Diabetes Types and Insulin Overview

Type 1 Diabetes

• Autoimmune destruction of pancreatic beta cells
• No insulin production
• Typically diagnosed in individuals under 30

Type 2 Diabetes

• Reduced tissue sensitivity to insulin
• Elevated blood glucose levels over time
• Pancreatic beta cell impairment and eventual death
• Initial treatment: Oral agents
• Later stages may require insulin

Insulin Types

Rapid Acting

• Onset: 15-30 minutes (HumaLOG), 10-20 minutes (NovoLOG)
• Peak: 0.5-2.5 hours (HumaLOG), 1-3 hours (NovoLOG)
• Duration: 3-6 hours (HumaLOG), 3-5 hours (NovoLOG)
• Clinical note: 15 minutes feels like 1 hour

Short Acting

• Onset: 30-60 minutes (Humulin R, Novolin R)
• Peak: 1-5 hours
• Duration: 6-10 hours
• Clinical note: Short staffed nurses went from 30 patients to 8

Intermediate Acting

• Onset: 60-120 minutes (Humulin N, Novolin N, NPH)
• Peak: 6-14 hours
• Duration: 16-24 hours
• Clinical note: Nurses play hero for 8 16-year-olds

Long Acting

• Onset: 70 minutes (Glargine), 60-120 minutes (Detemir)
• Peak: None (Glargine), 12-24 hours (Detemir)
• Duration: 18-24 hours (Glargine), variable (Detemir)
• Clinical note: The two long nursing shifts never peaked, but lasted 24 hours

Importance of Insulin Drug Levels

• Knowledge of onset, peak, and duration aids in accurate medication adjustments
• Type 1 diabetes patients do not produce endogenous insulin

Patient Education: Insulin

• Greatest risk: Hypoglycemia
• Monitor blood glucose and signs of hypoglycemia
• Interactions: Beta-blockers and other hypoglycemic agents
• Carry carb/protein snacks
• Proper injection technique, dosing, timing, and rotation of sites

Routes of Insulin Administration

• Cannot be absorbed in the stomach: requires injection, intravenous, or inhaler routes
• Insulin pump delivers continuous basal insulin and bolus doses.
• Pros: more accurate mimicry of body's insulin action, fewer injections, greater accuracy
• Cons: Contains insulin, causes weight gain, can cause DKA if catheter comes out

Inhaler Insulin

• Delivers powdered insulin to lungs
• Faster absorption, peak, and metabolism than injections

Metformin Monitoring

• Can decrease vitamin B12 and folic acid levels
• Monitor B12 levels, particularly in those with anemia or peripheral neuropathy

Metformin-Induced Lactic Acidosis

• Increased risk with alcohol, specific medications, age, surgery, and hypoxic states.

Alpha-glucosidase Inhibitors

• Delay carbohydrate digestion and absorption
• Used as an adjunct therapy for T1DM or T2DM with exercise and diet changes.
• Side effects: GI upset

Effectiveness of Sulfonylureas

• Stimulate insulin secretion and increase tissue sensitivity
• Effective as long as pancreas produces insulin, less effective as T2DM progresses

Sulfonylureas Interactions

• Alcohol: Increases adverse effects
• Beta-adrenergic blockers: Increase risk of hypoglycemia
• Tagamet (Cimetidine): May increase sulfonylurea levels and risk of hypoglycemia

Diabetic Medications and Weight

• Insulin and sulfonylureas can cause weight gain
• Metformin, DPP-4 inhibitors, and GLP-1 inhibitors can cause weight loss
• Glipizide does not cause weight gain or loss

Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors

• Newest diabetes drug
• Protects the heart and kidneys in type 2 diabetes

Approved to Reduce Risk of Major CV Events

• Used in patients with atherosclerotic cardiovascular heart disease, established HF, and or diabetic kidney disease.

Glitazones Warning

• May cause or exacerbate heart failure
• Severe liver injury with Rezulin (removed from market) but reversible when stopped
• Newer agents have lower incidence

Hypothyroidism

• Treatment goal: Replace missing thyroid hormone
• Undertreatment: Lethargy, fatigue, weight gain, skin changes, cold sensitivity, constipation
• Overtreatment: Heart palpitations, elevated HR, trouble sleeping, sweating, anxiety, diarrhea, weight loss, bone loss

Patient Education: Bisphosphonates

• Take with calcium and vitamin D for maximum effectiveness
• Remain upright for 30-60 minutes
• Take with a full glass of water (avoid possible throat and esophagus damage)
• Inform dentist of medication use

Monoclonal Antibodies

• Inhibit osteoclasts, decreasing bone resorption and increasing bone mass
• Serious side effects include severe infection (abdomen, urinary tract, ears), dermatologic reactions, back pain and musculoskeletal pain, atypical femur fractures, hypocalcemia

PDE-5 Inhibitors

• Take 1 hour before intercourse, no more than once daily
• Medication may be more effective with testosterone therapy
• Contraindications: Concurrent nitrates use

Hormonal Replacement Therapy (Contraindications)

• History of venous thromboembolism

Corticosteroids

• Treatment for rheumatoid arthritis (RA)
• Anti-inflammatory and immunosuppressive effects
• Use lowest effective dose

HPA Suppression

• Occurs when high cortisol/hormone levels disrupt normal feedback and decrease endogenous hormone production.
• Risk increases with 7+ days, should be withdrawn slowly

Systemic Corticosteroids

• Tapering not needed if 5 days or less of less than 40mg/day. Corticosteroids use: can cause hypothalamic pituitary adrenal (HPA) suppression
• Impact glucose metabolism: causes hyperglycemia.
• Impacts immune response: increases infection rates

Methotrexate

• Decreases inflammation caused by cell degradation by-products
• Contraindications: Pregnancy, breastfeeding, leukopenia

BBW - Remicade

• Serious infections and malignancy

BBW - Leflunomide

• Embryo-fetal toxicity and hepatotoxicity

Plaquenil

• QT interval prolongation

BBW - Tumor Necrosis Factor Inhibitors

• Increased serious infection and malignancy risk

Stimulants for Weight Loss

• Lead to insomnia, increased blood pressure, restlessness, drug dependence, and withdrawal symptoms

Orlistat (Alli)

• Deficiencies in fat-soluble vitamins (ADEK) possible due to decreased GI tract fat absorption
• Contraindications: Pregnancy, malabsorption syndrome, cholestasis

Contrave

• Affects neurotransmitters in the hypothalamus
• MOA: Decreases appetite, regulates appetite
• Can cause opioid withdrawal and increased blood pressure and heart rate
• Increased risk for neuropsychiatric effects

BBW - Suicidal Thinking (Contrave /other)

• Potential for suicidal thoughts or actions

Saxenda

• Slows gastric emptying, decreases food intake, increases beta-cell growth and replication
• Side effects: Increased heart rate, headache, hypoglycemia, gastrointestinal distress.
• BBW: Risk of medullary thyroid cancer

Bariatric Surgery

• Altered absorption of oral medication

Pregnancy Considerations (all drugs)

• Weight loss drugs not recommended, consult if pregnant or plan to become so

Disclaimer: This information is for educational purposes only and should not be considered medical advice. Always consult with a doctor or other qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment.