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Advanced Inpatient Diabetes Program at Community Medical CenterObjectives of Learning:

  • Compile and organize patient-specific diabetes information with the help of a standardized format so that patterns and trends can be analyzed.
  • Recognize signs and symptoms of hypoglycemia and treat according to current ADA guidelines.
  • Calculate carbohydrate content of a meal and apply it to correct dosage administration of medication.
  • Classify various types of diabetes medications according to mechanism of action, identify medication side effects, and evaluate for appropriate application to individual patients.
  • Cite reasons and implications for withholding metformin-containing medications 48 hours post contrast administration.
mna requirements
MNA Requirements
  • All authors of these modules for diabetes education have denied any conflict of interest
  • There is no commercial support of this educational activity
  • Approved provider status does not imply endorsement by the provider, ANCC or MNA of any commercial products displayed in conjunction with this activity.
  • Contact hours for this activity are good through May 5, 2012
  • To receive credit please complete MNA evaluation and return to Education Resources, attn. Stephanie Metcalfe
why joint commission certification
Why Joint Commission Certification?
  • To improve compliance with national standards
  • Clinical practice guidelines are used to improve patient outcomes
  • Use performance measurement data to improve quality of care and patient satisfaction
what does joint commission require
What does Joint Commission require?
  • Multidisciplinary team to manage
  • Staff education
  • Coordination of meals and insulin
  • Nutritional assessments
  • Written protocols for managing insulin infusions, hypo and hyperglycemia treatment
  • Glucose monitoring protocols
  • Patient understanding of self management
performance measures
Performance Measures
  • Percent of patients who receive accurate documentation of glucose, meals and insulin doses
  • Staff will receive mandatory education
  • Percent of patients who receive follow up of contrast administration when they use metformin
  • Percent of patients with A1c results within 60 days.
diabetes management
Diabetes management
  • Carbohydrate intake
    • glucose monitoring
  • Insulin dosing
  • Exercise
  • Patient
  • Dietitian
    • Monitor carbohydrate intake
    • Teach patients
    • Glucose draw
  • Nurse
    • Draw and monitor glucose
    • Dose insulin
    • Teach patients
    • Nurse Technician
      • If trained can do finger stick glucose
  • Provider
    • Monitor trends, change orders
  • Fewer episodes of hypo/hyperglycemia
  • Time savings
  • More accurate management
  • Fewer complications
  • Shorter LOS
  • More patient satisfaction
primary care provider letter
Primary Care Provider Letter
  • Dear ________________________;
  • Your patient _____________________________ was recently admitted to Community Medical Center for _________________________________________. During that visit we noticed that he/she is having problems with blood glucose control. This is detailed on the attached screening form.
  • Our staff is recommending diabetes education for your patient as there is evidence of improved glucose control when people receive diabetes education.
  • If you would like him/her to participate, please complete the referral form included with this letter and fax to the Diabetes and Nutrition Center at 327-4790. We will contact the patient and make arrangements from there.
  • Thank you,
  • Date___________ Time__________ Nurse Signature__________________________________________
  • Community Medical Center
  • Attachments: □ Referral Form □ Screening Form

Nursing Diabetes Screening at OutPatient Contact

  • Info obtained from:
  • □ Patient □ Family member(name)__________________________________________________
  • □ Other(name)___________________________________________________________________________
  • Admitting diagnosis ________________________________________________________________________________
  • Which health care professional do you normally see about your diabetes? ___________________
  • Present Diabetes Medications: See Medication Reconciliation form
  • How long have you had diabetes? ________________________________________________________________
  • Are you monitoring your own blood glucose? □ Yes □ No
  • If no, do you have a monitor? □ Yes □ No
  • Type of monitor? ____________________ Frequency? ______________ Range? __________________
  • Any diabetes related Emergency Department visits or admits in the past year? □ Yes □ No □ Unknown
  • Have you had an HgbA1C greater than 8% in the past year? □ Yes □ No □ Unknown
  • Do you have any of the following?
  • □ CAD □ HTN □ Foot problems □ Kidney problems □ Eye problems □ Unknown
  • LAB RESULTS (if available)
  • A1C___________/date_____
  • Creatinine on admit_______/date________
  • eGFR on admit______/date_____
  •  Date ________ Time ________ Nurses Signature ______________________________________________________
  • Assessment for Diabetes Care Needs as Identified by Patient
  • □ A1c frequently elevated >7% □ BG frequently <70 or >200 mg/dl
  • □ Questions about self care □ Education for home care giver
  • □ Questions about carb counts □ Will need to monitor BG, or other BG monitor problems
  • □ Medication changes from Admit to Discharge
  • □ Fax screening form, letter and referral form to Referring Provider _______________________
  • Comments _____________________________________________________________________
  • ______________________________________________________________________________Date ______Time ______ Nurse Signature ___________________________________________

