Lec 19: Endocrine: Diabetes and Obesity Drugs

Lec 19

What is the main form of treatment for type 1 DM?

Insulin replacement therapy

What is the target range before meals (Type 1 DM)

70-120

What is the target range after meals (Type 1 DM)

70-180

What are the ranges that indicate hyperglycemia?

>250mg/dL

What are the ranges that indicate hypoglycemia?

<50mg/dL

Goal A1C for type 1 DM?

<7%

What type of medication is insulin?

High alert medication

Rapid acting insulin:

• Onset

• Peak

• Duration

• O: Most rapid onset, 5-15 minutes

• P: 1-2 hours

• D: 3-5 hours

Which type of insulin has a high risk for rapid hypoglycemia, so should have food available

Rapid acting insulin

• Insulin lispro (Humalog)

Rapid acting insulin:

• Route

• SUBQ or Continous SUBQ infusion pump

• NOT IV

Short acting insulin:

• Routes

• Name

• IV bolus, IV infusion, IM, SUBQ

• Regular insulin

  • Humulin R

Short acting insulin: SUBQ

• Onset

• Peak

• Duration

• O: 30-60 minutes

• P: 2.5 hours

• D: 6-10 hours

Short acting insulin: IV

• Onset

• Duration

• O: Immediate

• D: 6-10 hours

Only which type of insulin can be given through IV?

Regular insulin

Intermediate acting insulin:

• Appearance

• Combination

• Cloudy

• Often combined with regular insulin

Intermediate acting insulin:

• Name

• Why

• Insulin isophane suspension (NPH)

• When patients cant handle multiple injections daily

Intermediate acting insulin:

• Onset

• Peak

• Duration

• O: 1-2 hours

• P: 4-8 hours

• D: 10-18 hours

Long acting insulin:

• Name

• Administration

• Provides

• Does NOT need

• Insulin glargine (Lantus)

• Dosed once daily - Same time every day

  • Can be dosed every 12 hours if needed

• Provides constant level of insulin in the body

  • Referred to as basal insulin

• Does NOT need to be given with food

Long acting insulin:

• Onset

• Peak

• Duration

• O: 1-2 hours

• P: None

• D: 24 hours

What are mixed insulin’s indicated for?

To reduce the number of daily injections for those who cannot do multiple injections / cannot afford additional supplies

Each mixed insulin contains:

• One

• Either one

• Never

• One intermediate acting (NPH)

• Either one rapid acting (Humalog/Novolog) or one short acting (Humulin)

• Never long acting

How should you mix insulin?

Draw clear insulin first (rapid/short acting) then cloudy (intermediate)

What drugs increase insulin effects?

• A

• O

• A

• A

• B

• Alcohol

• Other Antidiabetic drugs

• Antimicrobials (sulfonamides)

• ACE inhibs (captopril)

• Beta blockers (propranolol)

What drugs decrease insulin effects?

• O

• C

• D

• A

• L

• Oral contraceptives

• Corticosteroids (prednisone)

• Diuretics (hydrochlorothiazide)

• Adrengerics (albuterol)

• Levothyroxine

Where does insulin get injected into?

Subcutaneous fat

What should you make sure to do when injecting insulin?

Rotate injection sites to prevent lipodystrophy/cutaneous amyloidosis

Continuous Glucose Monitor (CGM):

• Constantly

• Reduces

• Stays

• Constantly assesses blood sugar via app

• Reduces need for finger sticks

• Stays in palce for 7-10 days

Insulin pump:

• Continuously

• Reduces

• Sites

• Continuous delivery basal insulin and bolus doses at meal times

• Reduces need for injections

• Sites change 2-3 days

Hypoglycemia =

<70mg/dL

Conscious patient:

1. A

2. M

3. R

1. Administer a rapidly absorbed carbohydrate

   1. Fruit juice, soda, honey, dextrose gel/tablet

2. Monitor symptoms

   1. Should subside within 15-20 minutes

3. Repeat as needed

   1. If not subsided, administer another dose of rapidly absorbed carbohydrate

Unconscious patient:

1. A

2. M

3. R

1. Administer parenteral dextrose / glucagon

   1. IV detrose solution if in healthcare setting

   2. SQ or IM glucagon if at home/elsewhere

2. Monitor symptoms

   1. Should subside within 15-20 minutes

3. Repeat as needed

   1. If patient does not respond to 1-2 doses of glucagon within 20 minutes, IV dextrose is indicated

A patient with type 1 DM is prescribed insulin lispro. WHich nursing action is most important before administration?

