Unit 10 & Unit 11

Pharm Endocrine function

Glucagon

Comes from the pancreatic alpha cells. Secreted when glucose level is low. Promotes glycogenolysis. Promotes breakdown of proteins and lipids.

Insulin

Comes from pancreatic beta cells.

Secreted when glucose levels are high.

Encourages formation of glycogen.

Gate keep of glucose entering body cells.

Prevents fat breakdown.

Blood Glucose Values?

Diabetic: 80-130

Non Diabetics: 60-110

Types of Diabetes Mellitus

Type 1:

• Beta cell death

• autoimmune, genetic, environment factors.

• Body cannot produce insulin so glucose cannot enter the cells.

• Insulin therapy is required for life.

Type 2:

• Insulin receptors malfunction and cells develop “insulin resistance”

• Increased blood glucose triggers more insulin secretion eventually leads to death of beta cells

• Initially managed with diet, exercise and oral antihyperglycemic meds

Onset, Peak, and Duration

Humulin R, Myredlin, Novolin R

Human Regular Insulin

Pancreatic hormone.

MOA: identical to insulin produced by the body. Increases cellular glucose uptake, inhibits glucagon release, stimulates storage of glucose as glycogen.

SHORT ACTING: onset 30-60 min, peak 2-4 hrs.

**CAN BE GIVEN IV!!*

Insulin Therapeutic Effects

• Lower blood glucose levels in patients with T1DM

• Combination therapy in patients with T2DM

• Can be used in gestational diabetes

Insulin Contraindications & Side Effects

• Hypoglycemia

• Pregnancy

• Kidney disease

• Thyroid disease

S/E

• hypoglycemia

• irritation @ injection site

• hypokalemia

• weight gain

Insulin Considerations and Teaching

• Rotate injection sites

• Can be used in pump

• Monitor blood glucose and A1C

• Wear medical alert

NovoLog

Insulin aspart → RAPID ACTING

• Modified to have a more rapid onset

• Can be used in pumps

• Onset 15-30 min

• Peak 30 min-3hr

• Be sure patient eats within 15 min of administration

Humulin N, Novolin N, NPH

Isophane insulin → INTERMEDIATE ACTING

• Begins working within 1-2 hrs

• Peaks 4-12 hrs

• Provides basal coverage between meals and at night

• Cloudy-draw up last and administer right away

Levemir

Insulin detemir→ LONG ACTING

• Modified to have a more slow onset and longer duration of action.

• Onset: 2-4 hrs

• Duration: up to 24 hrs

• Cannot be mixed with other insulins

Toujeo

Insulin glargine→ ULTRA LONG ACTING

• Constant, long duration

• No defined peak

• Lasts 24-42 hrs

• Once daily dosing (same time)

• Cannot be mixed with other insulins

Administration Considerations

• only regular human insulin can be given IV

• only regular or rapid acting for SQ pumps

• time meals depending on type administered

• ALWAYS know blood glucose at the time of administration

• Rotate and observe injection sites

• Monitor for hypoglycemia

Hypoglycemia Signs and Symptoms

• Tachycardia

• Hunger

• Palpitations

• Nervousness

• Irritability

• Weakness/dizziness

• Sweating

• Mental confusion

• Incoherent speech

• Blurred vision

• Headache

• Convulsions

• Hypokalemia

• Cold clammy skin

Hypoglycemia Treatment

• Administer at least 15 grams of fast-acting carbohydrates

• If patient cannot take oral carbs, administer glucagon IV, IM, SQ, or intranasally

Glucagon (GlucaGen)

Pancreatic hormone

MOA: increases glycogenolysis (prompts the liver to release stored glucose)

Glucagon Therapeutic Effects

Rapid increase in serum glucose levels to normal.

Used to treat hypoglycemia.

Glucagon Contraindications and Side Effects

• Hyperglycemia

• Clients who do not have glycogen stored in liver

• CAD, sensitivity to protein compounds

S/E

• Hyperglycemia

• Nausea

• Vomiting

• BP changing (transient increase)

• Tachycardia, hypo/hyperkalemia

Glucagon Considerations and Teaching

• Monitor blood glucose

• Wear medical alert

• Keep carbohydrates or glucagon with you at all times

• Limit alcohol intake.

Diabetes Type 2

Insulin Resistance

Leads to:

• Metabolic syndrome

• Obesity

• Asymptomatic elevation of blood glucose

• Hyperosmolar hyperglycemia state (HHS)

Metformin (Glucophage)

Biguanide

MOA: multiple mechanisms- suppresses hepatic production of glucose (gluconeogenesis), decreases intestinal reabsorption of glucose, increases cellular uptake of glucose.

Metformin (Glucophage) Contraindications and Side Effects

• Chronic kidney disease

• Use caution in heart or liver failure, hx of lactic acidosis, 2 days before or after radiographic contrast

• pregnancy

S/E

• Nausea

• Vomiting

• Metallic taste

• Diarrhea

• Weight loss

• Risk for lactic acidosis → BBW

Metformin (Glucophage) Considerations

• Rarely causes hypoglycemia

• Used off-label for PCOS

• Formulated as tablets, solution, and extended release

• Know signs and symptoms of lactic acidosis

  • fatigue, somnolence, n/v, tachycardia, tachypnea, jaundice, muscle weakness, muscle pain or cramping

Glyburide (DiaBeta)

Sulfonylurea

MOA: Stimulates insulin release from beta cells and increases tissue sensitivity to insulin.

Glyburide (Diabeta) Contraindications and Side Effects

• Sulfa allergy

• Primary tx for T1

• CKD

• Hepatic disease

S/E

• GI distress

• Hypoglycemia

• Hepatotoxicity, blood dyscrasias (rare)

Glyburide (DiaBeta) Considerations

• Avoid alcohol

• Take with food - hold if not eating

• May use during pregnancy, but discontinue 1 months before delivery

Repaglinide (Prandin)

Meglitinide

MOA: stimulates insulin release

Contraindications for T1DM

Caution: hepatic impairment, pregnancy, lactation

S/E: hypoglycemia, GI distress, headache, URI

• Take just before each meal. Rapid onset and short duration

• No renal excretion, so can be used with CKD

Rosiglitazone (Avandia)

Thiazolidinedione

MOA: Increases cell sensitivity to insulin and decreases glucose synthesis by the liver

Contraindications: severe heart or live disease, pregnancy, T1DM

S/E: edema, increased serum lipid levels, URI, increased fluid retention can worsen heart failure and increase risk of MI → BBW

• Not recommended with insulin or nitrates

  Monitor liver function

• Teach pt signs of liver/heart failure.

Semaglutide (Ozempic)

Incretin Mimetic

MOA: activates GLP-1 Receptors in the brain, pancreas, and GI tract. Works by increasing insulin secretion in response to increased blood glucose and decreasing glucagon release. Also slows gastric emptying.

Contraindications: fam hx of thyroid cancer, pregnancy/breastfeeding, T1DM

Caution: CKD, hx of pancreatitis, hx of suicide ideation

S/E: Nausea, vomiting, diarrhea, abdominal pain, heartburn, burping, constipation, headache, nervousness, hypoglycemia.

Semaglutide (Ozempic) Considerations

• Weekly SQ injection; dose usually increased after 4 weeks.

• Rotate site

• May increase risk of aspiration with surgery d/t delayed gastric emptying

• May change absorption of other medications

• Teach pt about potential liver failure and thyroid tumor.

Considerations with Oral Hypoglycemia Medications

• Monitor blood sugar levels

• Notify care provider of signs of illness or infection

• Monitor I&O’s

• Monitor appropriate labs: LFT’s, A1C

• Monitor for adverse effects

• Monitor for compliance

• Emphasize non-pharmacological management of DM

Patient/Family Teaching for Oral Hypoglycemic Meds

• Teach s/s and treatment for hypoglycemia

• Beta-blockers may antagonize effects and mask symptoms of hypoglycemia

• Avoid alcohol

• Wear medical bracelet

• Consult with provider if you are pregnancy or considering pregnancy

Thyroid Importance

Stimulates the basal metabolic rate of nearly all tissues.

• GI function

• Weight

• Increases oxidation of energy (heat)

• Increase in sympathetic activity

• Thought processes

Hypothyroidism

• Slowing of metabolic rate

• Myxedema- mucous type of edema

Causes: hashimoto’s, thyroid gland dysfunction, hypothalamus disorder.

Treatment: removing or destroying the thyroid causing hypothyroidism.

Levothyroxine (Synthroid)

Synthetic thyroid hormone

MOA: identical to endogenous thyroid hormone

Levothyroxine (Synthroid) Therapeutic Effects

Regulation of thyroid hormone:

• Increases O2 use, respirations, heart rate, nutrient metabolism

• Promotes growth and maturation

• Increases weight loss and diuresis

• Improves activity tolerance

NOT TO BE USED FOR WEIGHT LOSS→ BBW

Levothyroxine (Synthroid) Contraindications and Side Effects

• Acute MI

• Cardiovascular disease, current adrenal insufficiency, HTN

S/E

• Therapeutic dose should make patient feel normal

• High doses: anxiety, insomnia, palpitations, diarrhea

Interactions:

• may increase need for antidiabetic drugs

• increases effects of warfarin

• digoxin decreases effectiveness

Levothyroxine (Synthroid) Considerations and Teaching

• Administer 1 hour before food or other meds to prevent interference with absorption

• Check aspirin allergy (yellow dye)

• Monitor labs: T3, T4, TSH, CBC, electrolytes, glucose, lipids

• Patients with diabetes should check blood glucose frequently and watch for hypoglycemia

• Keep labs appointments to monitor dosage

• Weigh yourself 2-3 times/week and report changes

• Report symptoms of hypo/hyperthyroidism