of insulin receptors

Glipizide CI/C

• Hypersensitivity to sulfa drugs

• severe renal/liver disease

• critical illness

• pregnancy/lactation

• DM1 - requires a working pancreas

Glipizide AE

• hypoglycemia

• increases CV mortality

• anorexia

Glipizide DI

• alcohol

• beta blockers

• steroids

• levothyroxine

BIGuanides Prototype

MetforMIN

(think big vs mini)

Metformin MOA

• decreases production and increased uptake of glucose

• decreases glucose absorption in GI tract

Metformin CI/C

• infection

• alcohol use

• renal impairment

Metformin AE

• GI distress

  • Will subside over time

• Lactic acidosis (check lactic acid lvls if symptomatic)

  • especially in elderly

• vitamin b12/ folic acid deficiency (decreased the absorption of these vitamins)

• does NOT cause hypoglycemia

Metformin DI

contrast medium, cimetidine (increase the plasma concentration of med)

Metformin NI

• Monitor lactic acid levels and renal function (bc CKD is CI)

• stop 48 hours before AND after contrast

• may be used to prevent diabetes (esp in obese pts)

• May cause weight loss

• Monitor renal function as medicine is contraindicated in CKD

Alpha GlucosidASE Inhibitor Prototype

AcarbOSE

Acarbose MOA

slows absorption of carbs after a meal (does not enhance insulin)

Acarbose CI/C

inflammatory and malabsorptive diseases (Crohn's, UC, Cirrhosis)

Acarbose Adminstration

• take w/ first bite of meals 3xday PO

  • Must precede the mvt of food into the intestine for the absorption of carbs to be blocked

Acarbose AE

• GI upset

• anemia

• leukopenia

• hepatotoxicity

• flatus

Acarbose NI

• monitor CBC and LFT (ALT/AST)

• skip meal/skip med

MeGLItiNIDE Prototype

RepaGLINIDE

Repaglinide MOA

• increases insulin release

  • rapid onset (taken 30 minutes before meals)

Repaglinide AE

• gastric upset

• diarrhea

• hypoglycemia

Repaglinide DI

• Alcohol

• NSAIDs

• Warfarin (alter its effect)

• Loop diuretics

Repaglinide NI

skip meal/skip med

Thiazolidinediones Prototype

PioGLITAZONE (Actos)

Pioglitazone MOA

decreases insulin resistance of tissue

Pioglitazone CI/C

• active liver disease

• HX of bladder cancer

• severe HF

Pioglitazone AE

• hepatotoxicity

• CHF

• weight gain/fluid retention

• elevated LDL

• ovulation in females who have been anovulatory

Pioglitazone DI

-zoles (antifungals), rifampin, cimetidine, may reduce effectiveness of cantraceptives

Pioglitazone NI

• Monitor LFTs (AST/ALT) and lipids

• Monitor for s/s of HF

• Given once a day with or without food PO

Human AMyLIN Prototype

PrAMLINtide (Symlin)

Pramlintide MOA

• Reduces postprandial BG lvls by slowing gastric emptying, inhibiting the secretion of glucagon, and increasing feelings of satiety

• imitates amylin (inhibits glucagon/slows gastric emptying)

  • can be use w/ T1

Pramlintide Administration

Given before major meals SQ (2 in from insulin site)

Pramlintide CI/C

gastroparesis

Pramlintide AE

• When given with insulin pt at risk for severe hypoglycemia.

• Will decrease mealtime insulin by 50% if pt is also taking this drug

Pramlintide DI

any drug that slows GI (opioids) — take other meds 1 hr before or 2 hrs after pramlintide

Incretin Mimetics Prototype

Exenatide (Byetta)

Exenatide MOA

mimics effects of GLP-1 — promotes release of insulin, decreases release of glucagon, and slows gastric emptying

Exenatide CI/C

• kidney failure

• ulcerative colitis

• Crohn's

• hx of pancreatitis

• caution in elderly

• thyroid disease/carcinoma

• pregnancy

Exenatide DI

Oral contraceptives and antibiotics can slow absorption of oral meds — give 1 hr before or 2 hrs after Exenatide - sulfonylureas increase risk for hypoglycemia

Exenatide Administration

• SQ BID within 1 hour before morning/evening meal, available in extended release given once every 7 days

Exenatide NI

• skip meal/ skip med

• Keep injection pen in refrigerator and discard after 30 days

GLP-1 Receptor Agonists Prototype

LiraGLUTIDE (Victoza)/ DulaGLUTIDE (Trulicity)

GLP -> -GL-

Liraglutide MOA

increases insulin release and decreases glucagon release/ slows GI emptying

Liraglutide Administration

SQ once a day/some weekly

Liraglutide AE

• N/V

• pancreatitis

• thyroid tumors -> no family hx of thyroid cancer

Liraglutide NI

Skip meal, skip med

DPP-4 Inhibitors Prototype

SitaGLIPTIN (Januvia)

Sitagliptin MOA

• decreases glucagon release and increase insulin release

• slows down GLP-1 -> prolongs effects of insulin secretion, decreases glucagon, and slows GI emptying

Sitagliptin Administration

Taken once a day with or without food PO

Sitagliptin AE

• Pancreatitis

• respiratory infection

• HA

Sitagliptin DI

• Increased risk of hypoglycemia with insulin or sulfonylureas (glyburide, glipizide, or glimepiride).

• Can increase digoxin lvls

SGLT-2 Inhibitors Prototype

EmpaGLIFLOZIN (Jardiance)

Empagliflozin MOA

Prevent kidney from reabsorbing sugar, sugar is excreted in urine

Empagliflozin AE

• genital yeast infections

• UTI

• weight/bone loss

• dehydration

• increases risk of DKA

Empagliflozin CI/C

• renal failure w/ dialysis

• caution w/ renal disease/ hx of UTIs

Empagliflozin DI

• Decreased effect:

  • Rifampin, Phenytoin, Phenobarbital

• Increased effect:

  • Thiazide and loop diuretics

Empagliflozin NI

Need bone density test before starting treatment and periodically afterwards

Empagliflozin Administration

Take once a day before breakfast PO

Anti-Hypoglycemic Prototype

Glucagon

Glucagon MOA

• converts glycogen to glucose

  • secreted by alpha cells of pancreas in response to low blood glucose

Glucagon Treatment

Used for hypoglycemia related to insulin/oral AD meds, pancreatic cancer, anterior pituitary dysfunction (not anorexia)

Glucagon Administration

SQ, IM, IV (takes about 20 minutes for arousal)

Glucagon DI

anticoagulants

Glucagon AE

N/V

Glucagon CI/C

• Pregnancy/lactation

• renal/liver dysfunction

• CV disease

Glucagon Therapeutic Effects

increases BG and LOC

Glucagon NI

50% have N/V - turn patient on their side (aspiration precautions)

What meds are used for Type 1?

Insulin, Alpha Glucosidase (Acarbose), Amylin (Pramlintide), SGLT-2 (Canagliflozin)

What meds are used for Type 2?

All AD and Insulin

What meds slow the GI tract? (Do not give with GI disease)

DPP-4 (Sitafliptin), GLP-1 Receptor Agonist (Liraglutide/Dulaglutide), Amylin (Pramlintide)