• A) Ensure the patient has eaten within the last hour

• B) Verify that a meal tray is present and ready to eat

• C) Check for cloudy appearance in insulin

• D) Administer 30 minutes before the meal

B) Verify that a meal tray is present and ready to eat

Which statements about insulin glargine are correct? SATA

• A) It has no peak

• B) It should be given with meals

• C) It provides basal insulin coverage

• D) It is usually dosed once daily

• E) It can be mixed with NPH insulin

• A) It has no peak

• C) It provides basal insulin coverage

• D) It is usually dosed once daily

A patient with type 1 DM is unconscious and hypoglycemic at home. Which intervention is most appropriate?

• A) Administer IV dextrose

• B) Administer IM glucagon

• C) Give orange juice

• D) Apply glucose gel to gums

B) Administer IM glucagon

Which HbA1C percentage indicates type 2 DM?

> or equal to 7% for 2-3 months

What is the main treatment for type 2 DM?

Oral antidiabetic agents

Metformin: Therapeutic class?

Antidiabetic

Metformin: Pharmacological class?

Biguanides

Metformin: Action?

• Decreases hepatic glucose production

• Increases sensitivity to insulin

• Decreases intestinal glucose absorption

Metformin: Therapeutic effect?

• Improved glycemic control

Metformin: Indication?

Type 2 DM

Metformin: Route?

Oral

Metformin: Contraindication?

• Hypersensitivity

• Metabolic acidosis

• Severe renal impairment

• Hepatic impairment

• Contrast imaging

• Lactation

Metformin: Interactions?

• Alcohol

• Contrast media

• Certain antacids

• Certain diuretics (furosemide)

• Drugs that affect kidney function (NSAIDs, ACE Inhib)

Metformin: Side effects?

• Lactic acidosis

• Abdominal bloating, D/N/V, metallic taste

• Decrease vitamin B12 levels

Metformin: Nursing assessment?

• Monitor HbA1C, Folic acid (B9), Vitamin B12

• Administer with meals

• Hold metformin for studies requiring IV administration of iodonated contrast media + 48 hours after study

Metformin: Pt/family teaching?

• Therapy = long term

• Take same time every day

• Take missed doses ASAP, but do not double dose

• Review S/S lactic acidosis

• Notify HCP of all herbal products, surgeries, N/V, fever, inability to eat regular diet, uncontrolled glucose

Glipizide: Therapeutic class?

Antidiabetic

Glipizide: Pharmacological class?

Sulfonylureas

Glipizide: Action?

• Binds to beta cells to stimulate release of insulin

• Decrease secretion of glucagon

Glipizide: Therapeutic effect?

• Improved glycemic control

Glipizide: Indication?

Type 2 DM

Glipizide: Combination?

Can be given in combination with metformin

Glipizide: Route?

Oral

Glipizide: Contraindications?

• Hypoglycemia

• Reduced calorie intake

• Allergy to sulfa antibiotics

Glipizide: Interactions?

• SGLT2 inhibs

• GLP-1 agonist

• Fluoroquinolones

• Tetracycline

• Beta blockers (increased risk for hypoglycemia)

Glipizide: Side effects?

• Hypoglycemia

• Weight gain

• Skin rash

• Nausea

• Epigastric fullness

• Heartburn

Glipizide: Pt/family teaching?

• Therapy = long term

• Take 30 minutes before FIRST meal

• Monitor for signs of hypoglycemia

• Do not skip meals

• If missed dose, take when remember but do not double dose

Empagliflozan: Therapeutic class?

