Diabetes Medications

Diabetes Management: Medications, Diet, and Comorbidities By: Katie Welter, BS, RN

Objectives The RN will be able to verbalize onset, peak and duration of the 7 insulins used at Saratoga Hospital. The RN will be able to list appropriate nursing actions and patient education r/t the action and side effects of diabetes medications. The RN will be able to verbalize appropriate times to administer diabetes medications to aide in avoiding hypo and hyperglycemia.

ADA 2005 Diabetes Facts 20.8 million children and adults in the United States, or 7% of the population, have diabetes. 6.2 million people (or nearly one-third) are unaware that they have the disease. Approximately 5-10% of those who are diagnosed have Type I 41 million Americans have pre-diabetes, and are at high risk for developing Type 2 diabetes. The total annual economic cost of diabetes in 2002 was estimated to be $132 billion , or one out of every 10 health care dollars spent in the United States.

Evidence Base for Better Inpatient Glycemic Control Diabetes added an average of $11,500 to the cost of hospital admissions in 1997 dollars. In patients who are s/p MI, BG above 144mg/dL had a three-fold increase in mortality, and higher risk of CHF. A 2001 prospective, randomized, controlled study of 1,548 patients in a SICU found that patients whose BG was controlled to be between 80-100 vs 180-200, reduced: Mortality by 34% Septicemia by 46% Acute renal failure by 41%

Humalog = Novolog Onset: 5-15 minutes Peak: 1 hour Duration: 2-3 hours Key Facts: Novolog is what we carry at Saratoga Hospital and can be substituted for Humalog. If a patient is hypoglycemic prior to a meal and has a poor appetite, it may be given immediately after the meal to make sure BG levels are normal again.

Regular Onset: 1 hour Peak: 2-4 hours Duration: 5-8 hours Key Facts Must be given half hour before meals to give the insulin time to start acting.

Novolin N (NPH) Onset: 2 hours Peak: 6-8 hours Duration: 18-24 Key fact: Dose should be evaluated/decreased if pt is NPO. Must be rolled prior to being drawn up.

Novolog 70/30 Onset: 30 minutes Peak: 4-8 hours Duration: up to 24 hours Key facts: Like Novolog and Regular, should be given prior to meals so that the insulin can work on the patients meal. It is a mix of rapid and intermediate acting insulin.

Lantus (Glargine) Onset: Slow Peak: None Duration: 10.8-24 hours Key facts: Do Not mix Lantus with any other insulins Usually started at 10 units qhs for Type 2 patients, though may be given in am.

Insulin Pumps Provide patients with continuous infusion of fast acting insulin adjusted to meet individual insulin requirements. Basals: are the hourly rate of insulin that is programmed to give the patient. Boluses: an amount of insulin calculated based on the ratio of 1 unit of insulin/# of carbohydrates. Minimed Pump

Inhaled insulin will be available for use this summer! Exubera is a fast acting insulin to be taken 10 minutes prior to meals. Patients requiring long acting insulin will still need to take injections. Side effects include hypoglycemia, dry mouth, chest discomfort, decreased lung capacity, dry cough

Glimepiride (Amaryl) Drug Class: Sulfonylurea Action: stimulates release of insulin from pancreatic beta cells; increases sensitivity of peripheral tissues to insulin. Recommended administration time: With the first meal of the day.

Glipizide (Glucotrol, XL form also) Drug Class: Sulfonylurea Action: May stimulate release of insulin from pancreas, reduce glucose output by liver, and increase peripheral sensitivity to insulin. Possible interaction with Coumadin: Elevated PT/INR levels or increased hypoglycemic effect. Recommended administration time: 30 minutes before meals Some patients may need twice daily dosing.

Pioglitazone hydrocloride (Actos) Drug Class: Thiazolidinedione Action: Decreases insulin resistance in the liver and periphery. This causes insulin to use glucose more effectively and decreases the amount of glucose released by the liver. Potential side effects to watch for: Excessive fluid volume; monitor pts with heart failure Pts with Class III or IV CHF should not take it. Recommended administration: Once daily, with or without meals

Rosiglitazone maleate (Avandia) Drug Class: Thiazolidinedione Action: Improves insulin sensitivity Potential side effects to watch for: Excessive fluid volume; monitor pts with heart failure Pts with Class III or IV CHF should not take it. Discontinue if deterioration in cardiac status occurs. Recommended administration: Once daily, with or without meals

Metformin (Glucophage,Glucophage XR) Drug Class: Biguanide Action: ↓ liver production of glucose and absorption of glucose, also improves insulin sensitivity. Potential side effects: With increased age and renal impairment can lead to lactic acidosis and then ARF. Must be stopped the day before IV contrast use and restarted no sooner than 48 hours later with monitoring of renal function. Recommended Administration: Before breakfast and dinner if BID is ordered.

Common Side Effects to Monitor Labs: Elevated BUN, creatine, liver enzymes Sulfonylureas: Monitor CBC for ↓ H/H and granulocyte and platelet counts. • Interaction with Beta Blockers: Possible prolonged hypoglycemic effect, masked symptoms of hypoglycemia.

Hypoglycemia- S&S Sympathetic : Shaking Fast heart rate Diaphoresis Other S&S: Dizziness Hunger Weakness/Fatigue Headache Impaired Vision Emotional : Anxious Irritable Change in Personality

Hypoglycemia- Causes Too little food for insulin taken Too much insulin or oral medication Exercise Stress

Hyperglycemia- S&S Drowsiness Frequent urination Thirst Hunger Nausea Vomiting

Hyperglycemia- Causes Corticosteroids Stress Hormones Infection Too much food Too little insulin Insulin resistance Release of stored glucose Medications

Nutrition and Diabetes Two of our Registered Dietitians are also Certified Diabetes Educators- use Meditec to refer patients to them for teaching. Carbohydrates should make up 45-65% of the total daily intake. Low Carb diets are NOT appropriate for patients with diabetes. There are safer weight-loss strategies. Some patients use carbohydrate counting- they eat a certain number of carbohydrates for the amount of insulin they give themselves. This helps maintain the right balance between intake and insulin. Evaluate the appropriateness of a patient’s size, weight and their ordered calorie intake.

Review Evaluate effectiveness of current diabetes treatment and possible causes of hyperglycemia in the hospital setting. Remember that patients are more than the number on the meter- their complex, individual physical and psychological make-up influences their diabetes. A motto to pass on: “ Diabetes doesn’t mean deprivation, it means living in moderation”

Questions? References: http://www.diabetes.org/- ADA website Diabetes Forecast

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