Chapter 39: Drug Therapy for Diabetes Mellitus

A nurse is providing patient education to a 13-year-old girl who was just diagnosed with type 1 diabetes mellitus. Which of the following statements by the patient will alert the nurse that special instructions regarding insulin are necessary? a) "We live in a two-story house." b) "My mother is going to give me my insulin." c) "I walk two blocks to school every day." d) "I am on the middle school track team."

"I am on the middle school track team." Explanation: Because the patient is on the track team, she will have increased exercise at various times that will require increased insulin and special instructions related to hypoglycemia that may come hours after she has ceased exercising. Walking two blocks every day and walking up stairs would not be considered increased physical exercise and would not be a factor. Wanting to have her mother administer the insulin is not uncommon for this age patient, and the nurse would normally instruct both the mother and the daughter in the administration of the drug.

What instructions would be important to give to a 50-year-old client with type 2 diabetes who has been switched from glyburide (DiaBeta), a sulfonylurea, to repaglinide, a meglitinide? a) "It is more potent and longer lasting, so you should take it every other day." b) "It is less potent, so you will need to take a larger dose." c) "The two medications are virtually the same." d) "It stimulates insulin production, so you need to eat soon after taking the medication."

"It stimulates insulin production, so you need to eat soon after taking the medication." Explanation: Glyburide's onset of action is 2 to 4 hours, and its duration is 24 hours. Repaglinide's onset of action is within 30 minutes, peak is 1 hour, and duration is approximately 3 to 4 hours. Repaglinide is taken 15 to 30 minutes before each meal because it stimulates the pancreas to secrete insulin to correspond to the food intake. If there is no food intake, the person is at risk of hypoglycemia. Glyburide, a sulfonylurea, also stimulates pancreatic cells, but not until 2 to 4 hours after it is taken. Repaglinide is not less potent, it is not more potent, and the two medications are not virtually the same.

A 59-year-old man with type 2 diabetes is prescribed metformin. When the patient returns to the clinic, he reports that he has lost 8 pounds in a month. How should the nurse respond? a) "Please continue taking the medication and monitoring your weight. This is an expected outcome of this drug therapy." b) "You should discontinue this medication immediately. I will contact your physician." c) "We should really report this to your physician. He will likely change medications." d) "We should really report this to your physician. The metformin dosage will need to be decreased."

"Please continue taking the medication and monitoring your weight. This is an expected outcome of this drug therapy." Explanation: The nurse should advise the patient to continue therapy as prescribed because weight loss is a beneficial adverse effect for type 2 diabetics. The patient need not seek a decrease in dosage or change in medication. Nor would discontinuation of the drug be warranted.

characteristics of intermediate-acting insulin

* only given sub-Q * commonly used for long term administration * modified by addition of protamine, a protein and zinc * cloudy appearance when correctly mixed in the vial * not recommended for acute situations * hypoglycemic reactions are more likely to occur during mid to late afternoon

15. Choice of Insulin

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16. Insulin Use in children

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17. Glyburide action

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pediatric diabetologist recommend maintaining blood glucose levels between -

100-200 milligrams per deciliter to prevent hypoglycemia. in addition , the bedtime snack and blood glucose measurement should never be skipped.

approx 75% of newly dx. cases of type 1 diabetes occur in people under the age of ___.

18

A nurse is assigned to administer glargine to a patient at a health care facility. What precaution should the nurse take when administering glargine? a) Administer glargine via IV route. b) Administer insulin that has been refrigerated. c) Avoid mixing glargine with other insulin. d) Shake the vial vigorously before withdrawing insulin.

Avoid mixing glargine with other insulin. Explanation: When administering glargine to the patient, the nurse should avoid mixing it with other insulin or solutions. It will precipitate in the syringe when mixed. If glargine is mixed with another solution, it will lose glucose control, resulting in decreased effectiveness of the insulin. Glargine is administered via SC once daily at bedtime. The nurse should not shake the vial vigorously before withdrawing insulin. The vial should be gently rotated between the palms of the hands and tilted gently end-to-end immediately before withdrawing the insulin. The nurse administers insulin from vials at room temperature. Vials are stored in the refrigerator if it is to be stored for about three months for later use.

A nurse is caring for a patient who has developed a hypoglycemic reaction. Which of the following interventions should the nurse perform if swallowing and gag reflexes are present in the patient? a) Give oral fluids or candy. b) Administer glucagon by the parenteral route. c) Administer the insulin via insulin pump. d) Administer oral antidiabetics to the patient.

