Chapter 57: Drugs for Diabetes Mellitus

Question 1

What are short and long term complications of DM?

Answer 1

short term: hypoglycemia, hyperglycemia, ketoacidosi
Long term: Macrovascular: stroke, heart disease, and hypertension. Microvascular: retinopathy, nephropathy, neuropathy). gastroparesis, amputation, ED

Question 2

Has tight glycemic control proven effective? how?

Answer 2

this is effective in the EARLY stages of DM. People may be able to reduce CV, kidney, eye, and nerve damage. One can monitor their own blood glucose level.

Question 3

What is fasting blood glucose? What level indicates DM

Answer 3

Fasting blood glucose: glucose that is collected after the patient has fasted for at least 8hrs. A glucose level that is > than or = to 126 mg/dL

Question 4

What is hemoglobin A1c (glycosated hemoglobin) How is it useful?

Answer 4

This is a measurement that reflects an average of glucose levels over 2-3month period. A1c is a glycosated derivative (glucose interacting with Hemoglobin in RBCs. It is useful for monitoring of disease progression and effectiveness of therapy.

Question 5

what are the differences between type I and type II DM?

Answer 5

Type I: usually presents in childhood/adolescence with abrupt onset. Immune system attacks pancreatic beta cells that produce insulin. High risk of ketoacidosis. usually no family history, present as thin/malnourished, very low insulin levels

Type II: Usually presents middle age, with gradual progression, lower risk for ketoacidosis, strong family history, obese, lowered insulin response, insulin levels may be normal. Cells in liver, muscle, and adipose tissue unable to metab. available glucose

Question 6

What are S/S of ketoacidosis?

Answer 6

Hyperglycemia: 600-800 range, ketoacids in serum and urine, elevated Hct., acidosis, coma

Question 7

What is HHNS? how is this treated?

Answer 7

Hyperglycemic Hyperosmolar Non-ketotic Syndrome: hyperglycemic crisis that occurs with type II DM. Gradual onset, blood glucose 600 mg/dL or greater, little/no ketones in blood, normal ketone level in urine, increased plasma osmolality. (often occurs with infection, acute illness, or stress.) DEHYDRATION
Treated with IV insulin, fluids, and electrolytes

Question 8

What is the treatment of DKA? what electrolyte should be monitored carefully as insulin is infused?

Answer 8

Insulin replacement via IV, bicarbonate to treat acidosis, water, and sodium replacement (large amounts). and potassium replacement. Potassium is the electrolyte that needs close monitoring.

Question 9

How would one manage a pt with DKA in the ED

Answer 9

Monitor for concomitant processes: infections, CVA, MI, sepsis, and DVT. 1st hour: monitor fluid and electrolyte loss, pH, and HCO3.

Question 10

What are the different types of insulin?

Answer 10

Short duration-rapid acting, short duration: slower acting, Intermediate duration, and Long duration

Question 11

What are the names of the short duration-rapid acting insulins, how long to take effect, duration, and peak?

Answer 11

Insulin lispro: (Humolog) 15-30 min onset, 3-6hr duration, peak: 0.5-2.5 hrs
Insulin aspart: (Novo-log) 10-20 min onset, 3-5hr duration, peak: 1-3 hrs
Insulin glusiline: (apidra) 10-15 min onset, 3-5hr duration, peak: 1-1.5hrs.
**all three are CLEAR, given subQ, require prescription

Question 12

What is the short duration-slower acting insulin, time of onset, duration, peak

Answer 12

Regular Insulin: (Humulin R, Novalin R) 30-60 min. onset, 6-10hr. duration, peak 1-5hrs.

Question 13

Which insulin has an Intermediate duration? What is its onset time, duration, and peak?

Answer 13

NPH insulin: Humulin N, Novalin N, 60-120min. onset, 16-24hr duration, Peak: 6-14hrs.

Question 14

What are the long duration insulins? its onset time, duration, and peak?

