Pharm Notes/Practice Questions Exam 3

Noninsulin Injectable Agents (Amylin Analog and Glucagon-like Peptide-1 (GLP-1) Receptor Agonists)

Increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, delay gastric emptying - watch for hypoglycemia

Neurologic Manifestations of HHS

1. Somnolence 2. Coma 3. Seizure 4. Hemiparesis 5. Aphasia

Regular Exercise (6)

1. reduces triglyceride, LDLs, cholesterol 2. Increase HDLs 3.Reduces BP 4. Improve circulation 5. Decreases insulin resistance 6. Weight loss

Nursing Management (Health Promotion)

Identify the risk 1.Being more than 20 percent above the ideal body weight 2. having a mother, father, brother, or sister with diabetes 3.Giving birth to a baby weighing more than 9 lbs or having diabetes during pregnancy 4. having blood pressure at or above140/90 mmHg 5. African American, American Indians, Hispanic, Asian.

Two-hour plasma glucose level

≥ 200 mg/dL

Random plasma glucose

≥ 200 mg/dL plus symptoms

Oral Agents (α - Glucosidase Inhibitors) (4)

1. Acarbose (Precose) 2. Delay the absorption of glucose in the intestines by slowing down the absorption of carbohydrate in the small intestine. 3. Take with the first bite of the meal, effective on controlling post-prandial blood glucose, effectiveness to be measured 2 hours after the meal. 4. Check 2-hour postprandial glucose levels

Nursing Management (5)

1. Active patient participation 2. Few or no episodes of acute hyperglycemic emergencies or hypoglycemia 3. Maintain normal blood glucose levels 4. Prevent or delay chronic complications 5. Lifestyle adjustments with minimal stress

Diabetic ketoacidosis (DKA) Interventions (4)

1. Airway patency, O2 administration 2. Correct fluid/electrolyte imbalance -IV infusion 0.45% or 0.9% NaCl to restore urine output and raise blood pressure -Early potassium replacement - insulin drives potassium into the cells and lead to hypokalemia (Cardiac Monitoring EKG) -Insulin therapy start when fluid resuscitation begins and potassium is normal -When blood glucose levels approach 250 mg/dl, 5%-10% dextrose added to regimen to prevent hypoglycemia/cerebral edema 3. IV Insulin directed towards correcting hyperglycemia and hyperketonemia -Insulin started at 0.1U/kg/hr by a continuous infusion. -Blood glucose reduction of 36 to 54 mg/dL/hr will avoid complications -Monitor fluid balance and potassium levels 4. Monitor patients with renal or cardiac compromise for fluid overload.

Type 1 DM (7)

1. Autoimmune disease, peak onset by 20 years old 2. Insulin dependent 3. Rapid & Acute 4. Classic symptoms: Polyuria, Polydipsia, Polyphagia 5. Others: weight loss, weakness, fatigue 6. There is an absence of endogenous insulin 7. Exposure to virus or genetic predisposition can cause onset

Exercise & Self-monitoring blood glucose (8)

1. Need medical clearance before exercise 2. Best to exercise 1-2 hours after meals 3. Small carbohydrate snacks can be taken during exercise to prevent hypoglycemia (10-15 g) 4. Monitor blood glucose levels before, during, and after exercise, keep hard candy 5. Hold exercise if glucose ≤ 100 mg/dl or if ≥ 250 mg/dL and ketones are present in the urine. 6. When patient is ill, blood glucose should be tested at least every 4 hours 7. Recommended exercise: 150 min/week (30min/ 5 days) 8. Exercise can increase body's sensitivity to insulin

Counterregulatory hormones

1. Oppose the effects of insulin by increasing blood glucose levels 2. Respond to a decline in blood glucose level during fasting or overnight 3. Stimulate lipolysis, gluconeogenesis, and glycogenolysis processes 4. Examples: glucagon, epinephrine, growth hormone, and cortisol

Nursing Management (DKA & HHS)

1. Patient closely monitored 2. Administration - IV fluids - Insulin therapy - Electrolytes (Patient may throw up) 3. Assessment - Cardiac monitoring - EKG - Renal status: , Is and Os, tissue turgor, laboratory values - Cardiopulmonary status; Lung Sounds (Crackles, to assess fluid buildup) - Level of consciousness - Vital Signs (Fever, Hypovolemic shock, Tachycardia, Kussmaul Respiration)

