Antidiabetic Agents

1. Antidiabetic Agents Insulin Oral Hypoglycemics Fall 2013

2. Insulin • Insulin is a hormone produced in the beta cells of the pancreas, secreted at a rate of 0.5 to 1 unit per hour. Average insulin secretion in adult is 30-50 Units per day. • Insulin is required for entry of glucose into skeletal and heart muscle and fat. • Insulin is important in protein and lipid metabolism. • Decrease in insulin = decrease in glucose into cell = hyperglycemia • Beef and pork discontinued in US in 2005 • Biosynthetic insulins are now available for most patients

3. Insulin Concentration • 100 Units per mL • Regular insulin may come 100 Units / mL or • 500 Units / mL for IV use • ONLY USE INSULIN SYRINGE

4. Mechanism of Action Exogenous insulin works the same as endogenous insulin • Transports glucose FROM the blood to the INSIDE of cells and • Takes excess glucose to the liver for storage • This results in LOWERING of the blood glucose level

5. Therapeutic uses • Insulin is the drug of choice for type 1 and type 2 uncontrolled by diet, exercise or oral hypoglycemic agents • Hormonal replacement - remember insulin is a hormone • Goal - maintain stable blood glucose levels

6. Administration • Subcutaneous injection • Syringe and needle • Pen injectors • Jet injectors • Inhalation • Exubera • Subcutaneous infusion • Portable insulin pumps • Implantable insulin pumps • Intravenous infusion

7. Adverse Effects • The most significant adverse effect is HYPOGLYCEMIA • The signs & symptoms are the same for any hypoglycemic reaction / state • BLOOD GLUCOSE MUST BE MONITORED

8. dosage • INDIVIDUALIZED • Insulin dosage is “tailored” to each patient specifics metabolic needs to achieve stable blood glucose levels

9. Insulin Peak / Onset / Duration • It is important to know the insulin’s onset, peak and duration • Onset- time required for the med to have an initial effect • Peak – when agent will have the maximum effect • Duration – length of time the agent remains active in the body

10. Rapid Acting • Humalog (lispro) or (Novolog) aspart • Synthetic form • Clear solution • Can be given separately or mixed with intermediate or long acting insulins • More rapid and shorter acting than human regular Insulin • Onset / Peak / Duration = 10 min / 1 -3 hr / 3-6 hrs • Administer within 10 – 15 minutes of a meal • Apidra (insulin glulisine) • Onset / Peak / Duration = 10-15 min / 1-1.5 hr / 3-5 hrs • Give within 15 min before meal • Can be used in insulin pump • Can be mixed with NPH for subcutaneous injection

11. Short Duration Regular Insulin • Humulin R, Novolin R • Onset / Peak / Duration = 30 to 60 min / 1-5 / 6-10 hrs • Can be given Sub Q and IV • Routes: IV, sub Q, IM, inhalation • Administer no sooner than 30 minutes before meal • Exubera – inhaled insulin • Onset / Peak / Duration = 15 to 30 min / 0.5-1.5 hrs / 6.5 hrs • Fine powder of regular insulin

12. Intermediate Acting Insulins NPH(Neutral protamine Hagedorn) • Onset / Peak / Duration 2-4 / 4-12 / 16-20 hrs • Contains specific amounts of regular insulin and protamine • Onset is delayed and action is extended. • Cloudy solution, must be gently agitated before drawing up. • Usually administered twice daily

13. Premixed Insulin Combinations • Humalog Mix 75 – 25 (75% Lispro protamine solution with 25 % Lispro solution) • Rapid onset with intermediate duration • Onset / Peak / Duration • 15-30 min / 1-6.5 /12-24 hrs • Humulin 50/50 (R=50, N=50) • Humulin 70/30, Novolin 70/30, (N=70, R=30) • 30 min / 2-12 hr / 24 hr

14. Long Acting Insulins Insulin detemir (Levemir) • Onset / Peak / Duration / 6-8 / 12-24 • Slow onset and dose dependent duration • Provides basal glycemic control • As compared with NPH, has slower onset and longer duration • Clear solution • Administered once or twice daily • Long Acting • Humulin U (Ultralente) Onset / Peak / Duration 6-8 / 12-16 / 20-30

15. Very Long Acting Insulin Very Long Acting • Insulin glargine (Lantus) • Onset 1 hour • no pronounced peak • Duration 24 hours

16. Lantus • NOT to be confused with LENTE • Long lasting basal insulin • Slow steady release of insulin needed to control blood glucose & keep cells supplied with energy when no food is being digested • ONCE-A-DAY - AT BEDTIME usually • Steady absorption - NO PRONOUNCED PEAK • Works twice as long as NPH (Lantus 24 hrs, NPH 14.5 hrs) • Used for adults with Type 2 or children and adults with Type 1

17. LANTUS • Does NOT replace short-acting insulins • Can be used with oral anti-diabetic medications • MUST NOT be diluted or mixed with any other insulin or solution • MUST use U-100 syringe • NOT intended for IV use • Patients experience same side effects (hypoglycemia & injection-site reactions)

19. Stop and Think • if you administer 10 units of regular insulin at 7:00 am when should you observe for hypoglycemia? • if you administer 5 units of Humulin R insulin and 22 units of Humulin N at 7:30 am when will you observe for hypoglycemia? • if you administer 7 units of Humulin R at 11:30 am when will you observe for hypoglycemia?