Teaching Results:

V= Verbalize Understanding

DU= Demonstrates Understanding

R= Needs Reinforcement

*= Refused (more details in nurses notes)

Fax both sides of this form to


□ Diabetes Provider

□ Outpatient Diabetes Education (#4728)

living well with diabetes topics covered
Living Well with Diabetes topics covered
  • Monitoring Blood Sugar
  • Taking Medication
  • Making Healthy Food Choices
  • Caring for Your Feet
sick day management
Sick Day Management
  • Check your blood glucose every 4 hours during the day
  • To prevent dehydration
  • If you take a diabetes medication containing metformin
  • Always take your usual amount of long-acting insulin
  • If possible, follow your usual meal plan

PHYSICIAN ORDERS for Diabetes Patients

  • □ Dietitian Consult
  • □ A1c (if not done in past 60 days)
  • □ Creatinine/ eGFR, if not done in ED
  • □ Label insulin pen for home use after discharge
  • □ Referral to diabetes education, Ext. 4323
  • Date _________ Time _________
  • Physician Signature________________
  • Increase quality of diabetes care
  • Eliminate episodes of hypo/hyper-glycemia
  • Improve patient confidence with their self care
  • Improve patient satisfaction
  • If you have any questions about any of the information in this module, please speak with your staff developer, call the Diabetes Education nurse at X4323, or Linda Hightower at X4133.
advanced inpatient diabetes program at community medical center1

Advanced Inpatient Diabetes Program at Community Medical Center

Chapter 2: Carbohydrate Counting

  • To increase knowledge of carbohydrate counting skills for those caring for patients with diabetes
  • Identify the relationship between carbohydrates and blood sugar
  • Determine the grams of carbohydrate in foods when using the nutritional food label and other carbohydrate-counting tools
  • Calculate the total grams of carbohydrate per meal
carbohydrate counting defined
Carbohydrate Counting Defined
  • A meal-planning approach for all patients with diabetes, based on the following ideas:
    • Carbohydrate is the main nutrient affecting postprandial glycemic response
    • Total amount of carbohydrates consumed is more important than the source of carbohydrates
  • CMC provides a Consistent Carbohydrate meal plan for diabetic management
    • The movement towards carbohydrate counting means the “ADA Diet” is no longer recognized. The correct

diet order is “Consistent Carbohydrate”

benefits of carbohydrate counting
Benefits of Carbohydrate Counting
  • More flexible than other meal-planning methods
    • Allowing a wider array of foods to choose from
  • All carbohydrate sources are allowed
    • Complex carbohydrates that break down slowly
    • Simple sugars that break down almost right away
  • Focuses attention on the foods that are most likely to make blood glucose levels go up
  • Provide for tighter control over blood glucose readings
foods that contain carbohydrates
Foods That Contain Carbohydrates
  • Breads, cereals, pasta, and grains
  • Rice, beans, and legumes
  • Starchy vegetables-potatoes, corn, and peas
  • Fruit and fruit juices
  • Milk, soy milk, and yogurt
  • Regular soda, fruit and sports drinks
  • Cakes, cookies, ice cream, candy, and jelly
carbohydrate servings
Carbohydrate Servings
  • One serving of carb is measured as 15 grams
    • One carbohydrate serving is a food that contains approximately 15 grams of carbohydrate
  • All carbohydrates affect blood glucose in the same way. It is the amount of carb eaten that is important, not the type of carb.