Answer 14

Insulin glargine: (Lantus) 70min onset, 18-24hr duration, peak: NONE (given at HS for next day coverage)
Insulin detemir: (Levemir) 60-120 min onset, 12-24hr duration, peak varies, levels are steady.

Question 15

which insulin is used for the hospital’s sliding scale and also typically used in patients who are npo for the OR

Answer 15

short acting insulins such as lispro or regular insulin

Question 16

which formulations of insulin act immediately? which one provides all day coverage and is given once a day at bedtime?

Answer 16

Immediate acting insulins: Insulin lispro, Insulin aspart, Insuln glusiline. Insulin glargine: lasts all day, given at night.

Question 17

Which insulin is cloudy? which ones should NEVER be cloudy?

Answer 17

Cloudy Insulins: Intermediate NPH insulin

Clear insulins: short-acting insulins, long duration; these should not be cloudy

Question 18

Which formulations of insulin can be mixed in one syringe?

Answer 18

Only NPH can be mixed with short-acting insulins. Glargine should not be mixed with them.

Question 19

which formulation of insulin may be given IV?

Answer 19

Insulin aspart, Insulin lispro, Insulin glulisine, and regular insulin

Question 20

Where should insulin be injected? What are some special considerations?

Answer 20

subQ, Injection sites: upper outer arm, anterior thigh, and abdomen.
Abd: aborbed the best in this area.
ant. thigh: area of slowest absorption
**injections sites should be given in same GENERAL area w/in one inch of previous site. The EXACT site must not be reused for 30days.

Question 21

What is the main, dangerous side effect of insulins? why be cautious when comb insulin and a beta blocker

Answer 21

Hypoglycemia (treat with oral glucose or IV dextrose) Lipodystrophies, allergic reactions, hypokalemia.
**caution when comb insulin with beta blockers as they delay awareness of hypoglycemia.

Question 22

What is Metformin? side effects?

Answer 22

Metformin: DM drug in Biguanides family. Glucophage,
Mechanism of Action: Inhibits glucose production in the liver, reduces glucose absorption in the gut, sensitizes insulin receptors in target tissues.
Side effects: decreased appetite, nausea, diarrhea, decreased absorption of B12 and folic acid, weight loss of 7-8lbs.

Question 23

What is lactic acidosis? who is at risk

Answer 23

Accumulation of lactic acid due to metformin’s action to inhibit oxidation in lactic acid. Increased risk: patients who have serious, active liver disease, kidney disease, or alcoholism.

Question 24

What advantage does metformin have over other oral hypoglycemic agents?

Answer 24

It does not create hypoglycemia; it is a good choice for patients who skip meals.

Question 25

What is pioglitazone? how does it work?

Answer 25

Thiazolidinediones: (glitazones) and works by reducing glucose levels by decreasing insulin resistance.

Question 26

Which patients are not good candidates for glitazones?

Answer 26

patients with heart failure due to fluid retention/pulmonary edema risk.

Question 27

what is glyburide? How does it work? side effects? Overdose issues?

Answer 27

promotes insulin release. A major side effect is hypoglycemia. Cardiac toxicity resulting in sudden cardiac death. An overdose would result in dangerously low blood glucose . Dextrose would be administered to counteract this.
**IV for unconscious or if glucose is under 50, quick dissolving tabs or table sugar if patient is conscious

Question 28

What are some drug interactions of concern with glyburide? (sulfonylureas)

Answer 28

alcohol: flushing, palpitations, nausea, potentiate effects of glyburide.
NSAIDs: sulfonamide antibiotics and cimetidene intensify effects of hypoglycemia.
Beta blockers: diminish effects of sulfonylureas by suppressing insulin release and masking symptoms of hypoglycemia.

Question 29

what is rapaglinide?

Answer 29

Hypotensive agent in the Melitinides class. It increases insulin release. Major side effect is hypoglycemia.

Question 30

What is sitagliptin?

Answer 30

Oral hypoglycemic in the gliptins class that enhances the action of incretin hormones. These hormones stimulate glucose-dependent release of insulin and suppress postprandial release of glucagon (this hormone decreases glucose production in the liver)