1. Insulin Oral Hypoglycemics
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 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 = min / 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. Exubera – inhaled insulin
Short Duration
Regular Insulin
Humulin R, Novolin R
Onset / Peak / Duration = 30 to 60 min / 1-5 / 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 / hrs / 6.5 hrs
Fine powder of regular insulin

12. Intermediate Acting Insulins
NPH (Neutral protamine Hagedorn)
Onset / Peak / Duration 2-4 / 4-12 / 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 / /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. Insulin detemir (Levemir) Onset / Peak / Duration / 6-8 / 12-24
Long Acting Insulins
Insulin detemir (Levemir)
Onset / Peak / Duration
/ /
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 / / 20-30

15. Very Long Acting Insulin
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
G needle (microfine) (Only administer in an insulin syringe)
5/8 inch
do not have to aspirate

32. Nursing Implications check the original doctor’s order
ALL insulin dosages MUST be DOUBLE 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
Continuous subcutaneous insulin infusion
3 mL syringe, needle at end of long tube.
Needle inserted into Sub q tissue
Needle is changed at least every 3 days.
Basal rate plus bolus doses
Insulins that can be used in pumps: Regular, Lispro, aspart, glulisine
Cost
Insulin Pumps. An insulin pump can improve blood glucose control and quality of life with fewer hypoglycemic episodes than multiple injections. The pumps correct for the “dawn phenomenon” (sudden rise of blood glucose in the morning) and allow quick reductions for specific situations, such as exercise. Many different brands are available.
The typical pump is about the size of a beeper and has a digital display. Some are worn externally and are programmed to deliver insulin through a catheter in the skin or the abdomen. They generally use rapid-acting insulin, the most predictable type. They work by administering a small amount of insulin continuously (the basal rate) and a higher dose (a bolus dose) when food is eaten.

39. Insulin Administration: Methods of Delivery: Insulin Injectors
Alternative to needle injections
Delivers insulin through the skin under pressure in an extremely fine stream.
Usually absorbed faster this route
Complication: Bruising

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

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

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

49. Order: Regular Insulin per sliding scale AC & HS
Sliding Scale Order
Blood glucose < give 0 u
Blood glucose give 4 u
Blood glucose 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 is 278, how much insulin will you give?
How would you administer it?
Sliding Scale Order
Blood glucose < give 0 u
Blood glucose give 4 u
Blood glucose 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 is 278, how much insulin will you give?
How would you administer it?

51. Oral Hypoglycemics Oral hypoglycemic agents work in one of three ways:
STIMULATE the pancreas to produce more insulin
DECREASE glucose production
INCREASE glucose uptake by the cell by enhancing the effectiveness of insulin
Oral hypoglycemics are usually only given to Type II diabetics

52. Sulfonylurea Oral Hypoglycemics: Second Generation
EXAMPLES Diabeta, Micronase (glyburide); Glucotrol (glipizide), Amaryl (glimepiride)
Action: Lowers blood sugar by stimulating the release of insulin from beta cells of the pancreas
Adverse reactions: hypoglycemia, nausea, heartburn, bloating, flatulence, anorexia, skin reactions, photosensitivity, allergic reaction, CNS - paresthesia, tinnitus, dizziness, wt gain, edema
Contraindicated with Sulfonamide allergy
Monitor for hepatotoxicity, blood dyscrasias, dermatologic reactions
Drug interactions: Beta Blockers may mask hypoglycemic reactions, alcohol may result in Anabuse like reaction

53. Biguanide Oral hypoglycemic agents
metformin (GLUCOPHAGE)
Action:
Decreases glucose released from liver
Decreases intestinal absorption of glucose, metformin
Improves insulin sensitivity
Resulting in improved blood glucose control
USES:
Type II diabetes
May be combined with other antidiabetic agents
SIDE / ADVERSE EFFECTS:
Primarily GI effects - bloating, nausea, cramping, diarrhea
Advantage: Does not cause hypoglycemia, does not cause wt gain, favorable effect on triglycerides
Increased risk for lactic acidosis and renal failure, Stop Metformin 48 h prior to and 48 h after diagnostic procedures using a contrast agent.

54. Alpha-Glucosidase Inhibitors
accarbose (Precose), miglitol (Glyset) Action: Delay absorption of complex carbohydrates in intestine, slow entry of glucose into systemic circulation, does not increase insulin secretion. SE: hypoglycemia, GI affects Administration: taken with first bite of food Monitor: LFT Not systemically absorbed

55. Non-Sulfonyrea Insulin Secretagogues
Examples
Repaglinide (Prandin) (SE – hypoglycemia)
Nateglinide (Starlix)
Action: Stimulate release of insulin from beta cells in the pancreas
Rapid action and short half life
Taken before each meal

56. Thiazolidinedione oral hypoglycemics (TZD) (thigh-a-zoe-lid-een-die-own)
Rosiglitazone (row-sih-GLIT-uh-zone) Avandia
Pioglitazone (pie-oh-GLIT-uh-zone) Actos
Action:
Increases sensitivity of muscle and fat tissue to insulin, allowing more glucose to enter the cells
May inhibit hepatic glycogenesis and decrease hepatic glucose output
SE Expected: N/V, anorexia, Abd cramps
SE unexpected: hypoglycemia, hepatotoxicity, wt. gain
Drug Interactions: Beta Blockers ay ask signs of hypoglycemia, may cause BC pills to be ineffective

