Hypoglycemics

Acute Complication of DM

-Diabetic ketoacidosis
Hyperosmolar- Hyperglycemic Syndrome

Diabetes Mellitus (DM)

Complex disorder of carbohydrate, fat, and protein metabolism resulting from the lack of insulin secretion by the beta cells of the pancreas or from defects of the insulin receptors

Exocrine Gland

Secretes digestive enzymes through the pancreatic duct

Endocrine Gland

Secretes hormones directly into the bloodstream
-Insulin
-Glucagon

Islet of Langerhans

Alpha cells
Beta cells

Alpha cells

Secrete glucagon

Beta cells

Secrete insulin

Glucose

-Stored in liver and skeletal muscle as glycogen
-Stored in adipose tissue as triglyceride body fat

Glycogenesis

Stimulated by glucagon and converts glycogen to glucose

Insulin

-Stimulates carb metabolism in muscle and adipose tissue
-Converts excess glucose to glycogen for storage in the liver
-Maintain homeostasis blood glucose of 70-100 mg/dL

Type 1 Diabetes Mellitus

-Lack of insulin production or production of defective insulin
-Tx \= exogenous insulin

Type 1 Diabetes Mellitus S/S

-Hyperglycemia
-Polyphagia
-Polyuria
-Polydipsia
-Glucosuria
-Fatigue
-Blurred vision
-Slow wound healing
-Recurrent infections
-Parathesias
-Cardiovascular symptoms

Type 2 DM

-Most common
-Insulin deficiency and resistance
-Tissues resistance (reduced number of insulin receptors and insulin receptors less responsive)

Metabolic Syndrome: 3 of 5 Traits

-1. Increased waist circumference (Men: \>40, Women: \>35)
2. Triglycerides: 150mg/dL or higher
3. HDL cholesterol (Men:

Insulin Receptors in T1 and T2 DM

T1: Normal
T2: Decreased or defective

Endogenous Insulin in T1 and T2 DM

T1: Little or none
T2: Normal or high levels early; reduced later

Acute Complications of DM

-DKA
-HHS

Diabetic Ketoacidosis (DKA)

A form of hyperglycemia in uncontrolled diabetes in which certain acids accumulate when insulin is not available.

Hyperosmolar Hyperglycemic Syndrome

Condition of extreme hyperglycemia associated with dehydration, hyperosmolar blood, and altered mental status

Chronic Complications of DM

-Macrovascular
-Microvascular

Macrovascular (atherosclerotic plaque)

-Coronary arteries
-Cerebral arteries
-Peripheral vessels

Microvascular (capillary damage)

-Retinopathy
-Neuropathy
-Nephropahty

Gestational Diabetes

-Hyperglycemia during pregnancy
-Uncontrolled: Birth defects, hypoglycemia in newborn, increased birth weight
-Usually subsides
-May develop T2 DM within 10-15 years

Gold Standard for diagnosing DM

Hemoglobin A1C

Glycemic Goal of Treatment

-HgbA1C < 6.5%
-Fasting blood glucose of 80-130mg/dL

Non-pharmacologic Treatment Interventions

T1: Always requires insulin therapy

T2: Weight loss, improved diet, smoking cessation, reduced alcohol consumption, regular physical exercise

Insulin functions as a...

substitute for the endogenous hormone

Insulin...

restores the diabetic patient's ability to:
-Metabolize carbs, fats, and proteins
-store glucose in the liver
-convert glycogen to fat stores

Rapid-acting Insulin Agent

Lispro (Humalog)

Rapid-acting Insulin Onset

15 minutes

Rapid-acting Insulin Peak

1 hour

Rapid-acting Insulin Duration

3-5 hours

Rapid-acting Insulin Indications

Meal-time

Short-acting Insulin Agent

Regular (Humulin, novolin)

