Pharm Ch 32 Antidiabetic Drugs

NOTES

-if a pt is NPO for a test or procedure, make sure to check with doc to clarify orders for antidiabetic drug therapy -concerns for pts w/diabetes increase when pt is under stress, has an infection, illness or trauma or is pregnant or lactating -also concern when pt is using corticosteroids because they can raise glucose levels in the blood

Basal-Bolus Insulin Dosing

-preferred method of treatment for hospitalized diabetic pts -delivers basal insulin constantly as basal and as needed as bolus -basal is long acting insulin (glargine) and bolus is rapid acting insulin (lispro or aspart)

CHAPTER REVIEW QUESTIONS

1) Which is a rapid-acting insulin with an onset of action of less than 15 minutes? insulin aspart (NovoLog) Correct 2) Which long-acting insulin mimics natural, basal insulin with no peak action and a duration of 24 hours? insulin glargine (Lantus) Correct Insulin glargine has a duration of action of 24 hours with no peaks, mimicking the natural, basal insulin secretion of the pancreas. 3) Which insulin can be administered by continuous intravenous infusion? regular insulin (Humulin R) Correct Regular insulin is the only insulin used for intravenous therapy.

The nurse enters the patient's room to complete the discharge process and finds the patient to be lying in bed unresponsive and breathing. The patient has a blood glucose reading of 48 mg/dL. What is the most appropriate response by the nurse? C) Roll the patient to the side and administer the ordered glucagon.

Correct answer: C Rationale: Glucagon, a natural hormone secreted by the pancreas, is available as a subcutaneous injection to be given when a quick response to severe hypoglycemia is needed. Because glucagon injection may induce vomiting, roll an unconscious patient onto his or her side before injection. Glucagon is useful in the unconscious hypoglycemic patient without established intravenous access. The patient is at risk for aspiration so nothing should be administered by mouth. CPR is not indicated.

A male patient who has a history of type 2 diabetes mellitus is admitted to the medical unit with a diagnosis of pneumonia. The patient has many questions regarding his care and asks the nurse why everyone keeps telling him about hemoglobin A1C. The nurse will inform the patient that hemoglobin A1C provides information regarding: C)patient compliance with treatment regimen for several months previously.

Correct answer: C Rationale: Hemoglobin A1C is a good indicator of the patient's compliance with the therapy regimen for several months previously.

After the 0700 report, the day shift nurse notices that a patient has a 0730 dose of insulin due and goes to the automated dispensing machine to retrieve the insulin. The nurse sees that the night shift nurse had removed the 0730 dose of insulin, but the medication administration record (MAR) has not been signed by the nurse. The patient is confused and says "she thinks" the night nurse gave her the insulin. The patient's blood glucose level is 142 mg/dL. What will the day shift nurse do? C)Ask the charge nurse to call the night nurse at home to clarify whether the insulin was given.

Correct answer: C Rationale: Never guess whether a drug was given. Taking the drug out of the machine does not mean it was given. The nurse should ask the night nurse what was done.

A woman who has type II diabetes is now pregnant. She wants to know whether to take her oral antidiabetic medication. What instructions will she receive? C)She will be switched to insulin therapy while she is pregnant.

Correct answer: C Rationale: Oral antidiabetic medications are generally not recommended for pregnant patients because of a lack of firm safety data. Insulin therapy is the currently recommended drug therapy for pregnant women.

The patient was taking metformin before this hospitalization. To facilitate better glucose control, the patient has been switched to insulin therapy while hospitalized. The patient asks the nurse why it is so important to time meals with the insulin injection and to give him an example of a long-acting insulin. Which drug will the nurse tell the patient is a long-acting insulin? C)Insulin detemir (Levemir)

Correct answer: C Rationale: The nurse should inform the patient that timing of meals with insulin and oral antidiabetic therapy is important to prevent hypoglycemia and to obtain the most optimal results from the antidiabetic therapy. Insulin detemir (Levemir) is a long-acting insulin while insulin glulisine (Apidra) is a rapid-acting insulin. Insulin isophane suspension (NPH) is an intermediate-acting insulin, and regular insulin (Humulin R) is a short-acting insulin.