57. Drug Interactions
There are SIGNIFICANT potential drug interactions between oral hypoglycemics and multiple classifications Sulfonylureas: alcohol, oral anticoagulants, antibiotics (sulfa), corticosteroids, thiazides, furosemide, thyroid drugs Biguanides: furosemide, digoxin, nifedipine, cimetidine Thiazolidinediones: reduces effectiveness of BC

58. signs / symptoms (hypo & hyper glycemia) blood glucose monitoring
Teaching Plan
medication regime
signs / symptoms (hypo & hyper glycemia)
blood glucose monitoring
avoidance of alcohol
medic alert identification
measures to deal with sun exposure (sulfonylureas)
follow up care

59. HbA1C: glycosylated hemoglobin A1C
Monitor lab test to determine BS control
An accurate long term index of the patient’s average blood glucose level
Reflects the average blood glucose level over the past days
Good control = 2.5 – 5.9 %
Fair Control = 6-8%
Poor control = > 8%

60. Glucose Testing
Using the Glucometer – (Measures capillary blood glucose)
Wash hands
Sterile 2x2, alcohol swab, towel, Glucometer, non-sterile gloves
Open sterile packages, place in reach, Don gloves
Select finger – lateral aspect of fingertips
Apply warm compress if cold fingers
Place towel under hand
Cleanse and allow to air dry
Puncture finger and squeeze
Wipe off 1st drop with 2x2
Collect blood on strip – cover entire area. 2x2 to site

62. Test Your Knowledge
A patient in the ICU requires intravenous insulin. The nurse is aware that:
insulin aspart or glargine can be administered IV.
any form of insulin can be used IV at the same dose ordered for subcutaneous administration.
insulin should never be given IV, and this order should be questioned.
only regular insulin can be administered IV.
Correct Answer: only regular insulin can be administered IV.
Cognitive Level: Application
Nursing Process: Analysis
NCLEX: Physiological Integrity
Text Reference: p. 657

63. Test Your Knowledge
A type 1 diabetic patient on insulin reports taking propranolol for hypertension. This provokes the concern that:
the beta blocker can produce insulin resistance.
the two agents used together will increase the risk of ketoacidosis.
propranolol will increase insulin requirements because of receptor blocking.
the beta blocker can mask the symptoms of hypoglycemia.
Correct Answer: 4 the beta blocker can mask the symptoms of hypoglycemia
Cognitive Level: Analysis
Nursing Process: Analysis
NCLEX: Physiological Integrity
Text Reference: p. 660

64. Test Your Knowledge
A nurse counsels a diabetic patient starting therapy with an alpha-glucosidase inhibitor. The patient should be educated about the potential for which adverse reaction(s)? You may select more than one answer.
Hypoglycemia
Flatulence
Elevated iron levels in the blood
Fluid retention
Diarrhea
Correct Answers: 2, 5 Flatulence, Diarrhea
Cognitive Level: Application
Nursing Process: Implementation
NCLEX: Physiological Integrity
Text Reference: p. 665

65. Test Your Knowledge
A diabetic client taking daily NPH insulin has been started on therapy with dexamethasone (Decadron). The nurse anticipates that which of the following adjustments in medication dosage will be made? 1. Decreased NPH insulin 2. Increased NPH insulin 3. Lower dose of dexamethasone (Decadron) than usual 4. Higher dose of dexamethasone (Decadron) than usual
ANS: 2 Increased NPH insulin
Rationale: Dexamethasone is a glucocorticoid and therefore can elevate the blood glucose level. Diabetic clients may need their dosage of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. This is most often a temporary change, needed to compensate for the actions of the medication.
Test-Taking Strategy: Remember that glucocorticoids can increase the blood glucose level. This concept will easily direct you to the correct option. Review the effects of corticosteroids if you had difficulty with this question.
DIF: Level of Cognitive Ability: Analysis
REF: Lehne, R. (2007). Pharmacology for nursing care (6th ed.). St. Louis: Saunders.
OBJ: Client Needs: Physiological Integrity
TOP: Content Area: Pharmacology
MSC: Integrated Process: Nursing Process-planning

66. Test Your Knowledge
The nurse monitors the blood glucose level of the client who received NPH insulin at 7 AM knowing that the client may experience a hypoglycemic reaction between:
9 to 11 AM
1 to 7 PM
7 to 11 PM
Midnight to 6 AM
ANS: A to 7 PM
Rationale: NPH insulin is an intermediate-acting insulin. It peaks in 6 to 12 hours after administration. (Its onset is in 1 to 2 hours, and its duration is 18 to 24 hours.) If the medication was given at 7 AM, the nurse would monitor for hypoglycemia during the time of peak action, which would be between 1 and 7 PM.
Test-Taking Strategy: Read the question carefully, noting that the question is asking about NPH insulin. Knowledge regarding the timing of the peak action is required to answer the question. Review these points regarding NPH (and regular) insulin if you are unfamiliar with them.
DIF: Level of Cognitive Ability: Analysis
REF: Lehne, R. (2007). Pharmacology for nursing care (6th ed.). St. Louis: Saunders.
OBJ: Client Needs: Physiological Integrity
TOP: Content Area: Pharmacology
MSC: Integrated Process: Nursing Process-assessment