Chapter 50: Antidiabetics Flashcards
What does diabetes mellitus mean?
Chronic disease results from deficient glucose metabolism
What are the 3 major symptoms of diabetes mellitus?
Polyuria
Polydispisa
Polyphagia
Too much pee
Too much thrist
Too hungry
What does insulin resistance mean?
Insulin receptors unresponsive or deficient in numbers
There are 4 types of diabetes what are they?
Type 1
Type 2
Secondary
Gestational
What is type 1 diabetes mellitus?
Insulin dependent DM
Normally known as childhood diabetes
Usually will need insulin for life because they simply are born without it
What is type 2 diabetes ?
Insulin resistance
Decrease insulin production!
Mainly known as 25+
Non insulin dependent DM
So you kinda bring it upon yourself
What is secondary diabetes mellitus?
Due to medications
Glucocorticoids
Thiazide
Diuretics
Epinephrine
What is gestational diabetes mellitus?
Due to hormonal changes
If you have gestational diabetes you have an increase what?
Increase risk for diabetes type 2
Why do you get those 3 ps for diabetes?
Because you have too much sugar in your blood instead of in your cells
So sugar dehydrates you when it’s in your blood stream, so drink lots of water ( thristy )
And you pee it out so much
Because of how much water you end up drinking
And your cells are hungry for the sugar so that sends a signal to brain to “eat” more
Type 1 diabetes comes on what?
Suddenly
Usually just out the blue
( most people are diagnosed with going to ER with diabetic ketoacidosis )
( a lot of weight loss typically )
When you are diagnose with pre diabetes, can you reverse it?
Yes
can you reverse diabetes type 2 and how?
Yes
Typically with exercise and good diet
What is a really big factor of diabetes type 2?
It’s a progressive type of diabetes in which insulin can slowly stop being produced
( over time you lose ability to produce insulin, so 80% of your pancreas doesn’t even work when you get diagnosed with diabetes type 2 sadly )
Why do patients with diabetes type 2 feel like failures ?
We have to remember that diabetes type 2 is progressive and the diagnose is usually really late, with already 80% of their pancreas already not producing insulin.
Patients can follow good exercise and diet and still again, it’s progressive that it just gets worse
So oral medication and insulin is usually increased and needed
Notes
With type 2 diabetes, you are not making enough insulin
And your body is becoming resistance to the insulin that you make
Its important to note that the insulin isn’t going to be used in the same way was before
Usually late diagnoses
Insulin is released from what?
Why are they secreted?
Beta cells of islets of langerhans in pancreas
In response to increase in blood glucose
What are the 2 functions of insulin?
Promotes uptake of glucoses, amino acids and fatty acids
Coverts glucose to glycogen in liver and muscle for future needs
What is normal blood glucose range?
70-99
What is hemoglobin A1C?
Like why do we do it and what does it tell us?
A test where it tells us our blood glucose
What is less than 5% in hemoglobin A1C tell us?
No diabetes
What is pre diabetes hemoglobin A1c?
5.7-6.4
What is hemoglobin A1C diabetes mellitus?
6.5 or more
Notes
Hemoglobin A1C
So like 6.5 of your sugar is attached to your blood cell
( so this means you have Diabetes )
Hemoglobin A1C looks at the average blood sugar for the past what?
3 months
For patients who have diabetes type 2 what is usually the goal for the their A1C levels?
Less than 7
Insulin is key that takes your ___ and __ from your bloodstream into your cells
So if you don’t have insulin what happens?
Glucose and potassium
The glucoses go out into the blood stream ( outside the cells )
What’s one thing we do to help patients with hyperkalemia and why?
Give people IV insulin & IV dextrose 5-10
Insulin will move that Potassium from their blood stream into your cells to get rid of that hyperkalemia
For someone who is getting a lot of insulin what do we have to worry about?
Hypokalemia
Cause all of that potassium will be moving into the cells
What are the 2 human insulin?
Usually this has low allergies and insulin resistance
Humilin R
Novolin N
What are 2 human insulin analogs modified onset and duration?
Insulin lispro
Insulin aspart
What are the 3 concentrations of insulin?
100 units / ML
500 units /ML rarely used
Both come in 10ML vials
What are the 5 insulin types we are going to talk about?
Rapid acting
Short acting
Intermediate acting
Long acting
Combinations
What are the 3 rapid acting insulin?
Lispro (humalog)
Aspart (novolog)
Glulisine (apidra )
Rapid acting insulin type
What is the onset?
What is the peak?
What is the duration?
10-30mins
30-90mind
1.5-5hours
What are the 2 short acting insulin?
Regular ( humulin R and novolin R)
Short acting insulin type
What is the onset? (2)
What is the peak?(2)
What is the duration?(2)
Sub Q-30mins
IV 15min
Subq 1.5-3.5hours
iv 15-30mins
Subq 4-12hours
IV 2-6 hours
What is the intermediate acting insulin ? (2)
NPH
( humulin N and novolin N )
Intermediate acting insulin type
What is the onset?
What is the peak?
What is the duration?
1.5H
4-12H
14-24H
What are your 3 long acting insulin?
Glargine (Lantus)
Detemir (Levemir)
Degludec (Tresiba)
Long acting insulin type
What is onset?
What is peak? (3)
What is duration?(2)
1-2H
Glargine-none
Determir (6-8H)
Degludec (12H)
Glargine & determir (24H)
Degludec (42H)
What is inhaled insulin ?
Afrezza
Notes
Old insulin used to come from pigs and cows
A lot of people had allergic reactions to
Now we manipulate insulin so it can last us longer for us
Usually last all morning until lunch time
All insulin come in what?
ML of what?
Concentration is what?
Vials
10ML
100units
Why would we have 500units concentrations?
Usually ICU
When patients blood sugar is like 1500 or whatever
Make sure to always read the labels!!!!
With rapid acting insulin, we know that the onset is 10mins.
What’s important about this? (2)
Do not give until food is there because it works really fast
Can cause quick hypoglycemia effects!
Rapid and short acting usually do the same thing
How many meals do you think they can handle or help?
First meal ; just one meal really
Intermediate acting
They have what letter?!!
N!!!
Remember the N
NPH!!
Intermediate acting is from breakfest and ends usually until when?
Dinner time really
Notes
Long acting insulin
Works in the background typically
!!!!
Why would we use an inhaled insulin? ( afrezza )
Very resistant to subq insulin
If you take a
Intermediate acting
When is it going to work?
( take it at breakers )
What if you take during dinner time?
Lunch time
Take a bed night snack is needed
Long acting usually is taken how many times a day?
One pill or maybe even two
If you have a patient who has a hard trouble complying to insulin
We usually do combination insulins
What are they? (2)
Composed of short & intermediate
Rapid & intermediate acting
What are 2 numbers of combinations?
NPH 70 & regular 30
NPH 50 & regular 50
Now onto insulin resistance and storage
What does insulin resistance mean?
Antibodies develop over time to animal insulin
Antibodies cause insulin resistance and insulin allergy
Obesity can lead to insulin resistance
How do we store insulin? (3)
Keep unopened bottles in refrigerator until open
Avoid storing insulin in direct sunlight or at high temperatures
Open vitals are good at room temperature for 1 month or refrigeration for 3 months
Who needs more insulin typically?
1 or 2?
2 because they are resistant and not making enough
What if a patient still has insulin when they have an open vial, what do we tell them?
Throw them out after a month
( usually tell them pick a day, 15th of month or first )
Or keep refrigerated for 3 months
( insulin is not stable for longer than a month ! )
What is the action of insulin?
Promote use of glucose by body cells, store glucose as glycogen in muscles
What is the usage or purpose of insulins?
Reduce blood glucose
Control diabetes mellitus
What is the only insulin given IV?
Regular insulin
What 2 diabetes increasing glucose medications?
They usually decrease the effectiveness of it so we need to amp up diabetes meds
Thyroid
Steroids
Insulin
Decrease glucose with tricyclic antidepressants, MAOIS, aspirin and oral anticoagulant
( decrease blood sugar, may need to lower the amount of insulin )
What are your two side effects of insulin?
Hypoglycemia
Lipodystrophy
What are side effects of hypoglycemia?
Can be emergency
Nervousness, trembling
Lack of coordination
Sweating, tachycardia
Headache, confusion
Can become combative and incoherent
What is lipodystrophy?
How do we fix?
What may be presented ?
Injecting insulin in the same spot over and over again
Rotate sites
Abnormal fat disposers and scaring
There is something called somogyi effect, what is it?
Rebound effect in which an overdose of insulin causes morning hypoglycemia
( too much insulin at night/day, and wake up in the morning with hypoglycemia )
When do we check or diagnose this somogyi effect?
2-4am checking sugars
What is the treatment for somogyi effect?
Have a snack or decrease insulin dose
( if predawn glucose less than 60 )
What is the side effects of somogyi effect? (3)
AM headache
Night sweats
Nightmares
What is the dawn phenomenon?
Morning hyperglycemia present on awakening
What are the side effects of dawn phenomenon?
Headaches
Night sweats
Nightmare
What is the main cause of sawn phenomenon?
Growth spurts
What is the treatment of dawn phenomenon?
Increasing the insulin dose
What is the biggest concern for diabetes?
What side effects ?
Hypoglycemia!!
( neuro problems )
If you find a patient who is unconscious and is on insulin what is the first thing we do?
Give them sugar.
( glucagon Typically )
If a patient is conscious and is taking insulin what do we do?
Check their blood sugar and correlate their symptoms
What are the methods of insulin administration? Dont over think?
Arm
Stomach
Thighs
Notes
Super skinny
45 degree
Padding ( fat )
90 degree
Now onto insulin regimens!
What are the 2 insulin regimens?
Bolus
Basal
Basal-Bolus
What is Bolus insulin regimens?
Shorter acting insulin
Used to control blood glucose during and immediately after meals
Rapid & short acting
What is basal insulin regimen?
Longer duration of action
Used to control glucose levels between meals and overnight
NPH and long acting insulin’s
Bolus is right before you eat
What type of insulin?
Basal is usually in the background ( snack )
What type of insulin?
Rapid & short
( intermediate ) NPH and long acting
People with type 2 diabetes when they go insulin what is the normal regimen do they get?
Basal insulin
Notes
Basal Bolus regimen
- long acting insulin ( once a day )
- then you do a Bolus for every meal
Check your blood sugar and sliding scale
Or calculate the insulin
Can you mix your long insulin?
NO!!
What is sliding scale insulin dosing?
Reacting to a blood sugar that’s high
Usually used in the hospital
We check blood sugar before Meal, then we calculate the blood sugar and based on that, how much unit we give
Can we use rapid and short in the same syringe?
Can we mix it with intermediate?
Yes
NPH is cloudy!!
Needs to be rolled ( only insulin that’s cloudy!)
Long acting is by itself
Rapid food need to be present
Short acting gives great risk of hypoglycemia
NPH can be mixed with rapid or short acting
15 grams of carbs
5 pieces of hard candy
4 cans of soda
With signs of hypoglycemia
If someone has type 1 diabetes typically they are usually insulin
Type 2 diabetes usually do oral
Oral antidiabtes drugs
Notes
Oral anti diabetic drugs
For type 2 DM
Can be used in combination
Insulin maybe added to OA medications do better control
Oral anti diabetic drugs
Work in some combination (3)
Either does one thing
Decrease insulin resistance
Increase insulin production
Decrease hepatic glucose production
What are the 5 oral medications for oral anti diabetic drugs?
Sulfonylureas
Biguandie: metformin
Thiazolondinediones
DDP-4
Glucagon
What is the side effect of sulfonylureas?
They do all 3 BTW!
Hypoglycemia !!
If you take a sulfonylrueas
And they don’t eat what happens?
Hypoglycemia!!
What medication for biguandie?
Metformin
What are the 4 side effects of metformin?
Metallic taste
Lactic acidosis
GI upset !!!!
Pancreatitis
What is usually the first choice of oral anti diabriecs? And does all 3 things?
Metformin
How do you get rid of the GI upset for diabetic oral medication?
Usually start at a low dose
If a patient is having a test for IV contrast, why do we withhold metformin?
And how long is the holding?
Before and after?
Because they both are excreted through the kidneys
They cause renal failure
48aftee and 48 before
Test question
A patient is schedule to do a test with IV contrast, but they took meformin this morning, what do we do?
Or metformin is ordered do we still give it?
Call the doctor and reschedule
No hold it for the 48 hours
Thiazoldinoediones
What is it heavily contrainicated for?
Actos and Avandia
Class 3 and class 4 heart problems
Edema and weight gain
DDP-4 inhibitor
What does it do?
- increase the level of incretin hormones
- increase insulin secretion
Take it with metformin
Not taken first time
- usually it’s an add on for metformin or sulf
What are the 3 examples?
Sitagliptin ( januvia)
Saxagliptin (onglyza)
Lingaliptin (tradjenta )
Guidelines for oral anti diabetic
Therapy for type 2 diabetes
Onset of diabetes mellitus at age 40 years or older
Diagnosis of diabetes for less than 5 years
Normal weight or over right
Fasting blood glucose 200MG
Less than 40 units of insulin
Normalcrenal and hepatic function
Glucagon like peptide Agonists
What are the 3 medications?
Think of tides!
Exenatide ( byetta)
Liraglutide ( victoza)
Semgalutide ( ozempic & wegovy )
( weight loss ^ )
What are the 6 side effects of the glucagon like peptide agonist?
Nausea
Vomit
Diarrhea
Constipation
Dyspepsia ( lost of appetite)
Restlessness
Glucagon like peptide agonists
Action
Is what?
Slow gastric emptying, reduce food intake
Sugar is at a steady state
Take with food for oral medication
To help with GI upset
What is glucagon???
Help with hypoglycemia!!
Increase blood glucose by stimulating
Last resort !!!
Where medical alert bracelet
( we give this if your unconscious)
Then call 911
In the hospital for help with hypoglycemia?
Dextrose 50%
What is diazoxide used for?
Hypoglycemia caused by hyperinsulinsm
( so too much insulin and we use this and they need to eat a shit ton of sugar )