Oral Agent (Thiazolidinediones) (4)

1. Pioglitazone (Actos), Rosiglitazone (Avandia) 2. Insulin sensitizers, improves insulin sensitivity, transport, and utilization at target tissues. 3. Do not increase insulin production. Thus will not cause hypoglycemia; impair liver function and do not use in pt. with MI, stroke or heart failure. 4. Increased change of bladder cancer; Pioglitazone (Actos)

Amylin Analog (9)

1. Praminitide (Symlin) 2. Amylin is secreted by B-cells of the pancreas 3. Slows gastric emptying 4. Reduces glucagon secretion 5. Increase satiety 6. Used concurrently w/insulin 7. Increase the risk of hypoglycemia during 3 hours of injection w/insulin 8. Eat a meal w/at least 250 calories 9. >1 hour before injecting Byetta.

Nursing Management (Ambulatory and home care) (6)

1. Reach an optimal level of independence 2. Insulin therapy and oral agent 3. Personal hygiene with emphasis on foot care 4. Medical identification and travel card 5. Patient and family teaching 6. Learn early symptoms of hyperglycemia and hypoglycemia

Combination Insulin Therapy (5)

1. Short- or rapid-acting combined with intermediate-acting or long-acting insulin to provide basal-bolus coverage 2. Commercially premixed formula available: 70/30, 75/25, 50/50, 70% is NPH and 30% is Regular. 3. Premixed is good for people who lack visual, manual, or cognitive skills to mix insulin themselves. 4. DRAWBACK: less optimal blood glucose control because less opportunity for flexible dosing based on need. 5. Air in NPH then follow Regular Insulin (RN).

Oral Agent (Dipeptidyl peptidase-4 (DDP-4) Inhibitors) (5)

1. Sitagliptin (Januvia) 2. DDP-4 inhibitors block the action of the DDP-4 enzyme which is responsible for inactivating incretin hormones 3. This results in increase in insulin release, decrease in glucagon secretion, and decrease in hepatic glucose production 4. Glucose dependent, lower risk for hypoglycemia 5. NO weight gain

Administration of insulin (5)

1. Subcutaneous, or IV (only for Regular insulin) 2. Fastest absorption from abdomen, followed by arm, thigh, buttock (Figure 49-5) - Do not inject in a site that is to be exercised (Injecting insulin in the muscle site that will be exercise will be painful later and will take longer to absorb) 3. Rotate injections within one particular site (1 week) - no need to rotate sites 4. Usually available concentration as 100 units of insulin/ml (U100) 5. Leave syringe in place for 10 seconds

Hypoglycemia

Low blood glucose < 70 mg/dl Cause: mismatch in timing of food intake and peak action of insulin or oral hypoglycemic agents

Hyperosmolar hyperglycemic syndrome (HHS) Manifestations

1. Common in patients over 60 years with type 2 2. Caused by dehydration - require greater fluid replacement 3. Patient has enough circulating insulin so ketoacidosis does not occur (Absent/minimal ketone bodies in blood or urine) 4. Produces fewer symptoms in earlier stages 5. Glucose >600 mg/dL, 6. Enough insulin to prevent DKA

Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (7)

1. Exenatide (Byetta) 2. Decrease w/ people who have type 2 3. Increase insulin synthesis and release from the pancreas 4. Inhibit glucagon secretion 5. Decrease gastric emptying 6. Reduce food intake by increasing satiety 7. Delayed absorption affects oral drugs (take those first an hour before injection)

Nutritional Therapy (4 +goal)

1. Food composition - achieve glucose, lipid, blood pressure goals. - Carbohydrates: should be ≥ 130 g/day (45 - 60 carbs/meal) , fiber intake 25-30 g/day - Fats - saturated fat <7% of total calories, < 200 mg/day of cholesterol, limited transfats - Protein - 15-20% of total calories, high-protein diet is not recommended 2. Alcohol: can cause severe hypoglycemia, should be consumed with food - Male: 2 glass of wine, - Female: 1 glass of wine, - Avoid Beer (Carbs) - Drink with something to eat, if not liver will be busy breaking down alcohol and can cause hypoglycemia 3. Low sodium - prevent hypertension 4. Teaching meal plan: Carbohydrate counting GOAL: Match exercise, insulin and meal time

