Week 5 Antidiabetic Drugs (Student) PDF

Nursing 2700: Integrated Nursing Sciences I Sealock & Seneviratne Ch 33: Antidiabetic Drugs Tyerman et al. Ch 52: Diabetes Mellitus Review Type 1 Diabetes Type 2 Diabetes Lack of insulin production, Most common type (90% or production of defective of a...

Nursing 2700: Integrated Nursing Sciences I Sealock & Seneviratne Ch 33: Antidiabetic Drugs Tyerman et al. Ch 52: Diabetes Mellitus Review Type 1 Diabetes Type 2 Diabetes Lack of insulin production, Most common type (90% or production of defective of all cases) insulin Caused by insulin Affected patients need deficiency and insulin exogenous insulin resistance Fewer than 10% of all Many tissues are resistant cases are type 1 to insulin Complications Reduced number of Diabetic ketoacidosis insulin receptors Hyperosmolar Insulin receptors less hyperglycemic state responsive Diabetes Treatment Interventions Type 1: Always requires insulin therapy (first line therapy) Diet and lifestyle are secondary and still important Type 2: Weight loss Improved dietary habits Smoking cessation Reduced alcohol consumption Regular physical exercise Oral medications Insulin therapy Glycemic Goal of Treatment HbA1c of less than 7% Fasting blood glucose goal for diabetic patients: 4 to 7 mmol/L 2-hour postprandial target of 5 to 10 mmol/L Glycemic targets are individualized and heavily influenced by age, life expectancy and goals of care Insulin Functions as a substitute for the endogenous hormone Effects are the same as those of normal endogenous insulin Restores the diabetic patient’s ability to: Metabolize carbohydrates, fats, and proteins Store glucose in the liver Convert glycogen to fat stores Human insulin Derived using recombinant deoxyribonucleic acid (DNA) technologies Recombinant insulin produced by bacteria and yeast Goal: tight glucose control To reduce the incidence of long-term complications Recall from 2055... Normally  insulin released continuously in the bloodstream in small, pulsatile increments (basal rate) and increased release (bolus) when food is ingested Released insulin lowers blood glucose Insulin Types Insulins differ with regard to onset, peak action, and duration Characterized as Rapid-acting Short-acting Intermediate-acting Extended long-acting Different types of insulin may be used for combination therapy Rapid Acting Insulin Most rapid onset of action (10 to 15 minutes) Injected 0-15 minutes before a meal Peak: 1 to 2 hours Duration: 3 to 5 hours Patient must eat a meal after injection Insulin lispro (Humalog®) Action similar to that of endogenous insulin Insulin aspart (NovoRapid®) Insulin glulisine (Apidra®) May be given subcutaneously or via continuous subcutaneous infusion pump (but not intravenously) Short-Acting Insulin Regular insulin (Humulin R®, Novolin ge Toronto®) Routes of administration: intravenous (IV) bolus, IV infusion, intramuscular, subcutaneous Injected 30-45 minutes before meals Onset (subcutaneous route): 30 minutes Peak (subcutaneous route): 2 to 3 hours Duration (subcutaneous route): 6.5 hours Intermediate-Acting Insulin Insulin isophane suspension (also called NPH) Cloudy appearance Often combined with regular insulin Onset: 1 to 3 hours Peak: 5 to 8 hours Duration: up to 18 hours Long-Acting Insulin Released steadily and continuously – no peak action Cannot be mixed with other insulin or solutions Insulin glargine (Lantus®) Insulin detemir Clear, colourless solution Duration of action is dose dependent Constant level of insulin in the body Lower doses require twice-daily dosing Usually dosed once daily Higher doses may be given once daily Can be dosed every 12 hours (in the morning or at bedtime) Referred to as basal insulin Onset: 90 minutes Peak: none Duration: 24 hours More common one Types of Insulin Summary Insulin Type Onset Peak Effect Duration of Action Rapid Acting 10-15 5-20 minutes 3-5 hours minutes Short Acting 30-60 2-3 hours 6-10 hours minutes Intermediate 2-3 hours 4-10 hours 10-16 hours Acting Long acting 2-4 hours None 24+ hours Fixed-Combination Insulin Each contains two different insulins, fixed combinations One intermediate-acting type Either one rapid-acting type (Humalog, NovoLog) or one short- acting type (Humulin R) Useful in patients who want fewer injections and tend to be habitual with diet and exercise Fixed combinations Humulin 30/70 Novolin 30/70, 40/60, 50/50 NovoMix® 30 Humalog Mix25® Humalog Mix50® Administration of Insulin Cannot be taken orally Subcutaneous injection for self-administration IV administration Fastest absorption from abdomen, followed by arm, thigh, and buttock Abdomen is the preferred site Rotate injections within one particular site Do not inject in a site to be exercised Administration of Insulin Usually available as U100 1 mL contains 100 units of insulin Handwashing with soap is adequate Do not recap the needle 45–90-degree angle, depending on fat thickness of the patient Insulin pens preloaded with insulin are used clinically Check expiration date and label vial with date opened If cloudy insulin (intermediate and mixed) is used, gently roll container to resuspend insulin – it should look uniformly milk  Insulins at TBRHSC. Mixing Insulin This will be covered in more detail during your medication administration labs Sliding-Scale Insulin Dosing Subcutaneous