Short-acting Insulin Onset

30-60 minutes

Short-acting Insulin Peak

2-3 hours

Short-acting Insulin Duration

4-6 hours

Short-acting Insulin Indications

Can be given IV

Intermediate-acting Insulin Agent

NPH

Intermediate-acting Insulin Onset

2-4 hours

Intermediate-acting Insulin Peak

6-8 hours

Intermediate-acting Insulin Duration

12-16 hours

Intermediate-acting Insulin Indication

AFTER food

Long-acting Insulin Agent

Glargine

Long-acting Insulin Onset

2 hours

Long-acting Insulin Peak

Continuous

Long-acting Insulin Duration

24 hours

Long-acting Insulin Indications

Basal dose, never mix

Clear before...

cloudy

Insulin Pumps-Portable

-Basal infusion plus bolus doses before each meal
-Typically with rapid-acting
-Adjustable
-Pt. calculate mealtime bolus dose
-Provides glycemic control, cause less hypoglycemia and weight gain, improves quality of life

Insulin Syringe

Orange cap

Bolus Insulin

-Rapid-acting
-After meals

Basal Insulin

-Long-acting
-Constant supply of oxygen
-Continuous

Sliding-Scale Insulin

-Rapid-acting or short-acting insulin
-Disadvantage: delays insulin administration until hyperglycemia occurs; results in large swings in glucose control

Hypoglycemia Alert

-Oral intake
-Glucose + Protein

Hypoglycemia Unconscious

-IV injection (dextrose)
-Glucose/glucagon at home

Somogyi Effect

Early-morning hyperglycemia that occurs as a result of nighttime hypoglycemic episodes

Dawn phenomenon

An increase in blood glucose in the early morning, most likely due to increased glucose production in the liver after an overnight fast

How to tell the difference of somogyi effect and dawn phenomenon\>

Check blood glucose around 2-3 am
-Low\=somogyi effect
-High/normal\=dawn phenomenon

SMBG (self-monitoring of blood glucose)

Recommended for all patients who use insulin and many who use oral antidiabetic drugs
-Goal: 80-130mg/dl before meals and less than 180 mg/dl 1-2 hours after meals

CGM (continuous glucose monitoring)

-Measures interstitial glucose
-Worn 6-7 days
and reads every five minutes
-Alarms for hypo/hyperglycemia

Oral Anti-diabetic Drugs are used for...

-T2 DM
-Involves: monitoring of blood glucose levels, therapy with one or more drugs, tx associated comorbid conditions

Metformin Adverse Effects

-Gi distress
-BBW: Lactic Acidosis
-B12 deficiency

Metformin Nursing Implications

-Take with food
-Monitor renal function
-Hold 48 hours before/after contrast dye
-NEVER cause hypoglycemia
-RENAL and HEPATIC

Glyburide Adverse Effects

Hypoglycemia

Glyburide Nursing Implications

-Cross-sensitivity w/sulfa drugs
-Monitor RENAL function
-Take w/food

Pioglitazone Adverse Effects

-Edema
-Hypoglycemia
-Headache
-Cold-like symptoms
-Bladder cancer
-Fractures
-BBB: CHF

Pioglitazone Nursing Implications

-Hepatotoxic
-w/o regard to food

Acarbose Adverse Effects

GI distress

Acarbose Nursing Implications

Beginning of meals

Sitagliptin Adverse Effects

-Arthralgia
-Pancreatitis/Pancreatic cancer
-Cold-like symptoms

Sitagliptin Nursing Implications

-Once daily
-w/o regard to food

Pramlintide (SubQ) Adverse Reactions

BBW: Hypoglycemia

Pramlintide (SubQ) Nursing Implications

-Contradiction: gastroparesis (slow gastric emptying)
-T1 and T2
-Take at least 1 hour before other drugs

Semaglutide (SubQ) Adverse Effects

-GI distress
-Increased risk for pancreatitis
-Hypersensitivity
-BBW: C-cell thyroid cancer

Semaglutide (SubQ) Nursing Implications

-Monitor for hypoglycemia
-Monitor for pancreatitis+enzymes
-Monitor for hypersensitivity
-Refrigerate
-1x weekly on same day

Drugs that Increase Blood Sugar

-Antidepressants
-Beta-2 stimulators
-Corticosteroids
-Estrogens
-Oral contraceptives
-Cardiac medications
-Thyroid medications

Drugs that Decrease Blood Sugar

-Some antibiotics
-Some cardiac medications