A patient with type 1 diabetes is admitted to the medical unit with an acute exacerbation of chronic obstructive pulmonary disease (COPD). He is placed on IVPB antibiotics, nebulizer treatments with albuterol, and an IV corticosteroid, and he is also taking a proton pump inhibitor for gastrointestinal esophageal reflux disease (GERD). He takes a dose of glargine insulin every evening. That evening the nurse notes that his blood glucose level is 170 mg/dL. The next morning, his fasting glucose level is 202 mg/dL. What is the most likely cause of his elevated glucose levels? D)The corticosteroid

Correct answer: D Rationale: Corticosteroids antagonize the hypoglycemic effects of insulin, resulting in elevated blood glucose levels.

The nurse has just administered the morning dose of a patient's lispro (Humalog) insulin. Just after the injection, the dietary department calls to inform the patient care unit that breakfast trays will be 45 minutes late. What will the nurse do next? D)Give the patient food, such as cereal and skim milk, and juice.

Correct answer: D Rationale: Lispro insulin's onset of action is 15 minutes. It is essential that a diabetic patient eat a meal after injection. Otherwise profound hypoglycemia may result.

The patient is being discharged home with insulin aspart (NovoLog) and insulin isophane suspension (NPH). Which information does the nurse include when providing discharge teaching to the patient? D)Draw up the insulin aspart (NovoLog) first, then the insulin isophane suspension (NPH) into the same syringe.

Correct answer: D Rationale: The rapid-acting (clear) then the intermediate-acting (cloudy) insulins should be mixed in the syringe after the appropriate amount of air has been injected. Insulin is stored at room temperature when it will be used within the month. The injection should be administered at a 90-degree angle for patients who have adequate body fat and at a 45-degree angle for patients who are very thin. Insulins should be rolled prior to administration and not shaken.

Type 2 Diabetes

- can sometimes manage w/lifestyle changes, diet and exercise or oral hypoglycemics, not always insulin dependant; can control with insulin when above no longer provides glycemic control -most commonly presents in adults, due to inactivity and weight gain; most common type, 90% of all cases; caused by insulin resistance and deficiency; -COMORBID conditions - obesity, CHD, dyslipidemia, hypertension, microalbuminemia (protein in urine), increased risk for clots; these conditions are referred to as metabolic syndrome or insulin resistance syndrome or syndrome x -It is recommended that type 2 pts be on aspirin and antihyperlypemic therapy

Type 1 Diabetes

- insulin dependent TREATMENT with daily insulin therapy; -genetic disorder w/complete or nearly complete lack of insulin production, most often in kids/adolescents; -fewer than 10% of diabetics; -KETOACIDOSIS(DKA): body can't use glucose as fuel source because no insuline, so body uses fat instead, is normally first sign pt has type 1 diabetes;

Hypoglycemia

-abnormally low blood glucose level (below 50 mg/dL) -mild cases can be treated w/diet; higher protein intake, lower carb intake, prevent rebound hypoglycemia -early symptoms are confusion, irritability, tremor, sweating -late symptoms are hypothermia, seizures; coma and death can occur if not treated -oral forms of concentrated glucose can be given; 50% dextrose in water; glucagon subcut -If hypoglycemia occurs: admin oral glucose if pt conscious; give tablets or gel, corn syrup, honey, fruit juice, nondiet soda or have pt eat small snack like crackers or half sandwitch; deliver D50W or glucagon IV if pt is unconscious; monitor levels

Gestational Diabetes

-hyperglycemia that develops during pregnancy; -insulin must be given to prevent birth defects (no oral meds) -30% of pts may develop type 2 w/in 10-15 yrs