For example, one slice of bread, a small piece of fruit, or

½ cup corn each have around 15 grams of carbohydrate

= =

carbohydrates in food groups
Carbohydrates in Food Groups
    • Starch: 1 serving equals about 15 grams carbohydrate
    • Fruit: 1 serving equals about 15 grams carbohydrate
    • Milk: 1 serving equals about 12 grams carbohydrate
    • Vegetables: 1 serving equals about 5 grams


    • Starchy Vegetables: 1 serving equals about 15 grams carbohydrate
starch group
Starch Group
  • Each amount listed below = 15 g carbohydrate
    • 1 slice of bread
    • ¾ c cereal
    • ½ c cooked cereal
    • ½ of an English muffin or small bagel
    • ⅓ c cooked pasta or rice
    • ½ hamburger or hotdog bun
    • ½ c mashed potatoes
    • ½ c corn, beans, chickpeas, peas
    • 1 small baked potato (3 oz)
fruit group
Fruit Group
  • Each amount listed below = 15 g carbohydrate
    • 1 small fresh fruit (4 oz)
    • ½ c canned fruit (in natural juice)
    • 2 T raisins or dried fruit
    • 17 grapes
    • ½ c fruit juice
    • 1 c melon or berries
    • ½ banana
milk group
Milk Group
  • Each amount listed below = approximately 12 g carbohydrate
    • 1 c skim, 1%, 2%, or whole milk
    • 3/4 c yogurt (6 oz)
    • 1 cup soy milk
vegetable group
Vegetable Group
  • Each amount listed below = 5 g carbohydrate
    • ½ c cooked vegetables
    • 1 c raw vegetables
    • ½ c vegetable juice
  • Remember - starchy vegetables (corn, peas, and potatoes) count as 15 g carbohydrate per serving
free foods
Free Foods
  • Free foods have 5 or fewer grams of carbohydrate
  • and fewer than 20 calories per serving.
  • They have no significant effect on blood glucose levels


Diet soft drinks, Club soda

Sugar-free drinks


Hot or iced tea (unsweetened)

Sugar-free gelatin


Sugar substitutes

Three or less servings per day

Sugar-free jam or jelly, 2 tsp

Ketchup, 1 T

Mustard, 2 T

Dill Pickle, 1 medium

Sugar-free popsicle, 1

Salsa, ¼ cup

Sugar-free syrup, 2 T

low carbohydrate foods
Low Carbohydrate Foods
  • Low carbohydrate foods differ from free foods in that they contain more calories per serving, and when eaten in large amounts can affect blood glucose levels.
  • For example: A serving of almonds (2 Tbsp) contains approximately 5 g carbohydrate, if you ate 2 servings (or 4 Tbsp) it would total 10 g carb!
  • Be mindful of serving sizes with low carb foods

Examples of carbohydrate-free or low carbohydrate snacks:

Cheese, 1 oz Cottage Cheese, ½ cup Tomato juice, ½ c

Meats, 1 oz Nuts or seeds, 2 T Raw Vegetables, 1 c

Hard boiled egg, 1 Beef jerky, 1 oz Peanut butter, 2 T

tools for carbohydrate counting
Tools for Carbohydrate Counting
  • Carbohydrate grams can be found using various sources:
    • CMC Menus
    • Food labels
    • Clinical diet manual
    • Dietitian or diet aide
consistent carbohydrate menus
Consistent Carbohydrate Menus

CMC provides CONSISTENT CARBOHYDRATE menus for diabetes management

  • The patient’s carb goal is written on the menu, the goal is based on physician orders and/or dietitian recommendations

Meal plans are based on individual needs and can range from 30 to over 90 g carb per meal, (the default meal plan is 60 g carb per meal)

  • The menus list the number of grams in each carbohydrate food item
  • Foods without carb grams listed contain either no carbohydrates or less than 5 grams per serving
  • At the end of a meal, total the grams of carb based on the patient’s intake
food labels
Food Labels
  • You will find the serving size

and grams of carb per serving

on food labels

  • Total Carbohydrates includes

all starches, sugars, and dietary


  • Always start by checking the

serving size on the label, if more than

1 serving is eaten, you need to do the math!

