Chapter 51

ANTIDIABETICS

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Diabetes Mellitus
Chronic disease of deficient glucose metabolism Insufficient insulin secretion from beta cells Impaired insulin utilization Major symptoms: polyuria, polydipsia, polyphagia Types

Type

1 (insulin-dependent DM) Type 2 (non-insulin-dependent DM) Gestational Diabetes mellitus

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Insulin Resistance

Insulin resistance

Body tissues do not respond to the action of insulin Insulin receptors are unresponsive Insulin receptors are deficient in numbers

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Insulin

Insulin
Released

from beta cells of islets of Langerhans in pancreas Responds to increase in blood glucose Function Promotes uptake of glucose, amino acids, and

fatty acids Converts to glycogen for future glucose needed in liver and muscle

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Insulin Types

Types of Insulin
Rapid-acting Short-acting Intermediate-acting Long-acting Combinations

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Insulin Types (contd)

Rapid-acting insulin

Humalog (Lispro), aspart, exubera Onset of action (5-15 minutes) Peak (30 minutes-1 hour) Duration (2-4 hours) Humulin R
Onset of action (30-60 minutes) Peak (2-3 hours) Duration (3-4 hours)

Short-acting insulin
Regular

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Insulin Types (contd)

Intermediate-acting
Humulin

N (NPH), Lente
Onset of action (2-4 hours) Peak (4-12 hours) Duration (18-24 hours)

Combinations
Composed

of short- and intermediate-acting or rapid-and intermediate-acting Humulin 70/30, 75/25

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Insulin Types (contd)

Long-acting
Humulin

Onset of action (4-8 hours) Peak (14-20 hours) Duration (24-36 hours) Lantus (Insulin Glargine) Evenly dispersed action Duration (24 hours)

U (Ultralente)

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Type of Insulin Rapid Acting Novolog (Aspart) Humalog (Lispro) Short Acting Humulin R (Human) Novolin R (Human) Intermediate Acting NPH (Humulin N, Novolin N) Lente (Humulin L, Novolin L)

Onset

Peak

Duration

5-10 mins 15-20 mins

1-3 hours 1-1.5 hours

3-5 hours 4-5 hours

30 mins-1 hr 30 mins-1 hr

2-4 hours 2-4 hours

5-7 hours 5-7 hours

1-2 hours 1-3 hours

6-14 hours 6-14 hours

24 hours 24 hours

Long Acting Ultralente (Humulin U) Insulin glargine (Lantus) Pre-mixed Insulin

6 hours -

18-24 hours -

36 hours 24 hours

70%NPH / 30% Regular (Humulin (70/30) 1/2-1 hour

2-12 hours

18-24 hours

50%NPH / 50% Regular (Humulin (50/50) 1/2 hour 75% Lispro protamine / 25% Lispro 10-15 mins

3-5 hours 1-6 hours

24 hours 24 hours
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Saunders, NCLEX-RN p.667

Insulins

Action

Promotes use of glucose by body cells, stores glucose as glycogen in muscles Reduce blood glucose Increased hypoglycemia with aspirin, oral anticoagulants, alcohol, oral hypoglycemics, BBs,TCAs, MAOIs, tetracyclines Decreased hypoglycemia with thiazides, glucocorticoids, oral contraceptives, thyroid drugs, smoking
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Use

Interactions

Insulins Side Effects

Hypoglycemia

Headache, dizziness, confusion, slurred speech Nervousness, anxiety, agitation Tremors, uncoordination, sweating, tachycardia, seizures Extreme thirst, dry mucous membranes Poor skin turgor, polyuria, fruity breath Fatigue, tachycardia, Kussmaul respirations

Hyperglycemia

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Insulins Side Effects

Lipodystrophy Dawn phenomenon Somogyi effect Insulin shock Diabetic ketoacidosis

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Insulin Administration

Nursing interventions

Monitor vital signs and glucose levels Instruct client to report hypoglycemia and hyperglycemia Encourage compliance with diet, insulin, exercise Advise client to wear medic-alert tag Teach client how to check blood glucose Teach client how to administer insulin

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Insulins Administration

Methods of insulin administration

Insulin pumps Insulin pen injectors Insulin injections

Sites for insulin injection.

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Sliding-Scale Insulin

Sliding-scale insulin coverage

Adjusted doses dependent upon individual blood glucose Usually done before eating and at bedtime Usually utilizes rapid or short-acting insulin

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Insulin Storage

Storage of insulin

Usually kept in refrigerator Remove from refrigerator 30 minutes prior to injection Avoid storing insulin in direct sunlight or at high-temperatures Prefilled syringes should be stored in the refrigerator

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Oral Antidiabetics for Type 2

Sulfonylureas

First-generation sulfonylureas Short-acting Intermediate-acting Long-acting Second-generation sulfonylureas

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Oral Antidiabetics for Type 2 (contd)

Sulfonylureas
Glipizide (Glucotrol), glyburide (Diabeta) Action Stimulates beta cells to secrete insulin, alters sensitivity of peripheral insulin receptors Use Control hyperglycemia in type 2 diabetes Cautions Liver or kidney dysfunction, elderly, malnourished, adrenal or pituitary insufficiency