Injectable Antidiabetic Drugs

-only used when others are ineffective

Sliding Scale Insulin Dosing

-subcu short-acting or regular insulin doses adjusted according to blood glucose test -typically used in hospitalized pts or those on TPN or enteral tube feedings -disadvantages are delays in insulin admin until hyperglycemia occurs, results in lg swings in glucose control

Oral Antidiabetic Drugs (Type 2 pts)

-Biguanides (Metformin)-do not increase insulin secretion; decrease prod of glucose by liver, intestinal absorption of glucose and increase uptake of glucose by tissues; adverse affects primarily affect GI tract, metallic taste, lactic acidosis rare but lethal; do not cause hypoglycemia -Sulfonylureas-stimulate insulin secretion from the beta cells of the pancreas, increasing insulin levels; adverse include hypoglycemia, hematologic effects, GI -Glinides-action similar to sulfonylureas; increase insulin secretion from the pancreas; shorter duration and take with each meal; adverse effects headache, hypoglycemic, weight gain, joint pain, resp infection or flulike symptoms -Thiazolidinediones- show onset, high cost, reserved for pts who can't tolerate the other drugs; increase risk of heart failure; decrease insulin resistance; adverse effects weight gain, edema, anemia, hepatic toxicity (monitor ALT levels) -Alpha-glucosidase inhibitors - less common, delayed absorption of glucose; adverse effects flatulance and diarrhea

Diabetes Mellitus

-Type 1 & Type 2 -SIGNS AND SYMPTOMS-elevated fasting blood glucose (>125mg/dL) or hemoglobin A1C >6.5; polyuria (pee), polydipsia (thirsty), polyphagia (hungry) -major long-term complications of both types include atherosclerotic plaque in arteries and vessels and capillary damage (retinopathy, neuropathy and nephropathy) -*screening recommended every 3 yrs for all pts 45 and older* -PREDIABETES- fasting glucose over *100mg/dL but less than 126mg/dL and A1C 5.7-6.4*

Insulins

-substitute for endogenous insulin; restores ability to metabolize carbs, fats and proteins, store glucose in liver and convert glycogen to fat stores -Human Insulin - derived using recombinant DNA, produced by bacteria and yeast -*RAPID ACTING- most rapid onset of action 5-15 minutes, shorter duration; pt MUST eat a meal after injection*; lispro (Humalog) and glulisine (Apidra) are both common; given subcu or infusion pump, NOT IV -*SHORT ACTING- regular insulin* (Humulin R); onset 30-60 minutes; only insulin product that can be given IV bolus, IV Infusion or IM -INTERMEDIATE ACTING- isophane suspension (NPH); cloudy appearance; slower in onset and more prolonged in duration than endogenous insulin -LONG ACTING- glargine (Lantus) or detemir (Levemir); clear colorless solution usually dosed once daily; referred to as BASAL insulin -FIXED COMBOS - combine long/short acting insulins, such as humulin 70/30 -when insulin is ordered, prepared doses are second checked with another nurse -always check glucose levels before giving insulin; roll vials between hands instead of shaking when mixing suspensions -ONLY use insulin syringes, calibrated in unites, to measure and give insulin -ensure correct timing w/meals -desired fasting blood glucose level for diabetic pt is 70-130mg/dL and A1C less than 7 -store insulin for current use at room temp, extra vials should be kept in refrigerator - never give cold insulin, avoid sunlight -when drawing up 2 types of insulin in one syringe, always withdraw the regular or rapid acting insulin first

CHAPTER REVIEW QUESTIONS

10) The nurse would include which statement when teaching a patient about insulin glargine? "You cannot mix this insulin with regular insulin and thus will have to take two injections." Correct Insulin glargine is a long-acting insulin with duration of action up to 24 hours. It should not be mixed with any other insulins. 11) The nurse is providing education to a patient about the time to take glipizide (Glucotrol). For maximum benefit, the nurse will tell the patient to administer glipizide at which time? 30 minutes before a meal Correct Glipizide works best if given 30 minutes before meals. This allows the timing of the insulin secretion induced by the glipizide to correspond to the elevation in the blood glucose level induced by the meal. 12) The nurse will advise the patient to treat hypoglycemia with which drug? glucagon Correct Glucagon stimulates glycogenolysis, raising serum glucose levels. 13) When caring for a patient newly diagnosed with gestational diabetes, the nurse would question an order for which drug? glipizide (Glucotrol) Correct Oral antidiabetic drugs are generally not recommended for pregnant patients.