For example, if a patient ate 6 crackers, how many total grams did they actually eat?

What is the serving size on the label: 2 crackers

How many grams of Total Carb per serving: 10 g

How many servings did they actually eat: 3 servings

3 servings x 10 grams per serving = 30 g carb

clinical diet manual
Clinical Diet Manual
  • The Clinical Diet Manual includes all diets provided at CMC and can be accessed in two ways:

1. The manuals are located on each unit, look for the large

white binders, labeled “Clinical Diet Manual”

2. The manual is also available on CMC’s intranet

  • From the home page, click Departments, then click Nutrition, then Nutrition Manual
  • Scroll through to find “Diabetes -Consistent Carbohydrate Diet”
  • Food lists with carb grams are located on page 7-9
carbohydrate to insulin ratios
Carbohydrate-to-Insulin Ratios
  • The Carbohydrate-to-Insulin ratio (CHO : INSULIN) is the number of carbohydrate grams that 1 unit of insulin will cover

For example, if a patient has a ratio of 15:1, it means that for every 15 grams of Carbohydrates he/she eats, 1 unit of insulin must be injected -- so that blood glucose readings are within normal range two hours later

Based on the above ratio, if a patient eats 45 grams

of carbohydrate, how many units of insulin

do you need to give?

3 units

carb counting putting it all together
Carb Counting – Putting it all together
  • The goal is to include a variety of foods as long as the total carbs specified for each meal and snack stay about the same

For a patient on a 45 gram per meal plan, here are two different breakfasts that each total around 45 grams carb:


2 slices whole wheat toast 28 g

1 pkt Sugar-free jelly

Scrambled Eggs

½ cup Orange Juice 15 g

Coffee w/ sugar substitute ____

43 g


¾ cup Bran cereal 25 g

½ cup Skim milk 6 g

½ Banana 14 g

Coffee w/ sugar substitute


46 g

The goal is to come within a 10 gram range of the meal plan

  • Carb counting allows for improved blood glucose control
  • Carb counting is more flexible and allows for a greater variety of food choices
  • Being consistent is the key to successful carb counting
  • Carb counting increases the quality of diabetes care

For further information contact a clinical dietitian

hemoglobin a1c
Hemoglobin A1c
  • A1C is a lab test used to assess a patient’s average blood glucose level
  • The test measures the amount of glucose adherent to the hemoglobin protein in the patient’s red blood cells (RBCs). Since the average lifetime of RBCs is 3 months, A1C reflects the patient’s average blood glucose level during that time period. Conditions which affect RBCs such as profound anemia, recent transfusion, hemoglobinopathies & pregnancy may result in inaccurate results
  • An A1C below 7% is the target goal to reduce complications from chronically elevated blood glucose
  • There are tables which correlate A1C to average daily blood sugar
estimated gfr
Estimated GFR
  • eGFR , or estimated glomerular filtration rate, is a measure of kidney function. It is a calculated value based on the patient’s serum Cr (creatinine), age & gender.
  • Creatinine in the bloodstream comes predominantly from the normal breakdown of muscle. Cr is then removed from the bloodstream by the kidneys. Serum Cr will rise if kidney filtration is below normal. However, patients who are elderly, female or underweight generally have less muscle mass than average males, which will result in a lower serum Cr level. In these populations the Cr level may appear falsely normal even when their kidney function is markedly decreased.
  • The creatinine level will not be raised above the normal range stated by most laboratories until 60% of normal kidney function is lost. Therefore The National Kidney Foundation recommends the reporting of eGFR when a metabolic profile is ordered, as it is a more accurate reflection of kidney function.
estimated gfr1
Estimated GFR
  • Currently, the severity of Chronic Kidney Disease, (CKD), is described by 5 stages:
    • Normal kidney function: GFR> 90ml/min without proteinuria
    • CKD stage 1: GFR> 90 ml/min WITH proteinuria
    • CKD stage 2 (mild): GFR 60-89 ml/min
    • CKD stage 3 (moderate): GFR 30-59 ml/min
    • CKD stage 4 (severe): GFR 15-29 ml/min
    • CKD stage 5 (end stage renal disease): GFR<15 ml/min. Some of these patients are on dialysis; many are not.
  • Diabetes & hypertension are the two most common causes of chronic kidney disease (as well as of cardiovascular disease). Both diabetes and hypertension damage the kidney filtration system. Therefore CKD is an early marker for risk of cardiac disease, stroke and peripheral arterial disease.
advanced inpatient diabetes program at community medical center3

Advanced Inpatient Diabetes Program at Community Medical Center

Chapter 4: Management of Hypoglycemia

hypoglycemia management
Hypoglycemia Management
  • The goal of blood glucose(BG) management is to keep BG between 70 and 180 mg/dl as much of the time as is feasible and safe for each person.
  • When BG goes below 70 mg/dl, treatment is warranted to bring the BG back into the normal range.
hypoglycemia management1
Hypoglycemia Management
  • People who have become accustomed to frequent high BG’s may develop symptoms of hypoglycemia even when their BG is in the lower end of the normal range.
  • A small amount of food for treatment may be given to relieve these symptoms but the BG does not need to be elevated into the range above normal.
  • This “inappropriate” sensation of low blood glucose is called “pseudohypoglycemia.”
hypoglycemia management mild to moderate
Hypoglycemia Management Mild to Moderate
  • Symptoms of hypoglycemia may include feeling shaky, hunger, diaphoresis (sweating), rapid heart rate, pallor, difficulty concentrating, confusion, irritability or irrational behavior, blurred vision, slurred speech, slowed reaction time, or extreme fatigue.
hypoglycemia management pseudohypoglycemia
Hypoglycemia managementPseudohypoglycemia
  • When BG goes below normal, the body naturally releases epinephrine (adrenaline) which helps to make the BG rise again. (Epinephrine releases glucose molecules which had been stored in muscle and liver cells.) Most symptoms of hypoglycemia are actually caused by this epinephrine release, not by the low blood glucose itself.
hypoglycemia management pseudohypoglycemia cont
Hypoglycemia managementPseudohypoglycemia (cont)
  • This epinephrine may still be present in circulation even after the BG has been corrected back up to normal. Therefore, the symptoms of hypoglycemia may persist until the epinephrine wears off, even though the BG may already be normal. As long as the CBG (capillary blood glucose; finger stick test) is above 80 mg/dl, giving additional carbohydrate food is not helpful. Giving excessive carbohydrate food may then cause a subsequent high blood sugar, which is not helpful. The epinephrine related symptoms will resolve over the next half hour or so. If there is concern about the BG going low again, retest the CBG.
hypoglycemia management mild to moderate1
Hypoglycemia Management Mild to Moderate
  • Treat with 15 gm carbohydrate food such as 4 ounces of unsweetened fruit juice, 8 ounces of milk, 1 slice of bread, 3 graham crackers, 4 ounces of gelatin (“regular,” not sugar free).
  • When symptoms are more pronounced, a liquid form of carbohydrate may be preferred for faster absorption.
  • If the person is unable to take carbohydrate food orally, carbohydrate may be given as D-50 (50% dextrose) 25 ml (12.5 gm carb) IV push.
hypoglycemia management mild to moderate2
Hypoglycemia Management Mild to Moderate
  • It is not helpful to give more than 15 gm of carbohydrate initially.
  • Wait 15 minutes for the carbohydrate to be absorbed, then recheck capillary BG (CBG).
  • If BG is now above 80mg/dl, no further treatment is needed.
  • If BG is still below 80 mg/dl, give another portion of 15 gm of carbohydrate, wait another 15 minutes and retest CBG.
  • Repeat this cycle until BG is above 80 mg/dl, then stop.
hypoglycemia management mild to moderate3
Hypoglycemia Management Mild to Moderate
  • In most cases the BG will continue to rise after the 15 minute CBG is done. If there is concern about the BG going below normal again, retest the BG again after 15-30 minutes or as needed.