rapid-acting (lispro or aspart) or short- acting (regular) insulins are adjusted according to blood glucose test results Typically used in hospitalized diabetic patients or those on total parenteral nutrition or enteral tube feedings Subcutaneous insulin is ordered in an amount that increases as the blood glucose increases Disadvantage: Delays insulin administration until hyperglycemia occurs, resulting in large swings in glucose control Recent research does not support sliding-scale use; nonetheless, sliding scale is still commonly used  Practice How much insulin will Mark Mark is taking insulin every receive in the following morning, with sliding-scale circumstances? coverage. The specified 1. Before breakfast if the blood dosages are: glucose level is 16.8 mmol/L 25u NPH + 6u novolin 1. NPH insulin, 25 units every morning before 2. Before lunch if the blood glucose breakfast level is 15.2 mmol/L 2. Regular (Novolin) insulin 4u Blood glucose sliding-scale less than 11.1 coverage, No additional coverage mmol/L before meals 2and Blood glucose 11.1 to 13.8 at units regular insulin 3. Before dinner if the blood mmol/L bedtime as follows: glucose level is 9.5 mmol/L; no Blood glucose 13.9 to 16.6 4 units regular insulin coverage mmol/L Basal-Bolus Insulin Dosing Preferred method of treatment for hospitalized patients with diabetes Mimics a healthy pancreas by delivering basal insulin constantly as a basal rate and then as needed as a bolus Basal insulin is a long-acting insulin (insulin glargine) Bolus insulin (insulin lispro or insulin aspart) Example order: 10 units Lantus SC at bedtime 5 units Humalog SC before meals Insulin Pump Continuous subcutaneous infusion Battery-operated device Connected via plastic tubing to a catheter inserted into subcutaneous tissue in abdominal wall Potential for tight glucose control Continuous Glucose Monitors CGM are used to measure glucose level of the ECF Caution, some are sensitive to drug administration (ex. Vitamin C consumption) which can influence the ability to recognize hypoglycemia They are not insulin pumps! Insulin pumps have tubing and actually administer rapid insulin Complications with Insulin Therapy Hypoglycemia Allergic reaction to addictive in insulin Lipodystrophy- same site continuously, then accumulation of adipose tissue Somogyi effect Rebound effect in which an overdose of insulin causes hypoglycemia Usually during hours of sleep Counterregulatory hormones released Rebound hyperglycemia and ketosis may occur Dawn phenomenon- with adolescents Characterized by hyperglycemia present on awakening in the morning Due to release of counterregulatory hormones in predawn hours Growth hormone/cortisol possible factors Insulin Practice Question The nurse is caring for a patient who received regular insulin 10 units subcutaneously at 0930 hours for a blood glucose level of 17.0 mmol/L. The nurse plans to monitor this patient for signs of hypoglycemia at which of the following peak action times? 1. 0945-1045 2. 1130-1230 3. 1530-1630 4. 2200-2300 Insulin Practice Question The nurse is administering regular insulin 30 units. The insulin is available in 50u/mL concentration. Identify on the syringe how much insulin the nurse should draw for this dose in mL. Insulin Practice Question Which long-acting insulin mimics natural, basal insulin, with no peak action and a duration of 24 hours? 1. Neutral protamine Hagedorn (NPH) insulin 2. Regular insulin (Humulin R) 3. Insulin glargine (Lantus) 4. Insulin glulisine (Apidra)  elements: Lifestyle changes Oral Antidiabetic Drugs Careful monitoring of blood glucose levels Therapy with one or more drugs Treatment of associated comorbid conditions such as high cholesterol and Used for type 2 diabetes high blood pressure Diabetes Canada (2018) recommendations for new-onset type 2 diabetes with A1C 14 mmol/L Thorough patient education is essential regarding: Disease process Insulin Diet and exercise recommendations requirement may increase during Self-administration of insulin or oral drugs periods of severe Potential complications stress, such as illness or surgery Nursing Implications When insulin is ordered, ensure: Correct drug Correct route Correct type of insulin Correct dosage Insulin order and prepared dosages are second-checked with another registered nurse (or per agency policy) Nursing Implications Insulin Check blood glucose level before giving insulin To mix suspensions, roll vials between hands instead of shaking them Ensure correct storage of insulin vials Only use insulin syringes, calibrated in units, to measure and give insulin Ensure correct timing of insulin dose with meals When drawing up two types of insulin in one syringe, always withdraw the regular or rapid-acting (clear) insulin first Provide thorough patient education regarding self- Nursing Implications Oral antidiabetic drugs Always check blood glucose levels before administering Usually given 30 minutes before meals α-Glucosidase inhibitors are given with the first bite of each main meal Metformin is taken with meals to reduce gastrointestinal effects Patients undergoing surgery or radiological procedures requiring contrast medium should hold their metformin on the day of surgery and to 48 hours postoperative Possible renal effects Begun after serum creatinine has been checked