CHAPTER REVIEW QUESTIONS

14) Which information should be included in a teaching plan for patients taking oral hypoglycemic drugs? (Select all that apply.) CorrectLimit your alcohol consumption. CorrectReport symptoms of anorexia and fatigue. CorrectNotify your physician if blood glucose levels rise above the level set for you. Oral hypoglycemic drugs must be taken on a daily scheduled basis to maintain euglycemia and prevent long-term complications of diabetes. 15) Which actions describe the beneficial effects produced by sulfonylurea oral hypoglycemics? (Select all that apply.) CorrectStimulate insulin secretion from beta cells CorrectEnhance action of insulin in various tissues CorrectInhibit breakdown of insulin by liver The sulfonylureas stimulate insulin secretion from the beta cells of the pancreas; enhance the actions of insulin in muscle, liver, and adipose tissue; and prevent the liver from breaking insulin down as fast as it ordinarily would (reduced hepatic clearance). Increased hepatic glucose production would serve to increase serum glucose levels, the opposite effect of oral hypoglycemic drugs.

CHAPTER REVIEW QUESTIONS

4) Assuming the patient eats breakfast at 8:30 AM, lunch at noon, and dinner at 6:00 PM, he or she is at highest risk of hypoglycemia following an 8:00 AM dose of NPH insulin at what time? 5:00 PM Correct Breakfast eaten at 8:30 AM would cover the onset of NPH insulin, and lunch will cover the 2 PM time frame. However, if the patient does not eat a mid-afternoon snack, the NPH insulin may be peaking just before dinner without sufficient glucose on hand to prevent hypoglycemia. 6) The nurse is caring for a patient scheduled to undergo a cardiac catheterization procedure utilizing iodine-based contrast material. The nurse would question an order for which medication to be given to this patient the day before the scheduled procedure? metformin (Glucophage) Correct The concurrent use of metformin and iodinated (iodine-containing) radiologic contrast media has been associated with both acute renal failure and lactic acidosis. Therefore metformin should be discontinued at least 48 hours prior to any radiologic study requiring such contrast media and should be held for at least 48 hours after the procedure.

CHAPTER REVIEW QUESTIONS

7) Which oral hypoglycemic drug has a quick onset and short duration of action, enabling the patient to take the medication 30 minutes before eating and skip the dose if he or she does not eat? repaglinide (Prandin) Correct Repaglinide is known as the "Humalog of oral hypoglycemic drugs." The drug's very fast onset of action allows patients to take the drug with meals and skip a dose when they skip a meal. 8) Pramlintide (Symlin) is added to the treatment plan for a patient with type 1 diabetes. What information about the action of this medication does the nurse include in the patient teaching? Pramlintide slows gastric emptying. Correct Pramlintide is a synthetic form of the naturally occurring hormone amylin. It works by slowing gastric emptying, suppressing glucagon secretion, and centrally modulating appetite and satiety. It is only administered subcutaneously. 9) The patient is prescribed 30 units regular insulin and 70 units NPH insulin subcutaneously every morning. The nurse will provide which instruction to the patient? "Draw up the regular insulin into the syringe first, followed by the cloudy NPH insulin." Correct Drawing up the regular insulin into the syringe first prevents accidental mixture of NPH insulin into the vial of regular insulin, which could cause an alteration in the onset of action of the regular insulin.