  • This technique is called the “15-15 Rule” (15 gm carbohydrate/15 minutes)
  • Symptoms of hypoglycemia may persist after the BG comes up into the normal range. As long as the BG is above 80 mg/dl, giving additional food or sugar is not helpful. The symptoms will resolve over the next half hour or so. If there is concern about the BG going low again, retest the BG.
hypoglycemia management severe
Hypoglycemia Management Severe
  • Severe hypoglycemia is defined as an episode during which the patient’s consciousness is sufficiently impaired that he/she cannot correct the problem without the assistance of another person. Symptoms of severe hypoglycemia include disoriented behavior, inability to swallow, loss of consciousness, inability to be aroused from sleep, or seizures.
hypoglycemia management severe1
Hypoglycemia Management Severe
  • Do not attempt to give oral food or liquid to a person who is unconscious, as this could cause aspiration.
  • Assess ABC’s (airway, breathing, and circulation) & treat accordingly. Do not leave the patient alone. Notify the physician immediately and administer 25ml of D-50 (50% Dextrose) ( ½ amp of 25g/50ml), given IV.
  • If there is no IV, administer glucagon IM. Dissolve 1 mg glucagon powder in 1 ml of diluent. Give the entire 1 ml for adults; give 0.5 ml (0.5 mg) for pediatric patients under 44 lb (20 kg). Try to obtain IV access.
  • The person should become responsive within about 15 minutes. If not, glucagon can be repeated. However, a more rapid correction of CNS effects of hypoglycemia will be obtained if D-50 can be given IV.
  • Glucagon can be given subQ if IM injection is contraindicated, but the response will likely be slower.
hypoglycemia management severe2
Hypoglycemia ManagementSevere
  • If glucagon has been given, then once the patient is responsive, give 15 gm of carbohydrate food orally. If the patient is treated with IV dextrose and not glucagon, he/she will be less likely to need additional carbohydrate food after regaining consciousness. However, either way, the patient should continue to be observed, with CBG checked periodically, such as every half hour or so, for a period of 1 to 2 hours. Additional carbohydrate food can be given orally if the BG goes below normal again.
  • Nausea can occur after severe hypoglycemia, especially if glucagon is given. If this occurs, and additional carbohydrate administration is needed, IV dextrose can be used again.
causes of hypoglycemia
Causes of Hypoglycemia
  • Common causes of hypoglycemia include:
    • Insulin errors: improper timing in relation to food, excessive insulin dose, or wrong type of insulin given
    • Erratic absorption of insulin: inadvertent IM injection of insulin; more rapid absorption due to baths or heat; injection into a body area which is physically active
    • Increased exercise: either prolonged or intense
    • Oral diabetes medications: inadequate food intake; overdose; renal failure leading to reduced clearance of medication
hypoglycemia management2
Hypoglycemia Management
  • After any episode of hypoglycemia is resolved, notify the patient’s physician/provider so that he/she can address strategies to prevent a repeat episode.
  • Before calling the provider, assemble information about events leading up to the hypoglycemia to help understand possible causes of the event. (Use SBAR technique.)
advanced inpatient diabetes program at community medical center4