Antidiabetic

Empagliflozan: Pharmacological class?

SGLT2 inhibitor

Empagliflozan: Action?

• Decreases glucose reabsorption in kidneys to increase glucose excretion in urine

• May increase insulin sensitivity, Muscle uptake of glucose, Decrease gluconeogensis

Empagliflozan: Therapeutic effects?

• Improved glycemic control, weight loss, cardio + kidney protective

Empagliflozan: Indications?

• Type 2 DM

• Chronic kidney disease

• Heart failure

Empagliflozan: Route?

Oral

Empagliflozan: Contraindication?

• DKA

• Severe kidney impairment

Empagliflozan: Interactions?

• Rifampin

  • Decreases effectiveness

Empagliflozan: Side effects?

• Yeast infections

• UTI - Increased urination

• Hypotension, Hypovolemia

• Hyperkalemia

• Ketoacidosis

• Necrotic fascitis of perineum

Empagliflozan: Pt/family education?

• Monitor for hypoglycemia

• Maintain hydration

• Report S/S perineum infection ASAP

• Monitor for ketoacidosis

Semaglutide (Ozempic): Therapeutic class?

• Antidiabetic

• Weight control agent

Semaglutide (Ozempic): Pharmacological class?

• Incretin mimetics

• GLP-1 receptor agonist

Semaglutide (Ozempic): Action?

• Stimulate glucose specific insulin secretion

• Reduce glucagon production

• Slow gastric emptying → Increases satiety

Semaglutide (Ozempic): Therapeutic effects?

• Improved glycemic control

• Weight loss

• Heart + Kidney protective

Semaglutide (Ozempic): Indications?

• T2DM

• Obesity

Semaglutide (Ozempic): Route?

Typically SUBQ

Semaglutide (Ozempic): Contraindications?

• Family Hx of medularry thyroid cancer

• Multiple endocrine neoplasia syndrome type 2

Semaglutide (Ozempic): Interactions?

• Can delay absorption of oral drugs

• Hypoglycemia with sulfonylureas

Semaglutide (Ozempic): Side effects?

• Thyroid c cell tumors = black box

• N/V/D

• Pancrreatitis

Semaglutide (Ozempic): Pt/family teaching?

• Do not share injector

• Inject on same day

• Do not inject within 2 inches of belly button

• Rotate injection site

What would be the expected therapeutic response to oral diabetic drugs?

• A) Fewer episodes of DKA

• B) Weight loss of 5 pounds

• C) A1C <7%

• D) Random blood glucose of 150

C) A1C <7%

Your patient is prescribed metformin for type 2 DM. Which reported symptom should the nurse recignize as most concerning and requiring immediate follow up?

• A) Nausea

• B) Vomitting

• C) Diarrhea

• D) Muscle pain

D) Muscle pain

Which nursing considerations apply to metformin? SATA

• A) Hold before and after contrast imaging

• B) Monitor renal function

• C) Administer on an empty stomach

• D) Monitor vitamin B12 levels

• E) DIscontinue if mild GI upset occurs

• A) Hold before and after contrast imaging

• B) Monitor renal function

• D) Monitor vitamin B12 levels

Orlistat: Therapuetic class?

Antiobesity drug

Orlistat: Pharmacologic class?

Lipase inhibitor

Orlistat: Action?

Blocks absorption of fat in small intestine

Orlistat: Route?

Oral before meals containing fats

Orlistat: Indications?

• Obesity (BMI >30)

• BMI >27 with risk factors

Orlistat: Adverse effects?

• GI: Flatus with discharge, oily stool, fecal urgency, abdominal pain

• Orlistat may also decrease absorption of fat soluble vitamins and warfarin

• Rapid weight loss increases the risk for cholelithasis

Orlistat: Contraindications?

• Hypersensitivity

• Malabsorption syndromes

• Gallbladder disease

• Hypothyroidism

• Anorexia

• Bulimia
  

Orlistat: Interactions?

• Absorption of statin medications may be increased

• May decrease the absorption of fat soluble vitamins