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Oral Antidiabetics for Type 2 (contd)

Glipizide (Glucotrol)

Interactions Alcohol may cause disulfiram-like reaction;

hypoglycemia with anticoagulants, cimetidine, anticonvulsants, aspirin, NSAIDs, sulfonamides Increases action of thiazide diuretics, barbiturates, phenothiazines; decreases action of thyroid drugs

Side effects Drowsiness, headache, confusion, visual

disturbances, anxiety, hunger, hypoglycemia, tachycardia, seizures, respiratory depression, coma

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Oral Antidiabetics for Type 2 (contd)

Nonsulfonylureas

Biguanides Metformin (Glucophage) Action: increases binding of insulin to receptors Alpha-glucosidase inhibitors Acarbose (Precose) Action: inhibits absorption of sugars from GI tract

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Oral Antidiabetics for Type 2 (contd)

Nonsulfonylureas

Thiazolidinediones Pioglitazone (Actos), rosiglitazone (Avandia) Action: affects insulin receptors by enhancing insulin
sensitivity of cells

Meglitinides Repaglinide (Prandin), neteglinide (Starlix) Action: stimulates release of insulin from pancreatic
islets

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Oral Antidiabetics for Type 2 (contd)

Nonsulfonylureas

Biguanides Metformin (Glucophage) Action

Use

Increases binding of insulin to receptors Improves tissue sensitivity to insulin Increases glucose transport into skeletal muscles and fatty tissues Control hyperglycemia in type 2 diabetes mellitus

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Oral Antidiabetics for Type 2 (contd)

Metformin (Glucophage)

Interactions Hypoglycemia potentiated by captopril, nifedipine,

procainamide, quinidine, digoxin, furosemide, cimetidine, ranitidine, azole antifungals, vancomycin Iodinated contrast dyes may lead to lactic acidosis or acute kidney failure

Side effects Dizziness, fatigue, headache, agitation, metallic

taste, GI distress, lactic acidosis

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Oral Antidiabetics for Type 2 (contd)

Nursing interventions

Monitor vital signs, glucose levels Administer with food to minimize GI distress Teach client to eat prescribed diet on schedule Teach client to recognize symptoms of hyperglycemia and hypoglycemia Encourage drug compliance Advise client to wear medic-alert tag Warn client to avoid alcohol Teach client the treatment for hypoglycemia and hyperglycemia
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Glucagon

Glucagon

Hyperglycemic hormone secreted by alpha cells of the islets of Langerhans in the pancreas Stimulates breakdown of stored glycogen to glucose in liver

Action

Use

Insulin induced hypoglycemia

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Case Study
A client has a 6 am blood glucose of 238 mg/dl and is to receive Lispro insulin on a sliding scale.

Critical Thinking

What is the onset, peak, and duration of Lispro insulin compared with other types of insulin?

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1. A client has a 6 am blood glucose of 238 mg/dl and was given regular insulin 12 U on a sliding scale. At what time should the nurse monitor the client for signs of hypoglycemia? a. 6:30-7:00am c. 11:00am-1:00pm b. 8:00-10:00am d. 10:30am-12:00nn 2. A client is about to do his morning routine of exercise. Which of the following instructions will the nurse give when giving a Humulin-R insulin? a. Inject insulin at least 30 mins before exercise b. Inject half of insulin dose before exercise and the other half after exercise c. Do not inject insulin d. Inject insulin 30 mins after exercise
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3. A client was rushed into the ER. Upon assessment the nurse observes a fruity breath with Kausmalls breathing pattern and flushed dry skin and mucous membranes. Random blood glucose was 438 mg/dl. Which of the following types of insulin will the nurse expect the MD will order? a. Lispro c. Lantus b. Humulin R d. NPH

4. A client was given regular insulin 10 U on a sliding scale. Which assessment findings should the nurse monitor the client 4 hours following insulin injections? a. Frequent urination (polyuria) b. Tremors and cold clammy skin c. Kausmalls breathing d. Dry mucous membranes
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5. A client was given Lantus insulin 8 U at 7am. When will the nurse expect to give the next dose of the insulin? a. 7:00 pm same day c. 1:00 pm same day b. 7:00 am next day d. 1:00 am next day

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Practice Question #1
Which time frame would be most appropriate for sliding scale Lispro insulin?
A. B. C. D.

Within 30 minutes of consuming breakfast When the breakfast tray is served and ready to eat Within 1 hour of obtaining blood glucose measurement Within 15 minutes of obtaining blood glucose measurement

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Practice Question #1 (contd)

Answer: B. Rationale: Lispro should be given 5 minutes before eating because the onset of action is 5 to 15 minutes.

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Practice Question #2
A client is prescribed metformin (Glucophage). Which of the following is a side effect/adverse effect common to metformin?
A. B. C. D.

Seizures Constipation Bitter or metallic taste Polyuria and polydipsia

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Practice Question #2 (contd)

Answer: C. Rationale: Metformin has a bitter or metallic taste. Seizures, constipation, polyuria, and polydipsia are not side effects/adverse effects of metformin.

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