Advanced Inpatient Diabetes Program at Community Medical Center

Chapter 5: Diabetes Medications

6 major classes of agents
6 Major Classes of Agents
  • Biguanides (metformin)
  • Thiazolidinediones (TZD’s): pioglitazone (Actos), rosiglitazone (Avandia)
  • Sulfonylurea secretagogues: glimepiride (Amaryl), glipizide (Glucotrol), glyburide (Micronase, Glynase, Diabeta)
  • Nonsulfonylurea secretagogues: repaglinide (Prandin), nateglinide (Starlix)
  • α-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset)
  • DPP-4 inhibitors (dipeptidyl-peptidase 4): sitagliptin (Januvia), saxagliptin (Onglyza)
  • GLP-1 agonists (glucagon-like peptide): exenatide (Byetta), liraglutide (Victoza)
type 2 diabetes pathophysiology
Type 2 Diabetes Pathophysiology
  • Insulin resistance
  • Causes BG to rise, especially after meals
  • Endogenous glucagon-like peptide 1 (GLP-1)and glucose-dependent insulinotropic polypeptide (GIP) lower BG levels by enhancing insulin secretion
  • Production of these hormones is insufficient in diabetes
  • Body cells don’t absorb fuel
improve insulin action
Improve insulin action

Biguanides: metformin

  • Reduces hepatic glucose production
  • Boosts insulin sensitivity in liver, muscle and fat
  • Little risk of hypoglycemia
  • Contraindicated in renal dysfunction, due to risk of lactic acidosis:
    • Serum Cr >1.5mg/dL men; >1.4 mg/dL women
    • Increased risk of lactic acidosis in dehydration, severe CHF or liver disease, history of alcohol abuse, or pre-existing metabolic acidosis.
  • It should be stopped day of surgery
  • It may be taken up to the time of any radiology or diagnostic imaging procedure.
  • It should not be restarted for at least 48 hours after contrast administration. Renal function should then be confirmed to be at normal levels before restarting metformin.
  • Adverse effects may include nausea, abdominal gassiness and cramping, or diarrhea. Take with a meal.
combat insulin resistance
Combat insulin resistance

TZD’s: pioglitazone (Actos), rosiglitazone (Avandia)

  • Used in combination with other diabetes meds
  • Not associated with hypoglycemia
  • Adverse effects: weight gain, fluid retention
  • Contraindicated in patients with class III or IV heart failure
increase insulin secretion
Increase insulin secretion

Sulfonylurea insulin secretagogues: glimepiride (Amaryl), glipizide (Glucotrol) and glyburide (Micronase, Glynase, Diabeta)

  • Stimulate the pancreas to increase insulin secretion
  • Need adequate β-cell function to be effective
  • Quick onset of action
  • Can cause hypoglycemia
  • Contraindicated in kidney or liver disease, sulfa allergy
increase insulin secretion1
Increase insulin secretion

Nonsulfonylurea insulin secretagogues or glinides: repaglinide (Prandin), nateglinide (Starlix)

  • Stimulate the pancreas to produce insulin in response to ingested carbohydrate
  • More rapid onset and shorter duration of action than sulfonylureas
  • Give 30 min before meal
  • Can cause hypoglycemia, but less so than sulfonylureas
slowing carbohydrate absorption
Slowing carbohydrate absorption

α-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset)

  • Slows intestinal absorption of carbohydrates. Should be given with the first bite of a meal.
  • As diabetes patients often have a slowing of insulin production this allows more time for internal insulin production to coordinate with the absorption of food.
  • May cause flatulence, bloating, abdominal discomfort, diarrhea.
  • Can cause hypoglycemia when used in combination with other diabetes meds. If this occurs, treat with glucose, not complex carbohydrates. (This is because the medication will delay the absorption of complex carbohydrates, including sucrose (table sugar). Glucose itself will still be absorbed normally.
restore incretin action
Restore incretin action
    • GLP-1 agonists: exenatide (Byetta), liraglutide (Victoza) injectable
    • DPP-4 inhibitors: sitagliptin (Januvia), saxagliptin (Onglyza) oral
  • Promotes insulin secretion
  • Suppresses glucagon release
  • Improves insulin sensitivity
  • Increases satiety. GLP-1 agonists may therefore facilitate weight loss. However, weight loss has not been seen with DPP-4 inhibitors.
combination therapy
Combination therapy

More than one agent to achieve glycemic


  • Metformin + glyburide (Glucovance)
  • Metformin + glipizide (Metaglip)
  • Metformin + rosiglitazone (Avandamet)
  • Metformin + pioglitazone (ActoPlusMet)
  • Metformin + sitagliptin (Janumet)
  • Longo, Rebecca; Understanding Oral Antidiabetic Agents; American Journal of Nursing, Vol. 110, No. 2, Feb. 2010, 49-52.
  • McCarron, Kim, Riebel, Tena; Spotlight on Type 2 Diabetes; Nursing Made Incredibly Easy, Sept/Oct 2008, 44-54. (Contact hours available)
  • Pearson, Kathleen; Improve Patient Safety with Glucose Control; Operating Room Nurse; June, 2008, 45-50.
  • Hall, Mellisa; Type 2 Diabetes: The Many Facets of Care; Home Healthcare Nurse; vol. 26, no.6, June 2008, 346-353. (Contact hours available)
advanced inpatient diabetes program at community medical center5