Diagnostic Studies - Prediabetes

1. Hemoglobin A1C (Hb A1C): 5.7% - 6.4% 2. Impaired fasting glucose (IFG): 100 mg/dl - 125 mg/dl 3. Impaired glucose tolerance (IGT): 2-hour oral glucose tolerance test (OGTT) level 140 -199 mg/dl

Oral Agent (Biguanides) (8)

1. Metformin (Glucophage) 2. Reduce glucose production by liver 3. Do not use in pt. with kidney disease, liver disease or heart failure. Hold it before and 48 hours after the procedure requiring contrast or till kidney function is normal. 4.It enhances insulin sensitivity at the level and improves glucose transport into the cell. 5.Beneficial effects on plasma lipids. 6. First choice drug for most people w/ type 2 diabetes because it causes moderate weight loss. More for patients that are overweight. 7. Prevention for prediabetes patients who are less than 60 and have risks factors such as hypertension or a history of gestational diabetes 8. IV dyes need to be held because Contract can cause necrosis of kidney tissue, insulin can cause lactic acidosis.

Diabetic ketoacidosis (DKA) Manifestations (7)

1. Hyperglycemia (glucose > 250 mg/dl) 2. Ketosis (ketones in blood and urine) 3. Acidosis (blood PH < 7.3, bicarbonate < 16 mEq/L) 4. Dehydration (poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension) 5. Kussmaul respirations: rapid deep breathing to attempt to reverse metabolic acidosis, bicarbonate consumed by body 6. Sweet fruity odor (acetone), abdominal pain, nausea/vomiting 7. Early symptoms include lethargy and weakness.

Hypoglycemic Intervention (10)

1. Hypoglycemic symptons may occur when very high blood glucose high blood glucose levels of 300 mg/ dL falling quickly to 180 mg/dL 2. If patient has history of chronic poor glycemic control, assume hypoglycemia and begin treatment. 3. Rule of 15: Eat/drink 15 g of quick-acting carbohydrate (4 - 6 oz soda, 8 - 10 lifesavers, etc.), wait 15 min, check glucose, too low, another 15 g 4. After 40 minutes, check again for safety 5. If no response to simple sugar, call doctor & do IV push of insulin w/50% dextrose. 20mL - 50mL 6. If not available (nursing home) Give 1 mg glucagon in an IM injection 7. Do not let it run under 70 mg/dL 8. What is best option to treat hypoglycemia? Candy bar not the best option 9. Regular meal, complex carbs only, not candy (sugars go up too high) 10. Give complex carb to patient after treatment of hypoglycemia, Ex. Peanut butter and crackers,

Type 2 DM (8)

1. Major contributor for heart, renal disease, and stroke 2. Associated with metabolic syndrome which is characterized by: - elevated glucose, abdominal obesity, hypertension - ↑ triglycerides & Low-density lipoproteins, ↓High-density lipoproteins 3. Asymptomatic in the early stage 4. May have classic symptoms of type 1 5. Nonspecific symptoms are common: fatigue, prolonged wound healing, visual changes 6. Increased circumference of the waist 7. Eye problems and fatigue 8. Insulin is insufficient or poorly used by the tissue

Clinical Manifestations (Hypoglycemia) (8)

1.confusion 2. irritability 3. diaphoresis 4. tremors 5. hunger 6. weakness 7. visual disturbances 8. can mimic alcohol intoxication

Secondary DM

Cushing syndrome, hyperthyroidism, pancreatitis, cystic fibrosis, hemochromatosis, parenteral nutrition, corticosteroids

Oral Agents (↑ Insulin production from pancreas - side effect: hypoglycemia)

Sulfonylureas: Glipizide (Glucotrol), Glyburide (Micronase), Glimepiride (Amaryl) Meglitinides (Short acting - taken 30 minutes before each meal): Repaglinide (Prandin), Nateglinide (Starlix) - More rapidly absorbed and eliminated - Less likely to cause Hypoglycemia

Hemoglobin A1C (most reliable diagnostic test) (2)

≥ 6.5% 1. Indicates the amount of glucose linked to hemoglobin. 2. Useful in determining the degree of glucose control in past 90-120 days

Fasting plasma glucose level

≥126 mg/dL (requires fasting for 8 hours)