and is normal Communication with provider Nursing Implications Hypoglycemia Assess for signs of hypoglycemia Low blood glucose ( less than 4mmol/L) Adrenergic – anxiety, tremors, sensation of hunger, palpitations, sweating Central nervous system – difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, dizziness and headache Later signs Hypothermia, seizures Coma and death will occur if not treated Hypoglycemia Treatment Patient not alert enough to At the first sign If alert enough to swallow swallow Check blood glucose 15–20 g of a simple Administer 1 mg of If 4 mmol/L, Regular soft drink Adverse effect: rebound investigate further for Six Life-saver candies hypoglycemia cause of signs or Recheck blood sugar 15 Have patient ingest a symptoms minutes after treatment complex carbohydrate If monitoring equipment Repeat until blood sugar after recovery not available, treatment >4 mmol/L In acute care settings should be initiated The patient should eat a 20–50 mL of 50% regularly scheduled meal dextrose IV push or snack to prevent rebound hypoglycemia. Check blood sugar again 45 minutes after eating the snack Nursing Implications Monitor therapeutic response Decrease in blood glucose levels to the level prescribed by physician Measure HbA1c to monitor long-term compliance with diet and drug therapy Watch for and monitor hypoglycemia and hyperglycemia Diabetes Nutrition Nutritional therapy is the cornerstone of care for the person with DM Nutrition is also the most challenging aspect Nutritional therapy can reduce A1c by an absolute 1 to 2% with the greatest impact at the initial stages of DM How becomes as important as what a person eats… Regular distribution of carbohydrates Replacing high-glycemic index carbohydrates is clinically beneficial Timing of alcohol intake with food Achieving nutritional goals requires a coordinated team effort that takes into account the behavioural, cognitive, socioeconomic, cultural, and spiritual aspects of the person it is recommended that a DM nurse educator and a registered dietitian with expertise in DM management be members of the team. Food Composition DM has been called a disease of carbohydrate metabolism It is actually a general metabolic disorder involving three categories of energy-providing nutrients Carbohydrates Fats Proteins Nutritional energy intake should be constantly balanced with the energy output of the individual, taking into account exercise and metabolic work of the body General Recommendations for Nutrient Balance Protein Fat Fibre Carbohydrate 15 to 20% of Less than 35% of Approximately 30 45 to 60% of energy energy to 50 g/day from energy There is no Combined a variety of food Carbohydrates evidence that saturated fats sources, including should include usual protein and trans-fatty soluble and cereal whole grains, intake (15–20% of acids should be fibres fruits, vegetables, energy) should be reduced to less and low-fat milk modified than 9% of Patients should Those with energy intake try to consume diabetic Polyunsaturated higher-fibre nephropathy fat should be sources of should limit limited to less carbohydrate protein intake to than 10% of Less than 10% of 15% of energy energy intake daily energy and be monitored Foods rich in should come from closely by a polyunsaturated sucrose (sugar) registered omega-3 fatty Low-carbohydrate dietitian acids and plant diets are not  Glycemic index (GI) is the term used to Glycemic Index (GI) describe the rise in blood glucose levels after a person has consumed carbohydrate- containing food A GI of 100 refers to the response to 50 g of glucose or white bread in a normal person without DM All other food with an equivalent carbohydrate value is measured against this standard For example, the GI of an apple is 52, regular milk 27, baked potato 93, cornflake cereal 119, and baked beans 69 Foods with a high GI increase blood sugar higher and faster than foods with a low GI. There are three GI categories: low GI (55 or less) medium GI (56-69) high GI (70 or more) Eat foods in the low GI category most often, the medium category less often, and eat foods in the high GI category the least often.  Complex vs. Simple Carbs Foods with a high GI (e.g., potatoes, white bread) will cause a sharp rise in blood glucose, whereas those with a low GI (e.g., brown rice) steadily increase blood glucose over a longer period Low GI Eating: Reduces Hypoglycemia Improves total cholesterol Improves overall glycemic control  Carbohydrate Counting Carb counting includes starches and sugar but not fibre. The dietary reference intakes (DRIs) specify a recommended dietary allowance (RDA) for available CHO of no less than 130 g/day for adult women and men >18 years of age, to provide glucose to the brain. Carbohydrate Counting Diabetes Canada Recommendations 1. Eating three meals per day at regular times and eating at intervals no more than 6 hours apart 2. Limiting sugars and sweets such as sugar, regular pop, desserts, candies, jam, and honey 3. Limiting the amount of high-fat food such as fried foods, chips, and pastries 4. Eating more high-fibre foods (whole-grain breads and cereals, lentils, dried beans and peas, brown rice, fruits, and vegetables) 5. Drinking water if thirsty as drink of choice 6. Adding physical activity to the lifestyle Nutritional Therapy Summary