Correct response: Give oral fluids or candy. Explanation: The nurse should administer oral fluids or candy to the hypoglycemic patient with swallowing and gag reflexes. If the patient is unconscious the nurse should administer glucose or glucagon parenterally. The nurse should administer insulin through an insulin pump to special categories of diabetic patients, such as pregnant women with diabetes and renal transplantation. Oral antidiabetic drugs are administered to patients with type 2 diabetes.

Your client is admitted to the intensive care unit with diabetic ketoacidosis. You know that your client will be placed on an intravenous insulin drip. The only type of insulin which can be administered intravenously is: a) NPH. b) Ultralente. c) Regular. d) Lente.

Correct response: Regular. Explanation: In general, regular insulin, a short-acting insulin, is used with major surgery or surgery requiring general anesthesia. IV administration of insulin is preferred because it provides more predictable absorption than subcutaneous injections. Only regular insulin is administered IV.

children of ethnic/minority groups such as ____,_____,_____,_____,and _______ are disproportionately affected.

Native Americans, Native Alaskans, african americans, mexican americans, and pacific islanders

A nurse is caring for a patient with type 2 diabetes receiving a meglitinide. For which of the following conditions of the patient is meglitinides contraindicated? a) Kidney disease b) Severe heart failure c) Liver disease d) Diabetic ketoacidosis

Diabetic ketoacidosis Explanation: Meglitinides are contraindicated in patients with diabetic ketoacidosis and type 1 diabetes. Thiazolidinediones are contraindicated in patients with severe heart failure and used with caution in patients with kidney disease, severe heart failure, and liver disease

The pathophysiology class is studying diabetes. A student asks the instructor what is considered a sign of a hypoglycemic reaction. The instructor's response would be what? a) Dry, flaky skin b) Diaphoresis c) Fruity breath d) Flushing of the face

Diaphoresis Explanation: Diaphoresis and cool, clammy skin are signs of hypoglycemia. A fruity breath is seen with ketoacidosis. Flushing of the face is associated with hyperglycemia

The pathophysiology class is studying diabetes. A student asks the instructor what is considered a sign of a hypoglycemic reaction. The instructor's response would be what? a) Fruity breath b) Dry, flaky skin c) Diaphoresis d) Flushing of the face

Diaphoresis Explanation: Diaphoresis and cool, clammy skin are signs of hypoglycemia. A fruity breath is seen with ketoacidosis. Flushing of the face is associated with hyperglycemia.

A young man has been diagnosed with type 2 diabetes and has been prescribed glyburide. Which of the following statements suggests that the nurse should perform further health education? a) "I know that glyburide won't cure my diabetes, but it will help me have safe blood sugar levels." b) "I'll plan to take my glyburide each night before I go to bed." c) "I'll make sure to check with my doctor before I start taking any other medications." d) "I'll keep in mind that glyburide can possibly cause me to have low blood sugar."

Glyburide is normally taken in the morning, before breakfast. No drug cures diabetes; the goal of therapy is the maintenance of safe blood glucose levels. The patient should check before taking other drugs and should indeed be aware of the risk of hypoglycemia.

Which of the following is the best indicator of overall diabetic control? a) Fasting blood glucose levels b) 2-hour postprandial blood glucose levels c) Glycosylated hemoglobin levels d) Absence of acetone in the urine

Glycosylated hemoglobin levels Explanation: The glycosylated hemoglobin indicates glucose bound to hemoglobin in red blood cells (RBCs) when RBCs are exposed to hyperglycemia. The binding is irreversible and lasts for the lifespan of RBCs (approximately 120 days). The test reflects the average blood sugar level during the previous 2 to 3 months. The goal is usually less than 7% (blood level 0.07). The range for people without diabetes is approximately 4% to 6% (blood level 0.04 to 0.06).

The nurse is explaining the action of exenatide to a patient. Which of the following would the nurse include? a) Increase in protein building b) Increase in glucagon release c) Increase in insulin resistance d) Increase in GI emptying

Increase in insulin resistance Explanation: Exenatide is an incretin mimetic, which increases insulin release, decreases glucagon release, stimulates the satiety center, and slows GI emptying.

A patient is admitted to the Emergency Department in diabetic ketoacidosis (DKA) with a blood glucose level of 33 mmol/L. The physician orders an initial dose of 25 U insulin IV. Which type of insulin will be administered? a) Regular insulin b) Humulin N insulin c) NPH insulin d) Humulin L insulin

Regular insulin Explanation: Regular insulin is a short-acting insulin that manages the hyperglycemia and hyperkalemia of DKA (diabetic ketoacidosis), which is a life-threatening complication that occurs with severe insulin deficiency. Humulin N, Humulin L, and NPH are intermediate-acting insulins

Insulin lispro, aspart, or glulisine may be used instead of -

Sub-Q regular insulin in most situations, but safe usage requires both health care providers and patients to be aware of differences.

lactic acidoses

a rare but serious adverse effect, approx 50% fatal. most likely with renal or hepatic impairment, advanced age, or hypoxia. this is a medical emergency that requires hospitalization for treatment.

diabetes in children usually appears after _______ years of age and peaks in incidence at ___ to ___ yrs for girls and ___ to ___ years for boys.

after 4 yrs of age 10 to 12 for girls 12 to 14 for boys

18. Other drug in class - Glipizide

an oral sulfonylureas. give 30 mins b4 breakfast and the evening meal to promote absorption and effictive plasma levels.

GI effects with metforman-

anorexia, nausea, vomiting, diarrhea, abdominal discomfort, decreased intestinal absorption of folate and vitamin B12.

______ and ______ do not develop normally in children withou adequate supply of glucose.

brain , spinal cord

S/S of hypoglycemia in young children

changes in behavior, including severe hunger, irritability, and lethargy mental functioning may be impaired in all age groups.

reasons to stop metforman include

decreased renal or hepatic function, a prolonged fast, or a very low calorie diet.

metforman and lactic acidosis-

drowsiness, malaise, respiratory destress, bradycardia and hypotension if severe blood lactate levels above 5 mmol/L, blood pH belowe 7.35.

allergic skin reactions on metforman

eczema, pruritus, erythema, urticaria

what is extremely important in promoting normal growth and development in children w/ diabetes

food intake synchronized w/insulin injections and usually involves three meals and three snacks, all at regular schedule times.

Regular insulin - insulin injection

has a rapid onset of action and can be given IV. Therefore, it is the insulin of choice during acute situations, such as DKA, severe infection or other illness, and surgical procedures.

___________ is effective in correcting acidosis and removing ___________.

hemodialysis and metforman

20. Pramlintide (Symlin)

inject sub-q into abdomen or thigh before meals. do not mix in same syringe with insulin. insulin dosage will be reduced by 50%. Rotate injection sites and do not administer at same site as insulin. opened vials can be kept in the refridgerator or at room temp for up to 28 days.

pramlintide injection is not recommended in the arm because -

injection in the arm results in variable absorption and is not recommended

________ is the only drug indicated for use, it is required as replacement therapy because affected children cannot ________.

insulin, insulin

Isophane insulin - NPH is often used for -

long- term insulin therapy. For many patients, a combination of NPH and a short-acting insulin provides more consistent control of blood glucose levels. Although several regimens are used, a common one is a mixture of regular and NPH insulin administered before the morning and evening meals. A commercial mixture is more convenient and probably more accurate than a mixture prepared by a patient or caregiver, if the proportions of insulinsvare appropriate for the patient.

lactic acidosis may be prevented by -

monitoring plasma lactate levels and stopping the drug if they exceed 3 mmol/L .

metforman should be stopped immediately if a pt has a

myocardial infarction or septicemia

Metforman and hepatic impairment

not recommended because of risk of lactic acidosis may be increased.

Hypoglycemia often develops in young children , partly because -

of anorexia and smaller glycogen reserves

__________________ are also approved for use in external insulin pumps that administer a sub-Q continuous infusion.

regular insulin, insulin aspart, and insulin glulisine

rotation of injection sites is important in children because-

relatively small area for injections at each anatomic site and to prevent lipodystrophy.

19. Metformin contraindication requirement before starting

requires assessment of renal-function before starting and at least annually during long-term therapy. it should be stopped if renal impairment occurs during treatment.

less than optimal treatment in children can lead to -

stunted growth, delayed puberty, and early development of complications such as retinopathy, nephropathy, or neuropathy.

how to minimize GI upset on metforman

take drug with meals and increasing dosage slowly.