Advanced Inpatient Diabetes Program at Community Medical Center

Chapter 6: Contrast Induced Nephropathy and Metformin

contrast induce nephropathy cin
Contrast induce nephropathy (CIN)
  • Contrast- induced nephropathy (CIN) has become a significant source of hospital morbidity and mortality with the ever-increasing use of iodinated contrast media in diagnostic imaging and interventional procedures such as angiography in high-risk patients. It is the third most common cause of hospital-acquired acute renal failure after surgery and hypotension. [1]
  • Contrast-induced nephropathy is most commonly defined as acute renal failure occurring within 48 hours of exposure to intravascular radiographic contrast material that is not attributable to other causes. [2] An arbitrary range of values between 25% and 50% increase in serum Creatinine levels from baseline has been suggested to define contrast-induced nephropathy. [2,3]
complication renal failure
Complication-renal failure
  • Since acute renal failure has been documented as a complication in diabetic patients receiving contrast, baseline renal function is of concern prior to administration of intravascular contrast. CMC’s protocol requires all patients with diabetes have a baseline BUN, serum Creatinine and GFR done prior to administering IV contrast. This is especially important for patients receiving metformin–containing medications.
metformin induced lactic acidosis
Metformin induced lactic acidosis
  • Despite normal renal function, resources warn that metformin-containing medications should be held until kidney function (serum creatinine) is reassessed 48 hours later. This is to prevent, in the context of CIN (contrast induced nephropathy), high serum metformin concentrations, which could lead to lactic acidosis. [4] 8% of cases of metformin-induced lactic acidosis occur in the presence of contrast induced nephropathy. [5]
when to hold metformin
When to hold metformin
  • Metformin does not need to be held prior to receiving intravascular iodinated contrast. If contrast nephropathy occurs, typically serum creatinine starts rising 24-48 hours after exposure and peaks at 4-7 days. Creatinine values tend to return to normal within 7-14 days. [6]
cmc policy
CMC policy
  • Given this information, CMC hospital policy states that all patients receiving metformin-containing medications will have their metformin held for 48 hours post-procedure until a repeat BUN and Creatinine is drawn and renal function evaluated. If the Creatinine level is elevated the radiologist will be contacted to inquire if metformin needs to be held longer, if patient needs more hydration and/or repeat BUN and Creatinine testing. Oftentimes, it is determined that kidney function, though slightly reduced, is adequate to restart metformin. The patient will be contacted by the radiology nurse and/or the patient’s personal care provider for post lab instructions. The personal care provider will be notified of any abnormal rises in Creatinine.
mna credit hours 2 0
MNA Credit Hours-2.0
  • In order to receive continuing nursing education credit from MNA for this activity, please do the following:
  • Sign in to Healthstream and complete post test with a passing grade of 80% or better.
  • Complete MNA evaluation form located in the learning packets on your unit and return it to Education Dept. for a certificate of completion & attendance.
  • Tublin ME, Murphy ME. Tessler FN. Current concepts in contrast media-induced nephropathy . AJR 1998:171:933-939.
  • Barrett BJ, Parfrey PS: Prevention of the nephrotoxicity induced by radiocontrast agents. N England Journal Med 1994; 331-1449-1450.
  • Parfrey PS, Griffiths SM, Barrett BJ, et al. Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. N England J Med1989; 320:143-153.
  • Mathew R et al. Acute renal failure induced by contrast medium: steps towards prevention. BMJ 2006:333: 539-40.
  • Thomas HS, Morcos SK. Contrast media and the kidney: European Society of Urogenitial Radiology (ESUR) guideline. BR J 2003:76: 51-8.
  • Narang, R. et al. Contrast Induced Nephropathy. Indian Heart Journal. 2004; 56(1): 1-12.