20. if your patient is NPO for breakfast and is due insulin at 7:30 am what should you do?

21. Insulin Storage • Insulin should not be allowed to freeze, nor be heated above room temperature. • Insulin should be stored in the refrigerator until opened, then may be stored at room temperature until gone. • At sustained temperatures above room temperature, insulins lose potency rapidly. • Excess agitation should be avoided to prevent loss of potency, clumping or precipitation. • All insulins except Regular, Lispro and Aspart should be gently rolled in the palms to resuspend solution. (Do not shake)

22. Nursing Implications • when mixing insulins - CLEAR TO CLOUDY • do not “shake” insulin vial to resuspend cloudy mixtures - gently rotate / roll vial in palm of hand or swirl, avoids bubbles • insulin must be stored in a stable temperature, refrigeration prolongs shelf life, in clinical settings - opened vial MUST be dated & initialed • schedule snacks to coincide with insulin PEAK’s

23. Safe Practice for Insulin Administration BEFORE ADMINISTERING: • Check the original doctor’s order • KNOW your patient’s blood sugar and “trends or patterns” • Check the last time your patient ate (what & how much) • Check other drugs patient is taking and question yourself about interactions

24. Review Administration • ADMINISTERED SUBQ(unless emergency and then ONLY Short ACTING insulin can be given IV) • 45 or 90 degree angle • 27 - 25 G needle (microfine) (Only administer in an insulin syringe) • 5/8 inch • do not have to aspirate

32. Nursing Implications • ALL insulin dosages MUST beDOUBLE CHECKED by a second LISCENED person • administer insulin only with an insulin syringe calibrated for that concentration of insulin • BEFORE ADMINISTERING: • check the original doctor’s order • KNOW your patient’s blood sugar and “trends or patterns” • Check the last time your patient ate • Check other drugs patient is taking and question yourself about interactions

34. Site Rotation • Diabetics should be taught to ROTATE their injection sites • This is done to prevent “lipoatrophy” / scarring at the injection site - which results in variable insulin absorption

35. Subcutaneous

37. Insulin Administration: Methods of Delivery: Insulin Pens

38. Insulins that can be used in pumps: regular, lispro, aspart, glulisine

39. Insulin Administration: Methods of Delivery: Insulin Injectors

41. Complications of Insulin Therapy Local Reactions • Redness, tenderness, swelling, induration • 1-2 hours after insulin administration • May occur at beginning of therapy and resolve

42. Complications of Insulin Therapy: Insulin Lipodystrophy Localized reaction • Lipoatrophy • loss of subcutaneous fat, appears as dimpling or pitting in of subcutaneous fat • Lipohypertrophy • the development of fibrofatty masses at the injections site. • Caused by repeated use of same injections site. • Insulin injected into scarred areas, absorption is delayed

45. Diabetics in the Hospital Setting • Hospitalization may drastically affect insulin requirements because of stress (infections, surgery, acute illness, inactivity, variable food intake) • It is often used to monitor patients on hyperalimentation • Blood glucose checks are ordered at specific intervals - most often ac & at bedtime • The insulin dose is then adjusted to a predetermined “scale” ordered by the physician • The ONLY type of insulin used in sliding scale is Short Acting (Regular Insulin)

46. Method of insulin “dosing” Dose is adjusted according to blood glucose results This method of dosing is most often used for hospitalized diabetics Sliding Scale

47. Sliding Scale Order Blood glucose < 200 - give 0 units Regular Insulin Blood glucose 201 - 249 give 4 units Regular Insulin Blood glucose 250 - 299 give 6 units Regular Insulin Blood glucose > 300 call Dr. • At 0730 your patient is scheduled to receive 20 units of Humulin N and 5 units of Humulin R, their blood sugar level is 247, what will you give?

48. Sliding Scale Order • EXAMPLE: Blood glucose < 200 - give 0 units Regular Insulin Blood glucose 201 - 249 give 4 units Regular Insulin Blood glucose 250 - 299 give 6 units Regular Insulin Blood glucose > 300 call Dr. • At 1130 your patient’s blood sugar is 284, how much insulin will you give? • What type of Insulin is ordered for sliding Scale?

49. Sliding Scale Order Blood glucose < 200 - give 0 u Blood glucose 201 - 249 give 4 u Blood glucose 250 - 299 give 6 u Blood glucose > 300 call Dr. • Order: Regular Insulin per sliding scale AC & HS • Order: Lantus 10 Units sub Q at bedtime. • Your patient’s blood glucose at 2100 is 278, how much insulin will you give? • How would you administer it?